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

Involving men in pregnancy: a cross-sectional analysis of the role of self-efficacy, gender-equitable attitudes, relationship dynamics and knowledge among men in Kinshasa

BACKGROUND

Although male participation in maternal health has gained increasing recognition and support over the years, little is known about male involvement during pregnancy in the Democratic Republic of the Congo. This paper identified male involvement patterns during pregnancy and evaluated their associations with pregnancy and birth preparedness knowledge, gender-equitable attitudes, self-efficacy, and co-parental relationship factors. Lastly, it explored the moderating effect of gender-equitable attitudes and intimate partner violence on the association between relationship satisfaction and male involvement.

METHODS

Data from the 2018 Momentum baseline study were analyzed to determine the predictors of involvement. Factor analysis was used to create male involvement indices for antenatal carebirth preparedness and shared decision making. The sample consisted of 1,674 male partners of nulliparous pregnant women who were 6 months pregnant at baseline.

RESULTS

Male involvement in individual pregnancy-related activities was low, ranging from 11% (finding a blood donor) to 49% (saving money during emergencies). Knowledge of the number of antenatal care visits, birth preparedness steps, and newborn danger signs were positively associated with involvement in antenatal care/birth preparedness activities while knowledge of antenatal care benefits was positively associated with involvement in shared decisions. Increasing relationship satisfaction and self-efficacy were associated with antenatal care/birth preparedness involvement and for shared decisions, a positive association with gender-equitable attitude and a negative association with self-efficacy were observed. Moderation effects were also detected.

CONCLUSIONS

The findings suggest that male involvement is multifaceted and factors influencing involvement vary depending on the type of involvement. Addressing these factors can improve male participation in maternal health.

Using the RE-AIM Framework to Evaluate Implementation of Male Involvement Strategies to Optimize the PMTCT Program in Malawi: A Mixed-Methods Study

Involvement of male partners has been shown to be key for the prevention of mother-to-child HIV transmission (PMTCT). Despite the recorded success, uptake and implementation of strategies to involve men in PMTCT continues to be low in Malawi. In this study, we used the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) implementation science framework to explore the implementation of male involvement (MI) strategies in Lilongwe, Malawi. We used a cross-sectional mixed-methods complementary-concurrent design from September to October 2020 in two health facilities. Qualitatively, we used a phenomenological approach and conducted seven focus group discussions (FGDs), three with women and four with men. We further conducted four key informant interviews (KIIs) among health care workers. Quantitatively, we conducted a cross-sectional study comprising 138 men presenting at an antenatal clinic (ANC). We used univariate analysis in Stata for the quantitative data, whereas a manual thematic analysis was applied to the qualitative data. Implementation and adoption of the strategies was high among health providers and there were indications of maintenance of the strategies. Provider's attitude, coordinated service provision, integrated training and service provision, information provision, and baby's HIV outcomes were driving factors in implementing the MI strategies. These factors have contributed to the sustained implementation of the strategies over time. In contrast, financial and time constraints, inadequate human resources, and male-friendly spaces impede the implementation of MI strategies. Improving MI will require a systems approach considering health system and individual-level factors for both providers and consumers.

'I did not get this disease on the street; it was brought home as a gift': Gender, violence and HIV vulnerability among Cuban women

While gay, bisexual and other men who have sex with men are most affected by HIV in Cuba, infections among women have increased over time, but there has been little research to contextualise their vulnerability to HIV. The purpose of this study was to explore the role of gender and violence in shaping vulnerability to HIV among Cuban women. Qualitative in-depth interviews were conducted with women living with HIV at an outpatient HIV clinic in Havana. Narrative and thematic technique were used to systematically analyse the data. Participants described negotiating sexual relationships in a context where traditional gender norms merge with the paradox of increasing professional opportunities for women alongside growing economic precarity. Interconnected economic and emotional dependence along with violence influenced the acceptance of certain behaviours that heightened vulnerability to HIV, including inconsistent condom use and infidelity. Gender transformative approaches that recognise the complex interplay between gender norms, economic precarity and violence are needed to address women's vulnerability to HIV in the Cuban context. Such efforts can reinforce existing strategies to promote behaviourally focused prevention while creating an enabling environment for the integration and expansion of biomedical innovation in HIV prevention.

A qualitative exploration of roles and expectations of male partners from PMTCT services in rural Malawi

BACKGROUND

Prevention of mother-to-child transmission of HIV (PMTCT) is effective in curbing rates of HIV infection in children because its interventions reduce the rates of transmission during pregnancy, in labour, and in breastfeeding. Male involvement (MI) greatly influences uptake and adherence to PMTCT services. Lack of clarity on the roles and expectations of men in PMTCT is one of the main barriers to MI. The main aim of the study was to explore the roles and expectations of male partners from PMTCT services in Malawi.

METHODS

This was a descriptive qualitative study that involved men whose partners were either pregnant or breastfeeding a child, health care workers working in PMTCT services for over six months, and traditional leaders. We conducted 9 in-depth interviews and 12 key informant interviews from January to March 2018. All interviews were audio-recorded, transcribed, and translated. Thematic analysis was employed to analyze data.

RESULTS

The subjective and community norms and attitudes of men towards PMTCT provide the context in which male partners define the specific roles they render and the services they expect from PMTCT services. The roles of men in PMTCT service were contextualized in what is socially acceptable and normalized in the setting and include supportive roles expressed as accompanying the wife to attend; antenatal care services, Dry blood sample collection (DBS) when its due, keeping appointments when is due to take the ARVs, providing financial support; HIV prevention behavior change and decision-making roles. The desired services within PMTCT include health assessment such as checking their weight; blood pressure; blood sugar and promotion activities such as education sessions that are provided in a male-friendly manner that is in tandem with existing socio-cultural norms and attitudes of men towards such services.

CONCLUSION

The roles of male partners in PMTCT services are underpinned by subjective norms and what is socially acceptable within a specific context. The services that men require from PMTCT services are influenced by their attitudes and beliefs towards PMTCT interventions. Services should be male-tailored provided in an atmosphere that allows and accepts male partners to exercise their roles in PMTCT services.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19384.

Socio-cultural and economic barriers, and facilitators influencing men's involvement in antenatal care including HIV testing: a qualitative study from urban Blantyre, Malawi

Background

Male partner involvement in antenatal care (ANC) is associated with positive maternal and neonatal outcomes. However, only a handful of men attend ANC with their partners. This study aimed to understand the underlying barriers and facilitators influencing men’s ANC attendance including HIV testing in Blantyre, Malawi.

Methods

Data were collected during a formative qualitative study of a cluster-randomised trial. Six focus group discussions (FGDs) with 42 men and women and 20 in-depth interviews (IDIs) were conducted at three primary health centres in urban Blantyre, Malawi. FGD participants were purposively sampled with IDI participants subsequently sampled after FGD participation. Thematic analysis was used to analyse the data.

