Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV-free survival

HIV status disclosure patterns and male partner reactions among pregnant women with HIV on lifelong ART in Western Kenya

Disclosure of HIV status to sexual partners in the context of prevention of mother-to-child transmission (PMTCT) may contribute to improved PMTCT outcomes. We administered a questionnaire to 200 women with HIV enrolled in a PMTCT study during pregnancy at 12 months after birth in Western Kenya between May-September 2017. Descriptive analysis of disclosure patterns and multivariate analysis of factors associated with male partner reactions is presented. Among 180 (90%) women who reported having a male partner, 95.5% reported disclosing their HIV status to that partner. The majority of women (82.8%) reported disclosure occurred within one year of their diagnosis, with 62.7% occurring within one week. The most common forms of disclosure were: self-disclosure (55.4%), during couple's HIV testing and counseling (CHTC) (31.5%), or at an antenatal care visit (7.7%). Most women (87.5%) reported that male partner reactions to their HIV status disclosure were positive. Those with negative reactions reported their partners were confused, annoyed, or threatened to leave, however there were no reports of intimate partner violence (IPV) or break ups. Disclosure via CHTC was associated with a positive male partner reaction compared to self-disclosure (adjusted OR (aOR) 20.2, 95% Confidence Interval (CI) 1.8-221.4). Those in concordant HIV status partnerships were more likely to have a positive reaction (aOR. 6.7, 95% CI 1.7-26.6). Women experiencing frequent verbal IPV were less likely to report a positive response (aOR 0.21, 95%CI 0.1-0.8). Most postpartum women with HIV in this cohort had disclosed to their male partners early after diagnosis and experienced a positive reaction. However, a minority had still not disclosed by 12 months after the birth and some experienced negative reactions to disclosure. The form of status disclosure and impact of intimate partner violence should be given greater attention within the context of PMTCT.

Optimal HIV testing strategies for South Africa: a model-based evaluation of population-level impact and cost-effectiveness

Although many African countries have achieved high levels of HIV diagnosis, funding constraints have necessitated greater focus on more efficient testing approaches. We compared the impact and cost-effectiveness of several potential new testing strategies in South Africa, and assessed the prospects of achieving the UNAIDS target of 95% of HIV-positive adults diagnosed by 2030. We developed a mathematical model to evaluate the potential impact of home-based testing, mobile testing, assisted partner notification, testing in schools and workplaces, and testing of female sex workers (FSWs), men who have sex with men (MSM), family planning clinic attenders and partners of pregnant women. In the absence of new testing strategies, the diagnosed fraction is expected to increase from 90.6% in 2020 to 93.8% by 2030. Home-based testing combined with self-testing would have the greatest impact, increasing the fraction diagnosed to 96.5% by 2030, and would be highly cost-effective compared to currently funded HIV interventions, with a cost per life year saved (LYS) of $394. Testing in FSWs and assisted partner notification would be cost-saving; the cost per LYS would also be low in the case of testing MSM ($20/LYS) and self-testing by partners of pregnant women ($130/LYS).

Towards a definition of male partner involvement in the prevention of mother-to-child transmission of HIV in Uganda: a pragmatic grounded theory approach

BACKGROUND

Male partner involvement has been shown to increase mothers' uptake of Prevention of Mother-to-Child Transmission of HIV (PMTCT) and improve maternal and infant HIV treatment outcomes. Currently, male involvement in PMTCT is measured primarily through men's attendance at HIV testing and counselling which may not be a true reflection of their engagement. This study therefore set out to explore the meaning of male partner involvement and propose a definition and theoretical model of this concept in PMTCT in Uganda.

METHODS

Eight focus group discussions and five in-depth interviews were conducted with couples at three public health facilities and community members in the health facility catchment areas in Uganda. The study employed a grounded theory approach underpinned by the pragmatic philosophical paradigm. Data were analyzed using the constant comparative method, performing three levels of open, axial, and selective coding.

RESULTS

Of the 61 participants, 29 (48%) were male and the majority 39 (63.9%) were in long term marital relationships, while about half were self-employed 29 (47.5%). Three themes emerged for the meaning of male involvement in PMTCT (a) HIV treatment support (b) economic support and (c) psychosocial support. HIV treatment support included adherence support, couples' HIV counseling and testing, and clinic attendance during and after pregnancy. Participants expressed that men were engaged in PMTCT when they offered economic support by providing basic needs and finances or when they included their female partners in financial planning for the family. Psychosocial support arose from the female participants who defined male involvement as family support, perceived societal recognition and emotional support. Emotional support also included the absence of harm resulting from women's disclosure of HIV test results to their male partner.

CONCLUSIONS

This study proposes a new definition for male partner involvement in PMTCT in Uganda. The definition extends beyond men's clinic attendance and HIV testing and counselling. Further research should seek to develop and validate tools to accurately measure male partner involvement as the next step in the development of interventions to improve PMTCT outcomes.

Male partner antenatal clinic attendance is associated with increased uptake of maternal health services and infant BCG immunization: a national survey in Kenya

BACKGROUND

Male partner antenatal clinic (ANC) attendance may improve maternal uptake of maternal child health (MCH) services.

METHODS

We conducted a cross-sectional survey of mother-infant pairs attending week-6 or month-9 infant immunizations at 120 high-volume MCH clinics throughout Kenya. Clinics were selected using probability proportionate to size sampling. Women were interviewed using structured questionnaires and clinical data was verified using MCH booklets. Among married women, survey-weighted logistic regression models accounting for clinic-level clustering were used to compare outcomes by male ANC attendance and to identify its correlates.

RESULTS

Among 2521 women attending MCH clinics and had information on male partner ANC attendance, 2141 (90%) were married of whom 806 (35%) had male partners that attended ANC. Among married women, male partner ANC attendance was more frequent among women with higher education, women who requested their partners to attend ANC, had male partners with higher education, did not report partner violence, and had disclosed their HIV status (p < 0·001 for each). Additionally, male ANC attendance was associated with higher uptake of ANC visits [adjusted Odds Ratio (AOR) = 1·67, 95% confidence interval (CI) 1·36-2·05,], skilled delivery (AOR = 2·00, 95% CI 1·51-2·64), exclusive breastfeeding (AOR = 1·70, 95% CI 1·00-2·91), infant Bacille Calmette Guerin (BCG) immunization (AOR = 3·59, 95% CI 1·00-12·88), and among HIV-infected women, antiretroviral drugs (aOR = 6·16, 95% CI 1·26-30·41).

CONCLUSION

Involving male partners in MCH activities amplifies benefits of MCH services by engaging partner support for maternal uptake of services.

Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-screening program in western Kenya

BACKGROUND

To be effective, population-based cervical cancer prevention programs must be tailored to meet the needs of the target population. One important factor in cervical cancer screening may include male involvement. To iteratively improve a screening program employing self-collected vaginal swabs for human-papillomavirus (HPV) testing in western Kenya, we examined the role of male partners and community leaders in decision-making and accessing screening services.

METHODS

We carried out 604 semi-structured, in-depth interviews (IDIs) with women and community health volunteers who took part in a multiphase trial of implementation strategies for HPV-based cervical cancer screening. IDIs were coded and themes related to decision-making, screening and treatment barriers, and influence of male partners and community leaders were identified and analyzed.

RESULTS

Women experienced both support and opposition from their male partners. Partner support took the form of financial support for transportation and emotional support and encouragement, while opposition ranged from anticipated negative reactions to lack of permission, isolation, and abandonment. Though most women described their own partners as supportive, many felt that other male partners would not be supportive. Most participants believed that increased HPV and cervical cancer knowledge would increase partner support. Women reported a general acceptance of involvement of community leaders in education and screening campaigns, in a setting where such leaders may hold influence over men in the community.

CONCLUSION

There was a clear interest in involving male partners in the cervical cancer prevention process, specifically in increasing knowledge and awareness. Future research should explore the feasibility and effectiveness of engaging male partners in cervical cancer screening and prevention programs.

Increasing male engagement in the prevention of vertical transmission of HIV: what works in sub-Saharan Africa?

Muktar Aliyu and colleagues discuss barriers, enablers, and research gaps in engaging male partners in prevention of vertical HIV transmission in sub-Saharan Africa

Impact of male partner involvement on mother-to-child transmission of HIV and HIV-free survival among HIV-exposed infants in rural South Africa: Results from a two phase randomised controlled trial

BACKGROUND

The Sub-Saharan Africa region still remains the epicentre of the global HIV/AIDS epidemic. With regards to new paediatric HIV infections, almost 90% of new HIV infections are among children (aged 0-14 years), largely through mother to child transmission. Male Partner Involvement in Prevention of Mother to Child Transmission programmes is now strongly advocated as being key in improving infant outcomes. This study describes the role of Male Partner Involvement on infant HIV infection and mortality survival in the first year among HIV-exposed infants born from HIV positive mothers.

METHODS

This study was a two-phase, two condition (intervention or control) longitudinal study as part of a clinic-randomized Prevention of Mother to Child Transmission controlled trial. For Phase 1, female participants were recruited without their male partners. In Phase 2, both female and male participants were enrolled in the study as couples in order to encourage active Male Partner Involvement during pregnancy. Participants had two assessments prenatally (8-24 weeks and 32 weeks) and three assessments postnatally (6 weeks, 6 months, and 12 months).

RESULTS

About 1424 women were eligible for recruitment into the study and 18 eligible women declined to participate. All women had a partner; 54% were unmarried, 26% were cohabiting, and 20% were married. Just over half (55%) of the women had been diagnosed with HIV during the current pregnancy. Phase 1 had significantly more HIV-infected infants than Phase 2 at 12-months postpartum (aOR = 4.55 [1.38, 15.07]). Increased depressive symptoms were associated with infant HIV infection at 12-months (aOR = 1.06 [1.01, 1.10]). Phase 1 also had a significantly greater proportion of dead and HIV-infected infants than Phase 2 at 12-months (aOR = 1.98 [1.33, 2.94]).

CONCLUSION

Male partner involvement in antenatal care is critical in ensuring infant survival and HIV infection among children born to HIV-positive mothers. This study highlights the high risk of ante-and-post natal depression and underscores the need of screening for depression during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.Gov; Trial Number NCT02085356.

