Should female health providers be involved in medical male circumcision? Narratives of newly circumcised men in Malawi

Background The Malawi government has endorsed voluntary medical male circumcision (VMMC) as a biomedical strategy for HIV prevention after a decade of debating its effectiveness in the local setting. The “policy” recommends that male circumcision (MC) should be clinically based, as opposed to the alternative of traditional male circumcision (TMC). Limited finances, acceptability concerns, and the health system’s limited capacity to meet demand are among the challenges threatening the mass rollout of VMMC. In terms of acceptability, the gender of clinicians conducting the operations may particularly influence health facility-based circumcision. This study explored the acceptability, by male clients, of female clinicians taking part in the circumcision procedure. Methods Six focus group discussions (FGDs) were conducted, with a total of 47 newly circumcised men from non-circumcising ethnic groups in Malawi participating in this study. The men had been circumcised at three health facilities in Lilongwe District in 2010. Data were audio recorded and transcribed verbatim. Data were analysed using narrative analysis. Results Participants in the FGDs indicated that they were not comfortable with women clinicians being part of the circumcising team. While few mentioned that they were not entirely opposed to female health providers’ participation, arguing that their involvement was similar to male clinicians’ involvement in child delivery, most of them opposed to female involvement, arguing that MC was not an illness that necessitates the involvement of clinicians regardless of their gender. Most of the participants said that it was not negotiable for females to be involved, as they could wait until an all-male clinician team could be available. Thematically, the arguments against female clinicians’ involvement include sexual undertones and the influences of traditional male circumcision practices, among others. Conclusion Men preferred that VMMC should be conducted by male health providers only. Traditionally, male circumcision has been a male-only affair shrouded in secrecy and rituals. Although being medical, this study strongly suggested that it may be difficult for VMMC to immediately move to a public space where female health providers can participate, even for men coming from traditionally non-circumcising backgrounds.

The effects of acute administration of Chinese aphrodisiacs sold in Blantyre City on sperm characteristics and fertility profile in guinea pigs

Background Chinese aphrodisiacs have become popular remedy for sexual dysfunction and improvement of libido in men in Malawi. However, selling of these drugs seems not to be well regulated. Probably the aphrodisiacs that are currently on the market have unknown efficacy, potency and safety profiles. The aim of this study was to assess the efficacy of imported Chinese aphrodisiacs using guinea pigs as a model. Materials and Methods Two types of drugs were purchased from vendors in Blantyre City. Tonic tea, which was purported to improve erectile function and libido, and sperm multiplier tablets which were claimed to increase the sperm count. The tonic tea was prepared by soaking one tea bag in 100ml boiling water. The tea was cooled and administered to eight male experimental animals in varying doses. Each animal was introduced into a separate cage with a female guinea pig. Sexual behaviour such as mounting, sniffing behind the female were observed and recorded. Each sperm multiplier tablet was dissolved in distilled water and administered to the experimental animals in the morning and evening for seven days. At the end of the treatment, the experimental and control animals were sacrificed, their semen collected and analysed sperm motility, concentration and morphology. Results For the tonic tea, there were no statistical differences between the experimental and the control animals in terms of the number of mountings and sniffing behind the female. The sperm multiplier drug showed statistically significant differences between the experimental and the control animals in terms of the sperm motility (78.24 ± 1.35 vs. 86.54 ± 1.88, p< 0.05), and concentration (54.28 ± 1.24 vs. 67.59 ± 2.12, p<0.05). Conclusion The tonic tea did not show any efficacy in improving erection and libido. The sperm multiplier tablets, purported to increase sperm production, significantly increased the sperm motility, sperm concentration in the treated animals.

Reproductive decisions of couples living with HIV in Malawi: What can we learn for future policy and research studies?

