“Male Involvement” in Women and Children's HIV Prevention: Challenges in Definition and Interpretation

Optimizing PMTCT Adherence by Treating Depression in Perinatal Women with HIV in South Africa: A Pilot Randomized Controlled Trial

BACKGROUND

South Africa (SA) has the greatest HIV prevalence in the world, with rates as high as 40% among pregnant women. Depression is a robust predictor of nonadherence to antiretroviral therapy (ART) and engagement in HIV care; perinatal depression may affect upwards of 47% of women in SA. Evidence-based, scalable approaches for depression treatment and ART adherence in this setting are lacking.

METHOD

Twenty-three pregnant women with HIV (WWH), ages 18-45 and receiving ART, were randomized to a psychosocial depression and adherence intervention or treatment as usual (TAU) to evaluate intervention feasibility, acceptability, and preliminary effect on depressive symptoms and ART adherence. Assessments were conducted pre-, immediately post-, and 3 months post-treatment, and included a qualitative exit interview.

RESULTS

Most (67.6%) eligible individuals enrolled; 71% completed at least 75% of sessions. Compared to TAU, intervention participants had significantly greater improvements in depressive symptoms at post-treatment, β =  - 11.1, t(24) =  - 3.1, p < 0.005, 95% CI [- 18.41, - 3.83], and 3 months, β =  - 13.8, t(24) =  - 3.3, p < 0.005, 95% CI [- 22.50, - 5.17]. No significant differences in ART adherence, social support, or stigma were found. Qualitatively, perceived improvements in social support, self-esteem, and problem-solving adherence barriers emerged as key benefits of the intervention; additional sessions were desired.

CONCLUSION

A combined depression and ART adherence intervention appears feasible and acceptable, and demonstrated preliminary evidence of efficacy in a high-need population. Additional research is needed to confirm efficacy and identify dissemination strategies to optimize the health of WWH and their children.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03069417. Protocol available at https://clinicaltrials.gov/ct2/show/NCT03069417.

Understanding the meanings of male partner support in the adherence to therapy among HIV-positive women: a gender analysis

BACKGROUND

Previous literature reports that low male partner support is a barrier to women's adherence and retention in HIV care programs.

OBJECTIVE

This qualitative study explored the relationships between partners to understand what is meant by male partner support in adherence of HIV-positive women in four healthcare facilities in Southern Malawi.

METHODS

We conducted 8 semi-structured focus group discussions (FGDs) with 73 participants (40 men and 33 women) and 10 in-depth interviews (IDIs) between August 2018 to December 2019. Participants were HIV-positive patients, healthcare workers (HCWs), expert patients (EPs), and couples attending the clinic. All data were digitally recorded, transcribed verbatim, and analysed using a gender-responsive grounded theory approach.

RESULTS

This study confirms previous literature, which suggests male partner support is expressed by providing access to transport to the clinic and accompaniment to appointments. However, we found that men can also control access to resources and decision-making. Support is more complex than previous literature reported and, in some cases, gender norms significantly limit women's capacity to engage in care independently of male support since women need male partner permission to access the resources to attend clinics.

CONCLUSIONS

This paper suggests that restrictive male-partner gender norms limit women's power to engage in care. Most importantly, the gender analysis reveals that what previous literature describes as male partner support can sometimes hide male partner control in permitting access to resources to attend health facilities. For this reason, policies enhancing male support should consider the gender power relationship between partners to avoid reinforcing gender inequality.

Improving Male Partner Involvement in HIV-Positive Women's Care Through Behavioral Change Interventions in Malawi (WeMen Study): A Prospective, Controlled Before-and-After Study

Several strategies and interventions have been implemented to improve male partner involvement (MI) in Sub-Saharan Africa, but evidence on successful interventions is scarce. This controlled before-and-after intervention study aims to evaluate the impact of three interventions on male partners' involvement in HIV+ women's care in Malawi. We piloted these three interventions: the organization of a special day for men, the deployment of male champions in communities to increase awareness on MI, and the delivery of an incentive (food package) for couples attending the facility. We observed a significant increase in the number of women accompanied by their partners (from 48.5 to 81.4%) and the number of women feeling safe at home (from 63.5 to 95.2%) after the special day intervention. This outcome increased after the deployment of male champions in communities (from 44.0 to 75.0%). No significant improvement was observed in the site where we delivered the incentive to couples. Our findings showed that the special day for men and the use of male champions might effectively increase the male involvement in the health of their female partners.

