Shifting focus from individuals to institutions

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Shifting focus from individuals to institutions the role of gendered health institutions on men's use of HIV services
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Role of gendered health institutions on men's use of HIV services
Dovel, Kathryn ( author )
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Denver, Colo.
University of Colorado Denver
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Doctorate ( Doctor of philosophy)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Health and Behavioral Sciences, CU Denver
Degree Disciplines:
Health and behavioral sciences


Subjects / Keywords:
HIV infections -- Prevention -- Africa, Sub-Sharan ( lcsh )
AIDS (Disease) -- Prevention -- Africa, Sub-Saharan ( lcsh )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Men in sub-Saharan Africa are less likely than women to use HIV services and, thus, are more likely to die from AIDS. While much of the literature argues that men's views of masculinity keep them from services, I use the theory of gendered organizations to provide another perspective. In this dissertation, I use a mixed methods approach to examine the gendered organization of facility-based HIV testing services in southern Malawi and how the organization of services creates additional barriers to men's use of care. ( ,,, )
I combine four types of data: (1) survey data with facility clients to assess if quality of care differs by sex of client; (2) in-depth interviews with health care providers and policy makers to examine perceptions of men as clients; (3) participant observation in health facilities to understand how institutional protocols are enacted at the local level; and (4) international and national policy documents to situate local health institutions within broader global constructs of gender and HIV priorities.
I find that heterosexual men have become an invisible category within both international and national HIV policy. When they are included, they are described as the problem, not part of the solution to HIV epidemics. On the ground, the organization of HIV testing services has followed suit.
Health institutions, like other organizations, are not gender-neutral. Men in southern Malawi were not recruited for health services, were less likely than women to receive health education when they did attend a facility, and were less likely to have access to HIV testing because services were, at times, only offered during hours for antenatal services. Furthermore, HIV testing was often located near antenatal services, again contributing to the perception that testing was designed for women -- because it was. Based on these findings, I argue that HIV testing is gendered across three levels of the health institution: (1) the organizational HIV policies; (2) the physical environment in which testing occurs; and (3) interactions within facilities that require clients to enact qualities typically viewed as feminine in order to successfully receive care (e.g., waiting long hours, being compliant, and being a caregiver).
Includes bibliographical references.
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by Kathryn Dovel.

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982699412 ( OCLC )
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KATHRYN DOVEL B.A., Vanguard University, 2007 M.P.H., University of California, Los Angeles, 2010
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Health and Behavioral Sciences

This thesis for the Doctor of Philosophy degree by Kathryn Dovel has been approved for the Health and Behavioral Sciences Program
Jean Scandlyn, Chair Sara Yeatman, Advisor Debbi Main
Deborah Mindry

Dovel, Kathryn (Ph.D., Health and Behavioral Sciences)
Shifting Focus from Individuals to Institutions: the Role of Gendered Health Institutions on Mens use of HIV Services
Thesis directed by Associate Professor Sara Yeatman.
Men in sub-Saharan Africa are less likely than women to use HIV services and, thus, are more likely to die from AIDS. While much of the literature argues that mens views of masculinity keep them from services, I use the theory of gendered organizations to provide another perspective. In this dissertation, I use a mixed methods approach to examine the gendered organization of facility-based HIV testing services in southern Malawi and how the organization of services creates additional barriers to mens use of care.
I combine four types of data: (1) survey data with facility clients to assess if quality of care differs by sex of client; (2) in-depth interviews with healthcare providers and policy makers to examine perceptions of men as clients; (3) participant observation in health facilities to understand how institutional protocols are enacted at the local level; and (4) international and national policy documents to situate local health institutions within broader global constructs of gender and HIV priorities.
I find that heterosexual men have become an invisible category within both international and national HIV policy. When they are included, they are described as the problem, not part of the solution to HIV epidemics. On the ground, the organization of HIV testing services has followed suit.
Health institutions, like other organizations, are not gender-neutral. Men in southern Malawi were not recruited for health services, were less likely than women to receive health education when they did attend a facility, and were less likely to have access

to HIV testing because services were, at times, only offered during hours for antenatal services. Furthermore, HIV testing was often located near antenatal services, again contributing to the perception that testing was designed for women because it was. Based on these findings, I argue that HIV testing is gendered across three levels of the health institution: (1) the organizational HIV policies; (2) the physical environment in which testing occurs; and (3) interactions within facilities that require clients to enact qualities typically viewed as feminine in order to successfully receive care (e.g., waiting long hours, being compliant, and being a caregiver).
The form and content of this abstract are approved. I recommend its publication. Approved: SaraYeatman

The dissertation process has been one of the most rewarding experiences in my professional career. I owe its success to the multiple people I have met and worked with along the way.
First and foremost I would like to thank my two mentors, Sara Yeatman and Susan Watkins, for the countless conversations, paper edits, and regular feedback. Their support has pushed me beyond my own expectations and taught me to reflect critically on my own work. Their feedback and encouragement have been truly invaluable not only to the development of this dissertation, but to the development of my career. I am indebted to them and am grateful to call them friends and colleagues.
This work would not have been possible without the support and insight from my friends and colleagues in Malawi. A big thank you to Francis Kamungu, McDafton Belosi, Esnart Sanudi, and Violet Boillo, exemplary research assistants who I worked with throughout my time in southern Malawi. Their skills as researchers and their company as friends truly enriched my experience and provided insight into the local context that I could never have gained on my own. I am very grateful to all the participants within the health facilities and key informants who gave their time to the study. I am particularly grateful to the health care providers who allowed me to enter their professional space and personal lives. Your tireless work is recognized and appreciated.
I would like to thank Invest in Knowledge (IKI) and Dignitas International (DI) for providing me a welcoming and intellectually stimulating place to call "home while in Malawi. The generosity of your staff, time, resources, and expertise are greatly appreciated.

I am especially grateful to James Mkandawire (IKI), Abdallah Chilungo (IKI), Davie Chitenge (IKI), Joep van Oosterhaut (DI), Monique van Lettow (DI) and Vanessa van Schoor (DI).
To my committee members, Debbi Main, Jean Scandlyn, and Deborah Mindry, thank you for your continued support throughout the dissertation process, from the studys conception in 2013 to the final writing stages in 2016. Your encouragement and advice over the years helped shaped the vision for this project. I am also grateful for Patrick Krueger and Abby Fitch who have both invested tremendous time over the years.
I would like to acknowledge the generous funding from the National Institute of Mental Health (National Research Service Award Predoctoral Individual Fellowship, F31-MH103078-01A1), the University of Colorado Denver (UCD) Health and Behavioral Sciences Department (Dissertation Grant), the UCD Global Health Center (Calvin L Wilson Scholarship, the Rotary Scholarship, and the Robinson Durst Scholarship), and the UCD Graduate School (Deans Travel Grant), that supported my dissertation research.
Finally, I would like to thank my friends and family for their endless support and love. Without you, none of this would be possible. You inspired me to keep going when graduation seemed impossible, and at the same time, helped me remember the small joys in life that keep me centered on what matters most. I am truly indebted to Teresa and Randy Dovel, Kallie and Adam Thomson, Connie and Kevin Monsees, and Janiece and Mariece Wright for the countless hours you have given in support of my degree. I cannot count the number of flights from California you have taken, or hot meals you have prepared, in order to help me through this season of life. Thank you. Most of all, I am grateful for my daughter, Ariella Hope, whose boundless joy motivates me to dream bigger and do better. You are the highlight of my last five years.

I. BACKGROUND..........................................................................1
HIV Epidemics in Sub-Saharan Africa...............................................4
Use of HIV Services...............................................................5
Barriers to Men's use of Testing.................................................13
Outline of Dissertation.............................................................18
II. THE FEMINIZATION OF HIV POLICIES..................................................20
International Policies..............................................................20
Why are Men Missing?.............................................................30
Malawian National Policies..........................................................33
Similarities throughout sub-Saharan Africa..........................................38
III. SETTING AND APPROACH.............................................................39
The Malawian Health Institution..................................................39
HIV Services in Malawi...........................................................40
Preliminary Research................................................................44
Research Questions Revisited.....................................................46
Mixed Methods Framework..........................................................47

Study Site..........................................................................48
Qualitative Data....................................................................49
Quantitative Data...................................................................56
STI Client Demographics...............................................................66
Implimentation of PITC among STI Clients..............................................70
Quality of PITC.....................................................................73
Implications .........................................................................77
Getting Tested......................................................................77
Gender and PITC for STI Clients.....................................................79
Barriers to PITC among STI Clients..................................................80
Understanding Street-Level Bureaucracy in the Context of Gendered Organizations.....83
Organizational Structure of PITC......................................................84
Allocation of HIV Service Providers.................................................85
Practices for PITC....................................................................90
Monitoring and Evaluation...........................................................93
Interactions within Health Facilities.................................................95
Provider Perceptions of Quality Care................................................95
Provider Perceptions of Sexual Health Education for Clients........................100

Gendered Identities: the Construction of Good ANC Clients versus Good STI Clients.......104
International Priorities and the Gendered Organization of Care........................109
Organizational Structure of Health Institutions.........................................113
Gendered Recruitment Strategies.......................................................113
Gendered Health Education Strategies..................................................117
Practices for HIV Testing Services......................................................121
Physical Environment..................................................................122
Interactions within Health Facilities...................................................126
Interactions with Providers...........................................................127
Interactions with Female-Clients......................................................128
Gendered Identites Rewarded in Health Facilities........................................130
Implications of the Gendered "Ideal Client" for Men's use of Services.................134
VII. CONCLUSION............................................................................139
The Relevance of Gendered Organizations for Men's use of HIV Services ..................139
Connecting International Policies to Local Realities..................................142
Hegemonic Masculinity within International Policies...................................143
The Misrecognition of Inequality Why are Health Institutions not Called into Question? ....144
Next Steps for Public Health Programming................................................145
Masculinity and Gendered Health Institutions: a Deadly Combination......................146

Final Conclusions...................................................150
A. ORIGINAL AIMS AND HYPOTHESES.....................................169
B. AN EXAMPLE OF THE STI REGISTER USED IN MALAWIAN HEALTH FACILITIES ..........................................................................171

1. Gender disparities in HIV testing and changing HIV policies in Malawi: 2004-2010........44
2. Characteristics of the five participating facilities in southern Malawi.................49
3. Additive scales of the quality of PITC and STI services.................................60
4. Similarities and differences between integrated and specialized STI services in southern
5. Characteristics of STI services in the five participating facilities in southern Malawi.68
6. Demographics of STI client participants in southern Malawi..............................69
7. Implementation of PITC for STI clients in five facilities in southern Malawi............70
8. Odds ratios from logistic regression models demonstrating associations between PITC
individual facilities in southern Malawi...................................................73
9. Quality of PITC for STI clients in five facilities in southern Malawi...................75
10. Odds ratios from ordinal logistic regression models demonstrating associations
between the quality of PITC and client and facility characteristics in southern Malawi.....77
11. Services recommended, frequency of visits, and target populations

1. HIV incidence by gender and age, Poulin M, Dovel K, Watkins S. Men with Money and the
'Vulnerable Women' Client Category in an AIDS Epidemic. Under Review.................5
2. Disparities in engagement in care in rural South Africa, disaggregated by sex. Lippman, S.
A., Shade, S. B., Gilvydis,}., & et al. (2015). Characterizing the continuum of care in a
population-based sample to target programming in North West Province, South Africa..9
3. Percentage of women and men ages 15-49 tested for HIV and received results of most
recent test, adapted from Staveteig and colleagues (2013)...........................10
4.12 populations left behind, from UNAIDS. Gap Report. 2014.........................27
5. Rollout of HIV services in Malawi................................................42
6. Mixed methods notation for the current study. Adapted from Creswal Clark (2011).
Designing and conducting mixed methods research. Losa Angeles:SAGE..................48
7. Recruitment and study respondents................................................66
8. Mechanisms through which Gendered Health Institutions influenced Mens use of HIV
Testing Services in Southern Malawi.....................................................141

Although womens health has received substantial attention, men not women bear the greatest burden of the top 10 causes of global disease and years of life lost due to ill health (Hawkes & Buse, 2013). Across the globe, men die at earlier ages than women (Hawkes & Buse, 2013; Wang, Dwyer-Lindgren, Lofgren, & et al, 2012). Gender disparities in health outcomes are not only due to mens higher rate of risky behavior, but also mens poor use of health services.
In settings as different as Malawi and the United States, men are underrepresented in health services that can prevent and manage illness. For example, men are less likely to receive general check-ups in Scotland (ISD, 2000), consultations for illness in the United Kingdom and the United States (Galdas, Cheater, & Marshall, 2005), and in sub-Saharan Africa, men are less likely to be tested for HIV than their female counterparts (Druyts et al., 2013; Venkatesh et al., 2011).
Why are men missing from health services? Research across the globe has focused on norms of masculinity as the primary barrier to mens use of services (e.g. Courtenay, 2000; Galdas etal., 2005; Noone & Stephens, 2008; Wyrod, 2011). While some facility-based barriers have been identified such as distance to the health facility and the hours of operation that conflict with working hours (Mimiaga et al., 2009; Moller-Leimkuhler, 2002) barriers that stem from health are poorly understood and under-emphasized. Indeed,

research has yet to truly examine how health institutions contribute to the problem of missing men.
In this dissertation, I apply the theory of gendered organization to health institutions in order to examine if health institutions are structured in ways that encourage womens care to the detriment of mens use of services, thus creating institutional, male-specific barriers to care. I draw specifically on the case of HIV testing services in southern Malawi. While I began my dissertation research with specific aims and testable hypotheses (see Appendix A), the ethnographic nature of my study led to a more exploratory, descriptive final product. I no longer focus on one testable hypothesis about how health care providers implement HIV policies (the original objective of the study). Instead, I more broadly examine the importance of health institutions on mens use of HIV testing services and demonstrate how the theory of gendered organizations can be used to provide a more comprehensive understanding of barriers to mens use of care. The overarching question addressed in this dissertation is, How is the structure of HIV testing services gendered in southern Malawi? To answer this question, I take a multi-level, mixed methods approach and focus on the below sub-questions. When taken together, the answers to these questions are meant to provide a holistic description of how HIV testing services are gendered in southern Malawi, and why the gendered organization of services exists.
(RQ1) How do international and national HIV policies engage men and women?
This question is important because, in the context of health services, local health institutions are greatly influenced by the global context in which they are placed. The impact of global

organizations is particularly strong in sub-Saharan Africa where donor money constitutes the majority of HIV-related funding.
(RQ2) Are health care providers less likely to implement provider-initiated-testing-and-counseling (PITC) a policy meant to be gender neutral to male versus female STI clients? Provider-initiated testing for STI clients is a policy explicitly crafted to be gender neutral all STI clients should be offered HIV testing; however, it is unclear if the implementation of the policy is actually gender neutral. This question represents one of the most tangible outcomes from the gendered organization of health institutions patient-provider interaction.
(RQ3) How are PITC services organized for different categories of clients, specifically comparing STI and antenatal clients?
Provider-initiated testing should be offered equally to both STI and antenatal clients, however, through observation it is clear that this is not the case. I examine how PITC is organized for STI versus antenatal clients, and examine how the organization of care influences providers' implementation of policy protocols.
(RQ4) What is the gendered organization of health institutions more broadly in southern Malawi?
In this question, I broadly examine how the organization of health institutions influences mens engagement in health services, and more specifically, how the organization influences mens access to and experiences with HIV testing.

HIV Epidemics in Sub-Saharan Africa
Over 24 million people in sub-Saharan Africa (SSA) are HIV positive, comprising 70% of the global HIV pandemic (UNAIDS, 2014). Prevalence in the region varies from 0.05% of adults of reproductive age in Senegal to 27% in Swaziland (UNAIDS, 2014). Southern Africa has been hit hardest, with nearly all countries averaging above 10% prevalence (UNAIDS, 2013).
Women comprise 59% of all HIV infections in sub-Saharan Africa (UNAIDS, 2014). HIV prevalence among youth is particularly gendered; young women ages 15-24 are twice as likely as young men to be infected (UNAIDS, 2014), drawing international attention and donor funding to the aid of what is now considered the "vulnerable women category (Higgins, Hoffman, & Dworkin, 2010; Poulin, Dovel, & Watkins, Under Review). However, young populations do not provide a complete picture of the gendered pandemic. While women comprise the majority of HIV infections, lifetime risk of contracting HIV is the same for men and women (Till Barnighausen et al., 2008; Eyawo et al., 2010; Gregson & Garnett, 2000). Rates of infection by gender typically cross-over around the middle years of life, as illustrated in Figure 1 using Demographic Health Survey (DHS) data (Poulin et al., Under Review). When men are older, they are more likely to have money, and thus, are more likely to afford girlfriends and sex increasing their risk of HIV infection (see Poulin et al., Under Review; Watkins, 2010).

