Increasing HIV testing among male partners

Implementing a prenatal health screening intervention for future fathers in Montreuil, France: most users are immigrants facing hardship

BACKGROUND

Prenatal care provides pregnant women with repeated opportunities for prevention, screening and diagnosis that have no current extension to future fathers. It also contributes to women's general better access to health. The goal of PARTAGE study was to evaluate the level and determinants of adherence to a prenatal prevention consultation dedicated to men.

METHODS

Between January 2021 and April 2022, we conducted a monocentric interventional study in Montreuil hospital. We assessed the acceptance of a prenatal prevention consultation newly offered to every future father, through their pregnant partner's prior consent to provide their contact details.

RESULTS

Three thousand thirty-eight women provided contact information used to reach the fathers; effective contact was established with 2,516 men, of whom 1,333 (53%) came for prenatal prevention consultation. Immigrant men were more likely to come than French-born men (56% versus 49%, p < 0·001), and the more they faced social hardship, the more likely they were to accept the offer. In multivariate analysis, men born in Subsaharan Africa and Asia were twice as likely to attend the consultation as those born in Europe or North America.

CONCLUSION

Acceptance of this new offer was high. Moreover, this consultation was perceived by vulnerable immigrant men as an opportunity to integrate a healthcare system they would have otherwise remained deprived of.

TRIAL REGISTRATION

Registry: ClinicalTrials.gov, US National Library of Medicine https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05085717 Clinical Trial number:  NCT05085717 . Date of registration: 20/10/2021.

Demand creation for HIV testing services: A systematic review and meta-analysis

BACKGROUND

HIV testing services (HTS) are the first steps in reaching the UNAIDS 95-95-95 goals to achieve and maintain low HIV incidence. Evaluating the effectiveness of different demand creation interventions to increase uptake of efficient and effective HTS is useful to prioritize limited programmatic resources. This review was undertaken to inform World Health Organization (WHO) 2019 HIV testing guidelines and assessed the research question, "Which demand creation strategies are effective for enhancing uptake of HTS?" focused on populations globally.

METHODS AND FINDINGS

The following electronic databases were searched through September 28, 2021: PubMed, PsycInfo, Cochrane CENTRAL, CINAHL Complete, Web of Science Core Collection, EMBASE, and Global Health Database; we searched IAS and AIDS conferences. We systematically searched for randomized controlled trials (RCTs) that compared any demand creation intervention (incentives, mobilization, counseling, tailoring, and digital interventions) to either a control or other demand creation intervention and reported HTS uptake. We pooled trials to evaluate categories of demand creation interventions using random-effects models for meta-analysis and assessed study quality with Cochrane's risk of bias 1 tool. This study was funded by the WHO and registered in Prospero with ID CRD42022296947. We screened 10,583 records and 507 conference abstracts, reviewed 952 full texts, and included 124 RCTs for data extraction. The majority of studies were from the African (N = 53) and Americas (N = 54) regions. We found that mobilization (relative risk [RR]: 2.01, 95% confidence interval [CI]: [1.30, 3.09], p < 0.05; risk difference [RD]: 0.29, 95% CI [0.16, 0.43], p < 0.05, N = 4 RCTs), couple-oriented counseling (RR: 1.98, 95% CI [1.02, 3.86], p < 0.05; RD: 0.12, 95% CI [0.03, 0.21], p < 0.05, N = 4 RCTs), peer-led interventions (RR: 1.57, 95% CI [1.15, 2.15], p < 0.05; RD: 0.18, 95% CI [0.06, 0.31], p < 0.05, N = 10 RCTs), motivation-oriented counseling (RR: 1.53, 95% CI [1.07, 2.20], p < 0.05; RD: 0.17, 95% CI [0.00, 0.34], p < 0.05, N = 4 RCTs), short message service (SMS) (RR: 1.53, 95% CI [1.09, 2.16], p < 0.05; RD: 0.11, 95% CI [0.03, 0.19], p < 0.05, N = 5 RCTs), and conditional fixed value incentives (RR: 1.52, 95% CI [1.21, 1.91], p < 0.05; RD: 0.15, 95% CI [0.07, 0.22], p < 0.05, N = 11 RCTs) all significantly and importantly (≥50% relative increase) increased HTS uptake and had medium risk of bias. Lottery-based incentives and audio-based interventions less importantly (25% to 49% increase) but not significantly increased HTS uptake (medium risk of bias). Personal invitation letters and personalized message content significantly but not importantly (<25% increase) increased HTS uptake (medium risk of bias). Reduced duration counseling had comparable performance to standard duration counseling (low risk of bias) and video-based interventions were comparable or better than in-person counseling (medium risk of bias). Heterogeneity of effect among pooled studies was high. This study was limited in that we restricted to randomized trials, which may be systematically less readily available for key populations; additionally, we compare only pooled estimates for interventions with multiple studies rather than single study estimates, and there was evidence of publication bias for several interventions.

CONCLUSIONS

Mobilization, couple- and motivation-oriented counseling, peer-led interventions, conditional fixed value incentives, and SMS are high-impact demand creation interventions and should be prioritized for programmatic consideration. Reduced duration counseling and video-based interventions are an efficient and effective alternative to address staffing shortages. Investment in demand creation activities should prioritize those with undiagnosed HIV or ongoing HIV exposure. Selection of demand creation interventions must consider risks and benefits, context-specific factors, feasibility and sustainability, country ownership, and universal health coverage across disease areas.

A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries

HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.

Diagnosis and treatment of sexually transmitted infections in male partners of pregnant women in Brazil

Sexually transmitted infections (STIs) can adversely affect a woman's pregnancy and the health of the developing fetus. The source of these infections may be the male sexual partner who remains under-diagnosed and un-treated due to a combination of lack of symptoms, decreased access to health care, and poor health-seeking behaviors. From September 2018 to November 2019, we offered a cohort of pregnant women (gestational age range: 4.6-41 weeks) clinic-based STI testing for HIV and syphilis (via lateral flow assay rapid tests) and for Neisseria (N.) gonorrhoeae, Chlamydia (C.) trachomatis, and Trichomonas (T.) vaginalis (via PCR-based testing) at Santa Casa Hospital and 10 affiliated prenatal clinics in Porto Alegre, Brazil. 400 women between the ages of 18 and 46 years (mean age: 27 years) enrolled and 24% were diagnosed with an STI. Each woman enrolled agreed to invite their male partners to clinic for the same panel of STI testing, and 255 men (64%) between the ages of 18 and 64 years (mean age: 29 years) attended clinic and all accepted full intervention. In these male partners, 40 (16%) were diagnosed with an STI including 22 (8.7%) testing positive for C. trachomatis, 15 (6%) for treponemal antibody (syphilis), 7 (2.8%) for T. vaginalis, 3 (1.2%) for N. gonorrhoeae, and 1 (0.4%) for HIV antibody. In our multivariate analysis, having symptoms of an STI (AOR 4.5, 95% CI 1.3-15.2) and arguing about jealousy (AOR 3.1, 95% CI 1.2-8.2) remained significantly associated with male diagnosis of an STI. Sexually transmitted infections are common in sexual partners of pregnant women in Brazil and should be addressed to prevent reinfection of pregnant women.

Male engagement guidelines in antenatal care: unintended consequences for pregnant women in Tanzania

BACKGROUND

The meaningful engagement of male partners in antenatal care (ANC) can positively impact maternal and newborn health outcomes. The Tanzania National Plan for the Elimination of Mother to Child Transmission of HIV recommends male partners attend the first ANC appointment as a strategy for HIV prevention and treatment. This recommendation seeks to increase uptake of HIV and reproductive healthcare services, but unintended consequences of these guidelines may negatively impact women's ANC experiences. This study qualitatively examined the impact of policy promoting male engagement on women's ANC experiences.

METHODS

The study was conducted in two urban clinics in Kilimanjaro Region, Tanzania. In-depth interviews were conducted with 19 participants (13 women and 6 male partners) attending a first ANC appointment. A semi-structured guide was developed, applying Kabeer's Social Relations Approach. Data were analyzed using applied thematic analysis, combining memo writing, coding, synthesis, and comparison of themes.

RESULTS

Male attendance impacted the timing of women's presentation to ANC and experience during the first ANC visit. Women whose partners could not attend delayed their presentation to first ANC due to fears of being interrogated or denied care because of their partner absence. Women presenting with partners were given preferential treatment by clinic staff, and women without partners felt discriminated against. Women perceived that the clinic prioritized men's HIV testing over involvement in pregnancy care.