Integration of a Relationship-focused Counseling Intervention with Delivery of the Dapivirine Ring for HIV Prevention to Women in Johannesburg: Results of the CHARISMA Pilot Study

Biomedical, female-initiated HIV prevention methods can help reduce disproportionately high HIV rates among women in sub-Saharan Africa, but male partner resistance and intimate partner violence (IPV) may impact ability to ensure effective use. To support consistent use of the dapivirine vaginal ring (VR), we pilot-tested the impact of the CHARISMA relationship counseling intervention ("CHARISMA") with women enrolled in the multi-site open-label Microbicide Trials Network (MTN) 025/HOPE trial at the Wits Reproductive Health and HIV Research Institute (Wits RHI) site in Johannesburg, South Africa. Lay counselors used a 42-item tool with five subscales to assess relationships and IPV and provide tailored counseling at enrolment, followed by a booster counselling session at Month 1 and follow-up checks at Months 3 and 6. We evaluated potential impact by examining self-reported ring disclosure to partners, partner clinic attendance, self-reported incident social harms (SH) and IPV, and biomarkers of ring adherence at Wits RHI. We subsequently compared these outcomes at three comparator HOPE study sites using multivariable regression models. Comparator study sites were purposively selected as those most similar to Wits RHI for baseline characteristics identified a priori. At Wits RHI, 95 of 96 (99%) HOPE participants enrolled into the CHARISMA pilot study. Mean age was 30, 36.8% lived with a partner, and 85.3% received their partner's financial support. During the six months of pilot study follow-up, participants reported: ring use disclosure to partners at 72.7% visits; 4.3% partners attending the research clinic; one partner-related SH; and 9.5% experienced incident IPV. The mean level of dapivirine released from returned used rings was 3.4 mg (SD 1.56), suggesting moderate adherence. Participants in the CHARISMA pilot had high background prevalence and incidence of IPV but were nevertheless able to adhere to ring use, and some male partners came to the research clinic. In adjusted regression models, compared to Wits RHI, partner clinic attendance was lower at all comparator sites; and significantly so at Site A (aRR 0.12, 95% CI 0.00-0.98). Sites B and C had lower levels of dapivirine released (suggesting lower adherence), but this difference was not significant. Site B women were more likely to report ring disclosure to partners at FU visits (aRR 1.12, 95% CI 1.00-1.25). IPV reported during follow-up was significantly lower at Site B (aRR 0.20, 95% CI 0.04-0.98, p = 0.047). CHARISMA taught women skills to decide on levels of ring-use disclosure to partners or others; therefore it is difficult to interpret differences in ring disclosure to partners with other sites. Similarly, CHARISMA heightened participants' awareness of abuse, possibly increasing IPV reports. Testing CHARISMA under fully-powered controlled conditions will improve understanding of its impact on women's relationships and ability to use female-initiated HIV prevention methods.

Towards a global framework for assessing male involvement in maternal health: results of an international Delphi study

PURPOSE

Currently, no standard instrument exists for assessing the concept of male involvement in maternal health, hampering comparison of results and interpretation of the literature. The aim of this study was to construct the key elements of a global multidimensional male involvement framework, based on the latest evidence and input of experts in the field.

METHODS

For this purpose, a Delphi study, including an international panel of 26 experts, was carried out. The study consisted of three rounds, with 92% of respondents completing all three surveys. Experts were asked to rate indicators within six categories in terms of validity, feasibility, sensitivity, specificity and context robustness. Furthermore, they were encouraged to clarify their rating with open text responses. Indicators were excluded or adapted according to experts' feedback before inclusion. A 85% agreement was used as threshold for consensus.

RESULTS

A general consensus was reached for a global framework for assessing male involvement in maternal health, consisting of five categories: involvement in communication, involvement in decision-making, practical involvement, physical involvement and emotional involvement.

CONCLUSIONS

Using the male involvement framework as a tool to assess the concept of male involvement in maternal health at local, national, and international levels could allow improved assessment and comparison of study findings. Further research is needed for refining the indicators according to context and exploring how shared decision-making, gender equality and women's empowerment can be assessed and facilitated within male involvement programmes.

Maternal Health Outcomes and Male Partner Involvement Among HIV Infected Women in Rural South Africa

INTRODUCTION

This study aimed to investigate the association between Male Partner Involvement (MPI) and maternal health outcomes among women attending Prevention of Mother-to-Child Transmission of HIV (PMTCT) services in rural South Africa. The association between Male Partner Participation in the main study (MPP) and maternal health outcomes among these women was also investigated.

METHODS

The study utilized data collected from 535 HIV infected women in a randomized controlled trial between 2015 and 2016. Maternal health outcome data (delivery mode, pregnancy systolic and diastolic blood pressure, pregnancy body mass index, pregnancy CD4 count, and pregnancy viral load) were collected from the women's antenatal record forms accessed from the primary healthcare facilities. Bivariate and multivariable logistic regression models were used to estimate the association between socio-demographic characteristics of the women, MPI, and MPP with maternal health outcomes.

