Mother-to-Child Transmission of HIV: Evidence to Support Prioritising of Male Partner Involvement in PMTCT Programmes

Purpose:

Universal access to antiretroviral treatment through Prevention of Mother-to-Child transmission (PMTCT) programs has resulted in significant decline in Mother to Child transmission (MTCT) rates from an annual figure of 400,000 in 2009 to 240,000 in 2013 (UNAIDS, 2014). However, in Sub-Sahara Africa, the risk of a mother infecting her infant during pregnancy, delivery, or breastfeeding remains high (Kellerman et al., 2013; Maman, 2011). This high risk is partly due to pregnant and breast-feeding women not fully utilising PMTCT interventions (Villar-Loubet et al., 2013). One social factor contributing to non-optimal use of PMTCT services is non-involvement of the male partner (Aluisio et al., 2011). Several studies have demonstrated the benefits of male partner involvement on uptake of PMTCT interventions, including increased uptake of antiretroviral drugs for PMTCT, early initiation of HAART and enhanced uptake of infant prophylaxis (Aluisio et al., 2011; Kibera, 2011; Madiba & Letsoalo, 2013; Medley, Garcia-Moreno, McGill, & Maman, 2004; Stirratt et al., 2006). The impact on outcomes, key being infant HIV acquisition, have not been extensively investigated, and the few that have investigated have gave conflicting results (Farquhar et al., 2004; Jasseron et al., 2013; Medley et al., 2004; Roxby et al., 2013). Moreover, PMCTC programmes have constantly been criticised for failing to actively and adequately involve the male partner (Aluisio et al., 2011; Farquhar et al., 2004). We therefore sought to evaluate the level of involvement of male partners among pregnant HIV positive women and the impact of their involvement (or lack of) on MTCT rates.

Methods:

This presentation reports on a matched case-control study conducted among HIV-positive women and their infants receiving HIV care and treatment at six referral hospitals in a rural County in Kenya. Cases were infants with positive 6 week HIV test while controls were infants who were HIV negative. For every case identified by review of facility-based HIV cohort register, four controls from the same facility were included by random sampling from a cohort of HIV exposed infants with a negative 6 week status. We collected data on male partner involvement along four constructs: Antenatal clinic accompaniment by the male partner, awareness of partner’s HIV status by the woman, disclosure of woman’s HIV status to the partner, and HIV couple testing, by administering a self-filled questionnaire.

Results:

Thirty six cases and 144 controls were included in the analysis. Only 16.7% (n=30) of participants had disclosed their HIV status to their partners, the rate being lower among cases [7.6% (n=11) vs 52.8% (n=19). On the other hand, 60% (n=109) of the women were aware of the HIV status of their male partners, cases being less aware than controls [cases-36.8% (n=14), controls-66.9% (n=95)]. Seventy-five percent were tested as a couple (cases-71.1%, controls-76.1%). Overall 18.3% (n=33) of women were accompanied by their partners to the clinic (cases-10.5% (n=4); controls-20.4% (n=29). Three of the four constructs were significantly associated with MTCT [(disclosure of HIV status to partner; OR-13.5 (95% CI 5.5-33.2), p<0.001]; [antenatal clinic accompaniment, OR=0.30 (0.1-0.5), p=0.001]; [awareness of partner’s status- OR=0.12 (0.1-0.90), p=0.001]. 

Conclusion:

From the study, non-disclosure of HIV status to a male partner contributed to a higher risk of HIV acquisition by the infant, while awareness of male partner HIV status and involvement of the male partner during antenatal follow up were both associated with reduced risk of infant HIV acquisition. These findings are possibly because in many rural African areas where PMTCT are offered, men are still the primary decision-makers (Kalembo, Zgambo, Mulaga, Yukai, & Ahmed, 2013),  and their involvement  is crucial in optimising uptake and utilisation of PMTCT services. Many reports point to the beneficial effect of male partner support in antenatal HIV services on prevention of paediatric infections (Medley et al., 2004; Morfaw et al., 2013). This support results in improved  attendance to antenatal clinic, use and adherence to maternal and infant ARVs, adherence to infant feeding method selected, and increased follow up among HIV exposed infants (Jasseron et al., 2013; Msuya et al., 2008; Roxby et al., 2013; Varga, Sherman, & Jones, 2006). Male partner involvement also improves uptake of appropriate infant feeding options as it encourages exclusive breastfeeding by releasing pressure from the mother on early initiation of mixed feeding usually advocated for by the extended family in an African setup (Madiba & Letsoalo, 2013). Additionally, a woman receiving her partner’s support is more likely to deliver at a health facility where they are likely to receive appropriate measures to lower the risk of MTCT (Kibera, 2011; Turan & Nyblade, 2013). Finally,  men involvement allows for shared responsibility for preventing HIV transmission to the unborn child, and adoption of safer sex practices (Medley et al., 2004). Ultimately, all these positive outcomes contribute to a lower vertical HIV transmission (Aluisio et al., 2011; Villar-Loubet et al., 2013).

This study reiterates the direct impact of male partner involvement on MTCT. Given the potential for PMTCT interventions to eliminate MTCT, and the evidence emanating from this study suggesting an important association among various aspects of male partner involvement and infant HIV acquisition, which hitherto was unclear, a re-examination of policies on male-partner engagement which serves the dual purpose of increasing awareness of HIV status and enhanced disclosure, ought to be prioritised. We propose that all PMTCT programmes re-evaluate their strategies at improving male involvement with the aim of addressing barriers to male engagement.