CONCLUSIONS

Study findings indicate the need to better assess and understand the unintended impact of policies promoting male partner attendance at ANC. Although male engagement can benefit the health outcomes of mothers and newborn children, our findings demonstrate the need for improved methods of engaging men in ANC. ANC clinics should identify ways to make clinic settings more male friendly, utilize male attendance as an opportunity to educate and engage men in pregnancy and newborn care. At the same time, clinic policies should be cognizant to not discriminate against women presenting without a partner.

Short Communication: Communication Between Pregnant Women and Male Partners About HIV Testing in the United States

Male partner uptake of HIV testing during antenatal care is poor despite women's reported desire for partner testing. This qualitative study of HIV-negative pregnant women and their partners in a high HIV prevalence city in the United States assessed communication between partners about HIV testing. Facilitators and barriers of partner testing were identified. Women are the driving force behind couples' communication; however, male partner uptake is underutilized. A common barrier to male partner uptake is the concept of "negative by proxy," as well as male partner lack of follow-up for testing and nondisclosure of results. Future research is needed to assess specific barriers to male partner HIV testing as an approach to preventing perinatal HIV transmission.

Couple oriented counselling improves male partner involvement in sexual and reproductive health of a couple: Evidence from the ANRS PRENAHTEST randomized trial

BACKGROUND

Male partner involvement (MPI) has been recognized as a priority area to be strengthened in Prevention of Mother to Child Transmission (PMTCT) of HIV. We explored the impact of Couple Oriented Counselling (COC) in MPI in sexual and reproductive health and associated factors.

METHOD

From February 2009 to October 2011, pregnant women were enrolled at their first antenatal care visit (ANC-1) and followed up until 6 months after delivery in the Mother and Child Center of the Chantal Biya Foundation within the randomized prenahtest multicentric trial. The MPI index was defined using sexual and reproductive health behaviour variables by using multiple correspondence analysis followed by mixed classification. Men were considered as highly involved if they had shared their HIV test results with their partner, had discussed on HIV or condom used, had contributed financially to ANC, had accompanied their wife to ANC or had practiced safe sex. Factors associated to MPI were investigated by the logistic model with GEE estimation approach.

RESULTS

A total of 484 pregnant women were enrolled. The median age of the women was 27 years (IQR: 23-31) and 55.23% had a gestational age greater than 16 weeks at ANC-1. Among them, HIV prevalence was 11.9% (95% CI: 9.0-15.4). The median duration of the women's relationship with their partner was 84 months (IQR: 48-120). MPI index at 6 months after delivery was significantly greater in the COC group than the classical counselling group (14.8% vs 8,82%; p = 0,043; Fig 1). The partners of the women who participated in the COC were more likely to be involved during follow up than others (aOR = 1.45; 95% CI = 1.00-2.10). Partners with no incoming activity (aOR = 2.90; 95% CI = 1.96-4.29), who did not used violence within the couple (aOR = 1.70; 95% CI = 1.07-2.68), and whose partner came early for ANC-1 (aOR = 1.37; 95% CI = 1.00-1.89) were more likely to be involved than others.

CONCLUSION

MPI remains low in stable couples and COC improves partner involvement. Our findings also support the need of strengthening outreach towards "stable" couples and addressing barriers. This could go a long way to improve PMTCT outcomes in Cameroon.

TRIAL REGISTRATION

PRENAHTEST, NCT01494961. Registered 15 December 2011-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01494961.

Sexual Relationship Types, Partner HIV Self-Testing, and Pre-Exposure Prophylaxis Among South African Adolescent Girls and Young Women: A Latent Class Analysis

BACKGROUND

Sexual relationships among adolescent girls and young women (AGYW) are influenced by social, economic, and gender dynamics. Understanding AGYW's different relationship types and their implications for HIV risk is important for development of tailored interventions. We sought to identify relationship typologies among AGYW and their impact on uptake of HIV prevention interventions.

METHODS

From May 2018 to February 2019, 2200 HIV-negative AGYW (ages 16-24) in Johannesburg, South Africa, participated in an HIV prevention intervention involving distribution of HIV self-test kits to their male partners. AGYW were also offered pre-exposure prophylaxis. At baseline, AGYW completed a questionnaire, and outcomes were assessed for 3 months. We used latent class analysis to identify relationship types and mixture modeling to estimate the impact of relationship type on engagement in prevention interventions.

RESULTS

We identified 3 relationship types: "stable, empowered relationships with older partners" (class 1, n = 973); "shorter, empowered relationships with peer partners" (class 2, n = 1067); and "shorter relationships with risky partners" (class 3, n = 160). Compared with AGYW in class 1 relationships, AGYW in class 2 and 3 relationships were less likely to complete partner testing alongside HIV results sharing (class 2 adjusted risk ratio: 0.89, 95% confidence interval: 0.85 to 0.95; class 3 adjusted risk ratio: 0.84, 95% confidence interval: 0.73 to 0.94). Pre-exposure prophylaxis uptake was highest in class 3 (11.2%) compared with class 2 (3.8%) and class 1 (1.0%; P < 0.001).

CONCLUSIONS

Relationship type impacts uptake of HIV prevention interventions among South African youth. Intervention effectiveness could be optimized by using tailored approaches to HIV risk mitigation among AGYW.

Cascade of Provider-Initiated Human Immunodeficiency Virus Testing and Counselling at Specific Life Events (Pregnancy, Sexually Transmitted Infections, Marriage) in Côte d'Ivoire

BACKGROUND

Despite the implementation of Provider Initiated Testing and Counselling (PITC) in 2009, PITC coverage remains low in Cote d'Ivoire. The purpose of this study is to determine whether an human immunodeficiency virus (HIV) test was offered and performed at specific life events where PITC is recommended by national guidelines.

METHODS

In 2017, a cross-sectional telephone survey was conducted among a representative sample of 3,867 adults from the general population in Côte d'Ivoire. The occurrences of the following events over the past 5 years were documented: pregnancy (event A) or partner's pregnancy (event B) of the last child, sexually transmitted infection (event C) and marriage (event D). For each of these events, participants were asked (i) if they consulted a health care professional, (ii) if they were offered an HIV test during that consultation and (iii) if they accepted it.

RESULTS

Consulting a health care provider was reported by 94.9%, 58.3%, 70.3% and 19.1% of those who reported events A, B, C and D respectively. In case of medical consultations following events A, B, C and D, respectively 70.1%, 33.1%, 28.1%, and 78.8% of individuals were offered an HIV test. The testing acceptance was high regardless of the event. Overall, testing coverage was 63.7%, 16.9%, 13.4% and 14.5% for events A, B, C and D respectively.

CONCLUSIONS

Increasing HIV testing coverage in Côte d'Ivoire requires (i) facilitating attendance to health services in case of sexually transmitted infections, marriage and pregnancy-for men-and (ii) strengthening routine testing offer on these occasions.

Improving male involvement in antenatal care in low and middle-income countries to prevent mother to child transmission of HIV: A realist review

BACKGROUND

Childhood Human Immunodeficiency Virus (HIV) infection occurs almost exclusively via mother to child transmission (MTCT) during pregnancy, birth, or through breastfeeding. Recent studies have shown that male involvement (MI) in antenatal care (ANC) and HIV testing, including couples voluntary counselling and testing (CVCT), increases the likelihood that women will adhere to prevention advice and comply with HIV treatment if required during their pregnancy; hence reducing the rates of MTCT of HIV. This realist review investigates how, why, when, and for whom MI in ANC works best to provide contextual advice on how MI in ANC can be best used for prevention of mother to child transmission (PMTCT) of HIV.

METHODS

A realist review of existing evidence was conducted. Realist review seeks to explain how and why an intervention works, or does not work, in a given context. This was completed through the five stages of realist synthesis; Eliciting the program theory, search strategy, study selection criteria, data extraction, and data analysis and synthesis. Findings are presented as context-mechanism-outcome (CMO) configurations outlining the mechanisms that work in given contexts to give an outcome.

RESULTS

Three CMO configurations were developed. These describe that 1) Couples in monogamous relationships have higher levels of trust, commitment and security leading to increased uptake of PMTCT programs together; 2) ANC spaces that make 'male friendly' adaptions promote normalisation of MI in PMTCT and are more welcoming, leading to increased willingness of male partners to participate in ANC; and 3) couples and communities with higher health literacy encourage increased informed decision making, ownership, and responsibility and thus increased participation in PMTCT of HIV.

CONCLUSIONS

The CMOs developed in this review give contextual advice on how one might improve ANC services to increase MI and help reduce MTCT of HIV. We propose that MI in ANC works best where couples are monogamous and trusting, where ANC spaces actively promote being a 'male friendly space' and where there are high levels of community education programs around MTCT.

