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

艾滋病毒是一个重大的公共卫生问题，主要的传播途径是母婴传播（MTCT），在非洲国家，母婴传播约占全国艾滋病毒负担的10%。预防这种传播方式（pMTCT）是全球艾滋病毒预防的一个关键因素，世界卫生组织建议应优先考虑撒哈拉以南非洲地区的pMTCT感染。在非洲的许多产科单位都有减少母婴传播的循证干预措施，但它们的使用率很低。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，在提供预防母婴传播的许多非洲国家，男性是主要决策者。研究表明，妇女更有可能(a)接受艾滋病毒检测；(b)向丈夫披露其艾滋病毒状况；(c)在怀孕期间坚持治疗；(d)在预防母婴传播机构分娩；(e)如果其伴侣参与了预防母婴传播规划，则遵守婴儿喂养建议。虽然男性的参与对预防母婴传播干预措施的采用具有潜在的积极影响，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，无意中将其男性伴侣排除在外。男性参与的实际影响是未知的，因为缺乏关于男性伴侣参与的好处和有效性的定量数据。最近的Cochrane荟萃分析发现，只有一项合格的研究评估了男性参与改善妇女接受预防母婴传播服务的有效性，而且该研究只关注围产期预防母婴传播级联的一部分。虽然男性的参与有望改善预防母婴传播干预措施的采用，但需要进一步进行严格的评估和实施研究。然而，这方面的努力必须首先解决研究和执行男性伴侣参与预防母婴传播的概念和方法问题。没有关于男性参与预防母婴传播规划的统一定义，也没有关于男性参与的标准化措施或可靠指标。还需要重新认识男性在预防母婴传播中的作用。有人认为，为了最大限度地提高预防母婴传播方案的健康成果，不应仅仅将男性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实践的组成部分。此外，将男性伙伴纳入妇女艾滋病毒预防工作的努力主要侧重于让男性支持其女性伙伴通过预防战略，而没有更广泛地考虑男性自身的健康需要或旨在促进更大程度的两性平等的社会议程。在未来的研究中，我们建议进行一项随机对照试验来评估以家庭为中心的多成分干预。该试验的假设是，与对照组相比，干预措施的实施将导致干预组对预防母婴传播规划的接受程度提高。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，设计一个合作伙伴参与的计划（即多组分EPiC-pMTCT干预），并评估进行聚类随机对照试验的可行性。这项开发工作的结果还将为选择参与拟议试验的中心提供信息，如果该试验被认为是可行的。这项研究的产出将包括综合关于男性参与预防母婴传播的障碍的证据，分析男性、女性、卫生专业人员和决策者对男性参与的看法，一揽子干预措施，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.