Background The rapid scale-up of free antiretroviral therapy has lead to decline in adult mortality at the population level and reduction of vertical transmission. Consequently, some couples living with HIV are maintaining their reproductive decisions; marrying and having children. This paper analyses policies and guidelines on HIV, AIDS and sexual and reproductive health in Malawi for content on marriage and childbearing for couples living with HIV. Methods A qualitative study using interpretive policy analysis approach was conducted from July to December 2010 in two phases. First, data on access to HIV, AIDS and sexual and reproductive health services were collected using in-depth interviews with twenty couples purposively sampled in matrilineal Chiradzulu and patrilineal Chikhwawa communities. Secondly, data were collected from Malawi policies and guidelines on HIV, AIDS and sexual and reproductive health. The documents were reviewed for content on marriage and childbearing for couples living with HIV. Data were analysed using framework approach for applied policy analysis. Results Four categories emerged from each phase. From the study, we extracted health workers attitudes, weak linkage between HIV, AIDS and sexual and reproductive health services, contradictory messages between media and the hospitals and lack of information as factors directly related to guidelines and policies. Analysis of guidelines and policies showed nonprescriptiveness on issues of HIV, AIDS and reproduction: they do not reflect the social cultural experiences of couples living with HIV. In addition, there is; lack of clinical guidelines, external influence on adoption of the policies and guidelines and weak linkages between HIV and AIDS and sexual and reproductive health services. Conclusion This synthesis along with more detailed findings which are reported in other published articles, provide a strong basis for updating the policies and development of easy-to-follow guidelines in order to effectively provide services to couples living with HIV in Malawi.

Impact of cost sharing on utilization of primary health care Services: providers versus household perspectives

This study is set to match and compare results of the analysis of impacts of cost sharing on households with those on health-care providers in two selected districts in Tanzania. The setting is intended to establish and compare concurrently the impact of cost sharing on health-care utilization as viewed from both the providers and beneficiary households. The findings of the study indicate that quality of primary health care has improved as a result of the introduction of cost sharing. Attendance and hence utilization in health facilities has also increased. Mortality rate, at least for one district has not worsened. By implication then, cost sharing appears to have a positive impact on the provision of primary health care, except for a few cases that fail to consult because of the fees. An appropriately managed exemption facility is likely to eliminate the negative impact.

Infestation of Tunga penetrans in villages near Zomba Central Hospital

An outbreak of Tunga Penetrans (Jigger Flea) infestation affecting a number of villages near to a Central Hospital in Malawi is described. Due to the large number of affected individuals, high parasitic load, and extended duration of infection an alternative to the recommended approach of surgical removal of the flea was required. Benzyl benzoate paint and liquid paraffin had been used in local Primary Healthcare settings previously and topical treatment with antiparasitic agents has been advocated in the literature, particularly for severe infestation. Benzyl benzoate and liquid paraffin were applied topically to four adults with numerous jigger flea burrows, and their progress assessed regularly. After completion of 7 days of treatment patients noted that fleas were dislodging spontaneously, and that embedded parasites had not increased in size to the same extent that untreated fleas had in previous infestations. Following confirmation of the viability of its implementation in a resource-poor setting, this treatment regimen has subsequently been adopted by the local branch of the District Health Office for distribution to infected communities.

Knowledge and perceptions of quality of obstetric and newborn care of local health providers: a cross-sectional study in three districts in Malawi

Aim Quality of service delivery for maternal and newborn health in Malawi is influenced by human resource shortages and knowledge and care practices of the existing service providers. We assessed Malawian healthcare providers’ knowledge of management of routine labour, emergency obstetric care and emergency newborn care; correlated knowledge with reported confidence and previous study or training; and measured perception of the care they provided. Methods his study formed part of a large-scale quality of care assessment in three districts (Kasungu, Lilongwe and Salima) of Malawi. Subjects were selected purposively by their role as providers of obstetric and newborn care during routine visits to health facilities by a research assistant. Research assistants introduced and supervised the self-completed questionnaire by the service providers. Respondents included 42 nurse midwives, 1 clinical officer, 4 medical assistants and 5 other staff. Of these, 37 were staff working in facilities providing Basic Emergency Obstetric Care (BEMoC) and 15 were from staff working in facilities providing Comprehensive Emergency Obstetric Care (CEMoC). Results Knowledge regarding management of routine labour was good (80% correct responses), but knowledge of correct monitoring during routine labour (35% correct) was not in keeping with internationally recognized good practice. Questions regarding emergency obstetric care were answered correctly by 70% of respondents with significant variation depending on clinicians’ place of work. Knowledge of emergency newborn care was poor across all groups surveyed with 58% correct responses and high rates of potentially life-threatening responses from BEmOC facilities. Reported confidence and training had little impact on levels of knowledge. Staff in general reported perception of poor quality of care. Conclusion Serious deficiencies in providers’ knowledge regarding monitoring during routine labour and management of emergency newborn care were documented. These may contribute to maternal and neonatal deaths in Malawi. The knowledge gap cannot be overcome by simply providing more training.