Figure 1. Incidence by gender and age for Zambia, Tanzania, Zimbabwe, and Malawi.
Figure 1. HIV incidence by gender and age, Poulin M, Dovel K, Watkins S. Men with Money and the 'Vulnerable Women' Client Category in an AIDS Epidemic. Under Review.
Use of HIV Services
While HIV prevalence remains high throughout much of sub-Saharan Africa, things are improving. For example, new infections in Southern Africa have decreased by 32% since the beginning of the 21st century (UNAIDS, 2015a). Recent declines are in part due to the expansion of antiretroviral therapy (ART); in 2014, 44% of all people living with HIV were on lifesaving treatment (UNAIDS, 2015b). Proper engagement in and adherence to HIV treatment reduces the risk of HIV transmission by almost completely removing the HIV

virus from the body (Gardner, McLees, Steiner, Del Rio, & Burman, 2011). Uptake of HIV testing and treatment also dramatically improves the well-being of people living with HIV, transforming HIV from a death sentence to a manageable, chronic disease (Bor, Herbst, Newell, & Barnighausen, 2013; Jahn et al., 2008). However, in order to see the best results, both for the health of those infected and the prevention of transmission, early and consistent engagement in health services is needed. Experts emphasize the need for engagement throughout the "treatment cascade, a model used to describe the various HIV services offered at all stages of the disease (Gardner et ah, 2011). Services include HIV testing, linkage to care once found positive, initiating treatment, and remaining in and adhering to treatment in order to reach viral suppression. Once clients reach the final stage of the treatment cascade and attain viral suppression, the virus has little impact one ones health and the risk of transmission is minimal (Gardner et ah, 2011).
While the positive impact of ART is encouraging, men have not benefitted from the life-saving potential of HIV services to the same extent as women. Although women in sub-Saharan Africa comprise the majority of HIV infections, men comprise the majority of HIV-related deaths (Dovel, Yeatman, Watkins, & Poulin, 2015a). Indeed, evidence suggests that men account for 60% of AIDS-related deaths in the region (Sonke Gender Justice Project, 2015) and as much as 70% of all AIDS-related deaths in some high-prevalence countries (Mills, Beyrer, Birungi, & Dybul, 2012). A meta-analysis conducted by Druyts and colleagues (2013) found that of clients starting HIV treatment in 15 sub-Saharan countries, men who initiated treatment had a 37% increased risk of death as compared to female initiates (Druyts et ah, 2013). Another study from South Africa found that men were 25% more likely to die from AIDS-related illnesses than women, a disparity that was correlated

with a 4-year increase in the gap between male and female life expectancies (in 2011, female life expectancy was 9 years greater than male's; T Barnighausen, Herbst, Tanser, Newell, & Bor, 2014).
Why does Gender Matter?
Why are men more likely to die? There are several explanations. First, since men become infected later in life, their immune systems are unable to fight the virus as well as younger populations, and therefore, once infected, mens immune systems deteriorate faster than womens (Gregson & Garnett, 2000; McGrath, Lessells, & Newell, 2015). For example, a recent study in South Africa showed that HIV positive women with a CD4 count above 500 cells/mm3 (considered good health) took an average of three years to decline to a CD4 count of less than 350 cells/mm3 (the eligibility requirement to start treatment at the time of the study). In contrast, men with good health (CD4 count above 500 cells/mm3) took less than twelve months to decline to 350 cells/mm3 (McGrath et al., 2015).
Another explanation is that men use HIV services less often than women. Men are less likely to be tested for HIV and, once tested positive, men are less likely to start and adhere to treatment than women, even when controlling for confounding factors (Alibhai et al., 2010; Bassett et al., 2010; Chen et al., 2008; Cornell et al., 2009; Nachega et al., 2006; Ochieng-Ooko et al., 2010). For example, in a province in South Africa, 57% of men who died from AIDS-related illnesses had never accessed HIV services, compared to only 41% of women who died from AIDS. The disparity persisted over time, even with the expanding reach of HIV testing and treatment services: over the 11-year period of the study (2000-2011), women experienced improvements in their use of services every year since 2006

while mens use of care remained the same since 2007 (Bor, Rosen, Chimbindi, et al., 2015).
Men who do initiate treatment do so at later stages of the disease (Hawkins et al., 2011). This is likely due to a combination of poor health seeking behavior and the fact that HIV often progresses faster in men than women. Sheri Lipmann and colleagues (2014) provide an example from rural South Africa of mens disproportionately poor use of services throughout the treatment cascade (Lippman, Shade, Gilvydis, & et al., 2015). Figure 2 shows that at every point of the cascade, a proportion of both men and women fail to engage in HIV services, leading to only 18% and 38% of HIV positive men and women, respectively, reaching viral suppression. While both men and women are missed in the treatment cascade, it is clear that men are especially vulnerable to poor use of care and, as a result, poor health outcomes. Similar leakages in the treatment cascade are seen throughout sub-Saharan Africa (Maman, Pujades-Rodriguez, Subtil, & et al., 2012; Kipp, Alibhai, Saunders, et al., 2010).

HIV Positive
Linked to Care
Retained in Care
Prescribed ART
Adherent to ART
Virally Suppressed (<5000 copies/mL)
Figure 2. Disparities in engagement in care in rural South Africa, disaggregated by sex. Lippman, S. A., Shade, S. B., Gilvydis, ]., & etal. (2015). Characterizing the continuum of care in a population-based sample to target programming in North West Province, South Africa.
Given mens poor representation in HIV services throughout the treatment cascade, it is not surprising that men are also at greater risk of AIDS-related morbidity and mortality (Braitstein et al., 2008; Druyts et al., 2013).
HIV Testing
HIV testing is a crucial entry point to the treatment cascade since a positive test is required before accessing HIV treatment. Unfortunately, men are largely missed (Bwambale, Ssali, Byaruhanga, Kalyango, & Karamagi, 2008; Dieffenbach & Fauci, 2009; Druyts etal., 2013; Johannessen, 2011; Mills, Beyrer, Birungi, & Dybul, 2012). In almost all countries in sub-

Saharan Africa, women are more likely to be tested than men, and importantly, are more likely to have had been recently tested (see Figure 3). Men who do get tested do so less frequently and are tested at later stages of the disease progression (Cornell, Myer, Kaplan, Bekker, & Wood, 2009; Obermeyer, Sankara, Bastien, & Parsons, 2009; Parrott et al., 2011; Skovdal et ah, 2011b).
Benin DHS 2006 Ghana OHS 2008 Congo (Brazzaville) AIS 2009 Senegal DHS 2010-11 Burtuna Faso DHS 2010 Mozambique AIS 2009 Zambia DHS 2007 Swaziland DHS 200607 Etfwopia DHS 2011 Burundi DHS 2010 Namibia DHS 200607 Cameroon DHS 2011 Tanzania DHS 2010 Kenya DHS 200809 Zimbabwe DHS 2010-11 Lesotho DHS 2009 Uganda AIS 2011 Malawi DHS 2010 Rwanda DHS 2010
Benin DHS 2006 Ghana DHS 2008 Congo (Brazzavie) AIS 2009 Senegal DHS 2010-11 Burtuna Faso DHS 2010 Mozambque AS 2009 Zambia DHS 2007 Swaziland DHS 200607 Ethiopia DF6 2011 Btnndi DHS 2010 Mamba DHS 200607 Cameroon DHS 2011 Tanzania OHS 2010 Kenya DHS 2008-09 Zimbabwe DHS 2010-11 Lesotho OHS 2009 Uganda AIS 2011 Malawi OHS 2010 Rwanda DHS 2010
Percent ever tested1 lor HIV
Percent recently tested2 for
' Per tentage ot women and men ages 15-49 who were ever tested lort*V end received resubof mo recent test
1 Percentage of women and men ages 15-49 vrho were teeted (or HIV In the peet 12 months and received results of most recent test.
* Due to a problem with the questionnaires tor the Malawi 2010 DHS and Uganda 2011 AIS. data on time since last HIV test are not available for some women. Therefore these estimates are omitted.
Figure 3. Percentage of women and men ages 15-49 tested for HIV and received results of most recent test, adapted from Staveteig and colleagues (2013)
A recent study in South Africa found that once men know their status, they initiate treatment faster than non-pregnant women (Schneider et ah, 2012). Mens timely uptake of ART is likely due to their late presentation of AIDS, meaning that men are already very sick

by the time they are tested for HIV, making them immediately eligible for treatment. Those who are eligible can start treatment as quickly as two weeks after diagnosis (MacPherson et al., 2012). However, these findings also show that some men will and do initiate treatment once tested positive, suggesting that mens timely use of HIV testing is a primary barrier to mens uptake of treatment. Unfortunately, despite the importance of testing, efforts to encourage men to test have been largely unsuccessful (Druyts et al., 2013; Johannessen, 2011; Mills et al., 2012). Strategies that have been successful are those that take testing outside of the clinic setting (such as community- and mobile-based testing); however, these strategies have not been taken to scale (Hensen, Taoka, Lewis, Weiss, & Hargreaves, 2014). Indeed, for resource-limited settings, such as Malawi where over 50% of health care positions are vacant and provider absenteeism is all too common (Manafa et al., 2009), the wide-spread implementation of outreach testing seems unlikely to take place anytime soon.
Provider-initiated-testing-and-counseling (PITC) is one strategy that could improve mens use of testing in resource-strained settings where extensive outreach is not feasible. Provider-initiated testing should be easier to implement than community- or mobile-testing strategies since providers are not taken away from other tasks at the health facility, facility resources can be used to offer testing, and the health facility does not have to pay transportation costs to and from local communities. Furthermore, PITC may be more amenable to men compared to voluntary HIV testing since men are already attending a facility due to a pre-existing illness, which should remove barriers related to transportation

and long wait times associated with high client loads in health facilities. The policy should also remove the necessity for men to initiate testing for themselves (WHO/UNAIDS, 2007).
In most sub-Saharan countries, policy dictates that providers should universally offer HIV testing to at least four categories of clients: antenatal care (ANC) clients, maternal health clients (meaning during delivery and post delivery), tuberculosis (TB) clients, and clients with other sexually transmitted infections (STI) besides HIV. Antenatal care and maternal health clients are prioritized under PMTCT strategies in order to reduce new infections among infants and children. STI and TB clients are prioritized because they are at greater risk of HIV infection than the general population.1 Because TB and STI clients have higher rates of infection than general populations, testing in these venues is an especially efficient and cost-effective way to identify new HIV cases (Roura, Watson-Jones, Kahawita, Ferguson, & Ross, 2013). It also presents a great entry point into the cascade of treatment so that those with HIV infections can be treated, decreasing the likelihood of HIV transmission to sexual partners. The impact of PITC on HIV transmission may be especially significant among STI clients because, since clients present with a pre-existing STI, it is likely that these clients participate in risky sexual behavior that also increases their chance of transmitting HIV.
Despite the advantages of PITC, the policy has not recognized as a viable strategy for improving mens use of testing in sub-Saharan Africa in a review of promising strategies, PITC was not mentioned once (Hensen et al., 2014). This may be due to the fact that men are still underrepresented in PITC strategies (Roura et al., 2013; Kranzer et al., 2010), or
1 Twenty-nine percent of STI clients and 60% of TB clients in Malawi are estimated to be HIV positive, compared to 11% of the general population. (Ministry of Health [Malawi], 2012a).

the fact that PITC for many high-risk clients, such as those receiving STI treatment, is not routinely implemented (Fetene & Feleke, 2010; Roura et al., 2013).
Barriers to Men's use of Testing
Mens under-representation in HIV services has been attributed to an array of factors, including: (1) mens perceptions of masculinity; (2) mens perception of clinics as female spaces; (3) HIV-related stigma; and (4) mens work schedules that conflict with clinic hours (Beck, 2004; Bwambale et al., 2008; Nattrass, 2008; Parrott et al., 2011; Skovdal et al., 2011b). While multiple barriers to care have been identified, local norms of masculinity held by men themselves have dominated current literature, with a particular focus on the negative effects of hegemonic masculinity (Bwambale etal., 2008; DiCarlo etal., 2014; Nattrass, 2008; Nyamhanga, Muhondwa, & Shayo, 2013; G. E. Siu, Seeley, & Wight, 2013; Godfrey E Siu, Wight, & Seeley, 2013; Skovdal et al., 2011b).
Hegemonic Masculinity
Hegemonic masculinity refers to the culturally dominant forms of masculinity that subordinate women and other men who are unable to attain the ideal attributes of what it means to be a "real man (Connell 2005; Connell and Messerschmidt 2005). In sub-Saharan Africa, attributes of hegemonic masculinity usually include physical strength and self-sufficiency, multiple sexual partners and sexual performance, and risk taking behavior (Jewkes & Morrell, 2010; Jewkes, Sikweyiya, Morrell, & Dunkle, 2011; Kalichman et al., 2007). These attributes are signifiers of manhood that are "used by men to negotiate social power and status, often to the detriment of their own health and the health of others

around them (Courtenay 2000, p. 1385). In the context of HIV, previous research has argued that men are reluctant to learn their status due to concerns that a positive test would compromise their masculinity and therefore negatively influence their social status (Beck, 2004; Nattrass, 2008; Parrott et al., 2011; Skovdal etah, 2011b).
The theory of hegemonic masculinity understands masculinity as multi-dimensional and continually shaped and reinforced by both global and local institutions (R. Connell, 2012; R. W. Connell, 2005; West & Zimmerman, 1987); however, the majority of work around masculinity and HIV services has applied the concept to individual men, exploring perceptions of masculinity held by men within local contexts without examining how gender norms are embedded within social systems and institutions outside the individuals control. For example, authors regularly conclude that mens continued desire to prove their masculinity leads to choices that prioritize "manly behavior over healthy behavior (for example, see DiCarlo etah, 2014; G. E. Siu et ah, 2013; Wyrod, 2011).
While individual beliefs about masculinity have received extensive attention, local gender norms do not fully explain gendered patterns in HIV testing. Studies on community-and work-based testing find that men do indeed participate in HIV testing when offered outside traditional health facilities (Corbett et ah, 2006; Hensen et ah, 2014; Obare et ah, 2009). One study in Malawi found that 91% of men and women consented to be tested through home-based methods (Obare et ah, 2009). Many other studies have found that men are just as likely as women to participate in mobile testing (Hensen et ah, 2014). Taken together, these findings suggest that it is not HIV testing itself, but the way in which HIV testing is offered, that limits mens use of services. Furthermore, the only study to empirically test the relationship between masculine beliefs and HIV testing found no

relationship between community-level attitudes toward masculinity and mens testing (Stephenson, Miriam Elfstrom, & Winter, 2013). Thus, instead of blaming men for their low representation in testing services, the institutions in which men must access care should be examined.
Despite the importance of health institutions, the role of institutions on mens HIV-related health outcomes has received little attention. While a small body of literature acknowledges that international HIV policies predominately focused on women contribute to mens poor representation in HIV services (R. Connell, 2012; Dovel, Yeatman, Watkins, & Poulin, 2015b; Johannessen, 2011; Mills et al., 2012), research has not examined the mechanisms that connect overarching policy to individuals use of services, and specifically, how global and national policy translates into the organization of health institutions and health services at the local level.2 This is problematic since examining individual-level barriers to care, without explicitly examining the structure within which men are expected to access services, provides a one-dimensional description of male-specific barriers.
Health Institutions
Why should we care about the organization of health institutions? Historically, researchers have tied service utilization to individual-level factors, such as education, poverty, income, health literacy, distance to a health facility, and personal motivation for receiving care (Babitsch, Gohl, & von Lengerke, 2012; Brennan, Morley, OLeary, Bergin, & Horgan, 2015; Moorman & Matulich, 1993). More recently, however, health institutions have been
2 Policies can influence the organization of social institutions by guiding funding allocation and setting priorities that influence monitoring and evaluation strategies.

