Understanding gender power relations, transactional sex and HIV in fishing communities in Southern Malawi

Over the past 30 years, HIV/AIDS has had a devastating impact on the lives of millions of people around the world. Despite successes in the roll out of HIV treatment programmes, HIV prevention programmes have been less successful in lowering incidence rates. Certain groups have been found to experience significantly higher prevalence than seen in the general population, with fishing communities representing one key group with significantly higher risk of HIV infection. In fishing communities, gender power relations and economic vulnerability intersect in ways that mean that individuals are particularly vulnerable to HIV infection. In the past decade, there has increasingly been a focus on structural drivers of HIV transmission such as gender power relations. Gender differences are fundamentally underpinned by power inequalities in society and can result in the subordination of women and their interests in a manner that favours men. This thesis set out to understand how gendered structural drivers shaped vulnerability to HIV in fishing communities, and to develop interventions to address these structural drivers. The research was conducted in two fishing communities in the rural district of Mangochi in Southern Malawi. The design of the study drew on social relations theory and second-wave feminism. The research methodology used qualitative and participatory methods to address four key research objectives: (1) to understand gender power relations in fishing communities in Southern Malawi; (2) to explore and document the key drivers and facilitators of participation in transactional sex in the study villages; (3) to document individual and community perceptions of HIV risk and transactional sex in the study villages; (4) to develop a HIV prevention strategy to address risk of HIV/AIDS among fishing communities in southern Lake Malawi. Key findings are that in fishing communities, transactional sex was common and took a variety of forms, ranging from gift-giving within relationships, to-sex-for fish exchanges, to sex worker encounters. Power differences between couples in transactional sexual encounters shaped individuals’ abilities to negotiate condom use. The context and motivations for transactional sex varied and were mediated by economic need and social position both of men and women. Microfinance is a tool that can alleviate poverty and potentially prevent HIV. However, in the fishing context microfinance loan repayment procedures often increased female fish traders’ vulnerability to HIV. Participants had a good understanding of HIV risk yet this did not result in the adoption of risk-reduction strategies. Building on these findings, the thesis presents suggested HIV interventions that were developed through participatory community workshops. Interventions identified included: working with men and boys to support transformation of gender roles and normative behaviour; enforcing legislation to improve the ecological environment to reduce the impact of decline fish stocks and environmental hazards on risk-taking behaviour; improving access to HIV testing and treatment services; and improving living and working conditions of men and women working in the fishing industry. In conclusion, this thesis demonstrates the urgent need to introduce structural interventions in fishing communities in Southern Malawi and provides clear recommendations for implementing potential interventions

Perspectives and Practices on Water, Sanitation, and Hygiene from a Fishing Community along Lake Malombe, Southern Malawi

People living in fishing communities have a high burden of preventable water, sanitation, and hygiene (WASH) related diseases but have often been neglected in research and policy. We explored practices and perspectives on WASH among fishing villages around Lake Malombe, Malawi. We employed a mixed methods design, and data were initially collected through participant observations (five weeks), followed by a second phase of qualitative interviews (n = 16), focus group discussions (n = 7), and quantitative surveys (n = 242). We observed that safe water sources were scarce; latrines were basic; and handwashing facilities were limited. Seventy-one percent (n = 174) of households collected water from unsafe sources (open wells and the lake). Eighty-six percent (n = 207) of households had basic short-term latrines. Twenty-four percent (n = 59) of households had handwashing facilities with soap. Qualitative data supported these observations and identified additional factors which compounded poor WASH practices including, a high transient population associated with the fishing trade, poor infrastructure design and construction which lacked consideration of the environmental factors, context and social and cultural norms. As such, fishing communities are underserved and marginalised with constrained access to WASH services, which must be addressed through behaviour-centered and context appropriate solutions

Fragile and conflict affected states: report from the Consultation on Collaboration for Applied Health Research and Delivery

Fragile and Conflict Affected States present difficult contexts to achieve health system outcomes and are neglected in health systems research. This report presents key debates from the Consultation of the Collaboration for Applied Health Research and Delivery, Liverpool, June, 2014

Factors shaping initial decision-making to self-test amongst cohabiting couples in urban Blantyre, Malawi.

