Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes

"Him Leaving Me - That is My Fear Now": A Mixed Methods Analysis of Relationship Dissolution Between Ugandan Pregnant and Postpartum Women Living with HIV and Their Male Partners

High rates of relationship dissolution among pregnant women living with HIV (PWLHIV) and their male partners might increase mothers' and children's vulnerability to financial hardship and poor health outcomes. This mixed methods analysis identified factors associated with separation between PWLHIV and their male partners. We utilized data from a randomized controlled trial ( www.ClinicalTrials.gov NCT03484533) of 500 PWLHIV attending antenatal care in Uganda and 237 male partners between 2018 and 2020 and followed until 12 months postpartum. Multivariate regression models estimated the impact of relationship factors on the adjusted relative risk of separation during follow up, and we conducted in-depth interviews with 45 women and 45 men enrolled in the trial. Overall, 23% of PWLHIV reported separation during the study period. HIV serodifferent status, financial burdens and gender expectations were sources of relationship conflict. Significant factors associated with separation included unmarried, non-cohabitating, shorter, polygamous relationships, as well as HIV non-disclosure and verbal abuse. Participants discussed potential positive and negative consequences of separation, including impact on their mental health, treatment continuation, financial security, and safety. Addressing relationship dynamics is essential to improve counseling messaging and support PWLHIV who are experiencing relationship conflict.

Male partners' participation in birth preparedness and complication readiness in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Maternal and neonatal health outcomes remain a challenge in low- and middle-income countries (LMICs) despite priority given to involving male partners in birth preparedness and complication readiness (BPCR). Men in LMICs often determine women's access to and affordability of health services. This systematic review and meta-analysis determined the pooled magnitude of male partner's participation in birth preparedness and complication readiness in LMICs.

METHODS

Literature published in English language from 2004 to 2019 was retrieved from Google Scholar, PubMed, CINAHL, Scopus, and EMBASE databases. The Joanna Briggs Institute's critical appraisal tool for prevalence and incidence studies were used. A pooled statistical meta-analysis was conducted using STATA Version 14.0. The heterogeneity and publication bias were assessed using the I2 statistics and Egger's test. Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis was carried out to validate publication bias and heterogeneity. The random effect model was used to estimate the summary prevalence and the corresponding 95% confidence interval (CI) of birth preparedness and complication readiness. The review protocol has been registered in PROSPERO number CRD42019140752. The PRISMA flow chart was used to show the number of articles identified, included, and excluded with justifications described.

RESULTS

Thirty-seven studies with a total of 17, 148 participants were included. The pooled results showed that 42.4% of male partners participated in BPCR. Among the study participants, 54% reported having saved money for delivery, whereas 44% identified skilled birth attendants. 45.8% of male partners arranged transportation and 57.2% of study participants identified health facility as a place of birth. Only 16.1% of the male partners identified potential blood donors.

CONCLUSIONS

A low proportion of male partners were identified to have participated in BPCR in LMICs. This calls countries in low- and middle-income setting for action to review their health care policies, to remove the barriers and promote facilitators to male partner's involvement in BPCR. Health systems in LMICs must design and innovate scalable strategies to improve male partner's arrangements for a potential blood donor and transportation for complications that could arise during delivery or postpartum haemorrhage.

Project ACCLAIM: Intervention Effect on Community Knowledge, Attitudes and Beliefs of Maternal and Child Health and HIV/AIDS in Eswatini, Uganda and Zimbabwe

The ACCLAIM Study aimed to assess the effect of a package of community interventions on the demand for, uptake of, and retention of HIV-positive pregnant/postpartum women in maternal and child health (MCH) and prevention of mother-to-child HIV transmission (PMTCT) services. The study occurred from 2013 to 2015 in Eswatini, Uganda, and Zimbabwe. The three interventions were: (1) a social learning and action component for community leaders, (2) community days, and (3) peer discussion groups. Household cross-sectional surveys on community members’ MCH and PMTCT knowledge, attitudes, and beliefs were analyzed pre- and post-intervention, using MCH, HIV stigma, and gender-equitable men (GEM) indicators. We used t-tests to measure the significance of mean pre- vs. post-intervention score changes stratified by gender within each intervention arm and generalized linear models to compare mean score changes of the cumulative intervention arms with the community leaders-only intervention. Response rates were over 85% for both surveys for men and women, with a total of 3337 pre-intervention and 3162 post-intervention responses. The combined package of three interventions demonstrated a significantly greater increase in MCH scores for both women (diff = 1.34, p ≤ 0.001) and men (diff = 2.03, p < 0.001). The arms that included interventions for both community leader engagement and community days (arms 2 and 3)led to a greater increase in mean GEM scores compared to the community leader engagement intervention alone (arm 1), for both women (diff = 1.32, p = 0.002) and men (diff = 1.37, p = 0.004). Our findings suggest that a package of community interventions may be most effective in increasing community MCH/HIV knowledge and improving gender-equitable norms.

Effect of a storytelling intervention on the retention of serodiscordant couples in ART/PrEP services at antenatal clinic in Namacurra province in Zambézia, Mozambique

Background

Sub-Saharan Africa reported 550,000 new HIV infections among women in 2018. Pregnancy and the postpartum period are associated with an increased risk of HIV acquisition (adjusted risk ratio [RR]: 2.8 during pregnancy and 4.0 in postpartum period vs. non-pregnant or postpartum women, respectively). Acquisition of HIV during pregnancy and breastfeeding increases risk of mother to child transmission. We propose to test the impact of a peer-delivered oral storytelling intervention to increase retention in, and adherence to, pre-exposure prophylaxis (PrEP)/combination antiretroviral treatment (ART) among expectant couples.

Design

We propose a randomized controlled trial (RCT) (35 intervention and 35 control couples) at a health facility where 11% of expectant couples were in serodiscordant relationships in 2018. Couples randomized to the storytelling arm will be visited by a two community volunteers and who successfully adhered to PrEP/ART during a recent pregnancy. This expert couple will orate to participating couples three stories (at 1, 3 and 5 weeks after study enrollment) designed to empower, educate, and establish “ideal” interpersonal communication strategies within couples/families, and support adherence practices among participants. The primary outcome among HIV-uninfected women will be adherence to PrEP at 3 months.

Conclusions

PrEP among at-risk pregnant women must be implemented so that high levels of adherence and retention are achievable for them and their partners. We will test our storytelling intervention to identify an optimal strategy for PrEP education and family engagement in a region with high HIV prevalence. Our results will have an impact by effectively engaging serodiscordant couples in prevention/treatment during pregnancy and beyond.

What contextual factors and mechanisms facilitate male involvement in women's sexual and reproductive health in Sub-Saharan Africa? A rapid realist review protocol

Background:  Sexual and reproductive health (SRH) outcomes of women within low resource contexts continue to be of concern to policymakers. Notably, sub-Saharan Africa (SSA) continues to lag behind other regions of the world in improving SRH outcomes for women in the region. A key suggested strategy is male involvement through interventions that respect, promote and facilitate women in taking care of themselves and their new-borns. However, factors such as social-cultural barriers may preclude men's involvement in these programmes. There is a need for a context-specific understanding of gender dynamics and interaction and the mechanisms that enhance or impede men's involvement.

Methods: We will employ a rapid realist review (RRR) methodology to examine what mechanisms and contextual factors are essential to facilitate the involvement of men in women's SRH programmes in SSA. In keeping with the realist literature we will follow six steps, which will include: (1) developing a theory, (2) developing a search strategy, (3) selecting and appraising documents, (4) extracting data, (5) analysing data and synthesising the evidence, and (6) presenting and disseminating a revised theory. We will also engage with key stakeholders who will provide local contextual insights and with experts in the subject area. The review findings will be shared with relevant stakeholders using a variety of avenues including through publications, at conferences and on social media platforms.