Results

The economic requirement to provide for their families exerted pressure on men and often negatively affected their decision to attend ANC together with their pregnant partners despite obvious benefits. Peer pressure and the fear to be seen by peers queueing for services at ANC, an environment traditionally viewed as a space for women and children made men feel treated as trespassers and with some level of hostility rendering them feeling emasculated when they attend ANC. Health system problems associated with overall organization of the ANC services, which favours women created resistance among men to be involved. An association between ANC and HIV testing services discouraged men from attending ANC because of their fear of testing HIV-positive in the presence of their partners. The availability of a male friendly clinic offering a private, quick, supportive/sensitive and flexible service was considered to be an important incentive that would facilitate men’s ANC attendance. Men described compensation to cover transport and opportunity cost for attending the clinic as a motivator to attending ANC services and accepting an HIV test.

Conclusion

Peer and economic influences were the most influential barriers of men attending ANC and testing for HIV with their pregnant partners. Addressing these socio-economic barriers and having a male friendly clinic are promising interventions to promote male ANC attendance in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10112-w.

Access to maternal-child health and HIV services for women in North-Central Nigeria: A qualitative exploration of the male partner perspective

BACKGROUND

In much of sub-Saharan Africa, male partners play influential roles in women's access to maternal-child healthcare, including prevention of mother-to-child transmission of HIV services. We explored male partner perspectives on women's access to maternal-child healthcare in North-Central Nigeria.

METHODS

Three focus groups were conducted with 30 men, purposefully-selected on the basis of being married, and rural or urban residence. Major themes explored were men's maternal-child health knowledge, gender power dynamics in women's access to healthcare, and peer support for pregnant and postpartum women. Data were manually analyzed using Grounded Theory, which involves constructing theories out of data collected, rather than applying pre-formed theories.

RESULTS

Mean participant age was 48.3 years, with 36.7% aged <40 years, 46.7% between 41 and 60 years, and 16.6% over 60 years old. Religious affiliation was self-reported; 60% of participants were Muslim and 40% were Christian. There was consensus on the acceptability of maternal-child health services and their importance for optimal maternal-infant outcomes. Citing underlying patriarchal norms, participants acknowledged that men had more influence in family health decision-making than women. However, positive interpersonal couple relationships were thought to facilitate equitable decision-making among couples. Financial constraints, male-unfriendly clinics and poor healthcare worker attitudes were major barriers to women's access and male partner involvement. The provision of psychosocial and maternal peer support from trained women was deemed highly acceptable for both HIV-positive and HIV-negative women.

CONCLUSIONS

Strategic engagement of community leaders, including traditional and religious leaders, is needed to address harmful norms and practices underlying gender inequity in health decision-making. Gender mainstreaming, where the needs and concerns of both men and women are considered, should be applied in maternal-child healthcare education and delivery. Clinic fee reductions or elimination can facilitate service access. Finally, professional organizations can do more to reinforce respectful maternity care among healthcare workers.

Improving male involvement in antenatal care in low and middle-income countries to prevent mother to child transmission of HIV: A realist review

BACKGROUND

Childhood Human Immunodeficiency Virus (HIV) infection occurs almost exclusively via mother to child transmission (MTCT) during pregnancy, birth, or through breastfeeding. Recent studies have shown that male involvement (MI) in antenatal care (ANC) and HIV testing, including couples voluntary counselling and testing (CVCT), increases the likelihood that women will adhere to prevention advice and comply with HIV treatment if required during their pregnancy; hence reducing the rates of MTCT of HIV. This realist review investigates how, why, when, and for whom MI in ANC works best to provide contextual advice on how MI in ANC can be best used for prevention of mother to child transmission (PMTCT) of HIV.

METHODS

A realist review of existing evidence was conducted. Realist review seeks to explain how and why an intervention works, or does not work, in a given context. This was completed through the five stages of realist synthesis; Eliciting the program theory, search strategy, study selection criteria, data extraction, and data analysis and synthesis. Findings are presented as context-mechanism-outcome (CMO) configurations outlining the mechanisms that work in given contexts to give an outcome.

RESULTS

Three CMO configurations were developed. These describe that 1) Couples in monogamous relationships have higher levels of trust, commitment and security leading to increased uptake of PMTCT programs together; 2) ANC spaces that make 'male friendly' adaptions promote normalisation of MI in PMTCT and are more welcoming, leading to increased willingness of male partners to participate in ANC; and 3) couples and communities with higher health literacy encourage increased informed decision making, ownership, and responsibility and thus increased participation in PMTCT of HIV.

CONCLUSIONS

The CMOs developed in this review give contextual advice on how one might improve ANC services to increase MI and help reduce MTCT of HIV. We propose that MI in ANC works best where couples are monogamous and trusting, where ANC spaces actively promote being a 'male friendly space' and where there are high levels of community education programs around MTCT.

Correlates of HIV-Positive Fathers' Involvement in Prevention of Mother-to-child Transmission Programs in Northern Nigeria

BACKGROUND

The involvement of men in prevention of mother-to-child HIV transmission (PMTCT) programs could accelerate the elimination of vertical transmission. Yet, little research has focused on HIV-positive male partners. This study determined the predictors of male partners' PMTCT knowledge and involvement in a tertiary hospital in northern Nigeria.

METHODS

A clinic-based sample of 401 HIV-positive male partners of women who delivered within 12 months prior were interviewed using structured questionnaires. PMTCT knowledge and involvement scores were computed. Adjusted odd ratios (AOR) for predictors were derived from multivariate logistic regression models.

RESULTS

The proportion of respondents with adequate PMTCT knowledge was 40.9%. Less than half (43.6%) of the respondents participated in PMTCT, with median involvement score of 2.00 (interquartile range, IQR = 0, 5.0). One quarter of respondents (25.7%, n =103) reported >1 sex partners, 10.5% consistently used condoms, and 20.7% had disclosed to all partners. Fathers' involvement in PMTCT was predicted by paternal education (AOR = 0.30; 95% Confidence Interval (CI): 0.12-0.77, no formal vs. post-secondary), HIV-positive child (AOR = 3.85; 95%CI: 1.41-10.54, yes vs. no), treatment duration (AOR = 4.17; 95%CI: 1.67-10.41, ≤1 vs. ≥10 years), disclosure to partner(s) (AOR = 1.21; 95%CI: 1.15-3.52, 'disclosed to all' vs. 'not disclosed'), condom use (AOR = 5.81; 95%CI: 3.07-11.0, always vs. never), and PMTCT knowledge (AOR = 0.62; 95%CI: 0.31-0.92, inadequate versus adequate).

CONCLUSION

The involvement of fathers in HIV PMTCT programs was low and predicted by paternal education, HIV-positive child, duration of antiretroviral treatment, disclosure to partner, consistent condom use, and level of PMTCT knowledge. Our findings will inform the development of policies to increase male partner involvement in PMTCT in Nigeria.

Reaching hard-to-reach men through home-based couple HIV testing among pregnant women and their male partners in western Kenya: a qualitative study

Background

Globally only 79% of adults living with HIV (human immunodeficiency virus) know their status and men in sub-Saharan Africa are considered a particularly hard-to-reach population for HIV testing. Home-based HIV couple testing during the antenatal period is a safe and effective method that has been used to test male partners of pregnant women. The goal of this qualitative study was to identify elements that made couple testing successful and describe important characteristics of this home-based intervention from couples’ perspectives.