understood as a critical component to health seeking behavior (Andersen & Newman,
2005) . For example, in the United States complex intake procedures and inflexible, inconvenient hours of operation have been shown to be barriers to the use of health services by minority populations (Scheppers, van Dongen, Dekker, Geertzen, & Dekker,
2006) . In low-resource settings around the world, long wait times continue to keep people from using available services (Duff, Kipp, Wild, Rubaale, & Okech-Ojony, 2010; Parrish & Kent, 2008; G. D. Smith, Chaturvedi, Harding, Nazroo, & Williams, 2000).
Finally, in settings as different as the United States and Kenya the implementation of male-friendly sexual health services, including male staff, after hour services that do not conflict with work hours, and male-specific waiting spaces, have dramatically improved mens use of care (Armstrong, Kalmuss, Franks, Hecker, & Bell, 2010; Hensen etal., 2014; Raine, Marcell, Rocca, & Harper, 2003). While it is clear that health institutions influence service utilization, an important question remains: Do health institutions differentially influence men and womens use of services? To answer this question I apply the theory of gendered organization.
Gendered Organizations
The theory of gendered organization posits that organizations within society shape and reaffirm notions of masculinities and femininities (Acker, 1990). The theory understands gender as structural in nature organizations are built on and reproduce not only gender norms, but also gender inequalities (Britton & Logan, 2008). The theory of gendered organizations has been widely applied to understand barriers to womens entry and advancement in traditionally male occupations (Wajcman, 1998; Williams, Muller, &

Kilanski, 2012), and to a lesser extent, mens entry into traditionally female occupations (Cottingham, 2014); however, this framework has not been systematically applied to health service utilization.3
There are many ways to conceptualize how organizations can be gendered. I use Ackers framing and understand that gendered organizations are defined, conceptualized, and structured based on assumptions about inherent differences between men and women (Britton, 2000). These assumed differences are often tied to different values placed on men and women. Gendered assumptions at the foundation of an organization lead to gendered structures, expectations, practices, and ultimately, gender inequitable outcomes within an organization.
Organizations can also be gendered across multiple levels. The primary levels are
(1) the structure of the organization, (2) the policies and practices of the organization, (3) interactions within the organization, and (4) the gendered identities that the organization either promotes or discourages (Acker 1990). The extent to which an organization is gendered at each level will influence the extent to which gender disparities are fostered and maintained (Britton, 2000). A key point is that while not all organizations are gendered in the same way or to the same extent, those that are gendered will inevitably produce some level of gender disparities, whether that be in job attainment, or in my case study, knowledge of ones HIV status.
I place the concept of gendered organizations within a multi-level framework to examine how larger actors, such as international bodies, influence mens access to, and
3 While social scientists have long recognized that the organization of health systems can influence gender disparities, the focus has almost exclusively been on barriers to womens health, not recognizing that men too may be disadvantaged by particular organizations of health institutions and health services (for example, see Pederson, Greaves, & Poole, 2015).

experiences with, HIV testing services. I adapt Connells (2000) approach to global masculinities and understand my study as an analysis of local experiences "embedded in ongoing, complex global processes that link the global to the local (Acker, 2004, p. 22). In sub-Saharan Africa, the organization and practices of health institutions mirror the priorities and strategies of international bodies. This is not surprising, especially in highly donor dependent countries, such as Malawi, where over 90% of the countrys HIV response is funded by international donors (PEPFAR, 2013a). Funding is tied to expectations about how money will be spent, which effectively aligns the countrys HIV strategies with international guidelines. Thus, the intersection between gender and health service utilization is not only affected by local interactions in southern Malawi, but by the gendered nature of international HIV strategies (for additional research on the influence of global policy on local health, see Earner & Randall, 2012; Foley, 2007; Van Hollen, 2011).
In this dissertation, I use multiple forms of qualitative and quantitative data from health facilities in southern Malawi to examine the gendered organization of Malawis health institution and whether the specific organization of HIV testing services creates additional barriers to mens use of care.4 By shifting the level of analysis from individual to organizational practice, I advance theoretical and empirical understandings of why men are underrepresented in HIV testing services.
Outline of the Dissertation
In what follows, I first examine the gendered nature of international and national policy
documents in order to situate the local health institution within the broader global
4 I focus on HIV testing instead of HIV treatment because men must first be tested before they can start treatment, making testing the gateway to other HIV services (WHO et at, 2010).

constructs of gender, health services, and HIV priorities. Second, I describe the specific context of Malawi and HIV services, the methodology used to conduct this study. I then describe the three major findings of my dissertation research:
(1) I examine the most tangible level of the gendered organization of services how health care providers offer PITC to male and female STI clients in southern Malawi.
(2) I then examine the gendered organization of PITC for STI and antenatal clients in order to understand why the policy is implemented differently based on the category of client receiving care. I focus the first two chapters of my findings on PITC for STI clients because: (i) PITC for STI clients presents an ideal opportunity to identify and treat HIV infections since those with an STI are more likely to be infected with HIV than the general population; (ii) the policy should address known barriers to mens use of HIV testing services; (hi) the policy should be feasible to implement within resource-limited settings; and (iv) on paper, the policy is gender-neutral and should impact male and female clients equally.
(3) Finally, I examine the overarching gendered organization of the health institution, focusing on mens access to voluntary HIV testing, the primary venue through which men can be tested. I conclude with a discussion that explicitly ties international and national policies to the gendered organization of HIV testing services, both for PITC and the overarching architecture of testing services within health facilities

In this chapter, I explore how international and national policy documents conceptualize men in the context of HIV epidemics in sub-Saharan Africa. This endeavor is important in order to understand the local experiences of men who are embedded within ongoing global processes (Acker, 2004). These global processes also inform the organization of local health institutions. Furthermore, policies have the potential to transfer ideas across levels of organization (from international organizations to country-level decision makers) and across groups of people (from program staff to general populations; Bacchi, 2009). Below, I examine men and womens representation in international HIV policy and then explore the gendered discourse that promotes these representations and justifies current international priorities. I then examine how these representations translate to Malawian national policies for HIV treatment and prevention.
International policies
I first turn to HIV documents published by the World Health Organization (WHO) because the WHO provides technical leadership to Ministries of Health and other international health organizations by setting standards for the response to HIV and providing practical text on how to implement recommended strategies (WHO, 2013a). I selected WHO publications that were available on the WHOs HIV webpage ( Six types of publications were available:

(1) guidelines; (2) progress reports; (3) toolkits, manuals, guides, reports, and policy briefs;
(4) posters; (5) journal articles; and (6) meeting reports. I collected all publications that were identified as either (1) guidelines (n=87), (2) progress reports (n=22), or (3) toolkits, manuals, guides, reports, and policy briefs (n=54) in order to capture the majority of WHOs high impact materials documents within these categories are most likely to influence the type of programs implemented in sub-Saharan Africa.
Of the 163 documents meeting the criteria, eight publications were not available, one focused on European countries, two were publically available software, not text publications, and six were duplicate publications. In total, 146 documents were analyzed. Dates ranged from 1999 to 2015, with the majority published after 2008 (n=84). Twelve publications were dedicated to children and adolescents, 16 to high-risk groups such as intravenous drug users, sex workers, MSM, and prison inmates, 16 were dedicated to the prevention-of-mother-to-child transmission of HIV (PMTCT), three to voluntary male medical circumcision (VMMC), and four to female-specific needs (outside PMTCT). I analyzed all documents in Atlas.ti v6.2.1 used auto-coding to identify text about women by searching for "women, "woman, "female(s), and/or "mother(s). To identify text about men I searched for "men, "man, "male(s), and/or "father(s). The paragraphs within which key words were found were coded as either "women or "men, if both men and women were discussed in the paragraph the text was double coded. I then used constant comparison methods to analyze the filtered text. I was especially interested in how discourses of vulnerability, blame, and unmet needs differed depending on the gender being discussed.

Across all documents, women are 3.23 times more likely to be mentioned than men (women are mentioned 13,882 times as compared to 4,302 times for men). When excluding publications dedicated to children, women, and PMTCT (n=31), women are still mentioned over twice as often as men (7,719 times compared to 3,697 times for men), meaning that in publications that are not explicitly focused on women, women are still the focus of specific strategies.
Discussions about women center around four predominant topics: (1) PMTCT; (2) gender inequality that increases womens risk of HIV; (3) female-specific challenges to accessing HIV services such as economic barriers and gender-based violence; and (4) strategies to empower women and address gender inequality, either to prevent HIV infection among women or improve womens use of treatment services. In contrast, discussions about men primarily focus on the specific needs of men who have sex with men (MSM) and the benefits of voluntary medical male circumcision (VMMC) for both men and women. When heterosexual men are discussed, documents tend to focus on mens role on womens health, emphasizing the negative impact that male gender norms have on womens risk for HIV infection and use of services.
Mens role as vectors of HIV, not as clients of HIV services, is present in nearly every document that provides specific text about gender. Mens views of masculinity are described as a major contributor to womens vulnerability to HIV. For example, the WHO guidelines document titled, "Priority Interventions. HIV/AIDS Prevention, Treatment and Care in the Health Sector (2010) has a section called "Delivering gender-responsive HIV interventions. The section is meant to provide tangible strategies in order to address gender-based barriers to HIV treatment and prevention. Within the section, the primary

recommendation is to reduce social gender inequalities that make "women and girls especially, but also men, vulnerable to HIV (pg. 114). Gender norms, and particularly norms surrounding masculinity, are seen to decrease womens autonomy and increase mens initiation of risky sexual practices. Gender norms and gender inequalities are also seen to limit womens use of HIV services:
In many settings, women and girls face barriers to HIV services because they lack the financial means to access care or they require permission from their husbands or other family members to go to a health care facility. [WHO, 2010, pg. 114)
Mens use of services is never mentioned. The only time men are discussed in this section is when describing how masculinity increases mens risk of HIV, presumably by leading men to have more risky sexual behaviors (WHO, 2010b, p. 114). Notably, men are considered at fault for this gender-based risk factor: it is mens own views of masculinity that lead them to choose riskier behavior, such as concurrent partners.
Two recent WHO publications acknowledge men as clients of HIV services, discussing mens poor representation in these services and, therefore, mens increased risk of AIDS-related death (WHO, 2013b, 2014a). However, these discussions are scarce, and even in the most recent publications, women and children are still the focus of HIV testing and treatment strategies. For example, the WHO Operational Plan for 2014-2015 emphasizes the unmet needs of fertile women but not the needs of men. In the "Towards 2015 section of the report, a section that reviews strategies to achieve global goals, the document states, "ART coverage is inadequate in several regions, and critical gaps in

coverage persist, notably among pregnant women, children and key populations (WHO, 2014b, pg. 2).
A 2015 WHO publication that offers technical guidance on accessing and using grants from the World Fund also misses the opportunity to engage men as clients of HIV services. Among the type of guidance available, the WHO offers "concrete tools and capacity development for integrated health service delivery for women, children, and adolescents in particular, but also for men. (WHO, 2015, pg. 55) and suggests that disease programs should have a defined target population, giving the examples of "male and female sex workers, women, children, prisoners, migrant populations, etc. (WHO, 2015, pg. 59). The general population of heterosexual men is not seen as potential clients of health services.
The very limited recognition of mens poor representation in HIV services has not translated into prioritized HIV strategies for men. For example, the WHOs 2012 Operational Plan, a key document meant to guide international and local strategies for HIV treatment and prevention, presents the WHOs four overarching priorities for the following year: (1) "Optimize HIV prevention, diagnosis, treatment and care outcomes; (2)
"Leverage broader health outcomes through HIV responses; (3) "Build strong and sustainable systems; and (4) "Reduce vulnerability and remove structural barriers to accessing services (WHO, 2012a).
Priorities 1 and 4 have the opportunity to address men as clients, but the text under each priority continues to focus on women and children. Priority 1 focuses primarily on children, adolescents, pregnant women, and the broad category of "adults. Heterosexual men are not mentioned (pgs. 7-20). Priority 4 includes two core elements that will be used in order to address barriers to services: the first is "promoting gender equality and the

second is to ensure HIV policies are "consistent with human rights (pg. 30). Although the core elements may appear to be gender-neutral, references to gender equality and human rights invariably refer to women's equality and women's rights. Immediately following the two core elements, the document continues to state:
National HIV responses can have a significant impact on the vulnerability of women and girls to HIV by promoting gender equality and equity in access to health services ... To support country HIV programmes and reduce gender-based health inequities, WHO is working with countries to identify and remove gender-based barriers to HIV services and provide support for advocacy and research on the relationship between HIV risk, gender-based violence and other human rights violations. [WHO, 2012a, p. 30)
In this context, the phrase "gender-based health inequities almost certainly means womens health inequities. Throughout the entire document, the only specific mentions of men who need targeted attention are prison populations and men who have sex with men. Heterosexual men are not a prioritized group.
The pattern in WHO publications is clear: women are vulnerable to HIV and poor health outcomes, at no fault of their own, and are therefore in need of saving. While men are at risk of HIV, mens risk is understood to be due to their own choices about masculinity and subsequent sexual behavior. Men choose poor health for themselves.
The focus on vulnerable women and the absence of heterosexual men is not unique to the WHO. The omission of men is pervasive throughout most international organizations, including UNAIDS, the Global Fund, and the Presidents Emergency Plan for AIDS Relief (PEPFAR). For example, the UNAIDS 2014 Gap Report has a section for "Populations Left Behind. In this section, 12 left behind populations are listed: (1) people

unaware of their HIV positive status; (2) young women; (3) prisoners; (4) migrants; (5) injecting drug users; (6) sex workers; (7) men who have sex with men; (8) transgender women; (9) pregnant women and children; (10) displaced persons; (11) people living with a disability; and (12) people aged 50+ (see Figure 4, UNAIDS, 2014, p. 119). In the context of sub-Saharan Africa, four of these categories explicitly target women (young women; sex workers; transgender women; and pregnant women). Three categories effectively capture most women who are at highest risk of HIV (young women; sex workers; and pregnant women). Although several categories include mensuch as prisoners, migrants, injecting drug users, and men who have sex with menthese categories do not capture the general population of heterosexual men who comprise the majority of male HIV infections and male deaths.

12 populations being left behind
Figure 4.12 populations left behind, from UNAIDS. Gap Report. 2014.
A similar focus on women is present in documents from the Global Fund and PEPFAR. These organizations are important because they provide the majority of HIV-specific global funding (Global Fund provides 19% and PEPFAR 61% of all HIV funding; Kates, Michaud, Wexler, & Valentine, 2013). The organizations reach is expansive: 114 of the 143 countries that receive foreign funding for HIV receive money from the Global Fund and PEPFAR (Kates et al., 2013). Both organizations place a large emphasis on gender and have specific strategies designed to address gender-based vulnerabilities to HIV and barriers to care. To date, these strategies have almost exclusively targeted women. For example, the Global Funds Gender Equality Strategy (2009) states:

The strength of the Global Fund is its ability to be a catalyst, supporting countries' efforts to take the gender dimensions of the three epidemic(s) [TB, Malaria and HIV] into account in their proposals and subsequent program implementation.
The document goes on to say:
The Gender Equality Strategy explores how the Global Fund can encourage a positive bias in funding towards programs and activities that address gender inequalities and strengthen the response for women and girls.... Because it is the needs of women that are often marginalized, this strategy focuses primarily on the needs of women and girls. However, the most vulnerable in society also includes men who have sex with men, transgender people, bisexual and lesbian populations -groups that have failed to receive the attention and focus they rightly deserve (Global Fund, 2009, p. 4).
In the above excerpt, all adult populations besides heterosexual men fit within the working definition of gender. The gender of heterosexual men is somehow irrelevant to their use of services and the prevention of disease, or at least it is not the concern of the Global Fund. Curiously, the Global Fund emphasizes funding populations that have failed to receive attention by social institutions and development organizations, presumably in the context of health programs and health services. Yet the only group not included in the above gender strategy, heterosexual men, is a group that has received minimal attention in regards to HIV priorities and programs.
PEPFARs gender strategy also frames gender to mean women. The organization promotes "gender programs as a strategy to address HIV epidemics. These programs have exclusively addressed gender-based barriers experienced by women, not men. For example, the 2013 Annual Report to Congress, in a section titled "Smart Investments, states:

Investing in gender programs to reduce vulnerability to HIV infection is a smart investment. HIV remains the leading cause of disease and death for women of reproductive age in low- and middle-income countries, and women and girls represent nearly 60 percent of people living with HIV in sub-Saharan Africa. Gender inequalities and gender-based violence increase vulnerability to HIV. Addressing such inequities increases access to services and improves health outcomes for individuals, families, and communities.... The interagency PEPFAR Gender Technical Working Group encourages country programs to focus on five key areas: increasing gender equity in HIV/AIDS programs and services, including reproductive health, preventing and responding to gender-based violence, engaging men and boys to address norms and behaviors, increasing women and girls'legal protection, and increasing women and girls' access to income and productive resources, including education. These investments and partnerships are having a major impact for women, girls, and gender equity. (PEPFAR, 2013b, para. 13)
Although it is understood that men and boys need to change their norms of masculinity and their behavior (a strategy called gender transformation), this strategy is encouraged in order to protect women; mens own health is not a primary concern. Notably, PEPFAR does not recognize that any of the five key areas of the programs focus could positively impact the health of men or boys. In fact, gender equity in HIV services, a primary concern in the literature for mens health, is seen as a tool to improve womens and girls health, not mens. Throughout PEPFAR documents, including the above report, men are effectively removed from the concept of gender and HIV: of the many annual reports to Congress, only one mentions the vulnerability of boys and men to HIV, and their vulnerability is attributed to peer pressure (Esacove, 2012).
The association of "gender with women has had large implications for national policies and local programming. For example, since 2005, over 30% of PEPFARs budget has been allocated to gender-focused programs that exclusively focus on the health of

women and girls (Esacove, 2012). Later in this chapter, I will specifically examine how this discourse has influenced national HIV policies within Malawi.
Why are Men Missing?
It is clear that HIV policies are largely unresponsive to mens risk of HIV and AIDS-related illnesses; however, the question remains: In light of the growing evidence of mens disproportional risk to poor health outcomes, why are heterosexual men still excluded from international strategies? There are three potential explanations.
First, international bodies place a large emphasis on the prevention of mother-to-child transmission (PMTCT) of HIV as a way to curb HIV epidemics in sub-Saharan Africa (Dovel et al., 2015b). Vertical transmission accounts for a significant portion of all HIV infections in sub-Saharan Africa, and new infections among children increase the burden on health institutions and childrens families who care for those infected (Kak, Chitsike, Luo, & Rollins, 2006). As well, strategies to prevent mother-to-child transmission are straightforward and, on paper, easy to implement women are tested during pregnancy and if tested positive, start and remain on treatment throughout their pregnancy and the duration of breastfeeding (WHO, 2010a). If implemented correctly, PMTCT is highly effective at preventing new infections and also benefits the health of pregnant or breastfeeding mothers. In the context of a long line of failed, multi-million dollar prevention strategies that promoted lifelong condom use and monogamy, an easily defined and time-bound strategy for preventing new infections is appealing. Finally, HIV infection among innocent infants sits poorly with international institutions that have a long history of prioritizing the health of children (see Chitembo et al., 2012).