Advanced HIV Disease among Males and Females Initiating HIV Care in Rural Ethiopia

Despite recommendations for rapidly initiating HIV treatment, many persons in sub-Saharan Africa present to care with advanced HIV disease. Baseline survey and clinical data were collected on 1799 adults newly enrolling at 32 district hospitals and local health HIV clinics in rural Ethiopia. Among those with complete HIV disease information, advanced HIV disease (defined as CD4 count <200 cells/mm³ or World Health Organization [WHO] HIV clinical stage III or IV disease) was present in 66% of males and 56% of females (P < .001). Males (compared to females) had lower CD4 counts (287 cells/mm³ versus 345 cells/mm³), lower body mass index (19.3 kg/m² versus 20.2 kg/m²), and more WHO stage III or IV disease (46% versus 37%), (P < .001). Men reported more chronic diarrhea, fevers, cough, pain, fatigue, and weight loss (P < .05). Most initiating care in this resource-limited setting had advanced HIV disease. Men had poorer health status, supporting the importance of earlier diagnosis, linkage to care, and initiation of antiretroviral therapy.

Qualitative characterizations of relationships among South African adolescent girls and young women and male partners: implications for engagement across HIV self-testing and pre-exposure prophylaxis prevention cascades

INTRODUCTION

Adolescent girls and young women (AGYW) in sub-Saharan Africa have emerged as a priority population in need of HIV prevention interventions. Secondary distribution of home-based HIV self-test kits by AGYW to male partners (MP) is a novel prevention strategy that complements pre-exposure prophylaxis (PrEP), a female-controlled prevention intervention. The objective of this analysis was to qualitatively operationalize two HIV prevention cascades through the lens of relationship dynamics for secondary distribution of HIV self-tests to MP and PrEP for AGYW.

METHODS

From April 2018 to December 2018, 2200 HIV-negative AGYW aged 16-24 years were enrolled into an HIV prevention intervention which involved secondary distribution of self-tests to MP and PrEP for AGYW; of these women, 91 participants or MP were sampled for in-depth interviews based on their degree of completion of the two HIV prevention cascades. A grounded theory approach was used to characterize participants' relationship profiles, which were mapped to participants' engagement with the interventions.

RESULTS

In cases where AGYW had a MP with multiple partners, AGYW perceived both interventions as inviting distrust into the relationship and insinuating non-monogamy. Many chose not to accept either intervention, while others accepted and attempted to deliver the self-test kit but received a negative reaction from their MP. In the few cases where AGYW held multiple partnerships, both interventions were viewed as mechanisms for protecting one's health, and these AGYW exhibited confidence in accepting and delivering the self-test kits and initiating PrEP. Women who indicated intimate partner violence experiences chose not to accept either intervention because they feared it would elicit a violent reaction from their MP. For AGYW in relationships described as committed and emotionally open, self-test kit delivery was completed with ease, but PrEP was viewed as unnecessary. MP experience with the cascade corroborated AGYW perspectives and demonstrated how men can perceive female-initiated HIV prevention options as beneficial for AGYW and a threat to MP masculinity.

CONCLUSIONS

Screening to identify AGYW relationship dynamics can support tailoring prevention services to relationship-driven barriers and facilitators. HIV prevention counseling for AGYW should address relationship goals or partner's influence, and engage with MP around female-controlled prevention interventions.

HIV testing barriers and intervention strategies among men, transgender women, female sex workers and incarcerated persons in the Caribbean: a systematic review

BACKGROUND

This systematic review summarises evidence on the HIV testing barriers and intervention strategies among Caribbean populations and provides pertinent implications for future research endeavours designed to increase rates of HIV testing in the region.

METHODS

We used a systematic approach to survey all literature published between January 2008 and November 2018 using four electronic databases (MEDLINE/PubMed, Embase, Web of Science and Global Health). Only peer-reviewed articles published in English that examined HIV testing uptake and interventions in the Caribbean with men, men who have sex with men, female sex workers, transgender women and incarcerated individuals were included.

RESULTS

Twenty-one studies met the inclusion criteria. Lack of confidentiality, access to testing sites, stigma, discrimination, poverty and low HIV risk perception were identified as key barriers to HIV testing. These barriers often contributed to late HIV testing and were associated with delayed treatment initiation and decreased survival rate. Intervention strategies to address these barriers included offering rapid HIV testing at clinics and HIV testing outreach by trained providers and peers.

CONCLUSION

HIV testing rates remain unacceptably low across the Caribbean for several reasons, including stigma and discrimination. Future HIV testing interventions should target places where at-risk populations congregate, train laypersons to conduct rapid tests and consider using oral fluid HIV self-testing, which allows individuals to test at home.

Mapping evidence of intervention strategies to improving men's uptake to HIV testing services in sub-Saharan Africa: A systematic scoping review

BACKGROUND

HIV testing serves as a critical gateway for linkage and retention to care services, particularly in sub-Saharan African countries with high burden of HIV infections. However, the current progress towards addressing the first cascade of the 90-90-90 programme is largely contributed by women. This study aimed to map evidence on the intervention strategies to improve HIV uptake among men in sub-Saharan Africa.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's (2005) framework and Levac et al. (2010) recommendation for methodological enhancement for scoping review studies. We searched for eligible articles from electronic databases such as PubMed/MEDLINE; American Doctoral Dissertations via EBSCO host; Union Catalogue of Theses and Dissertations (UCTD); SA ePublications via SABINET Online; World Cat Dissertations; Theses via OCLC; and Google Scholar. We included studies from January 1990 to August 2018. We used the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. The Mixed Method Appraisal Tool version 2018 was used to determine the methodological quality of the included studies. We further used NVivo version 11 to aid with content thematic analysis.

RESULTS

This study revealed that teaching men about HIV; Community-Based HIV testing; Home-Based HIV testing; Antenatal Care HIV testing; HIV testing incentives and HIV Self-testing are important strategies to improving HIV testing among men in sub-Saharan Africa. The need for improving programmes aimed at giving more information to men about HIV that are specifically tailored for men, especially given their poor uptake of HIV testing services was also found. This study further revealed the need for implementing Universal Test and Treat among HIV positive men found through community-based testing strategies, while suggesting the importance of restructuring home-based HIV testing visits to address the gap posed by mobile populations.

CONCLUSION

The community HIV testing, as well as, HIV self-testing strategies showed great potential to increase HIV uptake among men in sub-Saharan Africa. However, to address poor linkage to care, ART should be initiated soon after HIV diagnosis is concluded during community testing services. We also recommend more research aimed at addressing the quality of HIV self-testing kits, as well as, improving the monitoring systems of the distributed HIV self-testing kits.

MSM Behavior Disclosure Networks and HIV Testing: An Egocentric Network Analysis Among MSM in China

Men who have sex with men (MSM) disclose same-sex behaviors with others, creating disclosure networks. This study examined the characteristics of disclosure networks that are associated with HIV testing among MSM in China through an online nationwide survey. Name-generator questions were used to ask each participant ("ego") to nominate up to five social network members ("alters") with whom he had disclosed same-sex behaviors. Among the 806 men, the average disclosure network size was 4.05. MSM who reported larger disclosure networks were more likely to have been tested for HIV (aOR 1.21, 95% CI 1.08-1.34). The most common disclosure network alters were friends (45.1%), followed by sex partners (18.7%) and healthcare professionals (2.5%). Men who disclosed to healthcare professionals were more likely to test for HIV compared to men who disclosed to family members (aOR 5.43, 95% CI 2.11-14.04). Our findings can inform disclosure network-based interventions to promote MSM HIV testing.

Low Case Finding Among Men and Poor Viral Load Suppression Among Adolescents Are Impeding Namibia's Ability to Achieve UNAIDS 90-90-90 Targets

Background

In 2015, Namibia implemented an Acceleration Plan to address the high burden of HIV (13.0% adult prevalence and 216 311 people living with HIV [PLHIV]) and achieve the UNAIDS 90-90-90 targets by 2020. We provide an update on Namibia's overall progress toward achieving these targets and estimate the percent reduction in HIV incidence since 2010.

Methods

Data sources include the 2013 Namibia Demographic and Health Survey (2013 NDHS), the national electronic patient monitoring system, and laboratory data from the Namibian Institute of Pathology. These sources were used to estimate (1) the percentage of PLHIV who know their HIV status, (2) the percentage of PLHIV on antiretroviral therapy (ART), (3) the percentage of patients on ART with suppressed viral loads, and (4) the percent reduction in HIV incidence.

