TB and HIV stigma compounded by threatened masculinity: implications for TB health-care seeking in Malawi.

SETTING: Urban Blantyre, Malawi. OBJECTIVE: To understand why men with tuberculosis (TB) in the community remain undiagnosed. DESIGN: A multi-method qualitative study applying a modified grounded theory approach. Data were gathered from March 2011 to March 2012 from 134 men and women taking part in 1) focus group discussions with community members (n = 6) and health care workers (n = 2), and 2) in-depth interviews with TB patients (n = 20, females n = 14) and chronic coughers (n = 20, women n = 8). Data were analysed inductively to identify, refine and consolidate, and verify emerging concepts and themes. RESULTS: Two emerging themes highlighting compound stigma in this high human immunodeficiency virus (HIV) prevalence, low-income setting are presented. First, cough or any illness that portended a 'serious' condition were accompanied by portrayals of cough, TB and HIV as being interchangeable. Chronic coughers and TB patients described their illness in ways that foregrounded bodily decimation and rupture of social life and masculine identity. Second, 'resistance strategies' entailed resisting classification as (seriously) ill by evading or ambivalently approaching health care, or acknowledging the 'ill' status then actively pursuing health-appropriate behaviours, including changing lifestyle or adopting non-normative gender roles. CONCLUSIONS: Managing patients requires 1) going beyond syndromic management based on vital signs and clinical indicators to recognising and intervening on health care-seeking related tensions to retain individuals in care, and 2) understanding and addressing TB stigma as it manifests and affects men and women differently in specific settings.

Defining the research agenda to measure and reduce tuberculosis stigmas.

Crucial to finding and treating the 4 million tuberculosis (TB) patients currently missed by national TB programmes, TB stigma is receiving well-deserved and long-delayed attention at the global level. However, the ability to measure and evaluate the success of TB stigma-reduction efforts is limited by the need for additional tools. At a 2016 TB stigma-measurement meeting held in The Hague, The Netherlands, stigma experts discussed and proposed a research agenda around four themes: 1) drivers: what are the main drivers and domains of TB stigma(s)?; 2) consequences: how consequential are TB stigmas and how are negative impacts most felt?; 3) burden: what is the global prevalence and distribution of TB stigma(s) and what explains any variation? 4): intervention: what can be done to reduce the extent and impact of TB stigma(s)? Each theme was further subdivided into research topics to be addressed to move the agenda forward. These include greater clarity on what causes TB stigmas to emerge and thrive, the difficulty of measuring the complexity of stigma, and the improbability of a universal stigma 'cure'. Nevertheless, these challenges should not hinder investments in the measurement and reduction of TB stigma. We believe it is time to focus on how, and not whether, the global community should measure and reduce TB stigma.

AIDS related knowledge and sexual behaviour among commercial farm residents in Zimbabwe.

OBJECTIVE: To describe sexual behaviour among residents of commercial farms in Zimbabwe, their gender-specific differences; to examine implications of these for HIV/AIDS transmission. DESIGN: A cross sectional descriptive study. SETTING: Three commercial farming communities near Harare, Zimbabwe. SUBJECTS: Convenience sample of 218 adult (age 18+, or ever married) farm residents. MAIN OUTCOME MEASURES: Number of sexual partners, secondary sexual relationships outside marriage, condom ever-use, first sexual partner, sexually transmitted disease (STD) experience, unprompted knowledge of HIV. RESULTS: Knowledge of HIV transmission was high, with eight to 88% of respondents reporting various correct means of transmission. Males reported engaging in riskier behaviour than females, with 60% of currently married males (n = 81) reporting extra marital affairs compared to 4% of currently married females (n = 91) (OR: 4.02; 95% CI: 1.8 to 9.04). Males were more likely than females to report a second or further marriage (OR: 37.9; 95% CI: 16.01 to 92.1). Females were more likely than men to report first sexual partner as spouse. Fourteen percent of respondents had children of various ages outside their current union. Reported STD experiences under various circumstances were negligible with no differences by sex. CONCLUSION: While HIV/AIDS prevention measures largely rely on individual behavioural change, preventive efforts should also encompass differences in sexual behaviour between categories like male and female. Importantly, this will determine composition of preventive policy, but also allow a clearer determination of trends based on the gender-specific behaviours. There is also need for more research work that attends to determinants of reporting behaviour beyond aspects of reported behaviour per se.

Beliefs about sexual relationships and behaviour among commercial farm residents in Zimbabwe.

OBJECTIVES: To describe beliefs of farm residents about sexual relationships and sexual behaviours within these relationships, as a basis for understanding how these beliefs may influence sexual behaviour; and to document gender differences in these beliefs. DESIGN: Cross sectional descriptive study. SETTING: Three commercial farms in Mashonaland Central Province, Zimbabwe. SUBJECTS: Purposive convenience sample of 218 adult (age 18+, or ever-married) residents on the commercial farms. MAIN OUTCOME MEASURES: Views towards celibacy, wife inheritance, condom use, infertility, extra-marital affairs. RESULTS: 85% of respondents felt marriage was a cushion against HIV/AIDS. The majority (87.6%) viewed wife inheritance as improper; 37.6% felt that it facilitated the spread of HIV. Sixty two percent viewed condom use in marriage as unacceptable, and the majority of respondents felt that infertility was a problem in a person's life, with men being less likely than women to indicate this (OR: 0.26; 95% CI: 0.10 to 0.67). Male respondents expressed greater ability than their female counterparts to take protective steps in the event of suspecting STD/HIV/AIDS in their spouse. More male than female respondents felt they could leave marriage against perceived risk of infection with HIV from their partner (OR: 2.20; 95% CI: 1.22 to 4.00). CONCLUSION: Perceptions of wife inheritance are positive when viewed against known ways of HIV transmission. There is need for further work to allow women to express their integrity as individuals in their relationship with men, as a strategy to promote their reproductive health. Determinants of condom acceptance need further understanding because condom use is one of the effective ways of curbing the spread of HIV/AIDS.