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

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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.