Results

In the 2013 NDHS, knowledge of HIV status was higher among HIV-positive women 91.8% (95% confidence interval [CI], 89.4%-93.7%) than HIV-positive men 82.5% (95% CI, 78.1%-86.1%). At the end of 2016, an estimated 88.3% (95% CI, 86.3%-90.1%) of PLHIV knew their status, and 165 939 (76.7%) PLHIV were active on ART. The viral load suppression rate among those on ART was 87%, and it was highest among ≥20-year-olds (90%) and lowest among 15-19-year-olds (68%). HIV incidence has declined by 21% since 2010.

Conclusions

With 76.7% of PLHIV on ART and 87% of those on ART virally suppressed, Namibia is on track to achieve UNAIDS 90-90-90 targets by 2020. Innovative strategies are needed to improve HIV case identification among men and adherence to ART among youth.

Discordance, Disclosure and Normative Gender Roles: Barriers to Couple Testing Within a Community-Level HIV Self-Testing Intervention in Urban Blantyre, Malawi

A community-based HIV self-testing study in Blantyre, Malawi demonstrated that not all individuals living in couples tested with their partner. We describe factors dissuading individuals in couples from self-testing with their partner. Data were drawn from qualitative study exploring consequences of HIV self-testing within couples. In-depth interviews were conducted with 33 individuals living in couples who tested alone. Participants expressed fear of dealing with HIV-discordant relationships. Failure to self-test with a partner was correlated with gender, with more men than women overtly declining or unconsciously unable to have joint HIV self-test. Men feared exposure of infidelity and were often not available at home for economic reasons. Barriers to uptake of couple HIV self-testing seemed to be shaped by gendered dichotomies of social-relationships. To help achieve the first 90% of the UNAIDS 90:90:90 goals, it is important to overcome structural barriers to realise the full potential of HIV self-testing.

Improving Health Screening Uptake in Men: A Systematic Review and Meta-analysis

CONTEXT

Globally, uptake of health screening in men remains low and the effectiveness of interventions to promote screening uptake in men is not well established. This review aimed to determine the effectiveness of interventions in improving men's uptake of and intention to undergo screening, including interventions using information and communication technology and a male-sensitive approach.

EVIDENCE ACQUISITION

Studies were sourced from five electronic databases (October 2015), experts, and references of included studies. This study included RCTs or cluster RCTs that recruited men and reported uptake of or intention to undergo screening. Two researchers independently performed study selection, appraisal, and data extraction. The interventions were grouped into those that increase uptake and those that promote informed decision making. They were further sub-analyzed according to types of intervention, male-sensitive, and web- and video-based interventions. The analysis was completed in December 2016.

EVIDENCE SYNTHESIS

This review included 58 studies. Most studies were on prostate cancer (k=31) and HIV (k=11) screening. Most of the studies had low methodologic quality (79.3%) and after excluding them from the analysis, one study found that educational intervention (which was also male-sensitive) was effective in improving men's intention to screen (risk ratio=1.36, 95% CI=1.23, 1.50, k=1) and partner educational intervention increased men's screening uptake (risk ratio=1.77, 95% CI=1.48, 2.12, k=1). Video-based educational interventions reduced prostate cancer screening uptake (risk ratio=0.89, 95%CI=0.80, 0.99, k=1) but web-based interventions did not change men's screening intention or uptake.

CONCLUSIONS

This review highlights the need to conduct more robust studies to provide conclusive evidence on the effectiveness of different interventions to improve men's screening behavior.

A Risk Assessment Tool for Identifying Pregnant and Postpartum Women Who May Benefit From Preexposure Prophylaxis

Background

A human immunodeficiency virus (HIV) risk assessment tool for pregnant women could identify women who would most benefit from preexposure prophylaxis (PrEP) while minimizing unnecessary PrEP exposure.

Methods

Data from a prospective study of incident HIV among pregnant/postpartum women in Kenya were randomly divided into derivation (n = 654) and validation (n = 650) cohorts. A risk score was derived using multivariate Cox proportional hazards models and standard clinical prediction rules. Ability of the tool to predict maternal HIV acquisition was assessed using the area under the curve (AUC) and Brier score.

Results

The final risk score included the following predictors: having a male partner with unknown HIV status, number of lifetime sexual partners, syphilis, bacterial vaginosis (BV), and vaginal candidiasis. In the derivation cohort, AUC was 0.84 (95% confidence interval [CI], .72-.95) and each point increment in score was associated with a 52% (hazard ratio [HR], 1.52 [95% CI, 1.32-1.76]; P < .001) increase in HIV risk; the Brier score was 0.11. In the validation cohort, the score had similar AUC, Brier score, and estimated HRs. A simplified score that excluded BV and candidiasis yielded an AUC of 0.76 (95% CI, .67-.85); HIV incidence was higher among women with risk scores >6 than with scores ≤6 (7.3 vs 1.1 per 100 person-years, respectively; P < .001). Women with simplified scores >6 accounted for 16% of the population but 56% of HIV acquisitions.

Conclusions

A combination of indicators routinely assessed in antenatal clinics was predictive of HIV risk and could be used to prioritize pregnant women for PrEP.

Risk of Intimate Partner Violence and Relationship Conflict Following Couple-Based HIV Prevention Counseling: Results From the Harlem River Couples Project

Heterosexual transmission of HIV often occurs in the context of intimate sexual partnerships. There is mounting evidence that couple-based HIV prevention interventions may be more effective than individual-based interventions for promoting risk reduction within such relationships. Yet, concerns have been raised about the safety of couple-based prevention approaches, especially with regard to the risk of intimate partner violence against women. Although several international studies have examined the potential for adverse consequences associated with couple-based interventions, with inconsistent results, there is little data from U.S. studies to shed light on this issue. The current study analyzed data from a randomized trial conducted in New York City with 330 heterosexual couples to examine whether participation in couple-based or relationship-focused HIV counseling and testing (HIV-CT) interventions resulted in an increased likelihood of post-intervention breakups, relationship conflicts, or emotional, physical, or sexual abuse, compared with standard individual HIV-CT. Multinomial logistic regression was used to model the odds of experiencing change in partner violence from baseline to follow-up by treatment condition. A high prevalence of partner-perpetrated violence was reported by both male and female partners across treatment conditions, but there was no conclusive evidence of an increase in relationship dissolution or partner violence subsequent to participation in either the couple-based HIV-CT intervention or relationship-focused HIV-CT intervention compared with controls. Qualitative data collected from the same participants support this interpretation. HIV prevention interventions involving persons in primary sexual partnerships should be sensitive to relationship dynamics and the potential for conflict, and take precautions to protect the safety of both male and female participants.

Couples HIV counselling and couple relationships in India, Georgia and the Dominican Republic

BACKGROUND

Couples HIV counseling and testing is essential for combination HIV prevention, but its uptake remains very low. We aimed to evaluate factors associated with couples HIV counseling uptake in India, Georgia and the Dominican Republic, as part of the ANRS 12127 Prenahtest intervention trial.

METHODS

Pregnant women ≥15 years, attending their first antenatal care (ANC) session between March and September 2009, self-reporting a stable partner, and having received couple-oriented post-test HIV counseling (trial intervention) were included. Individuals and couple characteristics associated with the acceptability of couples HIV counseling were assessed using multivariable logistic regression for each study site.

RESULTS

Among 711 women included (232, 240 and 239 in the Dominican Republic, Georgia and India, respectively), the uptake of couples HIV counseling was 9.1% in the Dominican Republic, 13.8% in Georgia and 36.8% in India. The uptake of couples HIV counseling was associated with women having been accompanied by their partner to ANC, and never having used a condom with their partner in the Dominican Republic; with women having been accompanied by their partner to ANC in India; with women having a higher educational level than their partner and having ever discussed HIV with their partner in Georgia.

CONCLUSION

Couple HIV counseling uptake was overall low. Strategies adapted to local socio-cultural contexts, aiming at improving women's education level, or tackling gender norms to facilitate the presence of men in reproductive health services, should be considered.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01494961 . Registered December 15, 2011. (Retrospectively registered).

Offering pre-exposure prophylaxis for HIV prevention to pregnant and postpartum women: a clinical approach

Introduction: HIV prevention during pregnancy and lactation is critical for both maternal and child health. Pregnancy provides a critical opportunity for clinicians to elicit women’s vulnerabilities to HIV and offer HIV testing, treatment and referral and/or comprehensive HIV prevention options for the current pregnancy, the postpartum period and safer conception options for future pregnancies. In this commentary, we review the safety of oral pre-exposure prophylaxis with tenofovir/emtricitabine in pregnant and lactating women and suggest opportunities to identify pregnant and postpartum women at substantial risk of HIV. We then describe a clinical approach to caring for women who both choose and decline pre-exposure prophylaxis during pregnancy and postpartum, highlighting areas for future research.

