Background
Materials and methods
Study type and design
Study Setting and population
Data collection
Data management and analysis
Theme | Sub-theme |
---|---|
1. Knowledge about HIV transmission and source of infection | A. HIV transmission |
1. Unprotected sex | |
2. Other iatrogenic (razor blades, needles, blood transfusion) | |
3. Maternal-to-child transmission | |
B. Source of HIV information | |
1. Health facilities | |
2. Radio broadcasts and interpersonal contacts | |
3. Study nurses | |
C. Source of HIV infection | |
1. Unfaithful partners 2. Partners reluctant to disclose | |
2. Beliefs about condom effectiveness for HIV and pregnancy prevention | 1. Condoms prevent HIV, STIs, and pregnancy |
2. Worry about condom failure (e.g. breaking or having holes) for women without HIV | |
3. Partners view condoms as ineffective | |
4. Female condoms are more effective than male condoms due to female-control | |
3. Motivations for contraception | A. Facilitators |
1. Desire to improve economic status (with fewer children) | |
2. Desire to focus on other priorities in life (with fewer children) | |
3. Protection against pregnancy complications, such as blood loss | |
4. Partner support | |
5. Determination to use even without partner support (e.g. covert use) | |
B. Facilitators—Women with HIV | |
1. Pregnancy may lead to HIV progression, since both pregnancy and HIV suppress the immune system | |
4. Motivations for condom use | A. Facilitators |
1. Uncertainty about partner status | |
B. Barriers | |
1. Lack of woman’s control over decision making | |
2. Situational use only (e.g. during menses or not using other contraceptive method) | |
C. Facilitators—Women with HIV | |
1. Avoid infection with drug-resistant HIV strain | |
2. Dual protection for implant users due to drug interactions between ARV and implant |
Ethical considerations
Results
Characteristic | N = 41 |
---|---|
Age (mean, SD) | 33.4 (6.06) |
Education (number, %) | |
None | 5 (12.20) |
Some primary/primary | 19 (46.34) |
Some secondary/secondary | 17 (41.46) |
Number of children (mean, SD) | 2.7 (1.11) |
Relationship status (number, %) | |
Married or partner called “husband” | 28 (68.29) |
Separated or divorced | 9 (21.95) |
Widowed | 3 (7.32) |
Never married | 1 (2.44) |
HIV status (number, %) | |
Positive | 30 (73.17) |
Negative | 11 (26.83) |
Number of additional children desired (number, %) | |
0 | 24 (58.54) |
1–2 | 14 (34.15) |
3–4 | 3 (7.32) |
Roof material (number, %) | |
None or grass | 12 (29.27) |
Metal, wood or cement | 29 (70.73) |
Trouble paying for food, clothing, medicine in past 12 months (number, %) | |
Yes | 15 (36.59) |
No | 26 (63.41) |
Knowledge about HIV transmission and source of infection
Participants named a number of formal sources of HIV information including medical clinics, radio stations, and churches. The women also learned about HIV through family, friends and other informal community contacts. Most women considered medical institutions to be the main and most trusted source of HIV information primarily because they believed that health care workers were experts on HIV and family planning issues.I: Okay, how do you think a person gets HIV?R: Through unprotected sex. Some say that through needles or razor blades, but the common way people get HIV is through unprotected sex. (IDI, HIV-positive)
Given that the women received counseling messages in the main study about HIV acquisition and transmission risk with DMPA injection or LNG implant use, not surprisingly, some women named study nurses as their source of knowledge on this topic.F: Who do you think is the most trustworthy source of information?R: I think the hospital is the best place where you can get information. (FGD4, HIV-positive)R: The hospital is where you can get the right information. These other people get their information from the hospital and broadcast on the radio. (FGD1, HIV-positive)
Most HIV-positive women believed they contracted HIV through sexual contact with their male partners who had sexual relationships with other partners. They based this belief on becoming infected despite their faithfulness to their partner.I had a feeling that once I use this method [LNG implant] I will not contract HIV but later on the nurses explained to me that the method does not prevent the risks of contracting HIV. That’s why I was concerned. But now I am no longer concerned because if I find a new sexual partner I will make sure to always use condoms. (IDI, HIV-negative)
Another theme was that the women’s partners knew they were HIV positive but did not disclose their status to the women possibly due to fear of being blamed as bringing infection in the house. Some women talked about getting diagnosed while pregnant at the antenatal clinic, and when they disclosed their status to their partner, they discovered that he already knew he was infected and was probably waiting for this opportunity for the woman to have a test and put a blame on her.I just feel that I got infected from him because of his behaviour. I was faithful to him but he was promiscuous. (IDI, HIV-positive)I got HIV from my husband. He is a driver and I saw him bringing other women to our house. It reached to the extent that I knew all his girlfriends. He had girlfriends in different bars and I knew all about that (FGD1, HIV-positive)