RESULTS

The mean age of the women was 29.03 years (SD = 5.89). No significant associations were found between MPI and any of the maternal health outcomes contrary to what was hypothesized. Both the bivariate and multivariate analysis indicated a significant association between MPP and higher pregnancy viral load, contrary to the study hypothesis. Insignificant associations were found between MPP and both pregnancy CD4 count and pregnancy blood pressure. The only significant association between maternal health outcomes and socio-demographic characteristics, was between educational attainment and higher pregnancy CD4 count in both the bivariate and multivariate analysis.

CONCLUSION FOR PRACTICE

The study showed no significant support for MPI in improving maternal health outcomes of women in PMTCT in rural South Africa. Future studies should include additional maternal health outcomes for investigation.

Systematic review of the concept 'male involvement in maternal health' by natural language processing and descriptive analysis

INTRODUCTION

Experts agree that male involvement in maternal health is a multifaceted concept, but a robust assessment is lacking, hampering interpretation of the literature. This systematic review aims to examine the conceptualisation of male involvement in maternal health globally and review commonly used indicators.

METHODS

PubMed, Embase, Scopus, Web of Science and CINAHL databases were searched for quantitative literature (between the years 2000 and 2020) containing indicators representing male involvement in maternal health, which was defined as the involvement, participation, engagement or support of men in all activities related to maternal health.

RESULTS

After full-text review, 282 studies were included in the review. Most studies were conducted in Africa (43%), followed by North America (23%), Asia (15%) and Europe (12%). Descriptive and text mining analysis showed male involvement has been conceptualised by focusing on two main aspects: psychosocial support and instrumental support for maternal health care utilisation. Differences in measurement and topics were noted according to continent with Africa focusing on HIV prevention, North America and Europe on psychosocial health and stress, and Asia on nutrition. One-third of studies used one single indicator and no common pattern of indicators could be identified. Antenatal care attendance was the most used indicator (40%), followed by financial support (17%), presence during childbirth (17%) and HIV testing (14%). Majority of studies did not collect data from men directly.

DISCUSSION

Researchers often focus on a single aspect of male involvement, resulting in a narrow set of indicators. Aspects such as communication, shared decision making and the subjective feeling of support have received little attention. We believe a broader holistic scope can broaden the potential of male involvement programmes and stimulate a gender-transformative approach. Further research is recommended to develop a robust and comprehensive set of indicators for assessing male involvement in maternal health.

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

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

Impact of Male Partner Involvement on Women's Adherence to the Dapivirine Vaginal Ring During a Phase III HIV Prevention Trial

Although vaginal microbicides for HIV prevention are designed to be female-initiated, male partner influence has been identified as one of the most significant factors impacting women's willingness and ability to use them. As a result, research teams have sought to increase male partner involvement by encouraging disclosure of product use to male partners, promoting male partner engagement in the study through attendance at the study clinic, and helping women to garner male partner support for product use. This paper aims to assess the impact of these three elements of male partner involvement on women's adherence to the dapivirine vaginal ring during MTN-020/ASPIRE, a phase III randomized placebo-controlled clinical trial involving 2629 women in Malawi, South Africa, Uganda, and Zimbabwe. During the study, 64-80% of participants reported disclosure of ring use at each quarterly visit, and 13% reported that their partners had attended the study clinic at some point during the study. At study exit, 66% reported that their partner was supportive, 18% unsupportive, and 17% were unsure. After adjusting for age, site and time in study, women were more likely to have low ring adherence if they had an unsupportive male partner (aRR 1.29, 95% CI 1.03-1.62). Neither disclosure nor clinic attendance directly predicted ring adherence, but disclosure increased the probability of having a supportive partner (aRRR 24.17, 95% CI 16.38-35.66) or an unsupportive partner (aRRR 4.10, 95% CI 2.70-6.24), relative to an unknown level of partner support. Women were also more likely to have a supportive partner if their partner had attended the clinic (aRRR 3.77, 95% CI 1.36-10.42). This study suggests that although the vaginal ring is relatively discreet, lack of support from male partners remains a relevant barrier to use. Though both disclosure and clinic attendance may increase partner support, disclosure may also increase partner opposition. Interventions to reduce male partner opposition are needed to maximize the potential impact of the ring and other PrEP products for HIV prevention.

Social harms in female-initiated HIV prevention method research: state of the evidence

OBJECTIVES

Assessment of safety is an integral part of real-time monitoring in clinical trials. In HIV prevention research, safety of investigational products and trial participation has been expanded to include monitoring for 'social harms', generally defined as negative consequences of trial participation that may manifest in social, psychological, or physical ways. Further research on social harms within HIV prevention research is needed to understand the potential safety risks for women and advance the implementation of prevention methods in real-world contexts.

