HIV testing men in the antenatal setting: understanding male non-disclosure

Determinants of HIV testing uptake among partners of pregnant women in Addis Ababa, Ethiopia: a community-based study

Introduction

couples HIV testing and counseling is an important intervention to make an informed decision on reproductive health, to adopt preventive behaviors, support each other, and prevent mother-to-child HIV transmissions. Despite the importance of partners of pregnant women HIV testing uptake, there is limited study in Ethiopia. Hence, this study aimed to assess the proportion of HIV testing uptake and its determinants among partners of pregnant women.

Methods

a community-based cross-sectional study was conducted from January to February 2020 in Addis Ababa. A multistage cluster sampling technique was used to recruit 812 partners of pregnant women. A pre-tested and structured questionnaire was used to collect the data. Binary logistic regression analysis was performed to identify the determinants of HIV testing uptake among partners of pregnant women. Adjusted odds ratio with 95% confidence interval was used to declare statistical association and the direction of the association between the dependent variable and independent variables.

Results

overall, a total of 63.7% (95% CI: 60-67%) of partners of pregnant women were tested for HIV/AIDS. Knowledge on mother to child transmission of HIV (AOR=2.0, 95% CI: 1.37-3.06), previous history of couple HIV testing and counseling (AOR=3.8, 95% CI: 2.49-5.85), discussion with spouse (AOR= 6.6, 95% CI: 4.44-9.91), and having information about discordant HIV test result (AOR =2.3, 95% CI: 1.48-4.14) were significantly associated with partners of pregnant women HIV test uptake.

Conclusion

HIV testing uptake among partners of pregnant women was low. To increase the uptake of HIV testing, program designers and implementors should work on knowledge of the spouse´s on mother to child transition of HIV, to have more discussion between couples, and consider and strengthen activities that increase couple HIV testing and counseling at the community level before pregnancy.

Barriers to and Opportunities for Male Partner Involvement in Antenatal Care in Efforts to Eliminate Mother-to-child Transmission of Human Immunodeficiency Virus in Kenya: Systematic Review

Introduction:

Men’s involvement in antenatal care (ANC) is intended to encourage husbands to support women’s care and associated interventions, including prevention of mother-to-child transmission from pregnancy to delivery, and throughout the postnatal period. The present study aimed to systematically review the barriers and opportunities for male partner involvement in antenatal care in efforts to eliminate mother-to-child transmission of Human Immunodeficiency virus (HIV) in Kenya.

Methods:

A systematic search of articles was from the following databases; Scopus, Science Direct, PUBMED, OVID, and Google scholar. The reference list of included studies was manually searched for possible additional eligible articles. The searches were conducted from May 2019 to April 2020. Qualitative analysis was done and data were presented in thematic domains.

Results:

The search generated 2208 articles, of which only 19 met the inclusion criteria. The major findings were discussed under two thematic domains: 1) Barriers: Knowledge, Social-cultural/economic factors, Institutional factors, and Age. 2) Opportunities: Skilled Birth Attendant, Human Immunodeficiency virus-free infant and Human Immunodeficiency virus testing.

Conclusion:

The review notes that the main barriers to male partner involvement in antenatal care in efforts to eliminate mother-to-child transmission of Human Immunodeficiency virus in Kenya include; socio-cultural factors, the low maternal-child health education by the male partner, and institutional factors. It further provides insight on the opportunities associated with male partner involvement in antenatal care/prevention of mother-to-child transmission, which includes; having Human Immunodeficiency virus-free infants and increased, skilled birth deliveries. The review strongly calls out for sustainable initiatives to incorporate males into the antenatal care/prevention of mother to child transmission programs.

Determinants of Male Partner Involvement Towards Prevention of Mother to Child Transmission Service Utilization Among Pregnant Women Who Attended Focused Antenatal Care in Southern Ethiopia

BACKGROUND

Male partner involvement is an important and crucial determinant of prevention of mother to child transmission (PMTCT) of HIV. It creates an opportunity to reverse the transmission of HIV during pregnancy, labor, and breastfeeding. Thus, involving male partners during HIV screening of pregnant mothers at ANC is the key to fight against MTCT of HIV.

OBJECTIVE

This study was designed to assess the magnitude and factors associated with male partner's involvement on PMTCT service utilization among pregnant women who attended focused antenatal care (FANC) in Southern Ethiopia.