Discussion: This review will identify the mechanisms and contextual factors that facilitate or hinder men's involvement in women's SRH programmes in SSA. The rationale for adopting an RRR approach is to help gather the information within a relatively short period to ensure relevance of findings to policymakers in SSA. Results from this work also have the potential to be adapted to the other contexts, for example, Ireland and the UK, which have a growing population of people from SSA.

What contextual factors and mechanisms facilitate male involvement in women's sexual and reproductive health in Sub-Saharan Africa? A rapid realist review protocol

Background:  Sexual and reproductive health (SRH) outcomes of women within low resource contexts continue to be of concern to policymakers. Notably, sub-Saharan Africa (SSA) continues to lag behind other regions of the world in improving SRH outcomes for women in the region. A key suggested strategy is male involvement through interventions that respect, promote and facilitate women in taking care of themselves and their new-borns. However, factors such as social-cultural barriers may preclude men's involvement in these programmes. There is a need for a context-specific understanding of gender dynamics and interaction and the mechanisms that enhance or impede men's involvement. Methods: We will employ a rapid realist review (RRR) methodology to examine what mechanisms and contextual factors are essential to facilitate the involvement of men in women's SRH programmes in SSA. In keeping with the realist literature we will follow six steps, which will include: (1) developing a theory, (2) developing a search strategy, (3) selecting and appraising documents, (4) extracting data, (5) analysing data and synthesising the evidence, and (6) presenting and disseminating a revised theory. We will also engage with key stakeholders who will provide local contextual insights and with experts in the subject area. The review findings will be shared with relevant stakeholders using a variety of avenues including through publications, at conferences and on social media platforms. Discussion: This review will identify the mechanisms and contextual factors that facilitate or hinder men's involvement in women's SRH programmes in SSA. The rationale for adopting an RRR approach is to help gather the information within a relatively short period to ensure relevance of findings to policymakers in SSA. Results from this work also have the potential to be adapted to the other contexts, for example, Ireland and the UK, which have a growing population of people from SSA.

Strategies for retention of heterosexual men in HIV care in sub-Saharan Africa: A systematic review

Expansion of Antiretroviral Therapy (ART) programs in sub-Saharan Africa (SSA) has increased the number of people accessing treatment. However, the number of males accessing and being retained along the human immunodeficiency virus (HIV) care cascade is significantly below the UNAIDS target. Male gender has been associated with poor retention in HIV care programs, and little is known about strategies that reduce attrition of men in ART programs. This review aimed to summarize any studies on strategies to improve retention of heterosexual males in HIV care in SSA. An electronic search was conducted through Ovid^® for three databases (MEDLINE^®, Embase and Global Health). Studies reporting interventions aimed at improving retention among heterosexual men along the HIV care cascade were reviewed. The inclusion criteria included randomized-controlled trials (RCTs), prospective or retrospective cohort studies that studied adult males (≥15years of age), conducted in SSA and published between January 2005 and April 2019 with an update from 2019 to 2020. The search returned 1958 articles, and 14 studies from eight countries met the inclusion criteria were presented using the PRISMA guidelines. A narrative synthesis was conducted. Six studies explored community-based adherence support groups while three compared use of facility versus community-based delivery models. Three studies measured the effect of national identity cards, disclosure of HIV status, six-monthly clinic visits and distance from the health center. Four studies measured risk of attrition from care using hazard ratios ranging from 1.2–1.8, four studies documented attrition proportions at an average of 40.0% and two studies an average rate of attrition of 43.4/1000PYs. Most (62%) included studies were retrospective cohorts, subject to risk of allocation and outcome assessment bias. A pooled analysis was not performed because of heterogeneity of studies and outcome definitions. No studies have explored heterosexual male- centered interventions in HIV care. However, in included studies that explored retention in both males and females, there were high rates of attrition in males. More male-centered interventions need to be studied preferably in RCTs. Registry number: PROSPERO2020 CRD42020142923 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020142923.

Improving Treatment Adherence and Retention of HIV-Positive Women Through Behavioral Change Interventions Aimed at Their Male Partners: Protocol for a Prospective, Controlled Before-and-After Study

BACKGROUND

According to the World Health Organization, in 2018, 37.9 million people were living with HIV globally. More than two-thirds were residing in sub-Saharan Africa, where the HIV prevalence in the adult population (aged 15-49 years) was 3.9%. This population included 1.3 million pregnant women, of whom 82% had received antiretroviral therapy (ART) for the prevention of HIV mother-to-child transmission. In these countries, one challenge is an insufficient level of treatment adherence, particularly in HIV-positive pregnant women. Among the causes, the lack of involvement from a male partner is a significant contributor to the problem. This issue has strongly emerged in Malawi, one of the countries with the highest HIV prevalence in the world: 9.2% of its adult population were living with HIV in 2018.

OBJECTIVE

This study aims to assess 3 interventions that are aimed at improving ART adherence and retention among HIV-positive women through engagement with their male partners in 4 Malawian health care centers.

METHODS

The prospective, controlled before-and-after study is conducted in 3 phases (total duration: 24 months): preintervention, intervention, and postintervention analyses. The number of selected clusters (clinical centers) is limited to 4: one for each intervention, plus a cluster where no intervention is performed (control arm). The interventions are as follows: opening the facility on one Saturday per month only for men, defined as a special day; testing peer-to-peer counseling among men, male champions; and providing a noneconomic incentive to all women who are accompanied by their partners to the facility, nudge. The primary outcome of the study is to evaluate the differences in retention in care and adherence to therapeutic protocols among women; the intermediate outcome is the assessment of differences in male involvement. The level of male involvement in the health of their partners (intermediate outcome) will be evaluated through a dedicated questionnaire administered at baseline and in the postintervention phase. Data will be collected at the clinical centers and stored in 2 electronic databases managed using 2 different types of software.

RESULTS

The analysis of data collected in the 4 centers during the preintervention phase is ongoing, as enrollment ended on March 31, 2020. The total number of patients enrolled was 452 (Namandanje: 133; Kapeni: 78; Kapire: 75; and Balaka: 166). Meanwhile, several meetings have been conducted to organize the intervention phase.

CONCLUSIONS

The study will identify the best intervention that enhances the involvement of male partners in women's health, using an approach that considers a broad spectrum of behaviors. An important aspect is the use of educational tools focused on messages, thereby initiating a reflective discussion of stereotypes and false beliefs related to the idea of masculinity present in the Malawian culture.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19384.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

BACKGROUND

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

OBJECTIVES

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

METHODS

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

RESULTS

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

CONCLUSION

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Pathways for HIV Prevention Behaviors Following a Home-Based Couples Intervention for Pregnant Women and Male Partners in Kenya

Pregnancy is a time of heightened HIV risk, but also a phase when a couple can prioritize family health. We conducted secondary analysis of a home-based intervention in rural Kenya to explore couple-level adherence to HIV prevention behaviors. The intervention included health education, relationship-building skills, and Couples HIV Testing and Counseling. Pregnant women were randomized to the intervention (n = 64) or standard care (n = 63) along with male partners. Of 96 couples, 82 (85.0%) were followed to 3 months postpartum, when 31.0% of couples reported perfect adherence to HIV prevention. In logistic regression, intervention condition couples had three-fold higher odds of perfect adherence (AOR = 3.07, 95% CI = 1.01-9.32). A structural equation model found the intervention had moderate effects on couple communication, large effects on couple efficacy to take action around HIV, which in turn improved HIV prevention behaviors (CFI = 0.969; TLI = 0.955; RMSEA = 0.049). Strengthening couple communication and efficacy may help prevent the spread of HIV to infants or partners around the time of pregnancy.