Another woman said her husband did not disclose that he was HIV positive until after they were tested for HIV together:I: How do you think you contracted HIV?R: I think I got infected with HIV the time I was marrying my husband. By the time I came to the hospital when I was sick, he didn’t tell me that he was already HIV positive. He knew his status already and his immune system was okay during that time. (IDI, HIV-positive)
After the test, that’s when we were found to be HIV positive, and that’s when he told me that he is already on ART. By the time we went for the test we were not married, and he showed me his medication. (IDI, HIV-positive)
Beliefs about condom effectiveness for HIV and pregnancy prevention
When you use condoms, the semen remains in the condom. If you are HIV positive there is no possibility of the virus from the man entering your body. (IDI, HIV-positive) Condoms are effective in many ways, like they can protect against sexually transmitted infections and pregnancy. (FGD5, HIV-negative)
Second, other women talked about condoms with holes that put them at risk of contracting HIV or becoming pregnant:I: Do you think condoms are effective at preventing HIV?R: NoI: Why are they not effective?R: A condom is not 100% effective because it can break.” (IDI, HIV-negative)
For some women, concerns about condom effectiveness were reinforced by partners who also believed that condoms were not 100% effective in preventing HIV and pregnancy. This could negatively affect condom use among couples since men are most often the main decision makers about condom use.Some people say that condoms have a hole in them while others are okay. So I don’t know the whole truth of it. (FGD2, HIV-positive)
Despite the fact that female condoms are not widely used by women in Malawi, several HIV-positive and negative women felt that female condoms were more effective protection than male condoms. One woman felt assured that a female condom was less likely to have been tampered with because she had control of it herself. As a result, these women felt it was important to encourage other women to use female condoms.I: Do you think your husband believes that condoms are effective at preventing HIV?R: He does, but he also believes that they are not 100% effective.I: Why does he think that way?R: It can break anytime, it’s plastic! (IDI, HIV-negative)
When they use female condoms, they can be assured of protection because with the male condom, you can see the man wearing it, but they can pierce it, and you might end up being pregnant or getting HIV. So I think the female condom is more reliable because you put it on yourself (FGD1, HIV-positive)
Motivations for contraception use
Contraceptive use was seen as a tool for controlling the number of children:I have made up my mind not to have another child because he doesn’t help the children. I have been taking care of them alone. He takes advantage of me because I am working and I am able to support myself and the children, even pay school fees for them. (IDI, HIV-positive)
Some women felt that contraception helped them plan for future pregnancies when they would have enough time to care for them:He came back to me in 2012 claiming that he wanted to take care of our second born child. By then our first born was 6 years old. Then I became pregnant again and that’s when he left me. So I don’t want to face the same problem. I decided to come for family planning because I feel he can come back again … I don’t want to become pregnant again. (IDI, HIV-negative)
Women regardless of HIV status were aware of the problems that can arise during pregnancy, labor and delivery. Some talked about how women lose a lot of blood during labor and delivery, and therefore, women need to protect their health through contraception.I started using family planning because when you have children often, you do not have time to do other things and develop yourself and your home. However, when you use family planning, you are able to plan when to have children and develop yourself. There are distractions that come with children or pregnancy. (IDI, HIV-negative)
Childbirth experiences especially labour and delivery pain and post-partum complications (e.g. hemorrhage) were strong motivation for some women regardless of the number of children they had.Some women have problems when giving birth. Others lose a lot of blood during delivery and require blood transfusion. So many of them think about their health when choosing family planning methods. They would like to prevent these problems so they chose to use family planning methods (FGD2, HIV-positive)
