Factors determining prenatal HIV testing for prevention of mother to child transmission of HIV in Mpumalanga, South Africa

The barriers and facilitators of HIV-exposed infant testing as perceived by HIV-positive mothers in Botswana: A qualitative study

Background

Despite high rates of HIV testing and enrolment of HIV-positive pregnant women on antiretroviral therapy in Botswana, coverage for HIV-exposed infant (HEI) testing remains suboptimal. Many factors can contribute to suboptimal HEI testing rates, but they have seldom been thoroughly investigated in Botswana. Therefore, the aim of this study was to explore the experiences and perspectives of HIV-positive mothers on the barriers and facilitators of HEI testing to inform interventions to promote HEI testing in Botswana.

Methods

We conducted focus group discussions (FGDs) with HIV-positive mothers who gave birth in 2016 at the three largest public hospitals in Botswana. FGDs were held in Maun, Francistown, and Gaborone from September 2019 to March 2020. The maximum variation sampling method was used to select the participants using information that was abstracted from birth registers and other medical records at the study sites. Mothers were asked to describe their HEI testing experiences, what made it easy or difficult for them to return the HEI for testing, and what needs to be done to improve HEI testing in Botswana. A thematic approach was used to analyse the data.

Results

Fifteen FGDs with 142 mothers (aged 21–52 years) were held. Participants identified several facilitators to HEI testing, including a mother with adequate knowledge of PMTCT, intensive tracking of HEI by healthcare workers (HCWs), positive attitudes of HCWs toward clients, and social support from significant others. Staff shortages at health care facilities, frequent stock-outs of HIV test kits, fear of stigma, fear of positive test results for the child, and transportation challenges were identified as key barriers to HEI testing. Increasing staffing at healthcare facilities, having adequate supplies of HIV test kits, enhanced HEI tracking, easing access to HEI testing services in rural areas, and providing quality PMTCT education were among the proposed interventions to promote HEI testing.

Conclusion

Optimizing HEI testing in Botswana will require multi-level interventions at the policy, health system, community, interpersonal, and individual levels.

Prenatal HIV Test Uptake and Its Associated Factors for Prevention of Mother to Child Transmission of HIV in East Africa

Identifying the socioeconomic and structural issues that act as enablers and/or barriers to HIV testing services is critical in combatting HIV/AIDS amongst mothers and children in Africa. In this study, we used a weighted sample of 46,645 women aged 15–49 who gave birth in the two years preceding the survey from the recent DHS dataset of ten East African countries. Multivariable logistic regression was used to investigate the factors associated with prenatal HIV test uptake in East Africa. The overall prenatal HIV test uptake for the prevention of mother-to-child transmission (PMTCT) of HIV was 80.8% (95% CI: 74.5–78.9%) in East Africa, with highest in Rwanda (97.9%, 95% CI: 97.2–98.3%) and lowest in Comoros (17.0%, 95% CI: 13.9–20.7%). Common factors associated with prenatal HIV test service uptake were higher maternal education level (AOR = 1.29; 95% CI: 1.10–1.50 for primary education and AOR = 1.96; 95% CI: 1.53–2.51 for secondary or higher education), higher partner education level (AOR = 1.24; 95% CI: 1.06–1.45 for primary education and AOR = 1.56; 95% CI: 1.26–1.94 for secondary or higher school), women from higher household wealth index (AOR = 1.29; 95% CI: 1.11–1.50 for middle wealth index; AOR = 1.57; 95% CL: 1.17–2.11 for rich wealth index), improved maternal exposure to the media, and increased awareness about MTCT of HIV. However, residents living in rural communities (AOR = 0.66; 95% CI: 0.51–0.85) and travelling long distances to the health facility (AOR = 0.8; 95% CI: 0.69–0.91) were associated with non-use of prenatal HIV test service in East African countries. In each East African country, factors associated with prenatal HIV test uptake for PMTCT varied. In conclusion, the pooled prenatal HIV test uptake for PMTCT of HIV was low in East Africa compared to the global target. Scaling up interventions to improve enablers whilst addressing barriers to the use of prenatal HIV test services are essential to end the HIV/AIDS epidemic in East African countries.

Fertility intentions of women living with HIV and their male partners during the perinatal period in rural South Africa

Understanding the fertility intentions of people living with HIV can guide safer conception planning and prevention of mother-to-child transmission (PMTCT). Most research has addressed fertility intentions among women, rather than couples, at a single time point. This clinical trial of a PMTCT intervention in rural Mpumalanga province, South Africa, examined longitudinal fertility intentions among perinatal women living with HIV and their male partners. Study assessments and intervention and control sessions were conducted prenatally and postpartum. Longitudinal predictors of participants' (n = 360 men, n = 917 women) fertility intentions were similar between sexes. Younger age and male involvement in perinatal care were associated with reporting fertility intentions at both baseline and 12 months postpartum. Having an HIV-positive infant and discussing pregnancy plans with a healthcare provider by 12 months postpartum were associated with incident fertility intentions after reporting no plans for further children at baseline. Results highlight the important role of healthcare providers to educate men and women on issues surrounding conception, as well as the potential for incorporating PMTCT and safer conception education into HIV clinical services.

Acceptance of HIV Counseling and Testing among Antenatal Clinic Attendees in Southern Ethiopia

Background

Counseling and testing for Human Immunodeficiency Virus (HIV) (HCT) during antenatal care (ANC) is a critical entry point for the prevention of mother-to-child transmission (PMTCT) of HIV. However, in Ethiopia limited evidence exists regarding the extent of acceptance of the service. The study aimed to assess the level and factors associated with acceptance of HCT in Hawassa city, Southern Ethiopia.

Methods

Cross-sectional study was conducted in four public health facilities found in the city. Five hundred and four ANC clients were selected using multistage sampling technique. Data were collected via interviewer administered questionnaire and analyzed using multivariable binary logistic regression analysis. The outputs are presented using adjusted odds ratio (AOR) with 95% confidence interval (CI).

Results

The vast majority, 84.1% (95% CI: 80.6-87.2%), of the respondents accepted the HCT. Acceptance was positively associated with being married [AOR=5.60 (95% CI: 1.87-16.50)], having two or more ANC visits [4.93 (95% CI: 2.40-10.07)], history of prior HIV testing [4.23 (95% CI: 1.90-9.74)], having good knowledge about MTCT [4.91 (95% CI: 2.07-11.6)] and PMTCT [6.22 (95% CI: 2.87-13.50)] and having no fear of stigma and discrimination [3.32 (95% CI: 1.57-7.02)].

Conclusion

Acceptance of HCT can be further improved by enhancing the knowledge of mother about PMTCT and combating stigma and discrimination.

Influences on Exclusive Breastfeeding Among Rural HIV-Infected South African Women: A Cluster Randomized Control Trial

South African guidelines for prevention-of-mother-to-child-transmission (PMTCT) of HIV emphasize exclusive breastfeeding (EBF). This study examined the impact of a PMTCT intervention and male involvement on EBF. In a two-phase cluster-randomized trial, rural South African community health centers were randomized to offer HIV-infected pregnant women PMTCT standard of care plus either: a behavioral PMTCT intervention, or a time-equivalent attention-control condition. Phase 1 women had non-participating male partners; Phase 2 women had participating partners. Pregnant women (n = 1398) were assessed on HIV stigma, disclosure of HIV status to partner, male involvement, and family planning knowledge. Feeding practices were assessed 6 weeks postpartum (56% retained). Reduced depressive symptomatology predicted EBF 6 weeks postpartum, adjusting for attrition (AOR = 0.954, p = 0.001). Neither male involvement in antenatal care, phase, HIV stigma, disclosure, nor family planning knowledge predicted EBF. Future studies and perinatal care should address depression, which has important implications for infant health.

A cluster randomized controlled trial of lay health worker support for prevention of mother to child transmission of HIV (PMTCT) in South Africa

BACKGROUND

We evaluate the impact of clinic-based PMTCT community support by trained lay health workers in addition to standard clinical care on PMTCT infant outcomes.

METHODS

In a cluster randomized controlled trial, twelve community health centers (CHCs) in Mpumalanga Province, South Africa, were randomized to have pregnant women living with HIV receive either: a standard care (SC) condition plus time-equivalent attention-control on disease prevention (SC; 6 CHCs; n  = 357), or an enhanced intervention (EI) condition of SC PMTCT plus the "Protect Your Family" intervention (EI; 6 CHCs; n  = 342). HIV-infected pregnant women in the SC attended four antenatal and two postnatal video sessions and those in the EI, four antenatal and two postnatal PMTCT plus "Protect Your Family" sessions led by trained lay health workers. Maternal PMTCT and HIV knowledge were assessed. Infant HIV status at 6 weeks postnatal was drawn from clinic PCR records; at 12 months, HIV status was assessed by study administered DNA PCR. Maternal adherence was assessed by dried blood spot at 32 weeks, and infant adherence was assessed by maternal report at 6 weeks. The impact of the EI was ascertained on primary outcomes (infant HIV status at 6 weeks and 12 months and ART adherence for mothers and infants), and secondary outcomes (HIV and PMTCT knowledge and HIV transmission related behaviours). A series of logistic regression and latent growth curve models were developed to test the impact of the intervention on study outcomes.

RESULTS

In all, 699 women living with HIV were recruited during pregnancy (8-24 weeks), and assessments were completed at baseline, at 32 weeks pregnant (61.7%), and at 6 weeks (47.6%), 6 months (50.6%) and 12 months (59.5%) postnatally. Infants were tested for HIV at 6 weeks and 12 months, 73.5% living infants were tested at 6 weeks and 56.7% at 12 months. There were no significant differences between SC and EI on infant HIV status at 6 weeks and at 12 months, and no differences in maternal adherence at 32 weeks, reported infant adherence at 6 weeks, or PMTCT and HIV knowledge by study condition over time.

CONCLUSION

The enhanced intervention administered by trained lay health workers did not have any salutary impact on HIV infant status, ART adherence, HIV and PMTCT knowledge. Trial registration clinicaltrials.gov: number NCT02085356.

The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability

The Joint United Nations Programme on HIV and AIDS proposed to reduce the vertical transmission of HIV from ∼72,200 to ∼8300 newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the implementation, uptake, and sustainability of the PMTCT protocol in rural SA. Forty-eight qualitative interviews, 12 focus groups discussions (n = 75), and one two-day workshop (n = 32 participants) were conducted with district directors, clinic leaders, staff, and patients from 12 rural clinics. The delivery and uptake of the PMTCT protocol was evaluated using the Consolidated Framework for Implementation Research (CFIR); 15 themes associated with challenges and solutions emerged. Intervention characteristics themes included PMTCT training and HIV serostatus disclosure. Outer-setting themes included facility space, health record management, and staff shortage; inner-setting themes included supply use and availability, staff-patient relationship, and transportation and scheduling. Themes related to characteristics of individuals included staff relationships, initial antenatal care visit, adherence, and culture and stigma. Implementation process themes included patient education, test results delivery, and male involvement. Significant gaps in care were identified in rural areas. Information obtained from participants using the CFIR framework provided valuable insights into solutions to barriers to PMTCT implementation. Continuously assessing and correcting PMTCT protocol implementation, uptake and sustainability appear merited to maximize HIV prevention.

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

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

Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa

BACKGROUND

Stigma is a known barrier to HIV testing and care. Because access to antiretroviral therapy reduces overt illness and mortality, some scholars theorized that HIV-related stigma would decrease as treatment availability increased. However, the association between ART accessibility and stigma has not been as straightforward as originally predicted.

METHODS

We conducted a "situational analysis"--a rapid, community-based qualitative assessment to inform a combination HIV prevention program in high prevalence communities. In the context of this community-based research, we conducted semi-structured interviews and focus groups with 684 individuals in four low-resource sub-districts in North West Province, South Africa. In addition to using this data to inform programming, we examined the impact of stigma on the uptake of services.

RESULTS

Findings suggested that anticipated stigma remains a barrier to care. Although participants reported less enacted stigma, or hostility toward people living with HIV, they also felt that HIV remains synonymous with promiscuity and infidelity. Participants described community members taking steps to avoid being identified as HIV-positive, including avoiding healthcare facilities entirely, using traditional healers, or paying for private doctors. Such behaviors led to delays in testing and accessing care, and problems adhering to medications, especially for men and youth with no other health condition that could plausibly account for their utilization of medical services.

