Improving Treatment Adherence and Retention of HIV-Positive Women Through Behavioral Change Interventions Aimed at Their Male Partners: Protocol for a Prospective, Controlled Before-and-After Study

Background According to the World Health Organization, in 2018, 37.9 million people were living with HIV globally. More than two-thirds were residing in sub-Saharan Africa, where the HIV prevalence in the adult population (aged 15-49 years) was 3.9%. This population included 1.3 million pregnant women, of whom 82% had received antiretroviral therapy (ART) for the prevention of HIV mother-to-child transmission. In these countries, one challenge is an insufficient level of treatment adherence, particularly in HIV-positive pregnant women. Among the causes, the lack of involvement from a male partner is a significant contributor to the problem. This issue has strongly emerged in Malawi, one of the countries with the highest HIV prevalence in the world: 9.2% of its adult population were living with HIV in 2018. Objective This study aims to assess 3 interventions that are aimed at improving ART adherence and retention among HIV-positive women through engagement with their male partners in 4 Malawian health care centers. Methods The prospective, controlled before-and-after study is conducted in 3 phases (total duration: 24 months): preintervention, intervention, and postintervention analyses. The number of selected clusters (clinical centers) is limited to 4: one for each intervention, plus a cluster where no intervention is performed (control arm). The interventions are as follows: opening the facility on one Saturday per month only for men, defined as a special day; testing peer-to-peer counseling among men, male champions; and providing a noneconomic incentive to all women who are accompanied by their partners to the facility, nudge. The primary outcome of the study is to evaluate the differences in retention in care and adherence to therapeutic protocols among women; the intermediate outcome is the assessment of differences in male involvement. The level of male involvement in the health of their partners (intermediate outcome) will be evaluated through a dedicated questionnaire administered at baseline and in the postintervention phase. Data will be collected at the clinical centers and stored in 2 electronic databases managed using 2 different types of software. Results The analysis of data collected in the 4 centers during the preintervention phase is ongoing, as enrollment ended on March 31, 2020. The total number of patients enrolled was 452 (Namandanje: 133; Kapeni: 78; Kapire: 75; and Balaka: 166). Meanwhile, several meetings have been conducted to organize the intervention phase. Conclusions The study will identify the best intervention that enhances the involvement of male partners in women’s health, using an approach that considers a broad spectrum of behaviors. An important aspect is the use of educational tools focused on messages, thereby initiating a reflective discussion of stereotypes and false beliefs related to the idea of masculinity present in the Malawian culture. International Registered Report Identifier (IRRID) DERR1-10.2196/19384


Introduction
It is not hard to create a good learning environment, and you do not have to be an expert to do it. But it is important to work on becoming a better facilitator by developing certain attitudes and skills. This is especially important for men who are training to be Male Engagement (ME) facilitators. When men take on this facilitation role, they are not only being asked to help groups of men discuss issues of gender, violence, and sexual health. They are also being asked to model the attitudes and behaviours that men will need to protect their own and others' health, safety, and well-being.
• Using body language to show interest and understanding. In most cultures, this will include nodding your head and turning your body to face the person who is speaking.
• Showing interest and understanding to reflect what is being said. It may include looking directly at the person who is speaking. In some communities, such direct eye contact may not be appropriate until the people speaking and listening have established some trust.
• Listening not only to what is said, but to how it is said, by paying attention to the speaker's body language.
• Asking questions of the person who is speaking, in order to show that you want to understand.
• Summing up the discussions to check that what has been said was understood. Ask for feedback.

Being nonjudgmental
Remember that information should be provided in nonauthoritarian, nonjudgmental, and neutral ways. You should never impose your feelings on the participants.

Effective questioning
Being able to ask effective questions is also a core skill for a ME facilitator. Effective questions help a facilitator to identify issues, get facts clear, and draw out differing views on an issue. Skillful effective questioning also challenges assumptions, shows you are really listening, and demonstrates that the opinions and knowledge of the group are valuable. Effective questioning also increases participation in group discussions and encourages problem solving. Ways to achieve effective questioning include: • Ask open-ended questions: Why? What? When? Where? Who? How? • Ask probing questions. Follow up with further questions that delve deeper into the issue or problem. • Ask clarifying questions by re-wording a previous question. • Discover personal points of view by asking how people feel and not just what they know.

Facilitating group discussions
There is no single best way to facilitate a group discussion. Different facilitators have different styles. Different groups have different needs. But there are some common aspects of good group facilitation, described below.