Challenges and motivators for male partner involvement in prenatal care for HIV testing in a tertiary setting in Brazil

Male partner involvement in prenatal care has been shown to improve outcomes for the entire family in low- and middle income countries. In Brazil, partners of pregnant women are encouraged to attend prenatal care for HIV testing. From November 2016 to July 2017, male partners of women delivering at Hospital Conceiçao were interviewed using computer-assisted telephone interviews regarding individual, relationship and system-wide facilitators and barriers to attending prenatal care. Of 403 men interviewed, 202 attended prenatal care and 201 did not. Individual factors that predicted prenatal care attendance included over-estimating the risk of mother to child transmission (AOR 2.13, 95% CI: 1.35–3.4), and endorsing that HIV-infected individuals can live satisfying lives (AOR 7.24, 95% CI: 1.9–47.5). Partnership factors associated with attendance included invitation by partner (AOR 5.6, 95% CI: 2.4–15.6). Systemic factors negatively associated with prenatal care attendance included a history of not being able to afford medical care (AOR 0.3, 95% CI: 0.15–0.6) and identifying work as a barrier to prenatal care attendance (AOR 0.19 95% CI: 0.11–0.31). Partners should be actively invited to prenatal care during flexible flexible hours. Once involved, almost all would accept HIV and sexually transmitted infection (STI) testing to protect partners and unborn infants during this vulnerable period.

Integrating safer conception services into primary care: providers' perspectives

Background

In 2012, South Africa adopted the Contraception and Fertility Planning guidelines to incorporate safer conception services into care for HIV-affected couples trying to conceive. These guidelines lacked clear implementation and training recommendations. The objective of this study was to investigate factors influencing integration of safer conception services in a clinical setting.

Methods

Twenty in-depth interviews were conducted between October–November 2017 with providers and staff at Witkoppen Clinic in Johannesburg, where the Sakh’umndeni safer conception demonstration project had enrolled patients from July 2013–July 2017. Semi-structured interview guides engaged providers on their perspectives following the Sakh’umndeni project and possible integration plans to inform the translation of the stand-alone Sakh’umndeni services into a routine service. A grounded theory approach was used to code interviews and an adaptation of the Atun et al. (2010) ‘Integration of Targeted Interventions into Health Systems’ conceptual framework was applied as an analysis tool.

Results

Five themes emerged: (1) The need for safer conception training; (2) The importance of messaging and demand generation; (3) A spectrum of views around the extent of integration of safer conception services; (4) Limitations of family planning services as an integration focal point; and (5) Benefits and challenges of a “couples-based” intervention. In-depth interviews suggested that counselors, as the first point of contact, should inform patients about safer conceptions services, followed by targeted reinforcement of safer conception messaging by all clinicians, and referral to more intensively trained safer conception providers.

Conclusion

A safer conception counseling guide would facilitate consultations. While many providers felt that the services belonged in family planning, lack of HIV management skills, men and women trying to conceive within family planning may pose barriers.

The role of women's empowerment and male engagement in pregnancy healthcare seeking behaviors in western Kenya

We sought to understand whether women's empowerment and male partner engagement were associated with use of antenatal care (ANC). Women presenting for ANC in Nyanza province of Kenya between June 2015 and May 2016, were approached for participation. A total of 137 pregnant women and 96 male partners completed baseline assessments. Women's empowerment was measured using the modified Sexual Relationship Power Scale. ANC use measures included timing of the first ANC visit and number of visits. Male engagement was based on whether a husband reported accompanying his wife to one or more antenatal visits during the pregnancy. Multiple linear and logistic regression analyses were used to identify factors independently related to use and timing of ANC. Women with higher mean empowerment scores were likely to have more than one ANC visit in the index pregnancy [Adjusted Odds Ratio (AOR) = 2.8, 95% Confidence Interval (CI): 1.1-7.3], but empowerment was not associated with early ANC use. Women who were more empowered were less likely to have a husband who reported attending an ANC visit with his wife (AOR = 0.1, 95% CI: 0.03-0.8). Women's empowerment is important and may be related to ANC use and engagement of male partners in complex ways.

Targeted HIV testing for male partners of HIV-positive pregnant women in a high prevalence setting in Nigeria

BACKGROUND

Partner HIV testing during pregnancy has remained abysmally low in sub-Saharan Africa, particularly in Nigeria. Males rarely attend antenatal clinics with their female partners, limiting the few opportunities available to offer them HIV testing. In this study, we evaluated the scale-up of the Healthy Beginning Initiative (HBI), a community-driven evidenced-based intervention to increase HIV testing among pregnant women and their male partners. Our objectives were to determine the: (1) male partner participation rate; (2) prevalence of HIV among male partners of pregnant women; (3) factors associated with HIV positivity among male partners of HIV-positive pregnant women.

METHODS

We reviewed program data of expectant parents enrolled in HBI in Benue State, north-central Nigeria. During HBI, trained lay health workers provided educational and counseling sessions, and offered free onsite integrated testing for HIV, hepatitis B virus and sickle cell genotype to pregnant women and their male partners who participated in incentivized, church-organized baby showers. Each participant completed an interviewer-administered questionnaire on demographics, lifestyle habits, and HIV testing history. Chi-square test was used to compare the characteristics of HIV-positive and HIV-negative male partners. Simple and multivariable logistic regression models were used to determine the association between participants' characteristics and HIV positivity among male partners of HIV-positive women.

RESULTS

Male partner participation rate was 57% (5264/9231). Overall HIV prevalence was 6.1% (891/14495) with significantly higher rates in women (7.4%, 681/9231) compared to men (4.0%, 210/5264). Among the 681 HIV-positive women, 289 male partners received HIV testing; 37.7% (109/289) were found to be HIV-positive. In multivariate analysis, older age (adjusted odds ratio [aOR]: 2.45, 95% confidence interval [CI]: 1.27-4.72 for age 30-39 years vs. <30 years; aOR: 2.39, CI: 1.18-4.82 for age ≥40 years vs. <30 years) and self-reported daily alcohol intake (vs. never (aOR: 0.35, CI: 0.13-0.96)) were associated with HIV positivity in male partners of HIV-positive women.

CONCLUSION

The community-based congregational approach is a potential strategy to increase male partner HIV testing towards achieving the UNAIDS goal of 90% HIV screening. Targeting male partners of HIV-positive women for screening may provide a higher yield of HIV diagnosis and the opportunity to engage known positives in care in this population.

The role of male partner in utilization of maternal health care services in Ethiopia: a community-based couple study

BACKGROUND

Ethiopia has recorded substantial progress in maternal health recently. However, poor utilization of maternal health care services is challenging further improvement. Although male partners are decision-makers in households, the impact of their involvement on maternal health care services has not been well studied. Thus, the objective of this study was to examine the association between male partners' involvement in maternal health care on utilization of maternal health care services.

METHODS

A community-based cross-sectional study was conducted on male/female couples with a baby less than 6 months old (N = 210) in Addis Ababa, Ethiopia. The main independent variable of the study was male partners' involvement in maternal health care. Two structured questionnaires were used to collect the data from men and women. Bivariate and multivariate logistic regression models were used to examine the relationship between the dependent and independent variables.

RESULTS

Mean age in years was 28.7 (SD = 5.4) for women and 36.2 (SD = 8.8) for men. Half of the men (51.4%) have accompanied their partner to antenatal care (ANC) at least once. However, only 23.1% of them have physically entered the ANC room together. Overall involvement of male partners was poor in 34.8% of the couples (involved in two or fewer activities). After controlling for other covariates, the odds of having 1st ANC visit within the first trimester of pregnancy and skilled delivery attendant at birth were higher in women whose male partners took time to know what happened during ANC visits (AOR = 1.93; 95%CI = 1.04-3.60; AOR = 2.93; 95%CI = 1.24-5.6.90, respectively). Similarly, the odds of having at least one ANC visit, first ANC visit within twelve weeks, HIV testing, skilled birth attendant, and birth in a health facility were higher in couples with higher overall male partner involvement.

CONCLUSION

The study demonstrated significant associations between male partners' involvement in maternal health care and utilization of some maternal health care services by female partners.

HIV self-testing alone or with additional interventions, including financial incentives, and linkage to care or prevention among male partners of antenatal care clinic attendees in Malawi: An adaptive multi-arm, multi-stage cluster randomised trial

BACKGROUND

Conventional HIV testing services have been less comprehensive in reaching men than in reaching women globally, but HIV self-testing (HIVST) appears to be an acceptable alternative. Measurement of linkage to post-test services following HIVST remains the biggest challenge, yet is the biggest driver of cost-effectiveness. We investigated the impact of HIVST alone or with additional interventions on the uptake of testing and linkage to care or prevention among male partners of antenatal care clinic attendees in a novel adaptive trial.

