Pilot of an Intervention for Malawian Pregnant Women with HIV to Improve Depression, Viral Suppression and Engagement of Partners in HIV Self-Testing

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HIV infection remains one of the biggest killers globally. Malawi has a successful programme for prevention of mother to child transmission of HIV based on routine antenatal testing. However, 23% of women attending HIV antenatal care are lost to care at one year. Depression is an important cause of poor adherence to medication for the treatment of HIV and disengagement from HIV care. Depression is two to three times higher in people living with HIV than in the general population, and common in pregnant and post-natal women in Southern Africa. Symptoms of depression such as reduced concentration, memory, problem-solving ability and motivation, adversely affect engagement with health care and adherence to medication. Malawi's successful programme of antenatal testing presents an opportunity to engage their male partners in HIV testing. Men are less likely than women to test for HIV and know their status. In Malawi over 45% of HIV-positive women in stable relationships have an HIV-negative partner. Without intervention, HIV-negative partners acquire HIV at up to 12% per year. Supporting women to adhere optimally to their HIV medication to ensure their virus is well controlled reduces the risk of transmission to zero. HIV self-testing, whereby an individual collects their own sample, conducts the test and interprets their result increases coverage and frequency of testing. Partner-delivered self-test kits, where woman distribute a test to their male partner, is becoming routine antenatal policy and practice in high HIV prevalence settings including Malawi. The aim of the proposed research is to finalise and test the feasibility and acceptability of an intervention for pregnant women living with HIV and depression, to reduce depression and optimise engagement in HIV care, and to increase uptake of HIV testing, prevention and care for their male partners. This will be achieved through conducting formative work using qualitative methods to adapt an intervention to treat depression and optimise adherence to HIV medication for the Malawian antenatal context. For the male partners of HIV positive pregnant women, we will develop a mobile phone based SMS platform where the male partner will be able to receive instructions on how to use an HIV self-test kit via SMS. We will develop messages providing key information on living with HIV, or HIV prevention strategies The study will take place in an antenatal clinic in Blantyre, Malawi. We will recruit 40 HIV positive women in the 2nd trimester of their pregnancy and randomise them to receive the intervention or enhanced usual care. The 'TENDAI Together' intervention will consist of six sessions of therapy for depression and engagement in HIV care delivered by a trained and supervised HIV Diagnostic Assistant, an assessment for an antidepressant. The women recruited to the trial will also be given a self-test kit to distribute to their male partners. Instructions on how to use the self-test kit and key information on living with HIV or with an HIV positive partner to address post-test worries will be sent via SMS.We will collect assessment measures at baseline and at 6 month follow up. This will include outcomes to determine the feasibility of a larger trial, such as the proportion of eligible participants recruited and then retained in the study. We will assess the acceptability of the intervention by the number of sessions attended and exit interviews with the women who received the intervention. We will also determine feasibility of collecting clinical outcome measures such as HIV and depression outcomes for the women and her male partner, and clinical outcomes for the infant 2 months post-delivery. Locally validated, evidence-based measures will be used for the psychological entry criteria and outcome data.