Discussion: Evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine is safe in pregnancy and lactation. Identifying women vulnerable to HIV and eligible for pre-exposure prophylaxis is challenging in light of the myriad of individual, community, and structural forces impacting HIV acquisition. Validated risk calculators exist for specific populations but have not been used to screen and offer HIV prevention methods. Partner testing and engagement of men living with HIV are additional means of reaching at-risk women. However, women’s vulnerabilities to HIV change over time. Combining screening for HIV vulnerability with HIV and/or STI testing at standard intervals during pregnancy is a practical way to prompt providers to incorporate HIV screening and prevention counselling. We suggest using shared decision-making to offer women pre-exposure prophylaxis as one of multiple HIV prevention strategies during pregnancy and postpartum, facilitating open conversations about HIV vulnerabilities, preferences about HIV prevention strategies, and choosing a method that best meets the needs of each woman.

Conclusion: Growing evidence suggests that pre-exposure prophylaxis with tenofovir/emtricitabine during pregnancy and lactation is safe and effective. Shared decision-making provides one approach to identify at-risk women and offers pre-exposure prophylaxis but requires implementation research in diverse clinical settings. Including pregnant and breastfeeding women in future HIV prevention research is critical for the creation of evidence-driven public health policies and clinical guidelines.

A Framework for Health Communication Across the HIV Treatment Continuum

Supplemental Digital Content is Available in the Text.

Background:

As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum.

Conceptual Framework:

This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social–ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters.

Discussion:

The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.

Investigating interventions to increase uptake of HIV testing and linkage into care or prevention for male partners of pregnant women in antenatal clinics in Blantyre, Malawi: study protocol for a cluster randomised trial

BACKGROUND

Despite large-scale efforts to diagnose people living with HIV, 54% remain undiagnosed in sub-Saharan Africa. The gap in knowledge of HIV status and uptake of follow-on services remains wide with much lower rates of HIV testing among men compared to women. Here, we design a study to investigate the effect on uptake of HIV testing and linkage into care or prevention of partner-delivered HIV self-testing alone or with an additional intervention among male partners of pregnant women.

METHODS

A phase II, adaptive, multi-arm, multi-stage cluster randomised trial, randomising antenatal clinic (ANC) days to six different trial arms. Pregnant women accessing ANC in urban Malawi for the first time will be recruited into either the standard of care (SOC) arm (invitation letter to the male partner offering HIV testing) or one of five intervention arms offering oral HIV self-test kits. Three of the five intervention arms will additionally offer the male partner a financial incentive (fixed or lottery amount) conditional on linkage after self-testing with one arm testing phone call reminders. Assuming that 25% of male partners link to care or prevention in the SOC arm, six clinic days, with a harmonic mean of 21 eligible participants, per arm will provide 80% power to detect a 0.15 absolute difference in the primary outcome. Cluster proportions will be analysed by a cluster summaries approach with adjustment for clustering and multiplicity.

DISCUSSION

This trial applies adaptive methods which are novel and efficient designs. The methodology and lessons learned here will be important as proof of concept of how to design and conduct similar studies in the future. Although small, this trial will potentially present good evidence on the type of effective interventions for improving linkage into ART or prevention. The trial results will also have important policy implications on how to implement HIVST targeting male partners of pregnant women who are accessing ANC for the first time while paying particular attention to safety concerns. Contamination may occur if women in the intervention arms share their self-test kits with women in the SOC arm.

TRIAL REGISTRATION

ISRCTN, ID: 18421340 . Registered on 31 March 2016.

Psychosocial Aspects of ART Counseling: A Comparison of HIV Beliefs and Knowledge in PMTCT and ART-Naïve Women

Antiretroviral therapy (ART)-readiness counseling has been deemed critical to adherence, instilling knowledge, and promoting positive beliefs and attitudes. In the landscape of changing policy in South Africa, some ART initiators have had prior ART-readiness counseling (e.g., for prevention-of-mother-to-child-transmission [PMTCT] programs). The extent to which previous counseling resulted in retained knowledge and belief is unknown, which may be important to the promotion of women's ART adherence. We compared 320 women living with HIV and initiating ART, with and without prior PMTCT on HIV knowledge, treatment, beliefs, and attitudes. The PMTCT group held more accurate beliefs and more positive attitudes about ART. Both groups lacked understanding of basic HIV biology. Nondisclosure of HIV status was high. Thus, in individuals re-initiating therapy, some knowledge about HIV and its treatment was not well retained. Tailored education and counseling may be critical to adherence, with a focus on biological concepts that impact ART resistance.

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.

Are partners of HIV-infected people being tested for HIV? A mixed-methods research from Gujarat, India

Setting: Four selected antiretroviral therapy (ART) centres of Gujarat State, India, which accounts for 8% of the human immunodeficiency virus (HIV) burden in India. Objectives: 1) To assess the proportion of people living with HIV (PLHIV) whose partners were not tested for HIV; 2) to assess sociodemographic and clinical characteristics of index cases associated with partner testing; and 3) to understand perceived facilitators and barriers to partner testing and make suggestions on how to improve testing from the perspective of the health-care provider. Design: A mixed-method design with a quantitative phase that involved reviewing the programme records of married PLHIV enrolled during 2011-2015, followed by a qualitative phase of key informant interviews. Results: Of 3884 married PLHIV, 1279 (33%) did not have their partners tested for HIV. Factors including index cases being male, illiterate, aged >25 years, belonging to key populations, substance use and being in advanced clinical stages were more likely to be associated with partner non-testing. Non-disclosure of HIV status (due to fear of marital discord) and lack of awareness and risk perception were the key barriers to testing. Conclusion: One third of PLHIV did not have their partners tested for HIV. Several factors were identified as being associated with the non-testing of partners, and solutions were explored that need to be implemented urgently if we are to achieve the 90-90-90 targets and end HIV.

What Do Men Want from a Health Screening Mobile App? A Qualitative Study

There is a lack of mobile app which aims to improve health screening uptake developed for men. As part of the study to develop an effective mobile app to increase health screening uptake in men, we conducted a needs assessment to find out what do men want from a health screening mobile app. In-depth interviews and focus group discussions were conducted with 31 men from a banking institution in Kuala Lumpur. The participants were purposely sampled according to their job position, age, ethnicity and screening status. The recruitment was stopped once data saturation was achieved. The audio-recorded interviews were transcribed verbatim and analyzed using thematic approach. Three themes emerged from the analysis and they were: content, feature and dissemination. In terms of the content, men wanted the app to provide information regarding health screening and functions that can assess their health; which must be personalized to them and are trustable. The app must have user-friendly features in terms of information delivery, ease of use, attention allocation and social connectivity. For dissemination, men proposed that advertisements, recommendations by health professionals, providing incentive and integrating the app as into existing systems may help to increase the dissemination of the app. This study identified important factors that need to be considered when developing a mobile app to improve health screening uptake. Future studies on mobile app development should elicit users' preference and need in terms of its content, features and dissemination strategies to improve the acceptability and the chance of successful implementation.

Impact of approaches in improving male partner involvement in the prevention of mother-to-child transmission (PMTCT) of HIV on the uptake of PMTCT services in sub-Saharan Africa: a protocol of a systematic review and meta-analysis

INTRODUCTION

Several studies have reported approaches used in improving the delivery of prevention of mother-to-child transmission (PMTCT) of HIV services through the involvement of male partners, but evidence from a systematic review is limited. We aim at determining the impact of male partner involvement on PMTCT in sub-Saharan Africa.

METHODS AND ANALYSIS

This will be a systematic review of published literature. Interventional and observational studies on male involvement in PMTCT carried out in sub-Saharan Africa will be included irrespective of the year and language of publication. OVID Medline, Embase, PschINFO, and Cochrane database of controlled trials will be searched. After manual searching of articles, authors shall be contacted for further information. 2 authors (NFT and CJ) will independently screen potential articles for eligibility using defined inclusion and exclusion criteria. Critical Appraisal Skills Programme (CASP) tools, Jadad scale and the STROBE checklist will be used for critical appraisal, and the 2 authors will independently assess the quality of articles. Authors will independently extract data from studies using a pre-established data collection form, and any discrepancies will be sorted by a third author (TRK). Outcomes will be analysed using STATA V.12.0. The random effect model will be used to produce forest plots. The heterogeneity χ(2) statistics and I(2) will be used to assess for heterogeneity. Publication bias will be assessed using funnel plots. This protocol is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines.