Factor structure of a male involvement index to increase the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programs: revised male involvement index

Male involvement in the prevention of mother to child transmission of HIV (PMTCT) during pregnancy is encouraged, but the accuracy of its measurement has not been established. The purpose of this cross-sectional study was to establish the factor structure of an index of male involvement in PMTCT. Using a structured questionnaire, 1369 HIV positive pregnant women and 522 male partners were recruited in rural Mpumalanga, South Africa. A principal component analysis with varimax rotation yielded two components accounting for 49.9% of the variance. The first factor, named Communication-Based Male Involvement and addressing partner discussions about prenatal, HIV, birth and postnatal issue, accounted for 39.8% of the variance. The second, named Action-Based Male Involvement and addressed partner awareness and actions, and information provided during antenatal visits, financial support, and attendance to visits, accounted for 10.1% of the variance. Given the low rates of male involvement participation in antenatal care, interventions are needed to increase male involvement. However, a method of quantifying male partner participation was needed to assess the effectiveness of such interventions. We hope that the Revised Male Involvement Index will stimulate further research in this area, thus increasing the effectiveness of PMTCT programs aimed at increasing male partner involvement.

Community perspectives: An exploration of potential barriers to men's involvement in maternity care in a central Tanzanian community

Background

Male involvement in maternal health has been linked to positive health outcomes for women and children, as they control household resources and make significant decisions, which influence maternal health. Despite of the important role they have in maternal health care, their actual involvement remains low. The objective of this study was to explore community perspectives on potential barriers to men’s involvement in maternity care in central Tanzania.

Methods

Qualitative research methods were used in data collection. We conducted 32 focus group discussions (16 FGDs with men and 16 FGDs with women) and 34 in-depth interviews with community leaders, village health workers and health care providers. Interview guides were used to guide the focus group discussions and in-depth interviews. The interviews and discussions were audio recorded, transcribed and translated into English and imported into QSR NVivo 9 software for thematic analysis. Three themes emerged from the data; men’s maternity care involvement indicators, benefits of men’s involvement in maternity health care services and barriers to men’s involvement in maternity health care services.

Results

Both men and women participants acknowledged the importance of men’s involvement in maternity health care services, even though few men actually got involved. Identified benefits of men’s involvement in maternity health care services include: Learning any risk factors directly from the health care providers and getting prepared in addressing them; and reinforcing adherence to instruction received from the health care provider as family protectors and guardians. Barriers to men’s involvement in maternity health care services are systemic; starting from the family, health care and culture-specific gender norms for maternity related behaviour as well as healthcare facilities structural constrains inhibiting implementation of couple-friendly maternity health care services.

Conclusions

Men’s involvement in maternity care is influenced by culture-specific maternity-related gender norms. This situation is compounded by the conditions of deprivation that deny women access to resources with which they could find alternative support during pregnancy. Moreover, structures meant for maternal health care services lack privacy, thus inhibiting male partners’ presence in the delivery room. Intervention to increase men’s involvement in maternity care should address individual and systemic barriers to men’s involvement.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

What interventions are effective in improving uptake and retention of HIV-positive pregnant and breastfeeding women and their infants in prevention of mother to child transmission care programmes in low-income and middle-income countries? A systematic review and meta-analysis

OBJECTIVE

This review was conducted to identify interventions effective in improving uptake and retention of HIV-positive mothers and their infants in prevention of mother to child transmission (PMTCT) services in low-income and middle-income countries (LMICs) in order to inform programme planning.

METHODS

We conducted a systematic review of studies comparing usual care with any intervention to improve uptake and retention of HIV-positive pregnant or breastfeeding women and their children from birth to 2 years of age in PMTCT services in LMICs. Twenty-two electronic databases were searched from inception to 15 January 2018, for randomised, quasi-randomised and non-randomised controlled trials, and interrupted time series studies; reference lists of included articles were searched for relevant articles. Risk of bias was assessed using the Cochrane Effective Practice and Organisation of Care group criteria. Random-effects meta-analysis was conducted for studies reporting similar interventions and outcomes.

RESULTS

We identified 29 837 articles, of which 18 studies were included in our review. Because of heterogeneity in interventions and outcome measures, only one meta-analysis of two studies and one outcome was conducted; we found a statistically significant increase in antiretroviral therapy (ART) use during pregnancy for integration of HIV and antenatal care relative to standard non-integrated care (pooled AOR=2.69; 95% CI 1.25 to 5.78, p=0.0113). The remaining studies assessing other patient, provider or health system interventions were synthesised narratively, with small effects seen across intervention categories for both maternal and infant PMTCT outcomes based predominately on evidence with moderate to high risk of bias.

CONCLUSIONS

Evidence on the effectiveness of interventions to improve uptake and retention of mothers and infants in PMTCT care is lacking. Our findings suggest that integration of HIV and antenatal care may improve ART use during pregnancy. Future studies to replicate promising approaches are needed. Improved reporting of key methodological criteria will facilitate interpretation of findings and improve the utility of evidence to PMTCT programme planners.

PROSPERO REGISTRATION NUMBER

CRD42015020829.

Male Partner Involvement in the Utilization of Hospital Delivery Services by Pregnant Women Living with HIV in Sub Saharan Africa: A Systematic Review and Meta-analysis

Objective The level of male partner involvement in hospital delivery by pregnant women living with HIV in sub Saharan Africa (SSA) is low. We conducted a systematic review and meta-analysis to identify the approaches that are used in improving male partner involvement and their impact on the utilization of hospital delivery services by pregnant women living with HIV in SSA. Methods Ovid Medline, Embase, PsycINFO, Cochrane library, ClinicalTrials.gov, Web of Science and Current Controlled Trials were searched. Only studies carried out in SSA that reported an approach used in involving male partners and the impact on the uptake of hospital delivery services irrespective of the language and date of publication were included. Odds ratios were extracted or calculated from studies and combined in a meta-analysis using the statistical package Stata version 11.0. A forest plot was used to show the impact of various male involvement approaches. A funnel plot was used to report publication bias. Results From an initial 2316 non-duplicate articles, 08 articles were included in the systematic review and meta-analysis. The overall pooled OR was 1.56 (95% CI 1.45-1.68). After stratification, the odds ratios were: 1.51 (95% CI 1.38-1.65), 1.58 (95% CI 1.38-1.80), 3.47 (95% CI 2.16-5.58) for complex community interventions without community health workers (CHWs), complex community interventions with community health workers, and verbal encouragement respectively. The overall I-square was 91.0% but after stratification into the three different approaches, the I-squared within the complex community intervention without CHWs group was 0.0%. Conclusions for Practice Complex community interventions and verbal encouragement increase the utilization of hospital delivery services by pregnant women living with HIV in SSA. The overall heterogeneity was high but very low for studies that used complex community interventions without CHWs. More well conducted studies (including randomized controlled trials) are needed in future to add to the quality of evidence.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

DESIGN

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

CONCLUSIONS

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

Perceptions on male involvement in pregnancy and childbirth in Masasi District, Tanzania: a qualitative study

BACKGROUND

Despite the efforts to promote male involvement in maternal and child health, studies in low and middle income countries have reported that male participation is still low. While factors that hinder male partners from participating in maternal and child healthcare are well documented, there is dearth of studies on local perceptions about male involvement in pregnancy and delivery care. The main objective of this study was to explore local perceptions about male involvement in pregnancy and childbirth in Tanzania.