METHODS

Secondary analysis of quantitative data from three randomized, double-blind, placebo-controlled trials of microbicide candidates in sub-Saharan Africa was conducted. Additionally, we assessed data from two prospective cohort studies that included participants who became HIV-positive or pregnant during parent trials.

RESULTS

Social harms reporting was low across the largest and most recent microbicide studies. Social harm incidence per 100 person-years ranged from 1.10 (95% CI 0.78-1.52) to 3.25 (95% CI 2.83-3.74) in the phased trials. Reporting differed by dosing mechanism (e.g. vaginal gel, oral tablet, ring) and study, most likely as a function of measurement differences. Social harms were most frequently associated with male partners, rather than, for example, experiences of stigma in the community.

CONCLUSION

Measurement and screening for social harms is an important component of conducting ethical research of novel HIV prevention methods. To date, social harm incidence reported in microbicide trials has been relatively low (<4% per 100 person-years), and the majority have been partner-related events. However, any incidence of social harm within the context of HIV prevention is important to capture and understand for the safety of individuals, and for the successful impact of prevention methods in a real-world context.

Impact of Partner-Related Social Harms on Women's Adherence to the Dapivirine Vaginal Ring During a Phase III Trial

Background:

Long-acting female-initiated methods such as the dapivirine ring may give women greater agency in HIV-1 prevention. However, social harms, defined as nonmedical adverse consequences of study participation or dapivirine ring use, may reduce product adherence and consequently HIV-1 protection.

Methods:

We assessed whether experiencing social harms from male partners was associated with lower adherence to the dapivirine ring in the MTN-020/ASPIRE trial. Reports of social harms were solicited quarterly. Low adherence was defined by plasma dapivirine levels ≤95 pg/mL or residual dapivirine levels in returned rings >23.5 mg.

Results:

Among 2629 women enrolled in ASPIRE, 85 (3.2%) reported 87 social harms during a median follow-up of 1.6 years. Women were significantly more likely to have low adherence, measured by plasma dapivirine levels, at visits with a social harm in the past month than at visits where no social harm was reported (adjusted risk ratio 2.53, 95% confidence interval: 1.37 to 4.66, P = 0.003). There was no association for social harms reported ≥1 month prior, suggesting an acute, short-term effect. Women were significantly more likely to not return a ring at visits with a social harm reported (adjusted risk ratio 24.70, 95% confidence interval: 18.57 to 32.85, P < 0.001). In rings that were returned, social harms were not associated with residual dapivirine levels.

Conclusions:

Although social harms were uncommon (<5% of women with >1 year of use), participants reporting social harms by male partners had lower adherence to the dapivirine ring. Strategies to mitigate nonadherence to product use related to social harms should be evaluated in future studies of female-controlled HIV-1 prevention options.

Towards a definition of male partner involvement in the prevention of mother-to-child transmission of HIV in Uganda: a pragmatic grounded theory approach

BACKGROUND

Male partner involvement has been shown to increase mothers' uptake of Prevention of Mother-to-Child Transmission of HIV (PMTCT) and improve maternal and infant HIV treatment outcomes. Currently, male involvement in PMTCT is measured primarily through men's attendance at HIV testing and counselling which may not be a true reflection of their engagement. This study therefore set out to explore the meaning of male partner involvement and propose a definition and theoretical model of this concept in PMTCT in Uganda.

METHODS

Eight focus group discussions and five in-depth interviews were conducted with couples at three public health facilities and community members in the health facility catchment areas in Uganda. The study employed a grounded theory approach underpinned by the pragmatic philosophical paradigm. Data were analyzed using the constant comparative method, performing three levels of open, axial, and selective coding.

RESULTS

Of the 61 participants, 29 (48%) were male and the majority 39 (63.9%) were in long term marital relationships, while about half were self-employed 29 (47.5%). Three themes emerged for the meaning of male involvement in PMTCT (a) HIV treatment support (b) economic support and (c) psychosocial support. HIV treatment support included adherence support, couples' HIV counseling and testing, and clinic attendance during and after pregnancy. Participants expressed that men were engaged in PMTCT when they offered economic support by providing basic needs and finances or when they included their female partners in financial planning for the family. Psychosocial support arose from the female participants who defined male involvement as family support, perceived societal recognition and emotional support. Emotional support also included the absence of harm resulting from women's disclosure of HIV test results to their male partner.

CONCLUSIONS

This study proposes a new definition for male partner involvement in PMTCT in Uganda. The definition extends beyond men's clinic attendance and HIV testing and counselling. Further research should seek to develop and validate tools to accurately measure male partner involvement as the next step in the development of interventions to improve PMTCT outcomes.

Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-screening program in western Kenya

BACKGROUND

To be effective, population-based cervical cancer prevention programs must be tailored to meet the needs of the target population. One important factor in cervical cancer screening may include male involvement. To iteratively improve a screening program employing self-collected vaginal swabs for human-papillomavirus (HPV) testing in western Kenya, we examined the role of male partners and community leaders in decision-making and accessing screening services.

METHODS

We carried out 604 semi-structured, in-depth interviews (IDIs) with women and community health volunteers who took part in a multiphase trial of implementation strategies for HPV-based cervical cancer screening. IDIs were coded and themes related to decision-making, screening and treatment barriers, and influence of male partners and community leaders were identified and analyzed.

RESULTS

Women experienced both support and opposition from their male partners. Partner support took the form of financial support for transportation and emotional support and encouragement, while opposition ranged from anticipated negative reactions to lack of permission, isolation, and abandonment. Though most women described their own partners as supportive, many felt that other male partners would not be supportive. Most participants believed that increased HPV and cervical cancer knowledge would increase partner support. Women reported a general acceptance of involvement of community leaders in education and screening campaigns, in a setting where such leaders may hold influence over men in the community.

CONCLUSION

There was a clear interest in involving male partners in the cervical cancer prevention process, specifically in increasing knowledge and awareness. Future research should explore the feasibility and effectiveness of engaging male partners in cervical cancer screening and prevention programs.

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

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

Impact of a Rapid Results Initiative Approach on Improving Male Partner Involvement in Prevention of Mother to Child Transmission of HIV in Western Kenya

A rapid results initiative (RRI) aimed at increasing male involvement in prevention of mother-to-child transmission (PMTCT) and service uptake among pregnant women at 116 antenatal clinics in Western Kenya was compared at baseline, during the RRI, and 3-months post-RRI. Male involvement increased from 7.4 to 54.2% during RRI (risk difference [RD] 0.47, CI 0.45-0.48) then 43.4% post-RRI (RD 0.36, CI 0.35-0.37). Among HIV-infected women, facility delivery increased from 40.0 to 49.9% (RD 0.10, 95% CI 0.06-0.13) and 65.0% post-RRI (RD 0.25, 95% CI 0.22-0.28). HIV-infected pregnant women linkage to HIV care increased from 58.6 to 85.9% (RD 0.27, CI 0.24-0.30) and 97.3% post-RRI (RD 0.39, CI 0.36-0.41). Time to ART initiation reduced from 29 days (interquartile range [IQR] 6-56) to 14 days (IQR 0-28) to 7 days (IQR 0-20). A male-centered RRI can significantly increase men's engagement in antenatal care leading to improved partner utilization of PMTCT and antenatal services.

Understanding women and men's acceptability of current and new HIV prevention technologies in KwaZulu-Natal, South Africa

Despite significant advances to the HIV epidemic, prevention remains a challenge globally. Adolescent girls and young women in southern and Eastern Africa are still at high risk of acquiring HIV infection with limited prevention options. The expanding product pipeline of novel drugs and delivery approaches has highlighted the importance of acceptability and uptake of these anti-retroviral based products to realize their full prevention potential. Community engagement is now imperative to inform both product development and uptake; with research directed to understand what potential users are willing to use given the broader cultural-gender context in which HIV prevention product choices are made/negotiated. We conducted ten gender specific discussion groups with 112 participants in three of the eight highest HIV prevalence districts in urban, peri-urban, and rural KwaZulu-Natal. The participants where purposively selected according to age, location and sex. The data was analysed thematically in terms of the key enablers and barriers of accepting three key HIV dosing strategies; the oral pill, the vaginal ring and the injectable among men and women. The study found that women are willing to consider HIV prevention options that align with their current sexual and reproductive health routines, offers the longest duration of protection, and requires minimal/no partner involvement, in contrast most men were not supportive of their partners using of any form of PrEP, irrespective of dosing strategies and formulations as it raised questions of infidelity and side effects on men. The findings is indicative of the complexities of women's product choices, which are often embedded in a system of personal preference on an intrapersonal level, but also of male dominance, gender norms and cultural contexts at an interpersonal level. Understanding this intrapersonal-interpersonal interplay can enhance PrEP messaging and promotion; further highlighting the need to expand biomedical innovations for women initiated technologies.

"The co-authors of pregnancy": leveraging men's sense of responsibility and other factors for male involvement in antenatal services in Kinshasa, DRC

Background

Despite efforts to improve male involvement (MI), few male partners typically attend antenatal care (ANC). MI in ANC and interventions to prevent mother-to-child HIV transmission have been demonstrated to be beneficial for the HIV-positive mother and her child. This study aimed to explore factors influencing partner attendance and highlight interventions with potential to improve MI within a Congolese context.

