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

Effect of male partners' involvement and support on reproductive, maternal and child health and well-being in East Africa: A scoping review

Background and Aims

East African countries have high rates of maternal and child mortality and morbidity. Studies have shown that the involvement of male partners in reproductive health can benefit maternal and child health (MCH). This scoping review aims to provide an overview of the evidence across East Africa that describes male partner involvement and its effect on maternal, reproductive, and child well-being.

Methods

Ten databases were searched to identify quantitative data on male's involvement in East Africa. Studies reporting qualitative data, "intention to use" data or only reporting on male partner's education or economic status were excluded. Studies were organized into five a priori categories: antenatal care (ANC), human immunodeficiency virus, breastfeeding, family planning, and intimate partner violence with further categories developed based on studies included.

Results

A total of 2787 records were identified; 644 full texts were reviewed, and 96 studies were included in this review. Data were reported on 118,967 mothers/pregnant women and 15,361 male partners. Most of the studies (n = 83) were reported from four countries Ethiopia (n = 49), Kenya (n = 14), Tanzania (n = 12) and Uganda (n = 10). The evidence indicates that male partner involvement and support is associated with improved reproductive, MCH across a wide range of outcomes. However, the studies were heterogeneous, using diverse exposure and outcome measures. Also, male partners' lack of practical and emotional support, and engagement in violent behaviors towards partners, were associated with profound negative impacts on MCH and well-being.

Conclusions

The body of evidence, although heterogeneous, provides compelling support for male involvement in reproductive health programs designed to support MCH. To advance research in this field, an agreement is needed on a measure of male partner "involvement." To optimize benefits of male partners' involvement, developing core outcome sets and regional coordination are recommended.

Strategies for promoting male partner involvement in maternal, newborn and child health care in Kiambu County

Introduction

the 1994 International Conference on Population and Development (ICPD) recommended that men should share responsibility and be actively involved in sexual and reproductive health. The level of male partner involvement in Kenya remains low despite growing evidence showing its benefits in maternal and newborn health. This study sought to explore strategies for encouraging male partners to accompany their spouses to Maternal and Child Health (MCH) department.

Methods

a qualitative exploratory study was used to gather the views of nurse-midwives and invited men on mechanisms to encourage men to accompany their spouses to MCH clinic. Three and two focused group discussions (FGDs) composed of six to eight participants from nurse-midwives and men were conducted respectively. The FGDs were audio recorded and lasted 60-90 minutes. Content analysis was used to generate themes using MAXQDA 2022 software.

Results

seven categories emerged as strategies that can encourage male partner participation in the Maternal Neonatal and Child Health (MNCH) services: creating community awareness and sensitization, engaging men in the MCH department, reducing waiting time, provision of health services that address male health needs, inviting male partners to the MCH clinic, encouraging MCH staff to be receptive to couples and re-scheduling of MCH working days as well as extension of hours.

Conclusion

evidence-based strategies that adopts multi-level interventions with greater focus on community sensitization and re-organization of the MCH services are important in encouraging men accompany their spouses to clinic and actively participate in the MNCH.

'When I receive ARVs through my group, my heart settles': Participants' perceptions and experiences of Friends for Life Circles for Option B+ in Kampala and Mityana Districts, Uganda

The Friends for Life Circles (FLC) was a parallel randomized controlled trial testing the efficacy of a group peer support intervention to support long-term adherence to Option B+ in Kampala and Mityana districts in Uganda. We explored FLC participants' experiences and perceptions of the intervention on adherence to Option B+ for PMTCT and potential implications for strengthening the PMTCT program. We collected data from six focus group discussions with lactating women enrolled in the FLC intervention, and from 14 key informant interviews with health workers, district and national level stakeholders, as well as male partners of FLC participants. Data were analysed using a content thematic approach in a continuous and iterative process. Women described the FLC intervention as acceptable and beneficial in enhancing their understanding of HIV and the need for ART. The FLC helped women, especially those newly diagnosed with HIV infection to come to terms with their diagnosis and overcome the fear of death linked to testing HIV positive, and provided opportunities to enhance ART initiation, resumption and adherence. The FLC provided safe spaces for women, to learn about ART, and to receive support from peers including adherence reminders through home visits and 'coded' reminder messages. Receiving ART from support groups protected members from stigma and long lines at health facilities. Fear of stigma, health system challenges, the high cost of caring for animals and lack of money to save in groups were key challenges noted. The FLC support groups were crucial in providing needed support for women to initiate, resume and adhere to lifelong ART for Option B+. It is important that women who test HIV positive and start ART for life receive psychosocial support from peers and health workers to improve chances of preventing HIV transmission from mothers to children.

Mixed-methods cross-sectional study of the prevention of vertical HIV transmission program users unaware of male partner's HIV status, in six South African districts with a high antenatal HIV burden

BACKGROUND

Elimination of vertical HIV Transmission (VHT) and maternal deaths are global health priorities. Male involvement is one of the most important factors that influences women's decisions, including the uptake of Prevention of vertical HIV transmission (P-VHT). We sought to understand not knowing a male partner's HIV status (MPHIVs) amongst women using services to prevent vertical HIV transmission in six South African districts with high antenatal HIV burden.

METHODS

A mixed-methods cross-sectional study was conducted in six South African districts, and data collected through face-to-face interviews with women and focus group discussions (FGDs) with women or male partners. The quantitative data were analyzed using STATA SE-17.0 and an inductive approach was used for qualitative data analysis.

RESULTS

Overall, 28.7% of women were unaware of their MPHIVs, while 25.3% and 46.0% knew the MPHIVs was positive or negative, respectively. In multivariable logistic regression, single marital status and unplanned pregnancy increased the odds of not knowing a MPHIVs while a woman's disclosure of her HIV status to the male partner reduced the odds. FDGs highlighted complexities around MPHIVs disclosure, e.g., reluctance to test for HIV and potential interventions including healthcare worker (HCW) assisted HIV disclosure.

CONCLUSION

User-informed interventions to address MPHIVs non-disclosure amongst women of child-bearing age, particularly those at risk of unstable sexual partners and unplanned pregnancies, should be strengthened.

Understanding communication in community engagement for maternal and newborn health programmes in low- and middle-income countries: a realist review

As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.

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.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Impact of the Momentum pilot project on male involvement in maternal health and newborn care in Kinshasa, Democratic Republic of the Congo: a quasi-experimental study

Background

The World Health Organization recommends that programs that seek to improve maternal and newborn health outcomes actively involve men during pregnancy, childbirth, and postpartum. However, there is little evidence on what strategies work to increase male knowledge of and involvement in antenatal and postnatal care. This study assessed the impact of the Momentum project on male involvement in maternal health and newborn care. The project involved monthly home visits to a cohort of first-time mothers aged 15–24 recruited at six-months gestation and group education sessions for their male partners using the Program P toolkit. Participants were followed-up for 16 months.

Methods

The study used a quasi-experimental design with three intervention and three comparison health zones. Baseline data were collected in 2018 and endline data in 2020. Exploratory factor analysis was used to develop scales of male involvement. We measured the causal influence of Momentum using an intent-to-treat analysis at the health-zone level and a dose–response analysis at the individual level. We used random-effects probit and linear models for outcomes measured at baseline and endline, and treatment effects models with inverse-probability weighting for outcomes measured only at endline. The impact analysis involved 1,204 male partners of first-time mothers with live births.

Results

Intervention health zones were associated with an 18.1 percentage point (95% CI [(10.6, 25.6]) increase in knowledge of three or more obstetric danger signs and a 13.9 percentage point (95% CI [6.3, 21.6]) increase in knowledge of newborn danger signs. Significant increases in male involvement in antenatal care (average treatment effect (ATE) = 0.728, 95% CI [0.445, 1.010]), birth planning (ATE = 0.407, 95% CI [0.157, 0.657]), and newborn care (ATE = 0.690, 95% CI [0.359, 1.021]) were found. The magnitude of Momentum’s impact increased steadily with the number of prenatal home visits and was statistically significant for all behavioral outcomes except shared decision making. Exposure to both home visits and group education sessions during the prenatal period had a significant impact on all outcomes relative to no exposure.