A second explanation is that the structure of health institutions in sub-Saharan Africa more broadly has historically focused on maternal and child health (M. Cornell, J. McIntyre, & L. Myer, 2011). Even outside HIV services, mens health is often sidelined in favor of more female-focused services that are believed to benefit children. This is especially true for sexual and reproductive health services that tend to dominate most resource-constrained health facilities in sub-Saharan Africa (Varga, 2001). Perhaps HIV services have piggybacked onto already existing infrastructure developed for sexual health services, facilitating a focus on maternal and child health (Robinson, 2011).
A third explanation is that priorities are shaped by the ways in which international bodies conceptualize African men and women as sexual beings, and as clients of health services. My analysis of international documents suggests that policies are not necessarily blind to men, unaware of mens representation in HIV epidemics; instead, heterosexual men seem to be intentionally omitted from HIV strategies due to international perceptions of African men as dominant and sexually aggressive. Time and time again international documents describe the vulnerable African woman whose infection or poor use of services is due to gender inequality, at no fault of her own. Men are seen to control womens sexuality and use of health services, limiting womens autonomy and ability to make healthy choices for themselves. At the same time, when mens risk of poor health is mentioned, which is rare, it is also tied to gender inequality and norms of masculinity, asserting that mens social dominance and masculine norms lead men to choose risky behavior over healthy ones. Men are therefore at fault and responsible for their own poor health outcomes, as well as those of women. In short, men are the problem, and their views of manhood make it difficult for them to be part of the solution.

These findings corroborate those of other researchers. Higgins et al. (2010) describe the perceptions that guide international HIV policy as follows: "heterosexual men are active transmitters of HIV but not active agents of prevention. The paradigm [womens vulnerability] assumes not only that women (but not men) want to prevent HIV but lack the power to do so, but also that men are more likely than women to bring HIV into the partnership (Higgins et al., 2010, p. 435). Interestingly, the epidemiological data show that in reality women are just as likely as men to bring HIV into a stable relationship (Eyawo, Walque, Ford, & et al., 2010); therefore, the common discourse about womens innocence and mens betrayal does not match the reality of epidemics in sub-Saharan Africa.
In her analysis of PEPFAR documents, Esacove found a dismissive stance toward men, who when mentioned, were portrayed as dangerous, predatory and sexually insatiable. Women were portrayed as desexualized they sought sex only for their survival or that of their children and they were unable to refuse mens sexual advances (Esacove, 2012, 2013). Others have noted that the international emphasis on womens need to negotiate safe sex stems from, and perpetuates, perceptions of male sexuality as inherently uncontrollable by men themselves (see Mindly, 2010; Vitellone, 2000). Women must save themselves from men. The broader discourse around African men likely contributes to policys limited focus on men. Why should international bodies focus on men if it is assumed men are at fault and will not change?
In an interview with African Relief, Stephen Lewis, the United Nations Special Envoy for HIV/AIDS in Africa between 2001 and 2006, summed up the dominant discourse surrounding African men and HIV:

Finally the world seems to understand that [in Africa] this is a gender-based pandemic. Unless there is recognition that women are most vulnerable... and you do something about social and cultural equality for women, you're never going to defeat this pandemic. This is the fundamental centerpiece of the whole blessed crisis! Men haven't changed their behaviour, so women somehow have to be strengthened to be able to ward off the men. (Africa Recovery, 2001, p. 12)5
To my knowledge, neither the media, the UN, nor any other organization disputed the comment, a silence that speaks to the overall perception of HIV and gender: women need protection from selfish, uncontrollable men. The categorization of heterosexual women as good and heterosexual men as bad may have extensive implications for what strategies are prioritized in the international response to HIV.
Malawian National Policies
I now turn to Malawis national HIV policy and guideline documents. While the country is theoretically autonomous and free to develop uniquely Malawian strategies and approaches to HIV, its dependency on donor dollars suggests that policies will likely follow international guidelines.6 National documents are important because they directly guide national- and district-level funding allocation, inform national and local monitoring and evaluation strategies, and provide the core curricula for provider training activities meant to build capacity in local health facilities. In some cases, national HIV documents are directly distributed to health care managers and providers for regular referencing. Documents also have the potential to influence programming outside the health institution. The National AIDS Committee, an organization in Malawi that partners with the Ministry of
51 first found the quote in an article by Deborah Mindry (2010] on the gendered nature of humanitarian aid.
6 In Malawi, donor funding comprises 90% of all HIV funding.

Health to oversee aspects of HIV prevention and treatment, uses national policies and guidelines to allocate funding to community-based organizations whose work addresses local HIV epidemics. One component of making funding decisions is the organizations alignment with national HIV priorities applicants are often advised to cite national policies in their applications to show that their program fits within the national agenda of HIV treatment and prevention.
To understand how men are represented in national documents, I collected HIV documents published by the Malawian Ministry of Health (MoH) and/or the Malawian National AIDS Commission (NAC). Documents were attained from the MoH and NAC offices in Lilongwe, Malawi and from District Health Offices and health facilities throughout the southeastern zone of Malawi. I included four types of documents in the final analysis: (1) HIV policies and manuals (n=21); (2) strategic plans (n=25); (3) evaluation reports (n=7); and (4) other reports (n=15). In total, 68 documents were included and spanned from 2002-2013. All documents were analyzed using Atals.ti v6.2. As with WHO documents, I used auto-coding to identify discussions about women (searching for women, woman, female(s), and mother(s)) and about men (searching for men, man, male(s), and father(s)). Like WHO documents, paragraphs within key words were coded as either "women or "men and paragraphs with both men and women were double coded.
Men are better represented in Malawian documents than in WHO documents (women are 1.29 times more likely to be mentioned in Malawian national documents than men (5,717 times versus 4,427 times). Throughout key Malawian documents men are recognized as a population at risk of HIV infection; however, men are still not included in national priorities. For example, the National Action Framework for HIV/AIDS for 2010-

2012 has a section devoted to "Prevention and Behavior Change. The introduction of this
section describes the epidemiology of HIV by gender:
Incidence of HIV occurs at a younger age in females than males but with relatively equal cumulative incidence or prevalence impact over time as male prevalence exceeds that of females at age 30 and above. Differential age specific incidence rates (early in females and delayed in males) highlight the need to address HIV risk behaviours in youth with attention to underlying gender factors that increase vulnerability to HIV (Ministry of Health [Malawi], 2009, p. 32)
Despite the emphasis on men and womens equal cumulative risk of HIV, the National Action Framework quickly moves to prioritizing strategies focused on youth and addressing gender inequality that increases risk of infection for women. Strategies targeting older ages, when men are most at risk of infection, are not included.
Since 2011, some documents recognize men as a group underrepresented in HIV services. Gender inequality is discussed as a risk factor for womens infection, but female-focused services are recognized as a main reason why men are less likely than women to be tested. For example, the Malawi National HIV and AIDS Strategic Plan (2011 2016) has a section on "Social, Cultural, and Economic Issues. In this section it states:
Women are known to have limited influence over their sexual and reproductive health due to entrenched negative gender norms which are embedded in a culture that promotes male dominance in relationships, and views multiple and concurrent sexual partnerships as normal... Additionally, because of male dominance in some situations, women are unable to access HIV and AIDS services without the approval of their partners. [Ministry of Health [Malawi], 2011d, p. 17)
In the same document under a section entitled "Key Gaps in the National Response mens health and access to testing are also discussed:

Though women have access to HIV testing and counselling (HTC) services through ANC visits, inadequate numbers of men are being tested for HIV or accessing ART services. There is a pressing need to engage men more in health seeking behaviours and the promotion of HTC as a gateway to accessing HIV care. (Ministry of Health [Malawi],
201 Id, p. 22)
The guiding principles for Malawis HIV strategies are also more inclusive of men than those presented in the WHO. Of the nine guiding principles in the 2011 Strategic Plan, one focuses on gender sensitivity, including, to a lesser extent, mens health:
Gender sensitivity: women and girls in Malawi are particularly vulnerable to HIV and youth and men also have their particular issues which must be addressed by gender specific interventions. [Ministry of Health [Malawi], 2011d, p. 30)
While Malawian documents take a more nuanced view to gender and HIV, this does not translate into HIV strategies that explicitly target men as clients of HIV services. After listing the unique vulnerabilities of men and women, documents go on to prioritize gender-sensitive and gender transformative programs. These priorities are listed as bullet points, so it is unclear if the programs include strategies specifically for men; however, based on international guidelines it is likely that gender-sensitive programs, in practice, mean women-sensitive programs. On the ground, it is evident that this is the case beside VMMC, the Malawian Ministry of Health has not scaled strategies focused on men.
The absence of men within national HIV priorities influences the structural landscape of HIV services and, more broadly, the landscape of community-based organizations whose

work aligns with national HIV strategies. For example, in 2013, NAC had five new national HIV programs they supported. One was exclusively male-focused, VMMC. One was related to general access to HIV services. The remaining three programs were directly focused on women. Community-based organizations also follow suit. In the southern district in which I work, in 2014 over 30 community-based organizations were registered with the city council and addressed at least one component of the HIV epidemic. Of these 30 organizations, just over 42% focused on the specific needs of women none focused on the specific needs of men.
The absence of men in national HIV priorities also influences the monitoring and evaluation strategies prioritized in the health institution. This is important since monitoring and evaluation tools are the primary ways in which unmet needs and disparities in health services can be identified at the national level. In Malawi, national monitoring and evaluation tools for health services include sections dedicated to maternal health. This means that when health services fail to reach pregnant and/or breastfeeding women, a category that represents a large portion of the female population, it is apparent and can be quickly addressed by individual facilities and by the Ministry of Health. When services disproportionately miss men, however, the gap goes largely unnoticed by Ministries of Health because national HIV data are not disaggregated by gender.
Recent research on mens use of HIV services highlights this gap in national monitoring and evaluation strategies. Multiple studies in Malawi and other regions of sub-Saharan Africa now show that HIV+ men are less likely to remain in care and are more likely to die while in care than their female counterparts. Yet Malawis national monitoring and evaluation data on loss-to-follow-up or AIDS-related mortality are not disaggregated

by gender, therefore national reports and guidelines are unable to identify that men comprise the majority of those dying from HIV, and importantly, are unable to identify the health facilities or geographical regions in which men face more acute disparities.
Similarities throughout Sub-Saharan Africa
The absence of men in national HIV strategies is not unique to Malawi. A review of National Strategic Plans for HIV found that across 13 countries in sub-Saharan Africa, very few national plans highlight the need to include men as clients. Most plans promote mens engagement for the benefit of women and children through strategies such as male involvement in PMTCT, but mens health is rarely mentioned. Plans that do address mens need for HIV services do not clearly articulate how mens engagement could be accomplished (Sonke Gender Justice Project, 2015).
Similarities in national approaches to gender and HIV should not be a surprise. HIV policies and programs are not developed in a vacuum but are informed by the larger historical context that has guided the development enterprises of the West (Bacchi, 2009; Seidel & Vidal, 1997). Furthermore, most of these countries receive extensive funding and technical guidance from the same international bodies, such as WHO, UNAIDS, the Global Fund and PEPFAR. Since a female-focused approach to HIV is seen throughout sub-Saharan Africa, results from my study based in Malawiwhile specific to the context in some respectsare likely illustrative of broad patterns that characterize other high HIV-prevalence countries in the region.

Nearly 11% of Malawians of reproductive age are HIV positive. Women comprise 60% of all new infections (NSO & ORC Macro, 2011). Malawi is one of the poorest in the world with a gross national income per capita of $250 (World Bank, 2014). Nearly 85% of the population lives outside of urban centers (World Bank, 2014).
The Malawian Health Institution
The Malawian health institution is organized in a pyramid structure: dispensaries are the smallest facility, then health centers, hospitals, and finally district hospitals. The majority of facilities in Malawi are health centers (70% of all facilities in 2013), followed by hospitals and dispensaries (13%, and 3%, respectively). Hospitals are primarily based in urban centers; therefore health centers are critical for reaching the majority of Malawians who live in rural areas. Government-run public health facilities comprise roughly 60% of all services provided in the country while the Christian Health Association of Malawi (CHAM) provides just under 40% of all services. Although private facilities are available, they represent a very small proportion of the countrys health services (Ministry of Health [Malawi], 2004).
Malawi has historically struggled with staff shortages within the health sector. In 2011, 51% of all health care positions were reported vacant (Ministry of Health [Malawi], 2011c). Smaller, rural facilities are particularly understaffed and providers are often

undertrained; most are low- or mid-level staff who receive only one or two years of training (Manafa et al., 2009). Unsurprisingly, staff are not adequately prepared for the tasks they are expected to preform (Manafa et al., 2009). In addition, most facilities receive more clientele than their staff are able to manage, resulting in either poor quality care in order to serve the majority of clients, or turning away clients who have not been treated by the end of the work day.
HIV Services in Malawi
Throughout the country, access to both HIV testing and treatment services has increased dramatically in the last decade (Harries, Makombe, Libamba, & Schouten, 2011). Figure 5 illustrates the rollout of HIV testing and treatment in Malawi. I include HIV treatment because decisions to access testing are likely influenced by the availability of treatment (Conroy, Yeatman, & Dovel, 2013; Njau et al., 2014). For example, poor access to treatment may decrease motivation for testing if, without treatment, a positive test is seen as a death sentence (Conroy et al., 2013; Amy Kaler & Watkins, 2010).
HIV testing was first introduced in Malawi in the 1990s but was only available to the urban wealthy. In 2003, testing expanded to government hospitals and in 2004, testing services were decentralized to rural clinics and became available free-of-charge (Makwiza et al., 2009). Although access to testing increased, there were still substantial barriers to care. First, the number of testing sites in rural areas was limited, meaning that the majority of Malawians had to travel long distances to access care. Second, HIV testing used oral swabs that were analyzed in urban laboratories (Angotti et al. 2009). As a result, clients had to wait several weeks and return to the VCT site to receive their results. Third, by

2004, treatment was only available to the urban wealthy; availability was still extremely limited for the rural poor. While ART was theoretically offered free-of-charge in 2004, only the 18 largest public health facilities in the country offered treatment, effectively limiting treatment availability to urban populations. Indeed, by 2004, there were still conversations among rural Malawians that HIV was a death sentence without a real cure since their experience with treatment was limited (Conroy, Yeatman, & Dovel, 2013).
By 2005, rapid blood tests were widely used that dramatically decreased waiting times for test results (clients had to wait only 15 minutes as opposed to several weeks; Yoder & Matinga, 2004). At the same time, treatment services expanded throughout the country, making treatment available at select local health facilities free-of-charge. By 2012, free treatment was available in over 640 public health facilities and stockouts were relatively rare (Ministry of Health [Malawi], 2012a).
Eligibility criteria for treatment initiation also expanded, potentially increasing motivation for testing. In 2008, adults were eligible for ART only at WHO Stage 3/4 or CD4 count<250 cells /mm3, meaning once they were very sick with an AIDS-defining illness such as wasting or reoccurring pneumonia. In 2011 the CD4 cutoff was increased to <350 cells/mm3 (MoH, 2014). Adults clients who did not qualify for ART could initiate pre-ART upon a positive diagnosis, a drug regimen aimed to reduce the incidence of HIV-related diseases and enable early ART initiation due to regular monitoring of CD4 count. However, pre-ART stockouts were widespread and drugs were not consistently available to most of the population.

