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Understanding the relationship between couple dynamics and engagement with HIV care services: insights from a qualitative study in Eastern and Southern Africa
  1. Joyce Wamoyi1,
  2. Jenny Renju2,3,
  3. Mosa Moshabela4,5,
  4. Estelle McLean2,3,
  5. Daniel Nyato1,
  6. Doris Mbata1,
  7. Oliver Bonnington2,
  8. Janet Seeley2,4,
  9. Kathryn Church2,
  10. Basia Zaba2,
  11. Alison Wringe2
  1. 1 National Institute for Medical Research, Mwanza, Tanzania
  2. 2 London School of Hygiene and Tropical Medicine, London, UK
  3. 3 Malawi Epidemiology and Intervention Research Unit, Karonga, Malawi
  4. 4 Africa Health Research Institute, KwaZulu Natal, South Africa
  5. 5 University of KwaZulu Natal, Durban, South Africa
  1. Correspondence to Dr Joyce Wamoyi, National Institute for Medical Research, P.O Box 1462 Mwanza, Tanzania; jwamoyi{at}


Objective To explore the interplay between couple dynamics and the engagement of people living with HIV (PLHIV) with HIV care and treatment services in three health and demographic surveillance sites in Tanzania, Malawi and South Africa.

Methods A qualitative study was conducted involving 107 in-depth interviews with PLHIV with a range of HIV care and treatment histories, including current users of HIV clinics, and people not enrolled in HIV care. Interviews explored experiences of living with HIV and how and why they chose to engage or not with HIV services. Thematic analysis was conducted with the aid of NVivo 10.

Results We found an interplay between couple dynamics and HIV care and treatment-seeking behaviour in Tanzania, Malawi and South Africa. Being in a relationship impacted on the level and type of engagement with HIV services in multiple ways. In some instances, couples living with HIV supported each other which improved their engagement with care and strengthened their relationships. The desire to fulfil societal expectations and attract a new partner, or have a baby with a new partner, or to receive emotional or financial support, strengthened on-going engagement with HIV care and treatment. However, fear of blame, abandonment or abuse resulted in unwillingness to disclose and often led to disputes or discord between couples. There was little evidence of intracouple understanding of each other’s lived experiences with HIV, and we found that couples rarely interacted with the formal health system together.

Conclusions Couple dynamics influenced engagement with HIV testing, care and treatment for both partners through a myriad of pathways. Couple-friendly approaches to HIV care and treatment are needed that move beyond individualised care and which recognise partner roles in HIV care engagement.

  • HIV
  • Couples
  • Relationships
  • Tanzania
  • Malawi
  • South Africa

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  • Contributors The study was conceived by BZ, AW and KC. AW, JW, MM and KC designed the protocol and study tools, which were adapted and implemented in the different settings. Analyses were conducted by JW, MM, EM, JK, DM and DN. The manuscript was drafted by JW, with input from all authors. All authors read and approved the final manuscript.

  • Funding The Bottlenecks Study was funded by the Bill and Melinda Gates Foundation (OPP1082114). This paper was also made possible with the support of The Wellcome Trust (085477/Z/08/Z). Research (undertaken in Kisesa and) reported in this publication was supported by the National Institute Of Allergy and Infectious Diseases (NIAID), Eunice Kennedy Shriver National Institute Of Child Health & Human Development (NICHD), National Institute on Drug Abuse (NIDA), National Cancer Institute (NCI) and the National Institute of Mental Health (NIMH), in accordance with the regulatory requirements of the National Institutes of Health under Award Number U01AI069911East Africa IeDEA Consortium. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AW is funded by a Population Health Scientist award, jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement and is also part of the EDCTP2 programme supported by the European Union.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethical approval was granted by the London School of Hygiene and Tropical Medicine (#10389) and the relevant ethics boards at each of the study settings: Malawi National Health Sciences research committee #15/5/1427; Tanzania medical research coordination committee MR/53/100/370; biomedical research and ethics committee in Kwa-Zulu Natal, South Africa BE 338/15. Informed and written consent was obtained from all participants.

  • Provenance and peer review Commissioned; externally peer reviewed.

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