Therapeutic commitment for general nurses in dealing with mental health problems of People Living with HIV/AIDS in Blantyre, Malawi

Introduction Therapeutic commitment of general nurses influences their provision of mental health care to clients. It is the general nurses’ predisposition for working therapeutically with clients who have mental health problems (MHPs). In Malawi, general nurses are the majority of health care professionals who care for people living with HIV/AIDS (PLWHA) and they are expected to deal with the mental health problems of these patients. The provision of mental health care to PLWHA is vital because apart from the physical illnesses associated with the virus, these people are also affected by mental health problems. However, most general nurses, feel neither confident nor competent when dealing with the mental health problems of their clients in Malawi. This may negatively influence their therapeutic commitment in dealing with mental health problems of PLWHA. However, therapeutic commitment of general nurses in providing mental health care to PLWHA in Malawi remains unknown. Materials and Methods The study used a quantitative descriptive survey design. a convenient sample comprising of 136 general nurses was used and data was collected using Mental Health Problems Perception Questionnaire. Permission to use the tool in this study was granted by Prof. Lauder. Ethical approval to conduct the study was granted by Ethics Committees at University of KwaZulu Natal and University of Malawi. Data were analysed using Statistical Package for Social Sciences version 15.0. Results The study findings revealed that there is a linear relationship between general nurses’ levels of knowledge and skills and their therapeutic commitment (r=.40, n=136, p<.05) to provide mental health care of PLWHA. Conclusion This study suggests general nurses’ levels of therapeutic commitment in dealing with MHPs of PLWHA vary and their levels of knowledge and skill to deal with MHPs influence their willingness to provide mental health care to PLWHA.

Interpreting and dismissing the relevance of the “wait and wipe” finding from the circumcision studies conducted in Africa

Some of the secondary findings from the circumcision studies conducted in Africa, are both interesting and difficult to explain. This paper focuses on the finding that uncircumcised men who waited for ten minutes after sexual intercourse and then wiped their penises using a dry cloth, had lower rates of HIV infection compared to those who cleaned using a wet cloth or those who cleaned within three minutes of having intercourse. The paper also focuses on the finding on men who became infected and yet they reported no sexual acts or 100% condom use. Interpretations that have been provided so far in trying to explain these two interesting findings are somewhat inadequate. Because of the inadequate interpretation that has been provided, anti-circumcision lobbyist are presenting the “wait and wipe strategy” as an alternative to circumcision for HIV prevention. In this paper, we argue that waiting for ten minutes and wiping with a dry cloth does not prevent men from becoming infected by HIV. We therefore attempt to present some alternative views.

‘Teaching corner’: Management of Diabetic Retinopathy

Sub-Saharan Africa faces an epidemic of diabetes. Visual loss from diabetic retinopathy (DR) is both preventable and treatable. This article reviews the epidemiology and clinical features of DR and current evidencebased interventions in three areas: primary prevention of retinopathy by optimum medical management, early detection of pre-symptomatic disease and management of established retinopathy to prevent or mitigate visual loss. There are significant challenges to DR care in resource poor environments. Appropriate provision of effective interventions by health services can reduce social and economic costs associated with patient care.