title: Combining qualitative and quantitative evidence to determine factors leading to late presentation for antiretroviral therapy in Malawi.
abstract: BACKGROUND
  Treatment seeking delays among people living with HIV have adverse consequences for outcome. Gender differences in treatment outcomes have been observed in sub-Saharan Africa.
  
  
  OBJECTIVE
  To better understand antiretroviral treatment (ART) seeking behaviour in HIV-infected adults in rural Malawi.
  
  
  METHODS
  Qualitative interviews with male and female participants in an ART cohort study at a treatment site in rural northern Malawi triangulated with analysis of baseline clinical and demographic data for 365 individuals attending sequentially for ART screening between January 2008 and September 2009.
  
  
  RESULTS
  43% of the cohort presented with late stage HIV disease classified as WHO stage 3/4. Respondents reported that women's frequency of testing, health awareness and commitment to children led to earlier ART uptake and that men's commitment to wider social networks of influence, masculine ideals of strength, and success with sexual and marital partners led them to refuse treatment until they were sick. Quantitative analysis of the screening cohort provided supporting evidence for these expressed views. Overall, male gender (adjusted OR 2.3, 95% CI1.3-3.9) and never being married (adjusted OR 4.1, 95% CI1.5-11.5) were risk factors for late presentation, whereas having ≥3 dependent children was associated with earlier presentation (adjusted OR 0.31, 95% CI0.15-0.63), compared to those with no dependent children.
  
  
  CONCLUSIONS
  Gender-specific barriers and facilitators operate throughout the whole process of seeking care. Further efforts to enrol men into care earlier should focus on the masculine characteristics that they value, and the risks to these of severe health decline. Our results emphasise the value of exploring as well as identifying behavioural correlates of late presentation.
authors: Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom. f.r.parrott@uva.nl
authors: Fiona R
authors: FR
authors: Parrott
authors: Charles
authors: C
authors: Mwafulirwa
authors: Bagrey
authors: B
authors: Ngwira
authors: Sothini
authors: S
authors: Nkhwazi
authors: Sian
authors: S
authors: Floyd
authors: Rein M G J
authors: RM
authors: Houben
authors: Judith R
authors: JR
authors: Glynn
authors: Amelia C
authors: AC
authors: Crampin
authors: Neil
authors: N
authors: French
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara; D000368:Aged; D000369:Aged, 80 and over; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001294:Attitude to Health; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003657:Decision Making; D005260:Female; D006678:HIV / Q000472:pathogenicity*; D015658:HIV Infections / Q000517:prevention & control* / Q000523:psychology* / Q000821:virology; D006801:Humans; D008295:Malawi; D008297:Male; D008875:Middle Aged; D010358:Patient Participation / Q000523:psychology*; D012307:Risk Factors; D012424:Rural Population; D012737:Sex Factors; D012725:Sexual Behavior; D013997:Time Factors; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents