Compliance with antiretroviral regimens to prevent perinatal HIV-1 transmission in Kenya

Adverse Impact of Intimate Partner Violence Against HIV-Positive Women During Pregnancy and Post-Partum: Results From a Meta-Analysis of Observational Studies

Objectives: Intimate partner violence (IPV) against pregnant or human immunodeficiency virus (HIV)-positive women have been previously studied. However, data on the impact of IPV on HIV-positive pregnant women have not been systematically synthesized. We performed a meta-analysis to explore this issue and provide evidence regarding IPV prevention and HIV infection control. Method: The PubMed, Web of Science, Cochrane Library, and Embase databases were systematically searched. Studies that quantitatively assessed the association between IPV and its adverse impact on HIV-positive women during pregnancy and post-partum were eligible for inclusion. Pooled odds ratios (ORs) were calculated. Findings: Eight studies were identified to meet our eligibility criteria. The adverse impacts of IPV against HIV-positive pregnant women mainly included nonadherence to maternal antiretroviral treatment during pregnancy, nondisclosure of HIV-positive status to male partners, nonadherence to infant antiretroviral prophylaxis, and antenatal depression. IPV caused a 180% and 145% increase in the odds of antenatal depression and nonadherence to infant antiretroviral prophylaxis, respectively, among HIV-positive women, compared to the odds of their IPV-free counterparts [OR = 2.80, 95% confidence interval (CI): 1.66-4.74; OR = 2.45, 95% CI: 1.40-4.27]. Conclusion: Limited evidence has suggested that IPV against HIV-positive pregnant women caused maternal depression during pregnancy and led to the possible failure of HIV prophylaxis adherence in infants. Interventions to address IPV may ultimately reduce the risk of depression-related adverse birth outcomes and vertical transmission in infants exposed to maternal HIV. Prevention and control against IPV should be developed for HIV-positive pregnant women.

Accelerating caregivers' HIV status disclosure to community-based lay social welfare volunteers in Tanzania

Background

HIV status disclosure facilitates access to HIV-related prevention and treatment services and increases opportunities for social support, HIV risk reduction with partners, and index testing for sexual partners or children. This study assessed the effect of a program model of community-based social welfare volunteers on HIV status disclosure among caregivers of orphans and vulnerable children (OVC).

Methods

This was a longitudinal study, which was based on OVC caregivers who were beneficiaries of the USAID Kizazi Kipya project in Tanzania. They were enrolled (baseline) by community social welfare volunteers during 2017–2018, received services, and reassessed at midline in 2019. Caregivers who reported having been HIV tested, were asked to voluntarily report the status in order for the volunteers to establish and provide needed services. Those who reported their HIV status as negative or positive were grouped as “disclosed”, and those who knew their status but did not report it were documented as “undisclosed”. McNemar’s tests compared disclosure rates at baseline and midline. Multivariable analysis was conducted using generalized estimating equation (GEE).

Results

The study analyzed 140,664 caregivers (72% female) from 81 district councils of Tanzania. Their mean age at enrollment was 47.4 years. Overall, 81.3% of the caregivers disclosed their HIV status to the project staff at baseline; this increased significantly to 96.1% at midline (p < 0.001). Disclosure at baseline varied significantly by sociodemographic characteristic (p < 0.05), with higher disclosure in females, among urban residents, and higher educated caregivers. However, the observed disclosure variations by sociodemographic characteristics at baseline disappeared at midline and disclosure reached around 96% across the characteristics (p > 0.05). In the multivariable analysis, caregivers’ likelihood of HIV status disclosure was nearly 6 times higher at midline than at baseline, when baseline characteristics were adjusted for (OR = 5.76, 95% CI 5.59–5.94, p < 0.001). There were 26,329 caregivers who did not disclose their HIV status at baseline (i.e., 0% diclosure rate at baseline), but 94.7% (n = 24,933) had disclosed by midline, and their disclosure trend was rapidly increasing as their duration of exposure to the project increased.

Conclusions

This study detected an increased caregivers’ HIV status disclosure to the USAID Kizazi Kipya project staff by 14.8%, from 81.3% at baseline to 96.1% at midline within an average project exposure period of 1.4 years. The observed loss of sociodemographic differences in HIV status disclosure rate at midline implies that community-based interventions may be well-positioned to successfully address and eliminate sociodemographic barriers to service uptake and consequently improve services coverage and health outcomes.

A qualitative study of the barriers and enhancers to retention in care for pregnant and postpartum women living with HIV

Retention in care is a major challenge for pregnant and postpartum women living with HIV (PPHIV) in the prevention of mother-to-child HIV transmission (PMTCT) continuum. However, the factors influencing retention from the perspectives of women who have become lost to follow-up (LTFU) are not well described. We explored these factors within an enhanced sub-cohort of the East Africa International Epidemiology Databases to Evaluate AIDS Consortium. From 2018-2019, a purposeful sample of PPHIV ≥18 years of age were recruited from five maternal and child health clinics providing integrated PMTCT services in Kenya. Women retained in care were recruited at the facility; women who had become LTFU (last visit >90 days) were recruited through community tracking. Interview transcripts were analyzed thematically using a social-ecological framework. Forty-one PPHIV were interviewed. The median age was 27 years, 71% were pregnant, and 39% had become LTFU. In the individual domain, prior PMTCT experience and desires to safeguard infants' health enhanced retention but were offset by perceived lack of value in PMTCT services following infants' immunizations. In the peer/family domain, male-partner financial and motivational support enhanced retention. In the community/society domain, some women perceived social pressure to attend clinic while others perceived pressure to utilize traditional birth attendants. In the healthcare environment, long queues and negative provider attitudes were prominent barriers. HIV-related stigma and fear of disclosure crossed multiple domains, particularly for LTFU women, and were driven by perceptions of HIV as a fatal disease and fear of partner abandonment and abuse. Both retained and LTFU women perceived that integrated HIV services increased the risk of disclosure. Retention was influenced by multiple factors for PPHIV. Stigma and fear of disclosure were prominent barriers for LTFU women. Multicomponent interventions and refining the structure and efficiency of PMTCT services may enhance retention for PPHIV.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania

Background

HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania.

Methods

Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January–March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers’ HIV status disclosure being the outcome variable was conducted.

Results

The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16–1.28); unmarried (OR = 1.12, 95% CI 1.03–1.23); widowed (OR = 1.12, 95% CI 1.07–1.18); those without health insurance (OR = 1.36, 95% CI 1.28–1.45); age 61 + years (OR = 1.72, 95% CI 1.59–1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04–1.25); and rural residents (OR = 1.58, 95% CI 1.34–1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001).

Conclusion

While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population.

Development of a Novel Scale to Measure Male Partner Involvement in the Prevention of Mother-to-Child Transmission of HIV in Kenya

Male partner involvement is an important factor in prevention of mother-to-child transmission (PMTCT). Yet, poor conceptualization has hindered optimal assessment of male involvement. We created and evaluated a brief 10-item male partner involvement scale using principal components analysis and scree plots, Cronbach's alpha, and linear regression with survey data from postpartum women with HIV (n = 200) in Kenya. The scale had a two-factor structure: male encouragement/reminders and active participation. The overall scale and the encouragement/reminders sub-scale displayed strong internal reliability. In the multivariable models, the scales were positively associated with constructive relationship dynamics, HIV status disclosure, and couple HIV testing and counseling, and negatively associated with internalized HIV stigma. The encouragements/reminders sub-scale was also negatively associated with a new HIV diagnosis during pregnancy. This work furthers the conceptualization of male partner involvement in PMTCT and provides a valid measure to assess male involvement as a pathway to better PMTCT outcomes.

Factors associated with HIV status disclosure to partners and its outcomes among HIV-positive women attending Care and Treatment Clinics at Kilimanjaro region, Tanzania

BACKGROUND

Sub Saharan Africa continues to be the epicenter of HIV with 70% of people living with HIV globally. Women form nearly 60% of those living with HIV. Studies have shown disclosure of one's HIV status is important in HIV prevention, in increasing partners who are tested and getting into care early as well as in improving retention in PMTCT and ART programs. This study aimed to determine the prevalence, factors and outcomes of HIV status disclosure to partners among HIV-positive women attending HIV care-and-treatment clinics (CTCs) at Kilimanjaro region, northern Tanzania.

METHODS

A cross-sectional study was conducted from January to June 2014 in 3 out of the 7 districts of Kilimanjaro region. The study population was HIV-positive women aged 15-49, who were attending for routine HIV care at 19 selected clinics. Face-to-face interviews were conducted with consenting women to collect necessary information. Multivariate logistic regression analyses were used to determine the independent predictors of HIV status disclosure to partner.

RESULTS

A total of 672 HIV-positive women in Moshi municipal, Hai and Mwanga districts were enrolled. Of them, 609 HIV-positive women reported to have a regular partner. Prevalence of serostatus disclosure to partners was 66%. Of the 400 who had disclosed; 56% did so within the first month of knowing their HIV status. In a multiple logistic regression model, HIV serostatus disclosure was higher among women who: were married/cohabiting (AOR = 4.16, 95% CI: 2.39-7.25; p<0.001), currently on ART (AOR = 2.06, 95% CI: 1.11-3.82; p = 0.020), and who reported had ever communicated with partners on number of children (AOR = 1.85, 95% CI: 1.15-2.98; p = 0.010) and contraceptives use (AOR = 2.01, 95% CI: 1.27-3.20; p = 0.208). Most of the women (81%) who disclosed their HIV status to did not reported negative outcomes.

CONCLUSION

In this setting still a third of the HIV-positive women (34%) fail to disclose their HIV- serostatus to partners. Interventions to impart skills in communication and negotiation between partners may help in improving disclosure of HIV. Efforts to involve men in general sexual and reproductive health including couple counseling and testing will contribute in improving disclosure and communication on HIV among 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.

You Will Know That Despite Being HIV Positive You Are Not Alone: Qualitative Study to Inform Content of a Text Messaging Intervention to Improve Prevention of Mother-to-Child HIV Transmission

Background

Prevention of mother-to-child HIV transmission (PMTCT) relies on long-term adherence to antiretroviral therapy (ART). Mobile health approaches, such as text messaging (short message service, SMS), may improve adherence in some clinical contexts, but it is unclear what SMS content is desired to improve PMTCT-ART adherence.

Objective

We aimed to explore the SMS content preferences related to engagement in PMTCT care among women, male partners, and health care workers. The message content was used to inform an ongoing randomized trial to enhance the PMTCT-ART adherence.

Methods

We conducted 10 focus group discussions with 87 HIV-infected pregnant or postpartum women and semistructured individual interviews with 15 male partners of HIV-infected women and 30 health care workers from HIV and maternal child health clinics in Kenya. All interviews were recorded, translated, and transcribed. We analyzed transcripts using deductive and inductive approaches to characterize women’s, partners’, and health care workers’ perceptions of text message content.

Results

All women and male partners, and most health care workers viewed text messages as a useful strategy to improve engagement in PMTCT care. Women desired messages spanning 3 distinct content domains: (1) educational messages on PMTCT and maternal child health, (2) reminder messages regarding clinic visits and adherence, and (3) encouraging messages that provide emotional support. While all groups valued reminder and educational messages, women highlighted emotional support more than the other groups (partners or health care workers). In addition, women felt that encouraging messages would assist with acceptance of their HIV status, support disclosure, improve patient-provider relationship, and provide support for HIV-related challenges. All 3 groups valued not only messages to support PMTCT or HIV care but also messages that addressed general maternal child health topics, stressing that both HIV- and maternal child health–related messages should be part of an SMS system for PMTCT.

Conclusions

Women, male partners, and health care workers endorsed SMS text messaging as a strategy to improve PMTCT and maternal child health outcomes. Our results highlight the specific ways in which text messaging can encourage and support HIV-infected women in PMTCT to remain in care, adhere to treatment, and care for themselves and their children.

Trial Registration

ClinicalTrials.gov NCT02400671; https://clinicaltrials.gov/ct2/show/NCT02400671 (Archived by WebCite at http://www.webcitation.org/70W7SVIVJ)

Medication adherence in pregnant women with human immunodeficiency virus receiving antiretroviral therapy in sub-Saharan Africa: a systematic review

BACKGROUND

The use of antiretroviral therapy (ART) is a core strategy proposed by the World Health Organization in preventing mother to child transmission (MTCT) of HIV. This systematic review aimed to examine the enablers and barriers of medication adherence among HIV positive pregnant women in sub-Saharan Africa.

METHODS

We used the following keywords: HIV AND (Pregnancy OR Pregnant*) AND (PMTCT OR "PMTCT Cascade" OR "Vertical Transmission" OR "Mother-to-Child") AND (Prevent OR Prevention) AND (HAART OR "Antiretroviral Therapy" OR "Triple Therapy") AND (Retention OR Concordance OR Adherence OR Compliance) to conduct electronic searches in the following databases: MEDLINE Complete (1916-Dec 2017), Embase (1947-Dec 2017), Global Health (1910-Dec 2017) and CINAHL Complete (1937-Dec 2017). Of the four databases searched, 401 studies were identified with 44 meeting the inclusion criteria. Seven studies were added after searching reference lists of included articles, resulting in 51 articles in total.

RESULTS

The review demonstrated that stigma, cost of transportation, food deprivation and a woman's disclosure or non-disclosure of her HIV status to a partner, family and the community, could limit or define the extent of her adherence to prescribed antiretroviral drugs during pregnancy. Furthermore, the review indicated that knowledge of HIV status, either before or during pregnancy, was significantly associated with medication adherence. Women who knew their HIV status before pregnancy demonstrated good adherence while women who found out their HIV infection status during pregnancy were linked with non-adherence to ART.

CONCLUSION

This review revealed several barriers and enablers of adherence among pregnant women taking ART in sub-Saharan Africa. Major barriers included the fear of HIV infection status disclosure to partners and family members, stigma and discrimination. A major enabler of adherence in women taking ART was women's knowledge of their HIV status prior to becoming pregnant. Enhanced effort is needed to facilitate women's knowledge of their HIV status before pregnancy to enable disease acceptance and management, and to support pregnant women and her partner and family in dealing with fear, stigma and discrimination about HIV.

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.

Factors Affecting Exclusive Breastfeeding among Women in Muheza District Tanga Northeastern Tanzania: A Mixed Method Community Based Study

Objectives

Estimates shows exclusive breastfeeding (EBF) has the potential to prevent 11.6 % of all under-five deaths in developing countries. Prevalence of EBF is low globally (35 %), and in sub Saharan Africa ranges between 22 and 33 %. Like other developing countries the prevalence of EBF is 50 % in Tanzania. There is limited information in Tanzania on factors influencing EBF apart from information specific for HIV positive women. This study aimed at examining factors that affect EBF practice among women in Muheza district, Tanga region, northeastern Tanzania.

Methods

A community based cross-sectional study using both qualitative and quantitative methods was conducted from April to June 2014. To collect relevant information, a total of 316 women with infants aged 6–12 months were interviewed using a questionnaire and 12 key informants using in-depth interview guide. Qualitative data was analyzed using thematic analysis while bivariate and multivariate logistic regression analysis were used assess association between EBF and predictor variables.

Results

The prevalence of EBF was 24.1 %. The perception that mothers’ breast milk is insufficient for child’s growth, child being thirsty and the need to introduce herbal medicine for cultural purposes were among the important factors for early mixed feeding. In multivariate analysis advanced maternal age (OR 2.6; 95 % CI 1.18–5.59) and knowledge on EBF duration and advantages (OR 2.2; 95 % CI 1.2–3.8) remained significantly associated with EBF practice.

Conclusions

The prevalence of EBF in our study is low compared with the national prevalence. Strategies to target beliefs that breast milk is insufficient for growth need to be strengthened in the community. Furthermore opportunity to increase EBF training during ante and postnatal visits for women should be enhanced as more than 90 % of women in the district use skilled attendants during pregnancy and delivery.

Prescription medicine sharing: exploring patients' beliefs and experiences

Background

Prescription medicine sharing has been defined as the lending of medicines (giving prescription medicines to someone else) or borrowing of medicines (being given and using a medicine prescribed for another person). This qualitative study explored the views of patients, to elicit information regarding factors influencing medicine sharing behaviours, their experiences of the consequences of prescription medicine sharing, and their risk assessment strategies when deciding to share.

Methods

One-on-one, face-to-face, semi-structured interviews were carried out in Auckland, New Zealand between September 2013 and August 2014 with 17 patients, purposively sampled to provide information from different socio-demographic backgrounds. The interviews were audio recorded, transcribed verbatim and analysed using a general inductive approach. The study received ethical approval, and all interviewees provided written informed consent.

Results

Findings were captured within five overarching themes: types of shared medicines; perceived benefits of sharing medicines; negative experiences of sharing; factors influencing sharing behaviours; and risk assessment strategies. Participants reported that sharing helped them to avoid treatment costs and the inconvenience associated with medical visits such as booking appointments. Conversely, unanticipated side effects, allergies, and taking inappropriate medicines were the main adverse consequences of sharing. Altruism, limited access to medicines/health services, sociocultural factors, and having unused prescription medicines were factors influencing sharing behaviours. Participants reported assessing the safety of sharing a medicine primarily based on symptom matching, past illness experiences, and knowledge about the medicines.

Conclusions

This study enriches previous survey findings, by providing insight into patients' reasons for medicines sharing. Healthcare providers should consider asking their patients about any medicines they have shared and their future sharing intentions, in order to use the opportunity for discussing safer sharing practices, without promoting the behaviour. The findings are helpful for informing the development of potential interventions and targeted educational messages about safe medicine use for patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s40545-016-0075-5) contains supplementary material, which is available to authorized users.

Male involvement in PMTCT and associated factors among men whom their wives had ANC visit 12 months prior to the study in Gondar town, North west Ethiopia, December, 2014

INTRODUCTION

Globally, male involvement has been recognized as a priority focus area to be strengthened in PMTCT but, testing male partners for HIV in the context of preventing mother-to-child transmission remains a challenge in most low- and middle-income countries including Ethiopia. In Ethiopia even though male involvement is one of the guiding principle in testing and counseling of HIV, the magnitude of male involvement in PMTCT is not well known. The objective was to assess the magnitude of male involvement in PMTCT and associated factors among men whom their wives have ANC visit 12 months prior to the study in Gondar town, North west Ethiopia.

METHODS

A community-based cross-sectional survey was conducted from December 1- 20, 2014 among men whose wives had ANC follow up in the last 12 months prior to study period in Gondar town. Cluster sampling was used to get the total of 802 participants.

RESULTS

From all participants, only 20.9% of men had high involvement index in prevention of mother to child transmission of HIV/AIDS. Men with secondary and post secondary education (AOR=3.59, 95%CI: 1.36, 9.44), government employment by occupation (AOR=2.23, 95%CI: 1.53, 4.02) men who were married and in union (AOR=4.37, 95%CI: 1.85, 10.32), and men who have heard about PMTCT (AOR=1.74, 95%CI=1.21, 2.49) were more likely to have high involvement index in PMTCT.

CONCLUSION

Male involvement in PMTCT programme was low in the study area. Having information about PMTCT, attending Secondary and post secondary education, being government employer and living in union with partner were factors significantly associated with male involvement in PMTCT. Improving male involvement by creating husband's awareness regarding benefit of PMTCT through provision of balanced information for all male partners is recommended.

Impact of Male Partner Antenatal Accompaniment on Perinatal Health Outcomes in Developing Countries: A Systematic Literature Review

Encouraging male partners to accompany women to antenatal care (ANC) is an important first step in engaging men on maternal and newborn health. However, little is known regarding the impact of male partner antenatal accompaniment beyond HIV-related perinatal outcomes. A systematic review was conducted to synthesize the evidence on the influence of male accompaniment on non-HIV outcomes during pregnancy and into the postpartum period. Eligible studies were published in English from 2003 to 2013 and evaluated the effect of male antenatal accompaniment on perinatal health in a developing country. Four electronic databases and selected reference lists were searched. Out of 84 potential citations retrieved, seven publications were retained for the assessment of male antenatal accompaniment's influence using iterative thematic analysis. During pregnancy, male antenatal accompaniment positively impacted women's knowledge of danger signs, but did not affect birth preparedness, ANC utilization, or miscarriages. During labor and delivery, men's ANC presence was associated with increases in institutional delivery and skilled birth attendance, but with no effect for birth-related outcomes. During the early postnatal period, male antenatal accompaniment was associated with higher uptake of postnatal services, but with mixed effects on breastfeeding and newborn survival. Couples' increased communication on pregnancy care and men's subsequent motivation to ensure safe delivery may explain these observed benefits. Inadequate communication, late accompaniment, or partner type may explain the lack of influence on some outcomes. More efforts are needed to expand the implementation and evaluation of male involvement strategies to improve perinatal health.

Are couple-based interventions more effective than interventions delivered to individuals in promoting HIV protective behaviors? A meta-analysis

Despite several advantages to bringing couples together to learn how to protect themselves and new-born children from the risk of HIV infection, most interventions are designed for individuals or groups, not for dyads. This meta-analysis provides a direct test of whether couple-based interventions are more effective in promoting HIV protective behaviors than interventions delivered to individuals. We conducted systematic searches of five electronic databases and 60 journals. Eligible studies were controlled trials or prospective cohort designs; evaluated a couple-based intervention compared to an individual-level intervention; assessed at least one HIV prevention outcome (e.g., protective sex, drug use, HIV testing, medication adherence, and sexually transmitted infections [STI]); and were published between 1988 and 2014. Fifteen interventions, including 21,882 participants from China, Kenya, Rwanda, Tanzania, Trinidad, Zambia, and the USA, were evaluated. The results of random-effects models showed statistically significant intervention effects for protective sex (OR = 1.60, 95% CI = 1.21, 2.11), HIV testing (OR = 1.79, 95% CI = 1.31, 2.45), and Nevirapine uptake (OR = 1.51, 95% CI = 1.02, 2.24). The evidence demonstrates the usefulness of couple-based interventions in protecting individuals, partners, and new-born children from the risk of HIV transmission and infection.

A community-based assessment of correlates of facility delivery among HIV-infected women in western Kenya

BACKGROUND

Childbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region.

METHODS

Women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery.

RESULTS

Overall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier (4.9 vs. 5.4 months, p = 0.016), were more likely to know partner's HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals (87.1% vs. 77.4%, p = 0.063) compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women.

CONCLUSIONS

Utilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling.

HIV-positive status disclosure and use of essential PMTCT and maternal health services in rural Kenya

Supplemental Digital Content is Available in the Text.

Background:

In sub-Saharan Africa, women's disclosure of HIV-positive status to others may affect their use of services for prevention of mother-to-child transmission of HIV (PMTCT) of HIV and maternal and child health—including antenatal care, antiretroviral drugs (ARVs) for PMTCT, and skilled birth attendance.

Methods:

Using data from the Migori and AIDS Stigma Study conducted in rural Nyanza Province, Kenya, we compared the use of PMTCT and maternal health services for all women by HIV status and disclosure category (n = 390). Among HIV-infected women (n = 145), associations between disclosure of HIV-positive status and the use of services were further examined with bivariate and multivariate logistic regression analyses.

Results:

Women living with HIV who had not disclosed to anyone had the lowest levels of maternity and PMTCT service utilization. For example, only 21% of these women gave birth in a health facility, compared with 35% of HIV-negative women and 49% of HIV-positive women who had disclosed (P < 0.001). Among HIV-positive women, the effect of disclosure to anyone on ARV drug use [odds ratio (OR) = 5.8; 95% confidence interval (CI): 1.9 to 17.8] and facility birth (OR = 2.9; 95% CI: 1.4 to 5.7) remained large and significant after adjusting for confounders. Disclosure to a male partner had a particularly strong effect on the use of ARVs for PMTCT (OR = 7.9; 95% CI: 3.7 to 17.1).

Conclusions:

HIV-positive status disclosure seems to be a complex yet critical factor for the use of PMTCT and maternal health services in this setting. The design of interventions to promote such disclosure must recognize the impact of HIV-related stigma on disclosure decisions and protect women's rights, autonomy, and safety.

Messages on pregnancy and family planning that providers give women living with HIV in the context of a Positive Health, Dignity, and Prevention intervention in Mozambique

Background

Family planning is an important HIV prevention tool for women living with HIV (WLHIV). In Mozambique, the prevalence of HIV among women of reproductive age is 13.1% and the average fertility rate is high. However, family planning and reproductive health for WLHIV are under-addressed in Mozambique. This study explores provider descriptions of reproductive health messages in order to identify possible barriers and facilitators to successfully addressing family planning and pregnancy concerns of WLHIV.

Methods

In 2006, a Positive Health, Dignity, and Prevention program was introduced in Mozambique focused on training health care providers to work with patients to reduce their transmission risks. Providers received training on multiple components, including family planning and prevention of mother-to-child transmission (PMTCT). In-depth interviews were conducted with 31 providers who participated in the training in five rural clinics in three provinces. Data were analyzed using qualitative content analysis.

Results

Analysis showed that providers’ clinical messages on family planning, pregnancy, and PMTCT for WLHIV could be arranged along a continuum. Provider statements ranged from saying that WLHIV should not become pregnant and condoms are the only valid form of family planning for WLHIV, to suggesting that WLHIV can have safe pregnancies.

Conclusion

These data indicate that many providers continue to believe that WLHIV should not have children and this represents a challenge for integrating family planning into the care of WLHIV. Also, not offering WLHIV a full selection of family planning methods severely limits their ability to protect themselves from unintended pregnancies and to fully exercise their reproductive rights. Responding to the reproductive health needs of WLHIV is a critical component in HIV prevention and could increase the success of PMTCT programs.

Adherence to extended postpartum antiretrovirals is associated with decreased breast milk HIV-1 transmission

OBJECTIVE

Estimate association between postpartum antiretroviral adherence and breast milk HIV-1 transmission.

DESIGN

Prospective cohort study.

METHODS

Mother-infant pairs were randomized after delivery to immediately begin receiving 28 weeks of either triple maternal antiretrovirals (zidovudine, lamivudine, and either nevirapine, nelfinavir, or lopinavir-ritonavir) or daily infant nevirapine as part of the Breastfeeding, Antiretrovirals, and Nutrition (BAN) study. Associations between postpartum antiretroviral adherence and rate of breast milk HIV-1 transmission were estimated using Cox models. We measured adherence over four postpartum time intervals using pill count, suspension bottle weight, and maternal self-report. Adherence was categorized and lagged by one interval. Missing adherence measures were multiply imputed. Infant HIV-1 infection was determined by DNA PCR every 2-6 weeks. The primary endpoint was infant HIV-1 infection by 38 weeks of age among infants alive and uninfected at 5 weeks.

RESULTS

Analyses included 1479 mother-infant pairs and 45 transmission events. Using pill count and bottle weight information, 22-40% of mother-infant pairs at any given interval were less than 90% adherent. Having at least 90% adherence was associated with a 52% [95% confidence interval (CI) 3-76] relative reduction in the rate of breast milk HIV-1 transmission, compared with having less than 90% adherence when controlling for study arm, breastfeeding status, and maternal characteristics. Complete case analysis rendered similar results (n = 501; relative reduction 59%, 95% CI 6-82).

CONCLUSION

Nonadherence to extended postpartum antiretroviral regimens in 'real world' settings is likely to be higher than that seen in BAN. Identifying mothers with difficulty adhering to antiretrovirals, and developing effective adherence interventions, will help maximize benefits of antiretroviral provision throughout breastfeeding.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Efficacy of single dose Nevirapine in reducing viral load in HIV positive mother in labour and transmission of HIV infection to new born babies as part of prevention of parent to child transmission

BACKGROUND

Prevention of parent to child transmission (PPTCT) program was initiated in Armed Forces to reduce the vertical transmission of HIV by instituting single dose Nevirapine (sdNVP) in untreated HIV positive mothers in labour. The aim of this study was to evaluate the role of sdNVP to decrease viral load of HIV infected mother during labour and its efficacy in prevention of mother to child transmission of HIV.

METHODS

Thirty antenatal women tested positive for HIV at our PPTCT centre and delivered between Jan 2006 and May 2008 were evaluated. During labour these women were given sdNVP. Newborns were given syrup Nevirapine. The babies were tested for HIV infection at 48 h and six weeks after delivery.

RESULTS

Thirty HIV positive women delivered at our centre and four newborns were found positive for HIV infection at 48 h. After six weeks interval three neonates were detected for HIV infection as one infant at six weeks was found to be negative for HIV infection.

CONCLUSION

The protection rate of Nevirapine in untreated HIV positive women is not ideal. It is recommended that all HIV positive women should be offered Highly Active Antiretroviral therapy as primary mode for PPTCT.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Health Outcomes of Infants in a PMTCT Program in Kinshasa

Effective follow-up of mother-infant pairs is critical for ensuring the success of preventing mother-to-child transmission (PMTCT) programs. The objective of this study was to identify factors associated with health outcomes of exposed infants in a PMTCT program in the Democratic Republic of Congo (DRC). Data were collected from January 2005 through December 2008 in 2 maternities in Kinshasa, DRC. The exposed infant's health status was used as outcome. Multiple logistic regressions were used to identify the determinants of infant outcomes. A total of 309 mother-infant pairs were included in this study. Younger maternal age, breast-feeding but weaning before the age of 6 months, and HIV testing of the child and a mother who is not sick were associated with better infant health outcome. The follow-up of mother-infant pairs in PMTCT programs remains critical and challenging. There is a need for innovative and efficient strategies to improve retention of mother-infant pairs in PMTCT programs.

Client perspectives on design and implementation of a couples-based intervention to reduce sexual and drug risk behaviors among female sex workers and their noncommercial partners in Tijuana and Ciudad Juárez, México

This mixed-methods study examined the acceptability of a hypothetical couples-based HIV prevention program for female sex workers and their intimate (non-commercial) male partners in Mexico. Among 320 participants, 67 % preferred couples-based over individual programs, particularly among men. Reasons cited for preferring couples-based programs included convenience and health benefits for both partners. Participants reported that they would benefit from general health information and services, HIV counseling and testing, job training (particularly for men) and other services. However, qualitative interviews revealed that barriers relating to the environment (i.e., poor access to services), providers (i.e., lack of a therapeutic alliance), and intimate relationships (i.e., mistrust or instability) would need to be addressed before such a program could be successfully implemented. Despite women's concerns about privacy and men's preferences for gender-specific services, couples-based HIV prevention programs were largely acceptable to female sex workers and their intimate male partners.

High rates of relationship dissolution among heterosexual HIV-serodiscordant couples in Kenya

HIV-1 serodiscordant couples may experience increased risks of relationship dissolution; however, longitudinal stability of these relationships is poorly understood. We determined rates and correlates of separation among 469 serodiscordant couples in Nairobi and found that 113 (24 %) separated during 2 years of follow-up. Couples with a female HIV-1 infected partner (F+M-) and no income were more likely to separate than M+F- couples without income (HR = 5.0; 95 % CI 1.1-25.0), and F+M- and M+F- couples with income (HR = 2.4; 95 % CI 1.3-4.5 and HR = 2.3; 95 % CI 1.2-4.8, respectively). High separation rates may be important for couple support services and for conducting discordant couple studies.

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

Background

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

Objective

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

Study design

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

Results

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

Conclusions

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

Facilitating HIV status disclosure for pregnant women and partners in rural Kenya: a qualitative study

Background

Women’s ability to safely disclose their HIV-positive status to male partners is essential for uptake and continued use of prevention of mother-to-child transmission (PMTCT) services. However, little is known about the acceptability of potential approaches for facilitating partner disclosure. To lay the groundwork for developing an intervention, we conducted formative qualitative research to elicit feedback on three approaches for safe HIV disclosure for pregnant women and male partners in rural Kenya.

Methods

This qualitative acceptability research included in-depth interviews with HIV-infected pregnant women (n = 20) and male partners of HIV-infected women (n = 20) as well as two focus groups with service providers (n = 16). The participants were recruited at health care facilities in two communities in rural Nyanza Province, Kenya, during the period June to November 2011. Data were managed in NVivo 9 and analyzed using a framework approach, drawing on grounded theory.

Results

We found that facilitating HIV disclosure is acceptable in this context, but that individual participants have varying expectations depending on their personal situation. Many participants displayed a strong preference for couples HIV counseling and testing (CHCT) with mutual disclosure facilitated by a trained health worker. Home-based approaches and programs in which pregnant women are asked to bring their partners to the healthcare facility were equally favored. Participants felt that home-based CHCT would be acceptable for this rural setting, but special attention must be paid to how this service is introduced in the community, training of the health workers who will conduct the home visits, and confidentiality.

Conclusion

Pregnant couples should be given different options for assistance with HIV disclosure. Home-based CHCT could serve as an acceptable method to assist women and men with safe disclosure of HIV status. These findings can inform the design and implementation of programs geared at promoting HIV disclosure among pregnant women and partners, especially in the home-setting.

Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review

Objectives

To investigate and synthesize reasons for low access, initiation and adherence to antiretroviral drugs by mothers and exposed babies for prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.

Methods

A systematic literature review was conducted. Four databases were searched (Medline, Embase, Global Health and Web of Science) for studies conducted in sub-Saharan Africa from January 2000 to September 2012. Quantitative and qualitative studies were included that met pre-defined criteria. Antiretroviral (ARV) prophylaxis (maternal/infant) and combination antiretroviral therapy (ART) usage/registration at HIV care and treatment during pregnancy were included as outcomes.

Results

Of 574 references identified, 40 met the inclusion criteria. Four references were added after searching reference lists of included articles. Twenty studies were quantitative, 16 were qualitative and eight were mixed methods. Forty-one studies were conducted in Southern and East Africa, two in West Africa, none in Central Africa and one was multi-regional. The majority (n=25) were conducted before combination ART for PMTCT was emphasized in 2006. At the individual-level, poor knowledge of HIV/ART/vertical transmission, lower maternal educational level and psychological issues following HIV diagnosis were the key barriers identified. Stigma and fear of status disclosure to partners, family or community members (community-level factors) were the most frequently cited barriers overall and across time. The extent of partner/community support was another major factor impeding or facilitating the uptake of PMTCT ARVs, while cultural traditions including preferences for traditional healers and birth attendants were also common. Key health-systems issues included poor staff-client interactions, staff shortages, service accessibility and non-facility deliveries.

Conclusions

Long-standing health-systems issues (such as staffing and service accessibility) and community-level factors (particularly stigma, fear of disclosure and lack of partner support) have not changed over time and continue to plague PMTCT programmes more than 10 years after their introduction. The potential of PMTCT programmes to virtually eliminate vertical transmission of HIV will remain elusive unless these barriers are tackled. The prominence of community-level factors in this review points to the importance of community-driven approaches to improve uptake of PMTCT interventions, although packages of solutions addressing barriers at different levels will be important.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of HIV serostatus disclosure to partners among HIV-positive pregnant women in Morogoro, Tanzania

Background

Prevention of mother to child transmission of HIV (PMTCT) has been scaled, to more than 90% of health facilities in Tanzania. Disclosure of HIV results to partners and their participation is encouraged in the program. This study aimed to determine the prevalence, patterns and predictors of HIV sero-status disclosure to partners among HIV positive pregnant women in Morogoro municipality, Tanzania.

Methods

A cross sectional study was conducted in March to May 2010 among HIV-positive pregnant women who were attending for routine antenatal care in primary health care facilities of the municipality and had been tested for HIV at least one month prior to the study. Questionnaires were used to collect information on possible predictors of HIV disclosure to partners.

Results

A total of 250 HIV-positive pregnant women were enrolled. Forty one percent (102) had disclosed their HIV sero-status to their partners. HIV-disclosure to partners was more likely among pregnant women who were < 25 years old [Adjusted odds ratio (AOR) = 2.2; 95% CI: 1.2–4.1], who knew their HIV status before the current pregnancy [AOR = 3.7; 95% CI: 1.7–8.3], and discussed with their partner before testing [AOR = 6.9; 95% CI: 2.4–20.1]. Dependency on the partner for food/rent/school fees, led to lower odds of disclosure to partners [AOR = 0.4; 95% CI: 0.1–0.7]. Nine out of ten women reported to have been counseled on importance of disclosure and partner participation.

Conclusions

Six in ten HIV positive pregnant women in this setting had not disclosed their results of the HIV test to their partners. Empowering pregnant women to have an individualized HIV-disclosure plan, strengthening of the HIV provider initiated counseling and testing and addressing economic development, may be some of the strategies in improving HIV disclosure and partner involvement in this setting.

Increasing HIV testing among male partners

OBJECTIVE

Couple-oriented posttest HIV counselling (COC) provides pregnant women with tools and strategies to invite her partner to HIV counselling and testing. We conducted a randomized trial of the efficacy of COC on partner HIV testing in low/medium HIV prevalence settings (Cameroon, Dominican Republic, Georgia, India).

METHODS

Pregnant women were randomized to receive standard posttest HIV counselling or COC and followed until 6 months postpartum. Partner HIV testing events were notified by site laboratories, self-reported by women or both combined. Impact of COC on partner HIV testing was measured in intention-to-treat analysis. Socio-behavioural factors associated with partner HIV testing were evaluated using multivariable logistic regression.

RESULTS

Among 1943 pregnant women enrolled, partner HIV testing rates (combined indicator) were 24.7% among women from COC group versus 14.3% in standard posttest HIV counselling group in Cameroon [odds ratio (OR) = 2.0 95% CI (1.2-3.1)], 23.1 versus 20.3% in Dominican Republic [OR = 1.2 (0.8-1.8)], 26.8 versus 1.2% in Georgia [OR = 29.6 (9.1-95.6)] and 35.4 versus 26.6% in India [OR = 1.5 (1.0-2.2)]. Women having received COC did not report more conjugal violence or union break-ups than in the standard posttest HIV counselling group. The main factors associated with partner HIV testing were a history of HIV testing among men in Cameroon, Dominican Republic and Georgia and the existence of couple communication around HIV testing in Georgia and India.

CONCLUSION

A simple prenatal intervention taking into account the couple relationship increases the uptake of HIV testing among men in different socio-cultural settings. COC could contribute to the efforts towards eliminating mother-to-child transmission of HIV.

Women's expectation of partner's violence on HIV disclosure for prevention of mother to child transmission of HIV in North West Ethiopia

Background

All violence against women has serious consequences for their mental, physical wellbeing, reproductive and sexual health including HIV infection and no study was conducted in this regard in Ethiopia and particularly in the present study area.

Findings

A cross-sectional study was conducted in Gondar town from 22 July–18 August 2011. Of the 400 pregnant women who actively participated in this study, 314 (78.50%) expected a negative reaction for HIV positive test result from their partners. A positive reaction from the partner was associated with women having their own income (Adjusted odds ratio (AOR) (95% CI) =2.18 (1.21, 3.92)), residing in the urban areas (AOR (95% CI) =2.26 (1.21, 4.22)), having education level of secondary level and above (AOR (95% CI) = 6.05 (3.12, 11.72)), not having a stigmatizing attitude towards people living with HIV (AOR (95% CI) = 2.15 (1.24, 3.73)), having a positive attitude towards counselors (AOR (95% CI) = 2.46 (1.42, 4.25)) and being able to access health facilities (AOR (95% CI) = 2.35(1.22, 4.50)).

Conclusion

Most of the participants in this study expected their partner to react negatively towards a positive HIV test result. Since women’s having their own income is strongly associated with a positive partner’s reaction on HIV test disclosure for prevention of mother to child transmission of HIV services, emphasis should be given for education and economic empowerment of women. A well functioning and accessible health facility with prevention of mother to child transmission of HIV service is important, especially in rural areas.

Impact of Pill Sharing on Drug Resistance Due to a Wide-Scale Oral Prep Intervention in Generalized Epidemics

BACKGROUND

The first antiretroviral drug (Truvada) to be used as a pre-exposure prophylaxis (PrEP) in preventing HIV transmission is about to be approved. Behavioral studies suggest that a portion of users may share anti-retroviral drugs with sex partners, family, or friends. Pill sharing will decrease PrEP efficacy and adherence level, and potentially create an environment favorable for the development of drug resistance. We aim to evaluate the potential impact of pill sharing on the PrEP effectiveness and on the rates of drug-resistance development in heterosexual populations.

METHODS

A transmission dynamic model was used to assess the population-level impact of oral PrEP. The fractions of new HIV infections prevented (CPF), drug resistance prevalence and the proportion of new infections in which drug-resistant HIV is transmitted (TDR) are evaluated over fixed time periods. The influence of different factors on CPF and TDR is studied through simulations, using epidemic parameters representative of the countries in Sub-Saharan Africa.

RESULTS

Without pill sharing, a 70% efficacious PrEP used consistently by 60% of uninfected individuals prevents 52.8% (95% CI 49.4%-56.4%) of all new HIV infections over ten years with drug-resistant HIV transmitted in 2.2% of the new infections. Absolute CPF may vary by 9% if up to 20% of the users share PrEP while the level of TDR and total resistance prevalence may increase by up to 6-fold due to pill sharing in some intervention scenarios.

CONCLUSION

Pill sharing may increase the PrEP coverage level achieved in the population but it also affects the PrEP efficacy for the users who do not follow the prescribed schedule. More importantly, it creates a pool of untracked users who remain unreached by the effort to avoid sub-optimal PrEP usage by infected people. This increases substantially the potential risk of drug resistance in the population.

Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review

Introduction

Male participation is a crucial component in the optimization of Maternal and Child Health (MCH) services. This is especially so where prevention strategies to decrease Mother-to-Child Transmission (MTCT) of Human Immunodeficiency Virus (HIV) are sought. This study aims to identify determinants of male partners’ involvement in MCH activities, focusing specifically on HIV prevention of maternal to child transmission (PMTCT) in sub-Saharan Africa.

Methods

Literature review was conducted using the following data bases: Pubmed/MEDLINE; CINAHL; EMBASE; COCHRANE; Psych INFORMATION and the websites of the International AIDS Society (IAS), the International AIDS Conference and the International Conference on AIDS in Africa (ICASA) 2011.

Results

We included 34 studies in this review, which reported on male participation in MCH and PMTCT services. The majority of studies defined male participation as male involvement solely during antenatal HIV testing. Other studies defined male involvement as any male participation in HIV couple counseling. We identified three main determinants for male participation in PMTCT services: 1) Socio-demographic factors such as level of education, income status; 2) health services related factors such as opening hours of services, behavior of health providers and the lack of space to accommodate male partners; and 3) Sociologic factors such as beliefs, attitudes and communication between men and women.

Conclusion

There are many challenges to increase male involvement/participation in PMTCT services. So far, few interventions addressing these challenges have been evaluated and reported. It is clear however that improvement of antenatal care services by making them more male friendly, and health education campaigns to change beliefs and attitudes of men are absolutely needed.

Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis

OBJECTIVE

To estimate antiretroviral therapy (ART) adherence rates during pregnancy and postpartum in high-income, middle-income, and low-income countries.

DESIGN

Systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, SCI Web of Science, NLM Gateway, and Google scholar databases were searched. We included all studies reporting adherence rates as a primary or secondary outcome among HIV-infected pregnant women. Two independent reviewers extracted data on adherence and study characteristics. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity, and publication bias were assessed.

RESULTS

Of 72 eligible articles, 51 studies involving 20 153 HIV-infected pregnant women were included. Most studies were from United States (n =  14, 27%) followed by Kenya (n = 6, 12%), South Africa (n = 5, 10%), and Zambia (n = 5, 10%). The threshold defining good adherence to ART varied across studies (>80, >90, >95, 100%). A pooled analysis of all studies indicated a pooled estimate of 73.5% [95% confidence interval (CI) 69.3-77.5%] of pregnant women who had adequate (>80%) ART adherence. The pooled proportion of women with adequate adherence levels was higher during the antepartum (75.7%, 95% CI 71.5-79.7%) than during postpartum (53.0%, 95% CI 32.8-72.7%; P = 0.005). Selected reported barriers for nonadherence included physical, economic and emotional stresses, depression (especially postdelivery), alcohol or drug use, and ART dosing frequency or pill burden.

CONCLUSION

Our findings indicate that only 73.5% of pregnant women achieved optimal ART adherence. Reaching adequate ART adherence levels was a challenge in pregnancy, but especially during the postpartum period. Further research to investigate specific barriers and interventions to address them is urgently needed globally.

Community-based approaches for prevention of mother to child transmission in resource-poor settings: a social ecological review

INTRODUCTION

Numerous barriers to optimal uptake of prevention of mother to child transmission (PMTCT) services occur at community level (i.e., outside the healthcare setting). To achieve elimination of paediatric HIV, therefore, interventions must also work within communities to address these barriers and increase service use and need to be informed by evidence. This paper reviews community-based approaches that have been used in resource-limited settings to increase rates of PMTCT enrolment, retention in care and successful treatment outcomes. It aims to identify which interventions work, why they may do so and what knowledge gaps remain.

METHODS

First, we identified barriers to PMTCT that originate outside the health system. These were used to construct a social ecological framework categorizing barriers to PMTCT into the following levels of influence: individual, peer and family, community and sociocultural. We then used this conceptual framework to guide a review of the literature on community-based approaches, defined as interventions delivered outside of formal health settings, with the goal of increasing uptake, retention, adherence and positive psychosocial outcomes in PMTCT programmes in resource-poor countries.

RESULTS

Our review found evidence of effectiveness of strategies targeting individuals and peer/family levels (e.g., providing household HIV testing and training peer counsellors to support exclusive breastfeeding) and at community level (e.g., participatory women's groups and home-based care to support adherence and retention). Evidence is more limited for complex interventions combining multiple strategies across different ecological levels. There is often little information describing implementation; and approaches such as "community mobilization" remain poorly defined.

CONCLUSIONS

Evidence from existing community approaches can be adapted for use in planning PMTCT. However, for successful replication of evidence-based interventions to occur, comprehensive process evaluations are needed to elucidate the pathways through which specific interventions achieve desired PMTCT outcomes. A social ecological framework can help analyze the complex interplay of facilitators and barriers to PMTCT service uptake in each context, thus helping to inform selection of locally relevant community-based interventions.

Male participation in prevention programmes of mother to child transmission of HIV: a protocol for a systematic review to identify barriers, facilitators and reported interventions

BACKGROUND

Infection with the HIV and AIDS are leading causes of morbidity and mortality among women and children worldwide. Prevention of mother-to-child transmission of HIV (PMTCT) programs were developed to protect women and their babies from having HIV infection. However, knowledge on how male participation has been applied to these programs is limited. We present a research protocol for a review which seeks to determine the effects of male participation on female uptake of PMTCT programs, and assess how this male participation has been investigated and documented worldwide.

METHODS

This is a systematic review of published literature. We will attempt to identify all studies relevant to the subject written in the English language from January 1998 to June 2011. Electronic searches of the PubMED, EMBASE, CINAHL, and LILACS databases will be conducted using the relevant medical subject headings. Reference lists of identified studies and previous reviews will be manually checked for articles of interest. We shall also contact authors on the field for any relevant material. Two authors (FM and LM) will independently screen potential articles for eligibility using well-defined inclusion and exclusion criteria. They will independently assess the methodological quality of each included paper using the Jadad scale for randomized controlled trials, and the Newcastle-Ottawa scale for observational studies. Then they will independently extract data from the studies using a pre-established data extraction form. The primary outcome data will be female uptake of PMTCT services following a male/couple intervention, while secondary outcome measures will include indicators and barriers of male participation in PMTCT activities among others. During the data extraction process, discrepancies between the two authors will be sorted out by discussion or consultation with a third party (LT). The analysis and reporting of the review will be according to the PRISMA and MOOSE guidelines. Any identified clinical or statistical heterogeneity will be explored. Where possible, a random-effects meta-analysis will be performed to obtain aggregate estimates. We will also assess publication bias using funnel plots. Analysis of other outcomes will be descriptive.

Uptake of prevention of mother to child transmission interventions in Kenya: health systems are more influential than stigma

Background

We set out to determine the relative roles of stigma versus health systems in non-uptake of prevention of mother to child transmission (PMTCT) of HIV-1 interventions: we conducted cross-sectional assessment of all consenting mothers accompanying infants for six-week immunizations.

Methods

Between September 2008 and March 2009, mothers at six maternal and child health clinics in Kenya's Nairobi and Nyanza provinces were interviewed regarding PMTCT intervention uptake during recent pregnancy. Stigma was ascertained using a previously published standardized questionnaire and infant HIV-1 status determined by HIV-1 polymerase chain reaction.

Results

Among 2663 mothers, 2453 (92.1%) reported antenatal HIV-1 testing. Untested mothers were more likely to have less than secondary education (85.2% vs. 74.9%, p = 0.001), be from Nyanza (47.1% vs. 32.2%, p < 0.001) and have lower socio-economic status. Among 318 HIV-1-infected mothers, 90% reported use of maternal or infant antiretrovirals. Facility delivery was less common among HIV-1-infected mothers (69% vs. 76%, p = 0.009) and was associated with antiretroviral use (p < 0.001). Although internal or external stigma indicators were reported by between 12% and 59% of women, stigma was not associated with lower HIV-1 testing or infant HIV-1 infection rates; internal stigma was associated with modestly decreased antiretroviral uptake. Health system factors contributed to about 60% of non-testing among mothers who attended antenatal clinics and to missed opportunities in offering antiretrovirals and utilization of facility delivery. Eight percent of six-week-old HIV-1-exposed infants were HIV-1 infected.

Conclusions

Antenatal HIV-1 testing and antiretroviral uptake was high (both more than 90%) and infant HIV-1 infection risk was low, reflecting high PMTCT coverage. Investment in health systems to deliver HIV-1 testing and antiretrovirals can effectively prevent infant HIV-1 infection despite substantial HIV-1 stigma.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial Registration

ClinicalTrials.gov Identifier: NCT01144234.

Male partner voluntary counselling and testing associated with the antenatal services in Kinshasa, Democratic Republic of Congo: a randomized controlled trial

Low male participation in voluntary counselling and testing (VCT) services at antenatal clinics (ANCs) represents a lost HIV-prevention opportunity. A three-arm randomized controlled trial (RCT) was conducted that offered VCT at a neighbourhood health centre, bar or church to the male partners of pregnant women attending a maternity unit in Kinshasa, Democratic Republic of Congo (DRC). The primary outcome was the proportion of male participation at VCT; secondary outcomes were uptake of couple counselling and determinants of male and couple participation. From a total of 2706 women included in the study, 591 male partners (22%) attended one of the three venues. Male participation was significantly higher in bars (26%, P < 0.001), and higher but not statistically significant in church-based VCT (21%, P = 0.163) compared with health centre VCT (18%). Male participation in VCT associated with ANCs was higher in non-health service settings, particularly in bars. A combination of different strategies rather than single targeted interventions will be needed to increase VCT uptake in male partners of women seeking VCT at ANCs.

Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection

BACKGROUND

Antiretroviral drugs reduce viral replication and can reduce mother-to-child transmission of HIV either by lowering plasma viral load in pregnant women or through post-exposure prophylaxis in their newborns. In rich countries, highly active antiretroviral therapy (HAART) which usually comprises three drugs, has reduced the mother-to-child transmission rates to around 1-2%, but HAART is not always available in low- and middle-income countries. In these countries, various simpler and less costly antiretroviral regimens have been offered to pregnant women or to their newborn babies, or to both.

OBJECTIVES

To determine whether, and to what extent, antiretroviral regimens aimed at decreasing the risk of mother-to-child transmission of HIV infection achieve a clinically useful decrease in transmission risk, and what effect these interventions have on maternal and infant mortality and morbidity.

SEARCH STRATEGY

We sought to identify all relevant studies regardless of language or publication status by searching the Cochrane HIV/AIDS Review Group Trials Register, The Cochrane Library, MEDLINE, EMBASE and AIDSearch and relevant conference abstracts. We also contacted research organizations and experts in the field for unpublished and ongoing studies. The original review search strategy was conducted in 2002 and updated in 2006 and again in 2009.

SELECTION CRITERIA

Randomised controlled trials of any antiretroviral regimen aimed at decreasing the risk of mother-to-child transmission of HIV infection compared with placebo or no treatment, or compared with another antiretroviral regimen.

DATA COLLECTION AND ANALYSIS

Two authors independently selected relevant studies, extracted data and assessed trial quality. For the primary outcomes, we used survival analysis to estimate the probability of infants being infected with HIV (the observed proportion) at various specific time-points and calculated efficacy at a specific time as the relative reduction in the proportion infected. Efficacy, at a specific time, is defined as the preventive fraction in the exposed group compared to the reference group, which is the relative reduction in the proportion infected: 1-(Re/Rf). For those studies where efficacy and hence confidence intervals were not calculated, we calculated the approximate confidence intervals for the efficacy using recommended methods. For analysis of results that are not based on survival analyses we present the relative risk for each trial outcome based on the number randomised. No meta-analysis was conducted as no trial assessed identical drug regimens.

MAIN RESULTS

Twenty-five trials including 18,901 participants with a median trial sample size of 627 ranging from 50 to 1,844 participants were included in this update. Twenty-two trials randomised mothers (18 pre-natally and four in labour) and followed up their infants, and three trials randomised infants. The first trial began in April 1991 and assessed zidovudine (ZDV) versus placebo and since then, the type, dosage and duration of drugs to be compared has been modified in each subsequent trial. We present the results stratified by regimen and type of feeding.Antiretrovirals versus placebo In breastfeeding populations, three trials found that:ZDV given to mothers from 36 to 38 weeks gestation, during labour and for 7 days after delivery significantly reduced HIV infection at 4-8 weeks (Efficacy 32.00%; 95% CI 1.50 to 62.50), 3 to 4 months (Efficacy 33.07%; 95% CI 5.57 to 60.57), 6 months (Efficacy 34.55%; 95% CI 9.05 to 60.05), 12 months (Efficacy 34.31%; 95% CI 9.30 to 59.32) and 18 months (Efficacy 29.74%; 95% CI 2.73 to 56.75).ZDV given to mothers from 36 weeks gestation and during labour significantly reduced HIV infection at 4 to 8 weeks (Efficacy 43.78%; 95% CI 8.78 to 78.78) and 3 to 4 months (Efficacy 36.95%; 95% CI 2.94 to 70.96) but not at birth.ZDV plus lamivudine (3TC) given to mothers from 36 weeks gestation, during labour and for 7 days after delivery and to babies for the first 7 days after birth (PETRA 'regimen A') significantly reduced HIV infection (Efficacy 62.75%; 95% CI 40.76 to 84.74) and a combined endpoint of HIV infection or death (Efficacy 62.75 [, ]61.00%; 95% CI 40.76 to 84.74) at 4 to 8 weeks but these effects were not sustained at 18 months.ZDV plus 3TC given to mothers from the start of labour until 7 days after delivery and to babies for the first 7 days after birth (PETRA 'regimen B') significantly reduced HIV infection (Efficacy 41.83%; 95% CI 12.82 to 70.84) and HIV infection or death at 4 to 8 weeks (Efficacy 35.91%; 95% CI 8.41 to 63.41) but the effects were not sustained at 18 months.ZDV plus 3TC given to mothers during labour only (PETRA 'regimen C') with no treatment to babies did not reduce the risk of HIV infection at either 4 to 8 weeks or 18 months.In non-breastfeeding populations, three trials found that:ZDV given to mothers from 14 to 34 weeks gestation and during labour and to babies for the first 6 weeks after birth significantly reduced HIV infection in babies at 18 months (Efficacy 66.22%; 95% CI 33.94 to 98.50).ZDV given to mothers from 36 weeks gestation and during labour with no treatment to babies ('Thai-CDC regimen') significantly reduced HIV infection at 4 to 8 weeks (Efficacy 50.26%; 95% CI 13.80 to 86.72) but not at birthZDV given to mothers from 38 weeks gestation and during labour with no treatment to babies did not influence HIV transmission at 6 months.Longer versus shorter regimens using the same antiretrovirals One trial in a breastfeeding population found that:ZDV given to mothers during labour and to their babies for the first 3 days after birth compared with ZDV given to mothers from 36 weeks and during labour (similar to 'Thai-CDC') resulted in HIV infection rates that were not significantly different at birth, 4-8 weeks, 3 to 4 months, 6 months and 12 months.Three trials in non-breastfeeding populations found that:ZDV given to mothers from 28 weeks gestation during labour and to infants for the first 3 days after birth compared with ZDV given to mothers from 35 weeks gestation through labour and to infants from birth to 6 weeks significantly reduced HIV infection rate at 6 months (Efficacy 45.35 %; 95% CI 1.39 to 89.31) but compared with the same regimen ZDV given to mothers from 28 weeks gestation through labour and to infants from birth to 6 weeks did not result in a statistically significant difference in HIV infection at 6 months. ZDV given to mothers from 35 weeks gestation during labour and to infants for the first 3 days after birth was considered ineffective for reducing transmission rates and this regimen was discontinued.An antenatal/intrapartum course of ZDV used for a median of 76 days compared with an antenatal/intrapartum ZDV regimen used for a median 28 days with no treatment to babies in either group did not result in HIV infection rates that were significantly different at birth and at 3 to 4 months.In a programme where mothers were routinely receiving ZDV in the third trimester of pregnancy and babies were receiving one week of ZDV therapy, a single dose of nevirapine (NVP) given to mothers in labour and to their babies soon after birth compared with a single dose of NVP given to mothers only resulted in HIV infection rates that were not significantly different at birth and 6 months. However the reduction in risk of HIV infection or death at 6 months was marginally significant (Efficacy 45.00%; 95% CI -4.00 to 94.00).Antiretroviral regimens using different drugs and durations of treatmentIn breastfeeding populations, three trials found that:A single dose of NVP given to mothers at the onset of labour plus a single dose of NVP given to their babies immediately after birth ('HIVNET 012 regimen') compared with ZDV given to mothers during labour and to their babies for a week after birth resulted in lower HIV infection rates at 4-8 weeks (Efficacy 41.00%; 95% CI 11.84 to 70.16), 3-4 months (Efficacy 38.91%; 95% CI 11.24 to 66.58), 12 months (Efficacy 35.98 [9.25, 62.71]36.00%; 95% CI 8.56 to 63.44) and 18 months (Efficacy 39.15%; 95% CI 13.81 to 64.49). In addition, the NVP regimen significantly reduced the risk of HIV infection or death at 4-8 weeks (Efficacy 41.74%; 95% CI 14.30 to 69.18), 3 to 4 months (Efficacy 40.00%; 95% CI 14.34 to 65.66), 12 months (Efficacy 32.17%; 95% CI 8.51 to 55.83) and 18 months (Efficacy 32.57 [9.93, 55.21]33.00%; 95% CI 9.93 to 55.21).The 'HIVNET 012 regimen' plus ZDV given to babies for 1 week after birth compared with the 'HIVNET 012 regimen' alone did not result in a statistically significant difference in HIV infection at 4 to 8 weeks.A single dose of NVP given to babies immediately after birth plus ZDV given to babies for 1 week after birth compared with a single dose of NVP given to babies only significantly reduced the HIV infection rate at 4 to 8 weeks (Efficacy 36.79%; 95% CI 3.57 to 70.01).Five trials in non-breastfeeding populations found that:In a population in which mothers were receiving 'standard' antiretroviral for HIV infection a single dose of NVP given to mothers in labour plus a single dose of NVP given to babies immediately after birth ('HIVNET 012 regimen') compared with placebo did not result in a statistically significant difference in HIV infection rates at birth and at 4 to 8 weeks.The 'Thai CDC regimen' compared with the 'HIVNET 012 regimen' did not result in a significant difference in HIV infection at 4 to 8 weeks.A single dose of NVP given to babies immediately after birth compared to ZDV given to babies for the first 6 weeks after birth did not result in a significant difference in HIV infection rates at 4-8 weeks and 3 to 4 months. (ABSTRACT TRUNCATED)

Couple-based HIV prevention in the United States: advantages, gaps, and future directions

This article presents an overview of couple-based HIV prevention research to date, advantages of using and core components of couple-based interventions, gaps in the current understanding of couple-based HIV prevention, status of dissemination research and the transportability of effective couple-based HIV prevention and treatment to real-world settings, and recommendations for future directions in couple-based prevention and treatment. Couple-based studies conducted among several populations-heterosexuals, men who have sex with men, and drug users-reported in the research literature were reviewed. Commonalities and limitations were noted in customary focus areas of the couple-based approaches: sexual and drug risk reduction, HIV testing behaviors, adherence to HIV treatment, and prevention of mother-to-child transmission. Couple-based intervention strategies have been rigorously tested and are a valuable addition to the arsenal of HIV prevention strategies. Immediate needs and opportunities include couple-based intervention strategies for prevention of HIV and other sexually transmitted infections among serodiscordant couples, couples who do not know their HIV status, and couples in whom both partners are HIV negative but at risk of HIV infection. There is a particular need to develop couple-based intervention strategies for men who have sex with men and for drug-involved couples.

Attitudes to routine HIV counselling and testing, and knowledge about prevention of mother to child transmission of HIV in eastern Uganda: a cross-sectional survey among antenatal attendees

BACKGROUND

HIV testing rates have exceeded 90% among the pregnant women at Mbale Regional Referral Hospital in Mbale District, eastern Uganda, since the introduction of routine antenatal counselling and testing for HIV in June 2006. However, no documented information was available about opinions of pregnant women in eastern Uganda about this HIV testing approach. We therefore conducted a study to assess attitudes of antenatal attendees towards routine HIV counselling and testing at Mbale Hospital. We also assessed their knowledge about mother to child transmission of HIV and infant feeding options for HIV-infected mothers.

METHODS

The study was a cross-sectional survey of 388 women, who were attending the antenatal clinic for the first time with their current pregnancy at Mbale Regional Referral Hospital from August to October 2009. Data were collected using a pre-tested questionnaire and analysed using descriptive statistics and logistic regression. Permission to conduct the study was obtained from the Makerere University College of Health Sciences, the Uganda National Council of Science and Technology, and Mbale Hospital.

RESULTS

The majority of the antenatal attendees (98.5%, 382/388) had positive attitudes towards routine HIV counselling and testing, and many of them (more than 60%) had correct knowledge of how mother to child transmission of HIV could occur during pregnancy, labour and through breastfeeding, and ways of preventing it. After adjusting for independent variables, having completed secondary school (odds ratio: 2.5, 95% confidence interval: 1.3-4.9), having three or more pregnancies (OR: 2.5, 95% CI: 1.4-4.5) and belonging to a non-Bagisu ethnic group (OR: 1.7, 95% CI: 1.0-2.7) were associated with more knowledge of exclusive breastfeeding as one of the measures for prevention of mother to child transmission of HIV. Out of 388 antenatal attendees, 386 (99.5%) tested for HIV and 382 (98.5%) received same-day HIV test results.

CONCLUSIONS

Routine offer of antenatal HIV counselling and testing is largely acceptable to the pregnant women in eastern Uganda and has enabled most of them to know their HIV status as part of the prevention of mother to child transmission of HIV package of services. Our findings call for further strengthening and scaling up of this HIV testing approach in many more antenatal clinics countrywide in order to maximize its potential benefits to the population.

Determinants of failure to access care in mothers referred to HIV treatment programs in Nairobi, Kenya

BACKGROUND

As prevention of mother-to-child transmission of HIV (PMTCT) programs and HIV treatment programs rapidly expand in parallel, it is important to determine factors that influence the transition of HIV-infected women from maternal to continuing care.

DESIGN

This study aimed to determine rates and co-factors of accessing HIV care by HIV-infected women exiting maternal care. A cross-sectional survey of women who had participated in a PMTCT research study and were referred to care programs in Nairobi, Kenya was conducted.

METHODS

A median of 17 months following referral, women were located by peer counselors and interviewed to determine whether they accessed HIV care and what influenced their care decisions. Fisher's exact test was used to assess the association between client characteristics and access to care.

RESULTS

Peer counselors traced 195 (82%) residences, where they located 116 (59%) participants who provided information on care. Since exit, 50% of participants had changed residence, and 74% reported going to the referral HIV program. Reasons for not accessing care included lack of money, confidentiality, and dislike of the facility. Women who did not access care were less likely to have informed their partner of the referral (p=0.001), and were less likely believe that highly active antiretroviral therapy (HAART) is effective (p<0.01). Among those who accessed care, 33% subsequently discontinued care, most because they did not qualify for HAART. Factors cited as barriers to access included stigma, denial, poor services, and lack of money. Factors that were cited as making care attractive included health education, counseling, free services, and compassion.

CONCLUSION

A substantial number of women exiting maternal care do not transit to HIV care programs. Partner involvement, a standardized referral process and more comprehensive HIV education for mothers diagnosed with HIV during pregnancy may facilitate successful transitions between PMTCT and HIV care programs.

A qualitative study of participant adherence in a randomized controlled trial of herpes suppressive therapy for HIV prevention in Tanzania

Poor participant adherence to treatment may contribute to lack of impact in some biomedical HIV prevention trials. This qualitative study explored adherence in a randomized controlled trial of herpes suppressive therapy to reduce HIV acquisition and infectivity among 1305 Tanzanian women. The trial found participants completed 72% of visits on treatment; 52-56% of women on treatment had > or = 90% adherence by pill count estimate; and between six and nine months 30/86 (35%) of urine samples from acyclovir recipients tested acyclovir negative, and 7/86 (8%) from placebo recipients tested acyclovir positive. Twenty in-depth interviews (IDIs) were conducted after 30 months with respondents randomly selected from "acyclovir negative" acyclovir recipients and "acyclovir positive" placebo recipients, or by preliminary pill count adherence categories ("under users," "good users," and "over users"). Almost all respondents reported appropriate adherence and positive trial attitudes, e.g., trusting staff, appreciating services, perceiving pills as beneficial. Fourteen understood placebo use, and six understood the trial purpose. Notably, 5/9 acyclovir recipients and 1/11 placebo recipients believed their pills had treated pre-existing sexually transmitted infections. Limited understanding did not negatively affect reported adherence. Reported adherence problems usually related to illness, travel, and/or family obligations (e.g., husband's disapproval). "Acyclovir positive" placebo recipients denied taking other participants' pills. The IDIs also did not resolve discrepant reports of pill loss or theft. Biomedical HIV interventions often have strong behavioral components that require close attention during intervention development, trial design, and process and impact evaluation. This study identified topics which warrant further consideration, including: information reinforcement and comprehension assessment throughout a trial for long-term participant understanding; involving partners in adherence promotion activities; strategizing with participants to maintain adherence during familial illnesses or other crises; and close monitoring, identification, and follow-up of (1) individuals with discrepant biological tests, and (2) other sources of the treatment in the trial area. Methodological research is also needed to improve adherence measures.

Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey

BACKGROUND

Mother-to-child transmission of HIV (MTCT) accounts for over 95% of all paediatric HIV infections worldwide. Several studies have shown that male participation in the antenatal care of their spouses together with couple counselling and testing for HIV, increases use of the interventions for HIV prevention. The prevention programme of MTCT (PMTCT) was launched in Uganda in 2000 and Mbale in 2002. Less than 10% of the pregnant women accepted antenatal HIV testing at Mbale Regional Referral Hospital in 2003; couple counselling and testing for HIV was low. Therefore, we conducted the study to determine the level of male involvement and identify its determinants in the PMTCT programme.

METHODS

A cross-sectional survey of 388 men aged 18 years or more, whose spouses were attending antenatal care at Mbale Regional Referral Hospital, was conducted in Mbale district, Eastern Uganda. A male involvement index was constructed based on 6 questions. The survey was complemented by eight focus group discussions and five in-depth interviews.

RESULTS

The respondents had a median age of 32 years (inter-quartile range, IQR: 28-37). The majority (74%) had a low male involvement index and only 5% of men accompanied their spouses to the antenatal clinic. Men who had attained secondary education were more likely to have a high male involvement index (OR: 1.9, 95% CI: 1.1-3.3) than those who had primary or no formal education. The respondents, whose occupation was driver (OR: 0.3, 95% CI: 0.1-0.7) or those who had fear of disclosure of their HIV sero-status results to their spouses (OR: 0.4, 95% CI: 0.2-0.8), were less likely to have a high male involvement index. Barriers to male involvement in the PMTCT programme were related to both the poor health system, to socio-economic factors and to cultural beliefs.

CONCLUSIONS

Structural and cultural barriers to men's involvement in the PMTCT programme in Mbale district were complex and interrelated. Community sensitization of men about the benefits of antenatal care and PMTCT and improving client-friendliness in the clinics needs to be prioritised in order to improve low male participation and mitigate the effect of socio-economic and cultural factors.

Male involvement in antenatal HIV counseling and testing: exploring men's perceptions in rural Malawi

Antenatal care can act as an excellent tool to improve access to HIV counseling and testing services. This paper investigates an issue that may weaken its potential, namely lack of male involvement. We explored married men's perceptions of HIV in pregnancy and male involvement in antenatal HIV testing and counseling in Southern Malawi through 11 focus group discussions and a cross-sectional survey (n=388). The main findings were that men were largely unaware of available antenatal HIV testing and counseling services, and perceived it overall problematic to attend female-oriented health care. Most men supported provision of antenatal HIV testing. They perceived husbands to participate in the process indirectly through spousal communication, being faithful during pregnancy, and supporting the wife if found HIV-positive. Involvement of husbands was compromised by men's reluctance to learn their HIV status and the threat that HIV poses on marriage. Men stressed the importance of prior spousal agreement of antenatal HIV testing and considered HIV testing without their consent a valid reason for divorce. We suggest that male involvement in antenatal HIV testing requires refocusing of information and health services to include men. To avoid negative social outcomes for women, comprehensive and early involvement of men is essential.