METHODS

An institutional-based cross-sectional study was conducted among 420 randomly selected pregnant women who enrolled in PMTCT service at ANC clinics. Pre-tested and structured self-administered questionnaires were used to collect the data. Multiple logistic regression analysis was used to determine the presence of statistically significant associations between the outcome variable and the independent variables with a p-value less than 0.05.

RESULTS

A total of 409 pregnant women who had ANC follow-up have participated in this study. The majority 160 (39.1%) of the participants were in the age group of 25-29 years. The magnitude of male involvement in PMTCT service was 129 (29.8%). Number of ANC visits (3rd visit (AOR=2.36, CI=1.09, 5.10), 4th visit (AOR=3.49, CI=1.65, 7.38), birthplace interest (AOR=3.01, CI=1.16, 7.84), awareness about partner monthly income (AOR=2.17, CI=1.15, 4.11), source of family saving scheme (partner (AOR=2.99, CI=1.39, 6.43), self (AOR=8.59, CI=3.92, 18.82), both (AOR=5.13, CI=2.21, 11.92), maternal perception about the importance of consulting partner before HIV testing (AOR=9.30, CI=2.65, 32.64), and kinds of partner support (psychological (AOR=0.08, CI=0.02, 0.29), financial (AOR=0.33, CI=0.17, 0.68) were found to be significantly associated with male involvement in PMTCT.

CONCLUSION

This study found out that male partner involvement in PMTCT is low. Therefore, improving male partner involvement in PMTCT is recommended for improving maternal FANC service utilization and adherence with notification of their partner and provision of psychological and financial support.

Developing a Safer Conception Intervention for Men Living with HIV in South Africa

Within sexual partnerships, men make many decisions about sexual behavior, reproductive goals, and HIV prevention. There are increasing calls to involve men in reproductive health and HIV prevention. This paper describes the process of creating and evaluating the acceptability of a safer conception intervention for men living with HIV who want to have children with partners at risk for acquiring HIV in KwaZulu-Natal, South Africa. Based on formative work conducted with men and women living with HIV, their partners, and providers, we developed an intervention based on principles of cognitive-behavioral therapy to support men in the adoption of HIV risk-reduction behaviors such as HIV-serostatus disclosure and uptake of and adherence to antiretroviral therapy. Structured group discussions were used to explore intervention acceptability and feasibility. Our work demonstrates that men are eager for reproductive health services, but face unique barriers to accessing them.

Post-test adverse psychological effects and coping mechanisms amongst HIV self-tested individuals living in couples in urban Blantyre, Malawi

Introduction

Mandatory face-to-face counselling is necessary during HIV testing but difficult to implement within the context of HIV self-testing. We investigated adverse psychological effects and coping mechanisms following HIV-positive and HIV-discordant test results amongst self-tested individuals living in couples in urban Blantyre, Malawi.

Methods

Qualitative data from 35 in-depth interviews with self-tested individuals living in couples for more than 3 months were collected and analysed using thematic content analysis.

Results

Adverse psychological effects seemed to mostly occur among individuals learning for the first-time that they were HIV-positive or living in HIV-discordant relationship. Irrespective of test outcomes, women living in couples expressed difficulty making important decisions about the future of their relationships while men seemed to shoulder the emotional burden associated with feeling or being seen as responsible for introducing HIV into the relationship. Post-test psychosocial support and ascertained positive behaviour change of the perceived index partner allowed some couples to overcome adverse psychological effects linked to test results.

Conclusion

Self-tested individuals living in couples may lack collective coping capability to collaboratively manage post-test adverse events after new HIV-positive or HIV-discordant results. Psychosocial support seemed to enable couples to foster both an individual and a collective ability to manage adverse psychological effects within the context of a couple. More research is needed to ascertain the magnitude of the deficiency of collective coping competency in couples following an HIV test.

Taking into Account the Quality of the Relationship in HIV Disclosure

Despite growing interest in HIV disclosure, most theoretical frameworks and empirical studies focus on individual and social factors affecting the process, leaving the contribution of interpersonal factors relatively unexplored. HIV transmission and disclosure often occur within a couple however, and this is where disclosure has the most scope as a HIV transmission intervention. With this in mind, this study explores whether perceived relationship quality influences HIV disclosure outcomes. Ninety-five UK individuals with HIV participated in a cross-sectional survey. Retrospective data were collected on their perceived relationship quality prior to disclosing their HIV positive status, and on disclosure outcomes. Perceived relationship quality was found to significantly affect disclosure outcomes. Positive qualities in the relationship were associated with positive outcomes, whereas negative qualities were associated with negative outcomes. Results further confirmed that this association was not merely correlational, but demonstrated predictive power. Relationship quality might act as either a risk or a resilience factor in the disclosure process, and thus warrants greater attention in future research.