METHODS AND FINDINGS

An adaptive multi-arm, 2-stage cluster randomised trial was conducted between 8 August 2016 and 30 June 2017, with antenatal care clinic (ANC) days (i.e., clusters of women attending on a single day) as the unit of randomisation. Recruitment was from Ndirande, Bangwe, and Zingwangwa primary health clinics in urban Blantyre, Malawi. Women attending an ANC for the first time for their current pregnancy (regardless of trimester), 18 years and older, with a primary male partner not known to be on ART were enrolled in the trial after giving consent. Randomisation was to either the standard of care (SOC; with a clinic invitation letter to the male partner) or 1 of 5 intervention arms: the first arm provided women with 2 HIVST kits for their partners; the second and third arms provided 2 HIVST kits along with a conditional fixed financial incentive of $3 or $10; the fourth arm provided 2 HIVST kits and a 10% chance of receiving $30 in a lottery; and the fifth arm provided 2 HIVST kits and a phone call reminder for the women's partners. The primary outcome was the proportion of male partners who were reported to have tested for HIV and linked into care or prevention within 28 days, with referral for antiretroviral therapy (ART) or circumcision accordingly. Women were interviewed at 28 days about partner testing and adverse events. Cluster-level summaries compared each intervention versus SOC using eligible women as the denominator (intention-to-treat). Risk ratios were adjusted for male partner testing history and recruitment clinic. A total of 2,349/3,137 (74.9%) women participated (71 ANC days), with a mean age of 24.8 years (SD: 5.4). The majority (2,201/2,233; 98.6%) of women were married, 254/2,107 (12.3%) were unable to read and write, and 1,505/2,247 (67.0%) were not employed. The mean age for male partners was 29.6 years (SD: 7.5), only 88/2,200 (4.0%) were unemployed, and 966/2,210 (43.7%) had never tested for HIV before. Women in the SOC arm reported that 17.4% (71/408) of their partners tested for HIV, whereas a much higher proportion of partners were reported to have tested for HIV in all intervention arms (87.0%-95.4%, p < 0.001 in all 5 intervention arms). As compared with those who tested in the SOC arm (geometric mean 13.0%), higher proportions of partners met the primary endpoint in the HIVST + $3 (geometric mean 40.9%, adjusted risk ratio [aRR] 3.01 [95% CI 1.63-5.57], p < 0.001), HIVST + $10 (51.7%, aRR 3.72 [95% CI 1.85-7.48], p < 0.001), and phone reminder (22.3%, aRR 1.58 [95% CI 1.07-2.33], p = 0.021) arms. In contrast, there was no significant increase in partners meeting the primary endpoint in the HIVST alone (geometric mean 17.5%, aRR 1.45 [95% CI 0.99-2.13], p = 0.130) or lottery (18.6%, aRR 1.43 [95% CI 0.96-2.13], p = 0.211) arms. The lottery arm was dropped at interim analysis. Overall, 46 male partners were confirmed to be HIV positive, 42 (91.3%) of whom initiated ART within 28 days; 222 tested HIV negative and were not already circumcised, of whom 135 (60.8%) were circumcised as part of the trial. No serious adverse events were reported. Costs per male partner who attended the clinic with a confirmed HIV test result were $23.73 and $28.08 for the HIVST + $3 and HIVST + $10 arms, respectively. Notable limitations of the trial included the relatively small number of clusters randomised to each arm, proxy reporting of the male partner testing outcome, and being unable to evaluate retention in care.

CONCLUSIONS

In this study, the odds of men's linkage to care or prevention increased substantially using conditional fixed financial incentives plus partner-delivered HIVST; combinations were potentially affordable.

TRIAL REGISTRATION

ISRCTN 18421340.

The impact of approaches in improving male partner involvement in the prevention of mother-to-child transmission of HIV on the uptake of safe infant feeding practices by HIV positive women in sub-Saharan Africa. A systematic review and meta-analysis

BACKGROUND

The low level of male partner involvement in Prevention of Mother to Child Transmission of HIV services such as safe infant feeding practices poses a serious challenge to the implementation of guidelines on safe infant feeding and may undermine efforts towards elimination of mother to child transmission of HIV in sub Saharan Africa(SSA). We conducted a systematic review and meta-analysis to identify the approaches that have been utilized to improve male partner involvement in PMTCT services as well as their impact on the uptake of safe infant feeding practices by HIV positive mothers in SSA.

METHODS

In this systematic review and meta-analysis, Ovid Medline, Embase, PsycINFO, Cochrane library, ClinicalTrials.gov, Web of Science and Current Controlled Trials were searched. Only studies performed in SSA that reported an approach that specifically involved male partners and its impact on the uptake of safe infant feeding practices (irrespective of the language and date of publication) were included. Odds ratios were extracted or calculated from studies and combined in a meta-analysis using the statistical package Stata version 11.0. Forest plots were generated using the random effect model.

RESULTS

From an initial 2416 non-duplicate articles, 06 articles were included in the systematic review and meta-analysis. The overall pooled unadjusted OR was 3.08[95%CI: 2.58-3.68], while the effect sizes for interventions aimed at promoting male partner involvement such as verbal encouragement, complex community intervention and enhanced psychosocial interventions were 1.93[95%CI: 1.34-2.79], 3.45[95%CI: 2.79-4.25] and 5.14[95%CI: 2.42-10.90] respectively. Using only adjusted odd ratios, the pooled adjusted OR = 1.78[95%CI: 1.35-2.34]. The I2 = 60.1% p = 0.057 using adjusted ORs.

CONCLUSION

Interventions aimed at promoting male partner involvement such as enhanced psychosocial interventions, verbal encouragement and complex community interventions increase the uptake of safe infant feeding options. The heterogeneity was moderate among studies. More studies including randomised trials that will recruit larger, representative samples of patients are needed in the future. Prospero registration number: 42016032673.

HIV Disclosure Among Pregnant Women Initiating ART in Cape Town, South Africa: Qualitative Perspectives During the Pregnancy and Postpartum Periods

For women enrolled in prevention of mother-to-child transmission (PMTCT) programs, non-disclosure of their HIV status can be a significant barrier to sustained HIV care engagement. To explore decision-making surrounding HIV disclosure among HIV-infected pregnant women, we conducted repeated in-depth interviews during pregnancy and postpartum with 20 women recruited from a PMTCT clinic in Cape Town, South Africa. Three domains were examined using thematic analysis: (1) disclosure experiences, (2) challenges associated with partner disclosure, and (3) implications of nondisclosure. All women had disclosed to someone by the time of the baby's birth, typically limiting their disclosure to trusted individuals. Only half of participants disclosed to the father of the child. Nondisclosure, particularly to partners, was a significant source of worry and stress. Women used pregnancy as an explanation for using medication and attending frequent clinic appointments, and recognized impending challenges in the postpartum period when this excuse would no longer apply. Results suggest that PMTCT programs have a key role to play in helping individuals to make decisions about HIV disclosure, and assisting patients to navigate the disclosure process, especially with partners.

HIV-Uninfected Kenyan Adolescent and Young Women Share Perspectives on Using Pre-Exposure Prophylaxis During Pregnancy

To optimize scale-up of pre-exposure prophylaxis (PrEP) for pregnant women at risk of HIV in high HIV burden settings, implementation strategies must be developed that account for perceptions of PrEP in this unique population. Semistructured focus group discussions were conducted with 68 HIV-uninfected Kenyan pregnant and postpartum women without prior PrEP knowledge or experience. A qualitative descriptive analysis was performed, using a constant comparison approach, to identify key themes related to the values and rationale impacting potential PrEP use in pregnancy. Median age was 19.5 years and participants were either pregnant or had 1-2 children. Almost all (96%) were married or had a steady partner. Women felt pregnancy was a time of high HIV risk because they desired sex less frequently, which may lead their partners to have outside partnerships. This made PrEP an attractive HIV prevention option for themselves and their infants. Although women believed male partner behaviors influenced their HIV risk, many women perceived that male partners would react negatively, including becoming physically violent, if they discovered that women used PrEP. Clinicians were identified as potential facilitators of PrEP use who could explain PrEP to male partners on behalf of pregnant women. Women said that community-level stigma against HIV and potential for conflating PrEP with antiretroviral therapy (ART) would necessitate that PrEP use be discreet. Our results indicate the importance of addressing risk perception of women, concerns of male partners, HIV stigma, and benefits of PrEP for HIV prevention as programs are developed for pregnant women.

Men's hopes, fears and challenges in engagement in perinatal health and the prevention of mother-to-child transmission of HIV in rural Kenya

Male involvement in antenatal care has been shown to improve health outcomes for women and infants. However, little is known about how best to encourage male partners to support essential perinatal health activities. We explored men's perceptions of facilitators and barriers to involvement in antenatal care and HIV prevention including fears, hopes and challenges. Forty in-depth interviews were conducted with the male partners of HIV-positive and HIV-negative pregnant women in southwest Kenya. Most male partners believed engaging in pregnancy health-related activities was beneficial for keeping families healthy. However, thematic analysis revealed several obstacles that hindered participation. Poor couple relationship dynamics seemed negatively to influence male engagement. Some men were apprehensive that clinic staff might force them to test for HIV and disclose the results; if HIV-positive, men feared being labelled as 'victimisers' in situations of serodiscordancy, and described fears of abandonment by their wives. Some men avoided accompanying their wives, citing local culture as rationale for avoiding the 'effeminate' act of antenatal care attendance. Amidst these obstacles, some men chose to use their partners' HIV status as proxy for their own. Findings suggest that improving male engagement in essential maternal and child health-related activities will require addressing both structural and interpersonal barriers.

Missed opportunities in antenatal care for improving the health of pregnant women and newborns in Geita district, Northwest Tanzania

Background

Despite the significant benefits of early detection and management of pregnancy related complications during antenatal care (ANC) visits, not all pregnant women in Tanzania initiate ANC in a timely manner. The primary objectives of this research study in rural communities of Geita district, Northwest Tanzania were: 1) to conduct a population-based study that examined the utilization and availability of ANC services; and 2) to explore the challenges faced by women who visited ANC clinics and barriers to utilization of ANC among pregnant women.

Methods

A sequential explanatory mixed method design was utilized. Household surveys that examined antenatal service utilization and availability were conducted in 11 randomly selected wards in Geita district. One thousand, seven hundred and nineteen pregnant women in their 3rd trimester participated in household surveys. It was followed by focus group discussions with community health workers and pregnant women that examined challenges and barriers to ANC.

Results

Of the pregnant women who participated, 86.74% attended an ANC clinic at least once; 3.62% initiated ANC in the first trimester; 13.26% had not initiated ANC when they were interviewed in their 3rd trimester. Of the women who had attended ANC at least once, the majority (82.96%) had been checked for HIV status, less than a half (48.36%) were checked for hemoglobin level, and only a minority had been screened for syphilis (6.51%). Among women offered laboratory testing, the prevalence of HIV was 3.88%, syphilis, 18.57%, and anemia, 54.09%. In terms of other preventive measures, 91.01% received a tetanus toxoid vaccination, 76.32%, antimalarial drugs, 65.13%, antihelminthic drugs, and 76.12%, iron supplements at least once. Significant challenges identified by women who visited ANC clinics included lack of male partner involvement, informal regulations imposed by health care providers, perceived poor quality of care, and health care system related factors. Socio-cultural beliefs, fear of HIV testing, poverty and distance from health clinics were reported as barriers to early ANC utilization.

Conclusion

Access to effective ANC remains a challenge among women in Geita district. Notably, most women initiated ANC late and early initiation did not guarantee care that could contribute to better pregnancy outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2014-8) contains supplementary material, which is available to authorized users.