HIV-positive women talked more about protecting maternal health through contraceptive use despite the fact that many women felt that HIV positive women also had the right to have children. Nearly all HIV-positive women considered contraception important since both pregnancy and HIV are physically taxing and associated with immune suppression.Like in my case, I have decided to come here to start using family planning methods because of what I faced during the time I was giving birth. ….I lost a lot of blood that required transfusion and I have made up my mind not to have another child despite having one child who is 15 years old. (FGD3, HIV-positive)
Additionally, HIV-negative women acknowledged the rights of HIV-positive women to have children but also encouraged them to think about their own health.Like myself, I don’t care whether I will have an HIV negative baby or not, I think about my health and I know that if I become pregnant my body immunity may decrease or increase. …. So it’s better I should be using family planning methods. ….When you have children more often, your immunity decreases and you get sick often and your body doesn’t look healthy. (FGD1, HIV-positive)When women give birth, some of them are weak and they decide to start using family planning. In addition to that, because of HIV many women decide to use family planning methods because when they have many children their body immunity drops and the fear of developing AIDS is one factor that encourages many women to use family planning. (FGD1, HIV-positive)
Both HIV-positive and negative women talked about the importance of discussing family size and contraceptive use with their partners. Women from both IDIs and FGDs acknowledged discussing with their partners plans to start family planning and that their partners’ approval played a positive role in their decisions to a mutually agreed upon contraceptive method.Women who are HIV positive have the right to have children but they need to think about their own health, the strength they had before they were infected and the strength they have now. They may have children but their immunity may drop more than a woman who is HIV negative. (FGD5, HIV-negative)
One woman talked about the encouragement she received from her partner to use family planning in spite of her disinterest in doing so:In my case, I talked with my husband, and he said that we should be using family planning methods instead of having many children. When you have children often your immunity drops and you are not healthy; and also you cannot do many things because of the children. (FGD4, HIV-positive)I was one of the people who used to have children every year, but when I sat down with my husband and told him that I would like to start using family planning methods he just asked me where I want to access the services. ….I started using family planning and my last born is 9 years old. (FGD6, HIV-negative)
Despite general agreement that partners should be involved in contraceptive use decisions, some focus group and in-depth interview participants preferred to make informed decisions on contraceptive use on their own. Many of these (women ultimately, used contraceptive methods covertly due to the lack of partner support. Despite their desire to make informed decisions about contraceptive use and the decision to use contraceptives covertly, they also acknowledged that covert use comes at a cost, especially if the partner discovered that the wife is using contraceptives without their knowledge or if side effects occur.He thinks it is a good idea, I did not want to use family planning, he is the one who told me about it and convinced me to be using family planning. He said, “When you are using family planning, you have time to take care of the home and have plans to develop the family and ensure that the family has a good life.” (IDI, HIV negative)
R: I made the decision on my own I didn’t consult him because I knew that if I did, he wouldn’t allow me to [use it]. I told him when I had already started using Depo, and he complained that I had wronged him because he wanted to have another child. (FGD4, HIV-positive)Before his child was born I was on family planning. I used pills, so at the time I had two health passports, the one for family planning and the other one for day-to-day health-related problems. So I hid the other book and kept the other one in the open. (IDI, HIV-positive)
Motivations for condom use
In addition, some HIV-negative women said they always have condoms with them to be prepared for sex because sex often happens without any discussion about pregnancy, STI, or HIV prevention measures. Being prepared helps, but as one woman explained, it cannot protect you from all HIV risk since unprotected sex can happen unexpectedly.They told me that if I have unprotected sex, I may get HIV. I know my status because I got tested, but I do not know about my husband, maybe he is HIV positive. So I need to protect myself by using condoms. (IDI, HIV-negative)
Sometimes you might be sleeping and just realize that the man is on top of you [having sex]. (IDI, HIV-negative)