Relationship Dynamics and Partner Beliefs About Viral Suppression: A Longitudinal Study of Male Couples Living with HIV/AIDS (The Duo Project)

Accurate beliefs about partners' viral suppression are important for HIV prevention and care. We fit multilevel mixed effects logistic regression models to examine associations between partners' viral suppression beliefs and objective HIV RNA viral load tests, and whether relationship dynamics were associated with accurate viral suppression beliefs over time. Male couples (N = 266 couples) with at least one HIV-positive partner on antiretroviral therapy completed five assessments over 2 years. Half of the 407 HIV-positive partners were virally suppressed. Of the 40 % who had inaccurate viral load beliefs, 80 % assumed their partner was suppressed. The odds of having accurate viral load beliefs decreased over time (OR = 0.83; p = 0.042). Within-couple differences in dyadic adjustment (OR = 0.66; p < 0.01) and commitment (OR = 0.82; p = 0.022) were negatively associated with accurate viral load beliefs. Beliefs about a partner's viral load may factor into sexual decision-making and social support. Couple-based approaches are warranted to improve knowledge of partners' viral load.

Factors Associated with Non-disclosure of HIV Status in a Cohort of Childbearing HIV-Positive Women in Ukraine

Ukraine has one of the largest populations of persons living with HIV in Europe. Data on 2019 HIV-positive married or cohabiting women enrolled in a postnatal cohort from 2007 to 2012 were analysed to investigate prevalence and factors associated with self-reported non-disclosure of HIV status. Median age at enrolment was 27.5 years, with two-thirds diagnosed during their most recent pregnancy. Almost all had received antenatal antiretroviral therapy and 24 % were taking it currently. One-tenth (n = 198) had not disclosed their HIV status to their partner and 1 in 20 (n = 93) had disclosed to no-one. Factors associated with non-disclosure were: unmarried status (AOR 2.99 (95 % CI 1.51-5.92), younger age at leaving full-time education (AOR 0.41 (95 % CI 0.19-0.88) for ≥19 years vs ≤16 years) and lack of knowledge of partner's HIV status (AOR 2.01 (95 % CI 1.09-3.66). Further work is needed to support disclosure in some groups and to explore relationships between disclosure and psychological factors in this setting, including depression, lack of support and perception of stigma.

How reliable are self-reports of HIV status disclosure? Evidence from couples in Malawi

INTRODUCTION

The majority of research on human immunodeficiency virus (HIV) disclosure utilizes the perspective from a single individual, which cannot be substantiated in the absence of supporting data such as from a primary partner.

OBJECTIVES

The objectives of this study were to evaluate: (1) the extent to which self-reported HIV disclosure was confirmed by a primary partner; (2) individual and relationship-level predictors of self-reported versus confirmed disclosure; and (3) whether confirmed disclosure was a stronger predictor of correctly assessing a partner's HIV status compared to self-reported disclosure.

METHODS

As part of an 8-wave longitudinal study from 2009 to 2011 in southern Malawi, 366 individuals (183 couples) were interviewed about their primary relationship (wave 3), individually tested for HIV (wave 4), and then asked whether they disclosed to their primary partner (wave 5).

RESULTS

While 93% of respondents reported that they disclosed, only 64% of respondents had confirmed reports from their partner. Having communicated with partner about HIV was positively associated with self-reported disclosure; this association remained significant but became more precise in the models for confirmed disclosure. Confirmed disclosure, but not self-report, was a significant predictor of correctly assessing a partner's HIV status. Being male, having lower perceived partner infidelity, having higher relationship unity, and testing HIV-negative were positively and significantly associated with correct assessment. Dyadic data from two partners provide an improved measure of disclosure as compared to a single individual's self-report and could be used to identify behavioral and biomedical opportunities to prevent HIV transmission within couples.

Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission

Introduction

Prevention of mother-to-child transmission (PMTCT) has the potential to eliminate new HIV infections among infants. Yet in many parts of sub-Saharan Africa, PMTCT coverage remains low, leading to unacceptably high rates of morbidity among mothers and new infections among infants. Intimate partner violence (IPV) may be a structural driver of poor PMTCT uptake, but has received little attention in the literature to date.

