Home Visits during Pregnancy Enhance Male Partner HIV Testing: A Randomized Clinical Trial

www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Home Visits during Pregnancy Enhance Male Partner HIV Testing: A Randomized Clinical Trial

Alfred Osoti MBChB MMed MPHDepartment of Epidemiology

University of Washington

7TH IAS Conference on HIV Pathogenesis, Treatment and Prevention


Benefits of male partner involvement

HIV infected pregnant woman• Improve uptake of

PMTCT

• Enhance infant HIV free survival

HIV uninfected pregnant woman

• Reduce high maternal HIV incidence in discordant relationships

Aluisio et al. JAIDS 2011 Kinuthia et al. CHR 2010


Male partner involvement is lowCountry Tested (%) Author (Year)

Uganda 1.8 Kizito (2008)

Zimbabwe 7.0 Chandisarewa (2007)

Zambia 9.2 Semrau (2005)

Tanzania 12.5 Msuya (2008)

Kenya 15.0 Farquhar (2005)

Cote d’Ivoire 19.6 Brou (2007)

Multi-country 21.5 Orne-Gliemann (2013)*

South Africa 32.0 Mohlala (2011)www.pepfar.gov/press/81257.htm

• Male HIV testing considered “marker” of male partner involvement • All studies were facility based

*Cameroon, India, Georgia, Dominican Republic


Enhancing male partner involvement

How else can we reach these men if they will not come to clinic?


Home-based HIV Counseling and Testing (HBCT)

• Door-to-door HBCT– Acceptability >70%– Testers~25% men~13% couples≈4% pregnancy

• For PMTCT, it may be more efficient to focus on testing men when their partners are pregnant

Alsop Z. Lancet 2010.Naik BMC Public Health 2012.


Men as Partners in PMTCT (MAP) study

Primary objective• Compare effectiveness of home visit vs. invitation

for clinic visit in increasing male partner HIV counseling and testing among women seeking prenatal care

Secondary objectives• Evaluate relationship stability and intimate partner

violence following male partner HIV testing


Study population and setting

• Study population• Pregnant women unaccompanied by

partners• On 1st antenatal care (ANC) visit• Legal age• No couple HCT in this pregnancy• Reside in area with partner for

≥ 6 weeks

• Ahero Sub-district Hospital, Nyanza, Kenya• Antenatal HIV-1 prevalence

~ 20%

Nyanza 13.9%National 6.3%

• HIV prevalence


Immediate Home Visit(ACASI & Couple HCT)

Invitation for Clinic Visit (ACASI & Couple HCT)

Intimate partner violenceRelationship stability

RandomizationAntenatal HCT

Male partners tested for HIV, through Couple HCT

Design: a randomized controlled trial

Screening, Enrollment, Interview[Audio Computer Assisted Self Interview (ACASI)]


495 screened during 1st ANC visit

150 home visit 150 clinic visit

312 (63%) eligible

300 (96%) randomized

Results: Enrollment and follow-up of women

183 (37%) ineligible

12 (4%) declined

149 (99%)followed-up

150 (100%)followed-up

1 loss to follow-up


Results: baseline characteristics of women

Characteristic

Home visit (N=150)

Clinic visit (N=150)

Number (%) or Median (IQR)

Age (years)

22

(20,25)

22

(20,26)

Highest education level

Primary or lower

103

(69%)

99

(66%)

Marital status

Monogamous

131

(87%)

131

(87%)

Economic status

Daily household income <2 $

111

(74%)

113

(75%)

Daily cell phone use 107 (71%) 116 (77%)

Physical threat from male partner (past 6 months)

34

(23%)

36

(24%)

HIV prevalence

21

(14%)

27

(18%)

$=United States dollars


133 (89%) male partners accessed

55 (37%) male partners accessed

Results: male partner access and HIV testing

128 (85%) male partners HIV tested

54 (36%) male partners HIV tested

HOME VISIT(150 women enrolled)

CLINIC VISIT(150 women enrolled)


Results: Main outcomes

OutcomeHome visit (%)

Clinic visit (%)

RR 95% CI P value

Male partner HIV testing and mutual disclosure 85 36 2.37 1.90-2.96 <0.001*

Reported improved quality of relationship

67 28

2.36 1.79-3.13 <0.001*

Physically threatened over the past six months 16 19 0.85 0.51-1.43 0.544

*Statistically significantRR=Relative Risk CI= Confidence interval


Results: overall male partner HIV status

Male partner HIV Status Home visit Clinic visit RR 95%CI P value

No (%) No (%)

HIV positive 18 (12.0) 12 (8.0) 1.5 0.74-3.00 0.248

HIV negative 110 (73.3) 42 (28.0) 2.62 1.99-3.45 <0.001*

HIV discordant 22 (14.7) 7 (4.7) 3.14 1.38-7.13 0.003*

HIV concordant positive 7 (4.7) 8 (5.3) 0.88 0.33-2.35 0.791

*Statistically significantRR=Relative Risk CI= Confidence interval


Results: relationship status at follow-up

P<0.001

P=1.000P= 0.767

Improved relationship Worse relationship Physically threatened 0

100

67

4

16

28

5

19

Home-visit Clinic-visit


Strengths and limitations

Strengths• Randomized design

• Generalizable to high HIV prevalence and resource-limited settings with similar partnerships

• Easily implementable, conducted after routine prenatal HCT

Limitations • Excluded single and those

in unstable relationships

• Short follow-up period, unable to assess long-term outcomes such as HIV free survival, linkage to care, cost-effectiveness


Conclusions

• Home visits for male partner testing and mutual disclosure– highly acceptable – enhanced access to male

partners and couple HCT (85%)

– did not adversely affect short-term relationship status

– found high prevalence of• HIV among male partners • HIV serodiscordant couples


Acknowledgements

University of Washington Carey Farquhar Grace John-Stewart Barbra Richardson Daisy Krakowiak International AIDS Research and Training Program

Study Participants and Staff

University of NairobiJames KiarieJohn Kinuthia

Funding: NIH , Fogarty International Centre


THANK YOU!


Enrollment status

• Ineligibility (n=183):– 14 accompanied by male partner– 32 male partners or themselves away for > 6 weeks– 53 HIV positive and knew before pregnancy– 38 single with no stable male partner – 25 single, primary to high school students– 9 separated from male partners – 2 widows– 2 non-pregnant (negative pregnancy test) – 8 visitors, not residents of the area

• Reasons for declining (n=12):– 5 consult partner – 4 time constraints – 3 another study

Documents

Home Visits during Pregnancy Enhance Male Partner HIV Testing: A Randomized Clinical Trial