METHODS

Semi-structured individual interviews were conducted with key respondents and a thematic approach was used to analyse data.

RESULTS

The findings revealed that women preferred to be accompanied by their partners to the clinics, especially on the first antenatal care visit. Men did not wish to be more actively involved in antenatal care and delivery. Respondents perceived men as being breadwinners and their main role in pregnancy and child birth was to support their partners financially. The key factors which hindered male participation were traditional gender roles at home, fear of HIV testing and unfavourable environment in health facilities.

CONCLUSION

This study concludes that traditional gender roles and health facility environment presented barriers to male involvement. District health managers should strengthen efforts to improve gender relations, promote men's understanding of the familial and social roles in reproductive health issues as well as provide male friendly services. However, these efforts need to be supported by women and the society as a whole.

Uptake of Home-Based Syphilis and Human Immunodeficiency Virus Testing Among Male Partners of Pregnant Women in Western Kenya

BACKGROUND

Few men are tested for syphilis or human immunodeficiency virus (HIV) during their partner's pregnancy, a high-risk period for HIV and syphilis transmission. Offering home-based rapid testing of syphilis to couples during pregnancy can support prevention efforts to reduce transmission of sexually transmitted diseases and adverse pregnancy outcomes.

METHODS

We assessed men's uptake of paired (separate tests, single blood draw) point-of-care syphilis and HIV tests within a randomized controlled trial of pregnant women who received clinic or home partner HIV testing. We evaluated acceptance of paired HIV-syphilis testing during pregnancy or at 6 months postpartum, and evaluated whether addition of syphilis testing affected the uptake of HIV testing among men.

RESULTS

Of 601 women, we were unable to meet 101 male partners, and 180 tested before syphilis tests were available. Paired syphilis and HIV testing was offered at home to 80 men during pregnancy and to 230 men postpartum. For syphilis, 93% of men agreed to test during pregnancy and 98% agreed postpartum. For paired syphilis and HIV testing, 91% of men tested for both during pregnancy and 96% tested postpartum. Before syphilis test introduction, 96% of men accepted HIV testing, compared with 95% of men who accepted HIV testing when paired testing was offered.

CONCLUSIONS

Uptake of syphilis and HIV testing was high among male partners offered couple testing at home. Introducing syphilis testing did not adversely affect HIV testing among men. Point-of-care diagnostics outside facilities can increase testing of male partners who rarely accompany women to antenatal clinics.

Development and Piloting of a Home-Based Couples Intervention During Pregnancy and Postpartum in Southwestern Kenya

Engaging both partners of a pregnant couple can enhance prevention of mother-to-child transmission of HIV and promote family health. We developed and piloted an intervention to promote couple collaboration in health during pregnancy and postpartum in southwestern Kenya. We utilized formative data and stakeholder input to inform development of a home-based couples intervention. Next, we randomized pregnant women to intervention (n = 64) or standard care (n = 63) arms, subsequently contacting their male partners for enrollment. In the intervention arm, lay health workers conducted couple home visits, including health education, couple relationship and communication skills, and offers of couple HIV testing and counseling (CHTC) services. Follow-up questionnaires were conducted 3 months postpartum (n = 114 women, 86 men). Baseline characteristics and health behaviors were examined by study arm using t-tests, chi-square tests, and regression analyses. Of the 127 women randomized, 96 of their partners participated in the study. Of 52 enrolled couples in the intervention arm, 94% completed at least one couple home visit. Over 93% of participants receiving couple home visits were satisfied and no adverse social consequences were reported. At follow-up, intervention couples had a 2.78 relative risk of having participated in CHTC during the study period compared with standard care couples (95% confidence interval: 1.63-4.75), and significant associations were observed in other key perinatal health behaviors. This pilot study revealed that a home-based couples intervention for pregnant women and male partners is acceptable, feasible, and has the potential to enhance CHTC and perinatal health behaviors, leading to improved health outcomes.

Male partner involvement in increasing the uptake of infant antiretroviral prophylaxis/treatment in sub Saharan Africa: A systematic review and meta-analysis

Background

Infant antiretroviral prophylaxis plays an important role towards ensuring the reduction of HIV transmission from mother to child in the postpartum period. However in sub Saharan Africa (SSA), the low level of involvement of male partners may hinder the uptake of such services by HIV positive mothers. We conducted a systematic review and meta-analysis to determine the impact of male partner involvement approaches on the uptake of infant antiretroviral prophylaxis in SSA.

Methods

In this systematic review and meta-analysis, Ovid Medline, Embase, PsycINFO, Cochrane library, ClinicalTrials.gov, Web of Science and Current Controlled Trials were searched from 1st December 2015 up until 30th March 2016. Only studies carried out in SSA that reported an approach used in involving male partners and the impact on the uptake of infant antiretroviral prophylaxis irrespective of the Language and date of publication were included. Odds ratios were extracted or calculated from studies and combined in a meta-analysis using the statistical package Stata version 11.0. Forest plots were generated using the random effect model.

Results

From an initial 2316 non-duplicate articles, 09 articles were included in the systematic review and meta-analysis. The pooled unadjusted odds ratio was 2.09(95% CI: 1.31 to 3.36) while the unadjusted odds ratios for enhanced psychosocial interventions (02 studies pooled), complex community interventions (02 studies pooled), verbal encouragement (02 studies pooled) and invitation letters(03 pooled studies) were 3.48(95% CI: 1.42 to 8.53), 1.85(95%CI: 0.85 to 4.03), 2.37(95%CI: 1.22 to 4.61) and 1.81(95%CI: 0.64 to 5.14) respectively. I squared was 89.5%, p < 0.001 and the heterogeneity was not explained by any of the variables in meta-regression.

Conclusion

There was stronger evidence for enhanced psychosocial intervention and verbal encouragement in increasing the uptake of infant prophylaxis. The high heterogeneity suggests more studies are needed to draw a definite inference from the meta-analysis. More studies with larger sample sizes that are conducted using similar methods are needed in the future.

Trial registration

Prospero registration number: 42016032673.

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

OBJECTIVES

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

SETTING

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

PARTICIPANTS

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

OUTCOMES

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

42016032673.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Prevalence, trend and risk factors for antiretroviral therapy discontinuation among HIV-infected adults in Ethiopia in 2003-2015

BACKGROUND

It is well acknowledged that antiretroviral therapy (ART) discontinuation hampers the progress towards achieving the UNAIDS treatment targets that aim to treat 90% of HIV diagnosed patients and achieve viral suppression for 90% of those on treatment. Nevertheless, the magnitude, trend and risk factors for ART discontinuation have not been explored extensively. We carried out a retrospective data analysis to assess prevalence, trend and risk factors for ART discontinuation among adults in Southwest Ethiopia.

METHODS

12 years retrospective cohort analysis was performed with 4900 HIV-infected adult patients between 21 June 2003 and 15 March 2015 registered at the ART clinic at Jimma University Teaching Hospital. ART discontinuation could be loss to follow-up, defaulting and/or stopping medication while remaining in care. Because data for 2003 and 2015 were incomplete, the 10 years data were used to describe trends for ART discontinuation using a line graph. We used binary logistic regression to identify factors that were correlated with ART discontinuation. To handle missing data, we applied multiple imputations assuming missing at random pattern.