Conclusions

The study demonstrated the effectiveness of Momentum on male involvement in maternal health and newborn care.

Provider Perspectives on Navigating Relationship Challenges in Assisting HIV-Affected Couples to Meet Their Reproductive Goals: Lessons Learned from a Safer Conception Counseling Intervention in Uganda

In Uganda, 60% of HIV-affected couples are serodiscordant, many of whom want children. There is a need to assess their reproductive intentions and provide appropriate services that limit transmission risks while meeting reproductive goals. Our Choice intervention engaged male and female HIV-infected clients and their partners in safer conception counseling (SCC) or family planning based on their childbearing decision. We report findings of provider experiences and recommendations for engaging couples in SCC. The intervention was implemented in four clinics offering either SCC1, an intensive training and supervision arm, or SCC2, utilizing the Ministry of Health's standard approach. Qualitative interviews were conducted at 12 (N = 23) and 24 months (N = 25) after initiation of the intervention. Many partners attended at least some SCC sessions, although engaging male partners was more challenging. Providers reported partner involvement improved understanding and facilitated successful implementation of SCM, whereas confusion and challenges were common when the client participated alone. Providers shared successful strategies for engaging male partners.

Supporting the implementation of guidelines to prevent mother-to-child-transmission of HIV in Malawi: a multi-case study

BACKGROUND

High HIV infection and fertility rates contributed to over 12,000 children acquiring HIV from their mothers in 2011 in Malawi. To prevent mother-to-child transmission of HIV, Malawi adopted the Option B+ guidelines, and for three years, the University of North Carolina (UNC) Project provided support to strengthen guideline implementation in 134 health centres. Little is known about how implementation support strategies are delivered in low resource countries or contextual factors that may influence their delivery. The limited descriptions of support strategies and salient contextual factors limits efforts to replicate, target, and further refine strategies. Guided by the Interactive Systems Framework for Dissemination and Implementation, this study describes factors influencing implementation of support strategies and how they impacted health center staff capacity to implement Option B+ in Malawi.

METHODS

A qualitative multi-case study design was applied. Data were collected through site visits to 4 heath centres (2 low- and 2-high performing centres). We interviewed 18 support providers and recipients between October 2014 and October 2015. Data were analysed using content, thematic, and cross-case analysis.

RESULTS

Four categories of strategies were used to support Option B+ guidelines implementation: training, technical assistance (TA), tools, and resources. All heath-centres implemented Option B+ guidelines for care provided between the antenatal and labor and delivery periods. Gaps in Option B+ implementation occurred during community activities and during post-delivery care, including gaps in testing of children to ascertain their HIV status at 6 weeks, 12 months, and 24 months. Salient contextual factors included staffing shortages, transportation challenges, limited space and infrastructure, limited stocks of HIV testing kits, and large patient populations.

CONCLUSIONS

Understanding factors that influence implementation support strategies and delivery of the Option B+ guidelines, such as availability of staff and other materials/drug resources, is critical to designing effective implementation support for low resource settings.

Contextualising men's role and participation in PMTCT programmes in Malawi and Zambia: A hegemonic masculinity perspective

This study sought to explore and contextualise the man's role in antenatal services, and the barriers and strategies for engaging men in prevention of mother-to-child HIV transmission (PMTCT). We conducted 143 interviews with pregnant and breastfeeding women, male partners, health workers and policy makers in Malawi and Zambia. We employed thematic and critical discourse analysis using the hegemonic masculinity perspective. We found that men's roles in PMTCT reflected hegemonic masculinities. As breadwinners, men supported their partners with material and financial resources. As decision makers, men were involved in decision making on the health of their partners. As social protectors, men supported their partners in accessing and adhering to antenatal care, HIV treatment and care. Barriers and challenges to male involvement in antenatal care were often the result of conflict between the clinic operating hours and men's working hours, the perception of antenatal care services as female spaces, and men's fear of HIV testing. Proposed strategies to increase male engagement in PMTCT included sensitising men about HIV and pregnancy; engaging leaders and employers, providing services outside working hours, and providing incentives. We conclude that men's role and participation in PMTCT services are an extension and adaptation of hegemonic masculinities.

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.

Testing strategies for couple engagement in prevention of mother-to-child transmission of HIV and family health in Kenya: study protocol for a randomized controlled trial

Background

HIV-related maternal deaths and HIV infection among infants remain unacceptably high across sub-Saharan Africa despite increased antenatal care attendance and provision of antiretroviral therapy to pregnant women. In the Jamii Bora (“Better Family” in Swahili) Study, we seek to test the efficacy of an interdependence theory-based couple intervention. The intervention reaches pregnant women and male partners through home visits by male-female pairs of lay health workers. The aim is to increase access to home-based couples’ HIV testing and counseling services to improve family health.

Methods

This is a three-arm randomized control trial among 1080 pregnant women 15 years of age or older, living with their male partners, and who have not undergone couples’ HIV testing and counseling in Kisumu and Migori Counties in Kenya. Couples will be randomized into three groups: home-based couple visits, HIV self-testing kits for couple use, or standard care (male partner clinic invitation letters). Participants will be followed up to 18 months postpartum. The study has three aims: in aim 1, we will determine the effects of the intervention on our primary outcome of couple HIV testing, compared to HIV self-testing kits and standard care; in aim 2, we will examine the intervention impact on HIV prevention behaviors, facility delivery, and postnatal healthcare utilization, as well as secondary health outcomes of maternal viral suppression and HIV-free child survival up to 18 months for couples living with HIV; and in aim 3, we will compare the cost-effectiveness of the home-based couple intervention to the less resource-intensive strategies used in the other two study arms. Assessments with couples are conducted at baseline, late pregnancy, and at months 3, 6, 12, and 18 after birth.

Discussion

The results from this study will inform decision-makers about the cost-effective strategies to engage pregnant couples in the prevention of mother-to-child transmission and family health, with important downstream benefits for maternal, paternal, and infant health.

Trial registration

ClinicalTrials.gov NCT03547739. Registered on May 9, 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-020-04956-1.

Women's preferences, expectations, and experiences with male partner support throughout prevention of mother to child transmission of HIV services: a mixed-methods study

Male involvement in prevention of mother to child transmission of HIV (PMTCT) care improves maternal and child outcomes. We conducted a mixed-methods study at two Kenyan government hospitals. We quantitatively assessed women's expectations and preferences for male partner involvement in PMTCT and male partner attendance at PMTCT appointments. Qualitative interviews with women during the postpartum period assessed types of support women received from their male partners. At enrollment, most participants wanted (75%) and expected (69%) male partners to attend appointments; yet, only 9% had a male partner attend any appointments. Most women agreed that their partner would: support them financially (81%), help follow doctor's guidance (61%), support a hospital-based delivery (85%), and want to receive text messages (68%). Expectations and preferences varied by women's characteristics, most notably experiences with mistreatment, disclosure status, and knowledge of male partner's HIV status. In qualitative interviews, instrumental (financial) support was the most frequently discussed type of support. Male partners also provided informational support by reminding women of medication or appointments. Women reported a variety of ways in which their male partners supported them through PMTCT; however, there was a gap between women's expectation for male partner attendance and the level of male attendance achieved.

Social determinants of male partner attendance in women's prevention-of mother-to-child transmission program in Malawi

BACKGROUND

Male partners are rarely present during PMTCT (Prevention-Mother-To-Child-Transmission) services in Sub-Saharan Africa (SSA). Male involvement is increasingly recognised as an important element of women's access to care. This study aims to identify the socio-demographic characteristics, HIV-Knowledge, Attitude and Practice (KAP) among women accompanied and not accompanied by their male partners.

METHODS

We included pregnant women enrolled in PMTCT programme between August 2018 and November 2019 in the Southern Region of Malawi. Eligible women were aged 18 years or older, living with a male partner, enrolled for the first time in one of the four selected facilities. We provided a KAP survey to women and their partners attending the facilities. Our primary objective was to assess and analyse the proportion of women who were accompanied by their partner at least once. We applied descriptive statistics and logistic regressions to study the association between being accompanied and explanatory variables.

RESULTS

We enrolled 128 HIV-positive women: 82 (64.1%) were accompanied by their male partners and 46 (35.9%) were alone. In the multivariable model, women's unemployment and owning a means of transport are negatively associated with male attendance (respectively adjusted OR 0.32 [95% CI, 0.11-0.82] and 0.23 [95% CI, 0.07-0.77]), whereas, in the univariable model, high women's level of knowledge of HIV is positively associated with male attendance (OR 2.17 [95% CI, 1.03-4.58]). Level of attitude and practice toward HIV were not significantly associated to our study variable.

CONCLUSIONS

Our study shows a high male attendance in Malawi compared to other studies performed in SSA. This study highlights that women's level of knowledge on HIV and their economic condition (employment and owning a means of transport) affects male attendance. Moreover, the study points out that gender power relationships and stringent gender norms play a crucial role thus they should be considered to enhance male involvement.

PMTCT Option B+ 2012 to 2018 - Taking stock: barriers and strategies to improve adherence to Option B+ in urban and rural Uganda

Since 2012, PMTCT Option B+ has been recommended by the World Health Organization to reduce vertical transmission but numerous adherence challenges remain. We conducted a qualitative study at baseline using six focus group discussions and 14 in-depth interviews to explore knowledge, beliefs, attitudes and challenges towards the Option B+ strategy for PMTCT among HIV-infected pregnant and post-partum women and health workers engaged in Uganda's national Option B+ PMTCT programme. Data were analysed using a thematic approach to capture latent and manifest content with the social ecological model as a theoretic foundation in order to make contextual sense of key stakeholders' needs for an effective Option B+ intervention. Overall, among all study participants, we found multi-level barriers to adhering to Option B+ cutting across all levels of the social ecological model. In line with the model, our study revealed barriers at personal, relational, organizational and societal levels. Some personal beliefs such as that the baby's health is more important that the mother's, organizational (negative attitudes and behaviour of health workers), structural such as poverty, work conflicts, fear and lack of disclosure related to community stigma were all critical obstacles to women adhering to the Option B+ programme. We found that both health workers and participants in the programme have a relatively clear understanding of the benefits of adhering to their treatment; though a more nuanced understanding and thus emphasis in counselling on side effects, is critical to helping patients adhere.

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

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

HIV Disease Progression Among Antiretroviral Therapy Patients in Zimbabwe: A Multistate Markov Model

