The prevention of mother-to-child transmission of HIV programme in Eastern Uganda. Men’s involvement in a changing HIV testing policy context

Abstract

Introduction: The prevention of mother-to-child transmission of HIV-1 (PMTCT) was launched in Uganda in early 2000 and in Mbale Regional Referral Hospital in Eastern Uganda in 2002. The initial challenges were the low antenatal HIV testing rates and low male partner involvement. The aim of this thesis was to explore determinants of women’s and men’s participation in the PMTCT programme in Eastern Uganda and find ways to improve male involvement. Methods: The thesis contains four studies: (a) a retrospective analysis of routine data from hospital records on 54 429 new antenatal attendees and 469 male partners over a 7-year period; (b) a cross-sectional survey conducted in 2009 among 388 new antenatal attendees, who were tested for HIV; (c) a cross-sectional survey conducted in 2004 among 388 male partners of pregnant women attending antenatal care at Mbale hospital, and in addition, 5 key informant interviews and 8 focus group discussions; and (d) a double blind, randomized intervention trial to increase male participation using an invitation letter to the male partner as the intervention and an information leaflet to the partner as the control, conducted in 2009-10 among 1060 new antenatal attendees (530 in each arm) in the antenatal clinic at Mbale Hospital, with a follow-up period of four weeks. Descriptive statistics and logistic regression analyses were used to assess the study outcomes, content-thematic analysis of the qualitative data was done and intention to treat analysis was conducted to assess the primary outcome of the trial. Results: There was a significant increase in HIV testing rates among the new antenatal attendees from 22% during the period of voluntary counselling and testing for HIV to 88% following the change in HIV testing policy to provider-initiated HIV testing and counselling (PITC). Our survey showed that PITC was highly acceptable to the pregnant women, increasing testing rates considerably and decreasing stigma. However, male partners HIV testing rates remained low. Our survey among male partners indicated that determinants of male partner participation in the PMTCT programme included social, cultural, and health system factors, and that the men had never been invited to the antenatal clinic. A simple and cheap intervention, such as a letter to the male partner, increased couple antenatal clinic attendance by 10 percentage points and the large majority of men attending the antenatal clinic accepted HIV testing. However, the two study arms had a similar effect. Conclusions: PITC remarkably increased the HIV testing rates among the antenatal attendees and was highly acceptable to them and can therefore be actively promoted in antenatal clinics and possibly other clinical settings. Although cheap and underutilised, the use of an invitation letter addressed to the male partners of the ANC attendees increased male antenatal attendance and HIV testing. It should be promoted in antenatal clinics in Eastern Uganda where it has been shown to work and tried in other areas with low male antenatal attendance, both in Uganda and beyond.