RESULTS

In total, 4900 adult patients enrolled on ART, of whom 1090 (22.3%) had discontinued, 954 (19.5%) had transferred out, 300 (6.1%) had died, 2517 (51.4%) were alive and on ART, and the remaining 39 (0.8%) had unknown outcome status. The trend of ART discontinuation showed an upward direction in the recent times and reached a peak, accounting for a magnitude of 10%, in 2004 and 2005. Being a female (AOR = 2.1, 95%CI: 1.7-2.8), having an immunological failure (AOR = 2.3, 1.9-8.2), having tuberculosis/HIV co-infection (AOR = 1.5, 1.1-2.1) and no previous history of HIV testing (AOR = 1.8, 1.4-2.9) were the risk factors for ART discontinuation.

CONCLUSIONS

One out of five adults had discontinued from ART, and the trend of ART discontinuation increased recently. Discontinued adults were more likely to be females, tuberculosis/HIV co-infected, with immunological failure and no history of HIV testing. Therefore, it is vital to implement effective programs such as community ART distribution and linkage-case-management to enhance ART linkage and retention.

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

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

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

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

Strategies to improve male involvement in PMTCT Option B+ in four African countries: a qualitative rapid appraisal

Background

The World Health Organization recommends that antiretroviral therapy be started as soon as possible, irrespective of stage of HIV infection. This ‘test and treat’ approach highlights the need to ensure that men are involved in prevention of mother-to-child HIV transmission (PMTCT). This article presents findings from a rapid appraisal of strategies to increase male partner involvement in PMTCT services in Uganda, Democratic Republic of Congo, Malawi, and Côte d'Ivoire in the context of scale-up of Option B+ protocol.

Design

Data were collected through qualitative rapid appraisal using focus groups and individual interviews during field visits to the four countries. Interviews were conducted in the capital city with Ministry of Health staff and implementing partners (IPs) and at district level with district management teams, facility-based health workers and community health cadres in each country.

Results

Common strategies were adopted across the countries to effect social change and engender greater participation of men in maternal, child and women's health, and PMTCT services. Community-based strategies included engagement of community leaders through dialogue and social mobilization, involving community health workers and the creation and strengthening of male peer cadres. Facility-based strategies included provision of incentives such as shorter waiting time, facilitating access for men by altering clinic hours, and creation of family support groups.

Conclusions

The approaches implemented at both community and facility levels were tailored to the local context, taking into account cultural norms and geographic regional variations. Although intentions behind such strategies aim to have positive impacts on families, unintended negative consequences do occur, and these need to be addressed and strategies adapted.

A consistent definition of ‘male involvement’ in PMTCT services and a framework of indicators would be helpful to capture the impact of strategies on cultural and behavioral shifts. National policies around male involvement would be beneficial to streamline approaches across IPs and ensure wide-scale implementation, to achieve significant improvements in family health outcomes.

Factors Associated with PMTCT Cascade Completion in Four African Countries

Background. Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low. Methods. A cross-sectional survey was performed across 26 communities in Cameroon, Cote d'Ivoire, South Africa, and Zambia. Women who reported a pregnancy within two years were enrolled. Participant responses were used to construct the PMTCT cascade with all of the following steps required for completion: at least one antenatal visit, HIV testing performed, HIV testing result received, initiation of maternal prophylaxis, and initiation of infant prophylaxis. Factors associated with cascade completion were identified using multivariable logistic regression modeling. Results. Of 976 HIV-infected women, only 355 (36.4%) completed the PMTCT cascade. Although most women (69.2%) did not know their partner's HIV status; awareness of partner HIV status was associated with cascade completion (aOR 1.4, 95% CI 1.01–2.0). Completion was also associated with receiving an HIV diagnosis prior to pregnancy compared with HIV diagnosis during or after pregnancy (aOR 14.1, 95% CI 5.2–38.6). Conclusions. Pregnant women with HIV infection in Africa who were aware of their partner's HIV status and who were diagnosed with HIV before pregnancy were more likely to complete the PMTCT cascade.

Engagement of Men in Antenatal Care Services: Increased HIV Testing and Treatment Uptake in a Community Participatory Action Program in Mozambique

Uptake of HIV testing and antiretroviral therapy (ART) services during antenatal care (ANC) in rural Mozambique is disappointing. To nurture supportive male engagement in ANC services, we partnered with traditional birth attendants and trained a new type of male-to-male community health agent, "Male Champions", who focused on counseling male partners to create new, male-friendly community norms around engagement in spousal/partner pregnancies. We assessed ANC service uptake using a pre-post intervention design. The intervention was associated with increases in: (1) uptake of provider-initiated counseling and testing among pregnant woman (81 vs. 92 %; p < 0.001); (2) male engagement in ANC (5 vs. 34 %; p < 0.001); and (3) uptake of ART (8 vs. 19 %; p < 0.001). When men accepted HIV testing, rates of testing rose markedly among pregnant women. With the challenges in scale-up of Option B+ in sub-Saharan Africa, similar interventions may increase testing and treatment acceptability during pregnancy.

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.

Evaluation of a male engagement intervention to transform gender norms and improve family planning and HIV service uptake in Kabale, Uganda

Men's limited understanding of family planning (FP) and harmful cultural gender norms pose obstacles to women's FP use. Thirty-two model men called 'Emanzis' were recruited from the community in Kabale, Uganda to lead men from their peer group through a 10-session curriculum designed to transform gender norms and motivate men to engage in FP and HIV services. Cross-sectional surveys were conducted before (n = 1251) and after (n = 1122) implementation. The Gender Equitable Men (GEM) Scale was used to assess the effect on gender attitudes. The intervention achieved negligible changes in responses to GEM items. Improvements in some gender-influenced health-seeking behaviours and practices in men were noted, specifically in visiting health facilities, HIV testing, and condom use. For future application, the intervention should be adapted to require higher peer educator qualifications, longer intervention duration, and more frequent supervision. Practical guidance is needed on where to direct investments in gender-transformative approaches for maximum impact.

Promoting male partner HIV testing and safer sexual decision making through secondary distribution of self-tests by HIV-negative female sex workers and women receiving antenatal and post-partum care in Kenya: a cohort study

BACKGROUND

Increased uptake of HIV testing by men in sub-Saharan Africa is essential for the success of combination prevention. Self-testing is an emerging approach with high acceptability, but little evidence exists on the best strategies for test distribution. We assessed an approach of providing multiple self-tests to women at high risk of HIV acquisition to promote partner HIV testing and to facilitate safer sexual decision making.

METHODS

In this cohort study, HIV-negative women aged 18-39 years were recruited at two sites in Kisumu, Kenya: a health facility with antenatal and post-partum clinics and a drop-in centre for female sex workers. Participants gave informed consent and were instructed on use of oral fluid based rapid HIV tests. Participants enrolled at the health facility received three self-tests and those at the drop-in centre received five self-tests. Structured interviews were conducted with participants at enrolment and over 3 months to determine how self-tests were used. Outcomes included the number of self-tests distributed by participants, the proportion of participants whose sexual partners used a self-test, couples testing, and sexual behaviour after self-testing.

FINDINGS

Between Jan 14, 2015, and March 13, 2015, 280 participants were enrolled (61 in antenatal care, 117 in post-partum care, and 102 female sex workers); follow-up interviews were completed for 265 (96%). Most participants with primary sexual partners distributed self-tests to partners: 53 (91%) of 58 participants in antenatal care, 91 (86%) of 106 in post-partum care, and 64 (75%) of 85 female sex workers. 82 (81%) of 101 female sex workers distributed more than one self-test to commercial sex clients. Among self-tests distributed to and used by primary sexual partners of participants, couples testing occurred in 27 (51%) of 53 in antenatal care, 62 (68%) of 91 from post-partum care, and 53 (83%) of 64 female sex workers. Among tests received by primary and non-primary sexual partners, two (4%) of 53 tests from participants in antenatal care, two (2%) of 91 in post-partum care, and 41 (14%) of 298 from female sex workers had positive results. Participants reported sexual intercourse with 235 (62%) of 380 sexual partners who tested HIV-negative, compared with eight (18%) of 45 who tested HIV-positive (p<0·0001); condoms were used in all eight intercourse events after positive results compared with 104 (44%) after of negative results (p<0·0018). Four participants reported intimate partner violence as a result of self-test distribution: two in the post-partum care group and two female sex workers. No other adverse events were reported.