ETHICS AND DISSEMINATION

No ethical approval since included studies will be published studies that had already obtained ethical approvals. The findings will guide HIV programmes on the best approaches towards involving male partners in PMTCT with a view to improving PMTCT services in sub-Saharan Africa.

PROSPERO REGISTRATION NUMBER

42016032673.

Predictors of couple HIV counseling and testing among adult residents of Bukomero sub-county, Kiboga district, rural Uganda

Background

Studies have shown that couple HIV counseling and testing (CHCT) increased rates of sero-status disclosure and adoption of safer sexual behaviors with better linkage to treatment and care. However, current evidence suggests that new HIV infections are occurring among heterosexual couples in stable relationships where the majority of the individuals are not aware of their partner’s serostatus. This study examined the predictors of CHCT uptake among married or cohabiting couples of Bukomero sub-county Kiboga district in Uganda.

Methods

This cross-sectional correlational study was conducted among 323 individuals who were either married or cohabiting, aged 18–49 years. Participants were enrolled from randomly selected households in Bukomero sub-county. Data were collected using an interviewer-administered questionnaire on socio-demographics, self-rating on awareness of CHCT benefits, couple discussion about HIV testing and CHCT practices. Couples were compared between those who had reported to have tested as a couple and those who had not. Binary logistic regression was performed to determine the adjusted odds ratio [aOR] and 95 % confidence intervals [CI] for CHCT uptake and the other independent variables.

Results

Of the participants 288 (89.2 %) reported to have ever taken an HIV test only 99 (34.4 %) did so as a couple. The predictors of testing for HIV as a couple were discussing CHCT with the partner (adjusted odds ratio 4.95[aOR], 95 % confidence interval [CI]:1.99–12.98; p < 0.001), awareness of CHCT benefits (aOR 3.23; 95 % CI 1.78–5.87; p < 0.001) and having time to test as a couple (aOR 2.61; 95 % CI 1.22–5.61; p <0.05).

Conclusion

Uptake of HIV counseling and testing among couples was low. Discussing CHCT with partner, awareness of CHCT benefits, and availability of time to test as a couple were predictive of CHCT uptake. Thus CHCT campaigns should emphasize communication and discussion of HIV counseling and testing among partners.

Home-based HIV testing for men preferred over clinic-based testing by pregnant women and their male partners, a nested cross-sectional study

BACKGROUND

Male partner HIV testing and counseling (HTC) is associated with enhanced uptake of prevention of mother-to-child HIV transmission (PMTCT), yet male HTC during pregnancy remains low. Identifying settings preferred by pregnant women and their male partners may improve male involvement in PMTCT.

METHODS

Participants in a randomized clinical trial (NCT01620073) to improve male partner HTC were interviewed to determine whether the preferred male partner HTC setting was the home, antenatal care (ANC) clinic or VCT center. In this nested cross sectional study, responses were evaluated at baseline and after 6 weeks. Differences between the two time points were compared using McNemar's test and correlates of preference were determined using logistic regression.

RESULTS

Among 300 pregnant female participants, 54% preferred home over ANC clinic testing (34.0%) or VCT center (12.0%). Among 188 male partners, 68% preferred home-based HTC to antenatal clinic (19%) or VCT (13%). Men who desired more children and women who had less than secondary education or daily income < $2 USD were more likely to prefer home-based over other settings (p < 0.05 for all comparisons). At 6 weeks, the majority of male (81%) and female (65%) participants recommended home over alternative HTC venues. Adjusting for whether or not the partner was tested during follow-up did not significantly alter preferences.

CONCLUSIONS

Pregnant women and their male partners preferred home-based compared to clinic or VCT-center based male partner HTC. Home-based HTC during pregnancy appears acceptable and may improve male testing and involvement in PMTCT.

High rates of HIV seroconversion in pregnant women and low reported levels of HIV testing among male partners in Southern Mozambique: results from a mixed methods study

INTRODUCTION

Prevention of acute HIV infections in pregnancy is required to achieve elimination of pediatric HIV. Identification and support for HIV negative pregnant women and their partners, particularly serodiscordant couples, are critical. A mixed method study done in Southern Mozambique estimated HIV incidence during pregnancy, associated risk factors and factors influencing partner's HIV testing.

METHODS

Between April 2008 and November 2011, a prospective cohort of 1230 HIV negative pregnant women was followed during pregnancy. A structured questionnaire, HIV testing, and collection of dried blood spots were done at 2-3 scheduled visits. HIV incidence rates were calculated by repeat HIV testing and risk factors assessed by Poisson regression. A qualitative study including 37 individual interviews with men, women, and nurses and 11 focus group discussions (n = 94) with men, women and grandmothers explored motivators and barriers to uptake of male HIV testing.

RESULTS

HIV incidence rate was estimated at 4.28/100 women-years (95%CI: 2.33-7.16). Significant risk factors for HIV acquisition were early sexual debut (RR 3.79, 95%CI: 1.04-13.78, p = 0.04) and living in Maputo Province (RR 4.35, 95%CI: 0.97-19.45, p = 0.05). Nineteen percent of women reported that their partner had tested for HIV (93% knew the result with 8/213 indicating an HIV positive partner), 56% said their partner had not tested and 19% did not know their partner test status. Of the 14 seroconversions, only one reported being in a serodiscordant relationship. Fear of discrimination or stigma was reported as a key barrier to male HIV testing, while knowing the importance of getting tested and receiving care was the main motivator.

CONCLUSIONS

HIV incidence during pregnancy is high in Southern Mozambique, but knowledge of partners' HIV status remains low. Knowledge of both partners' HIV status is critical for maximal effectiveness of prevention and treatment services to reach elimination of pediatric HIV/AIDS.

Systematic review of couple-based HIV intervention and prevention studies: advantages, gaps, and future directions

We conducted a systematic review of couple-based HIV biobehavioral (skills-building, VCT, and adherence) and biomedical (ART, circumcision) prevention and intervention studies designed to reduce sexual- and drug-risk behaviors and HIV transmission and acquisition. Of the 11,162 papers identified in the search, 93 peer-reviewed papers met the inclusion criteria and yielded a total of 33 studies conducted globally. Biobehavioral couple-based prevention and intervention studies have been efficacious in reducing sexual- and drug-risk behaviors, increasing access to HIV testing and care, and improving adherence. Biomedical couple-based studies were found to reduce HIV incidence among HIV-negative sex partners and viral load among HIV-positive partners. Despite much progress, couple-based HIV prevention and intervention studies remain limited; a number of methodological gaps exist and studies focusing on MSM, people who inject drugs, and sex workers are scarce.

Factors Associated with HIV Testing History among Pregnant Women and Their Partners in Georgia: The ANRS 12127 Prenahtest Trial

Despite the benefits of timely diagnosis of HIV infection and the wide availability of VCT services, the acceptance of HIV testing and counseling still remains a challenge in Georgia. The goal of our study was to assess the history of HIV testing and associated factors among pregnant women. The recruitment of study participants took place during routine antenatal care visits at one of the large Maternity Hospitals in Tbilisi, capital of Georgia. A total of 491 pregnant women were included in the sample. More than a third of women (38.5%) reported that they were tested for HIV before the current pregnancy and almost all of them (91.5%) were tested during previous pregnancies. Bivariate analysis revealed statistically significant association of women's history of HIV testing with age, education level, remunerated activity, history of STI, and multiparity. In multivariate analysis, the only independent predictor of being HIV tested was ever being pregnant. In conclusion, HIV testing history among women at reproductive age was poor in Georgia. Women mostly received HIV testing at prenatal centers. Efforts should be made to promote HIV testing in primary care settings, which would increase its acceptability and overall testing rate in the population.

"Men are always scared to test with their partners … it is like taking them to the Police": Motivations for and barriers to couples' HIV counselling and testing in Rakai, Uganda: a qualitative study

INTRODUCTION

Uptake of couples' HIV counselling and testing (couples' HCT) can positively influence sexual risk behaviours and improve linkage to HIV care among HIV-positive couples. However, less than 30% of married couples have ever tested for HIV together with their partners. We explored the motivations for and barriers to couples' HCT among married couples in Rakai, Uganda.

METHODS

This was a qualitative study conducted among married individuals and selected key informants between August and October 2013. Married individuals were categorized by prior HCT status as: 1) both partners never tested; 2) only one or both partners ever tested separately; and 3) both partners ever tested together. Data were collected on the motivations for and barriers to couples' HCT, decision-making processes from tested couples and suggestions for improving couples' HCT uptake. Eighteen focus group discussions with married individuals, nine key informant interviews with selected key informants and six in-depth interviews with married individuals that had ever tested together were conducted. All interviews were audio-recorded, translated and transcribed verbatim and analyzed using Nvivo (version 9), following a thematic framework approach.