Methods

This was an exploratory, qualitative study conducted in two urban and two semi-urban catchment areas of Kinshasa, DRC in June–September 2016. Two women-only and two men-only focus group discussions (FGDs) were held; participants were recruited from ANC clinics and surrounding communities. Key informants purposively selected from health facility leadership and central government were also interviewed. Guide topics included MI barriers and facilitators, experiences with couples’ ANC attendance and perceptions of MI interventions and how to improve them. Data from FGDs and interviews were analyzed to determine three interventions that best addressed the identified MI facilitators and barriers. These interventions were explored further through dialogues held with representatives from community organizations.

Results

This study included 17 female and 18 male FGD participants, 3 key informants and 21 community dialogue participants. Receipt of clinic staff advice was the most commonly-reported factor facilitating male attendance. No time off work was the most commonly-reported barrier. Only men identified responsibility, referring to themselves as “authors of the pregnancy,” and wanting to be tested for HIV as facilitators. The most promising interventions perceived by FGD and interview participants were male partner invitation letters, couple- and male-friendly improvements to ANC, and expert peer-to-peer outreach. Community dialogue participants provided further detail on these approaches, such as invitation letter content and counseling messages targeting men attending ANC.

Conclusions

Common themes regarding male involvement in ANC that emerged from this study included men’s need to understand how the pregnancy is progressing and how best to care for their female partners and unborn children, and ANC settings that were misaligned to the needs of men and couples. Interventions at the individual, facility and community levels were discussed that could result in improvements to male attendance at pregnancy-related services.

Willingness to use short-term oral pre-exposure prophylaxis (PrEP) by migrant miners and female partners of migrant miners in Mozambique

Migrant miners from Mozambique who work in South Africa and their partners are at substantial risk for HIV infection. We conducted a cross-sectional study to assess the willingness of migrant miners and female partners of miners to take short-term pre-exposure prophylaxis (PrEP) for prevention of HIV acquisition. The study was conducted in Gaza Province, Mozambique, between September and October 2015. A total of 131 male miners and female partners of male miners completed a questionnaire. Subsequently, 48 in-depth interviews among male miners and female partners of miners and 3 focus-group discussions (6 participants each) among female partners of miners were conducted. Quantitative data were tabulated using Stata. A structured coding scheme was developed and qualitative data were analysed using Atlas.ti. Most participants (94%) were willing to take PrEP for short-term use. Facilitating factors for willingness to use PrEP were concerns about partner's sexual behaviour, desire for pregnancy and one's own sexual behaviour. The main barriers to PrEP use were concerns regarding side-effects, perceived difficulty adhering to daily pill taking and concern about partner/family disapproval. Overall, participants saw potential barriers for PrEP as minor obstacles that could be overcome. The male partner's influence on PrEP use was significant.

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

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

A Qualitative Exploration of the Meaning and Understanding of Male Partner Involvement in Pregnancy-Related Care among men in rural South Africa

Male partner involvement (MPI) during antenatal care has been promoted as an effective intervention to improve maternal and newborn health outcomes. Although MPI is commonly defined as men attending antenatal clinic visits with their female partner, few men attend antenatal clinic visits in rural communities in the province of Mpumalanga, South Africa. The study aimed to qualitatively explore the meaning and understanding of MPI as perceived by men visiting primary health care clinics in rural communities in Mpumalanga. Six focus groups discussions (n = 53) were conducted, digitally recorded, simultaneously transcribed, and translated verbatim into English. Data were analyzed using thematic content analysis. Perceptions of male roles during and after pregnancy differed among men. Male involvement was understood as giving instrumental support to female partners through financial help, helping out with physical tasks, and providing emotional support. Accompanying female partners to the clinic was also viewed as partner support, including behaviors such as holding a spot for her in the clinic queues. Community attitudes, traditional beliefs, and negative experiences in health facilities were barriers for MPI. This study provides support for concerted efforts to work with both men and women within the cultural context to explore the important roles of all members of the family in working together to provide the best possible health outcomes for mother and infant. In particular, future interventions should focus on making antenatal care services more responsive to male partners, and improving male partner accessibility in health care facilities.

Male Partner Participation in Antenatal Clinic Services is Associated With Improved HIV-Free Survival Among Infants in Nairobi, Kenya: A Prospective Cohort Study

OBJECTIVE

This prospective study investigated the relationship between male antenatal clinic (ANC) involvement and infant HIV-free survival.

METHODS

From 2009 to 2013, HIV-infected pregnant women were enrolled from 6 ANCs in Nairobi, Kenya and followed with their infants until 6 weeks postpartum. Male partners were encouraged to attend antenatally through invitation letters. Men who failed to attend had questionnaires sent for self-completion postnatally. Multivariate regression was used to identify correlates of male attendance. The role of male involvement in infant outcomes of HIV infection, mortality, and HIV-free survival was examined.