Husbands' knowledge and attendance at wives' postpartum care among rural farmers

We examined husbands' knowledge and attendance at their wives' postpartum visit in a sample of rural husband-and-wife farmer dyads in central Malawi. A cross-sectional matched-pairs survey of 70 husband-and-wife farmer dyads, who lived in rural communities in Ntcheu district, and had a live birth in the past year was conducted. Data were collected using an interviewer-administered, structured postpartum questionnaire adapted from WHO Safe Motherhood Needs Assessment Questionnaires. Many husbands did not know about postpartum assessments and education their wives received from health facilities. Percent agreement between dyads' responses was lower on questions referring to assessments than to education. The odds of reporting that the woman received postpartum assessments were greater among husbands than among wives. Fifty-nine percent of husbands did not go with their wives for 1-week postpartum visits. Top three reasons for not attending visits were: at work, out of town, and did not see the need.

Impact of a Rapid Results Initiative Approach on Improving Male Partner Involvement in Prevention of Mother to Child Transmission of HIV in Western Kenya

A rapid results initiative (RRI) aimed at increasing male involvement in prevention of mother-to-child transmission (PMTCT) and service uptake among pregnant women at 116 antenatal clinics in Western Kenya was compared at baseline, during the RRI, and 3-months post-RRI. Male involvement increased from 7.4 to 54.2% during RRI (risk difference [RD] 0.47, CI 0.45-0.48) then 43.4% post-RRI (RD 0.36, CI 0.35-0.37). Among HIV-infected women, facility delivery increased from 40.0 to 49.9% (RD 0.10, 95% CI 0.06-0.13) and 65.0% post-RRI (RD 0.25, 95% CI 0.22-0.28). HIV-infected pregnant women linkage to HIV care increased from 58.6 to 85.9% (RD 0.27, CI 0.24-0.30) and 97.3% post-RRI (RD 0.39, CI 0.36-0.41). Time to ART initiation reduced from 29 days (interquartile range [IQR] 6-56) to 14 days (IQR 0-28) to 7 days (IQR 0-20). A male-centered RRI can significantly increase men's engagement in antenatal care leading to improved partner utilization of PMTCT and antenatal services.

A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa

OBJECTIVE

We evaluated the effectiveness of interventions aimed at improving antiretroviral therapy (ART) adherence during pregnancy in sub-Saharan Africa.

METHODS

For this meta-analysis, the following databases were searched: MEDLINE Complete, Embase, Global Health, CINAHL Complete, and Google Scholar. Randomized and nonrandomized studies were considered for inclusion if they involved an intervention with the intent of improving medication adherence among pregnant women taking ART in sub-Saharan Africa. Databases were searched from inception to the end of August 2017. The primary outcome assessed was adherence to ART, defined as the proportion of women adherent to treatment in the control and intervention groups. Risk ratios and random effect meta-analysis were undertaken, and heterogeneity was examined with the I² statistic.

RESULTS

The systematic search of databases yielded a total of 402 articles, of which 19 studies were selected for meta-analysis with a total of 27,974 participants. Nine types of interventions were identified in the 19 studies to improve ART adherence. The test for the subgroup differences showed that there was a statistically significant difference among the 9 subgroups of interventions, χ² (8)=102.38; p=0.00001. Collectively, in the meta-analysis, the various intervention types made a significant impact on improving medication adherence. The overall effect estimate with 95% CI was as follows: 1.25 (95% CI=1.03, 1.52, p=0.03). The following risk ratio results for meta-analysis were obtained for the three interventions that showed significant impact on adherence; namely social support and structural support, 1.58 (95% CI=1.36, 1.84, p<0.00001); education, social support and structural support=2.60 (95% CI=1.95, 3.45, p<0.00001); and device reminder=1.13 (95% CI=1.05, 1.20, p=0.0004). The proportion of women who were adherent to ART as a result of the interventions was 59.3% compared with 22.5% in the control groups.

CONCLUSION

The use of device reminder, a combination of social support and structural support, and education, social support and structural support has the potential to improve ART adherence during pregnancy. Good quality prospective observational studies and randomized control trials are needed in sub-Saharan Africa to determine the most effective interventions.

Partners-based HIV treatment for seroconcordant couples attending antenatal and postnatal care in rural Mozambique: A cluster randomized trial protocol

BACKGROUND

In resource-limited rural settings, scale-up of services to eliminate mother-to-child transmission of HIV has not been as effective as in better resourced urban settings. In sub-Saharan Africa, women often require male partner approval to access and remain engaged in HIV care. Our study will evaluate a promising male engagement intervention ("Homens para Saúde Mais" (HoPS+) [Men for Health Plus]) targeting the elimination of mother-to-child transmission in rural Mozambique.

DESIGN

We will use a cluster randomized clinical trial design to engage 24 health facilities (12 intervention and 12 standard of care), with 45 HIV-infected seroconcordant couples per clinic. The planned intervention will engage male partners to address social-structural and cultural factors influencing eMTCT based on new couple-centered integrated HIV services.

CONCLUSIONS

The HoPS+ study will evaluate the effectiveness of engaging male partners in antenatal care to improve outcomes among HIV-infected pregnant women, their HIV-infected male partners, and their newborn children. Our objectives are to: (1) Implement and evaluate the impact of male-engaged, couple-centered services on partners' retention in care, adherence to antiretroviral therapy, early infant diagnosis uptake, and mother-to-child transmission throughout pregnancy and breastfeeding; (2) Investigate the impact of HoPS+ intervention on hypothesized mechanisms of change; and (3) Use validated simulation models to evaluate the cost-effectiveness of the HoPS+ intervention with the use of routine clinical data from our trial. We expect the intervention to lead to strategies that can improve outcomes related to partners' retention in care, uptake of services for HIV-exposed infants, and reduced MTCT.

Mother-to-Child Transmission of HIV and HIV-Free Survival in Swaziland: A Community-Based Household Survey

In Swaziland, no data are available on the rates of HIV infection and HIV-free survival among children at the end of the breastfeeding period. We performed a national crosssectional community survey of children born 18-24 months prior to the study, in randomly selected constituencies in all 4 administrative regions of Swaziland, from April to June 2015. Mother-to-child transmission (MTCT) of HIV and HIV-free survival rates were calculated for all HIV-exposed children. The overall HIV-free survival rate at 18-24 months was 95.9% (95% CI 94.1-97.2). The estimated proportion of HIV infected children among known HIV-exposed children was 3.6% (95% CI 2.4-5.2). Older maternal age, delivering at a health facility, and receiving antenatal antiretroviral drugs were independently associated with reduced risk for child infection or death. The Swaziland program for prevention of MTCT achieved high HIV-free survival (95.9%) and low MTCT (3.6%) rates at 18-24 months of age when Option A (infant prophylaxis) of the WHO 2010 guidelines was implemented.

Prevalence and correlates of non-disclosure of maternal HIV status to male partners: a national survey in Kenya

BACKGROUND

Prevention of mother-to-child HIV transmission (PMTCT) programs usually test pregnant women for HIV without involving their partners. Non-disclosure of maternal HIV status to male partners may deter utilization of PMTCT interventions since partners play a pivotal role in decision-making within the home including access to and utilization of health services.

METHODS

Mothers attending routine 6-week and 9-month infant immunizations were enrolled at 141 maternal and child health (MCH) clinics across Kenya from June-December 2013. The current analysis was restricted to mothers with known HIV status who had a current partner. Multivariate logistic regression models adjusted for marital status, relationship length and partner attendance at antenatal care (ANC) were used to determine correlates of HIV non-disclosure among HIV-uninfected and HIV-infected mothers, separately, and to evaluate the relationship of non-disclosure with uptake of PMTCT interventions. All analyses accounted for facility-level clustering, RESULTS: Overall, 2522 mothers (86% of total study population) met inclusion criteria, 420 (17%) were HIV-infected. Non-disclosure of HIV results to partners was higher among HIV-infected than HIV-uninfected women (13% versus 3% respectively, p < 0.001). HIV-uninfected mothers were more likely to not disclose their HIV status to male partners if they were unmarried (adjusted odds ratio [aOR] = 3.79, 95% CI: 1.56-9.19, p = 0.004), had low (≤KSH 5000) income (aOR = 1.85, 95% CI: 1.00-3.14, p = 0.050), experienced intimate partner violence (aOR = 3.65, 95% CI: 1.84-7.21, p < 0.001) and if their partner did not attend ANC (aOR = 4.12, 95% CI: 1.89-8.95, p < 0.001). Among HIV-infected women, non-disclosure to male partners was less likely if women had salaried employment (aOR = 0.42, 95%CI: 0.18-0.96, p = 0.039) and each increasing year of relationship length was associated with decreased likelihood of non-disclosure (aOR = 0.90, 95% CI: 0.82-0.98, p = 0.015 for each year increase). HIV-infected women who did not disclose their HIV status to partners were less likely to uptake CD4 testing (aOR = 0.32, 95% CI: 0.15-0.69, p = 0.004), to use antiretrovirals (ARVs) during labor (OR = 0.38, 95% CI 0.15-0.97, p = 0.042), or give their infants ARVs (OR = 0.08, 95% CI 0.02-0.31, p < 0.001).

CONCLUSION

HIV-infected women were less likely to disclose their status to partners than HIV-uninfected women. Non-disclosure was associated with lower use of PMTCT services. Facilitating maternal disclosure to male partners may enhance PMTCT uptake.

Expectant fathers' participation in antenatal care services in Papua New Guinea: a qualitative inquiry

Background

The importance of engaging men in maternal and child health programs is well recognised internationally. In Papua New Guinea (PNG), men’s involvement in maternal and child health services remains limited and barriers and enablers to involving fathers in antenatal care have not been well studied. The purpose of this paper is to explore attitudes to expectant fathers participating in antenatal care, and to identify barriers and enablers to men‘s participation in antenatal care with their pregnant partner in PNG.

Methods

Twenty-eight focus group discussions were conducted with purposively selected pregnant women, expectant fathers, older men and older women across four provinces of PNG. Fourteen key informant interviews were also conducted with health workers. Qualitative data generated were analysed thematically.