INTERPRETATION

Provision of multiple HIV self-tests to women at high risk of HIV infection was successful in promoting HIV testing among their sexual partners and in facilitating safer sexual decisions. This novel strategy warrants further consideration as countries develop self-testing policies and programmes.

FUNDING

Bill & Melinda Gates Foundation.

Evolution of HIV and AIDS Programmes in an African Institution of Higher Learning: The Case of the Copperbelt University in Zambia

BACKGROUND

Universities present the foundation for socio-economic and political development. Without structures and processes to fight HIV, there is no prospect of enhancing treatment, prevention, care and support services. Copperbelt University HIV and AIDS response was initiated in 2003 with the aim of building capacity of students and employees in HIV and AIDS.

OBJECTIVES

The main objective of this paper is to demonstrate how the CBU HIV response has evolved over time and provide a timeline of important milestones in the development process.

METHOD

Peer educators and counsellors conduct sensitization campaigns through one on one discussion, workshops, and drama performances, distribution of Information, Education and Communication (IEC) materials.

RESULTS

HIV Programme has been set up with players from policy, programme and community levels. Strategic processes, collaborations, funding, medical insurance schemes, prevention, treatment, care and support services, training of peer educators and counsellors have been established.

CONCLUSION

Copperbelt University HIV initiative has demonstrated potential to reduce new infections in the university, and is currently expanding her programme to encompass wellness and also spearhead the integration of HIV in the university curriculum.

Evaluating the effectiveness of selected community-level interventions on key maternal, child health, and prevention of mother-to-child transmission of HIV outcomes in three countries (the ACCLAIM Project): a study protocol for a randomized controlled trial

BACKGROUND

Efforts to scale up and improve programs for prevention of mother-to-child transmission of HIV (PMTCT) have focused primarily at the health facility level, and limited attention has been paid to defining an effective set of community interventions to improve demand and uptake of services and retention. Many barriers to PMTCT are also barriers to pregnancy, childbirth, and postnatal care faced by mothers regardless of HIV status. Demand for maternal and child health (MCH) and PMTCT services can be limited by critical social, cultural, and structural barriers. Yet, rigorous evaluation has shown limited evidence of effectiveness of multilevel community-wide interventions aimed at improving MCH and HIV outcomes for pregnant women living with HIV. We propose to assess the effect of a package of multilevel community interventions: a social learning and action component, community dialogues, and peer-led discussion groups, on the demand for, uptake of, and retention of HIV positive pregnant/postpartum women in MCH/PMTCT services.

METHODS/DESIGN

This study will undertake a three-arm randomized trial in Swaziland, Uganda, and Zimbabwe. Districts/regions (n = 9) with 45 PMTCT-implementing health facilities and their catchment areas (populations 7,300-27,500) will be randomly allocated to three intervention arms: 1) community leader engagement, 2) community leader engagement with community days, or 3) community leader engagement with community days and male and female community peer groups. The primary study outcome is HIV exposed infants (HEIs) returning to the health facility within 2 months for early infant diagnosis (EID) of HIV. Secondary study outcomes include gestational age of women attending for first antenatal care, male partners tested for HIV, and HEIs receiving nevirapine prophylaxis at birth. Changes in community knowledge, attitudes, practices, and beliefs on MCH/PMTCT will be assessed through household surveys.

DISCUSSION

Implementation of the protocol necessitated changes in the original study design. We purposively selected facilities in the districts/regions though originally the study clusters were to be randomly selected. Lifelong antiretroviral therapy for all HIV positive pregnant and lactating women, Option B+, was implemented in the three countries during the study period, with the potential for a differential impact by study arm. Implementation however, was rapidly done across the districts/regions, so that there is unlikely be this potential confounding. We developed a system of monitoring and documentation of potential confounding activities or actions, and these data will be incorporated into analyses at the conclusion of the project. Strengthens of the study are that it tests multilevel interventions, utilizes program as well as study specific and individual data, and it is conducted under "real conditions" leading to more robust findings. Limitations of the protocol include the lack of a true control arm and inadequate control for the potential effect of Option B+, such as the intensification of messages as the importance of early ANC and male partner testing.

TRIAL REGISTRATION

ClinicalTrials.gov (study ID: NCT01971710) Protocol version 5, 30 July 2013, registered 13 August 2013.

Community health workers can improve male involvement in maternal health: evidence from rural Tanzania

Background

Male involvement in maternal health is recommended as one of the interventions to improve maternal and newborn health. There have been challenges in realising this action, partly due to the position of men in society and partly due to health system challenges in accommodating men. The aim of this study was therefore to evaluate the effect of Home Based Life Saving Skills training by community health workers on improving male involvement in maternal health in terms of knowledge of danger signs, joint decision-making, birth preparedness, and escorting wives to antenatal and delivery care in a rural community in Tanzania.

Design

A community-based intervention consisting of educating the community in Home Based Life Saving Skills by community health workers was implemented using one district as the intervention district and another as comparison district. A pre-/post-intervention using quasi-experimental design was used to evaluate the effect of Home Based Life Saving Skills training on male involvement and place of delivery for their partners. The effect of the intervention was determined using difference in differences analysis between the intervention and comparison data at baseline and end line.

Results

The results show there was improvement in male involvement (39.2% vs. 80.9%) with a net intervention effect of 41.1% (confidence interval [CI]: 28.5–53.8; p <0.0001). There was improvement in the knowledge of danger signs during pregnancy, childbirth, and postpartum periods. The proportion of men accompanying their wives to antenatal and delivery also improved. Shared decision-making for place of delivery improved markedly (46.8% vs. 86.7%), showing a net effect of 38.5% (CI: 28.0–49.1; p <0.0001). Although facility delivery for spouses of the participants improved in the intervention district, this did not show statistical significance when compared to the comparison district with a net intervention effect of 12.2% (95% CI: −2.8–27.1: p=0.103).

Conclusion

This community-based intervention employing community health workers to educate the community in the Home Based Life Saving Skills programme is both feasible and effective in improving male involvement in maternal healthcare.

Safer disclosure of HIV serostatus for women living with HIV who experience or fear violence: a systematic review

Introduction

Supporting individuals as they disclose their HIV serostatus may lead to a variety of individual and public health benefits. However, many women living with HIV are hesitant to disclose their HIV status due to fear of negative outcomes such as violence, abandonment, relationship dissolution and stigma.

Methods

We conducted a systematic review of studies evaluating interventions to facilitate safer disclosure of HIV status for women living with HIV who experience or fear violence. Articles, conference abstracts and programme reports were included if they reported post-intervention evaluation results and were published before 1 April 2015. Searching was conducted through electronic databases for peer-reviewed articles and conference abstracts, reviewing websites of relevant organizations for grey literature, hand searching reference lists of included studies and contacting experts. Systematic methods were used for screening and data abstraction, which was conducted in duplicate. Study quality (rigor) was assessed with the Cochrane risk of bias tool.