Background: Antiretroviral therapy (ART) impact has prolonged survival of people living with HIV. We evaluated HIV disease progression among ART patients using routinely collected patient-level data between 2004 and 2017 in Zimbabwe. Methods: We partitioned HIV disease progression into four transient CD4 cell counts states: state 1 (CD4 ≥ 500 cells/μl), state 2 (350 cells/μl ≤ CD4 < 500 cells/μl), state 3 (200 cells/μl ≤ CD4 < 350 cells/μl), state 4 (CD4 < 200 cells/μl), and the absorbing state death (state 5). We proposed a semiparametric time-homogenous multistate Markov model to estimate bidirectional transition rates. Covariate effects (age, gender, ART initiation period, and health facility level) on the transition rates were assessed. Results: We analyzed 204,289 clinic visits by 63,422 patients. There were 24,325 (38.4%) patients in state 4 (CD4 < 200) at ART initiation, and 7,995 (12.6%) deaths occurred by December 2017. The overall mortality rate was 3.9 per 100 person-years. The highest mortality rate of 5.7 per 100 person-years (4,541 deaths) was from state 4 (CD4 < 200) compared to other states. Mortality rates decreased with increase in time since ART initiation. Health facility type was the strongest predictor for immune recovery. Provincial or central hospital patients showed a diminishing dose-response effect on immune recovery by state from a hazard ratio (HR) of 8.30 [95% confidence interval (95% CI), 6.64-10.36] (state 4 to 3) to HR of 3.12 (95% CI, 2.54-4.36) (state 2 to 1) compared to primary healthcare facilities. Immune system for male patients was more likely to deteriorate, and they had a 32% increased mortality risk (HR, 1.32; 95% CI, 1.23-1.42) compared to female patients. Elderly patients (45+ years) were more likely to immune deteriorate compared to 25-34 years age group: HR, 1.35; 95% CI, 1.18-1.54; HR, 1.56; 95% CI, 1.34-1.81 and HR, 1.53; 95% CI, 1.32-1.79 for states 1 to 2, state 2 to 3, and states 3 to 4, respectively. Conclusion: Immune recovery was pronounced among provincial or central hospitals. Male patients with lower CD4 cell counts were at a higher risk of immune deterioration and mortality, while elderly patients were more likely to immune deteriorate. Early therapeutic interventions when the immune system is relatively stable across gender and age may contain mortality and increase survival outcomes. Interventions which strengthen ART services in primary healthcare facilities are essential.

Impact of inter-partner HIV disclosure patterns in Malawi's PMTCT program: A mixed-method study

Background

Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women.

Methods

A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014–2016, all (34,637) mothers attending 54 under-5 clinics with their 4–26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were excluded. Data collected included socio-demographics, partner disclosure, maternal ART uptake, and adherence. Between 2016–2017, in-depth interviews and focus group discussions were conducted with adult mothers (n = 53) and their spouse/cohabiting partners (n = 19), adolescent mothers (n = 13), lost-to-follow up (LTFU) mothers (n = 22), community leaders (n = 23) and healthcare workers (n = 154).

Results

Of 3153 known HIV-infected mothers, 2882 (91.4%) reported having a spouse/cohabiting partner. Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART (aOR 4.7; 95%CI 2.5–8.8), suboptimal treatment adherence (aOR 1.8; 95%CI 1.1–2.8) and MTCT (aOR 2.1; 95%CI 1.1–4.1). Women’s fear of blame by partners was central to decisions not to disclose within couples and when starting new relationships. LTFU mothers struggled to accept and disclose their status, hindering treatment initiation; some were unable to hide ART and feared involuntary disclosure.

Conclusion

Partner disclosure seems to play an important role in women’s decisions regarding ART initiation and adherence. Inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence and MTCT.

Impact of male partner involvement on mother-to-child transmission of HIV and HIV-free survival among HIV-exposed infants in rural South Africa: Results from a two phase randomised controlled trial

BACKGROUND

The Sub-Saharan Africa region still remains the epicentre of the global HIV/AIDS epidemic. With regards to new paediatric HIV infections, almost 90% of new HIV infections are among children (aged 0-14 years), largely through mother to child transmission. Male Partner Involvement in Prevention of Mother to Child Transmission programmes is now strongly advocated as being key in improving infant outcomes. This study describes the role of Male Partner Involvement on infant HIV infection and mortality survival in the first year among HIV-exposed infants born from HIV positive mothers.

METHODS

This study was a two-phase, two condition (intervention or control) longitudinal study as part of a clinic-randomized Prevention of Mother to Child Transmission controlled trial. For Phase 1, female participants were recruited without their male partners. In Phase 2, both female and male participants were enrolled in the study as couples in order to encourage active Male Partner Involvement during pregnancy. Participants had two assessments prenatally (8-24 weeks and 32 weeks) and three assessments postnatally (6 weeks, 6 months, and 12 months).