Methods

Couples who received scheduled home-based couple testing during pregnancy in Kisumu, Kenya, were purposively sampled based on HIV status from January to May 2015. An interviewer administered all of the in-depth interviews and two coders were directly involved in the data analysis and reconciled codes several times in the process.

Results

Twenty-one couples were enrolled: 9 concordant HIV-negative couples, 8 HIV discordant couples, 3 HIV concordant HIV-positive couples, and 1 whose concordance status was unknown. Median age at the time of home-based couple testing was 24 and 28 years for women and men, respectively. Median relationship duration was 3 years and couples had a median of two pregnancies. The major themes that emerged were that home-based couple testing 1) removed the female burden of requesting couple testing, 2) overcame logistical barriers associated with clinic-based testing, 3) encouraged participants to overcome their fear of testing and disclosure, 4) provided privacy in the home, and 5) provided quality time with the health advisors. Importantly, some women appreciated individual testing at the clinic before couple testing and some couples preferred skilled, anonymous health advisors delivering the intervention rather than known community health workers.

Conclusions

The results of this qualitative study suggest that home-based couple testing during pregnancy overcame many of the barriers that limit men’s access to and uptake of clinic-based testing. It encouraged participants to overcome their fear of testing and disclosure through a setting that afforded privacy and quality time with skilled health advisors. These qualitative results may help design effective partner and couple HIV testing programs in the antenatal setting and alongside or within other assisted partner notification services.

Trial Registration

Clinicaltrials.gov registry: NCT01784783. Registered prospectively on June 15, 2012.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effectiveness of interventions to involve men living with HIV positive pregnant women in low-income countries: a systematic review of the literature

BACKGROUND

Male involvement (MI) along the continuum of HIV healthcare services has been promoted as a critical intervention in low-income countries and represents one of the reasons for dropout and low retention of women along the cascade of care. The present review aims to identify interventions adopted to improve MI across Antenatal Clinics (ANCs).

METHODS

For this systematic review, we searched electronic databases, including Scopus, PubMed, Web of Science (from 2008 to 2018) in English language. We included all interventions explicitly aimed at involving partners in pregnant women's HIV continuum of care and we excluded studies performed in developed countries, not involving pregnant women. We followed the PRISMA checklist.

RESULTS

We identified a total of 1694 records and excluded 1651 after duplicates were removed and abstract eligibility assessments were performed. Forty-three full-text articles were screened, but only 12 studies were included. Recurrent intermediate outcomes were antenatal partner attendance rate and male HIV testing. We subdivided articles according to the type of intervention: single intervention (7) and multiple interventions (5). Among single interventions, two studies evaluated the use of an invitation letter sent via women to encourage male attendance to the ANC. Four Randomized Controlled Trials (RCTs) compared the invitation card (standard of care, SC) to word of mouth, information letter, home visit and invitation card plus partner tracing. The partner attendance rate was lower in SC than in the intervention arm in three RCTs: information letter (14.2% vs 16.2%), home-visit (39% vs 87%) and invitation card plus partner tracing (52% vs 74%). Home visit strategies seemed the most effective. One study evaluated words of encouragement adopted to trigger women to invite their partners. Among multiple interventions, the most effective strategies in terms of male attendance included health promotion through education and healthcare worker development. These interventions were more likely to be effective in promoting MI than single interventions.

CONCLUSIONS

From the review emerges the importance of male involvement in HIV cascade for pregnant women in countries with a significant HIV incidence and the need to define more precise indicators for measuring MI.

"What Will I Be Doing There Among So Many Women?": Perceptions on Male Support in Prevention of Mother to Child Services in Lilongwe, Malawi

Participation of males in the prevention of mother-to-child transmission (PMTCT) programs remains a challenge despite the implementation of guidelines. The study aimed at exploring male involvement in the PMTCT program at a primary health facility in Lilongwe, Malawi. Focus group discussions and in-depth individual interviews were used to collect data from health care workers, men, and women who were attending PMTCT services. Snowball sampling was used to recruit participants who were purposively identified. Alcohol consumption, pressure from work places, stigma, role conflict, denial or nondisclosure of HIV status among women, and lack of awareness were among factors found to hinder male participation in PMTCT services. Therefore, to have an effective PMTCT program, male involvement is needed as this could positively influence the delivery of interventions including antiretroviral treatment among HIV-infected pregnant women. As such, health education awareness campaigns emphasizing the value of men in PMTCT services should be reinforced.

Prevention of mother-to-child transmission (PMTCT) of HIV: a review of the achievements and challenges in Burkina-Faso

BACKGROUND

Burkina-Faso's HIV/AIDS program is one of the most successful in Africa, with a declining HIV prevalence and treatment outcomes that rival those of developed countries. Prevention of mother-to-child transmission (PMTCT) guidelines in Burkina-Faso, initiated in the year 2000, were revised in 2004, 2006 and 2010. The guideline document has since undergone several stages of improvement, largely based on recommendations from WHO, with adaptations by local experts in the field. Option B+ adopted since August 2014 in Burkina-Faso has enabled maintenance of mothers on longer treatment and increasing their survival and that of their children. Through this review, we describe the achievements and challenges of HIV PMTCT programs in Burkina-Faso.

AIMS OF STUDY

This study had the following objectives: 1) describing the historical perspective of PMTCT implementation in Burkina-Faso; 2) presenting the effectiveness of interventions at improving PMTCT service delivery and promoting retention of mothers and babies in care; and 3) determining the impact of male partner involvement on PMTCT in Burkina-Faso.

METHODOLOGY

A literature search was conducted in PubMed and Google. Search terms included the following keywords: "HIV testing"; "prevention"; "mother"; "child"; "male partner"; "counseling"; "involvement"; "participation"; and the grouped terms "PMTCT and partners"; "VCT"; "barriers and/or factors"; "Male involvement in PMTCT"; and "Burkina-Faso". Data collection took place from May to October 2015. The search was limited to articles published between January 2002 and December 2015. UNICEF and UNAIDS web sites were also used to find relevant abstracts and documents.

RESULTS

Studies have revealed that with PMTCT, HIV transmission rate moved from 10.4% in 2006 to 0% in 2015. The PMTCT program remains the best way to care for HIV-infected pregnant women and their babies. The current PMTCT policy is based on evidence that male partner involvement is associated with women's completion of PMTCT.

CONCLUSION

This study shows that the reduction in mother to child transmission of HIV in Burkina-Faso over the years is mainly due to the improvement of PMTCT programs. Efforts still need to be made about the involvement of male partners.

Acceptability of couple antenatal education: A qualitative study of expectant couples attending antenatal clinics in Blantyre, Malawi

Background

Few studies have assessed the effectiveness and acceptability of male partner involvement in antenatal education. Yet, male involvement in antenatal care including antenatal education has been proposed as a strategy to improve maternal and neonatal outcomes. We conducted this study to add to the body of knowledge on acceptability of male partner involvement in antenatal education following an intervention.

Methods

This was a cross sectional qualitative study using 18 in-depth interviews with 10 couples, 5 women from the couples group and 3 nurse-midwife technicians. Participants were purposively selected and interviewed between July and November, 2017. The study setting was South Lunzu and Mpemba Health Centres and their catchment areas. All interviews were audiotaped, transcribed verbatim and translated from Chichewa into English. Data were coded in Nvivo 10.0 and analyzed thematically.

Findings

We identified three themes: benefit of content received; organization of couple antenatal education appropriate for male partner involvement; and delivery of couple antenatal education incentive for male involvement and learning. However, some improvements were suggested regarding content, organization and delivery of the education sessions.

Conclusion

Couple antenatal education was acceptable to the couples and the facilitators in terms of content received, organization and delivery. Nevertheless, adding naming the baby to the list of topics, creating a special day for couples to attend antenatal education and providing a readable leaflet are likely to make couple antenatal education more user friendly.

Exploring antenatal education content for couples in Blantyre, Malawi

BACKGROUND

Despite advocating for male involvement in antenatal education, there is unmet need for antenatal education information for expectant couples. The objective of this study was to gain a deeper understanding of the education content for couples during antenatal education sessions in Malawi. This is needed for the development of a tailor-made curriculum for couple antenatal education in the country, later to be tested for acceptability, feasibility and effectiveness.

METHODS

An exploratory cross sectional descriptive study using a qualitative approach was conducted in semi-urban areas of Blantyre District in Malawi from February to August 2016. We conducted four focus group discussions (FGDs) among men and women independently. We also conducted one focus group discussion with nurses/ midwives, 13 key informant interviews whose participants were drawn from both health-related and non-health related institutions; 10 in-depth interviews with couples and 10 separate in-depth interviews with men who had attended antenatal clinics before with their spouses. All the interviews were audiotaped, transcribed verbatim and translated from Chichewa, the local language, into English. We managed data with NVivo 10.0 and used the thematic content approach as a guide for analysis.

RESULTS

We identified one overarching theme: couple antenatal education information needs. The theme had three subthemes which were identified based on the three domains of the maternity cycle which are pregnancy, labour and delivery and postpartum period. Preferred topics were; description of pregnancy, care of pregnant women, role of men during perinatal period, family life birth preparedness and complication readiness plan, coitus during pregnancy and after delivery, childbirth and baby care.

CONCLUSION

Antenatal education is a potential platform to disseminate information and discuss with male partners the childbearing period and early parenting. Hence, if both men and women were to participate in antenatal education, their information needs should be prioritized. Men and women had similar choices of topics to be taught during couple antenatal education, with some minor variations.

Engaging community leaders to improve male partner participation in the prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania

Background

Male partner participation improves uptake, retention and outcomes of prevention of mother-to-child transmission of HIV (PMTCT) services. However, in patriarchal settings few men accompany their partners to antenatal care (ANC) and PMTCT services. We explored whether community leaders can improve male partner participation in ANC and PMTCT.

Methods

We integrated initiatives to increase male partner participation in routine ANC care in six health facilities (attending about 4,500 new pregnant women per quarter) in Dar es Salaam, Tanzania in 2015/16. These initiatives were adapted from a best performing health facility, on male partner participation in ANC and PMTCT, referred to as the “best practice site”. At the six purposively selected intervention sites, we sensitized and garnered commitment from healthcare providers to provide couple friendly services. We then worked with the providers to sensitize and engage community leaders to integrate and promote male partner participation initiatives in their routine community activities. We assessed change in male partner participation in ANC and PMTCT using the proportion of women testing for HIV together with their partners (i.e. couple HIV testing) by quarter. We used 203 ANC facilities (attending about 31,000 new pregnant women per quarter) in the same area as control sites.

Results

After one year, couple HIV testing in the six intervention sites had tripled from 11.9% at baseline to 36.0% (p<0.001) while there was very little change (from 17.7% to 18.3%) in the 203 control sites (p = 0.07). Statistically significant improvements in couple testing were observed in four of the six intervention sites (6.7% to 19.1%; 9.3% to 74.6%; 46.2% to 95.2%; and 4.7% to 15.1% respectively. p<0.001 for all sites). Two of these four sites, located in the same administrative district as the best practice site, achieved remarkably high couple HIV testing (95.2% and 74.6%). This may be attributable to the greater engagement and active participation of the community leaders in these two sites compared to the other four.

Conclusion

Effective engagement and functional partnerships between healthcare providers and community leaders can contribute to improve male partner participation in ANC and PMTCT services. PMTCT programs should capitalize on community leaders, in addressing low male partner participation in ANC and PMTCT, in order to improve effective uptake, retention and outcomes of HIV prevention and treatment services among pregnant and breastfeeding women, their partners, infants and families.

Understanding barriers preventing pregnant women from starting antenatal clinic in the first trimester of pregnancy in Ntcheu District-Malawi

Background

Exploring barriers contributing to low utilization of Antenatal Care (ANC) during the first trimester of pregnancy is of national programmatic importance. We conducted an exploratory study in 2013 at Bilira Health Centre in Ntcheu district-Malawi with an aim of understanding barriers that prevent pregnant women from attending antenatal clinics in the first trimester of pregnancy.

Method

This was cross sectional exploratory study using qualitative approach. Data were collected from ANC clients, key informants, health services professionals and women of child bearing age (15–49 years) using an in-depth interviews and Focus Group Discussions (FGDs). Data were analysed manually by reading the transcriptions and memos several times inorder to be familiar with the themes emerged. The emerged themes were coded.

Results

Most of the women reported that they have a feeling of starting ANC in the early days of their pregnancies, however, they also reported several barriers ranging from cultural beliefs, social economic to service delivery barriers. On cultural barriers many women wait for marriage counselors from husband’s side to give them advice before starting ANC in the process called “Kuthimba”. Some women hide the pregnancy in early months to avoid being bewitched. On social-economic barriers, some of the women mentioned that they don’t start ANC early waiting for new clothes. Poor attitude of health workers also has an effect on ANC attendants. Most women pointed out that they started ANC late because some health workers were rude and do not observe confidentiality. Men’s refusal to accompany their spouses to antenatal clinic in fear of HIV test and some by-laws which restrict women who had pregnancy outside marriage to seek an authorisation letter first from Traditional Leaders for them to start ANC at the health facility were also mentioned as contributing barriers.

Conclusion

Women should be oriented on the national guidelines on Focused ANC (FANC) which advocates for at least 4 visits. There should also be Information, Education and Communication (IEC) on ANC and interventions to deal with social-cultural issues while at the same time improving service delivery at the health facility so that ANC services can be accessible and responsive enough.

How can male rates of HIV testing be increased? Recommendations from a mixed methods study in southern Malawi

Background

In southern Malawi, 12.8% of adults are HIV positive. Men are less likely to have been tested than women. We investigated men's HIV knowledge and the attitudes, influencers, facilitators and barriers affecting HIV testing.

Methods

We conducted an explanatory mixed-methods study with analysis of secondary quantitative data from 425 rural men collected in January 2014 (time 1) and April 2015 (time 2) and qualitative interviews with 50 men in September 2015. All respondents lived in villages receiving HIV education and testing.