Results

Two interventions met the inclusion criteria: the Safe Homes and Respect for Everyone cluster-randomized trial of combination HIV and intimate partner violence (IPV) services in Rakai, Uganda, and the South Africa HIV/AIDS Antenatal Post-Test Support study individual randomized trial of an enhanced counselling intervention for pregnant women undergoing HIV testing and counselling. Both programmes integrated screening for IPV into HIV testing services and trained counsellors to facilitate discussions about disclosure based on a woman's risk of violence. However, both were implemented as part of multiple-component interventions, making it impossible to isolate the impact of the safer disclosure components.

Conclusions

The existing evidence base for interventions to facilitate safe HIV serostatus disclosure for women who experience or fear violence is limited. Development and implementation of new approaches and rigorous evaluation of safe disclosure outcomes is needed to guide programme planners and policy makers.

The effectiveness of interventions to improve uptake and retention of HIV-infected pregnant and breastfeeding women and their infants in prevention of mother-to-child transmission care programs in low- and middle-income countries: protocol for a systematic review and meta-analysis

BACKGROUND

Despite recent improvements, uptake and retention of mothers and infants in prevention of mother-to-child transmission (PMTCT) services remain well below target levels in many low- and middle-income countries (LMICs). Identification of effective interventions to support uptake and retention is the first step towards improvement. We aim to complete a systematic review and meta-analysis to evaluate the effectiveness of interventions at the patient, provider or health system level in improving uptake and retention of HIV-infected mothers and their infants in PMTCT services in LMICs.

METHODS/DESIGN

We will include studies comparing usual care or no intervention to any type of intervention to improve uptake and retention of HIV-infected pregnant or breastfeeding women and their children from birth to 2 years of age attending PMTCT services in LMICs. We will include randomized controlled trials (RCTs), cluster RCTs, non-randomized controlled trials, and interrupted time series. The primary outcomes of interest are percentage of HIV-infected women receiving/initiated on anti-retroviral prophylaxis or treatment, percentage of infants receiving/initiated on anti-retroviral prophylaxis, and percentage of women and infants completing the anti-retroviral regimen/retained in PMTCT care. The following databases will be searched from inception: Ovid MEDLINE and EMBASE, The WHO Global Health Library, CAB abstracts, EBM Reviews, CINAHL, HealthSTAR and Web of Science databases, Scopus, PsychINFO, POPLINE, Sociological Abstracts, ERIC, AIDS Education Global Information System, NLM Gateway, LILACS, Google Scholar, British Library Catalogue, DARE, ProQuest Dissertation & Theses, the New York Academy of Grey Literature, Open Grey, The Cochrane Library, WHO International Clinical Trials Registry, Controlled Clinical Trials, and clinicaltrials.gov. Reference lists of included articles will be hand searched and study authors and content experts contacted to inquire about eligible unpublished or in progress studies. Screening, data abstraction, and risk of bias appraisal using the Cochrane Effective Practice and Organization of Care criteria will be conducted independently by two team members. Results will be synthesized narratively and a meta-analysis conducted using the DerSimonian Laird random effects method if appropriate based on assessment of clinical and statistical heterogeneity.

DISCUSSION

Our findings will be useful to PMTCT implementers, policy makers, and implementation researchers working in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015020829.

Female sex workers' experiences with intended pregnancy and antenatal care services in southern Tanzania

Understanding the pregnancy experiences of female sex workers (FSWs), especially in the context of high rates of HIV and sexually transmitted infections (STIs), is essential to tailoring services to meet their needs. This study explores FSWs' experiences with intended pregnancy and access to antenatal care and HIV testing in two regions of Tanzania. Thirty in-depth interviews and three focus group discussions were conducted. FSWs sought to become pregnant to gain respect as mothers, to avoid stigma, and/or to solidify relationships, sometimes posing risks to their own and their partners' health. Pregnant FSWs generally sought antenatal care (ANC) services but rarely disclosed their occupation, complicating provision of appropriate care. Accessing ANC services presented particular challenges, with health care workers sometimes denying all clinic services to women who were not accompanied by husbands. Several participants reported being denied care until delivery. The difficulties participants reported in accessing health care services as both sex workers and unmarried women have potential social and health consequences in light of the high levels of HIV and STIs among FSWs in sub-Saharan Africa.

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.

Male involvement and maternal health outcomes: systematic review and meta-analysis

BACKGROUND

The developing world accounts for 99% of global maternal deaths. Men in developing countries are the chief decision-makers, determining women's access to maternal health services and influencing their health outcomes. At present, it is unclear whether involving men in maternal health can improve maternal outcomes. This systematic review and meta-analysis aimed to investigate the impact of male involvement on maternal health outcomes of women in developing countries.

METHODS

Four electronic databases and grey literature sources were searched (up to May 2013), together with reference lists of included studies. Two reviewers independently screened and assessed the quality of studies based on prespecified criteria. Measures of effects were pooled and random effect meta-analysis was conducted, where possible.

RESULTS

Fourteen studies met the inclusion criteria. Male involvement was significantly associated with reduced odds of postpartum depression (OR=0.36, 95% CI 0.19 to 0.68 for male involvement during pregnancy; OR=0.34, 95% CI 0.19 to 0.62 for male involvement post partum), and also with improved utilisation of maternal health services (skilled birth attendance and postnatal care). Male involvement during pregnancy and at post partum appeared to have greater benefits than male involvement during delivery.

CONCLUSIONS

Male involvement is associated with improved maternal health outcomes in developing countries. Contrary to reports from developed countries, there was little evidence of positive impacts of husbands' presence in delivery rooms. However, more rigorous studies are needed to improve this area's evidence base.

Correlates of male involvement in maternal and newborn health: a cross-sectional study of men in a peri-urban region of Myanmar

Background

Evidence suggests that increasing male involvement in maternal and newborn health (MNH) may improve MNH outcomes. However, male involvement is difficult to measure, and further research is necessary to understand the barriers and enablers for men to engage in MNH, and to define target groups for interventions. Using data from a peri-urban township in Myanmar, this study aimed to construct appropriate indicators of male involvement in MNH, and assess sociodemographic, knowledge and attitude correlates of involvement.

Methods

A cross-sectional study of married men with one or more children aged up to one year was conducted in 2012. Structured questionnaires measured participants’ involvement in MNH, and their sociodemographic characteristics, knowledge and attitudes. An ordinal measure of male involvement was constructed describing the subject’s participation across five areas of MNH, giving a score of 1–4. Proportional-odds regression models were developed to determine correlates of male involvement.

Results

A total of 210 men participated in the survey, of which 203 provided complete data. Most men reported involvement level scores of either 2 or 3 (64 %), with 13 % reporting the highest level (score of 4). Involvement in MNH was positively associated with wives’ level of education (AOR = 3.4; 95 % CI: 1.9-6.2; p < 0.001) and men’s level of knowledge of MNH (AOR = 1.2; 95 % CI: 1.1-1.3; p < 0.001), and negatively correlated with number of children (AOR = 0.78; 95 % CI: 0.63-0.95; p = 0.016).

Conclusions

These findings can inform the design of programs aiming to increase male involvement, for example by targeting less educated couples and addressing their knowledge of MNH. The composite index proved a useful summary measure of involvement; however, it may have masked differential determinants of the summed indicators. There is a need for greater understanding of the influence of gender attitudes on male involvement in Myanmar and more robust indicators that capture these gender dynamics for use both in Myanmar and globally.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0561-9) contains supplementary material, which is available to authorized users.