CONCLUSIONS

We conclude that providing access to ART alone will not end HIV-related stigma. Instead, individuals will remain hesitant to seek care as long as they fear that doing so will lead to prejudice and discrimination. It is critical to combat this trend by increasing cultural acceptance of being seropositive, integrating HIV care into general primary care and normalizing men and youths' accessing health care.

Perspectives on safer conception practices and preconception counseling among women living with HIV

Pregnancies are frequently unplanned, and higher rates of unplanned pregnancies occur among HIV-infected women. Reviewers examined reproductive decision making, conception practices, and patient-provider communication among women living with HIV. Qualitative interviews were conducted with 19 HIV-infected sexually active women aged 18-45 in southern Florida, USA. Using thematic analysis, we found decisions to conceive were influenced by women and partners; knowledge and use of safer conception practices were low. Discussion and support from partners, family, and providers was limited and diminished by stigma and nondisclosure. Preconception counseling discussions in HIV care should be comprehensive and initiated frequently by all health care providers.

Brief Report: HIV Testing Among Pregnant Women Who Attend Antenatal Care in Malawi

Malawi adopted the Option B+ strategy in 2011. Its success in reducing mother-to-child transmission depends on coverage and timing of HIV testing. We assessed HIV status ascertainment and its predictors during pregnancy. HIV status ascertainment was 82.3% (95% confidence interval: 80.2 to 85.9) in the pre-Option B+ period and 85.7% (95% confidence interval: 83.4 to 88.0) in the Option B+ period. Higher HIV ascertainment was independently associated with higher age, attending antenatal care more than once, and registration in 2010. The observed high variability of HIV ascertainment between sites (50.6%-97.7%) and over time suggests that HIV test kit shortages and insufficient numbers of staff posed major barriers to reducing mother-to-child transmission.

Women's willingness to be tested for human immunodeficiency virus during pregnancy: A review

Mother-to-child-transmission of human immunodeficiency virus (HIV) is a primary cause of pediatric infections with HIV. Many of these infections involve women who were not tested early enough in pregnancy, or who did not receive prevention services. HIV testing of pregnant women is considered to be one of the key strategies for preventing mother-to-child-transmission of HIV, but HIV testing rates among pregnant women in various countries remain suboptimal. Understanding the factors relating to women's willingness to be tested for HIV during pregnancy is critical for developing strategies to increase HIV testing rates among pregnant women. Extensive research points to various factors relating to women's willingness to be tested for HIV during pregnancy, and various recommendations aimed at improving testing rates among pregnant women have been suggested based on the research. In light of the goals set by the United Nations to reduce the rate of infants infected with HIV, it is necessary to summarize what is currently known regarding factors related to women's willingness to be tested for HIV during pregnancy. The purpose of this review is therefore to examine factors related to women's willingness to be tested for HIV during pregnancy, and to summarize recommendations for practice and further research.

Improving PMTCT uptake in rural South Africa

INTRODUCTION

Despite the widespread availability of prevention of mother-to-child transmission (PMTCT) programs, many women in sub-Saharan Africa do not participate in PMTCT. This pilot study aimed to utilize partner participation in an intervention to support PMTCT uptake.

METHODS

Couples (n ¼ 239) were randomized to receive either a comprehensive couples-based PMTCT intervention or the standard of care.

RESULTS

Compared to the standard of care, participants receiving the intervention increased HIV- and PMTCT-related knowledge (F1,474 ¼ 13.94, p ¼ .004) and uptake of PMTCT, as defined by infant medication dosing (74% vs. 46%, w2 ¼ 4.69, p ¼ .03).

DISCUSSION

Results indicate that increasing male attendance at antenatal clinic visits maybe "necessary but not sufficient" to increase PMTCT uptake. Increasing HIV knowledge of both partners and encouraging active male participation in the PMTCT process through psychoeducational interventions may be a strategy to increase the uptake of PMTCT in South Africa.