RESULTS

Motivations for couples' HCT included the need to know each other's HIV status, to get a treatment companion or seek HIV treatment together - if one or both partners were HIV-positive - and to reduce mistrust between partners. Barriers to couples' HCT included fears of the negative consequences associated with couples' HCT (e.g. fear of marital dissolution), mistrust between partners and conflicting work schedules. Couples' HCT was negotiated through a process that started off with one of the partners testing alone initially and then convincing the other partner to test together. Suggestions for improving couples' HCT uptake included the need for couple- and male-partner-specific sensitization, and the use of testimonies from tested couples.

CONCLUSIONS

Couples' HCT is largely driven by individual and relationship-based factors while fear of the negative consequences associated with couples' HCT appears to be the main barrier to couples' HCT uptake in this setting. Interventions to increase the uptake of couples' HCT should build on the motivations for couples' HCT while dealing with the negative consequences associated with couples' HCT.

Systematic review of strategies to increase men's HIV-testing in sub-Saharan Africa

OBJECTIVE

This systematic review summarizes evidence on the effectiveness of strategies to increase men's HIV-testing in sub-Saharan Africa.

METHODS

Medline, EmBase, Africa-Wide Information and Global Health were searched. Cluster and individually randomized trials evaluating interventions to increase the proportion of adults (≥ 15 years) testing for HIV were eligible if they were conducted in sub-Saharan Africa, included men in the study population, and reported HIV-testing data by sex. References were independently screened.

RESULTS

Of the 1852 references, 15 papers including 16 trials were eligible. Trials were judged too heterogeneous to combine in meta-analysis. Three interventions invited men to attend antenatal care-based HIV-testing via pregnant partners, of which two showed a significant effect on partner-testing. One intervention invited men to HIV-test through pregnant partners and showed an increase in HIV-testing when it was offered in bars compared with health facilities. A trial of notification to partners of newly diagnosed HIV-positive patients showed an increase in testing where notification was by healthcare providers compared with notification by the patient. Three interventions reached men already at health facilities and eight reported the effects of community-based HIV testing. Mobile-testing had a significant effect on HIV-testing compared with standard voluntary counselling and testing. Home-based testing also had a significant effect, but reached smaller numbers of men than mobile-testing.

DISCUSSION

Interventions to encourage HIV-testing can increase men's levels of HIV testing. Community-based programmes in particular had a large effect on population levels of HIV-testing. More data on costs and potential population impact of these approaches over different time-horizons would aid policy-makers in planning resource allocation to increase male HIV-testing.

South Africans with recent pregnancy rarely know partner's HIV serostatus: implications for serodiscordant couples interventions

BACKGROUND

Implementation of safer conception strategies requires knowledge of partner HIV-serostatus. We recruited women and men in a high HIV-prevalence setting for a study to assess periconception risk behavior among individuals reporting HIV-serodiscordant partnerships. We report screening data from that study with the objective of estimating the proportion of individuals who are aware that they are in an HIV-serodiscordant relationship at the time of conception.

METHODS

We screened women and men attending antenatal and antiretroviral clinics in Durban, South Africa for enrollment in a study of periconception risk behavior among individuals with serodiscordant partners. Screening questionnaires assessed for study eligibility including age 18-45 years (for women) or at least 18 years of age (for men), pregnancy in past year (women) or partner pregnancy in the past 3 years (men), HIV status of partner for recent pregnancy, participant's HIV status, and infected partner's HIV status having been known before the referent pregnancy.

RESULTS

Among 2620 women screened, 2344 (90%) met age and pregnancy criteria and knew who fathered the referent pregnancy. Among those women, 963 (41%) did not know the pregnancy partner's HIV serostatus at time of screening. Only 92 (4%) reported knowing of a serodiscordant partnership prior to pregnancy. Among 1166 men screened, 225 (19%) met age and pregnancy criteria. Among those men, 71 (32%) did not know the pregnancy partner's HIV status and only 30 (13%) reported knowing of a serodiscordant partnership prior to pregnancy.

CONCLUSIONS

In an HIV-endemic setting, awareness of partner HIV serostatus is rare. Innovative strategies to increase HIV testing and disclosure are required to facilitate HIV prevention interventions for serodiscordant couples.

WHO guidelines for antiretroviral therapy in serodiscordant couples in sub-Saharan Africa: how many fit?

To evaluate the implication of WHO guidelines for serodiscordant couples, we interviewed HIV-infected adults on their partner's serostatus. We found that 12% with more than 500 CD4+ cells/μl should be recommended antiretroviral treatment (ART) because their partner was seronegative; 24% could be recommended not to start ART because their partner was seropositive; and 64% could not be given any recommendation regarding ART early initiation because they had either no stable partnership (30%) or were in a stable partnership with a partner whose status they were not aware of (34%).

Intimate partner sexual and physical violence among women in Togo, West Africa: prevalence, associated factors, and the specific role of HIV infection

BACKGROUND

A substantial proportion of newly diagnosed HIV infections in sub-Saharan Africa occur within serodiscordant cohabiting heterosexual couples. Intimate partner violence is a major concern for couple-oriented HIV preventive approaches. This study aimed at estimating the prevalence and associated factors of intimate partner physical and sexual violence among HIV-infected and -uninfected women in Togo. We also described the severity and consequences of this violence as well as care-seeking behaviors of women exposed to intimate partner violence.

METHODS

A cross-sectional survey was conducted between May and July 2011 within Sylvanus Olympio University Hospital in Lomé. HIV-infected women attending HIV care and uninfected women attending postnatal care and/or children immunization visits were interviewed. Intimate partner physical and sexual violence and controlling behaviors were assessed using an adapted version of the WHO Multi-country study on Women's Health and Life Events questionnaire.

RESULTS

Overall, 150 HIV-uninfected and 304 HIV-infected women accepted to be interviewed. The prevalence rates of lifetime physical and sexual violence among HIV-infected women were significantly higher than among uninfected women (63.1 vs. 39.3%, p<0.01 and 69.7 vs. 35.3%, p<0.01, respectively). Forty-two percent of the women reported having ever had physical injuries as a consequence of intimate partner violence. Among injured women, only one-third had ever disclosed real causes of injuries to medical staff and none of them had been referred to local organizations to receive appropriate psychological support. Regardless of HIV status and after adjustment on potential confounders, the risk of intimate partner physical and sexual violence was strongly and significantly associated with male partner multi-partnership and early start of sexual life. Among uninfected women, physical violence was significantly associated with gender submissive attitudes.

DISCUSSION AND CONCLUSIONS

The prevalence rates of both lifetime physical and sexual violence were very high among HIV-uninfected women and even higher among HIV-infected women recruited in health facilities in this West African country. Screening for intimate partner violence should be systematic in health-care settings, and specifically within HIV care services. At a time of increased investments in couple-oriented HIV prevention interventions, further longitudinal research to better understanding of HIV-serodiscordant couple dynamics in terms of intimate partner violence is needed.

The 2013 WHO guidelines for antiretroviral therapy: evidence-based recommendations to face new epidemic realities

PURPOSE OF REVIEW

The review summarizes the key new recommendations of the WHO 2013 guidelines for antiretroviral therapy and describes the potential impact of these recommendations on the HIV epidemic.

RECENT FINDINGS

The 2013 WHO guidelines recommend earlier initiation of antiretroviral therapy (ART) at CD4 500 cells/μl or less for all adults and children above 5 years. Further recommendations include initiation of ART irrespective of CD4 cell count or clinical stage for people co-infected with active tuberculosis disease or hepatitis B virus with severe liver disease, pregnant women, people in serodiscordant partnerships, and children under 5 years of age. The ART regimen comprising a once daily fixed-dose combination of tenofovir + lamivudine (or emtricitabine) + efavirenz is recommended as the preferred first-line therapy. Several approaches are also recommended to reach more people and increase health service capacity, including community and self-testing, and task shifting, decentralization, and integration of ART care.

SUMMARY

If fully implemented, the 2013 WHO ART guidelines could avert at least an additional 3 million deaths and prevent close to an additional 3.5 million new infections between 2012 and 2025 in low- and middle-income countries, compared with previous treatment guidelines.

Uthando Lwethu ('our love'): a protocol for a couples-based intervention to increase testing for HIV: a randomized controlled trial in rural KwaZulu-Natal, South Africa

Background

Couples-based HIV counseling and testing (CHCT) is a proven strategy to reduce the risk of HIV transmission between partners, but uptake of CHCT is low. We describe the study design of a randomized controlled trial (RCT) aimed to increase participation in CHCT and reduce sexual risk behavior for HIV among heterosexual couples in rural KwaZulu-Natal, South Africa. We hypothesize that the rate of participation in CHCT will be higher and sexual risk behavior will be lower in the intervention group as compared to the control.