Methods

We conducted qualitative research in three Johannesburg antenatal clinics to understand the links between IPV and HIV-related health of pregnant women. We held focus group discussions with pregnant women (n=13) alongside qualitative interviews with health care providers (n=10), district health managers (n=10) and pregnant abused women (n=5). Data were analysed in Nvivo10 using a team-based approach to thematic coding.

Findings

We found qualitative evidence of strong bidirectional links between IPV and HIV among pregnant women. HIV diagnosis during pregnancy, and subsequent partner disclosure, were noted as a common trigger of IPV. Disclosure leads to violence because it causes relationship conflict, usually related to perceived infidelity and the notion that women are “bringing” the disease into the relationship. IPV worsened HIV-related health through poor PMTCT adherence, since taking medication or accessing health services might unintentionally alert male partners of the women's HIV status. IPV also impacted on HIV-related health via mental health, as women described feeling depressed and anxious due to the violence. IPV led to secondary HIV risk as women experienced forced sex, often with little power to negotiate condom use. Pregnant women described staying silent about condom negotiation in order to stay physically safe during pregnancy.

Conclusions

IPV is a crucial issue in the lives of pregnant women and has bidirectional links with HIV-related health. IPV may worsen access to PMTCT and secondary prevention behaviours, thereby posing a risk of secondary transmission. IPV should be urgently addressed in antenatal care settings to improve uptake of PMTCT and ensure that goals of maternal and child health are met in sub-Saharan African settings.

Stakeholders' perceptions on factors influencing male involvement in prevention of mother to child transmission of HIV services in Blantyre, Malawi

BACKGROUND

Male Involvement (MI) in the Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services is essential in a patriarchal society where men are decision makers of the household. Male partners have a role in the woman's risk of acquiring HIV, uptake of HIV testing and participation in Mother to Child Transmission (MTCT) prevention programmes. Although MI is important for uptake of PMTCT interventions, it remains low in Africa. The purpose of this study was to identify factors that promote and hinder MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi. Understanding of the factors that influence MI will assist in developing strategies that will involve men more in the programme thereby improving the uptake of PMTCT and HIV testing and counselling services by women and men respectively.

METHODS

An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face to face Key Informant Interviews (KIIs) with health care workers and four Focus Group discussions (FGDs) with 18 men and 17 pregnant women attending antenatal care at the clinic. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analysed using thematic content analysis.

RESULTS

Participants in both FGDs and KIIs identified the following barriers: lack of knowledge of MI in PMTCT, socioeconomic factors, relationship issues, timidity to be seen in a woman's domain, unplanned and or extramarital pregnancies, fear of knowing one's HIV status, unwillingness to be associated with the service, health facility based factors, peer influence and cultural factors. The factors that would potentially promote male involvement were categorized into community, health facility and personal or family level factors.

CONCLUSIONS

The factors that may hinder or promote MI arise from different sources. The success of MI lies on recognizing sources of barriers and averting them. Factors that promote MI need to be implemented at different levels of health care.

Assessment of strategies for male involvement in the prevention of mother-to-child transmission of HIV services in Blantyre, Malawi

Background

Despite the documented benefits of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) services, the uptake remains low in sub-Saharan Africa. The lack of male involvement (MI) may be one of the reasons for this. However, there are limited data on strategies for MI in PMTCT.

Objective

The objective of this study was to identify strategies that may promote MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi.

Study design

An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face-to-face key informant interviews (KIIs) with healthcare workers and four focus group discussions (FGDs) with 18 men and 17 pregnant women attending ANC at SLHC. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analyzed using thematic content analysis.

Results

Three major themes with several subcategories emerged. Theme 1 was a gatekeeping strategy with two subcategories: (1) healthcare workers refusing service provision to women accessing antenatal clinic without their partners and (2) women refusing ANC attention in the absence of a partner. Theme 2 comprised extending invitations and had six subcategories: (1) word of mouth, (2) card invites, (3) woman's health passport book invites, (4) telephonic invites, (5) use of influential people, and (6) home visits. Theme 3 was information education and communication, such as health education forums and advertisements. Of all the strategies, an invitation card addressed to the male partner was most preferred by study participants.

Conclusions

There are several strategies by which men may be involved in PMTCT. Healthcare workers should offer a pregnant woman all strategies available for MI for her to select the appropriate one. Further research and consultations with men should continue to achieve higher levels of MI.

HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence

The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this "PMTCT cascade". Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.

The social and gender context of HIV disclosure in sub-Saharan Africa: a review of policies and practices

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.