Results

While some men accompany their pregnant partners to the antenatal clinic and wait outside, very few men participate in antenatal consultations. Factors supporting fathers’ participation in antenatal consultations included feelings of shared responsibility for the unborn child, concern for the mother’s or baby’s health, the child being a first child, friendly health workers, and male health workers. Sociocultural norms and taboos were the most significant barrier to fathers’ participation in antenatal care, contributing to men feeling ashamed or embarrassed to attend clinic with their partner. Other barriers to men’s participation included fear of HIV or sexually transmitted infection testing, lack of separate waiting spaces for men, rude treatment by health workers, and being in a polygamous relationship. Building community awareness of the benefits of fathers participating in maternal and child health service, inviting fathers to attend antenatal care if their pregnant partner would like them to, and ensuring clinic spaces and staff are welcoming to men were strategies suggested for increasing fathers’ participation in antenatal care.

Conclusion

This study identified significant sociocultural and health service barriers to expectant fathers’ participation in antenatal care in PNG. Our findings highlight the need to address these barriers – through health staff training and support, changes to health facility layout and community awareness raising – so that couples in PNG can access the benefits of men’s participation in antenatal care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1759-4) contains supplementary material, which is available to authorized users.

Safe Water and Hygiene Integration with Human Immunodeficiency Virus and Antenatal Services: Leveraging Opportunities for Public Health Interventions and Improved Service Uptake

Integrating public health interventions with antenatal clinic (ANC) visits may motivate women to attend ANC, thereby improving maternal and neonatal health, particularly for human immunodeficiency virus (HIV)-infected persons. In 2009, in an integrated ANC/Preventing Mother-to-Child Transmission program, we provided free hygiene kits (safe storage containers, WaterGuard water treatment solution, soap, and oral rehydration salts) to women at their first ANC visit and refills at subsequent visits. To increase fathers' participation, we required partners' presence for women to receive hygiene kits. We surveyed pregnant women at baseline and at 12-month follow-up to assess ANC service utilization, HIV counseling and testing (HCT), test drinking water for residual chlorine, and observe handwashing. We conducted in-depth interviews with pregnant women, partners, and health workers. We enrolled 106 participants; 97 (92%) were found at follow-up. During the program, 99% of pregnant women and their partners received HCT, and 99% mutually disclosed. Fifty-six percent of respondents had ≥ 4 ANC visits and 90% delivered at health facilities. From baseline to follow-up, the percentage of women who knew how to use WaterGuard (23% versus 80%, P < 0.0001), had residual chlorine in stored water (0% versus 73%, P < 0.0001), had confirmed WaterGuard use (0% versus 70%, P < 0.0003), and demonstrated proper handwashing technique (21% versus 64% P < 0.0001) increased. Program participants showed significant improvements in water treatment and hygiene, and high use of ANC services and HCT. This evaluation suggests that integration of hygiene kits, refills, and HIV testing during ANC is feasible and may help improve household hygiene and increase use of health services.

Sexual risk during pregnancy and postpartum periods among HIV-infected and -uninfected South African women: Implications for primary and secondary HIV prevention interventions

BACKGROUND

HIV acquisition in pregnancy and breastfeeding contributes significantly toward pediatric HIV infection. However, little is known about how sexual behavior changes during pregnancy and postpartum periods which will help develop targeted HIV prevention and transmission interventions, including pre-exposure prophylaxis (PrEP).

METHODS

Cross-sectional study in HIV-infected and uninfected pregnant and postpartum women in Cape Town, South Africa. Interviewers collected survey data on demographic, sexual behaviors, and alcohol use among pregnant and post-partum women. We report descriptive results of sexual behavior by trimester and postpartum period, and results of multivariable logistic regression stratified by pregnancy status.

RESULTS

We enrolled 377 pregnant and postpartum women (56% pregnant, 40% HIV-infected). During pregnancy, 98% of women reported vaginal sex (8% anal sex, 44% oral sex) vs. 35% and 88% during the periods 0-6 and 7-12 months postpartum, respectively (p<0.05). More pregnant women reported having >1 partner in the past 12-months compared to postpartum women (18% vs. 13%, respectively, p<0.05). Sex frequency varied by trimester with greatest mean sex acts occurring during first trimester and >6-months postpartum (13 mean sex acts in first trimester; 17 mean sex acts >6-months postpartum). Pregnant women had increased odds of reporting condomless sex at last sex (aOR = 2.96;95%CI = 1.84-4.78) and ever having condomless sex in past 3-months (aOR = 2.65;95%CI = 1.30-5.44) adjusting for age, HIV status, and sex frequency compared to postpartum women.

CONCLUSION

We identified that sexual behaviors and risk behaviors were high and changing during pregnancy and postpartum periods, presenting challenges to primary and secondary HIV prevention efforts, including PrEP delivery to pregnant and breastfeeding women.

Facility-imposed barriers to early utilization of focused antenatal care services in Mangochi District, Malawi - a mixed methods assessment

BACKGROUND

Focused Antenatal Care (FANC) is advocated by the World Health Organization (WHO) as a key service approach to improving the health of pregnant women. Four targeted visits to antenatal clinics are recommended starting in the first trimester. First trimester attendance for FANC in Mangochi District, Malawi was low at 8%. FANC has mainly been promoted through health facility based communication activities with less emphasis on activities at community level. We developed and tested a community focused health communication approach "Community Driven Total FANC Attendance (CDTFA)" with the aim of increasing FANC clinic attendance. We included a research component in order to understand the context and responses of community members to this intervention.

METHODS

CDTFA meetings were designed in parallel with data gathering with approval of the local research ethics committee and community stakeholders. Participants in both the CDTFA meetings and data gathering activities, undertaken from December, 2015 to June, 2016 were of reproductive age (15-49 years). Data were collected through flexible interactive processes from participants through recording on pre-designed forms. Quantitative data were processed and analyzed in Microsoft Excel, while qualitative data were manually analyzed to identify themes.

RESULTS

In total, 403 CDTFA meetings were held. In the course of interactions with community members, some barriers that affected early utilization of FANC services were identified. Women who did not bring their partners and those who could not bring along with them cloth wraps for the newborn to clinics were not allowed to access FANC services. Payment for authorization letters from village heads for women who have no partners and user fees in non-governmental health facilities were also identified as barriers.

CONCLUSIONS

Despite the benefits of FANC services, health authorities in the District should ensure that use and promotion of the approach does not inadvertently bar some pregnant women from accessing services. There is a need to explore strategies and redesign an approach to health promotion that will promote uptake of the integrated services in FANC clinics without infringing on women's rights to access health care.

A qualitative analysis of the barriers to antiretroviral therapy initiation among children 2 to 18 months of age in Swaziland

HIV/AIDS remains one of the leading causes of death among children under 5 years old in Swaziland. Although studies have shown that early initiation of infants and children diagnosed with HIV on antiretroviral therapy (ART) significantly reduces mortality, many children do not initiate ART until the later stages of disease. This study was designed to collect qualitative data from mothers and caregivers of HIV-positive children to identify the barriers to ART initiation. Focus group discussion (FGD) sessions were conducted in siSwati between July and September 2014 among caregivers of aged children 2-18 months in Swaziland who did or did not initiate ART between January 2011 and December 2012 after HIV DNA PCR-positive diagnosis of the infants. Denial, guilt, lack of knowledge, tuberculosis (TB)/HIV co-infection, HIV-related stigma, lack of money, and distance to clinics were reported by the participants as barriers to ART initiation. The findings further revealed that non-initiation on ART was not linked to a negative perception of the treatment. Findings suggest a need to improve sensitivity among healthcare workers as well as education and counselling services that will facilitate the ART initiation process.

Non-disclosure of HIV-positive status to a partner and mother-to-child transmission of HIV: Evidence from a case-control study conducted in a rural county in Kenya

BACKGROUND

Many factors contribute to an enhanced risk of infant HIV acquisition, two of which may include failure of a mother to disclose her HIV-positive status to her partner and exclusion of male partners in preventing mother-to-child transmission of HIV (PMTCT) interventions. To justify why HIV programmes need to integrate male partner involvement and partner disclosure, we need to establish an association between the two factors and infant HIV acquisition.

OBJECTIVE

To determine whether failure to disclose an HIV-positive status to a male partner is associated with increased risk of infant HIV acquisition, and whether part of the association is explained by exclusion of male partner in PMTCT programmes.

METHODS

Using a case-control study design, we identified a total of 180 mother-baby pairs with HIV-exposed infants. Thirty-six pairs with HIV-positive babies (cases) were compared to 144 pairs with HIV-negative babies (controls) on whether the mothers had disclosed their HIV status to their partner in order to determine whether a disclosure or lack of it contributed to increased risk of mother-to-child transmission of HIV (MTCT). Each case pair was matched to four control pairs from the same facility.

RESULTS

Overall, 16.7% of mothers had not disclosed their HIV status to their partners, the proportion being significantly more among cases (52.8% vs. 7.6%, p < 0.001). Non-disclosure was significantly associated with infant HIV acquisition (aOR 9.8 (3.0-26.3); p < 0.001) and male partner involvement partially mediated the effect of non-disclosure on infant HIV acquisition (indirect coefficient = 0.17, p < 0.005).

CONCLUSIONS

Failure of an HIV-positive woman to disclose her status to her male partner and exclusion of male partners in PMTCT programmes are two social factors that may curtail success of interventions towards the goal of eliminating MTCT.

The impact of approaches in improving male partner involvement in the prevention of mother-to-child transmission of HIV on the uptake of maternal antiretroviral therapy among HIV-seropositive pregnant women in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

To identify the approaches that are used in improving on male partner involvement in the prevention of mother-to-child transmission (PMTCT) of HIV and their impact on the uptake maternal antiretroviral therapy (ART) in sub-Saharan Africa (SSA).

SETTING

This was a systematic review and meta-analysis of published studies carried out in SSA at all levels of healthcare (primary, secondary, tertiary and community).

PARTICIPANTS

The participants of the studies included were HIV-positive pregnant women and breastfeeding mothers with their male partners. Studies were included if they were conducted in SSA and mentioned an approach used in improving male partner involvement with data on the impact on the uptake of maternal ART uptake.