RESULTS

About 1424 women were eligible for recruitment into the study and 18 eligible women declined to participate. All women had a partner; 54% were unmarried, 26% were cohabiting, and 20% were married. Just over half (55%) of the women had been diagnosed with HIV during the current pregnancy. Phase 1 had significantly more HIV-infected infants than Phase 2 at 12-months postpartum (aOR = 4.55 [1.38, 15.07]). Increased depressive symptoms were associated with infant HIV infection at 12-months (aOR = 1.06 [1.01, 1.10]). Phase 1 also had a significantly greater proportion of dead and HIV-infected infants than Phase 2 at 12-months (aOR = 1.98 [1.33, 2.94]).

CONCLUSION

Male partner involvement in antenatal care is critical in ensuring infant survival and HIV infection among children born to HIV-positive mothers. This study highlights the high risk of ante-and-post natal depression and underscores the need of screening for depression during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.Gov; Trial Number NCT02085356.

Mainstreaming gender into global health programming to improve women's health

In this paper, a case is made for mainstreaming gender into global women's health programming and policies. The potential implications of conflating "gender" with "women'" in the design and evaluation of women's health programming are first considered. HIV/AIDS case studies are then used to depict examples of (a) where gender has been well integrated and (b) where policies fall short of gender mainstreaming. Finally, practical approaches to mainstream gender in a meaningful way into the design and evaluation of women's health programming and policies are provided for practitioners and researchers.

Evaluating China's mental health policy on local-level promotion and implementation: a case study of Liuyang Municipality

BACKGROUND

Since 2000, a series of national policies have been released to tackle mental health problems in China; however, their promotion and implementation at local level are under-evaluated. This study will evaluate the case of Liuyang Municipality, to present a deeper understanding of China's problems and lessons on implementation of mental health policy in developing countries.

METHODS

A rapid appraisal was conducted on Liuyang's mental health policy and plan, under two evaluation frameworks: (1) the WHO checklists for mental health policy and plan, (2) activities and time frames stated in Liuyang's mental health policy and plan. Documentation review, semi-structured interviews with nine key informants, and surveys on 32 front-line implementers were performed. Descriptive statistics and framework analysis were employed respectively to analyze quantitative and qualitative data.

RESULTS

As a local-level promotion of national mental health policies, Liuyang's mental health policy and plan had evidence base and received highest-level approval within local health system, but without stakeholders' consultation. The vision, principles and objectives were consistent with national policies. Twelve WHO-suggested areas for actions were unequally covered. Policy content had operational defects of lacking necessary details on evaluation, funding and activity. For implementation, health departments generally outperformed non-health ones. Discrepancies between planning and practices, and uneven regional implementation compromised implementation quality. Insufficient and poorly trained human resources, unguaranteed funding and low client acceptability were identified as implementation barriers.

CONCLUSIONS

The case of Liuyang is an active attempt to promote and implement national mental health policies at local level. As a reflection of mental health policy in China and developing countries, its highlights and problems demonstrate that evidence base, high-level approval, multi-sector involvement, operational content, and clear focuses promote policy implementation.

Gendered norms of responsibility: reflections on accountability politics in maternal health care in Malawi

Background

This paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws: local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed.

Methods

Findings are based on a qualitative study in five health centre catchment areas in Northern Malawi. Data were collected using meeting observations and document search, 36 semi-structured individual interviews and 19 focus group discussions with female maternal health service users, male community members, health workers, traditional leaders, local officials and health committee members. A gender and power sensitive thematic analysis was performed focusing on the formulation, interpretation and implementation process of the by-laws as well as its effects on women and men.

Results

In the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres’ and some community members contest them, in particular, the principles of individual responsibility and universality.

Conclusions

The study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, women bear the full responsibility for failures in maternal health care, suggesting a form of ‘reversed accountability’ of women towards global maternal health goals. This can negatively impact on women’s reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. Contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0848-3) contains supplementary material, which is available to authorized users.

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

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