Active invitation and tracing more likely to get men involved in couples HIV counselling and testing

Active invitation and tracing of male partners of pregnant women newly diagnosed with HIV substantially increased uptake of couples HIV counselling and testing (cHCT), resulting in close to half the male partners learning they had HIV for the first time. There was also a significant decline from 94% to 23% (p < 0.001) in unprotected sex among HIV-discordant couples in Lilongwe, Malawi, Nora Rosenberg told participants at the Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015) in Vancouver, Canada on Monday.

The strategies comprised invitation-alone and invitation plus tracing by phone or home visit if the couple did not present for couple HIV counselling and testing within seven days.

This randomised controlled trial recruited pregnant women newly diagnosed with HIV from the Bwaila District Hospital Antenatal Unit between March and October 2014. Uptake of couples HIV counselling and testing by male partners was 52% and 74% in the invitation alone and invitation plus tracing arms of the study, respectively, (p = 0.001).

There were no reports of intimate partner violence. Previous findings have been mixed regarding partner violence as a direct result of couples HIV counselling and testing.

Dr Rosenberg suggested that scale-up of an invitation-plus-tracing recruitment strategy within the Option B+ programme (lifelong ART for women living with HIV who are pregnant or breastfeeding) would have important public health benefits.

In spite of a sevenfold increase in the numbers of women starting antiretroviral therapy in 2011, the first year of the implementation of the Option B+ programme in Malawi, significant challenges remain including uptake, retention in care and adherence to treatment. Loss to follow-up at one year has been reported as being as high as 24% compared to an 8% rate in general health.

While HIV counselling and testing for pregnant women in Malawi’s antenatal programme is close to 100%, couples HIV counselling and testing is rare, even though it is part of the Option B+ guidelines. Findings from a 2014 study showed that few women (11%) came with their partner to the Bwaila District Hospital Antenatal Unit for couples HIV counselling and testing.

Rosenberg noted that couples HIV counselling and testing is critical for women with HIV. Their partners may be unaware of their status and in need of diagnosis and treatment or prevention. The potential benefits of mutual disclosure include the opportunity for them to make informed decisions together about HIV prevention and reproductive health including contraception.

Couples counselling and testing has been shown to improve adherence to treatment as well as breastfeeding protocols. It may also increase retention in Option B+ care.

Conversely, non-disclose may prevent access to treatment and care including prevention of mother-to-child transmission (PMTCT) interventions. The lack of male involvement is often cited as a barrier to uptake and retention.

Rosenberg and colleagues wanted to know if active male partner recruitment could enhance uptake of couples HIV counselling and testing. They assessed invitation-alone and invitation-plus-tracing recruitment strategies for couples HIV counselling and testing uptake, male HIV status, female Option B+ retention and consistent condom use.

Women newly diagnosed with HIV, aged 16 and over, with male partners were eligible to participate. After giving consent, those in the invitation-only arm received an invitation for male partners to attend antenatal care with their partners. Those women in the invitation-plus-tracing arm received the same invitation. However, if their partners did not visit the clinic within one week, they were traced by phone and/or home visit. Women were assessed one month later.

Of the 220 women eligible with a mean age of 27 years, 200 (90%) consented and enrolled. A total of 126 men presented for couples HIV counselling and testing. Of these, 25% already knew they were living with HIV, 47% learned of their HIV-positive status for the first time, and 25% were HIV-negative. There were no differences between the arms (p = 0.8).

At one month follow-up, antiretroviral treatment retention was higher among women in the invitation-plus-tracing arm compared to the invitation-alone arm, 91% and 83%, respectively (p = 0.09).

The invitation-plus-tracing strategy was highly effective in recruiting male partners for couples HIV counselling and testing and more so than the invitation-only strategy. Both strategies succeeded in identifying a large number of men with HIV as well as HIV-discordant couples. Couples HIV counselling and testing resulted in good retention rates, significant decreases in unprotected sex and, importantly, no intimate partner violence.

While male involvement is associated with improved retention and adherence as well as providing the opportunity to discuss HIV and sexual risk, it can result in abandonment as well as physical and psychological abuse. Three women (2%) reported social harms including blame (one) and separation (two). On the other hand, interviews with women suggested that disclosure had deepened the relationship for quite a number of women.

Dr Rosenberg noted study limitations including not adequately knowing the mechanism, a small sample size, a single site, short-term follow-up and only primary partners being involved.