HIV self-testing and PrEP to increase testing and prevention uptake among male partners and improve postpartum ART use in PMTCT B+ programs in Uganda

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ABSTRACT Uganda has the fifth highest HIV burden globally and one of the highest fertility rates in Africa. Prevention of mother-to-child transmission Option B+ (PMTCT B+) is national policy in Uganda. To maximize the prevention and clinical benefits of PMTCT B+, the challenges of low HIV testing by male partners and high rates of post- partum discontinuation of antiretroviral therapy (ART), insufficient ART adherence, and incomplete viral suppression need to be addressed. Women may be more likely to continue ART long-term and have higher adherence post-partum if their partners are tested, there is mutual disclosure of HIV status, and their partner takes ART or PrEP, depending on the partner’s status. Innovative approaches are needed to allow men to test in alternative settings to busy antenatal clinics, preferably privately where they are comfortable and do not miss work. We will use innovative technologies – HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) – to increase male partners’ engagement in HIV testing, prevention, and care services. We will train pregnant women in the use and interpretation of HIVST, provide them with two oral fluid-based HIVST kits to use with or give to their partners. We will offer men confirmatory testing, counseling, and if negative, PrEP and if positive, ART. We will provide counseling to minimize social harms of HIV self-testing. PrEP for HIV-negative male partners of HIV- positive pregnant women provides an effective intervention during an important ‘season of risk’ when they may have additional risk through other partners or when their partner may be viremic (during the first few months after ART initiation, post-partum ART discontinuation or due to viral resistance).. Integrated PrEP and ART delivery among East African HIV serodiscordant couples showed that PrEP as a ‘bridge’ until the HIV-positive partner was on ART for six months was very acceptable, achieved very high uptake and adherence to ART and PrEP, and nearly eliminated HIV transmission. We will use HIVST to identify HIV serodiscordant couples, and adapt the PrEP bridging strategy to Ugandan PMTCT B+ programs to increase ART continuation post-partum for clinical and prevention benefits. Aim 1: Determine whether an enhanced PMTCT program in Uganda that provides HIV self-testing for male partners and PrEP for HIV-negative men increases the proportion of men who test for HIV and initiate PrEP. Aim 2: Evaluate whether HIV testing and PrEP and ART use among male partners increases effective post-partum ART use among HIV-infected Ugandan women in PMTCT B+. Aim 3: Assess the acceptability of HIV self-testing and PrEP to pregnant women in PMTCT B+ and to their male partners, using qualitative and quantitative methods. In summary, this project will address key challenges in PMTCT B+ programs, by evaluating innovative strategies to increase male partner involvement in PMTCT B – HIVST to overcome men’s reluctance to test and their tendency to test ‘by proxy,’ coupled with offering PrEP to HIV-negative men, ART to HIV-positive men, and encouraging post-partum ART continuation and adherence among HIV-positive women.