OUTCOMES

In the protocol, maternal ART uptake, infant prophylaxis, safe infant feeding options, condom use and family planning were envisaged. However, only maternal ART has been reported here due to limitations on the word count.

RESULTS

From an initial 2316 non-duplicate articles, 17 articles were included in the systematic review and meta-analysis. In the combined model, the ORs for complex community interventions, enhanced psychosocial interventions, verbal encouragement and invitation letters were 4.22 (95% CI 2.27 to 7.77), 2.29 (95% CI 1.42 to 7.69), 2.39 (95% CI 1.26 to 4.53) and 1.21 (95% CI 0.89 to 1.63), respectively, whereas in the model using adjusted ORs, enhanced psychosocial interventions had a higher effect than any other intervention. The heterogeneity was moderate using adjusted ORs.

CONCLUSION

Enhanced psychosocial interventions and complex community interventions increase male partner involvement and the uptake of PMTCT services more than any other intervention. Invitation letters had no effect. More randomised trials and observational studies (that have adjusted for potential confounders) are needed in the future.

PROSPERO REGISTRATION NUMBER

42016032673.

Male partner involvement in efforts to eliminate mother-to-child transmission of HIV in Kisumu County, Western Kenya, 2015

INTRODUCTION

male partner involvement in elimination of mother-to-child transmission (eMTCT) of HIV activities remains low in Western Kenya, despite its importance in reducing rates of child HIV transmission. We sought to identify factors associated with male partner involvement in eMTCT in Kisumu East sub-County, Western Kenya.

METHODS

we conducted a cross-sectional study among women aged ≥ 18 years who had children aged ≤ 12 months and were attending a child health clinic for immunization services in one of four Western Kenya health centers between February and April, 2015. We assessed male involvement using an "involvement index" of five factors of equal weight: partner antenatal care (ANC) attendance, partner HIV testing, partner financial support to the woman during ANC, partner awareness of ANC services and partner participation in decision making on contraception including condom use. Male involvement was classified as high or low based on their index score. We calculated odds ratios (OR) and 95% confidence intervals (CI) to identify factors associated with high male partner involvement.

RESULTS

we recruited 216 female participants. Mean age was 26.1 years (± 5.5 years), 189 (87.5%) were married. The majority (94.4%) had attended ANC in public health facilities. Nineteen percent of women had high male involvement. Having > 8 years of formal education (AOR 3.9, CI = 1.51-10.08), having male partner who was employed, history of previous couple testing (AOR = 3.2, CI = 1.42-7.22) and reports of partner having read the mother-child booklet during ANC (AOR = 2.9, CI = 1.30-6.49), were associated with high male involvement.

CONCLUSION

based on our findings, we recommend targeted strategies to actively sensitize men and encourage their involvement in eMTCT, particularly among partners of women with fewer years of education and among partners who are not employed.

Factors Associated with Male Partner Involvement in Programs for the Prevention of Mother-to-Child Transmission of HIV in Rural South Africa

Male partner involvement (MPI) can contribute to the success of programs aimed at preventing mother-to-child transmission (PMTCT) of HIV. However, the definition and measures of MPI differ according to context. This study utilized secondary cross-sectional data to investigate the prevalence and determinants of MPI among 463 male partners of HIV-infected pregnant women in rural South Africa. Results indicated that 44.1% of male partners reported involvement in most or all specified male partner involvement activities (i.e., scores of 7 to 9). Descriptive, correlation and multiple linear-regression analyses were conducted. Positive predictors of MPI included relationship status, own HIV status, awareness of female partner's positive HIV status, female partner's desire to have more children, having family planning discussions with provider, condom use to prevent HIV and sexually transmitted infections (STIs), and partner reasoning skills. Negative predictors included partner verbal aggression. Overall, although MPI is low, the study underlines important information that could be used to develop interventions aimed at improving maternal and infant health in PMTCT programs in South Africa.

HIV testing among male partners of pregnant women in Nigeria: a missing link in the elimination of mother-to-child transmission of HIV

In this study, we assessed male partner testing and the serodiscordance rate among pregnant women and their partners in the prevention of mother-to-child transmission (PMTCT) programme in Nigeria. We conducted a retrospective analysis of the consolidated national health sector PMTCT data over a five-year period (2012-2016). Over the period, a total of 11,833,062 pregnant women were tested for HIV with a positivity rate of 2.2%. About 266,188 (2.2%) of sexual partners of pregnant women who presented at PMTCT clinics had an HIV test within the period. The uptake of male partner testing varied across the years, ranging from 22,269 (1.7%) in 2012 to 90,603 (2.9%) in 2014 (χ² for trend = 1320; p < 0.001). Overall, the proportion of partners of HIV-negative pregnant women who tested was higher than the proportion of partners of HIV-positive pregnant women (81% versus 19%, respectively). The serodiscordance rate among partners who tested over the five-year period was 18%. The serodiscordance rate declined from 24% in 2012 to 13% in 2016 (χ² for trend = 1202; p < 0.001). Partner testing in the PMTCT programme in Nigeria has remained low in the last five years while the clinic-based serodiscordance rate among partners appears to be declining. There is a need for multilevel interventions to address the possible barriers to partner testing in the PMTCT programme and intensification of the HIV combination prevention approach in the HIV response.

The Impact of Couple HIV Testing and Counseling on Consistent Condom Use Among Pregnant Women and Their Male Partners: An Observational Study

BACKGROUND

In sub-Saharan Africa couple HIV testing and counseling (CHTC) has been associated with substantial increases in safe sex, especially when at least one partner is HIV infected. However, this relationship has not been characterized in an Option B+ context.

SETTING

The study was conducted at the antenatal clinic at Bwaila District Hospital in Lilongwe, Malawi in 2016 under an Option B+ program.

METHODS

Ninety heterosexual couples with an HIV-infected pregnant woman (female-positive couples) and 47 couples with an HIV-uninfected pregnant woman (female-negative couples) were enrolled in an observational study. Each couple member was assessed immediately before and 1 month after CHTC for safe sex (abstinence or consistent condom use in the last month). Generalized estimating equations were used to model change in safe sex before and after CHTC and to compare safe sex between female-positive and female-negative couples.

RESULTS

Mean age was 26 years among women and 32 years among men. Before CHTC, safe sex was comparable among female-positive couples (8%) and female-negative couples (2%) [risk ratio (RR): 3.7, 95% confidence interval (CI): 0.5 to 29.8]. One month after CHTC, safe sex was higher among female-positive couples (75%) than among female-negative couples (3%) (RR: 30.0, 95% CI: 4.3 to 207.7). Safe sex increased substantially after CTHC for female-positive couples (RR 9.6, 95% CI: 4.6 to 20.0), but not for female-negative couples (RR: 1.2, 95% CI: 0.1 to 18.7).

CONCLUSIONS

Engaging pregnant couples in CHTC can have prevention benefits for couples with an HIV-infected pregnant woman, but additional prevention approaches may be needed for couples with an HIV-uninfected pregnant woman.

Changing times? Gender roles and relationships in maternal, newborn and child health in Malawi

Background

For years, Malawi remained at the bottom of league tables on maternal, neonatal and child health. Although maternal mortality ratios have reduced and significant progress has been made in reducing neonatal morality, many challenges in achieving universal access to maternal, newborn and child health care still exist in Malawi. In Malawi, there is still minimal, though increasing, male involvement in ANC/PMTCT/MNCH services, but little understanding of why this is the case. The aim of this paper is to explore the role and involvement of men in MNCH services, as part of the broader understanding of those community system factors.

Methods

This paper draws on the qualitative data collected in two districts in Malawi to explore the role and involvement of men across the MNCH continuum of care, with a focus on understanding the community systems barriers and enablers to male involvement. A total of 85 IDIs and 20 FGDs were conducted from August 2014 to January 2015. Semi-structure interview guides were used to guide the discussion and a thematic analysis approach was used for data analysis.

Results

Policy changes and community and health care provider initiatives stimulated men to get involved in the health of their female partners and children. The informal bylaws, the health care provider strategies and NGO initiatives created an enabling environment to support ANC and delivery service utilisation in Malawi. However, traditional gender roles in the home and the male ‘unfriendly’ health facility environments still present challenges to male involvement.

Conclusion

Traditional notions of men as decision makers and socio-cultural views on maternal health present challenges to male involvement in MNCH programs. Health care provider initiatives need to be sensitive and mindful of gender roles and relations by, for example, creating gender inclusive programs and spaces that aim at reducing perceptions of barriers to male involvement in MNCH services so that programs and spaces that are aimed at involving men are designed to welcome men as full partners in the overall goals for improving maternal, neonatal and child health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1523-1) contains supplementary material, which is available to authorized users.

Maternal Influences on Access to and Use of Infant ARVs and HIV Health Services in Uganda

Vertical transmission of HIV is responsible for about 14 % of new HIV cases reported each year in sub-Saharan Africa. Barriers that prevent women from accessing and using antiretroviral medications (ARVs) for themselves and their infants perpetuate the epidemic. To identify influences on access to and use of infant HIV health services, specifically nevirapine administration, we conducted a mixed methods study among HIV-positive women in Uganda. This included a cross-sectional survey (n = 384) and focus group discussions (n = 6, 5-9 participants each). Of the 384 women, 80 % gave nevirapine to their infants within 72 h of birth. Factors independently associated with nevirapine administration were lack of maternal adherence to ARVs (AOR 3.55, 95 % CI 1.36-9.26) and attending a support group (AOR 2.50, 95 % CI 1.06-5.83). Non-health facility births were inversely related to nevirapine use (AOR 0.02, 95 % CI 0.003-0.09). Focus group discussions identified four themes impacting access and use: attending a support group, health care worker attitudes, lack of partner support, and poor health messaging regarding ARVs. Improving health care worker messaging regarding ARVs and providing women with needed support to access and use infant ARV prophylaxis is critical to overcoming access barriers. Eliminating these barriers may prevent numerous HIV infections each year saving the lives of many HIV-exposed infants.