Methods/design

Heterosexual couples (N = 350 couples, 700 individuals) are being recruited to participate in a randomized trial of a couples-based intervention comprising two group sessions (one mixed gender, one single gender) and four couples’ counseling sessions. Couples must have been in a relationship together for at least 6 months. Quantitative assessments are conducted via mobile phones by gender-matched interviewers at baseline, 3, 6, and 9 months post-randomization. Intervention content is aimed to improve relationship dynamics, and includes communication skills and setting goals regarding CHCT.

Discussion

The Uthando Lwethu (‘our love’) intervention is the first couples-based intervention to have CHCT as its outcome. We are also targeting reductions in unprotected sex. CHCT necessitates the testing and mutual disclosure of both partners, conditions that are essential for improving subsequent outcomes such as disclosure of HIV status, sexual risk reduction, and improving treatment outcomes. Thus, improving rates of CHCT has the potential to improve health outcomes for heterosexual couples in a rural area of South Africa that is highly impacted by HIV. The results of our ongoing clinical trial will provide much needed information regarding whether a relationship-focused approach is effective in increasing rates of participation in CHCT. Our intervention represents an attempt to move away from individual-level conceptualizations, to a more integrated approach for HIV prevention.

Trial registration

Study Name: Couples in Context: An RCT of a Couples-based HIV Prevention Intervention

ClinicalTrials.gov identifier: NCT01953133.

South African clinical trial registration number: DOH-27-0212-3937

Home visits during pregnancy enhance male partner HIV counselling and testing in Kenya: a randomized clinical trial

BACKGROUND

HIV testing male partners of pregnant women may decrease HIV transmission to women and promote uptake of prevention of mother-to-child HIV transmission (PMTCT) interventions. However, it has been difficult to access male partners in antenatal care (ANC) clinics. We hypothesized that home visits to offer HIV testing to partners of women attending ANC would increase partner HIV testing.

METHODS

Women attending their first ANC were enrolled, interviewed using smartphone audio-computer-assisted self-interviews and randomized to home visits or written invitations for male partners to come to clinic, if they were married or cohabiting, unaccompanied by partners and had no prior couple HIV counselling and testing (CHCT). Enrolled men were offered CHCT (HIV testing and mutual disclosure). Prevalence of CHCT, male HIV seropositivity, couple serodiscordance and intimate partner violence, reported as physical threat from partner, were compared at 6 weeks.

RESULTS

Among 495 women screened, 312 were eligible, and 300 randomized to clinic-based or home-based CHCT. Median age was 22 years (interquartile range 20-26 years), and 87% were monogamous. CHCT was significantly higher in home-visit than in clinic-invitation arm (n = 128, 85% vs. n = 54, 36%; P < 0.001). Home-arm identified more HIV-seropositive men (12.0 vs. 8.0%; P = 0.248) and more HIV-discordant couples (14.7 vs. 4.7%; P = 0.003). There was no difference in intimate partner violence.

CONCLUSION

Home visits of pregnant women were safe and resulted in more male partner testing and mutual disclosure of HIV status. This strategy could facilitate prevention of maternal HIV acquisition, improve PMTCT uptake and increase male HIV diagnosis.

HIV risk perception among pregnant women in western India: need for reducing vulnerabilities rather than improving knowledge!

Since the beginning of the HIV/AIDS epidemic in India, pregnant women attending antenatal clinics (ANC) have been considered as a low HIV risk population. Yet, a substantial proportion of new HIV infections are occurring among stable heterosexual couples. This paper sought to investigate the proportion and profile of women who, within the low-risk population, are potentially at higher risk of HIV infection. HIV risk perception of pregnant women enrolled within the ANRS 12127 Prenahtest trial was described and associated socio-behavioral characteristics, husband's characteristics, and HIV-related characteristics were analyzed using univariate and multivariate logistic regression models. Among 484 women enrolled, baseline data were collected for 479 women and 460 women with completed data were considered for the present analysis (96%). Eighty-nine (19.4%) women perceived themselves at risk of HIV. Women with educational level <11years (Adjusted Odds Ratio, AOR = 2.4 [CI = 1.28-4.53]), who stayed in joint families (AOR = 1.89 [CI = 1.12-3.12]), who had experienced insult or hurt from the partner (AOR = 1.91 [CI = 1.11-3.27]) and whose partner were alcoholic (AOR = 2.19 [CI = 1.31-3.66]) were significantly more likely to perceive themselves at risk of HIV. Women who had heard about sexually transmitted infections were also more likely to report HIV risk perception (AOR = 3.36 [CI = 1.83-6.18]). Substantial proportion of women (one out of five) perceived themselves at risk of HIV and most of these have reported some form of vulnerability in their couple relationship such as intimate partner violence, alcoholic partner, lack of communication, and spaces for communication with partner. Though awareness and knowledge is the first step for prevention, considering the vulnerabilities associated with HIV risk perception, HIV prevention interventions in India should target overall sources of vulnerability to HIV. Targeted risk reduction for women in ANC should be considered for primary HIV prevention among couples.

HIV testing of male partners of pregnant women in Porto Alegre, Brazil: a potential strategy for reduction of HIV seroconversion during pregnancy

Pregnant women have a significantly higher risk of HIV acquisition during gestation than their non-pregnant counterparts due to behavioral and biological factors. Acute seroconversion during gestation results in increased HIV mother-to-child transmission rates and has been identified as a major public health challenge. In order to address potential HIV seroconversion in our pregnant patients, we conducted a prospective cohort study to evaluate the acceptability of offering HIV testing to sexual partners of HIV-negative pregnant women receiving antenatal care at two hospitals in Porto Alegre, Brazil. Over a 14-month study period, HIV-negative pregnant women at two hospital-based clinic sites were encouraged to bring their stable sexual partner for HIV voluntary counseling and testing during prenatal care. Women were re-interviewed following delivery to measure success of the intervention. Of the 1223 HIV-negative pregnant women enrolled in the study, 663 (54%) of their male sexual partners received HIV testing during antenatal care and 4 (0.6%) were diagnosed with HIV infection. A total of 645 women were interviewed at the time of delivery, with 620 (97%) confirming that HIV testing was suggested to their partner. The most common reason provided by women as to why partners did not come for testing was work (69%) and lack of perceived risk (14%). Independent predictors of successful partner testing included being white (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.18-2.12), married (OR 1.78, 95% CI 1.08-2.94), having an older age of sexual debut (OR 0.94, 95% CI 0.9-0.98), and being recruited at Hospital Conceiçao (OR 2.1, 95% CI 1.52-2.88). We conclude that HIV partner testing during prenatal care is acceptable, rendering this intervention attractive to public health programs targeting prevention of sexually transmitted infections.

[Enhanced prenatal HIV couple oriented counselling session and couple communication about HIV (ANRS 12127 Prenahtest Trial)]

BACKGROUND

The Prenahtest study investigated the efficacy of a couple-oriented HIV counselling session (COC) in encouraging couple HIV counselling and testing, and improving intra-couple communication about sexual and reproductive health. We report here on the effect of COC on intra-couple communication about HIV.

METHODS

Within this 4-country trial (India, Georgia, Dominican Republic and Cameroon), 484 to 491 pregnant women per site were recruited and individually randomized to receive either the COC intervention, enhanced counselling with role playing, or standard post-test HIV counselling. Women were interviewed at recruitment, before HIV testing (T0), and 2 to 8 weeks after post-test HIV counselling (T1). Four dichotomous variables documented intra-couple communication about HIV at T1: 1) discussion about HIV, 2) discussion about condom use, 3) suggesting HIV testing and 4) suggesting couple HIV counselling to the partner. An intra-couple HIV communication index was created: low degree of communication ("yes" response to zero or one of the four variables), intermediate degree of communication ("yes" to two or three variables) or high degree of communication ("yes" to the four variables). To estimate the impact of COC on the intra-couple HIV communication index, multivariable logistic regressions were conducted.

RESULTS

One thousand six hundred and seven women were included in the analysis of whom 54 (3.4%) were HIV-infected (49 in Cameroon). In the four countries, the counselling group was associated with intra-couple HIV communication (P≤0.03): women allocated to the COC group were significantly more likely to report high or intermediate degrees of intra-couple communication about HIV (versus low degree of communication) than women allocated to standard counselling.

CONCLUSION

COC improved short-term communication about HIV within couples in different sociocultural contexts, a positive finding for a couple approach to HIV prevention.