In sub-Saharan Africa, most new HIV infections occur in stable relationships, making couples testing an important intervention for HIV prevention. We explored factors shaping the decision-making of cohabiting couples who opted to self-test in Blantyre, Malawi. Thirty-four self-tested participants (17 couples) were interviewed. Motivators for HIV self-testing (HIVST) emerged at three main levels. Individual motivations included perceived benefits of access to treatment, and self-checking of serostatus in the hope of having been cured by prolonged treatment or faith-healing. HIVST was considered convenient, confidential, reassuring and an enabling new way to test with one's partner. Partnership motivations included both positive (mutual encouragement) and negative (suspected infidelity) aspects. For women, long-term health and togetherness were important goals that reinforced motivations for couples testing, whereas men often needed persuasion despite finding HIVST more flexible and less onerous than facility-based testing. Internal conflict prompted some partners to use HIVST as a way of disclosing their previously concealed HIV positive serostatus. Thus, the implementation of community-based HIVST should acknowledge and appropriately respond to decision-making processes within couples, which are shaped by gender roles and relationship dynamics

Thrombocytosis and abnormal liver enzymes:A trigger for investigation of underlying malignancy

BackgroundThrombocytosis is often an incidental finding in primary care with a range of causes. Despite evidence of a strong association between thrombocytosis and malignancy, guidelines for investigating thrombocytosis in the absence of red flag symptoms remain unclear. A novel automated system of laboratory analysis, intelligent Liver Function Testing (iLFT), launched in Tayside in 2018 and has identified a patient group with thrombocytosis and abnormal liver test (LFT) results. This study analysed the outcome of these patients and investigated the use of thrombocytosis combined with LFTs in predicting risk of cancer.Methods and findingsBetween August 2018 and August 2020, 6792 patients underwent iLFT, with 246 found to have both thrombocytosis and at least one abnormal LFT. A random case-matched control group of 492 iLFT patients with normal platelet count and at least one abnormal LFT was created. 7.7% (95% CI 4.7-11.8%) of patients with thrombocytosis had cancer compared to 2.0% (1.0-3.7%) of controls. Patients ConclusionsThese findings suggest a substantial increased risk of cancer in patients with thrombocytosis and raised ALP. This could be developed as an adjunct to current investigation algorithms, highlighting high-risk patients and prompting further investigation (such as computed tomography scans) where indicated

Sex, power, marginalisation and HIV amongst young fishermen in Malawi: Exploring intersecting inequalities

Through scale-up of effective treatment and prevention, HIV incidence rates are falling across Southern and Eastern Africa. However, key population groups, including people living in fishing communities, continue to face an elevated risk of infection and have high rates of undiagnosed disease. We set out to investigate how intersecting inequalities make young fishermen working on the southern shores of Lake Malawi particularly vulnerable to HIV-infection. We used qualitative research methods including observations (over a 15-month period), in-depth interviews (59) and focus group discussions (16) with a range of male and female participants living and working in two fishing villages. We found that the roles that men occupied in the fishing industry depended on several factors, including their age, socio-economic position and the amount of experience they had in the industry. In turn these roles shaped their lives, including exposure to occupational risks, mobility, living conditions, economic remuneration and social standing within the community. In this context, younger and poorer men occupied roles with the lowest social standing in the industry. Nevertheless, in these communities where poverty was pervasive, young fishermen were able to exert the power they gained through access to money and fish over poorer younger women – pressuring them into sex and increasing the risk of HIV for both men and women. Drawing on an intersectionality framework, we contextualised these findings to consider how young men’s social location, relationships and experiences of both privilege and marginalisation were shaped by broader economic and political processes. We conclude that interventions to prevent HIV in fishing communities need to address how power plays out in the broader social and economic environment

Household antibiotic use in Malawi: A cross-sectional survey from urban and peri-urban Blantyre

Antimicrobial resistance (AMR) is a significant threat to public health. Use of antibiotics, particularly in contexts where weaker regulatory frameworks make informal access easier, has been identified as an important driver of AMR. However, knowledge is limited about the ways antibiotics are used in communities in Malawi and sub-Saharan Africa. Between April and July 2021, we undertook a cross-sectional survey of community antibiotic use practices in Blantyre, Malawi. We selected two densely-populated neighbourhoods (Chilomoni and Ndirande) and one peri-urban neighbourhood (Chileka) and undertook detailed interviews to assess current and recent antibiotic use, supported by the innovative “drug bag” methodology. Regression modelling investigated associations with patterns of antibiotic recognition. We interviewed 217 households with a total of 1051 household members. The number of antibiotics recognised was significantly lower among people with poorer formal health care access (people with unknown HIV status vs. HIV-negative, adjusted odds ratio [aOR]: 0.76, 95% CI: 0.77-.099) and amongst men (aOR: 0.83, 95% CI: 0.69–0.99), who are less likely to support healthcare-seeking for family members. Reported antibiotic use was mostly limited to a small number of antibiotics (amoxicillin, erythromycin and cotrimoxazole), with current antibiotic use reported by 67/1051 (6.4%) and recent use (last 6 months) by 440/1051 (41.9%). Our findings support the need for improved access to quality healthcare in urban and peri-urban African settings to promote appropriate antibiotic use and limit the development and spread of AMR