Results

Quantitative data revealed that comprehensive HIV knowledge increased and was associated with having been tested by time 2. Educational level was positively associated with having been tested. Men's reasons for not getting tested were fear of learning their HIV status, fear of rejection by partners and wives and fear of discrimination. Wives influenced men's opinions about healthcare. The qualitative results demonstrated that men feared being seen at test sites and feared discrimination. Wives had the greatest reported influence on male testing. Men perceived services as female-oriented and stigmatizing. They preferred door-to-door testing.

Conclusions

Providers can improve uptake by increasing men's HIV knowledge, leveraging the influence of spouses and offering door-to-door testing with male health workers.

Are health systems interventions gender blind? examining health system reconstruction in conflict affected states

BACKGROUND

Global health policy prioritizes improving the health of women and girls, as evident in the Sustainable Development Goals (SDGs), multiple women's health initiatives, and the billions of dollars spent by international donors and national governments to improve health service delivery in low-income countries. Countries recovering from fragility and conflict often engage in wide-ranging institutional reforms, including within the health system, to address inequities. Research and policy do not sufficiently explore how health system interventions contribute to the broader goal of gender equity.

METHODS

This paper utilizes a framework synthesis approach to examine if and how rebuilding health systems affected gender equity in the post-conflict contexts of Mozambique, Timor Leste, Sierra Leone, and Northern Uganda. To undertake this analysis, we utilized the WHO health systems building blocks to establish benchmarks of gender equity. We then identified and evaluated a broad range of available evidence on these building blocks within these four contexts. We reviewed the evidence to assess if and how health interventions during the post-conflict reconstruction period met these gender equity benchmarks.

FINDINGS

Our analysis shows that the four countries did not meet gender equitable benchmarks in their health systems. Across all four contexts, health interventions did not adequately reflect on how gender norms are replicated by the health system, and conversely, how the health system can transform these gender norms and promote gender equity. Gender inequity undermined the ability of health systems to effectively improve health outcomes for women and girls. From our findings, we suggest the key attributes of gender equitable health systems to guide further research and policy.

CONCLUSION

The use of gender equitable benchmarks provides important insights into how health system interventions in the post-conflict period neglected the role of the health system in addressing or perpetuating gender inequities. Given the frequent contact made by individuals with health services, and the important role of the health system within societies, this gender blind nature of health system engagement missed an important opportunity to contribute to more equitable and peaceful societies.

"He does not have to wait under a tree": perceptions of men, women and health care workers on male partner involvement in prevention of mother to child transmission of human immunodeficiency virus services in Malawi

Background

The perception of male involvement (MI) in maternal child health services is multifaceted and differs among varying programs and populations. In the Prevention of Mother to Child Transmission (PMTCT) context, MI includes men’s attendance at antenatal care (ANC) clinics, undertaking an HIV tests within the ANC and financial and psychological support. Contexualising the definition of MI is fundamental in the development of MI in PMTCT policy and interventions. The objective of this study was to explore the perceptions of men, women and health care workers on male partner involvement in PMTCT services in Malawi.

Methods

A qualitative descriptive study was conducted at South Lunzu Health Centre (SLHC) in Blantyre, Malawi from December 2012 to January 2013. We conducted s Key Informant Interviews (KIIs) with 6 health care workers and moderated four Focus Group Discussions (FGDs) among 18 men and 17 pregnant women attending antenatal care at SLHC. We divided FGDs participants according to sex and age. We digitally recorded all FGDs and KIIs and simultaneously transcribed and translated verbatim into English. We employed thematic analysis to identify codes and themes.

Results

Men and women described MI in PMTCT as either a) Positive participation or b) Negative participation. Positive participation included total involvement of the male partner in PMTCT interventions, reminding the spouse of clinic and treatment schedules, and resource provision. Health care workers described MI as either a) Involvement along the pregnancy continuum or b) Passive Involvement. Participants’ preferred positive involvement of male partners.

Conclusions

There are multiple perceptions of MI in PMTCT with participants preferring positive involvement. There is a need to have a uniform description of MI in PMTCT to optimize development of strategies and interventions that accommodate and optimize MI in PMTCT. A uniform description will be useful in assessing a country’s progress towards achieving MI in PMTCT goals.

Antenatal HIV Testing in Sub-Saharan Africa During the Implementation of the Millennium Development Goals: A Systematic Review Using the PEN-3 Cultural Model

This study systematically explored the barriers and facilitators to routine antenatal HIV testing from the perspective of pregnant women in sub-Saharan Africa during the implementation period of the Millennium Development Goals. Articles published between 2000 and 2015 were selected after reviewing the title, abstract, and references. Twenty-seven studies published in 11 African countries were eligible for the current study and reviewed. The most common barriers identified include communication with male partners, patient convenience and accessibility, health system and health-care provider issues, fear of disclosure, HIV-related stigma, the burden of other responsibilities at home, and the perception of antenatal care as a "woman's job." Routine testing among pregnant women is crucial for the eradication of infant and child HIV infections. Further understanding the interplay of social and cultural factors, particularly the role of women in intimate relationships and the influence of men on antenatal care seeking behaviors, is necessary to continue the work of the Millennium Development Goals.

"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.

Acceptability of woman-delivered HIV self-testing to the male partner, and additional interventions: a qualitative study of antenatal care participants in Malawi

INTRODUCTION

In the era of ambitious HIV targets, novel HIV testing models are required for hard-to-reach groups such as men, who remain underserved by existing services. Pregnancy presents a unique opportunity for partners to test for HIV, as many pregnant women will attend antenatal care (ANC). We describe the views of pregnant women and their male partners on HIV self-test kits that are woman-delivered, alone or with an additional intervention.

METHODS

A formative qualitative study to inform the design of a multi-arm multi-stage cluster-randomized trial, comprised of six focus group discussions and 20 in-depth interviews, was conducted. ANC attendees were purposively sampled on the day of initial clinic visit, while men were recruited after obtaining their contact information from their female partners. Data were analysed using content analysis, and our interpretation is hypothetical as participants were not offered self-test kits.

RESULTS

Providing HIV self-test kits to pregnant women to deliver to their male partners was highly acceptable to both women and men. Men preferred this approach compared with standard facility-based testing, as self-testing fits into their lifestyles which were characterized by extreme day-to-day economic pressures, including the need to raise money for food for their household daily. Men and women emphasized the need for careful communication before and after collection of the self-test kits in order to minimize the potential for intimate partner violence although physical violence was perceived as less likely to occur. Most men stated a preference to first self-test alone, followed by testing as a couple. Regarding interventions for optimizing linkage following self-testing, both men and women felt that a fixed financial incentive of approximately USD$2 would increase linkage. However, there were concerns that financial incentives of greater value may lead to multiple pregnancies and lack of child spacing. In this low-income setting, a lottery incentive was considered overly disappointing for those who receive nothing. Phone call reminders were preferred to short messaging service.

CONCLUSIONS

Woman-delivered HIV self-testing through ANC was acceptable to pregnant women and their male partners. Feedback on additional linkage enablers will be used to alter pre-planned trial arms.