RESULTS

Among 830 enrolled women, 519 (62.5%) consented to male participation and 136 (26.2%) men attended the ANC. For the 383 (73.8%) women whose partners failed to attend, 63 (16.4%) were surveyed through outreach. In multivariate analysis, male report of previous HIV testing was associated with maternal ANC attendance (adjusted odds ratio = 3.7; 95% CI: 1.5 to 8.9, P = 0.003). Thirty-five (6.6%) of 501 infants acquired HIV or died by 6 weeks of life. HIV-free survival was significantly greater among infants born to women with partner attendance (97.7%) than those without (91.3%) (P = 0.01). Infants lacking male ANC engagement had an approximately 4-fold higher risk of death or infection compared with those born to women with partner attendance (HR = 3.95, 95% CI: 1.21 to 12.89, P = 0.023). Adjusting for antiretroviral use, the risk of death or infection remained significantly greater for infants born to mothers without male participation (adjusted hazards ratio = 3.79, 95% CI: 1.15 to 12.42, P = 0.028).

CONCLUSIONS

Male ANC attendance was associated with improved infant HIV-free survival. Promotion of male HIV testing and engagement in ANC/prevention of mother-to-child transmission services may improve infant outcomes.

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

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

Male Partner Influence on Women's HIV Prevention Trial Participation and Use of Pre-exposure Prophylaxis: the Importance of "Understanding"

There is widespread evidence that male partners influence women's ability and willingness to join HIV prevention trials and to use female-controlled prevention strategies such as microbicide gels. VOICE-C was an ancillary study to the Microbicide Trials Network's VOICE trial at the Johannesburg site that explored social and structural factors influencing women's use of study tablets and vaginal gel. Qualitative data were analyzed from 102 randomly-selected VOICE participants interviewed through in-depth interviews (IDI, n = 41); ethnographic interviews (n = 21) or focus group discussions (FGD, n = 40) and 22 male partners interviewed in 14 IDI and 2 FGD. Male partners' "understanding" pervaded as a central explanation for how male partners directly and indirectly influenced their female partners' trial participation and product use, irrespective of assignment to the gel or tablet study groups. The meaning behind "understanding" in this context was described by both men and women in two important and complementary ways: (1) "comprehension" of the study purpose including biological properties or effects of the products, and (2) "support/agreeability" for female partners being study participants or using products. During analysis a third dimension of "understanding" emerged as men's acceptance of larger shifts in gender roles and relationship power, and the potential implications of women's increased access to biomedical knowledge, services and prevention methods. Despite displays of some female agency to negotiate and use HIV prevention methods, male partners still have a critical influence on women's ability and willingness to do so. Efforts to increase their understanding of research goals, study design and products' mechanisms of action could ameliorate distrust, empower men to serve as product advocates, adherence buddies, and foster greater adherence support for women in situations where it is needed. Strategies to address gender norms and the broader implications these have for female-initiated HIV prevention should likewise be integrated into future research and program activities.

Improving men's participation in preventing mother-to-child transmission of HIV as a maternal, neonatal, and child health priority in South Africa

Wessel van den Berg and colleagues outline how increasing male partner involvement in efforts to reduce mother-to-child HIV transmission in South Africa may improve maternal and infant outcomes.

Pregnant women's experiences of male partner involvement in the context of prevention of mother-to-child transmission in Khayelitsha, South Africa

Male partner involvement (MPI) has been identified as a priority intervention in programmes for the prevention of mother-to-child transmission (PMTCT) of HIV, but rates of MPI remain low worldwide. This study used a quantitative survey (n=170) and two focus group discussions (FGDs) with 16 HIV-positive pregnant women attending a public sector antenatal care service in Khayelitsha, South Africa, to examine the determinants of high levels of involvement and generate a broader understanding of women's experiences of MPI during pregnancy. Among survey participants, 74% had disclosed their status to their partner, and most reported high levels of communication around HIV testing and preventing partner transmission, as well as high levels of MPI. High MPI was significantly more likely among women who were cohabiting with their partner; who had reportedly disclosed their HIV status to their partner; and who reported higher levels of HIV-related communication with their partner. FGD participants discussed a range of ways in which partners can be supportive during pregnancy, not limited to male attendance of antenatal care. MPI appears to be a feasible intervention in this context, and MPI interventions should aim to encourage male partner attendance of antenatal care as well as greater involvement in pregnancy more generally. Interventions that target communication are needed to facilitate HIV-related communication and disclosure within couples. MPI should remain a priority intervention in PMTCT programmes, and increased efforts should be made to promote MPI in PMTCT.