Setting the rules
It is important to create "ground rules" with which the group agrees to work. Ensure that ground rules are established regarding respect, listening, confidentiality, and participation.

Involving everyone
Helping all group members to take part in the discussion is a really important part of group facilitation. This involves paying attention to who is dominating discussions and who is not contributing. If a participant is quiet, try to involve them by asking them a direct question. But remember that people have different reasons for being quiet. They may be thinking deeply! If a participant is very talkative, you can ask him/her to allow others to take part in the discussion and then ask the others to react to what that person is saying.

Encourage honesty and openness
Encourage participants to be honest and open. They should not be afraid to discuss sensitive issues. Encourage the participants to honestly express what they think and feel, rather than say what they think the facilitator(s) or other participants want to hear.

Keeping the group on track
It is important to help the group stay focused on the issues being discussed. If it seems as if the discussion is going off the subject, remind the group of the objectives for the activity and get them back on track.

Dealing with difficult people
People often take on certain roles within groups. Some of these roles can interfere with the learning of the workshop. Facilitating a group discussion may mean dealing with negative or disruptive people or someone who continues to interrupt the discussion. Reminding the group of the ground rules and asking everyone to be responsible for maintaining them is a good way to deal with difficult people. If someone is always complaining, you can ask for specifics, address the complaint, or refer the complaint to the group. If a participant is disruptive, you can involve the group by having its members ask the difficult person to help, rather than hinder, the group, or you can deal with him apart from the group.

Dealing with difficult situations
The ME manual addresses many topics that are very sensitive and difficult to discuss. The activities in WEMEN project create ways for these topics to be discussed openly in a group setting. But it is likely that ME facilitators will have to deal with participants who make statements that are not in line with the views and values of the program. These could include sexist, homophobic, or racist remarks or opinions. Everyone has a right to their opinion. But they do not have a right to oppress others with their views. For example, a participant might say, "If a woman gets raped, it is because she asked for it. The man who raped her is not to blame." It is important that ME facilitators challenge such opinions and offer a viewpoint that effects the philosophy of the program. This can be difficult. But it is essential in helping participants work toward positive change. The following process is one suggestion for dealing with such a situation: Step 1: Ask for clarification "I appreciate you sharing your opinion with us. Can you tell us why you feel that way?" Step 2: Seek an alternative opinion "Thank you. So at least one person feels that way, but others do not. What do the rest of you think? Who here has a different opinion?" Step 3: If an alternative opinion is not offered, provide one "I know that a lot of people completely disagree with that statement. Most men and women I know feel that the only person to blame for a rape is the rapist. Every individual has the responsibility to respect another person's right to say 'no.'" Step 4: Offer facts that support a different point of view "The facts are clear. The law states that every individual has a right to say no to sexual activity. Regardless of what a woman wears or does, she has a right not to be raped. The rapist is the only person to be blamed." Please note that even after the facilitator takes these four steps to address the difficult statement, it is very unlikely that the participant will openly change his or her opinion. However, by challenging the statement, the facilitator has provided an alternative point of view that the participant will be more likely to consider and, it is hoped, adopt later.
Here are some general tips on presenting to groups: • Practice any presentation beforehand. • Move out from behind the podium or table and into the audience.
• Look at and listen to the person asking a question.
• Be aware of the sensitivities of your audience.
• Use humor, but do not wait for laughs.
• Never give a generic presentation. Try to customize it for the group, as there are many ways to cover the same material. Anger is a normal emotion that every human being feels at some point. The problem is that some people may confuse anger and violence, thinking they are the same thing and that violence is an acceptable way of expressing anger. However, there are many other ways of expressing anger, better and more positive ways. Learning to express our anger when we feel it is better than bottling it up inside. When we allow our anger to build up, we tend to explode. 12

Educational material
Violence makes a man stronger.
Conflict happens in all relationships. It is the way that you handle this conflict that makes all the difference. Learning how to take the time to think about your feelings and express yourselves in a calm and peaceful way is an important part of building healthy and respectful relationships. As men, it is important to reflect on how you react when someone has a different opinion than yours or when someone does something that makes you angry. It is not always easy, but it is important to take the time to think about your feelings before you react, especially when you are frustrated or angry. Sometimes, if you do not take the time to think about your feelings, you may react in a way that is hurtful or violent to another person or even yourself. Men need skills and support to talk with their wives and girlfriends about creating healthier relationships.

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Violence is just physical, it can be also emotional