Male partner involvement in PMTCT reduces HIV transmission risk

Male partner involvement in the prevention of mother-to-child transmission (PMTCT) services reduced the risks of vertical transmission and infant mortality by more than 40% compared to no involvement according to Adam Aluisio and colleagues in a prospective cohort study undertaken between 1999 and 2005 in Nairobi, Kenya published in the January 1st 2011 edition of the Journal of Acquired Immune Deficiency Syndromes.

Male involvement, the authors add, may be an underutilised public health intervention to address both infant HIV infection and mortality in resource-poor settings.

90% of the estimated 1,000 children infected daily with HIV live in sub-Saharan Africa. Vertical transmission accounts for approximately 95% of infections in children.

Even though access to antiretrovirals for PMTCT has improved, much more remains to be done in resource-poor settings. Over one-third of HIV-infected pregnant women and half of their infants do not get any treatment.

Infant mortality rates in sub-Saharan Africa are the highest in the world. HIV transmission, infant feeding practices as well as poverty contribute to this, note the authors. While there is evidence of diminishing vertical transmission rates, infant mortality remains high. Improved infant health outcomes necessitate addressing these public health problems together, they add.

Evidence shows that male involvement is associated with better use of PMTCT services. However, the authors note there is scant evidence of the link between male involvement and rates of vertical transmission or infant mortality.

From 1999 to 2002 HIV-infected pregnant women were recruited from antenatal clinics in Nairobi, Kenya and followed with their infants for one year. HIV DNA testing was done at birth and then at one, three, six, nine and 12 months after birth. Women were encouraged to bring their male partners for HIV prevention counselling and testing.

Out of a total of 510 HIV-infected women enrolled, a total of 10% (54) were lost to follow-up before delivery (27) or did not report a current male partner relationship (27).

Of the remaining 456 female participants, 140 (31%) were accompanied by their male partners to the antenatal clinic.

Of the 140 male partners, 75 (54%) were tested for HIV in the antenatal clinic; 42 (56%) tested positive.

Among 441 infants tested, 19% (82) were HIV-infected by one year of age.

Taking maternal viral load into account HIV-infection risk was over 40% lower  in infants born to women accompanied by their male partners compared to those unaccompanied (adjusted hazard ratio (aHR)=0.56; 95% CI: 0.33-0.98; P=0.042).

The same held true with reported prior partner HIV testing compared to no report of previous partner testing (adjusted hazard ratio (aHR)=0.52; 95% CI: 0.32-0.84; P=0.008).

Adjusting for maternal viral load and breastfeeding, the combined risk for vertical transmission or infant death was significantly lower with antenatal partner attendance than without (aHR=0.55; 95%CI: 0.35-0.88; P=0.012) as well as with reporting of previous partner testing than without (aHR=0.58; 95% CI: 0.34-0.88; P=0.01).

The authors note this study shows that male partner involvement provides a significantly lower risk for HIV infection as well as improved HIV-free survival in infants born to HIV-infected women when compared to infants born to women without male involvement.

While these findings are consistent with other studies, this study differs in that HIV-infection and infant mortality are looked at rather than numbers accessing an intervention, for example. This finding, the authors note, provides critical new evidence for male involvement as a potential, currently underused, public health intervention.

The authors note that while PMTCT programmes in sub-Saharan Africa promote partner HIV testing they do not specifically encourage antenatal attendance for partners of HIV-infected women.

These findings support the need to further define specific male partner factors that are associated with improved health outcomes in maternal and child health programmes, they note. Barriers to partner testing and participation in antenatal settings also need to be addressed, the authors add.

71 (16%) infants died, of whom 28 (39%) were HIV-infected, 31 (44%) HIV- uninfected, and the remaining 12 (17%) of unknown status.

The mortality risk among HIV-uninfected infants born to women with antenatal partner attendance was 63% less than in those whose mothers were unaccompanied. The authors note that with increasing rates of antenatal HIV testing and improved antiretroviral treatment HIV-exposed but uninfected children make up the majority of infants born to HIV-infected mothers. So bringing down the death rates among this group will provide considerable public health benefits.

However, the authors also noted a disturbing trend that needs further exploration:  increased mortality risk among HIV-infected infants born to women with partner attendance.

Limitations include not taking into account the possible negative effects of male involvement, in particular domestic violence. The authors suggest these be monitored in future studies.

A second limitation involves bias when answering sensitive questions concerning HIV testing and disclosure of their partner’s status.

The authors conclude that “these data suggest that incorporating men into PMTCT programmes with associated HIV testing may improve infant health outcomes by reducing both vertical transmission and mortality among uninfected infants.”

Aluiso A et al. Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV-free survival.  J Acquir Immune Defic Syndr 56(1):76-82, 2011.