Recruiting male partners for couple HIV testing and counselling in Malawi's option B+ programme: an unblinded randomised controlled trial

Abstract

Summary Background Couples HIV testing and counselling (CHTC) is encouraged but is not widely done in sub-Saharan Africa. We aimed to compare two strategies for recruiting male partners for CHTC in Malawi’s option B+ prevention of mother-to-child transmission programme: invitation only versus invitation plus tracing and postulated that invitation plus tracing would be more effective. Methods We did an unblinded, randomised, controlled trial assessing uptake of CHTC in the antenatal unit at Bwaila District Hospital, a maternity hospital in Lilongwe, Malawi. Women were eligible if they were pregnant, had just tested HIV-positive and therefore could initiate antiretroviral therapy, had not yet had CHTC, were older than 18 years or 16–17 years and married, reported a male sex partner in Lilongwe, and intended to remain in Lilongwe for at least 1 month. Women were randomly assigned (1:1) to either the invitation only group or the invitation plus tracing group with block randomisation (block size=4). In the invitation only group, women were provided with an invitation for male partners to present to the antenatal clinic. In the invitation plus tracing group, women were provided with the same invitation, and partners were traced if they did not present. When couples presented they were offered pregnancy information and CHTC. Women were asked to attend a follow-up visit 1 month after enrolment to assess social harms and sexual behaviour. The primary outcome was the proportion of couples who presented to the clinic together and received CHTC during the study period and was assessed in all randomly assigned participants. This study is registered with ClinicalTrials.gov, number NCT02139176. Findings Between March 4, 2014, and Oct 3, 2014, 200 HIV-positive pregnant women were enrolled and randomly assigned to either the invitation only group (n=100) or the invitation plus tracing group (n=100). 74 couples in the invitation plus tracing group and 52 in the invitation only group presented to the clinic and had CHTC (risk difference 22%, 95% CI 9–35; p=0·001) during the 10 month study period. Of 181 women with follow-up data, two reported union dissolution, one reported emotional distress, and none reported intimate partner violence. One male partner, when traced, was confused about which of his sex partners was enrolled in the study. No other adverse events were reported. Interpretation An invitation plus tracing strategy was highly effective at increasing CHTC uptake. Invitation plus tracing with CHTC could have many substantial benefits if brought to scale.

Promoting partner and couples HIV testing using self-test kits in Kenya

“…Further, a study in Malawi found a similar uptake of partner HIV testing among participants who received invitation cards for their partner (52%) (Rosenberg et al 2015). The similarity in male partner testing levels in the comparison group of our study with those reported in two other studies of the partner invitation approach provide further support for the validity of the measures obtained in our study.…”

“…This is a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used. Despite the potential for self-reporting to be associated with reporting bias, we believe that reporting bias was minimal given the consistency of our results for HIV testing uptake with other studies conducted in SSA (Choko et al 2011;Choko et al 2015;Thirumurthy et al 2016;Rosenberg et al 2015;Osoti et al 2014). In addition, any bias in reporting of HIV testing uptake is unlikely to be differential by study group, thereby maintaining the validity of examining the difference in HIV testing uptake between study groups.…”

Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trial

“…9 Our study suggests that a male partner intervention that is part of a package of PMTCT services and includes a combination of individual, facility-based, and community-based approaches (invitation letters delivered by wives, peer male champions, and male-friendly settings) is acceptable and feasible. The use of invitation letters and tracing to recruit male partners for couple HIV testing and counselling has been effective in option B+ settings, 29 and could prove feasible in our environment when option B+ becomes national policy. Our study also shows that male partners can provide assistance in the use of culturally sensitive and sustainable PMTCT care delivered by lower-cadre providers.…”

The effect of HIV counselling and testing on HIV acquisition in sub-Saharan Africa: a systematic review

“…Several strategies, such as partner notification and community invitations have been effective for increasing cHCT and could have important implications if brought to scale. [39][40][41] Such efforts would have benefits on reduced HIV incidence and on reaching global HIV targets, including the 90-90-90 goals and elimination of mother-to-child transmission [42][43][44] Assessing the impact of HCT on HIV acquisition is methodologically challenging. First, all assessments of HIV acquisition require large cohorts followed for long periods with low, nondifferential loss to follow-up.…”