On the other hand, condom use was considered very important by many HIV-positive women to avoid infection with a drug-resistant HIV strain and keep their HIV viral load low.I was having my monthly periods and he really wanted to have sex with me. So to compromise, I told him to use a condom and he did. (IDI, HIV-negative)I only used condoms while waiting for the date I was given to come back to the clinic to start family planning methods.” (IDI, HIV-negative)
Most women said they had heard about the risks of becoming pregnant while taking ART and using the LNG implant from the study clinic for the first time. Some expressed concern that women in the community did not know about these messages and chose family planning methods (the LNG implant) that interfere with the efavirenz-based ART regimen, leading to unwanted pregnancies.When both partners are taking ARVs [antiretroviral therapy], you may not fully trust your partner on whether they are taking the ARVs daily or not. If you do not use condoms, you share viruses that have developed resistance and that decreases your body immunity. (FGD1, HIV-positive)The time we came for HIV testing, we were counselled that we should always use condoms to prevent infecting others and re-infecting ourselves. We were told that re-infection can reduce our immunity. That’s why he does not have any problems using condoms. (IDI, HIV-positive)
Some HIV-positive women expressed some concerns about the potential risks of becoming pregnant while taking Efavirenz based ART (5A) and using the LNG implant due to the counselling messages they received at each study visit about these risks. Most of them mentioned the importance of using condoms as counselled by the study nurses despite being on contraceptives to prevent pregnancy and their strong desire to always use them.I heard the messages when I joined the study, before that people in the villages, they don’t know about these messages [drug-drug interaction between Efavirenz-based ART regimen and LNG implant]. Health workers come to our community, and just give out the birth control methods, and they don’t explain anything to the people. They don’t tell them anything about the drugs, even the fact that they can get pregnant. (FGD3, HIV-positive)
One woman reported to have heard about the message about drug-drug interaction before joining the study and the counselling messages increased her desire to use condoms.You should understand that it doesn’t mean that Jadelle®2 is 100% for people like me [people who are HIV-positive]. You can still get pregnant, that’s why we use condoms. (IDI, HIV-positive)They told me that I should use condoms all the time because ARVs are more powerful than Jadelle®1, and if I don’t use condoms I may end up being pregnant. So they told me to use condoms all the time. (FGD3, HIV-positive)
Nearly all HIV-positive women voiced that their partners theoretically agreed to condom use, but few used them consistently despite their effort to always have condoms with them and reminding their partners to use the. This could possibly be because most HIV-positive women either knew or suspected their partners were HIV-positive.When they put the implant, they called me some time to come back to the hospital. They had made a mistake, they wrote different ARV drugs to the ones I was taking at the time. They told me that if I take that type of ARV drug with the one I am taking now I can easily get pregnant because the drug interferes with the Implant. That’s why we are encouraged to always use condoms. (FGD2, HIV-positive)
Women also talked about the difficulties they faced when requesting their partners use condoms. Some felt powerless to demand condom use while those who did were accused of having outside relationships or being promiscuous. Another challenge raised by some women concerned the negative stereotype about condoms and sex work. These women talked about how men incorrectly believe that condoms should only be used with female sex workers and not married women.My husband accepts to use condoms most of the time, but there are times we don’t use them. I always put some condoms under the pillow, but there are times when I forget to put some, and I find it difficult to wake up and get them when we want to have sex because my husband insists that we should just have sex without a condom. (IDI, HIV-positive)
Other women talked about condom use side effects including how their partners found sex with condoms less pleasurable or fraught with physical side effects including the potential to develop a rash.Well, they could give me the condoms, and when I go home and ask my husband to use them he would say, “Why should we use condoms? You must be a sex worker then because the only people I can use condoms with are sex workers because they are not safe. I can’t have sex using condoms with my wife, no!” (IDI, HIV-negative)
At first, he was complaining that sex with a condom is not pleasurable but now he is used to them and we always use condoms. (IDI, HIV-positive)He is not comfortable using condoms because he has heard that people develop a rash when they use them. (IDI, HIV-positive)