Introduction
Methods
Rural site | Urban site | Total | ||
---|---|---|---|---|
Clinical officers | 1 | 3 |
4
| Higher-level providers (N = 12) |
Medical assistants | 4 | 0 |
4
| |
Nurses | 2 | 2 |
4
| |
HIV test counsellors | 3 | 0 |
3
| Lower-level providers (N = 13) |
Patient attendant | 1 | 4 |
5
| |
Lab technician | 1 | 0 |
1
| |
Ward clerk | 1 | 0 |
1
| |
Pharmacy assistant | 0 | 3 |
3
| |
Total
|
13
|
12
|
25
|
Provider attitudes
|
Childbearing among clients living with HIV
| What do you say to your HIV clients when they say that they would like to have children or that they are concerned about having children? Do you ask your clients about their desires and/or concerns about having children? How often? What have you heard or do you know about the attitudes or opinions of other health care providers regarding HIV clients’ desires to have children either at your clinic or in your experiences outside this clinic? |
Partner involvement in decisions about having children
| Do you think health care providers should involve clients’ partners in the decision making process about having children and in the delivery of reproductive/family planning services? What are the challenges in Malawi for involving partners in reproductive health/family planning? | |
Provider knowledge
|
HIV, reproductive health and PMTCT
| Have you had any training that has taught you about reproductive health/family planning needs of HIV clients? If so, in what way were you taught about meeting these needs? |
Safer conception
| What do you tell clients about having a child when the female partner is HIV+ and the male partner is HIV negative? Is there any specific advice you give about how to prevent transmission to the HIV uninfected partner in this situation? What do you tell clients about having a child when the male partner is HIV+ and the female partner is HIV-negative? Is there any specific advice you give about how to prevent transmission to the HIV uninfected partner in this situation? What do you tell clients if both partners are HIV+ and want to have a child? |
Results
Provider attitudes about childbearing
There are people who come and test positive even if they’re not expecting, whether men or women, they usually sometimes ask, ‘Now that I have tested positive for HIV, is there a chance for me to have children?’ …The questions come with someone worrying and we encourage them by telling them that this is possible provided they follow the counselling that they receive at the hospital. We tell them the choice is theirs because the hospital cannot force them [to not have children]. (Lower-level provider, rural site)
Firstly if the client understands very well the counselling before ARVs and of course the importance of having children and, at the same time, their wellbeing, at least they make a sound choice. Nobody is banned from having children but at the same time their wellbeing is the one [that] is most important as well as the unborn baby. So they are given the choices and they have to make choices out of those things. (Higher-level provider, urban site)
Let’s imagine maybe it’s a new couple, they are newlyweds, and they want a child. There is no way I can tell them not to get pregnant. I will encourage them to come … check their viral load, check their health status and also maybe their socioeconomic status, and then we will tell them this is the right time when you can get pregnant. But telling them not to get pregnant? I don’t think it will work. (Higher-level provider, urban site)And yet another provider explained that “Many women have the desire to have children because their marriages can fail if they don’t and so they try hard to have children”. (Lower-level provider, rural site)
The important thing is that we advise them and not tell them, because if we tell them, then anything goes wrong they blame us, so rather we advise them on good nutrition, how their health is, what they should do not to re-infect each other. (Lower-level provider, rural site)
We … tell them that if they already have children and still want to continue giving birth, the difficulties that they might face, make them see that with the way my status is, it’s better just to stay and look after the few children I already have. (Lower-level provider, rural site)Concerns were also raised when both partners were HIV-positive, with providers citing the challenges of taking care of orphans, asking “If you are encouraging somebody who is HIV positive to have children, what happens when he dies? Who will take care of those kids?” (Higher-level provider, urban site)The child is HIV-positive, the parents are also HIV-positive and are maybe dead and the child will be an orphan. So the child is an HIV-positive orphan, [and] this is what makes the country to be poor, by helping such people [to have children]. (Lower-level provider, rural site)
Provider attitudes about partner involvement in reproductive health
We should also be encouraging the HIV couples to be coming together at the same time at the clinic … When you do counselling to a couple I think they really understand what you are talking about instead [of] just talking to an individual and that client tells his partner or her partner. So even [when] the wife talks to the husband, the husband doesn’t understand. (Higher-level provider, urban site)
Like maybe during delivery, we also need the partner to be there for assistance. There are risks of transmission of HIV to the baby so the partner needs to be involved so that they assist each other for the care of the pregnancy as well as the care of the baby. They will need family planning so we have to involve the partner. (Higher level provider, urban site)
We medical personnel who have this information need to go out there and sensitize people … There should also be sensitization in villages with the chiefs to let them know the importance of both partners being present [for counselling about having children when one or both partners are HIV-positive]. (Lower-level provider, rural site)
Provider knowledge of prevention of mother-to-child transmission (PMTCT) and safer conception strategies
Some get tired of using condoms and stop and have unprotected sex, which could lead to pregnancy, which could lead to having a child who would be HIV-positive, so we really encourage family planning. (Lower-level provider, rural site)
We discourage against having children because of the risks involved, risks that the child can contract HIV are still there even if they’re taking medication, risks like infection when giving birth, and also some people still continue to breastfeed their babies even if they’re told not to because of poverty and this can lead to the child being infected with the virus and thereby adding problems to that child. So usually we counsel them to use condoms so that they do not get pregnant. (Lower-level provider, rural site)
A pregnant woman’s immunity normally drops so with the (HIV) virus it also drops further. This person can be in labor before their time since their immunity drops more. (Lower-level provider, rural site)
These people should be enlightened on the positives and negatives, the advantages and tell them the disadvantages… In the end, the choice is theirs that it’s not proper for them to have a child, like it has been explained concerning the immunity, which really goes down. So it’s not good to have a child since many times some die during childbirth. (Lower-level provider, urban site)
Okay, what we usually tell them is like we lay things on the table. You are HIV positive, you are HIV negative, [and] now you would like to have children. The idea is that if you would like to have children, … that means you will not be using the condoms, but the chances are that the partner who is not positive may end up having HIV. (Higher-level provider, rural site)Another provider also reported not providing any counselling about safer conception, but encouraged condom use, because “the chances of getting the virus when you are involved in unprotected sex are high and it’s up to you to make a decision, but these are the risks. You can have a child, yes, but there are risks that are attached. So that is the message that is given when a man is negative and a woman is positive”. (Higher-level provider, rural site)
We would go using the same procedure we say that at least she has to go for viral load check, CD4 and then if the viral load is lower and the CD4 is higher, she is not sick she is healthy then she can be told when she will be fertile, of that ovulation time at least not to use condom for 3 to 4 days then to continue using condoms. (Higher-level provider, urban site)
When someone tests positive for HIV, there’s some counselling that is done. When that counselling is done, maybe that person can have more questions and if we fail to answer some questions, we refer that person to another section where they can be assisted appropriately on those particular issues. (Lower-level provider, rural site)