Free ART program begins; largely confined to city hospitals.
implementation of Option B+ for pregnant and breastfeeding women
Effective combination therapy (HAART) is widely available in the
^es*' Extremely limited
access to ART; mostly fee-based; around 4000 people on ART
Free ART program expands to district hospitals.
ART expands to some local health centers. Now offered at 141 facilities.
Decentralization of ART to all facilities offering Mother and Child Health Services
Pre-ART added to standard care protocols
ART rollout
HIV testing rollout
HIV testing available in urban centers Oral swab test
Testing offered free-of-charge and available in rural clinics
Rollout of rapid
Testing available at blood tests
government hospitals
First Annual HIV Testing Week implemented throughout Malawi
High-risk PITC required for all STI clients
PMTCT is implemented in all antenatal clinics
High-risk PITC implemented for all TB clients
Figure 5. Rollout of HIV services in Malawi
Gender and HIV Services in Malawi
While HIV testing and treatment services have the potential to benefit all populations, Malawi, like the rest of sub-Saharan Africa, has experienced extensive gender disparities in service utilization. In 2010, 51% of men and 72% of women in Malawi reported ever being tested for HIV (Staveteig, Wang, Head, Bradely, & Nybro, 2013). In 2013, men comprised only 33% of those tested in Malawi and 34% of those registering for ART, even though they accounted for just over 40% of all new infections (Ministry of Health [Malawi], 2013).7
7 Registrations include first-time initiates, transfers, and those re-initiating ART. The gender distribution of first-time initiates is not available at the country-level.

While gender differences in HIV service utilization are evident, it is important to note that such disparities are not inherent to men and women. Indeed, early in the epidemic men and women accessed services equally. In Malawi, disparities developed overtime as HIV policies began to prioritize the prevention-of-mother-to-child-transmission (PMTCT) of HIV. Table 1 shows mens declining representation in HIV testing alongside policy changes for HIV services. In 2004, men comprised 50% of those tested for HIV (Ministry of Health [Malawi], 2005). In 2005, Malawi began to introduce provider-initiated (or opt-out) HIV testing for pregnant women and by 2006, men comprised 44% of those tested (Ministry of Health [Malawi], 2007b). We see a similar decline in mens representation with more recent changes in PITC policies. In 2009, provider-initiated testing for pregnant women was enforced and universally implemented at all antenatal clinics (WHO et al., 2010). By 2010, men accounted for only 33% of those tested for HIV (Makwiza etal., 2009; Ministry of Health [Malawi], 2010).

Table 1. Gender disparities in HIV testing and changing HIV policies in Malawi: 2004-2010
Proportion of HIV testing
HIV policies in Malawi clients who are men
Year Policy Year %
2004 HIV testing decentralized and offered free-off-charge1 2004 501
2005 Provider-initiated testing for pregnant women encouraged2 2006 443
2009 Provider-initiated testing for pregnant women required at all ANC clinics4 2010 332
1 Ministiy of Health [Malawi], (2005], Report of a Countiy-wide Survey of HIV/AIDS Services in Malawi for the Year 2005. HIV Unit, Department of Clinical Services, Lighthouse Trust and Center for Disease Control and Prevention. Lilongwe, Malawi.
2 Makwiza, I., Nyirenda, L., Bongololo, G., Banda, T., Chimzizi, R, & Theobald, S. (2009], Who has access to counseling and testing and Anti-Retroviral Therapy in Malawi an equity analysis. International Journal for Equity in Health, 8(13],
3 Ministiy of Health [Malawi], [2007], Report of a Countiy-wide Survey of HIV and AIDS Services in Malawi For the Year 2006. HIV Unit, Department of Clinical Services, National TB Control Program, Lighthouse Trust and Center for Disease Control and Prevention. Lilongwe, Malawi.
4 WHO, UNAIDS, & UNICEF. [2010], Towards universal access: scaling up priority HIV/AIDS interventions in the heatlh sector. Progress report. Geneva: WHO Press.
Preliminary Research
During the summer of 2012,1 spent six weeks in southern Malawi conducting preparatory research for the current study. My research team, two research assistants, conducted 21 exploratory, open-ended interviews with the following populations: ten HIV positive men (six using HIV treatment and four not using treatment); eight male and female healthcare

providers that offered HIV services; and three male key informants who managed HIV programs. Similar to Parrott and colleagues (2011), preliminary findings suggested that mens use of HIV services were limited due to: (1) fear about the repercussions of a positive test; (2) fear of gender-specific stigma related to blame for a positive test; (3) and work constraints related to the amount of time required to seek care. Local men said that men who do not use HIV services are "ignorant (without knowledge) and "selfish. There were extensive discussions about the association between mens poor use of care and mens selfish mindset that prioritized their friends and girlfriends over their family. Even men who did not use HIV services adopted the same morally charged language about mens poor use of services only a few respondents discussed structural barriers to care. Much like the current literature, the onus for mens poor representation of services was placed on the individual.
Healthcare providers also questioned the likelihood that men could be "good clients and saw men as too "irresponsible and "selfish to seek HIV testing in a timely manner. When asked to choose which gender providers preferred to treat, the majority preferred treating women because women were "more predictable and didnt question their [providers] authority. Notably, the importance of structural, supply-side barriers to care was largely unidentified by both men and providers. Barriers related to mens work schedules were identified; however, respondents related this barrier to mens availability and willingness to access services as opposed to facilities limited hours of operation.
These findings may reflect what Bourdieu has coined as the "misrecognition of inequality. Structural violence, or in this case, mens structural exclusion from health institutions, fosters the perception that inequalities are normal and natural, and thus, the

negative effects of inequality are the responsibility, or fault, of those who suffer (Bourdieu & Wacquant, 1992). While men in sub-Saharan Africa are rarely thought of as victims of structural violence, particularly in the context of gender and HIV, HIV policies for (PMTCT) systematically disadvantaged mens access to HIV treatment and testing services (Morna Cornell, James McIntyre, & Landon Myer, 2011; Dovel et al., 2015a). The fact that structural barriers to mens use of care were largely unidentified in preliminary research may not reflect the absence of structural barriers, but instead, may reflect that structural barriers are largely unseen.
Research Questions Revisited
In order to move beyond individual-level barriers to care, I chose a mixed methods approach that allows me to examine how HIV testing services are organized and why services are organized in certain ways. I focus on three distinct levels through which testing services are delivered in order to provide a holistic description of the gendered organization of HIV testing. First, I examine if providers implement provider-initiated testing differently to male STI clients as compared to female STI clients. This population is important because they are at increased risk of HIV infection, and thus transmitting HIV to their sexual partners. HIV testing services for STI clients is also important since it is one of the few models for the delivery of HIV testing that, in policy, explicitly targets men and women equally all male and female STI clients should be offered HIV testing. Second, I move beyond patient-provider interactions to examine how the gendered organization of PITC influences provider implementation of the policy. Finally, I examine the overarching

organization of the health institution in southern Malawi and how the organization influences mens access to and experiences with HIV testing.
Mixed Methods Framework
Combining both qualitative and quantitative methods provides a richer analysis of how services are organized and why they are organized in particular ways (Robins et al., 2008). Furthermore, multiple types of data allow for triangulation, providing more confidence that findings have validity and encompass a variety of complex ideas (Morse, 1991). I use qualitative methods to broadly explore the gendered organization of HIV services and why they are structured in particular ways. I then use quantitative methods to specifically examine if provider-initiated-testing-and-counseling (PITC) for STI clientsa policy explicitly crafted to be gender neutral is implemented differently for male versus female clients. Figure 6 uses standard mixed methods notation to describe the overarching analytic strategy of the study. All study activities received ethical approval from the Colorado Multiple Institutional Review Board and the National Health Sciences Review Committee in Malawi.

Concurrent Triangulation Design
d Observational Journals Participant Observation In-Depth Interviews
Exit Surveys
Data Analysis
Data Results Compared and Combined
Data Analysis
Figure 6. Mixed methods notation for the current study. Adapted from Creswal Clark (2011). Designing and conducting mixed methods research. Losa Angeles:SAGE.
Study Site
My dissertation study takes place in five health facilities in one of the larger districts in southern Malawi. Five health facilities were purposively selected to participate in the study based on the following criteria: (1) offered HIV testing and treatment; (2) offered STI services; and (3) received a high numbers of STI and HIV clients compared to other facilities in the district. Purposive sampling was used to include facilities that ranged in size, type, ownership, and model of care used to deliver both HTC and STI services (see Table 2).
The name of specific district will remain anonymous in order to protect the anonymity of the facilities and health care providers who participated in the study. The majority of the districts population lives in rural areas with limited opportunities for formal employment (85%): thus, most depend on subsistence farming, fishing, and small-scale retail businesses (National Statistical Office [Malawi], 2008). Most communities in the

districtas elsewhere in the southern regionfollow matrilineal and matrilocal systems (Peters, 1997).
Nearly 15% of the adult population is infected with HIV, higher than the national average (NSO & ORC Macro, 2011). As with the rest of the country, men represent 40% of new infections in the district but less than 30% of those tested and treated for HIV (Zonal Health Office [southern Malawi], 2012). In 2013, the time of data collection, the district housed 41 government-run health facilities, of which 29 offered HTC to the general population: 8 dispensaries, 19 health centers, and 2 hospitals.
Table 2. Characteristics of the five participating facilities in southern Malawi
Facility Facility type Facility ownership Location of HTC Privacy of HTC waiting spaces Time of day that HTC is offered HTC clients/day VMMC during study
1 District hospital Government Same building as ANC, GYN, under-five, ART, and STI services semi-pnvate All day 30 no
2 Semi-urban health center Government Outside facility walls (queue is visible from the street), near OPD not at all pnvate All day 13 no
3 Rural hospital CHAM Near adolescent, under-five, and STI services pnvate All day upon request, provider in the room during antenatal services 11 no
4 Rural health center CHAM In the ANC building semi-pnvate Dunng antenatal services 22 yes1
5 Rural clinic Government In the under-five building not at all pnvate Dunng antenatal services 11 yes2
1 Due to extended VMMC strategies, the number of people tested for HIV is higher than dunngnon-VMMC penods. On non-VMMC penods the facility averages 3 HTC clients per day
2 Due to extended VMMC strategies, the number of people tested for HIV is higher than dunngnon-VMMC penods. On non-VMMC penods the facility averages 2 HTC clients per day
Qualitative Data
I use three forms of qualitative data to explore the gendered organization of HIV testing services: (1) participant observation in health facilities; (2) observational journals written by local research assistants who observed interactions within facility waiting spaces;

(3) in-depth and key informant interviews with health care providers. Participant observation allowed me to draw data from more than just self-reports that, due to the misrecognition of inequality, may be unaware of potential structural barriers to care, while in-depth interviews allowed me to understand the perceptions and attitudes of those working within the health institutions.
Participant Observation
From December 2013 June 2014 I spent most afternoons and some mornings in the five health facilities interacting with providers and observing their interaction with one another. Afternoons usually consisted of helping providers stock drugs, going to providers houses, often located near or on facility grounds, and at times, observing provider-client interactions. By spending afternoons in the health facilities, a time when client-load was low, I was able to interact with providers when they were free to chat about their jobs, their clients, and their views about gender and HIV in the communities they served. I also observed three district-wide trainings for healthcare providers, all initiated by the Ministry of Health, one national dissemination conference on best practices for HIV, TB, and Malaria strategies, and four monitoring and evaluation visits implemented by the Ministry of Health.8
Throughout the study I also collected documents kept within each facility that were related to HIV or STI services, including Ministry of Health guidelines, digitized versions of clinic registers, and monitoring and evaluation forms. I also digitized any messages
8 The monitoring and evaluation visits took place at each facility on a quarterly basis in order to assess the number of clients served, stockouts, and any gaps in current services at each health facility.

displayed in the areas of the facility where HIV or STI services were provided. Messages included formal posters about HIV or STIs that targeted clients, formal posters about service protocols that targeted providers, and hand-written posters developed by the providers themselves to either remind them of best practices or direct potential clients. While most of my time was spent interacting with providers outside of formal health consultations, my time within the health institution allowed me ample opportunities to observe how services were organized and how priorities of the Ministry of Health and individual providers translated into the provision of care.
I took short-hand notes during participant observation activities and developed more detailed notes as soon as possible, usually at the end of every day, to maintain accurate and detailed descriptions of provider interactions (Emerson, Fretz, & Shaw, 2011). Detailed notes were then transcribed for analytical purposes. Informal interviews with providers were used to help interpret meanings behind observed interactions (Van Maanen, 2011).
By spending nearly 9 months in rural Malawi, I was able to participate in the everyday experiences of local Malawians, such as frequenting food markets, shopping for second hand clothes at the weekly clothes markets, eating at the small chip stands on the side of the road, observing water being drawn from local boreholes, attending religious ceremonies, and using public transportation. During these everyday events, I was able to observe gender norms around male and female interactions and male versus female work. These mundane experiences outside the health institution proved critical to orientating my understanding of how the gendered organization of HIV services is situated within broader social norms enacted in everyday life.

Observational Journals
Outside my own participant-observation, four paid research assistants observed the facilities public waiting spaces over a five-month period and documented these observations through observational journals. Observational journals are meant to capture the content of social interactions; what people say and how they interact with one another in everyday settings, which can be quite different from what they may say in a research setting. Research assistants listen, rather than ask questions. At the end of each day, they write what they heard and saw in their journals (simple notebooks), recalling, in as much as detail as possible, the context and content of interactions. They also describe characteristics of the participants, such as their gender and clothing. The method has been used to examine social dimensions of the HIV epidemic in a variety of settings (Nicole Angotti & Sennott, 2014; Conroy et al., 2013; Tavory & Swidler, 2009; Watkins & Swidler, 2009).
For this study, research assistants observed clinic waiting spaces over a five-month period, spending 3-8 weeks observing each facility on a full-time basis (five facilities in total). Research assistants were local to southern Malawi, between 32-44 years of age, spoke English, and were relatively well-educated (with the equivalent of a high-school degree). Three of the four assistants were recruited based on their previous experience with observational journals all three were considered some of the best, most consistent journalists for a 15-year project called the Malawi Journals Project (Kaler, Watkins, & Angotti, 2015). The fourth assistant was recruited based on my previous experience with him as a qualitative researcher. All assistants received a three-day training in ethnographic

methods, short notes, and the level of detail needed in the observational journals. The training included mock conversations and field notes, followed by observing local activities in the community, writing individual field notes, and comparing what was written with the rest of the group. After the training, I spent an additional day with each research assistant observing facility waiting spaces and discussing with the team what was observed and what should be included in the journals. Following others who have used observational journals, throughout the study period I continued to provide feedback on what was written and the level of detail desired (Angotti & Sennott, 2014).
Based on the primary research questions of the study, observation was primarily conducted near STI consultation rooms, but researchers also observed other waiting spaces when STI clients were not presentwhich was often. Research assistants took notes on conversations overheard and activities observed in clinic waiting spaces and expanded notes into full observational journals as soon as possible, usually that same day. In addition to describing interactions, research assistants described the physical environment of facility waiting spaces, including other services offered nearby, and the clinic protocols observed. Research assistants attended facilities in pairs, with one male and one female researcher observing each facility.
In total, the four research assistants filled fifty-two 80-page journals, each about 20 pages when typed. All journals were written in English and included multiple conversations and events. In the excerpts presented throughout the findings of my dissertation, I retain the original spelling and grammar of the journals in order to preserve the writers voice. Names in the journals are replaced with pseudonyms.