Male involvement in prevention programs of mother to child transmission of HIV: a systematic review to identify barriers and facilitators

BACKGROUND

Many reports point to the beneficial effect of male partner involvement in programs for the prevention of mother-to-child-transmission (PMTCT) of HIV in curbing pediatric HIV infections. This paper summarizes the barriers and facilitators of male involvement in prevention programs of mother-to-child-transmission of HIV.

METHODS

We searched PubMed, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies published in English from 1998 to March 2012. We included studies conducted in a context of antenatal care or PMTCT of HIV reporting male actions that affected female uptake of PMTCT services. We did not target any specific interventions for this review.

RESULTS

We identified 24 studies from peer-reviewed journals; 21 from sub-Saharan Africa, 2 from Asia and 1 from Europe. Barriers to male PMTCT involvement were mainly at the level of the society, the health system and the individual. The most pertinent was the societal perception of antenatal care and PMTCT as a woman's activity, and it was unacceptable for men to be involved. Health system factors such as long waiting times at the antenatal care clinic and the male unfriendliness of PMTCT services were also identified. The lack of communication within the couple, the reluctance of men to learn their HIV status, the misconception by men that their spouse's HIV status was a proxy of theirs, and the unwillingness of women to get their partners involved due to fear of domestic violence, stigmatization or divorce were among the individual factors. Actions shown to facilitate male PMTCT involvement were either health system actions or factors directly tied to the individuals. Inviting men to the hospital for voluntary counseling and HIV testing and offering of PMTCT services to men at sites other than antenatal care were key health system facilitators. Prior knowledge of HIV and prior male HIV testing facilitated their involvement. Financial dependence of women was key to facilitating spousal involvement.

CONCLUSIONS

There is need for health system amendments and context-specific adaptations of public policy on PMTCT services to break down the barriers to and facilitate male PMTCT involvement.

TRIAL REGISTRATION

The protocol for this review was registered with the International prospective register of systematic reviews (PROSPERO) record CRD42011001703.

Involving fathers in prevention of mother to child transmission initiatives--what the evidence suggests

Introduction

The current UNAIDS goal towards virtual ending or elimination of infants acquiring HIV by 2015 is perhaps the most achievable goal to date. Yet, models show that delivery of antiretroviral compounds alone will not suffice to achieve this goal, and a broader community-based approach to pregnancy, families and HIV is needed. Such an approach would highlight the important role of men in reproduction. Although early studies have shown it is cost-effective to include males, very few interventions have proceeded to involve men.

Methods

This review utilized systematic review techniques to explore the literature on effective interventions for the inclusion of men in the prevention of HIV to infants. A key word search of literature sources generated 248 studies for hand sorting and interrogation. Of these, 13 were found to contain some information on involvement of males in some form of provision. Data were abstracted from these and form the basis of this review.

Results

Background descriptive studies painted a picture of low male involvement, poor male inclusion and barriers to engagement at all stages. Yet, pregnancy intentions among men affected by HIV are high and the importance of fathers to family functioning – from relationships, through conception, pregnancy and parenting – is well established. Search strategies for interventions for males in HIV and pregnancy were used to generate studies of sufficient quality to inform strategies on the future of male involvement. Of the 317,434 papers on pregnancy and HIV, only 4178 included the term male (paternal or father). When these were restricted to intervention studies, only 248 remained for hand sorting, generating 13 studies of relevance for data extraction. The results show that all these interventions were concentrated around male partner HIV testing. In general, male partner testing was low and was amenable to change by offering voluntary counselling and testing (VCT) information, providing couple-based testing facilities and encouraging male attendance. All interventions used indirect approaches to men via their pregnant spouse. Non-health facility (clinic or hospital)-based provision (such as testing facilities in the community in bars and churches) were more effective than healthcare facilities in attracting male participation.

Conclusions

In conclusion, the review showed that approaches to men are limited to HIV testing with little innovative planning and provision for male treatment and care. As such, initiatives run the risk of alienating rather than including males. Direct approaches and the provision of male-specific facilities and benefits should be explored.

Missed opportunities: poor linkage into ongoing care for HIV-positive pregnant women in Mwanza, Tanzania

Background

Global coverage of prevention of mother-to-child (PMTCT) services reached 53% in 2009. However the number of pregnant women who test positive for HIV in antenatal clinics and who link into long-term HIV care is not known in many resource-poor countries. We measured the proportion of HIV-positive pregnant women in Mwanza city, Tanzania, who completed the cascade of care from antenatal HIV diagnosis to assessment and engagement in care in adult HIV clinics.