Male Partners Involvement in Prevention of Mother-to-Child Transmission of HIV Services in Southern Central Ethiopia: In Case of Lemo District, Hadiya Zone

Male partners' involvement is a vital issue to prevent human immunodeficiency virus (HIV) transmission from mother to child; because it is much expectable that women were more vulnerable and high risk group of population portion. Therefore, to save lives of mothers and their newborn from acquiring HIV, male partners should do their maximum endeavor regardless of any determinant factors as our results revealed its status in our study context and elsewhere at past time too.

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.

A descriptive study on demographic and behavioral characteristics of males and their responses to a male involvement intervention in Blantyre, Malawi

Introduction

Male involvement (MI) remains a key factor in the enrollment and retention of pregnant women in the Prevention of Mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services. The objective of this study was to describe the characteristics of men who accompanied their partners for PMTCT services and secondly, describe the reported reasons for the non-reporting by men for the services in Blantyre, Malawi.

Methods

All men included in this analysis were partners of pregnant women enrolled in a MI in PMTCT randomized controlled trial (RCT), which took place in Blantyre, Malawi from 14 June 2013 to 24 February 2014. After randomization women were asked to invite their male partners for PMTCT services either through an invitation card or word of mouth invite. Descriptive statistics were tabulated using Stata.

Results

Of the 462 women randomized, 109 (23.59%) women came back to the clinic with their male partner following the intervention. The majority, 307 (66.5%) women returned to the clinic without their partners. Although most men accepted the intervention, some failed to accompany their partners because of work obligations, a lack of interest in accompanying their partners for the service, and others promised to report at the next clinic visit.

Conclusion

The characteristics of men that reported were similar in the two groups, suggesting that demographic characteristics may not greatly influence their decision to be involved in PMTCT services. There is need to develop more flexible strategies to include men in PMTCT programmes.

Using a Cultural Framework to Understand Factors Influencing HIV Testing in Nigeria

With support from the U.S. President's Emergency Plan for AIDS Relief and the global fund for HIV, tuberculosis, and malaria, Nigeria offers free services for prevention of mother-to-child transmission of HIV. However, uptake of these services is low, and pediatric transmission of HIV remains a significant public health challenge. Using the PEN-3 cultural model as the theoretical framework, we examined social, cultural, and contextual factors that influenced uptake of HIV counseling and testing among pregnant women and their male partners. This was a qualitative study of participants in the Healthy Beginning Initiative (HBI), a congregation-based program to prevent mother-to-child transmission of HIV in Enugu, southeast Nigeria. We conducted eight focus group discussion sessions with 83 pregnant women and their male partners. Participants' perspectives on why they did or did not test for HIV were obtained. The most cited reasons for getting tested for HIV included the following: "the need to know one's status", "the role of prenatal testing" (positive perceptions); "the role of the church", "personal rapport with healthcare worker" (positive enablers); and the "influence of marriage" (positive nurturer). The most cited reason for not testing were: "fear of HIV test", "shame associated with HIV+ test results", "conspiratorial beliefs about HIV testing" (negative perceptions); "lack of confidentiality with HIV testing", (negative enabler); and "HIV-related stigma from family and community systems" (negative nurturer). Overall, numerous facilitators and barriers influence uptake of HIV testing in the study setting. Public health practitioners and policymakers need to consider how sociocultural and religious factors unique to specific local contexts may promote or hinder uptake of available HIV/AIDS prevention and care interventions.

Male partners' involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: A systematic review

In sub-Saharan Africa (SSA), male partners are rarely present during prevention of mother-to-child transmission (PMTCT) services. This systematic review aims to synthesize, from a male perspective, male partners' perceived roles, barriers and enablers of their involvement in PMTCT, and highlights persisting gaps. We carried out a systematic search of papers published between 2002 and 2013 in English on Google Scholar and PubMed using the following terms: men, male partners, husbands, couples, involvement, participation, Antenatal Care (ANC), PMTCT, SSA countries, HIV Voluntary Counseling and Testing and disclosure. A total of 28 qualitative and quantitative original studies from 10 SSA countries were included. Men's perceived role was addressed in 28% (8/28) of the studies. Their role to provide money for ANC/PMTCT fees was stated in 62.5% (5/8) of the studies. For other men, the financial responsibilities seemed to be used as an excuse for not participating. Barriers were cited in 85.7% (24/28) of the studies and included socioeconomic factors, gender role, cultural beliefs, male unfriendly ANC/PMTCT services and providers' abusive attitudes toward men. About 64% (18/28) of the studies reported enablers such as: older age, higher education, being employed, trustful monogamous marriages and providers' politeness. In conclusion, comprehensive PMTCT policies that are socially and culturally sensitive to both women and men need to be developed.

Home-Based HIV Testing Among Pregnant Couples Increases Partner Testing and Identification of Serodiscordant Partnerships

INTRODUCTION

Male partner HIV testing has been recognized as an important component of prevention of mother-to-child HIV transmission. Scheduled home-based couple HIV testing may be an effective strategy to reach men.

METHODS

Women attending their first antenatal visit at Kisumu County Hospital in Kenya were randomized to home-based education and HIV testing within 2 weeks of enrollment (HOPE) or to written invitations for male partners to attend clinic (INVITE). Male partner HIV testing and maternal child health outcomes were compared at 6 months postpartum.

RESULTS

Of 1101 women screened, 620 were eligible and 601 were randomized to HOPE (n = 306) or INVITE (n = 295). At 6 months postpartum, male partners were more than twice as likely [relative risk (RR) = 2.10; 95% CI (CI): 1.81 to 2.42] to have been HIV tested in the HOPE arm [233 (87%)] compared with the INVITE arm [108 (39%)]. Couples in the HOPE arm [192 (77%)] were 3 times as likely (RR = 3.17; 95% CI: 2.53 to 3.98) to have been tested as a couple as the INVITE arm [62 (24%)] and women in the HOPE arm [217 (88%)] were also twice as likely (RR = 2.27; 95% CI: 1.93 to 2.67) to know their partner's HIV status as the INVITE arm [98 (39%)]. More serodiscordant couples were identified in the HOPE arm [33 (13%)] than in the INVITE arm [10 (4%)] (RR = 3.38; 95% CI: 1.70 to 6.71). Maternal child health outcomes of facility delivery, postpartum family planning, and exclusive breastfeeding did not vary by arm.

CONCLUSIONS

Home-based HIV testing for pregnant couples resulted in higher uptake of male partner and couple testing, as well as higher rates of HIV status disclosure and identification of serodiscordant couples. However, the intervention did not result in higher uptake of maternal child health outcomes, because facility delivery and postpartum family planning were high in both arms, whereas exclusive breastfeeding was low. The HOPE intervention was successful at its primary aim to increase HIV testing and disclosure among pregnant couples and was able to find more serodiscordant couples compared with the invitation-only strategy.

TRIAL REGISTRATION

Clinicaltrials.gov registry: NCT01784783.

