Negotiating multiple barriers: health workers' access to counselling, testing and treatment in Malawi

Abstract

Malawi is facing a severe HIV and AIDS epidemic with an estimated 12% of its population living with the virus. Health workers are on the front lines of the HIV epidemic and they face the risk of HIV infection in both their personal and professional lives. This mixed method study aimed to explore the enablers and barriers to HIV counselling and testing and antiretroviral therapy by health workers in Malawi. After qualitative data were collected through in-depth interviews with health workers in the Mchinji and Nsanje districts, a survey questionnaire was constructed and administered to 906 health workers in eight districts in Malawi.

A majority (76%) of health workers surveyed reported having undergone HIV testing and counselling, of whom 74% reported repeat testing. A striking result of the study is that 22% of health workers reported testing after occupational exposure to HIV. The proportions of respondents reporting that they tested after experiencing symptoms, or self-testing for HIV were 11% each. The in-depth interviews and the survey revealed multiple challenges that health workers face to accessing HIV testing, counselling and treatment, including fear of a positive result, fear of stigma and lack of confidentiality. Additional barriers included health workers' personal acquaintance with those conducting testing, along with their perception of being “role models” which could exacerbate their fears about confidentiality. Given health workers' critical role in HIV delivery in Malawi, there is need to develop solutions to help health workers overcome these barriers.

Keywords:

• health workers
• Malawi
• access
• ART
• counselling and testing

Acknowledgements

We thank the health workers from across Malawi who gave their time to participate in this research; the Ministry of Health of Malawi for its support; the Department of HIV/AIDS of the World Health Organization for providing financial support and technical assistance for this project; and the Department for International Development for additional financial support. Thanks also to Barbara MacPake, Margaret Reeves and Mindy Hochgesang for contributions and advice on study design.

Notes

1. Clinical officers, medical assistants and medical officers all manage patients and give prescriptions, however, only medical officers have an MD qualification. Clinical officers and medical assistants have a diploma or certificate in clinical medicine from colleges, not universities. The HSAs are responsible for public health work such as counselling and testing, water and sanitation, vaccinations and health promotion in communities.

2. The minimum sample size for the national study was determined using the standard formula estimating sample size for a single proportion below:

Given confidence level = 95%, absolute width of confidence interval around the estimate =5%, proportion of the population having a particular characteristic of interest, in this case the proportion of health workers accessing HIV services. Since a single proportion was required, and the level of access to services was unknown, the study used a safety value of 0.5 or 50% to get the maximum sample size and design effect of 3.