Methods

Thirty antenatal and maternity ward health workers were interviewed about PMTCT activities. Nine antenatal HIV education sessions were observed. A prospective cohort of 403 HIV-positive women was enrolled by specially-trained clinicians and nurses on admission to delivery and followed for four months post-partum. Information was collected on referral and attendance at adult HIV clinics, eligibility for highly active antiretroviral therapy (HAART) and reasons for lack of attendance.

Results

Overall, 70% of PMTCT health workers referred HIV-positive pregnant women to the HIV clinic for assessment and care. Antenatal HIV education sessions did not cover on-going care for HIV-infected women. Of 310 cohort participants tested in pregnancy, 51% had received an HIV clinic referral pre-delivery. Only 32% of 244 women followed to four months post-partum had attended an HIV clinic and been assessed for HAART eligibility. Non-attendance for HIV care was independently associated with fewer antenatal visits, poor PMTCT prophylaxis compliance, non-disclosure of HIV status, and non-Sukuma ethnicity.

Conclusion

Most women identified as HIV-positive during pregnancy were not assessed for HAART eligibility during pregnancy or in the first four months post-partum. Initiating HAART at the antenatal clinic, improved counselling and linkages to care between PMTCT and adult HIV treatment services and reducing stigma surrounding disclosure of HIV results would benefit on-going care of HIV-positive pregnant women.

Disclosure of HIV status between spouses in rural Malawi

Disclosure of HIV status after HIV voluntary counseling and testing has important implications for the spread of the HIV epidemic and the health of individuals who are HIV positive. Here, we use individual and couples level data for currently married respondents from an ongoing longitudinal study in rural Malawi to (1) examine the extent of HIV status disclosure by HIV serostatus; (2) identify reasons for not sharing one's HIV status with a spouse; and (3) evaluate the reliability of self-reports of HIV status disclosure. We find that disclosure of HIV status is relatively common among rural Malawians, where most have shared their status with a spouse, and many disclose to others in the community. However, there are significant differences in disclosure patterns by HIV status and gender. Factors associated with non-disclosure are also gendered, where women who perceive greater HIV/AIDS stigma and HIV positive are less likely to disclose HIV status to a spouse, and men who are worried about HIV infection from extramarital partners are less likely to disclose their HIV status to a spouse. Finally, we test the reliability of self-reported HIV status disclosure and find that self-reports of HIV-positive men are of questionable reliability.

Promoting male involvement to improve PMTCT uptake and reduce antenatal HIV infection: a cluster randomized controlled trial protocol

BACKGROUND

Despite the availability of a dual therapy treatment protocol and infant feeding guidelines designed to prevent mother to child transmission (PMTCT) of HIV, of the over 1 million babies born in South Africa each year, only 70% of those born to HIV positive mothers receive dual therapy. Similar to other resource-poor nations facing the integration of PMTCT into routine pregnancy and infant care, efforts in South Africa to scale up PMTCT and reduce transmission to < 5% have fallen far short of the United Nation's goal of 50% reductions in paediatric HIV by 80% coverage of mothers.

METHODS/DESIGN

This study proposes to evaluate the impact of combining two evidence-based interventions: a couple's risk reduction intervention with an evidence based medication adherence intervention to enhance male participation in combination with improving medication and PMTCT adherence in antenatal clinics to increase PMTCT overall reach and effectiveness. The study will use a group-randomized design, recruiting 240 couples from 12 clinics. Clinics will be randomly assigned to experimental and control conditions and effectiveness of the combined intervention to enhance PMTCT as well as reduce antenatal seroconversion by both individuals and clinics will be examined.

DISCUSSION

Shared intervention elements may decrease sexual risk and enhance PMTCT uptake, e.g., increased male participation, enhanced communication, HIV counselling and testing, adherence, serostatus disclosure, suggest that a combined sexual risk reduction and adherence intervention plus PMTCT can increase male participation, increase couples' communication and encourage adherence to the PMTCT process. The findings will impact public health and will enable the health ministry to formulate policy related to male involvement in PMTCT, which will result in PMTCT.

TRIAL REGISTRATION

PACTR201109000318329.

Male partner antenatal attendance and HIV testing in eastern Uganda: a randomized facility-based intervention trial

Background

The objective of the study was to evaluate the effect of a written invitation letter to the spouses of new antenatal clinic attendees on attendance by couples and on male partner acceptance of HIV testing at subsequent antenatal clinic visits.