Factors associated with male involvement in the prevention of mother to child transmission of HIV, Midlands Province, Zimbabwe, 2015 - a case control study

Background

Uptake of and adherence to the prevention of mother to child transmission of HIV (PMTCT) interventions are a challenge to most women if there is no male partner involvement. Organizations which include the National AIDS Council and the Zimbabwe AIDS Prevention Project- University of Zimbabwe have been working towards mobilizing men for couple HIV testing and counseling (HTC) in antenatal care (ANC). In 2013, Midlands province had 19 % males who were tested together with their partners in ANC, an increase by 9 % from 2011. However, this improvement was still far below the national target, hence this study was conducted to determine the associated factors.

Methods

A1:1 unmatched case control study was conducted. A case was a man who did not receive HIV testing and counseling together with his pregnant wife in ANC in Midlands province from January to June 2015. A control was a man who received HIV testing and counseling together with his pregnant wife in ANC in Midlands province from January to June 2015. Simple random sampling was used to select 112 cases and 112 controls. Epi Info statistical software was used to analyze data. Written informed consent was obtained from each study participant.

Results

Independent factors that predicted male involvement in PMTCT were: having been previously tested as a couple (aOR) 0.22, 95 % CI = 0.12, 0.41) and having time to visit the clinic (aOR) 0.41, 95 % CI = 0.21, 0.80). Being afraid of knowing one’s HIV status (aOR 2.22, 95 % CI = 1.04, 4.76) was independently associated with low male involvement in PMTCT.

Conclusion

Multiple factors were found to be associated with male involvement in PMTCT. Routine PMTCT educational campaigns in places where men gather, community based couple HTC and accommodating the working class during weekends are essential in fostering male involvement in PMTCT thereby reducing HIV transmission to the baby.

What are the social and individual factors that are associated with undergoing male circumcision as an HIV prevention strategy? A mixed methods study in Malawi

BACKGROUND

There is compelling evidence that medical male circumcision (MMC) decreases transmission of HIV. Nevertheless, the uptake of MMC is generally very low. Understanding the characteristics of individuals who choose MMC could inform future strategies for scaling-up MMC. The main objective of this study was to explore the social and individual characteristics of men that are associated with the uptake of circumcision as an HIV prevention strategy.

METHODS

A mixed-methods study, comprising a cross-sectional survey and an exploratory qualitative study, was conducted in Malawi. A total number of 1644 men, of at least 18 years old, participated in this study. A multistage sampling approach was used in the survey while convenience sampling was adopted in the qualitative study. Descriptive statistics, bivariate analyses and multivariable logistic regression were performed to analyze the cross-sectional data and thematic content approach to analyze the qualitative data.

RESULTS

Individuals who chose MMC were more likely to be unemployed (AOR=1.65; 95% CI: 1.30-2.11), to be married (AOR=3.16; 95% CI: 2.21-4.52) and to have had exposure to MMC promotions (AOR=1.81; 95% CI: 1.41-2.33). They were also more likely to reside in rural areas (AOR=1.85; 95% CI: 1.44-2.38), to perceive themselves as more vulnerable to HIV (AOR=1.60; 95% CI: 1.19-2.15) and to be more knowledgeable about the benefits of MMC (AOR=1.51; 95% CI: 1.16-1.97).

CONCLUSIONS

The findings suggest that men who had certain social and individual characteristics (for example better knowledge of the benefits of MMC, greater perceived vulnerability to HIV, married and unemployed) were more likely to choose circumcision as a prevention strategy for HIV than those who lacked those characteristics. Strategies for increasing MMC take-up should recognize the current social/individual landscape of MMC uptake and ensure that deliberate efforts targeting marginalized categories of men are available.

Official invitation letters to promote male partner attendance and couple voluntary HIV counselling and testing in antenatal care: an implementation study in Mbeya Region, Tanzania

Background

The benefits of male partner involvement in antenatal care (ANC) and prevention of mother-to-child transmission of HIV (PMTCT) for maternal and infant health outcomes have been well recognised. However, in many sub-Saharan African settings, male involvement in these services remains low. Previous research has suggested written invitation letters as a way to promote male partner involvement.

Methods

In this implementation study conducted at three study sites in southwest Tanzania, acceptability of written invitation letters for male partners was assessed. Pre-study CVCT rates of 2–19 % had been recorded at the study sites. Pregnant women approaching ANC without a male partner were given an official letter, inviting the partner to attend a joint ANC and couple voluntary counselling and testing (CVCT) session. Partner attendance was recorded at subsequent antenatal visits, and the invitation was repeated if the partner did not attend. Analysis of socio-demographic indices associated with male partner attendance at ANC was also performed.

Results

Out of 318 women who received an invitation letter for their partner, 53.5 % returned with their partners for a joint ANC session; of these, 81 % proceeded to CVCT. Self-reported HIV-positive status at baseline was negatively associated with partner return (p = 0.033). Male attendance varied significantly between the rural and urban study sites (p < 0.001) with rates as high as 76 % at the rural site compared to 31 % at the urban health centre. The majority of women assessed the joint ANC session as a favourable experience, however 7 (75 %) of women in HIV-positive discordant or concordant relationships reported problems during mutual disclosure. Beneficial outcomes reported one month after the session included improved client- provider relationship, improved intra-couple communication and enhanced sexual and reproductive health decision-making.

Conclusion

Official invitation letters are a feasible intervention in a resource limited sub-Saharan African context, they are highly accepted by couple members, and are an effective way to encourage men to attend ANC and CVCT. Pre-intervention CVCT rates were improved in all sites. However, urban settings might require extra emphasis to reach high rates of partner attendance compared to smaller rural health centres.

The role of the parents' perception of the postpartum period and knowledge of maternal mortality in uptake of postnatal care: a qualitative exploration in Malawi

Background

Postpartum is the most risky period for both mothers and newborn babies. However, existing evidence suggests that utilization of postnatal care is relatively lower when compared to uptake of other similar health care services. Therefore, the aim of this study was to examine the perceptions of parents toward the postpartum period and postnatal care in order to deepen our understanding of the maternal care-seeking practices after childbirth.

Methods

A descriptive qualitative study, comprising four focus group discussions with 50 parents aged between 18 and 35 years, was conducted in Malawi between January and March 2014. Only young men and women who had either given birth or fathered a baby within 12 months prior to the study were eligible to participate in this study. This was to ensure that only participants who had recent first-hand postpartum experience were included. Local leaders purposively identified all parents who met the inclusion criteria and then simple random sampling was used to select participants from this pool of parents. Data analysis followed the six steps of thematic approach developed by Braun and Clarke, and NVivo software aided the process.

Findings

The parents interviewed described the various factors relating to pregnancy, childbirth, and postpartum periods that may possibly influence uptake of postnatal care. These factors were categorized into the following three themes: beliefs about the causes of maternal morbidity and mortality; risks associated with the pregnancy, childbirth and postpartum periods; and the importance of and barriers to postnatal care. Most participants perceived pregnancy and childbirth as the most risky periods to women, and their understanding of the causes of maternal death differed considerably from the existing evidence. In addition, segregation of mother and baby care in the clinics was identified as one of the potential barriers to postnatal care.

