Promoting Community-Based Couples Counseling in Malawi

Promoting Community-Based Couples Counseling in Malawi

A couple from Malawi receives counseling from a Community-Based Distribution Agent (CBDA)

In Kasungu District, Malawi, trained Community-Based Distribution Agents (CBDAs) gather for their final and perhaps most challenging training: couples counseling.

With HIV, couples often do not freely discuss issues and concerns. “Where communication has been a problem for couples, CBDAs in underserved areas will help in risk reduction,” explains Jane Ngwira, MSH’s Kasungu District Coordinator.

Amos Msampha from Nkhotakota completed the pre-service CBDA training supported by the USAID-funded, Management Sciences for Health-led Community-Based Family Planning and HIV & AIDS Services (CFPHS) project in December 2010. Clients were generally welcoming and satisfied, Msampha said of his first training experience. The final training equipped him for counseling and, Msampha shared, he “plans to follow up with his clients, especially with new skills from the training.”

What are these new skills exactly? The counseling training focused on sensitizing couples to address the lack of knowledge and awareness in rural communities.

For couples in Malawi, the intervention is a critical point of opportunity. While the Malawi Demographic and Health Survey shows that HIV prevalence is declining, there are approximately 90,000 new HIV infections each year. The majority of these new infections are in individuals who were previously categorized to be at low risk: couples and partners in stable sexual relationships.

Specifically, it is estimated that 40 percent of all new infections occur within long-term relationships.

"In Malawi, women are not supposed to be active," said Elton Chongwe, a HIV testing and counseling trainer. "With couples counseling, women should feel free to talk and each partner should participate freely. This approach needs to be scaled up to the community.”

Before testing, the couple agrees who should be told the results and the counselor helps ensure that confidentiality is made very clear. The couple must agree that neither one will disclose their partner’s results without permission. This also helps to address issues of gender where typically, a man is free to say anything. “In the training we are breaking that spirit,” explains Chongwe.

Chongwe and fellow trainers describe how when it is a man who is positive, the woman supports him. But when the woman is positive, there is discrimination and stigma. CBDAs play a significant role in diffusing potential violence and averting blame. The counselors promote the concept of HIV as a problem that is affecting “family, we, us” and that HIV is “our problem rather than your problem.”

When asked to share a success story of a trainee, Chongwe lights up. Chongwe describes one young man that immediately comes to mind:

“Using existing counseling structures, leaders, Community Based Organizations, and village chiefs, [this man] sensitized groups and starting testing couples. The demand was so high he could not manage to get enough test kits. By employing group counseling in a health center, he used 50 tests (enough for 25 couples) in one day alone. Considering this is volunteer work, he put so much life into it – he acted like a paid employee. At the District Hospital we are still struggling to promote couple HIV testing and counseling, and here is a guy in the community who managed to change the mindset of the people.”

The CBDA trainers in Kasungu often use this example. “Here is what your friend has done. How is this possible?” asks Chongwe with a smile.

The Kasungu district has trained 117 CBDAs from 2008-2009. Of those, 63 CBDAs received training in couples counseling and know how to refer cases effectively.

“We appreciate the District Health Management Team support – we’ve worked together very well,” said Ngwira.

Hillary Anderson is a MSH Communications Intern in Malawi.