Methods

The trial was conducted with 1060 new attendees from October 2009 to February 2010 in an antenatal clinic at Mbale Regional Referral Hospital, Mbale District, eastern Uganda. The intervention comprised an invitation letter delivered to the spouses of new antenatal attendees, while the control group received an information letter, a leaflet, concerning antenatal care. The primary outcome measure was the proportion of pregnant women who attended antenatal care with their male partners during a follow-up period of four weeks. Eligible pregnant women were randomly assigned to the intervention or non-intervention groups using a randomization sequence, which was computer generated utilizing a random sequence generator (RANDOM ORG) that employed a simple randomization procedure. Respondents, health workers and research assistants were masked to group assignments.

Results

The trial was completed with 530 women enrolled in each group. Participants were analyzed as originally assigned (intention to treat). For the primary outcome, the percentage of trial participants who attended the antenatal clinic with their partners were 16.2% (86/530) and 14.2% (75/530) in the intervention and non-intervention groups, respectively (OR = 1.2; 95% CI: 0.8, 1.6). For the secondary outcome, most of the 161 male partners attended the antenatal clinic; 82 of 86 (95%) in the intervention group and 68 of 75 (91%) in the non-intervention group were tested for HIV (OR = 2.1; 95% CI: 0.6 to 7.5).

Conclusions

The effect of the intervention and the control on couple antenatal attendance was similar. In addition, the trial demonstrated that a simple intervention, such as a letter to the spouse, could increase couple antenatal clinic attendance by 10%. Significantly, the majority of male partners who attended the antenatal clinic accepted HIV testing. Therefore, to further evaluate this simple and cost-effective intervention method, adequately powered studies are required to assess its effectiveness in increasing partner participation in antenatal clinics and the programme for prevention of mother to child transmission of HIV.

Trial Registration

ClinicalTrials.gov Identifier: NCT01144234.

HIV/AIDS stigma and refusal of HIV testing among pregnant women in rural Kenya: results from the MAMAS Study

HIV/AIDS stigma is a common thread in the narratives of pregnant women affected by HIV/AIDS globally and may be associated with refusal of HIV testing. We conducted a cross-sectional study of women attending antenatal clinics in Kenya (N = 1525). Women completed an interview with measures of HIV/AIDS stigma and subsequently information on their acceptance of HIV testing was obtained from medical records. Associations of stigma measures with HIV testing refusal were examined using multivariate logistic regression. Rates of anticipated HIV/AIDS stigma were high—32% anticipated break-up of their relationship, and 45% anticipated losing their friends. Women who anticipated male partner stigma were more than twice as likely to refuse HIV testing, after adjusting for other individual-level predictors (OR = 2.10, 95% CI: 1.15–3.85). This study demonstrated quantitatively that anticipations of HIV/AIDS stigma can be barriers to acceptance of HIV testing by pregnant women and highlights the need to develop interventions that address pregnant women’s fears of HIV/AIDS stigma and violence from male partners.

Towards a family-centered approach to HIV treatment and care for HIV-exposed children, their mothers and their families in poorly resourced settings

This article provides a summary of emerging psychosocial evidence relevant to the success of comprehensive family-centered approaches to HIV prevention, treatment, care and support programs in poorly resourced settings. This report synthesizes current evidence on maternal, paternal and family experiences of HIV prevention, diagnosis, treatment, adherence and disclosure, with special focus on HIV-infected mothers and HIV-exposed children. Taking a developmental approach, we explore the current challenges and opportunities towards a family-centered approach within the continuum of HIV treatment and care, beginning in pregnancy and following the course of childhood. The discussion is limited to early and middle childhood and excludes discussion of special issues emergent in adolescence, which would warrant discussion outside the scope of this article. Attention is drawn to the complexity of problems arising within the family context and the need for improvements in the integration of aspects of treatment, care and support. While this article focuses on examples from sub-Saharan Africa, the lessons learnt and future challenges outlined are applicable to most low- and middle-income countries, and to poorly resourced contexts in higher-income countries.

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

OBJECTIVE

To investigate the relationship between male involvement in prevention of mother-to-child HIV transmission services and infant HIV acquisition and mortality, a prospective cohort study was undertaken between 1999 and 2005 in Nairobi, Kenya.

METHODS

HIV-infected pregnant women were enrolled and followed with their infants for 1 year with infant HIV DNA testing at birth, 1, 3, 6, 9, and 12 months postpartum. Women were encouraged to invite male partners for prevention counseling and HIV testing.

