Engaging Partners in Childbirth for Prevention of Mother-To-Child Transmission of HIV (EPiC-pMTCT): preliminary work for a randomised controlled trial

艾滋病毒是一个主要的公共卫生问题，一个主要的传播途径是母婴传播(MTCT)，它约占非洲国家艾滋病毒负担的10%。预防这种传播方式(母婴传播)是全球艾滋病毒预防的一个关键因素，世界卫生组织建议在撒哈拉以南非洲优先考虑艾滋病毒感染的母婴传播。非洲的许多产科病房都有基于证据的干预措施，以减少母婴传播，但它们的普及程度很低。吸收的障碍与男性伴侣在妇女围产期护理中的作用密切相关。众所周知，在许多提供预防母婴传播的非洲国家，男子是主要的决策者。研究表明，妇女更有可能(A)接受艾滋病毒检测，(B)向丈夫披露自己的艾滋病毒状况，(C)在怀孕期间坚持治疗，(D)在防止母婴传播机构分娩，以及(E)如果其伴侣参与防止母婴传播方案，则遵守婴儿喂养建议。虽然男性参与可能对采取防止母婴传播的干预措施产生积极影响，但在撒哈拉以南非洲，预防艾滋病毒母婴传播的举措主要集中在妇女身上，而无意中排斥了她们的男性伴侣。男性参与的实际影响尚不清楚，因为缺乏关于男性伴侣参与的益处和有效性的量化数据。Cochrane最近的一项荟萃分析发现，只有一项合格的研究评估了男性参与改善女性预防母婴传播服务的有效性，而且这项研究只关注了围产期预防母婴传播级联反应的一部分。虽然男性参与有望改善对防止母婴传播干预措施的接受，但还需要进一步进行严格的评估和实施研究。然而，在这方面的努力必须从解决男性伴侣参与防止母婴传播研究和实施中的概念和方法问题开始。对男性参与防止母婴传播方案没有统一的定义，也没有关于男性参与的标准化衡量标准或可靠指标。还需要对男性在防止母婴传播中的作用进行重新定义。有人认为，为了最大限度地提高防止母婴传播方案的健康结果，不应简单地将男子视为使妇女能够获得保健服务的“促进因素”，而应将其视为生殖健康政策和做法的组成部分。此外，将男性伴侣纳入女性艾滋病毒预防的努力主要集中在让男性支持其女性伴侣采取预防战略，而没有更广泛地考虑男性自身的健康需求或旨在促进更大性别平等的社会议程。在未来的一项研究中，我们建议进行一项随机对照试验，以评估以家庭为中心的多成分干预措施。这项试验的假设是，与对照组相比，干预措施的实施将导致干预组对防止母婴传播方案的吸收有所改善。在开始试验之前，我们建议开展开发工作(目前的研究)，根据文献中的证据和本研究的定性数据，制定合作伙伴的参与计划(即多组分的EPIC-PMTCT干预)，并评估进行整群随机对照试验的可行性。这项开发工作的结果还将为选择将参加拟议试验的中心提供信息，如果认为可行，这项研究的产出将包括关于防止母婴传播中男子参与的障碍的证据的综合，对男子、妇女、保健专业人员和政策制定者对男子参与的观点的分析，干预一揽子计划，以及关于收集试验所需数据的可行性的报告。

HIV is a major public health problem, and a major route of transmission is Mother-To-Child Transmission (MTCT) which accounts for about 10% of the national HIV burden in African countries. Prevention of this mode of transmission (pMTCT) is a key element in global HIV prevention and the World Health Organisation has recommended that pMTCT of HIV infection should be prioritized in sub-Saharan Africa.Evidence-based interventions to reduce MTCT are available in many maternity units in Africa, but their uptake is poor. The barriers to uptake are closely linked with the role of the male partners in perinatal care of the woman. It is known that men are the primary decision makers in many African countries where pMTCT is offered. Studies show that women are more likely to (a) undergo HIV testing, (b) disclose their HIV status to their husband, (c) adhere to treatment during pregnancy (d) deliver in a pMTCT facility and, (e) comply with infant feeding recommendations if their partners are engaged in the pMTCT programme. While male participation has a potentially positive impact on the uptake of pMTCT interventions, initiatives to prevent mother-to-child HIV transmission in sub-Saharan Africa have focused overwhelmingly on women, to the unintended exclusion of their male partners. The actual impact of male involvement is unknown, as there is a lack of quantitative data on the benefits and effectiveness of male partner engagement. A recent Cochrane meta-analysis found only one eligible study that assessed the effectiveness of male involvement in improving women's uptake of pMTCT services, and that study only focused on one part of the perinatal pMTCT cascade. While male involvement holds promise for improving uptake of pMTCT interventions, further rigorous evaluation and implementation research is needed.Efforts in this direction must, however, begin by addressing conceptual and methodological issues in the study and implementation of male partner involvement in pMTCT. A uniform definition of male participation in pMTCT programmes does not exist, and there are no standardized measures or reliable indicators of male involvement. Also needed is a reconceptualisation of the role of men in pMTCT. It has been argued that to maximize the health outcomes of pMTCT programs, men should not be seen as simply "facilitating factors" that enable women to access health-care services, but be recognized as a constituent part of reproductive health policy and practice. Also, efforts to include male partners in HIV prevention for women have focused primarily on engaging men to support their female partners in adopting a prevention strategy, without also offering broader consideration for men's own health needs or of a social agenda aimed at promoting greater sex equality.In a future study we propose to undertake a randomised controlled trial to assess a multi-component family-centred intervention. The hypothesis for the trial is that implementation of the intervention would result in improved uptake of pMTCT programmes in the intervention arm compared with the control arm. Before embarking on the trial, we propose to undertake development work (the current study) that will devise a programme of engagement of partners (i.e. the multi-component EPiC-pMTCT intervention) based on evidence in the literature and qualitative data from this study, and also assess the feasibility of conducting the cluster randomised controlled trial. The results from this development work will also inform the selection of centres that will participate in the proposed trial if it is deemed feasible.The outputs from this research will comprise a synthesis of the evidence on barriers to male engagement in pMTCT, an analysis of the perspectives of men, women, health professionals and policy makers on male engagement, an intervention package, and a report on the feasibility of collecting the data required for the trial.