Gender Disparities in High-Risk PITC: The Role of Policy on Provider Practices

描述(由申请人提供)：拟议的研究金将使申请人为专注于艾滋病毒政策及其在实践中的实施的研究生涯做好准备。一项全面的培训计划伴随着拟议的研究，目标如下：(1)发展有关撒哈拉以南非洲(SSA)艾滋病毒政策和艾滋病毒检测方案执行情况的知识；(2)提高调查、深入访谈和政策话语分析的方法能力；(3)发表和介绍研究成果。这项拟议研究的具体重点是检查男性未充分利用艾滋病毒检测，从而延长生命的治疗。在SSA中，男性占艾滋病相关发病率和死亡率的大多数，尽管他们感染的可能性比女性小。男性艾滋病相关死亡率高的一个主要原因是他们未能获得艾滋病毒检测：在将进行这项研究的马拉维，接受艾滋病毒检测的男性仅占33%。一种常见的解释是，男性比女性更不愿意了解自己的艾滋病毒状况，因为担心积极的状况会损害他们的男子气概。另一个看似合理的解释是结构性的，而不是个体的：由于强调女性对艾滋病毒过度敏感的女性化政策，医疗保健提供者向男性提供的艾滋病毒检测服务比女性少。在马拉维，几乎所有寻求产前护理的妇女都要接受艾滋病毒检测，但男性必须明确要求进行检测。然而，即使在应该为所有客户提供艾滋病毒检测的场所，就像患有结核病或性传播感染(STI)的马拉维人一样，男性也不太可能接受检测。一种可能的解释是，女性化的艾滋病毒政策影响了提供者与男性客户与女性客户的互动方式。尽管高收入国家的研究表明，女性化的性健康政策可能导致提供者向男性提供的保健服务比女性少，但在艾滋病毒高发的SSA国家没有类似的研究。马拉维拟议的这项研究将首次审查艾滋病毒政策是否影响提供者对性别和艾滋病毒的看法，以及这是否影响提供者对结核病和性传播感染客户执行艾滋病毒检测方案。这项研究有三个目的：(1)使用政策话语分析来检查艾滋病毒政策中男性和女性是如何被描绘的，使用国家政策和提供者培训材料作为文本；(2)收集和分析来自对医疗保健提供者的深入访谈的数据，以评估他们对男性和女性客户的看法是否存在差异；(3)收集和分析来自结核病和性传播感染客户的出口调查数据，以测试提供者是否向男性客户和女性客户提供不同的艾滋病毒检测。这三个目标的结果将通过混合方法分析一起进行审查，以探索艾滋病毒政策、提供者的看法和提供者执行艾滋病毒检测方案之间的关系。研究结果将对艾滋病毒政策产生影响，并可为旨在增加男子使用艾滋病毒服务的干预措施提供信息。该项目通过解决高危人群在艾滋病毒服务利用方面存在差异的原因，与国家卫生保健中心的使命和目标相一致。

DESCRIPTION (provided by applicant): The proposed fellowship will prepare the applicant for a research career focused on HIV policies and their implementation in practice. A comprehensive training plan accompanies the proposed study and has the following objectives: (1) develop knowledge of both HIV policies and the implementation of HIV testing protocols in sub-Saharan Africa (SSA); (2) increase methodological capacity in surveys, in-depth interviews, and policy discourse analysis; and (3) publish and present research findings. The specific focus of the proposed study is to examine men's underutilization of HIV testing, and thus life-prolonging treatment. Men constitute the majority of AIDS-related morbidity and mortality in SSA even though they are less likely than women to be infected. A primary contributor to men's high rate of AIDS-related mortality is their failure to access HIV testing: in Malawi, where the study will be conducted, men comprise only 33% those tested for HIV. A common explanation is that men are more reluctant than women to learn their HIV status due to concerns that a positive status would compromise their masculinity. A plausible additional explanation is structural rather than individual: as a result of feminized policies that emphasize women's excess vulnerability to HIV, healthcare providers offer fewer HIV testing services to men than women. In Malawi, virtually all women seeking antenatal care are tested for HIV, but men must specifically request testing. Yet even in venues where all clients should be offered HIV testing, as is the case for Malawians with TB or sexually transmitted infections (STIs), men are less likely to be tested. A possible explanation could be that feminized HIV policies affect how providers interact with male versus female clients. Although studies in high-income countries show that feminized sexual health policies can lead providers to offer fewer health services to men than women, there are no equivalent studies in the high HIV-prevalence countries of SSA. The proposed study in Malawi will be the first to examine if HIV policy influences providers' perceptions of gender and HIV, and whether this affects providers' implementation of HIV testing protocols for TB and STI clients. The study has three aims: (1) To use policy discourse analysis to examine how men and women are portrayed in HIV policy, using as texts both national policies and provider-training materials; (2) To collect and analyze data from in-depth interviews with healthcare providers to assess whether there are differences in their perceptions of male and female clients; (3) To collect and analyze data from exit surveys with TB and STI clients to test whether providers offer HIV testing differently to male versus female clients. Findings from the three aims will be examined together through mixed methods analysis in order to explore the relationship between HIV policy, provider perceptions, and provider implementation of HIV testing protocols. Findings will have implications for HIV policies and can inform interventions designed to increase men's use of HIV services. The project aligns with the mission and objectives of NIMH by addressing the causes of disparities in HIV service utilization among high-risk groups.