Invitation to test for HIV ups test rate among male partners of pregnant women in South Africa

Providing pregnant women with a written invitation to test for HIV for their male sexual partners significantly increased the numbers of males attending HIV voluntary counselling and testing at antenatal clinics (ANC) compared to those invited for pregnancy information sessions (PIS) in Khayelitsha, a township with a high HIV prevalence, in Cape Town, South Africa according to Boshishi K. F. Mohlala and colleagues in a randomised controlled trial published in the advance online edition of AIDS.

Community sensitisation activities encouraging male participation were conducted and antiretroviral therapy was available.

As in a Kenyan study the proportion of self-reported intimate partner violence was small and did not differ between the two groups; for women: 4% (7) in the male sexual partner voluntary counselling and testing arm (MSP VCT) compared to 7% (10) in the male sexual partner pregnancy information session (MSP PIS), p=0.207; for men: 0.5% (1) and 3% (4) for the MSP VCT and MSP PIS, respectively, p=0.167.

The authors suggest these numbers may be due to under-reporting.

An estimated 2.1 million children under the age of 15 are living with HIV; the majority of whom were infected perinatally.

Preventing the sexual and perinatal transmission of HIV during pregnancy needs communication and cooperation between partners, note the authors.

In many prevention of mother-to-child transmission (PMTCT) programmes men and their role, they add, isignored.

Yet, in many sub-Saharan communities men are the primary decision-makers regarding health care. For expectant couples this can include the mode of delivery as well as infant feeding.

Couples counselling is considered an effective strategy to improve the uptake of PMTCT interventions and minimise adverse outcomes associated with disclosure. However, few studies have evaluated the effectiveness of engaging male partners in PMTCT programmes in areas of high prevalence.

So in a randomised controlled trial the authors chose to compare a pregnant woman’s acceptance of a written invitation for VCT or PIS for their male sexual partners and the consequent effect on the uptake of VCT.

From November 2006 to December 2007 pregnant women attending the Site B Midwife and Obstetrician Unit in Khayelitsha for their ANC booking visit were consecutively screened for the study. The clinic was chosen because it had facilities for interviewing men and provided ART.

Criteria for enrolment included being less than 30 weeks pregnant and being willing and able to give informed consent.

At the booking visit women were offered antenatal care, HIV group education and individual VCT. Half were randomly assigned to the MSP VCT arm and the other half to the MSP PIS.

Each woman in the MSP VCT and MSP PIS arms was given a written invitation to give to her sexual partner inviting him the following week to attend ANC and VCT or ANC and PIS with her, respectively,

The couples were interviewed at weeks one and twelve of the two study visits.

Men in the VCT and PIS arms were offered VCT or PIS, respectively.  Men in the PIS arm whose partners tested positive were offered VCT at the first couple visit. VCT was available to all who requested it throughout the study.

All 1000 women in the study accepted the letter and agreed to invite their partner.  No male partner attended the booking visit.

35% (175/500) of women given VCT invites were accompanied by their male sexual partners to ANC compared to 26% (129/500) given PIS invites (RR: 1.36, 95% CI: 1.12-1.64, p=0.002).

92% (161/175) of male sexual partners who attended ANC because of the VCT invite had HIV couples testing compared to 44% (57/129) of those who attended PIS.

In the Kenyan study only 38% of male partners who went to ANC had couples testing. Neither community sensitisation nor ART were available in this setting prompting the authors to suggest these can play a role in increasing couples testing.

In a multivariate analysis the VCT invite and a woman’s HIV positive status were positive predictors of a male sexual partner’s attendance.

Knowing their positive status, the authors suggest, may have motivated the women to encourage their partners to attend. Conversely ART availability may have motivated the men to take the opportunity to know their HIV status.

The authors highlight the importance of their findings: increasing the number of male sexual partners attending ANC and VCT by inviting them may encourage safer behaviours; may reduce the number of males having multiple partners; and help support HIV positive pregnant women to benefit from PMTCT interventions.

Additional benefits include earlier diagnosis and treatment leading to viral load suppression so reducing transmission.

The authors suggest further studies look at whether ANC and VCT can be sustained in future pregnancies and whether their results can be generalised.

Reference

Boshishi KFM et al. The forgotten half of the equation: randomised controlled trial of a male invitation to attend couple VCT in Khayelitsha, South Africa. AIDS 25 xxx xxx, doi: 10.1097/QAD.0b013e328348fb85, 2011.