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

Background Men 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. Methods Focus 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. Findings 20 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 men’s ‘selfish’ and ‘prideful’ nature, resulting in little HCW sympathy for men’s poor use of care. Interpretation Our 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. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial None ### Funding Statement This work was funded by the Bill and Melinda Gates Foundation (INV-001423), the National Institute of Mental Health (NIMH R01-MH122308), Fogarty International (K01-TW011484-01) and UCLA GSTTP. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for the parent study was attained by the Institutional Review Board at University of California Los Angeles and the National Health Sciences Review Committee in Malawi. Participants were not paid for participation but were given refreshments during the FGDs. Oral consent was provided. No identifiers were collected. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes The data that support the findings of this study are available from the corresponding author, KD, upon reasonable request.