Discordance, Disclosure and Normative Gender Roles: Barriers to Couple Testing Within a Community-Level HIV Self-Testing Intervention in Urban Blantyre, Malawi

Men and women were afraid of the disclosure of HIV-discordant relationships and the potential negative consequences of this test result on their relationships, which were based on trust. Our data showed that participants did not understand what HIV-discordance was and how it occurred in trust relationships characterised by unprotected sex. In addition, study participants did not know what sexual partners should do after HIV-discordant results were revealed, and many considered divorce as the only solution. Thus, partners in a relationship with a previous history of confirmed or suspected infidelity were afraid to self-test together fearing that one partner might test HIV-positive. Among the perceived harmful effects of being in an HIV-discordant relationship (as cited by the study participants) are physical or psychological violence, separation, deprivation of unprotected sex and divorce:

…when the result shows that your partner has been found with the virus and you have not been found with the disease, ‘can the marriage continue?’ No, it can end because the uninfected partner would be afraid of getting infected. This is what frustrated me from testing with my wife…. (Male, 27 years, HIV-positive, concordant, secondary education, informal employment)

A positive HIVST result for one partner was said to invite unfavourable dynamics within the relationship often carried out by the HIV-uninfected partner. In terms of effects on the sexual relationship the uninfected partner was usually worried about contracting HIV while the infected partner was afraid of being denied access to unprotected sex. Men and women seemed to anticipate the social effects linked to an HIV-discordant relationship differently. The fears of marriage dissolution following HIV-discordant results were more profound amongst women as they were primarily worried that a positive result would jeopardise financial support for themselves and their children and severely damage their respectability in the community:

…if I am found with it [HIV] while my husband doesn’t have it, he would consider me as a prostitute and may choose to chase me away [divorce]. (Female, 29 years, HIV-positive, concordant, primary education, unemployed)

Men were mostly worried that a positive result would undermine their masculine authority in the household and were afraid to relinquish control over unprotected sex, as described by a woman in this quote:

He was afraid that if we test together and our results are HIV-positive, the counsellor would instruct us to use ‘zishango’ [condoms] which he does not like to use. (Female, 27 years, HIV-positive, discordant, secondary education, formal employment)

Fear of exposing a possible or in some cases an already known HIV-positive result to a partner through joint testing emerged as a common theme among individuals who self-tested in absence of the sexual partner. For some men who tested alone, the main reason their female partner refused couples testing was not being prepared to have her HIV-positive status known by her partner through a joint HIVST. Declining to self-test with a partner was common among some women who already knew their HIV-positive status but were unprepared to disclose it to a male partner, as recalled by a man whose partner refused a joint HIVST:

My wife was also at home (when HIVST was offered through door-to-door approach). She refused because she was not ready to test at that time. (Male, 31 years, HIV-positive, concordant, secondary education, informal employment)

The man also indicated that his partner seemed to have been aware of her HIV-positive status but did not disclose it out of fear of possible marriage dissolution.

In contrast, women who self-tested alone indicated that their male partners frequently refused a joint HIVST because they feared having an initial HIV test in the presence of a partner. Men feared blame from a partner for introducing HIV into the relationship. Some men even issued strong threats to their partner to intimidate them from pursuing the joint HIVST agenda as illustrated in a quote by an unemployed female partner recalling how her male partner refused an offer of a joint HIVST:

‘I don’t want. I cannot test, no. I will go to a clinic myself to test. What have you seen in me?’ He also threatened me that ‘if you test, we will see what will happen to you inside the house’. (Female, 29 years, HIV-positive, concordant, primary education, unemployed)

In this example, the male partner, who later also self-tested HIV-positive, used his authority to suppress and discourage his partner’s request for a joint HIVST, a theme that recurred in most of the interviews. Men’s position of power within the household gave them greater leverage to obstruct or neutralize any suggestion to undergo a joint HIVST coming from their partner.