Challenging gender inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base

Men's involvement in the health of women and children is considered an important avenue for addressing gender influences on maternal and newborn health. The impact of male involvement around the time of childbirth on maternal and newborn health outcomes was examined as one part of a systematic review of maternal health intervention studies published between 2000 and 2012. Of 33,888 articles screened, 13 eligible studies relating to male involvement were identified. The interventions documented in these studies comprise an emerging evidence base for male involvement in maternal and newborn health. We conducted a secondary qualitative analysis of the 13 studies, reviewing content that had been systematically extracted. A critical assessment of this extracted content finds important gaps in the evidence base, which are likely to limit how 'male involvement' is understood and implemented in maternal and newborn health policy, programmes and research. Collectively, the studies point to the need for an evidence base that includes studies that clearly articulate and document the gender-transformative potential of involving men. This broader evidence base could support the use of male involvement as a strategy to improve both health and gender equity outcomes.

Acceptability of vaginal microbicides among female sex workers and their intimate male partners in two Mexico-US border cities: a mixed methods analysis

Female sex workers (FSWs) may benefit from pre-exposure prophylaxis (PrEP) including microbicides for HIV prevention. Since adherence is a key factor in PrEP efficacy, we explored microbicide acceptability and potential barriers to use within FSWs' intimate relationships in Tijuana and Ciudad Juárez, Mexico, where HIV prevalence is increasing. FSWs and their verified intimate (non-commercial) male partners completed quantitative and qualitative interviews from 2010 to 2012. Our complementary mixed methods design followed an iterative process to assess microbicide acceptability, explore related relationship dynamics and identify factors associated with concern about male partners' anger regarding microbicide use. Among 185 couples (n=370 individuals), interest in microbicides was high. In qualitative interviews with 28 couples, most participants were enthusiastic about microbicides for sex work contexts but some explained that microbicides could imply mistrust/infidelity within their intimate relationships. In the overall sample, nearly one in six participants (16%) worried that male partners would become angry about microbicides, which was associated with higher self-esteem among FSWs and lower self-esteem and past year conflicts causing injury within relationships among men. HIV prevention interventions should consider intimate relationship dynamics posing potential barriers to PrEP acceptability and adherence, involve male partners and promote risk communication skills.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

The importance of addressing gender inequality in efforts to end vertical transmission of HIV

ISSUES

The recently launched "Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive" sets forth ambitious targets that will require more widespread implementation of comprehensive prevention of vertical HIV transmission (PMTCT) programmes. As PMTCT policymakers and implementers work toward these new goals, increased attention must be paid to the role that gender inequality plays in limiting PMTCT programmatic progress.

DESCRIPTION

A growing body of evidence suggests that gender inequality, including gender-based violence, is a key obstacle to better outcomes related to all four components of a comprehensive PMTCT programme. Gender inequality affects the ability of women and girls to protect themselves from HIV, prevent unintended pregnancies and access and continue to use HIV prevention, care and treatment services.

LESSONS LEARNED

In light of this evidence, global health donors and international bodies increasingly recognize that it is critical to address the gender disparities that put women and children at increased risk of HIV and impede their access to care. The current policy environment provides unprecedented opportunities for PMTCT implementers to integrate efforts to address gender inequality with efforts to expand access to clinical interventions for preventing vertical HIV transmission. Effective community- and facility-based strategies to transform harmful gender norms and mitigate the impacts of gender inequality on HIV-related outcomes are emerging. PMTCT programmes must embrace these strategies and expand beyond the traditional focus of delivering ARV prophylaxis to pregnant women living with HIV. Without greater implementation of comprehensive, gender transformative PMTCT programmes, elimination of vertical transmission of HIV will remain elusive.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Unraveling the divergent results of pre-exposure prophylaxis trials for HIV prevention

Although the balance of recent evidence supports the efficacy of antiretroviral (ARV)-based pre-exposure prophylaxis (PrEP) against HIV-1 infection, recent negative trial results are perplexing. Of seven trials with available HIV endpoints, three different products have been tested: tenofovir 1% vaginal gel, oral tenofovir disoproxil fumarate (TDF) tablets, and TDF/emtricitabine tablets. Six of these trials were conducted exclusively in sub-Saharan Africa; all found the products to be well tolerated, and four demonstrated effectiveness. Furthermore, the HIV Prevention Trial Network (HPTN) 052 trial recently confirmed that antiretroviral treatment leads to 96% reduction in transmission to HIV-negative partners in HIV-serodiscordant couples. These results, along with human and animal data, provide substantial evidence for the efficacy of antiretroviral-based HIV prevention. Yet assessment of oral TDF/emtricitabine in the FEM-PrEP study and of oral and vaginal tenofovir in the Microbicide Trial Network (MTN)-003 trial (VOICE) was stopped for futility. How do we make sense of these discrepant results? We believe that adherence is a key factor, although it cannot be the only factor. Expanding upon a recent editorial in the Lancet, we discuss the impact of suboptimal product adherence on PrEP efficacy in the context of variable drug concentration at the exposure site, integrity of the vaginal epithelium, and the role of acute infection.