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

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

Intersecting epidemics among pregnant women: alcohol use, interpersonal violence, and HIV infection in South Africa

A critical factor for understanding negative health outcomes is acknowledging the synergistic quality that clusters of health problems create. An important step in addressing clusters of health problems involves gaining an awareness of the contextual factors that connect them. This paper considers the intersection of 3 mutually reinforcing health problems: alcohol use, interpersonal violence (IPV), and HIV infection among pregnant women residing in South Africa. We explore how SAVA (substance abuse, violence and AIDS) - a syndemics related theory - underscores the dire need to intervene in various areas of psycho-social health and general well-being. Based on World Health Organization data, we highlight the remarkably high rates of alcohol use, IPV, and HIV infection among South African women compared with women residing in other countries around the world. We conclude by highlighting the need for improved recognition of the intersection of these epidemics and for improved surveillance of the prevalence of alcohol use among pregnant women. Finally, based on the literature reviewed, we provide recommendations for future interventions.

Alcohol consumption as a barrier to prior HIV testing in a population-based study in rural Uganda

Early receipt of HIV care and ART is essential for improving treatment outcomes, but is dependent first upon HIV testing. Heavy alcohol consumption is common in sub-Saharan Africa, a barrier to ART adherence, and a potential barrier to HIV care. We conducted a population-based study of 2,516 adults in southwestern Uganda from November-December 2007, and estimated the relative risk of having never been tested for HIV using sex-stratified Poisson models. More men (63.9 %) than women (56.9 %) had never been tested. In multivariable analysis, compared to women who had not consumed alcohol for at least 5 years, women who were current heavy drinkers and women who last drank alcohol 1-5 years prior, were more likely to have never been tested. Alcohol use was not associated with prior HIV testing among men. HIV testing strategies may thus need to specifically target women who drink alcohol.

HIV-untested men who have sex with men in South Africa: the perception of not being at risk and fear of being tested

A community-based needs assessment among men who have sex with men (MSM) in South Africa found that 27 % (n = 280/1,045) of MSM had never been tested for HIV. The most frequently reported reasons for not having been tested were the perception of not being at risk (57 %) and fear of being tested (52 %). This article explores factors associated with these two reasons among the untested MSM. In multiple logistic regressions, the perception of not being at risk of HIV infection was negatively associated with being black, coloured or Indian, being sexually active, knowing people living with HIV, and a history of sexually transmitted infections (STIs) in the past 24 months (adj. OR = .24, .32, .38, and .22, respectively). Fear of being tested for HIV was positively associated with being black, coloured or Indian, preferred gender expression as feminine, being sexually active, a history of STIs, and experience of victimization on the basis of sexual orientation (adj. OR = 2.90, 4.07, 4.62, 5.05, and 2.34, respectively). Results suggest that HIV prevention programs directed at South African MSM will be more effective if testing and treatment of STIs are better integrated into HIV testing systems. Finally, social exclusion on the basis of race and sexual orientation ought to be addressed in order to reach hidden, at-risk, populations of MSM.

HIV knowledge and sexual risk behavior among pregnant couples in South Africa: the PartnerPlus project

In sub-Saharan Africa, 60 % of people living with HIV are women and most are of childbearing age. Alarmingly, seroconversion rates during pregnancy are high and increase as pregnancy progresses, highlighting the importance of increasing HIV-knowledge among pregnant women and their partners. This study compared sexual risk behavior, HIV knowledge and condom use pre- to post-partum among South African couples (n = 239 couples) randomly assigned to an intervention or an enhanced standard of care with the PMTCT protocol at rural community health antenatal clinics. Consistent condom use and HIV-related knowledge increased baseline to post-intervention and was maintained at long term follow up post-partum among participants in the intervention condition. HIV knowledge mediated the relationship between the intervention and consistent condom use. Results from this pilot study provide support for the integration of HIV risk reduction interventions for both women and men into existing PMTCT services during and following pregnancy.

Sexual risk, serostatus and intimate partner violence among couples during pregnancy in rural South Africa

The aim of this study was to describe sexual risk behavior among 239 couples during pregnancy and to examine the relationship of sexual risk behavior with HIV serostatus and intimate partner violence. One-third (31.8 %) of pregnant women and 20.9 % of male partners were HIV positive. HIV risk factors included lack of knowledge of partners' HIV serostatus, unprotected sexual intercourse and multiple sexual partners. Among men, multivariate logistic regression identified awareness of HIV negative partner status, multiple sexual partners and low levels of partner violence and among women Zulu or Swati ethnicity were associated with unprotected intercourse. HIV positive concordance was associated with protected sex and in multilevel analysis of couples HIV positive status and awareness of the partner's HIV positive status were associated with protected sex. High levels of HIV risk behaviour was found among couples during pregnancy calling for HIV risk reduction interventions.