Missed opportunities for HIV control: Gaps in HIV testing for partners of people living with HIV in Lima, Peru

Introduction

Based on the hypothesis that HIV programs struggle to deliver health services that harmonize necessities of treatment and prevention, we described the outcomes of routinely provided HIV testing to partners of people living with HIV (PLWH) through a secondary analysis of routine data collected at a public hospital in Lima, Peru.

Methods

Among PLWH enrolled in the study center’s HIV program between 2005 and 2014, we identified index cases (IC): PLWH who reported a unique partner not previously enrolled. We grouped partners according to their HIV status as reported by IC and collected data on HIV testing, clinical characteristics and admissions. The main outcome was the frequency of HIV testing among partners with reported unknown/seronegative HIV status.

Results

Out of 1586 PLWH who reported a unique partner at enrollment, 171 had a previously enrolled partner, leaving 1415 (89%) IC. HIV status of the partner was reported as unknown in 571 (40%), seronegative in 325 (23%) and seropositive in 519 (37%). Out of 896 partners in the unknown/seronegative group, 72 (8%) had HIV testing, 42/72 (58%) tested within three months of IC enrollment. Among the 49/72 (68%) who tested positive for HIV, 33 (67%) were enrolled in the HIV program. The proportion in WHO clinical stage IV was lower in enrolled partners compared to IC (37% vs 9%, p = 0.04). Non-tested partners (824) were likely reachable by the hospital, as 297/824 (36%) of their IC were admitted in the study center at least once, 51/243 (21%) female IC had received pregnancy care at the study center, and 401/692 (64%) of IC on antiretroviral therapy had achieved viral suppression, implying frequent visits to the hospital for pill pick-up.

Conclusion

In this setting, HIV testing of partners of PLWH was suboptimal, illustrating missed opportunities for HIV control. Integration of HIV strategies in primarily clinical-oriented services is a challenging need.

Acceptability of woman-delivered HIV self-testing to the male partner, and additional interventions: a qualitative study of antenatal care participants in Malawi

INTRODUCTION

In the era of ambitious HIV targets, novel HIV testing models are required for hard-to-reach groups such as men, who remain underserved by existing services. Pregnancy presents a unique opportunity for partners to test for HIV, as many pregnant women will attend antenatal care (ANC). We describe the views of pregnant women and their male partners on HIV self-test kits that are woman-delivered, alone or with an additional intervention.

METHODS

A formative qualitative study to inform the design of a multi-arm multi-stage cluster-randomized trial, comprised of six focus group discussions and 20 in-depth interviews, was conducted. ANC attendees were purposively sampled on the day of initial clinic visit, while men were recruited after obtaining their contact information from their female partners. Data were analysed using content analysis, and our interpretation is hypothetical as participants were not offered self-test kits.

RESULTS

Providing HIV self-test kits to pregnant women to deliver to their male partners was highly acceptable to both women and men. Men preferred this approach compared with standard facility-based testing, as self-testing fits into their lifestyles which were characterized by extreme day-to-day economic pressures, including the need to raise money for food for their household daily. Men and women emphasized the need for careful communication before and after collection of the self-test kits in order to minimize the potential for intimate partner violence although physical violence was perceived as less likely to occur. Most men stated a preference to first self-test alone, followed by testing as a couple. Regarding interventions for optimizing linkage following self-testing, both men and women felt that a fixed financial incentive of approximately USD$2 would increase linkage. However, there were concerns that financial incentives of greater value may lead to multiple pregnancies and lack of child spacing. In this low-income setting, a lottery incentive was considered overly disappointing for those who receive nothing. Phone call reminders were preferred to short messaging service.

CONCLUSIONS

Woman-delivered HIV self-testing through ANC was acceptable to pregnant women and their male partners. Feedback on additional linkage enablers will be used to alter pre-planned trial arms.

Viral Suppression and Retention in Care up to 5 Years After Initiation of Lifelong ART During Pregnancy (Option B+) in Rural Uganda

BACKGROUND

Lifelong antiretroviral therapy (ART) is recommended for all HIV-infected pregnant women, but early studies suggest that women often drop out of care postpartum and data are limited on virologic outcomes.

METHODS

We evaluated viral suppression (primary outcome) and retention in care up to 5 years after ART initiation among HIV-infected women who started lifelong ART during pregnancy, irrespective of CD4 count, in a study in rural Uganda (NCT00993031). Participants were followed in the study for up to 1 year postpartum, then referred to clinics in surrounding communities. A random sample (N = 200) was invited to participate in a cross-sectional follow-up study after completing the trial, involving one visit for a questionnaire and pregnancy and HIV-1 RNA testing. Retention in care was defined as having attended an HIV clinic in the last 90 days. Logistic regression models were used to examine factors associated with viral suppression (HIV-1 RNA <400 copies/ml) at follow-up.

RESULTS

One hundred fifty women (75%) were successfully contacted for follow-up at a median of 4.2 years after starting ART; 135 were retained in care [90%, 95% confidence interval (CI): 84.0% to 94.3%] and 121 demonstrated viral suppression (80.7%, 95% CI: 73.4% to 86.7%). Women who had disclosed their HIV status to their primary partner had greater odds of viral suppression (adjusted odds ratio: 4.51, 95% CI: 1.02 to 19.8).

CONCLUSIONS

High rates of viral suppression can be achieved up to 5 years after initiating ART during pregnancy among women retained in care. Interventions to facilitate disclosure may improve long-term outcomes among women who initiate ART during pregnancy under universal treatment.

Linkage to Care, Early Infant Diagnosis, and Perinatal Transmission Among Infants Born to HIV-Infected Nigerian Mothers: Evidence From the Healthy Beginning Initiative

BACKGROUND

In 2014, Nigeria accounted for 33% of all new childhood HIV infections that occurred among the 22 Global Plan priority countries where 80% of HIV-infected women reside. Even with a vertical HIV transmission rate of 27%, only 6% of infants born to HIV-infected women in Nigeria receive early infant diagnosis (EID). This article reports rates of antiretroviral prophylaxis, EID, and mother-to-child transmission in a congregation-based Healthy Beginning Initiative (HBI) designed to increase HIV testing among pregnant women in southeast Nigeria.

METHODS

This is a nested cohort study of HIV-exposed infants (HEI) within the HBI trial originally designed as a 2-arm cluster randomized trial. HIV-infected mothers and infants were followed between January 2013 and August 2014.

RESULTS

Across both arms of the study, 72 HIV-infected women delivered 69 live infants (1 set of twins) and 4 had miscarriages. Of the 69 live-born HEI, HIV status was known for 71% (49/69), 16% (11/69) died before sample collection, and 13% (9/69) were lost to follow-up. Complete information was available for 84% of HEI (58/69), of which 64% (37/58) received antiretroviral prophylaxis. Among the 49 infants tested for HIV, 88% (43/49) received EID within 2 months and 12% (6/49) received antibody testing after 18 months. The mother-to-child transmission rate was 8.2% (4/49).

CONCLUSIONS

EID was higher and HIV transmission rate was lower among the HBI participants compared to reported rates in 2014. However, further progress is needed to achieve goals of elimination of infant HIV infection.

Male partner involvement in the prevention of mother to child transmission of HIV infection in Mwanza Region, Tanzania

INTRODUCTION

Globally, there are 3.3 million children < 15 years of age living with HIV infection. About 95% of HIV infected children have acquired infection from their mothers. Although new pediatric HIV infection in Tanzania has declined by 48% and Prevention of Mother to Child Transmission (PMTCT) coverage of highly active anti-retroviral therapy (HAART) has increased to 77%, the MTCT rate remains high (15%). Poor male partner involvement in PMTCT services is one of the factors contributing to reduced effectiveness of the PMTCT and hence failure to achieve the elimination of maternal to child transmission of HIV. This study examined the predictors of male involvement in PMTCT services in Mwanza Region, Tanzania from perspectives of the mother.

METHODS

A cross sectional study involving selected health facilities was conducted in Mwanza urban from October 2013 through January 2014. HIV positive pregnant women attending ante-natal clinic (ANC) were interviewed using a semi structured questionnaire. Univariate analysis was used to describe the study respondents where bivariate and logistic regression was used to determine predictors of male involvement.

RESULTS

A total of 300 HIV positive mothers attending ANC with the mean age of 27.5 + 5.6 were interviewed. Few mothers (24.7%) had their male partners involved in PMTCT. Predictors of male partner involvement in PMTCT were mothers being proactive (Adjusted Odds Ratio (AOR) 28.6; Confidence Interval (CI) 7-116), perceived partners knowledge on PMTCT (AOR 24.6, CI 5.9-102.8), exposure to TV/Radio announcements on PMTCT (AOR 4.6, CI 1.5-14) and married status of the mother (AOR 3.7, CI 1.5-9). Mothers who never wanted to be escorted by their male partners and busy partners were associated with reduced odds of male involvement into PMTCT (AOR 0.07, CI 0.007-0.68) and (AOR 0.46 CI 0.21-0.99) respectively. Male partner involvement was associated with 98% reduced odds of violence (Crude Odds Ratio 0.018 CI 0.002-0.14).

CONCLUSION

Male partner involvement in PMTCT is still low in Mwanza Region. Proactive mothers, partner's knowledge on PMTCT and announcements from television/radio were the major facilitating factors for male involvement in PMTCT as perceived by mothers. Busy male partners and mothers who did not want to be escorted by their partners were a hindrance to male involvement in PMTCT services. These factors highlight the importance of women role in promotion of PMTCT male involvement.

Exploring the Experiences of Women and Health Care Workers in the Context of PMTCT Option B Plus in Malawi

Introduction:

Malawi has embarked on a “test-and-treat” approach to prevent mother-to-child transmission (PMTCT) of HIV, known as “Option B+,” offering all HIV-infected pregnant and breastfeeding women lifelong antiretroviral therapy (ART) regardless of CD4 count or clinical stage. A cross-sectional qualitative study was conducted to explore early experiences surrounding “Option B+” for patients and health care workers (HCWs) in Malawi.

Methods:

Study participants were purposively selected across 6 health facilities in 3 regional health zones in Malawi. Semi-structured interviews were conducted with women enrolled in “Option B+” (n = 24), and focus group discussions were conducted with HCWs providing Option B+ services (n = 6 groups of 8 HCWs). Data were analyzed using a qualitative thematic coding framework.