Effect of distribution of educational material to mothers on duration and severity of diarrhoea and pneumonia, Midlands Province, Zimbabwe: a cluster randomized controlled trial

BACKGROUND

Exclusive breastfeeding rates remain low in most countries in sub-Saharan Africa. We assessed the effects of a mother-based intervention on duration of diarrhoea and pneumonia in communities that were trained and those not trained in community infant and young child feeding (cIYCF) in Midlands Province, Zimbabwe.

METHODS

We evaluated communities with village health workers who received training in cIYCF and the distribution of educational materials (newsletter) to mothers in promotion of exclusive breastfeeding using a two-by-two factorial cluster randomized controlled trial. The trial arms included clusters trained in cIYCF only, clusters with mothers that received a newsletter only, clusters that received both interventions and clusters receiving no intervention. Consenting mother-infant pairs identified within 72 hours of delivery were followed up at 14 and 20 weeks where duration of diarrhoea and pneumonia as well as severity of diarrhoea was assessed. Clusters were facility catchment areas assigned by an independent statistician using randomization generated by a computer using Stata 10. All admitting facilities and facilities at borders were excluded as buffer zones and eight clusters were analysed. Nutritionists who collected data were not aware of the hypothesis being tested and analysis was by intention-to-treat.

RESULTS

A total of 357 mother-infant pairs were available for analysis in all the clusters. The interaction between cIYCF training and the newsletter was statistically significant at 14 weeks (p = 0.022). The mean duration of diarrhoea was 2.9 (SD = 0.9) days among infants of mothers who resided in communities trained and received a newsletter compared to 5.2 (SD = 1.1) days in communities that received neither. The protective efficacy of the cIYCF plus newsletter was 76% during the first 20 weeks of life. In the two way ANOVA, the newsletter was more effective on duration of pneumonia (p = 0.010) at 14 weeks and remained significantly effective at 20 weeks (p < 0.0001).

CONCLUSIONS

A combined community and distribution of a newsletter to mothers on promotion of exclusive breastfeeding reduces duration of diarrhoea at 14 weeks. At 20 weeks, the newsletter worked better for both duration of diarrhoea and pneumonia compared to cIYCF training alone.

Implementing comprehensive prevention of mother-to-child transmission and HIV prevention for South African couples: study protocol for a randomized controlled trial

BACKGROUND

In rural South Africa, only two-thirds of HIV-positive pregnant women seeking antenatal care at community health centers took full advantage of 'prevention of mother-to-child transmission' (PMTCT) services in 2010. Studies generally support male involvement to promote PMTCT, but the nature and impact of that involvement is unclear and untested. Additionally, stigma, disclosure and intimate partner violence pose significant barriers to PMTCT uptake and retention in care, suggesting that male involvement may be 'necessary, but not sufficient' to reduce infant HIV incidence. This study expands on a successful United States President's Emergency Plan for AIDS Relief (PEPFAR)-supported PMTCT couples intervention pilot study conducted in the Mpumalanga province, targeting HIV-positive pregnant women and their partners, the primary objective being to determine whether male partner involvement plus a behavioral intervention will significantly reduce infant HIV incidence.

METHODS/DESIGN

The study follows a cluster randomized controlled design enrolling two cohorts of HIV-positive pregnant women recruited from 12 randomly assigned Community Health Centers (CHC) (six experimental, six control). The two cohorts will consist of women attending without their male partners (n = 720) and women attending with their male partners (n = 720 couples), in order to determine whether the influence of male participation itself, or combined with a behavioral PMTCT intervention, can significantly reduce infant HIV infection ante-, peri- and postnatally.

DISCUSSION

It is our intention to significantly increase PMTCT participation from current levels (69%) in the Mpumalanga province to between 90 and 95% through engaging women and couples in a controlled, six session ante- and postnatal risk-reducing and PMTCT promotion intervention addressing barriers to PMTCT (such as stigma, disclosure, intimate partner violence, communication, infant feeding practices and safer conception) that prevent women and men from utilizing treatment opportunities available to them and their infants. Based upon the encouraging preliminary results from our pilot study, successful CHC adoption of the program could have major public health policy implications for containing the epidemic among the most vulnerable populations in rural South Africa: HIV-positive pregnant women and their infants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02085356 (registration date: 10 March 2014).

Assessment of peer-based and structural strategies for increasing male participation in an antenatal setting in Lilongwe, Malawi

In sub-Saharan Africa, although male involvement in antenatal care is associated with positive outcomes for HIV-infected women and their infants, men rarely accompany female partners. We implemented a project to increase the number of male partners attending an antenatal clinic at Bwaila Hospital in Lilongwe, Malawi. We evaluated changes in the proportion of women who came with a partner over three periods. During period 1 (January 2007 - June 2008) there was didactic peer education. During period 2 (July 2008 - September 2009) a peer-led male-involvement drama was introduced into patient waiting areas. During period 3 (October 2009 - December 2009) changes to clinical infrastructure were introduced to make the clinic more male-friendly. The proportion of women attending ANC with a male partner increased from 0.7% to 5.7%, to 10.7% over the three periods. Peer education through drama and male-friendly hospital infrastructure coincided with substantially greater male participation, although further gains are necessary.

Uptake of prevention of mother-to-child-transmission using Option B+ in northern rural Malawi: a retrospective cohort study

To identify points of dropout on the pathway from offering HIV testing to maintenance on antiretroviral therapy (ART), following the introduction of the Option B+ policy for pregnant women in Malawi (lifelong ART for HIV-positive mothers and 6 weeks nevirapine for the infants), a retrospective cohort study within a demographic surveillance system in northern Malawi. Women living in the demographic surveillance system who initiated antenatal care (ANC) between July 2011 (date of policy change) and January 2013, were eligible for inclusion. Women who consented were interviewed at home about their health facility attendance and care since pregnancy, including antenatal clinic (ANC) visits, delivery and postpartum care. Women's reports, patient-held health records and clinic health records were manually linked to ascertain service use. Among 395 women, 86% had tested for HIV before the pregnancy, 90% tested or re-tested at the ANC visit, and <1% had never tested. Among 53 mothers known to be HIV-positive before attending ANC, 15 (28%) were already on ART prior to pregnancy. Ten women tested HIV-positive for the first time during pregnancy. Of the 47 HIV-positive mothers not already on ART, 26/47 (55%) started treatment during pregnancy. All but five women who started ART were still on treatment at the time of study interview. HIV testing was almost universal and most women who initiated ART were retained in care. However, nearly half of eligible pregnant women not on ART at the start of ANC had not taken up the invitation to initiate (lifelong) ART by the time of delivery, leaving their infants potentially HIV-exposed.

The role of family planning in elimination of new pediatric HIV infection

PURPOSE OF REVIEW

We reviewed recent literature on the role of family planning in eliminating new pediatric HIV infections.

RECENT FINDINGS

Global commitments to eliminate new pediatric HIV infections recognize that preventing unintended pregnancies among women with HIV is essential to achieving this goal. However, substantial shortcomings exist in translating this policy support into widespread practice. Programs to prevent mother-to-child transmission of HIV continue to be implemented and evaluated as a narrow set of interventions that typically begins in antenatal care, after a woman is already pregnant. In addition, data suggest that women living with HIV experience high rates of unmet need for family planning and unintended pregnancies. Evidence is growing that integrating family planning and HIV services is an effective strategy for increasing access to contraception among women with HIV who do not wish to become pregnant. A number of health system obstacles must be resolved to achieve effective, sustained delivery of integrated services at scale.

SUMMARY

Prevention of unintended pregnancies among women with HIV must be elevated as a programmatic priority. By strengthening family planning programs for all women, and better integrating family planning and HIV services, progress toward ending new pediatric HIV infections will be accelerated.