Conclusion

The study findings suggest that parents’ perception of the postpartum period and postnatal care as well as their knowledge of maternal morbidity and mortality play a vital role in the uptake of postnatal care. The study has also established that lack of knowledge of postnatal care, long waiting time for treatment, and separation of the mother and baby care in clinics are some of the key barriers to postnatal care. We recommend massive maternal health education programs as well as the integration of all postdelivery health care services provided in clinics, so that mothers and neonates receive health care together.

Pregnant women with HIV in rural Nigeria have higher rates of antiretroviral treatment initiation, but similar loss to follow-up as non-pregnant women and men

BACKGROUND

We examined antiretroviral therapy (ART) initiation and retention by sex and pregnancy status in rural Nigeria.

METHODS

We studied HIV-infected ART-naïve patients aged ≥15 years entering care from June 2009 to September 2013. We calculated the probability of early ART initiation and cumulative incidence of loss to follow-up (LTFU) during the first year of ART, and examined the association between LTFU and sex/pregnancy using Cox regression.

RESULTS

The cohort included 3813 ART-naïve HIV-infected adults (2594 women [68.0%], 273 [11.8%] of them pregnant). The proportion of pregnant clients initiating ART within 90 days of enrollment (78.0%, 213/273) was higher than among non-pregnant women (54.3%,1261/2321) or men (53.0%, 650/1219), both p<0.001. Pregnant women initiated ART sooner than non-pregnant women and men (median [IQR] days from enrollment to ART initiation for pregnant women=7 days [0-21] vs 14 days [7-49] for non-pregnant women and 14 days [7-42] for men; p<0.001). Cumulative incidence of LTFU during the first year post-ART initiation was high and did not differ by sex and pregnancy status. Persons who were unemployed, bedridden, had higher CD4+ counts, and/or in earlier WHO clinical stages were more likely to be LTFU.

CONCLUSIONS

Pregnant women with HIV in rural Nigeria were more likely to initiate ART but were no more likely to be retained in care. Our findings underscore the importance of effective retention strategies across all patient groups, regardless of sex and pregnancy status.

The effect of mass media campaign on Men's participation in maternal health: a cross-sectional study in Malawi

BACKGROUND

Men's participation in antenatal, childbirth and postnatal care is crucial to the health of the mothers and neonates. Nevertheless, very few men participate in maternal health, especially in developing countries. Mass media is one of the popular and effective tools for health promotion and behavioral change globally. However, this approach is rarely recognized in maternal health literature and its impact on men's participation in maternal health is not thoroughly understood. Therefore, the objective of this study was to assess the effect of mass media campaign on men's involvement in maternal health.

METHODS

A cross-sectional study involving 3,825 women of childbearing age (15-49 years) was conducted between July and December 2013 in Malawi's Mchinji district. Our interest was to establish if husbands of the women who were exposed to the maternal health radio program called Phukusi la Moyo (PLM) were significantly different to those of the women who were not exposed, especially in terms of their involvement in maternal health. We collected data on exposure to the radio campaign and men's involvement in maternal health through face-to-face interviews using electronic structured questionnaires. The univariate, bivariate and multiple logistic regression analyses were used during analysis of the data. The level of significance was set at p ≤ 0.05.

RESULTS

Husbands of the women who were exposed to the PLM radio program were more likely to participate in antenatal care (OR1.5 [95% confidence interval 1.3-1.8]), to be involved in childbirth (OR 1.7 [95% confidence interval 1.5-2.0]) and to participate in postnatal care (OR 1.9 [95% confidence interval 1.7-22]) than their counterparts.

CONCLUSION

The use of mass media in promoting the involvement of men in antenatal care, childbirth and postnatal care is effective. Henceforward, we recommend the inclusion of mass media in projects or interventions designed to promote men's engagement in maternal health.

Invitation cards during pregnancy enhance male partner involvement in prevention of mother to child transmission (PMTCT) of human immunodeficiency virus (HIV) in Blantyre, Malawi: a randomized controlled open label trial

Introduction

Male involvement (MI) is vital for the uptake of Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) interventions. Partner notification (PN) is among the strategies identified for MI in PMTCT services. The purpose of this randomized controlled trial was to evaluate the efficacy of an invitation card to the male partners as a strategy for MI in PMTCT services by comparing the proportion of pregnant women that were accompanied by their partners between the intervention and the non-intervention study groups.

Methods

Pregnant women attending antenatal care without a male partner at South Lunzu and Mpemba health centres in Blantyre, Malawi, were enrolled in the study from June to December 2013. In an intention-to-treat analysis, we compared all participants that were randomized in the invitation card group with the standard of care (SoC) group. Risk ratios (RR) with 95% confidence intervals (CI) were computed to assess the efficacy of the invitation card.

Results

Of the 462 randomized women, 65/230 (28.26%) of the women in the invitation card group reported to the antenatal care clinic with their partners compared to 44/232 (18.97%) women in the SoC group. In an unadjusted intention-to-treat analysis women in the invitation card group were 50% more likely to be accompanied by their male partners than those in the SoC group RR: 1.49 (95% CI: 1.06-2.09); p = 0.02. Our random effects analysis showed that there was no clustering by site of recruitment with an inter cluster correlation coefficient (ICC) of 1.98x 10^-3, (95% CI: 1.78 x10^-7 - 0.96 x 10^-1); p =0.403.

Conclusion

An invitation card significantly increased the proportion of women who were accompanied by their male partners for the PMTCT services. An invitation card is a feasible strategy for MI in PMTCT.

Assessment of a couples HIV counseling and testing program for pregnant women and their partners in antenatal care (ANC) in 7 provinces, Thailand

BACKGROUND

Couples HIV testing and counseling (CHTC) at antenatal care (ANC) settings allows pregnant women to learn the HIV status of themselves and their partners. Couples can make decisions together to prevent HIV transmission. In Thailand, men were tested at ANC settings only if their pregnant partners were HIV positive. A CHTC program based in ANC settings was developed and implemented at 16 pilot hospitals in 7 provinces during 2009-2010.

METHODS

Cross-sectional data were collected using standard data collection forms from all pregnant women and accompanying partners who presented at first ANC visit at 16 hospitals. CHTC data for women and partners were analyzed to determine service uptake and HIV test results among couples. In-depth interviews were conducted among hospital staff of participating hospitals during field supervision visits to assess feasibility and acceptability of CHTC services.

RESULTS

During October 2009-April 2010, 4,524 women initiating ANC were enrolled. Of these, 2,435 (54%) women came for ANC alone; 2,089 (46%) came with partners. Among men presenting with partners, 2,003 (96%) received couples counseling. Of these, 1,723 (86%) men and all pregnant women accepted HIV testing. Among 1,723 couples testing for HIV, 1,604 (93%) returned for test results. Of these, 1,567 (98%) were concordant negative, 6 (0.4%) were concordant positive and 17 (1%) were HIV discordant (7 male+/female- and 10 male-/female+). Nine of ten (90%) executive hospital staff reported high acceptability of CHTC services.

CONCLUSIONS

CHTC implemented in ANC settings helps identify more HIV-positive men whose partners were negative than previous practice, with high acceptability among hospital staff.