Does perceived life stress mediate the association between HIV status and alcohol use? Evidence from adults living in Cape Town, South Africa

South Africa has the highest prevalence of HIV in the world. Because living with HIV is stressful and because alcohol consumption is often used to cope with stress, we examined whether stress mediates the association between HIV status and alcohol use among adults residing in South African townships. Field workers approached pedestrians or patrons of informal alcohol-serving venues (i.e., shebeens) and invited their participation in a survey. Of the 1717 participants (98% Black, 34% women, mean age = 31 years), 82% were HIV-negative, 9% were HIV-positive, and 9% did not know their test result. Participants living with HIV reported greater perceived life stress compared to participants whose HIV status was negative or unknown. Perceived stress was associated with an increase in the frequency of alcohol use (drinking days, intoxication, and drinking in shebeens/taverns). Subsequent analyses showed that stress mediated the association between HIV status and alcohol use. These findings indicate that greater frequency of drinking days, perceived intoxication, and drinking at shebeens was associated with elevated stress levels among participants who were HIV positive. Perceived life stress mediates the association between HIV status and alcohol use. Programs to enhance stress management among HIV-positive South Africans may help to reduce alcohol consumption, which may, in turn, lead to reduced rates of HIV transmission.

The efficacy of a brief intervention to reduce alcohol misuse in patients with HIV in South Africa: study protocol for a randomized controlled trial

Background

Alcohol abuse comes with risks for increased morbidity and mortality among patients with HIV. This study aims to determine the prevalence of alcohol use and other risk factors in a sample of primary care patients with HIV in South Africa and to assess a brief intervention to reduce the use of alcohol in this group.

Methods/Design

A single-blinded randomized controlled trial is designed to determine the efficacy of a brief intervention to reduce hazardous alcohol use in patients with HIV. The study will be carried out on out-patients with HIV in two primary healthcare HIV clinics near Pretoria, South Africa. Alcohol use will be assessed with the Alcohol Use Disorder Identification Test questionnaire. Other data that will be collected relate to health-related quality of life, depression, sexual behavior, internalized AIDS stigma, HIV-related information and adherence to antiretroviral therapy (self-reported 7-day recall of missed doses, Visual Analog Scale and pill count). The intervention consists of a brief counseling session to reduce alcohol risk; the control group receives a health education leaflet.

Discussion

The findings will be important in the public health setting. If the intervention proves to be efficient, it could potentially be incorporated into the HIV care policy of the Ministry of Health.

Trial registration

Pan African Clinical trial Registry: PACTR201202000355384

HIV disclosure, sexual negotiation and male involvement in prevention-of-mother-to-child-transmission in South Africa

HIV-seroconversion during pregnancy is a serious concern throughout South Africa, where an estimated 35 to 40% of pregnant women have HIV/AIDS and drop-out is high at all stages of the prevention-of-mother-to-child-transmission (PMTCT) process. The likelihood of PMTCT success may be linked to partner support, yet male involvement in antenatal care remains low. This qualitative study examined the influence of pregnant couples' expectations, experiences and perceptions on sexual communication and male involvement in PMTCT. A total of 119 couples participated in a comprehensive intervention in 12 antenatal clinics throughout South Africa. Data were collected between December 2010 to June 2011 and analysed using a grounded theory approach. Findings point to the importance of sexual communication as a factor influencing PMTCT male involvement. Analysis of themes lends support to improving communication between couples, encouraging dialogue among men and increasing male involvement in PMTCT to bridge the gap between knowledge and sexual behaviour change.

Barriers to HIV testing in Côte d'Ivoire: the role of individual characteristics and testing modalities

Background

Expanding HIV testing requires a better understanding of barriers to its uptake. We investigated barriers to HIV testing in Côte d'Ivoire, taking into account test circumstances (client vs. provider-initiated).