Improving pathways to care through interventions cocreated with communities: a qualitative investigation of men’s barriers to tuberculosis care-seeking in an informal settlement in Blantyre, Malawi

Introduction Men have a higher prevalence of undiagnosed tuberculosis (TB) than women and can spend up to a year longer contributing to ongoing transmission in the community before receiving treatment. Health outcomes are often worse for patients with TB living in informal settlements especially men. This study aimed to understand the barriers preventing men from seeking care for TB and cocreate interventions to address these barriers. Methods We used qualitative research methods including in-depth interviews and participatory workshops. Researchers worked with women and men living in Bangwe, an informal settlement in Blantyre, Malawi to develop interventions that reflected their lived realities. The study took place over two phases, in the first phase we undertook interviews with men and women to explore barrier to care seeking, in the second phase we used participatory workshops to cocreate interventions to address barriers and followed up on issues emerging from the workshops with further interviews. In total, 30 interviews were conducted, and 23 participants joined participatory workshops. The team used a thematic analysis to analyse the data. Results Three interconnected thematic areas shaped men’s health TB seeking behaviour: precarious socioeconomic conditions; gendered social norms; and constraints in the health system. Insecurity of day labour with no provision for sick leave; pressure to provide for the household and a gendered desire not to appear weak and a severely under-resourced health system all contributed to men delaying care in this context. Identified interventions included improved patient–provider relations within the health-system, improved workers’ health rights and broader social support for households. Conclusion Improving mens’ pathways to care requires interventions that consider contextual issues by addressing individual level socioeconomic factors but also broader structural factors of gendered social dynamics and health systems environment

“I wanted evidence that my status had changed, so that is why I tested”: experiences with HIV self-testing among female sex workers in Malawi

Maximising HIV testing among female sex workers (FSWs) is an established global health priority. HIV self-testing (HIVST) seems to have the potential to address issues of confidentiality, privacy and convenience among this key population. HIVST, however, may result in unintended consequences as its implementation unfolds in a complex sex work context characterised by unequal power relations, stigma and high HIV prevalence. This study aimed to explore the experiences of FSWs with HIVST in the context of retesting and antiretroviral usage in Blantyre, Malawi. We used an ethnographic approach to understand meanings and views around HIV self-testing and retesting. We found high levels of retesting, especially among those on antiretroviral, two of which received ‘false negative’ results. We identified three broad narratives: (1) retesting in response to experiences in the sex work context, (2) retesting driven by the desire to self-monitor HIV negative status, and (3) retesting in the hope of sero-reversion. The experiences of these women indicate that the implementation of HIV self-testing in the context of sex work is complex with potential for unintended harms such as coercive testing. HIVST programmes must include clear and appropriate messaging to reduce retesting while on ART and ensure effective strategies are in place to address FSW concerns and anxieties about the accuracy of their HIV positive test results

The ‘Drug Bag’ method:Lessons from anthropological studies of antibiotic use in Africa and South-East Asia

Understanding the prevalence and types of antibiotics used in a given human and/or animal population is important for informing stewardship strategies. Methods used to capture such data often rely on verbal elicitation of reported use that tend to assume shared medical terminology. Studies have shown the category 'antibiotic' does not translate well linguistically or conceptually, which limits the accuracy of these reports. This article presents a 'Drug Bag' method to study antibiotic use (ABU) in households and on farms, which involves using physical samples of all the antibiotics available within a given study site. We present the conceptual underpinnings of the method, and our experiences of using this method to produce data about antibiotic recognition, use and accessibility in the context of anthropological research in Africa and South-East Asia. We illustrate the kinds of qualitative and quantitative data the method can produce, comparing and contrasting our experiences in different settings. The Drug Bag method produce accurate antibiotic use data as well as provide a talking point for participants to discuss antibiotic experiences. We propose it can help improve our understanding of antibiotic use in peoples' everyday lives across different contexts, and our reflections add to a growing conversation around methods to study ABU beyond prescriber settings, where data gaps are currently substantial