Of Goats and Chickens: Village Leaders Champion HIV Self-Testing in Malawi

By Sabrina Sidhu, Writer, UNITAID

Malicious gossip can spread faster than wildfire. Traditional leaders in rural Neno District, Malawi, are only too aware of its destructive nature. In May this year, they grew worried that rumours could jeopardize HIV self-testing, a new health service that relies on strict confidentiality for its success.

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Traditional leaders and gate-keepers of Neno District, Malawi. Photo Credit: Sabrina Sidhu/UNITAID

HIV self-testing allows people to check whether they have been infected with the HIV virus by using a kit in the privacy of their own homes.

“There is a lot of gossiping in our villages so we knew there would be rumours flying,” explains 44-year-old Village Head Charles Kambalame from Chapita village.

To beat the rumour mill, the village leaders threatened to fine anyone spreading rumours about who was taking the tests. “We decided that an adolescent would be fined a goat and an adult a chicken if they gossiped about anyone using an HIV self-test,” says 36-year-old Village Head Maria Juma, from Hariot village. 

Not a single fine has been imposed so far, suggesting that the threat of fines may have had a dissuasive effect. The support of village leaders has smoothed the way for an experiment that is bringing HIV self-testing to people’s doorsteps.

Community health workers like 25-year-old Veronica Kapichi have been able to talk easily to villagers about HIV self-testing. So far Veronica has already distributed 173 HIV self-test kits in the Group Chapita area where the nearest Chifunga Health Centre is 15 kilometres away.

The most senior of the local leaders is Chief Charles Chibisa. Dressed in resplendent green robes, 52- year- old chief has been the Traditional Authority (TA) in the Mulawuli area for the past 15 years. He has been instrumental in drumming up support for the initiative from other village leaders and from the community. “We sat together with community chiefs and local people and discussed the merits of the self-testing project,” says TA Chibisa. “We chose the Chifunga area as it’s very far from the nearest health centre.”

Veronica now feels empowered to meet people in their homes to explain how they can conduct an HIV self-test. Often, she even goes to their place of work, which helps to convince men who are reluctant to use the kit at home. “I have only covered three villages since I started, and already people from other villages have been approaching me,” says Veronica, who is eight months pregnant with her second child.

Veronica has become so well-known in the community that a couple, together with their nephew, even came to Veronica’s home to ask for HIV self-test kits.

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Veronica, the community health worker who distributes HIV self-tests in Chapita, is no stranger in her community. Over the past year, she has been distributing condoms and contraceptives in Chapita. As a result, she has developed a good rapport with the community, and young people find it very easy to approach her. Photo credit: UNITAID/ Sabrina Sidhu

 

“People are jumping at the opportunity to get self-tested as this has reduced the distance they travel and the cost of having a test,” quips Chief Chibisa.

One such person is 45- year-old Rhoda Nyalapa, who is a mother of six.  Rhoda finds the self-test very convenient and can use the time she would have spent travelling to and from a health centre more productively.

Others like 29-year-old Watson and his friends, who test once every three months, also save a lot of time. “Self-testing is better because it’s faster and then you have time to chat with friends and do some business,” says 20-year-old McDonald.

“Most men are not eager to go to their health centre for testing. They rely on their partner’s result, which is often called ‘proxy testing,” says Dr. Karin Hatzold, Project Director of the initiative.

Sometimes couples can be sero-discordant, meaning that one is positive and the other is negative. “As Village Head, we would bring in unity and coordination between the couple,” says 46-year-old Village Head Michael Kambalame of Zimphungu who promises to “go door-to-door to create awareness about why the programme is important”.

Reducing time and costs

Besides reducing time and costs, the HIV self-test uses a swab, making it is less intimidating than being pierced with a syringe. Chief Chibisa himself attests to that, having been the first to use the kit. He finds the menu easy to follow, with instructions in Chichewa, the local language.

“We are going to work hard to make sure that this is a success in my area because that is going to encourage people in other areas to demand the same,” quips Chief Chibisa.

Word has already spread about the self-testing. “Other leaders come and ask if the initiative is going to extend to their areas,” says Village Head Kambalame Dziphango, who came into the role four years ago.

With their out-of-the-box thinking, traditional leaders have helped to open doors and bring a critical health service to rural Malawians.


Reducing costs of HIV testing
Time is of the essence here as most people earn a living selling charcoal, for which they travel long distances. Others rely on farming, which is equally time-consuming. “Going to the health centre is a low priority for many villagers as they are preoccupied with earning their livelihood,” says 50-year-old Village Head Juma Douglas, from Hariot village.

Besides the time it takes to get there, a visit to the health centre is also expensive business. “It costs almost 500 Malawian kwacha or USD $1 to go to the Chifunga Health Centre to do a HIV test,” says Village Head Ronnick Jolodani from Lamia village of Group Chapita. The 51-year-old village head would know as he has worked at the district health centre. Sometimes village leaders even have to lend money to patients.

“Going to Blantyre to do a HIV test costs USD $ 3 as it includes transport fare, and the cost of buying food at the testing facilities,” says Dr. Liz Corbett, Research Director of the initiative. “This is expensive as the average income here is less than US $1 per day.” In the time they travel, people also forgo the income they could be earning. “The price of the oral fluid test is USD $3, but we offer the test for free in the communities,” adds Dr. Karin Hatzold.