Health care workers internal bias toward men as HIV clients in Malawi and Mozambique: A qualitative study

BackgroundMen are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs buy-in for male-specific interventions. MethodsFocus group discussions (FGDs) were conducted in 2016 with HCWs from 15 facilities across Malawi and Mozambique, and were originally conducted to evaluate barriers to universal treatment (not gender or internal bias). FGDs were conducted in local languages, recorded, translated to English, and transcribed. For this study, we focused on HCW perceptions of men as HIV clients, using inductive and deductive coding in Atlas.ti v.8, and analyzed codes using constant comparison methods. Findings20 FGDs with 154 HCWs working in HIV treatment clinics were included. Median age was 30 years, 59% were female, and 43% were providers versus support staff. HCWs held strong implicit bias against men as clients. Most HCWs believed men could easily navigate HIV services due to their elevated position within society, regardless of facility-level barriers faced. Men were described in pejorative terms as ill-informed and difficult clients who were absent from health systems. Men were largely seen as "bad clients" due to assumptions about mens selfish and prideful nature, resulting in little HCW sympathy for mens poor use of care. InterpretationOur study highlights a strong implicit bias against men as HIV clients, even when gender and implicit bias were not the focus of data collection. As a result, HCWs may have little motivation to implement male-specific interventions or improve provider-patient interactions with men. Framing men as problematic places undue responsibility on individual men while minimizing institutional barriers that uniquely affect them. Implicit bias in local, national, and global discourses about men must be immediately addressed.