The journals provide a rich description of daily interactions in clinic settings, capturing both mundane and unusual interactions. For example, most entries include stories about how queues were formed, the demographic make-up of groups in the waiting spaces, when and how providers opened the health facility, and the commonplace conversations held by clients as they waited for services. Each of the four research assistants had a particular style of writing, but the descriptions of the activities were consistent, providing confidence that they did not make up entries (see also Watkins and Swidler 2009).
In-Depth and Key Informant Interviews
Participant observation was complemented with formal in-depth interviews. The same research assistants and I conducted 18 in-depth interviews with healthcare providers at participating facilities and 11 key informant interviews throughout the country (29 interviews total). Healthcare providers interviewed included providers who offered STI services (n=10), health surveillance assistants (HSAs) that offered HIV testing (n=5), and providers who offered antenatal services (n=3). Some providers offered multiple health services; over 70% of providers interviewed offered two or more types of services. Key informant interviews were conducted with an array of people, including clinical officers and nurses who oversaw each participating facility (n=5), Ministry of Health personnel (n=4), and HIV researchers and service managers that worked directly with the Ministry of Health (n=2).
Interviews with providers were conducted near the end of the study period while key informant interviews were conducted throughout the study period. Providers were

recruited after several months of participant observation so that rapport was already established. Interviews took place in the afternoons (the slowest period for Malawian clinics) and were often conducted off clinic grounds in order to facilitate open conversations between the interviewer and participants. All interviews were recorded and participants were compensated $4 USD for participation. Key informants were not compensated since interviews fell within their job description.
A preliminary interview guide was developed and was piloted with 8 providers during preliminary research in 2012. The guide was modified based on findings from participant observation, ethnographic journals, exit surveys, and input from local key informants (Creswell, 2012). The final guide varied based on the type of participant, but covered the following topics: (1) perception of HIV strategies; (2) implementation of HIV strategies in local facilities; (3) perception of men and women as clients; (4) mens role in the HIV epidemic; (5) men and womens vulnerability to HIV; and (6) reasons why men are underrepresented in HIV services. In addition, providers who offered STI services were specifically asked about (1) their knowledge and perceptions of PITC protocols, (2) barriers to implementing PITC for STI clients, and (3) perceptions of how PITC should be offered to male versus female clients.
Research assistants transcribed participant observation, observational journals, and in-depth interview data. I analyzed data in Atlas.ti and applied a series of iterative codes (Atlas.ti v.6, 2011). As themes emerged, I developed a coding framework for the different levels in which health institutions could be gendered: (1) the organizations structure; (2)

policies and practices; (3) local interactions; and (4) the gendered identities either promoted or discouraged for clients within the organization (Acker, 1990). I then used inductive coding techniques to develop themes within each level of the health institution. While other forms of gendering within health institutions may exist, I do not address them here. Constant comparison methods and triangulation of data were used to develop a coherent, holistic description of the gendered organization of health institutions, and more specifically, HIV testing services (Bernard, 1994; Glaser & Strauss, 1967).
Quantitative Data
I use exit surveys to examine if male STI clients are offered provider-initiated testing differently than female STI clients. STI clients were selected instead of TB clients, another category of clients that are offered PITC, because STIs are transmitted through the same pathway as HIV, suggesting that this population has overcome general barriers to the uptake of sexual health services. Furthermore, TB is assumed to be a predictor of HIV -over 60% of TB clients in Malawi test HIV positive meaning that nearly all TB clients are tested for HIV and initiated on treatment (MoH, 2014). Exit surveys were used instead of STI registry data in order to understand the quality of PITC provided, clients acceptance of PITC, and factors associated with the implementation and acceptance of PITC, such as perceived illness and sexual risk behavior of the client.
Inclusion Criteria
Inclusion criteria for respondents included: (1) received STI services on the day of recruitment; (2) were at least 18 years of age; (3) were cognitively able to consent; and (4)

were not an employee of the participating health facility.9 We did not ask about HIV status during recruitment, but respondents who identified as HIV positive during the survey were excluded from the final analysis since they did not need to be offered another HIV test.
Sampling Size
Sample size was calculated based on a standard estimate of the effect size between male and female clients (0.5), >95% power (< 0.2 type II error), a fixed 0.05 alpha (type I error), assumed normal distribution of independent variables and assumed similar variance within groups (J. Cohen, 1988). 210 respondents were needed for the study. Since we did not ask HIV status during recruitment, and since HIV positive respondents are removed from the final analyses, the sample size was increased to account for the percentage of HIV positive clients in the sample population. The Ministry of Health estimates that 30% of STI clients are HIV positive (Ministry of Health [Malawi], 2012a), therefore I increased the number of respondents by 30%, resulting in 273 respondents needed in order to attain 210 respondents who were HIV negative or with an unknown HIV status. Finally, I increased the sample size by roughly 10% in order to ensure that the sample was large enough for meaningful statistical analyses, leaving room for the occasional incomplete or incorrect survey. In total, 299 STI clients completed an exit survey.
Clients were recruited immediately after receiving STI services. For most facilities, there were a limited number of STI clients seen each day (4 facilities averaged 0.25-3 STI clients per day). In these facilities, every STI client was recruited. The district hospital had
9 In the first several weeks of recruitment at the first facility we found that there was an increase of STI clients among facility staff once the survey started. Subsequently, facility staff were excluded from survey recruitment at all facilities in order to promote "business as usual for STI services.

significantly more STI clients than all other facilities (average of 17 STI clients a day). In this facility, every third female client was recruited; however, since men in Malawi account for only 40% of all STI clients, all male STI clients in the district hospital were recruited to ensure that enough men were present in the study sample. The number of respondents recruited from each facility was determined based on the client load at each facility in facilities with greater client loads we recruited a higher number of respondents.
The same four research assistants who wrote observational journals recruited potential participants and conducted all surveys. Research assistants recruited participants during facility hours, working full-time at one facility until the desired number of participants was reached. Being full time at one facility for at least three weeks allowed research assistants to build rapport with healthcare providers. Furthermore, by being present every day that facilities were open and throughout the entire workday, usually from 8am until 4pm, the study sample is likely to be fairly representative of the actual STI clientele.10
Exit surveys were conducted immediately after recruitment in a private, confidential room or outside space on facility grounds. Participants and interviewers were matched by gender and participants were compensated 1 USD, regardless of finishing the survey. Surveys lasted approximately 30 minutes.
Survey Instrument
Participants were asked to report on their demographic characteristics, self-rated health,
10 While research assistants could recruit potential participants throughout the workday, most clients were recruited before 2pm. After 1 or 2 pm providers usually stopped seeing clients and used the afternoon hours to "prepare for the next day.

perceived risk of HIV, sexual risk behavior, gender of the provider seen for STI services, whether they were offered HIV testing, the quality of PITC received, and the quality of STI services provided. Most survey questions were adopted from the Demographic Health Survey (NSO & ORC Macro, 2011). The survey was piloted with 15 STI clients in December, 2014.
Demographic Data
All respondents were asked about demographic characteristics, such as age, sex, marital status, and work status. I also include two measures for socioeconomic status. Wealth was measured through a wealth index measure for the respondents household that accounts for ownership of household assets, such as a bicycle, materials used for housing construction, and type of sanitation facility (Filmer & Pritchett, 2001). Educational attainment was measured as a continuous variable based on the year of school last completed.
Quality of Care
Two measures were used to capture PITC. The first was a dichotomous variable asking, "Did the provider tell you to be tested for HIV? The second was an additive scale of seven questions that measures the quality of PITC offered. The scale was previously used to examine the quality of PITC offered in antenatal clinics across four countries, including Malawi (see Table 3; Hardon et al., 2012). Although the scale was used with pregnant women and not STI clients, PITC protocols are the same across client populations and therefore also apply to PITC for STI clients.

Quality of STI services, excluding PITC, was also included in the survey to examine if quality of care more broadly is associated with the implementation of PITC. Quality of STI services was measured through an additive scale of 6 questions developed from the Malawian STI Management Guidelines document that is distributed to all health facilities (see Table 3; Ministry of Health [Malawi], 2007a). While PITC is part of the protocol for STI services, it was excluded from this scale since quality of STI services was used to predict the implementation of PITC.
Table 3. Additive scales of the quality of PITC and STI services
Quality of care for those offered PITC1
Did the provide tell you to get tested for HIV?
Did the provider explain the importance of HIV testing?
Did the provider explain that you had a choice to accept or refuse HIV testing?
Did the provider explain the role of HIV treatment if found HIV positive?
Did the provider give you time to ask questions about HIV and HIV testing?
Did the provider explain that your results would not be shared?
Quality of STI services1 2
Did the provider offer male condoms?
Did the provider offer female condoms?
Did the provider give you a partner slip to inform your partner that they should come to the health facility?
Did the provider give you medication for an STI?
Did the provider give you advice on how to prevent STIs in the future?
Did the provider ask you about your sexual partners?
1 Adapted from Hardon, A., Vernooij, E., Bongololo-Mbera, G., Cherutich, P., Desclaux, A., Kyaddondo, D.,... Obermeyer, C. (2012). Women's views on consent, counseling and confidentiality in PMTCT: a mixed-methods study in four African countries. BMC Public Health, 12,26.
2 Adapted from Ministry of Health [Malawi], 2007. Management of sexually transmitted infections using syndromic management approach: guidelines for service providers. Third Edition. Lilongwe, Malawi.

Self-Rated Health
I included self-reported health in the survey since providers may be more likely to offer HIV testing to clients who are very sick as compared to clients who are not sick. While self-rated health is not a perfect measure of illness, subjective reports of health may be more useful than reports of specific medical conditions since in Malawi access to care is limited and respondents may not have record of specific illnesses, especially men. Furthermore, self-rated health is predictive of prospective mortality in low-income countries (Frankenberg & Jones, 2004; Olgiati, Barnighausen, & Newell, 2012). In this study, self-rated health was measured on an ordinal scale with categories for excellent (4), very good, good, fair, and poor (0).
Perceived Likelihood of HIV Infection and Sexual Behavior
Finally, I included measures for perceived likelihood of currently being infected with HIV and sexual activity. These factors may influence how providers interpret clients risk of HIV or their willingness to be tested. Perceived likelihood of being infected with HIV was measured on an ordinal scale with categories for high likelihood (3), medium, low, and no likelihood (0).
Two measures were used to indicate sexual activity. First, I used a dummy variable to indicate whether respondents were currently married or not. Second, I included a dichotomous variable for having two or more sexual partners in the past 12 months.

I used descriptive statistics to understand the prevalence of PITC among STI clients. I then used logistic regression and ordinal logistic regression models to predict if clients were told about PITC (dichotomous variable) and the quality of PITC received (ordinal variable), respectively. (Corbett etal., 2006; Gage &Ali, 2005; Peltzer, Matseke, Mzolo, & Majaja, 2009). Gender of client was the key independent variable. Models controlled for age, age-squared, education level, marital status, wealth, perceived likelihood of being HIV positive, and self-rated health of the respondent.11 For analytic purposes, I collapsed the response categories for perceived likelihood of HIV infection into low/no likelihood (0) and high/medium likelihood (1). Facility and facility characteristics were also included in the models. Models were run first with all potential predictors and then with interactions by gender. Gender-specific interactions with client and facility characteristics were not statistically significant, and therefore are not included in the final analyses.
I ran two sets of models. First, I ran weighted models to account for the gender-stratified sampling design used in the largest health facility (every third female STI client and every male STI client were recruited). Second, I used mixed-effects regression models to account for the nested nature of the data (Kunter, Nachtsheim, & Neter, 2004). I ran two-level logistic models (told about PITC) and two-level ordered logistic models (quality of PITC) with a random intercept for health facilities. While my data could theoretically benefit from a three-level logistic model (facility-provider-client), the number of clients nested within each provider is too small to allow for meaningful results. Weighted and mixed-effects models produced the same results, with almost identical point estimates. II
II Age as both a continuous and squared variable is included in all models to capture any nonlinear association between age and being offered HIV testing.

Therefore, I used the weighted models in order to best represent the population of STI clients represented in the data. Survey data was analyzed using STATA v.12 (StataCorp, 2011).

In the context of feminized HIV policies (described in Chapter 2), it becomes important to understand exactly what male-friendly venues for testing are available, and how such services are organized and implemented. We know that community-based and after-hour testing strategies effectively reach men (Hensen et al., 2014). Despite multiple successes, however, their implementation outside research settings is restricted due to funding constraints and the limited capacity of local health facilities. For example, in the study district where I worked, one non-profit offered community-based testing, but during my time in Malawi, they only implemented a handful of outreach activities due to funding restrictions. The Ministry of Health did not provide either after-hour or community-based testing.
To date, voluntary counseling and testing (VTC) at static health facilities is the primary way through which men can be tested. Voluntary testing allows clients to seek out services on their own accord an individual decides that they want to be tested, travels to a health facility, and then seeks out the HIV testing room where VCT is conducted. Not surprisingly, VCT requires a high degree of motivation. Those who want to be tested must travel long distances to health facilities, wait long hours for care, and risk compromising their anonymity of HIV testing. Furthermore, in high epidemic regions, populations should be tested on a regular basis before they become sick. This means that barriers to VCT should be overcome before individuals reach advanced stages of AIDS, requiring clients to

overcome barriers to care without having an illness to motivate their use of services. The multiple barriers to care, along with the need to access services while still healthy, makes VCT a difficult choice for many men living in southern Malawi.
Provider-initiated-testing-and-counseling (PITC) is one way to overcome the barriers that limit mens use of VCT. With PITC, clients who are already attending a health facility should be offered HIV testing during their routine consultation. Not only does a preexisting illness motivate mens attendance to a health facility, but PITC removes the necessity for men to initiate testing by obligating providers to offer testing when giving other health services (WHO/UNAIDS, 2007). Additionally, PITC should reduce barriers related to limited anonymity since testing should be integrated into regular, and more gender-neutral, health services.
Despite the potential benefits of PITC for men, studies from surrounding countries show that men remain underrepresented in PITC strategies for high-risk clients, even though these services are supposedly gender-neutral (Roura et al., 2013; Kranzer et al., 2010). This raises an important question: "Is PITC truly gender-neutral?
I use two different sets of data to answer this question. First, I use exit surveys with STI clients to examine if providers offer PITC differently to male versus female STI clients. Second, in Chapter 6,1 use ethnographic data to examine the gendered organization of PITC strategies more broadly in order to understand why PITC has dramatically improved the uptake of HIV testing among pregnant women (CDC, 2013), but has done little for STI clients (Ministry of Health [Malawi], 2012b). All data are described in detail in Chapter 3.