Results:

Patients and HCWs identified the lack of male involvement as a barrier to retention in care and expressed concerns at the rapidity of the test-and-treat process, which makes it difficult for patients to “digest” a positive diagnosis before starting ART. Fear regarding the breach of privacy and confidentiality were also identified as contributing to loss to follow-up of women initiated under the Option B+. Disclosure remains a difficult process within families and couples. Lifelong ART was also perceived as an opportunity to plan future pregnancies.

Conclusions:

As “Option B+” continues to be rolled out, novel interventions to support and retain women into care must be implemented. These include providing space, time, and support to accept a diagnosis before starting ART, engaging partners and families, and addressing the need for peer support and confidentiality.

Barriers and facilitators for men to attend prenatal care and obtain HIV voluntary counseling and testing in Brazil

Background

Providing HIV voluntary counseling and testing (VCT) to men who attend their partner's prenatal care is an intervention with potential to reduce HIV transmission to women and infants during the vulnerable period of pregnancy. Little is known about the acceptability of this intervention in global settings outside of Africa.

Methods

We conducted in-depth qualitative interviews to evaluate potential barriers and facilitators to prenatal care attendance for HIV VCT with 20 men who did and 15 men who did not attend prenatal care with their partners at Hospital Conceiçao in Porto Alegre, Brazil. Men were recruited at the labor and delivery unit at Hospital Conceiçao via a scripted invitation while visiting their newborn infant. Interviews lasted from 35–55 minutes and were conducted in Portuguese by a local resident trained extensively in qualitative methods. All interviews were transcribed verbatim, translated, and then analyzed using Atlast.ti software. An analysis of themes was then conducted using direct quotes and statements. We applied and adapted the AIDS Risk Reduction Theoretical Model and HIV Testing Decisions Model to the qualitative data to identify themes in the 35 interviews.

Results

If offered HIV testing during prenatal care, all men in both groups stated they would accept this intervention. Yet, individual, relationship and systemic factors were identified that affect these Brazilian men's decision to attend prenatal care, informing our final conceptual model. The men interviewed had a general understanding of the value of HIV prevention of mother to child transmission. They also described open and communicative relationships with their significant others and displayed a high level of enthusiasm towards optimizing the health of their expanding family. The major barriers to attending prenatal care included perceived stigma against HIV infected individuals, men’s lack of involvement in planning of the pregnancy as well as inconvenient scheduling of prenatal care, due to conflicting work schedules.

Conclusions

Brazilian men displayed high levels of HIV-related knowledge as well as open communication about HIV testing; especially when compared to findings from African studies. Future efforts should reorient prenatal care towards providing care to the entire family with a clear focus on protecting the infant from preventable diseases. Formally inviting men to prenatal care and providing them an acceptable medical excuse from work may enhance male involvement.

Community-based strategies to strengthen men's engagement in the HIV care cascade in sub-Saharan Africa

Monica Sharma and colleagues discuss evidence-based approaches to improving HIV services for men in sub-Saharan Africa.

Barriers to uptake of early infant HIV testing in Zambia: the role of intimate partner violence and HIV status disclosure within couples

BACKGROUND

Early detection of pediatric HIV through uptake of infant HIV testing is critical for access to treatment and child survival. While structural barriers have been well described, a greater understanding of social and behavioral factors that may relate to maternal uptake of early infant HIV testing services is urgently needed. The aim of this study was to explore how gender power dynamics within couples affect HIV-positive women's uptake of early infant HIV testing at a large health center in Lusaka, Zambia.

METHODS

In 2014, 320 HIV-positive married postpartum women were recruited at a large public health facility in Lusaka to participate in a cross-sectional survey. Data on uptake of early infant HIV testing by 4-6 weeks of age was collected through medical records. Simple and multiple logistic regression models determined significant predictors of maternal uptake of early infant HIV testing.

RESULTS

In the adjusted model, uptake of early infant HIV testing was associated with female-directed emotional intimate partner violence (aOR 0.41; 95% CI 0.21-0.79; p < 0.01), HIV status disclosure to the male partner (aOR 13.73, 95% CI 3.59-52.49, p < 0.001), and maternal postpartum ART adherence (aOR 2.28, 95% CI 1.15-4.55, p < 0.05).

CONCLUSIONS

Domestic relationship dynamics, including emotional violence and HIV status disclosure to the male partner, may play an important role in maternal uptake of early infant HIV testing. These findings provide additional evidence for the link between intimate partner violence against women and poor HIV-related health outcomes. Programs that adequately screen for and address various forms of intimate partner violence within the context of prevention of mother-to-child transmission are recommended.

The role of family planning in achieving safe pregnancy for serodiscordant couples: commentary from the United States government's interagency task force on family planning and HIV service integration

INTRODUCTION

People living with HIV (PLHIV) have the right to exercise voluntary choices about their health, including their reproductive health. This commentary discusses the integral role that family planning (FP) plays in helping PLHIV, including those in serodiscordant relationships, achieve conception safely. The United States (US) President's Emergency Plan for AIDS Relief (PEPFAR) is committed to meeting the reproductive health needs of PLHIV by improving their access to voluntary FP counselling and services, including prevention of unintended pregnancy and counselling for safer conception.

DISCUSSION

Inclusion of preconception care and counselling (PCC) as part of routine HIV services is critical to preventing unintended pregnancies and perinatal infections among PLHIV. PLHIV not desiring a current pregnancy should be provided with information and counselling on all available FP methods and then either given the method onsite or through a facilitated referral process. PLHIV, who desire children should be offered risk reduction counselling, support for HIV status disclosure and partner testing, information on safer conception options to reduce the risk of HIV transmission to the partner and the importance of adhering to antiretroviral treatment during pregnancy and breastfeeding to reduce the risk of vertical transmission to the infant. Integration of PCC, HIV and FP services at the same location is recommended to improve access to these services for PLHIV. Other considerations to be addressed include the social and structural context, the health system capacity to offer these services, and stigma and discrimination of providers.

CONCLUSION

Evaluation of innovative service delivery models for delivering PCC services is needed, including provision in community-based settings. The US Government will continue to partner with local organizations, Ministries of Health, the private sector, civil society, multilateral and bilateral donors, and other key stakeholders to strengthen both the policy and programme environment to ensure that all PLHIV and serodiscordant couples have access to FP services, including prevention of unintended pregnancy and safer conception counselling.

Factors associated with mother to child transmission of HIV despite overall low transmission rates in HIV-exposed infants in rural Kenya

Despite the availability of efficacious prevention of mother-to-child transmission (PMTCT) interventions and improved access to preventive services in many developing countries, vertical HIV transmission persists. A matched case-control study of HIV-exposed infants between January and June 2012 was conducted at 20 clinics in Kenya. Cases were HIV-infected infants and controls were exposed, uninfected infants. Conditional logistic regression analysis was conducted to determine characteristics associated with HIV infection. Forty-five cases and 45 controls were compared. Characteristics associated with HIV-infection included poor PMTCT service uptake such as late infant enrollment (odds ratio [OR]: 7.1, 95% confidence interval [CI]: 2.6-16.7) and poor adherence to infant prophylaxis (OR: 8.3, 95%CI: 3.2-21.4). Maternal characteristics associated with MTCT included lack of awareness of HIV status (OR: 5.6, 95%CI: 2.2-14.5), failure to access antiretroviral prophylaxis (OR: 22.2, 95%CI: 5.8-84.6), and poor adherence (OR: 8.1, 95%CI: 3.7-17.8). Lack of clinic-based HIV education (OR: 7.7, 95%CI: 2.0-25.0) and counseling (OR: 8.3, 95%CI: 2.2-33.3) were reported by mothers of cases. Poor uptake of PMTCT services and a reported absence of HIV education and counseling at the clinic were associated with MTCT. More emphasis on high-quality, comprehensive PMTCT service provision are urgently needed to minimize HIV transmission to children.

What do You Need to Get Male Partners of Pregnant Women Tested for HIV in Resource Limited Settings? The Baby Shower Cluster Randomized Trial

Male partner involvement has the potential to increase uptake of interventions to prevent mother-to-child transmission of HIV (PMTCT). Finding cultural appropriate strategies to promote male partner involvement in PMTCT programs remains an abiding public health challenge. We assessed whether a congregation-based intervention, the Healthy Beginning Initiative (HBI), would lead to increased uptake of HIV testing among male partners of pregnant women during pregnancy. A cluster-randomized controlled trial of forty churches in Southeastern Nigeria randomly assigned to either the HBI (intervention group; IG) or standard of care referral to a health facility (control group; CG) was conducted. Participants in the IG received education and were offered onsite HIV testing. Overall, 2498 male partners enrolled and participated, a participation rate of 88.9%. Results showed that male partners in the IG were 12 times more likely to have had an HIV test compared to male partners of pregnant women in the CG (CG = 37.71% vs. IG = 84.00%; adjusted odds ratio = 11.9; p < .01). Culturally appropriate and community-based interventions can be effective in increasing HIV testing and counseling among male partners of pregnant women.

Acceptability and Preferences among Men and Women for Male Involvement in Antenatal Care

Introduction. Male involvement in antenatal care (ANC) has been associated with improved prevention of mother-to-child transmission outcomes in Sub-Saharan Africa; yet it remains uncommon. We assess acceptability of male involvement from the male and female perspectives and potential incentives for men to attend ANC. Methods. Adult pregnant women and men attending primary healthcare at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, from October 2013 to January 2014, were recruited using stratified random sampling to ensure equal representation across gender and HIV status. Results. 300/332 individuals (93.8%) offered participation consented. Among the 150 women, 97% had a partner; the majority (92%) preferred partner attendance at ANC, and 14% reported partner attendance during this pregnancy. The 150 men had low knowledge of services rendered at ANC outside of pregnancy monitoring, and few (19%) had previously attended ANC. Blood pressure screening, fatherhood information, and HIV testing were identified by men as incentives for attendance. Women and men expressed high willingness to, respectively, deliver (95%) and respond (97%) to ANC letter invitations. Conclusion. Invitation letters to promote male involvement in ANC are highly acceptable to pregnant women and men. Focusing invitation messages on fatherhood and primary healthcare rather than HIV testing may provide greater motivation for male involvement.