RESULTS

Among 456 female participants, 140 partners (31%) attended the antenatal clinic. Eighty-two (19%) of 441 infants tested were HIV infected by 1 year of age. Adjusting for maternal viral load, vertical transmission risk was lower among women with partner attendance compared with those without [adjusted hazard ratio (aHR) = 0.56, 95% confidence interval (CI): 0.33 to 0.98; P = 0.042] and among women reporting versus not reporting previous partner HIV testing (aHR = 0.52, 95% CI: 0.32 to 0.84; P = 0.008). The combined risk of HIV acquisition or infant mortality was lower with male attendance (aHR = 0.55; 95% CI: 0.35 to 0.88; P = 0.012) and report of prior male HIV testing (aHR = 0.58; 95% CI: 0.34 to 0.88; P = 0.01) when adjusting for maternal viral load and breastfeeding.

CONCLUSIONS

Including men in antenatal prevention of mother-to-child HIV transmission services with HIV testing may improve infant health outcomes.

Fathers and HIV: considerations for families

BACKGROUND

Fathers are intricately bound up in all aspects of family life. This review examines fathers in the presence of HIV: from desire for a child, through conception issues, to a summary of the knowledge base on fathers within families affected by HIV.

METHODS

A mixed-methods approach is used, given the scarcity of literature. A review is provided on paternal and male factors in relation to the desire for a child, HIV testing in pregnancy, fatherhood and conception, fatherhood and drug use, paternal support and disengagement, fatherhood and men who have sex with men (MSM), and paternal effects on child development in the presence of HIV. Literature-based reviews and systematic review techniques are used to access available data Primary data are reported on the issue of parenting for men who have sex with men.

RESULTS

Men with HIV desire fatherhood. This is established in studies from numerous countries, although fatherhood desires may be lower for HIV-positive men than HIV-negative men. Couples do not always agree, and in some studies, male desires for a child are greater than those of their female partners. Despite reduced fertility, support and services, many proceed to parenting, whether in seroconcordant or serodiscordant relationships. There is growing knowledge about fertility options to reduce transmission risk to uninfected partners and to offspring.Within the HIV field, there is limited research on fathering and fatherhood desires in a number of difficult-to-reach groups. There are, however, specific considerations for men who have sex with men and those affected by drug use. Conception in the presence of HIV needs to be managed and informed to reduce the risk of infection to partners and children. Further, paternal support plays a role in maternal management.

CONCLUSIONS

Strategies to improve HIV testing of fathers are needed. Paternal death has a negative impact on child development and paternal survival is protective. It is important to understand fathers and fathering and to approach childbirth from a family perspective.

Family-centred approaches to the prevention of mother to child transmission of HIV

BACKGROUND

Prevention of mother to child transmission (PMTCT) programmes have traditionally been narrow in scope, targeting biomedical interventions during the perinatal period, rather than considering HIV as a family disease. This limited focus restricts programmes' effectiveness, and the opportunity to broaden prevention measures has largely been overlooked.Although prevention of vertical transmission is crucial, consideration of the family environment can enhance PMTCT. Family-centred approaches to HIV prevention and care present an important direction for preventing paediatric infections while improving overall family health. This paper reviews available literature on PMTCT programmatic models that have taken a broader or family-centred approach. We describe findings and barriers to the delivery of family-centred PMTCT and identify a number of promising new directions that may achieve more holistic services for children and families.

METHODS

Literature on the effectiveness of family-centred PMTCT interventions available via PubMed, EMBASE and PsycINFO were searched from 1990 to the present. Four hundred and three abstracts were generated. These were narrowed to those describing or evaluating PMTCT models that target broader aspects of the family system before, during and/or after delivery of an infant at risk of acquiring HIV infection (N = 14).

RESULTS

The most common aspects of family-centred care incorporated by PMTCT studies and programme models included counselling, testing, and provision of antiretroviral treatment for infected pregnant women and their partners. Antiretroviral therapy was also commonly extended to other infected family members. Efforts to involve fathers in family-based PMTCT counselling, infant feeding counselling, and general decision making were less common, though promising. Also promising, but rare, were PMTCT programmes that use interventions to enrich family capacity and functioning; these include risk assessments for intimate partner violence, attention to mental health issues, and the integration of early childhood development services.

CONCLUSIONS

Despite barriers, numerous opportunities exist to expand PMTCT services to address the health needs of the entire family. Our review of models utilizing these approaches indicates that family-centred prevention measures can be effectively integrated within programmes. However, additional research is needed in order to more thoroughly evaluate their impact on PMTCT, as well as on broader family health outcomes.