STI Client Demographics
299 STI clients completed an exit survey. 58 clients reported being HIV positive and were excluded from the final analyses. 18 women reported being pregnant and were excluded from the final analyses. Because pregnant women are assumed to be tested during ANC services, STI providers may not test them again. In total, 223 clients were included in the final analyses (see Figure 7).
Figure 7. Recruitment and study respondents
Two models of care were used to provide STI services: integrated care where STI services were offered alongside all other out-patient services, such as treatment for malaria or a broken arm; and specialized care where STI services were offered in a separate room by a provider who specialized in STI care and was only responsible for STI clients (see

Table 4 for differences between the two models of care). Clinics with specialized models were based in urban and semi-urban facilities, saw more STI clients, and had one or two providers who managed the STI room and were trained in STI services. Facilities with integrated models of care were rural, smaller, saw fewer clients, and were more likely to have staff who were not trained in STI protocols (see Table 5 for a description of facilities by model of care).
Table 4. Similarities and differences between integrated and specialized STI services in southern Malawi
Integrated STI services
Providers Providers are trained and responsible for an array of general out-patient health services, including STI services
Providers must implement multiple protocols in one day based on patient symptomology
Specialized STI services
Providers are trained and primarily responsible for STI services, although they may assist with other services when needed
Providers must impliment one protocol for STI clients in a day, although protocols will vary slightly by symptomologic diagnosis
Providers may not have experiences with HIV testing services
Providers often have experiences with HIV testing services
All out-patient clients are seen by the same provider and queu in the same line, including STI clients
STI clients are seen by a separate provider and queu in a separate line from the other out-patient clients
Clients may not be aware that they have an STI when seeking care
Most out-patient departments include long queues
Logistics The STI clinic register is often not available in each room, so providers take note of STI clients on scrap pieces of paper and transfer data to registers at the ei of the day
In order to access STI services, clients must be aware that they may have an STI, or be referred from the general out-patient department
Queues for STI services are often shorter than those for general out-patient services
The STI clinic register remains in the STI room and providers are expected to complete the register after each consultation
Multiple providers are responsible for the STI register
One or two providers are responsible for the STI register
Unwanted disclosure of an STI is unlikely because care is integrated with all other services
Facilities tend to see fewer STI clients
Unwanted disclosure of an STI is more likely because STI clients must wait in a separate queue from other clients
Facilities tend to see more STI clients

Table 5. Characteristics of STI services in the five
Facility Model of STI care Number of providers offering STI services Location of HTC Percentage of providers trained in STI services Percentage of providers trained in HIV Testing Percentage of providers with experience in HIV services Approx, daily STI client attendance STI respondents
1 Specialized 1 Same corridor as STI services 100% 100% 100% 17 63
2 Specialized 2 Separate corridor from STI services 100% 50% 50% 3 40
3 Integrated 3 Separate corridor from STI services 50% 33% 67% 2.3 37
4 Integrated 4 Separate building from STI services 25% 50% 50% 2.5 56
5 Integrated 3 Separate building from STI services 0% 33% 66% 0.3 27
Table 6 shows the demographic characteristics of respondents by gender and by the model of STI services provided. The average respondent was 30 years of age, married, and had approximately 7.7 years of education. Male respondents were more likely than female respondents to report multiple partners in the past year (44.0% versus 7.0%), less likely to have ever been tested for HIV (82.6% versus 94.7%), and less likely to have ever received STI services before the day of the survey (35.8% versus 60.5%).
Respondents were distributed across the two models of care, with women slightly more likely to receive integrated as opposed to specialized services (meaning women were more likely to access care in rural facilities). In general, respondent demographics did not vary by facility attended, although respondents from Facility 1 (the district hospital) tended to be wealthier and had higher levels of education than clients in more rural facilities (not shown).
Notably, the quality of STI services was poor in both specialized and integrated models of care; the majority of clients received treatment for their infection (97.3%), but only 26.0% were offered male condoms, 15.7% were given a partner slip to encourage

their sexual partners to receive treatment for an STI, and 38.6% were counseled on how to prevent STIs in the future.12
Table 6. Demographics of STI client participants in southern Malawi
Percentage or mean
Variable Women Men Integrated Specialized All
Age, range:18-65 (mean) 29.9 30.4 30.4 29.7 30.1
(8.4) (7.9) (8.5) (7.7) (8.1)
Female - - 61.4 38.6 51.1
Years of education, range: 0-15 (mean) 6.8 8.6 7.5 8.0 7.7
(3.7) (3.3) (3.9) (3.2) (3.6)
Household goods index, range: 0-10 (mean) 3.5 4.6 3.8 4.3 4.0
(2.4) (2.2) (2.3) (2.4) (2.4)
Marital status (%)
Married 79.6 62.4 75.8 65.7 71.2
Formerly married 15.0 5.5 10.8 9.8 10.4
Never married 5.3 32.1 13.3 24.5 18.5
Previously tested for HIV (%)
Within the last month 7.0 11.0 8.3 9.7 9.0
1-12 months 51.8 48.6 50.8 49.5 50.2
1 year+ 36.0 22.9 28.3 31.1 29.6
Never tested 5.3 17.4 12.5 9.7 11.2
Ever treated for an STI before (%) 60.5 35.8 46.2 50.5 48.4
Multiple sexual partners in the past 12 months (%) 7.0 44.0 22.5 28.2 25.1
Self rated health, %
Poor 11.4 9.2 10 10.7 10.3
Fair 57.9 26.6 52.5 31.1 42.6
Good 29.0 53.2 30.8 52.4 40.8
Very good 1.8 9.2 5.8 4.9 5.4
Excellent 0.0 1.8 0.8 1.0 0.9
Quality of STI services received
Offered male condoms 15.8 37.6 14.2 40.8 26.5
Offered female condoms 2.6 0.9 1.7 1.9 1.8
Partner slip 16.0 15.3 18.7 12.4 15.7
Medication for STI 98.3 96.3 98.3 96.1 97.3
Advice on how to prevent STIs 31.6 45.9 25.8 53.4 38.6
Asked about sexual partners 27.0 35.5 22.2 41.6 31.2
Told about HIV testing 35.1 44.0 20.8 61.2 39.5
12 While female condoms are part of the national guidelines, their acceptance and use is very poor, discouraging providers from offering them. During my observations, all but one facility had untouched boxes of female condoms sitting in the STI or pharmaceutical room.

Implementation of PITC among STI Clients
I measure the implementation of PITC in two ways. First, I examine if PITC was implemented at all. This could include a single sentence about testing, telling clients to be tested as they walk out of the consultation room, or it could include an extended, compressive counseling session about the importance of testing. The quality of PITC may vary substantially, but as long as clients reported being told about HIV, I categorize them as being offered some level of PITC.
Table 7 shows the number of STI clients who were told about HIV testing by facility. In total, 39% of respondents were told that they should be tested for HIV. The implementation of PITC varied substantially by the model of STI services used, with clients in specialized models of care more likely to be told about testing than clients in integrated models (61.2% for specialized models versus 20.8% for integrated models).
Table 7. Implementation of PITC for STI clients in five facilities in southern Malawi
Facility 1 (%] Facility 2 (%] Facility 3 (%] Facility 4 (%] Facility 5 (%] Total (%]
Model of care Specialized Specialized Integrated Integrated Integrated -
Number of respondents 63 40 37 56 27 223
Number of women 24 (38.1] 20 (50] 24 (64.9] 32 (57.1] 14 (51.9] 114(51.1]
Number of men 39 (61.9] 20 (50] 13 (35.1] 24 (42.9] 13 (48.1] 109 (58.9]
Told about HIV testing 32 (50.8] 31 (77.5] 10 (27.0] 10 (17.9] 5 (18.5] 88 (39.4]
Women 13 (54.2] 14(70] 5 (38.4] 5 (15.6] 3 (21.4] 40 (35.1]
Men 19 (48.7] 17 (85] 5 (20.8] 5 (20.8] 2 (15.4] 48 (44.0]
Data are number of participants (%]

Table 8 shows the results of logistic regression models that examine the relationship between being told about HIV testing, client characteristics, and facility characteristics. Model 1 shows the relationship between client demographics and being told about testing. Age had an inverted u-relationship with PITC younger and older respondents were less likely to be offered PITC than middle-aged respondents. No other demographic characteristics predicted PITC, including the gender of clients. Model 2 includes client demographics, self-rated health, likelihood of HIV infection, and sexual risk behavior in the past 12 months. Age remained significantly associated with the implementation of PITC. In this model, married clients were significantly less likely to be told about HIV testing than respondents who were not currently married. This is an important finding since in Malawi most HIV infections take place within marriage (NSO & ORC Macro, 2011), representing a key population of STI clients currently missed by PITC strategies. Importantly, gender was again not associated with PITC, disproving my hypothesis that providers are less likely to offer PITC to male STI clients. In fact, women were less likely than men to be told about HIV testing, although this did not reach significance.
Model 3 includes client characteristics and the model of STI services used in each facility. In this model, attending an integrated (versus specialized) health facility was the strongest predictor of PITC; clients in integrated facilities were 87% less likely to be told about testing than clients in specialized facilities (AOR=0.1, 95% CI=0.1-0.3). Age and marital status remained significantly associated with PITC.
Model 4 includes the quality of STI services provided to clients. As expected, clients

who received higher quality STI services, such as discussing ways to prevent future STIs or being given a partner referral slip, were more likely to be told about HIV testing. However, even when controlling for quality of STI services, clients in integrated facilities were still less likely to be told about testing than clients in specialized facilities (AOR=0.16, Cl 95%= 0.07-0.33), suggesting that simply improving quality of STI services more broadly would not completely address the poor implementation of PITC.13 Younger and older clients were still less likely to be offered testing. Interestingly, perceived likelihood of being infected with HIV reached significance in Model 4 and was negatively associated with PITC. In other words, clients who thought they were likely to be infected with HIV were less likely to be told about testing. As with Models 1 and 2, the gender of clients was not associated with PITC in either Model 3 or 4.
The sample size from each integrated facility is too small to test the association between PITC and client characteristics for individual facilities, but among specialized facilities, the associations described above hold for individual facilities (not shown).
13 Results for quality of STI services included a range of quality of care, including high- and low-levels of quality care, although the majority of clients reported mid-level quality of STI services.

Table 8. Odds ratios from logistic regression models demonstrating associations between
PITC and client and facility characteristics in southern Malawi
Model 1 Model 2 Model 3 Model 4
(95% Cl) (95% Cl) (95% Cl) (95% Cl)
Demographic variables Female (=1) 0.8 0.7 0.9 1.1
(0.4-1.5) (0.4-1.4) (0.4-1.9) (0.5-2.6)
Age 1.5* 1.5** 1.6** 1.5*
(1.1-2.0) (1.1-2.0) (1.1-2.1) (1.1-2.0)
Age-squared 0.9* Q 9** Q 9** Q 9**
(0.9-0.9) (0.9-0.9) (0.9-0.9) (0.9-0.9)
Married (=1) 0.5 0.5* 0.4* 0.5
(0.2-1.1) (0.2-0.9) (0.2-0.9) (0.2-1.1)
Years of education 0.9 - - -
Household asset scale (0.9-1.1) 0.9
Self rated health (0.8-1.2) 0.9 0.6 0.6
Muliptle partners in the last year (0.5-1.8) 0.7 (0.3-1.2) 0.7 (0.3-1.2) 0.7
Perceived high risk of HIV (0.3-1.5) 0.6 (0.3-2.0) 0.5 (0.2-2.1) 0.4*
Model of Care Integrated model of care Quality of STI services (excluding PITC) Constant 0.003* (0.3-1.5) 0.004* (0.3-1.0) Q ^*** (0.1-0.3) 0.006* (0.2-0.8) Q 2*** (0.1-0.3) 2 Q*** (1.3-2.9) 0.003*
(0.0-0.3) (0.0-0.4) (0.0-0.7) (0.0-0.5)
N=223; p<0.05, ** p<0.01, *** pcO.OOl
Quality of PITC
The second way I measure the implementation of PITC is through the quality of PITC provided. The quality of PITC is important because it likely influences clients acceptance of testing. Provider-initiated testing should include multiple components to motivate clients to test and should adhere to the following protocols, regardless of the category of client (STI, ANC, or TB client): (1) explain how HIV is transmitted and the importance of testing;
(2) explain that clients can refuse testing; (3) explain that test results are confidential;

(4) give time for clients to ask questions; and (5) provide HIV testing as part of the consultation (Hardon etal., 2012; Ministry of Health [Malawi], 2011a). Ideally, testing should be done before other services are completed. However, exit surveys show that the implementation of PITC did not follow these guidelines.
Only 5.4% of all respondents received all six components of the PITC protocol. Among clients who were told that they should be tested for HIV, (only 39% of all respondents), over 30% were not given any explanation as to the importance of testing, implications of a positive test, or that services would be confidential. Responses to open-ended questions in the survey show that these clients were simply told to "go for testing, usually as clients left the consultation room nothing else was said. Among clients told about testing, only 25% were given an opportunity to ask questions about HIV testing or treatment and 29% were told about five or more of the six components of PITC (see Table 9). Notably, only 3 respondents were escorted to the VCT room, all other respondents were expected to seek out testing for themselves. None of the respondents were tested in the STI consultation room. This means that even if STI clients were told about testing, which was rare, they still had to overcome the standard barriers associated with traditional VTC -they had to seek out HIV testing, wait extended time periods of time in the VCT queue, and potentially have to return another day if providers for HIV testing were not available.

Table 9. Quality of PITC for STI clients in five facilities in southern Malawi

Variable Percentage
Integrated Specialized Total
Quality of care for those offered PITC (n=25) (n=63) (n=88)
Told to get tested for HIV, nothing more 24.0 22.2 22.7
Did the provider explain the importance of HIV testing? 52.0 60.7 58.0
Did the provider explain that you had a choice to accept or refuse HIV testing? 52.0 60.7 58.0
Did the provider explain the role of HIV treatment if found HIV positive? 29.2 33.9 32.5
Did the provider give you time to ask questions about HIV and HIV testing? 24.0 25.0 24.7
Did the provider explain that your results would not be shared? 52.0 53.6 53.1
Additive scale for quality PITC only including those offered testing (n=25) (n=63) (n=88)
1 (told to get tested) 24.0 33.3 30.7
2 28.0 9.5 14.8
3 8.0 15.9 13.6
4 12.0 11.1 11.4
5 12.0 17.5 15.9
6 16.0 12.7 13.6
Additive scale for quality PITC -including those not offered testing (n=120) (n=103) (n=223)
0 (not offered HIV testing) 79.2 38.8 60.5
1 (told to get tested) 5.0 20.4 12.1
2 5.8 5.8 5.8
3 1.7 9.7 5.4
4 2.5 6.8 4.5
5 2.5 10.7 6.3
6 3.3 7.8 5.4
Table 10 shows the associations between the quality of PITC received and client and facility characteristics. Only clients who were told about HIV testing were included in the

models (n=87). In Models 1, 2, and 3, client demographics, sexual risk behavior, and facility characteristics were not associated with the quality of PITC received.
In Model 4,1 include the quality of STI services received. In this model, the quality of STI services received and clients self-rated health were significantly associated with the quality of PITC services provided. The model of STI services, client characteristics, and clients perceived likelihood of HIV infection remained unassociated with the quality of PITC received. Importantly, analyses by the model of STI services provided are limited due to the small sample size in each model of care (for example, only 25 clients were offered PITC in integrated facilities), therefore these findings should be interpreted with caution.

Table 10. Odds ratios from ordinal logistic regression models demonstrating associations between the quality of PITC and client and facility characteristics in southern Malawi
Model 1 Model 2 Model 3 Model 4
(95% Cl) (95% Cl) (95% Cl) (95% Cl)
Demographic variables
Female (=1) 1.3 0.5 0.5 0.8
(0.5-3.6) (0.2-1.4) (0.2-1.3) (0.3-2.1)
Age 1.4 1.0 1.0 1.1
(0.8-2.3) (0.6-1.7) (0.6-1.7) (0.7-1.7)
Age-squared 0.9 0.9 0.9 0.9
(0.9-1.0) (0.9-1.0) (0.9-1.0) (0.9-1.0)
Married (=1) 0.8 0.9 0.9 0.9
(0.3-2.1) (0.4-2.4) (0.3-2.3) (0.3-2.9)
Years of education 1.1 (0.9-1.3)
Household asset scale 1.2 (0.9-1.5)
Self rated health 0.5 (0.2-1.3) 0.5 (0.2-1.3) 0.4* (0.2-0.9)
Muliptle partners in the last year 0.6 (0.2-1.8) 0.6 (0.2-1.6) 0.7 (0.3-2.1)
Perceived likelihood of HIV
infection 0.9 (0.4-2.4) 0.9 (0.4-2.4) 0.5 (0.2-1.5)
Model of Care
Integrated model of care Quality of STI services (excluding PITC) 1.5 (0.6-3.9) 1.6 (0.6-4.1) 2 2*** (1.4-3.3)
N=87; p<0.05, ** p<0.01, *** p<0.001
Implications Getting Tested
Exit-surveys show that PITC for STI clients is poorly implemented in participating facilities in southern Malawi, (only 39% of clients were told about testing). Implementation varied based on the model of STI services provided. In integrated facilities, only 20.8% of clients

were told about HIV testing compared to 61.2% of clients in specialized facilities. This is concerning since the majority of facilities in Malawi are rural and likely face similarly low levels of PITC. The bigger concern, however, is the limited impact of PITC even when it was offered, regardless of the model of care used. For clients who were told about testing, the quality of PITC was poor: only 29% of these clients were given five or more components of PITC. More importantly, testing was not facilitated within the STI consultation. STI clients who were motivated for testing still had to seek out testing for themselves and face the same barriers to care that would be experienced if they sought services independently from PITC. As organized, PITC for STI clients was not an opt-out strategy as intended. At best, PITC provided a small cue to action but did not remove barriers to care. At worst, and more commonly, PITC was not implemented at all. There was little resemblance between PITC in theory and PITC in practice.
The result? STI clients were not tested. During observation, the research assistants saw only two STI clients return to the provider who offered STI services one told the provider her HIV status, the other told the provider that the line for testing was too long. During exit surveys, over 40% of respondents told research assistants that they would likely be tested for HIV that same day; however, observation by research assistants showed that time and time again, clients left the health facility without ever being tested (research assistants saw the majority of clients exiting the facility compound after completing the survey). Respondents may have returned for testing on another day, but given the often long distance to the health facility, and the long wait required to receive services, this seems unlikely. Unfortunately, data from this study cannot confirm if clients were tested or not. Data from the Ministry of Healths STI registers suggests that, throughout Malawi, HIV