Men who felt they were distrusted by their partner opted for an initial individual self-test to preserve their ability to conceal their status in the event that the test-results came back positive and thus be able to maintain their moral credibility. In short, many participants seemed uncomfortable and/or lacked the skills to openly discuss these issues with their partner. Within the context of established couples, HIV-positive results are usually synonymous with previous or current infidelity, as one man explained:

…should I test together with my wife, no….if she knows my status, she might be think[ing] that I sleep around with other women. It is better for me to test alone. (Male, 20 years, HIV-negative, partner sero-status unknown, primary education, informal employment)

Thus, men declined joint testing in order to safeguard trust within the relationship. This demonstrates that men have a higher perception of subjective risk, leading to fears of testing for HIV on the one hand and of disclosing their HIV positive sero-status on the other. Men were much more likely than women to fear self-testing together with their partner due to a previous or current record of infidelity as illustrated by this quote:

I had fear after doing something [engaging in sexual misconduct]. If I say something, you know what I mean…. If I have slept [had sex] with other women… I was afraid of considering that the truck [him as a man] had travelled a long distance and with heavy load of goods to reach the destination to deliver the goods. (Male, 32 years, HIV-negative, discordant, tertiary education, formal employment)

In this quote, the word ‘truck’ was a metaphor for ‘man,’ the ‘load of goods’ represented the number of women that he had had sex with, and the ‘distance to the destination’ referred to the time from the onset of being sexually active. The partner’s suspicions of sexual malpractice amplified the man’s fear of the consequences following self-testing in the presence of his partner. Apart from exposing concealed infidelity, male participants were also worried that an HIV diagnosis through a joint HIVST would render them vulnerable to blame and accusation for introducing HIV into the relationship, as illustrated in this quote.

When you have been stepping your bare feet on thorns [having risky sexual affairs], it makes you feel that you have injured [infected] your friend [sexual partner]. I avoided testing together with her because I felt that she would blame me. (Male, 32 years, HIV-positive, concordant, secondary education, informal employment)

In the quote above, stepping on thorns refers to engaging in unprotected sexual encounters. The quote illustrates a feeling of not wanting to hurt a sexual partner but also a degree of cognitive dissonance between behaviour and intention. While men were worried about blame following HIV status disclosure, women feared being branded as unfaithful and a possible domestic violence for requesting a joint HIVST.

The absence of one partner at home at a time of a CC’s door-to-door visit deterred some couples from having a joint HIVST. While this reason was provided by both men and women, it was especially frequent among women who self-tested alone because their partner was not at home. Since HIVST was mostly offered during the normal working hours, the CCs found women at home more often, as men had gone to work. Women commonly stated that they self-tested without a partner because the male partner was at work when HIVST was offered. This quote speaks to the unavailability of the male partner:

… he was at work… I self-tested alone because it is me who has this body and it is me who feels the pain. Because of this, they say ‘a bag of life is cared by oneself’. (Female, 41 years, HIV-positive, concordant, primary education, unemployed)

The quote illustrates to some degree that people act in their own interest where an individual cannot expect support from his/her partner, based on a premise that the couple is in this together. It also demonstrates the potential to be blamed for the inability to care for one’s own state of health. A metaphor ‘bag of life’ was used in this context to demonstrate that safeguarding one’s health is one’s own responsibility. Men who self-tested as individuals mostly cited that they tested alone because their female partner had either gone to the market, to the hospital or to the village at the time HIVST was offered. The places mentioned here correspond with the normative gender roles ascribed to women in the study setting:

… at that time, my wife had gone to under-five clinic with a child. …I thought that ‘since the person [CC] is already here, I should just self-test. (Male, 31 years, HIV-positive, concordant, secondary education, informal employment)

The masculine provider role meant that many men were away from home while the feminine caregiving role kept most women at home and increased their likelihood of being reached by HIVST. Despite the fact that the community-based HIVST model appealed to both men and women, its design rendered HIV testing more accessible to women than men, thereby reproducing the current HIV-testing variations.