Methods

We used data from the 2005 nationally representative Demographic and Health Survey conducted in Côte d'Ivoire. Socio-demographic characteristics, sexual behaviour and knowledge and attitudes toward HIV/AIDS associated with recent (<2 years) HIV testing were identified using gender-specific univariate and multivariate logistic regressions. Among women, differential effects of barriers to testing according to test circumstance (whether they have been offered for a prenatal test or not) were assessed through interaction tests.

Results

Recent HIV testing was reported by 6.1% of men and 9.5% of women (including 4.6% as part of antenatal care). Among men, having a low socioeconomic status, having a low HIV-related knowledge level and being employed [compared to those inactive: adjusted Odds Ratio (aOR) 0.46; 95% confidence interval (CI) 0.25–0.87] were associated with lower proportions of recent HIV testing. Among women without a prenatal HIV testing offer, living outside the capital (aOR 0.38; CI 0.19–0.77) and reporting a unique lifetime sexual partner constituted additional barriers to HIV testing. By contrast, among women recently offered to be tested in prenatal care, none of these variables was found to be associated with recent HIV testing.

Conclusions

Various dimensions of individuals' characteristics constituted significant barriers to HIV testing in Côte d'Ivoire in 2005, with gender specificities. Such barriers are substantially reduced when testing was proposed in the framework of antenatal care. This suggests that provider-initiated testing strategies may help overcome individual barriers to HIV testing.

Investigation into the use of short message services to expand uptake of human immunodeficiency virus testing, and whether content and dosage have impact

OBJECTIVE

South Africa has one of the highest human immunodeficiency virus (HIV) prevalence rates in the world, but despite the well-established benefits of HIV counseling and testing (HCT), there is low uptake of HCT. The study aimed to investigate the effectiveness of using short message services (SMSs) to encourage HCT while interrogating the impact of altering SMS content and dosage (the number of SMSs).

MATERIALS AND METHODS

About 2,533 participants were recruited via an SMS sent to 24,000 mobiles randomly sampled from a pre-existing database. Recruits were randomly allocated to four intervention groups that received 3 or 10 informational (INFO) or motivational (MOTI) SMSs, and a control group. After the intervention, participants were prompted to go for HCT, and postintervention assessment was done after 3 weeks.

RESULTS

In comparison with the control, receipt of 10 MOTI messages had the most impact on uptake of HCT with a 1.7-fold increased odds of testing (confidence interval 95%; p=0.0036). The lack of efficacy of three SMSs indicates a threshold effect, that is, a minimum number of MOTI SMSs is required. INFO SMSs, whether 3 or 10 were sent, did not have a statistically significant effect. The cost can be calculated for the marginal effect of the SMSs, that is, the cost to get people to test over and above those who were likely to test without the intervention. Use of 10 MOTI SMSs yielded a cost-per-tester of $2.41.

CONCLUSIONS

While there are methodological issues apparent in our study, the results demonstrate the potential of SMSs to influence the uptake of HCT, the importance of appropriate content, and the need to determine a threshold for SMS-based interventions. These results indicate a potential for SMSs to be used more generally for interventions encouraging people to take health-related actions, and the need for further research in this field. The reasonable cost-per-tester is promising for the scale-up of such an intervention.

Adding fuel to the fire: alcohol's effect on the HIV epidemic in Sub-Saharan Africa

Alcohol consumption adds fuel to the HIV epidemic in sub-Saharan Africa (SSA). SSA has the highest prevalence of HIV infection and heavy episodic drinking in the world. Alcohol consumption is associated with behaviors such as unprotected sex and poor medication adherence, and biological factors such as increased susceptibility to infection, comorbid conditions, and infectiousness, which may synergistically increase HIV acquisition and onward transmission. Few interventions to decrease alcohol consumption and alcohol-related sexual risk behaviors have been developed or implemented in SSA, and few HIV or health policies or services in SSA address alcohol consumption. Structural interventions, such as regulating the availability, price, and advertising of alcohol, are challenging to implement due to the preponderance of homemade alcohol and beverage industry resistance. This article reviews the current knowledge on how alcohol impacts the HIV epidemic in SSA, summarizes current interventions and policies, and identifies areas for increased research and development.

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

PACTR201109000318329.