status is ascertained for 45% of STI clients (either with a recent test conducted before receiving STI services or with a test conducted on the day of STI services) (Ministry of Health [Malawi], 2014); however, participant observation shows that these registers are not filled out correctly and vastly overestimate status ascertainment (discussed in detail in Chapter 5). Based on the fact that only 39% of clients were told about testing, only 5.4% of all respondents were given quality PITC, and testing was not integrated into STI services, it is likely that research assistants observations are correct STI clients are not being tested for HIV.
Gender and PITC for STI clients
Implementation of PITC did not vary by gender of client in either integrated or specialized models of care. Indeed, gender was not associated with the implementation of PITC in any of the regression models. This finding disproves my hypothesis that providers are less likely to offer testing to male versus female STI clients. There are two potential explanations as to why the gender of clients was not associated with PITC implementation. First, providers did not prioritize PITC for any STI client. Most providers were not concerned with getting clients tested, but with getting through the queue of clients (discussed in detail in Chapter 5). The lack of focus on HIV testing in general may mean that provider perceptions about gender do not influence how they implement PITC.
Second, The limited number of facilities (n=5) and the small number of clients from each facility (the smallest facility only had 27 respondents who were seen by 3 providers) may make it impossible to detect small differences in PITC by gender.
Third, provider perceptions of gender and HIV may contribute to the equal

implementation of PITC across gender of STI clients. In-depth and informal interviews with health care providers showed that nearly all providers believed men were more likely to be HIV positive than women due to mens risky sexual behavior. Nearly three quarters of providers discussed feeling sorry for wives because they were put at risk of infection due to the "selfish behavior of their husbands men were seen as the primary ones getting infected and bringing HIV into the home. Based on this perception, providers regularly discussed the problem of missing men in HIV services and HIV prevention activities, such as using condoms or staying faithful to partners. Providers discourse of vulnerability and blame, which matches closely to the discourse found in international and national policy documents, may not translate into the prioritization of women for health services. Instead, by labeling men as the problem and at increased risk of infection, providers may try to test men more often. In contrast, womens testing may be promoted as a way to protect women against dangerous men. Both mechanisms may result in similar rates of provider-initiated tested across the gender of STI clients.
Barriers to PITC among STI Clients
Why was PITC not implemented for STI clients? Research has shown that throughout sub-Saharan Africa, PITC among STI clients is rarely implemented as intended. Scholars have identified three primary barriers that influence implementation: (1) trained HIV testing counselors are not deployed to STI clinics, meaning that clients still have to seek out testing at the standard HTC site; (2) providers do not have time to offer PITC due to high client load; and (3) providers do not have the skillsets needed to offer PITC (Kwaitana D, 2007; Makwiza et al., 2009). In general, current literature points to the limitations of resource-

constrained health institutions as the primary barrier to PITC among STI clients. However, applying the theory of gendered organizations provides a different perspective and questions the assumption that health institutions in sub-Saharan Africa do not have capacity to properly implement PITC. In the next chapter, I examine the organization of PITC strategies among STI and ANC clients in order to understand how the gendered organization of care influences the implementation of PITC services for STI clients, one of the few client populations where men should theoretically be targeted for HIV services.

Provider-initiated testing among antenatal clients is heralded as one of the major public health successes in the prevention of HIV (PEPFAR, 2010; WHO, 2010a). In Malawi, 82% of all pregnant women attending at least one antenatal visit and 93% of all women giving birth in health facilities knew their HIV status (MoH, 2014). In contrast, I found that only 39% of STI clients with an unknown HIV status were told about testing; the number of clients who were actually tested is unknown, but is likely much lower.
In the context of limited resources, where over 50% of health care worker positions are vacant (Ministry of Health [Malawi], 2011c), why is PITC for antenatal clients thriving while PITC for STI clients is almost non-existent? PITC policies are the same for both ANC and STI clients: the HIV status of all clients who present for antenatal or STI services should be ascertained through opt-out testing strategies (Ministry of Health [Malawi], 2011b).14 In theory, the same PITC protocols should be applied to both client categories. Therefore, something besides policy must drive disparities in PITC implementation.
In this chapter, I use a gendered organization framework to examine how the organization of PITC services in southern Malawi influenced providers implementation of provider-initiated testing for ANC and STI clients. Using observational and interview data, I examine PITC services along the four levels of gendered organization identified by Acker:
14 Those who can prove a positive HIV test or have been tested in the past month do not need to be tested again.

(1) the organizations structure; (2) practices; (3) local interactions; and (4) gendered identities either promoted or discouraged within the organization (Acker, 1990).
Understanding Street-Level Bureaucracy in the Context of Gendered Organizations
Policies are not always implemented as intended. The theory of street-level bureaucracy asserts that healthcare providers interpret and implement policies differently than originally intended by policymakers based on several factors: (1) structural barriers to implementation; (2) provider objectives for their career and personal life; (3) provider knowledge and perceptions of the policy; (4) provider perceptions of the problem at hand; and (5) provider perceptions of the community served (Lipsky, 1980). Studies in sub-Saharan Africa show that providers do indeed modify how sexual health policies are implemented (Angotti, Dionne, & Gaydosh, 2010; Angotti, 2012; Kaler & Watkins, 2010; Robins, 2009). For example, even though PITC strategies should be opt-out and allow clients to refuse testing, social and institutional structures that emphasize the benefit of testing for the prevention of mother-to-child-transmission can lead providers to pressure pregnant women into getting tested, creating, in practice, a compulsory PITC strategy (Nicole Angotti, Dionne, & Gaydosh, 2011; Rujumba, Neema, Tumwine, Tylleskar, & Heggenhougen, 2013; Tripathi, King, Finnerty, Koshovska-Kostenko, & Skipalska, 2013). Providers have justified compulsory testing for ANC clients because (1) testing could prevent mother-to-child-transmission and thus mitigate the risks of HIV and (2) providers are fearful that they could face negative consequences if a child becomes positive and they did not test the mother (Tripathi et al., 2013).

Importantly, the different factors that influence providers implementation of policy are directly tied to the gendered organization of health institutions. For example, structural barriers to implementation are often the direct result of how services are organized. And provider perceptions and knowledge can be influenced by daily interactions within the health institution that shapes provider perceptions of their own work and perceptions of the communities they serve. In what follows, I place constructs from street-level bureaucracy within the gendered organization of care in order to understand how gendered organizations influence implementation of PITC.
Organizational Structure of PITC
The organizational structure of PITC differed for ANC and STI services and was influenced by the overall structure of the two services. Across all participating facilities, ANC was offered by specialized providers and was separate from all other services. Antenatal care only offered on particular days of the week and at particular times of the day, usually first thing in the morning. Clients who tried to access ANC outside designated times were turned away. As a result, it was very easy to identify ANC clients and to ensure that providers were available to provide the required services.
In contrast, STI services outside the largest facilities were integrated into standard out-patient services. Clients could seek STI services at all hours of facility operation alongside other clients seeking care for malaria, broken bones, or the standard flu. Clients did not gather in groups specific to STI services and tailored health education was not

provided.15 As a result, STI clients were hard to identify and it was difficult to ensure that needed services were available at the point of care. The different structures of ANC and STI services influenced how staff were allocated to provide HIV testing services to the different client categories.
Allocation of HIV Service Providers
In Malawi, the responsibility of HIV testing and counseling shifted from traditional health care providers, such as nurses, to Health Surveillance Assistants (HSAs), a largely community-based cadre that received a 10-week basic training in health services and a 3-week training in HIV testing and counseling, certifying them as testing counselors (Bemelmans et al., 2010). In very large facilities, several HSAs were allocated to offer HIV testing and counseling throughout the clinic workday, ensuring that testing was available. In smaller facilities, however, HSAs conducted an array of other activities and allocated only a limited amount of time to HIV testing. Other HSA activities included: (1) weekly under-five services, ANC, and family planning outreach strategies; (2) outreach community education that covered an array of health topics, such as malaria prevention, nutrition, clean water, and HIV treatment and prevention; and (3) tracing HIV positive clients who defaulted from treatment, usually ANC clients. While other health care providers could be trained in HIV testing, service implementation was the primary responsibility of HSAs -only providers who were certified as HTC counselors (a 3-week training) could offer testing services.
15 In some facilities, those who arrive early in the morning may hear a general talk provided to all facility clients, however, this talk will not be tailored to sexual health or STI infections.

Allocation of HSAs for Antenatal Clients
Across Malawi, any facility that offered ANC was required to have at least one HSA allocated to HIV testing during antenatal hours all antenatal clients must have the opportunity to test (Ministry of Health [Malawi] & World Health Organization, 2014). In response, facilities took one of two approaches: (1) pregnant women tested in a special room separate from standard VCT rooms and HSAs were allocated specifically to ANC clients, or (2) pregnant women tested at the standard VCT room but facilities ensured that staff were available for standard VCT whenever antenatal care was provided. In the latter approach, pregnant women always skipped the VCT queue in order to receive testing in a timely manner. In both approaches, antenatal clients first met as a group to receive health education trainings by ANC providers, were then escorted for HIV testing with an HSA, and afterward, received one-on-one antenatal consultations from the ANC provider. Importantly, the allocation of HSAs to ANC clients was fairly easy since antenatal services were only offered on particular days of the week and particular times of day HSAs knew exactly when ANC clients would arrive.
The dedication of HSAs to testing ANC clients had several benefits. First, in theory and in practice, HIV testing was almost always available to ANC clients. Furthermore, since at least one HSA was responsible for testing and ANC clients were always prioritized for care, PITC did not dramatically delay ANC services. Providers did not have to wait hours for clients to be tested before providing antenatal care. A second benefit was that having a dedicated HSA meant that there was always a trained and experienced counselor to implement PITC and motivate clients to test. Providers who offered antenatal services need not worry about motivating HIV testing or ensuring that testing was available for clients -

all components of HIV testing were handled by trained HSAs. Third, having a dedicated HSA created accountability among providers to implement PITC. The HSAs expected antenatal clients to be sent to them for testing, creating accountability for ANC providers to escort clients to the testing site. In turn, after testing was complete and clients returned to the ANC room, ANC providers were meant to look through each clients health book to check if the client had indeed been tested for HIV. The second check held HSAs responsible for actually testing ANC clients. In a health institution where official monitoring and evaluation systems were scarce, the added accountability between providers helped institutionalize PITC for pregnant women.
Allocation of HSAs for STI Clients
In contrast to the HSAs that were dedicated to antenatal clients, STI clients were not allocated HIV testing counselors nor were specific steps taken to ensure that testing was available for this client category. Unfortunately, STI and HIV services were not linked at any point of the continuum of care there was no cooperation between the two services. If the general VCT site was open, STI clients could be tested, but in smaller facilities, availability was sporadic. For example, providers from the three smaller facilities reported that at times the VCT site was closed for multiple days at a time when HSAs had other activities or were recruited for outside projects run by NGOs, which paid better than government facilities. This of course did not happen on days when antenatal services were offered. Furthermore, even when testing was available, queues for VCT were often long and, since STI and HIV services were not linked, STI clients could not skip the general VCT queue like pregnant women.

Within this structure, there was little that STI providers could do to encourage or offer testing. Most STI service providers could not test clients for HIV, even if they wanted to, since the responsibility of testing was shifted to HSAs and many STI providers were not trained as VCT counselors. The structure of staff allocation for STI services meant that, at best, providers could counsel STI clients to be tested but could not fully integrate testing into STI care.
STI providers inability to implement PITC policies may have decreased their motivation to counsel clients on the importance of testing. Since testing was not integrated within STI services, most providers believed that even when clients said they would go for testing, they usually did not. One provider who specialized in STI services at a larger facility reflected on the problem: "Once they have the drugs [STI treatment], they run away. They tell you one thing but do another (Female STI provider, February 14, 2014).
Most providers suggested that without the structure to facilitate HIV testing within the STI consultation, as was done for ANC clients, telling STI clients to be tested had little impact on the uptake of care. For example, one provider said:
It doesn't matter what we tell them. People have already made their mind about HIV testing. If they are not ready you cannot change their mind. It is only those who do not know that you can educate. (Female provider, June 20, 2014)
Not surprisingly, several STI service providers suggested that HIV testing should be integrated into STI consultations clients should either be tested or show their previous test results before receiving STI treatment. While providers supported this idea in theory, they also recognized that, based on the current structure of PITC for STI services, integration was not practical. All but one provider questioned the feasibility of integrated

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! aV ABEF@BQF y BK= y LKMMK[ POD@!FO<=!FOD!=D! W'")!o!),*!-KCD@=PD=F Y @?=!ODD=D@D=AD@DA!K@><=B]! ED@CBQDE2!WNX!R<@FBQBR<=F!K5ED@C!ER< QDE_! Facility Facility type Facility ownership Location of HTC Privacy of HTC waiting spaces Time of day that HTC is offered HTC clients/day VMMC during study 1 District hospital Government Same building as ANC, GYN, under-five, ART, and STI services semi-private All day 30 no 2 Semi-urban health center Government Outside facility walls (queue is visible from the street), near OPD not at all private All day 13 no 3 Rural hospital CHAM Near adolescent, under-five, and STI services private All day upon request, provider in the room during antenatal services 11 no 4 Rural health center CHAM In the ANC building semi-private During antenatal services 22 yes 1 5 Rural clinic Government In the under-five building not at all private During antenatal services 11 yes 2 1 Due to extended VMMC strategies, the number of people tested for HIV is higher than during non-VMMC periods. On non-VMMC periods the facility averages 3 HTC clients per day 2 Due to extended VMMC strategies, the number of people tested for HIV is higher than during non-VMMC periods. On non-VMMC periods the facility averages 2 HTC clients per day Table 2. Characteristics of the five participating facilities in southern Malawi


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! NTf \#):!WGHNHBQ!CBEBK=!GHNH Y GHNg2!R@DCD=FB=>!PKFOD@ Y FK Y QOBMA! F@<=EPBEEBK=!KL!#$/!FK!@D6!K=!#$/t0$.":!(D=DC<;!"[BF]D@M<=A: \#):!WGHNG5X:!-<=B]@!K?@!>K!<=A!?FBMB]B=>!@DEK?@QDE!L@KP!FOD! (MK5<=BE<=B]FK=;!+"0: \6@KA;!,:!WGHNNX:!-P<:! I+6'!")56'(!C)>=!RW WaX;! aa` Y agT: 8KAD@;!J:!":!o -< ; J:! WGHHaX:! /KM?=F<@6!QK?=EDMMB=>!<=A!FDEFB=>!W/*&X!LK@!#$/!B=! -
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! NTV !55-).2a *%2/2)!,'!20#'!).'4]5*$4-#-# SPECIFIC AIMS AND HYPOTHESES The study is designed as a multi site, mixed method project in Zomba, Malawi, with the following aims: Aim 1. Examine how men are portrayed in Malawi's national HIV policies and their dissemination materials. Conduct policy discourse analysis on national HIV policy documents, provider training materials, and clinic posters related to H IV. Hypothesis 1.1 Men are represented less frequently than women and with more negative connotations. Aim 2. Explore provider perceptions of HIV testing protocols and high risk clients and how HIV policy influences these perceptions. Conduct participant observation and 12 in depth interviews with healthcare providers who offer STI services at two clinics in Zomba. Hypothesis 2.1 Providers hold negative perceptions toward high risk male clients. Hypothesis 2.2 Feminized HIV policies directly influence p rovider perceptions of high risk clients and HIV testing protocols. Hypothesis 2.3 Feminized HIV policies indirectly influence provider perceptions of high risk clients and HIV testing protocols through provider training materials and clinic media about H IV services. Aim 3. Assess if providers offer poorer quality high risk PITC to male versus female STI clients. Conduct 150 exit surveys with STI clients in two clinics in Zomba.

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! NIH Hypothesis 3.1 Providers are less likely to offer HIV testing to male clients than female clients. Hypothesis 3.2 Providers are less likely to offer comprehensive PITC to male clients than female clients. Hypothesis 3.3 Provider perceptions of HIV testing protocols a nd high risk clients are associated with how they implement high risk PITC.

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! NIN 55-).2a !)'-a!05,-'*1'$4-'#$2'%-/2#$-%'3#-.'2)'0!,!+2!)'4-!,$4'1!&2,2$2-#