Engaging Male Partners in Home-based Couple Education and Testing for Syphilis and HIV
For HIV and other sexually transmitted infections (STIs), men seek care at more advanced stages of disease and are less likely to initiate treatment.1-4 Male partner participation in antenatal care (ANC) has been shown to increase male and female HIV testing,5,6 identification of HIV-discordant couples,7,8 female participation in ANC and uptake of PMTCT services1,9 as well as reduce infant HIV acquisition and mortality.10 Despite these significant benefits, rates of male attendance to clinic-based antenatal services remain very low.1,2,11 in part because efforts to engage men have focused on reducing HIV transmission risks to mothers and children without directly addressing the sexual health needs of men. Advocating for the health of fathers as equally important and reframing men as positive contributors to the health of the family shifts the balance from a maternal and child health approach to a family health approach that addresses HIV and STI control within the larger community.12 The advent of rapid and inexpensive point-of-care (POC) tests for syphilis and HIV has greatly expanded test coverage, especially in areas with difficult-to-reach populations or without access to laboratory diagnostics.19,20 POC tests also enabled the development of home-based education and testing (HBT), a novel approach utilizing trained counselors to deliver individualized sexual and reproductive education and testing to couples in the privacy of their homes.21 Engaging men by providing HBT for syphilis and HIV during pregnancy can have synergistic and cost-saving effects on reducing HIV and syphilis transmission and adverse pregnancy outcomes. HBT has been shown to increase HIV test uptake by men and identify more serodiscordant couples who can be targeted for high-yield HIV prevention, 7,8,21,22 but less is known about the effects of HBT on linking individuals to care and treatment. Within a randomized control trial of pregnant women attending a first antenatal visit in Western Kenya, women and their male partners received either: (1) a home-based couple education and testing (HBT) intervention, or (2) an invitation letter for clinic-based couple HIV testing. We assessed the uptake of home-based POC syphilis and HIV testing during pregnancy and at 6 months postpartum and assessed whether introduction of syphilis testing affected HIV testing. At 6 months postpartum, we examined whether HBT affected male partner utilization of STI and HIV prevention and care services (i.e. STI consultation, medical male circumcision and HIV care and treatment) and female partner HIV viral suppression. Syphilis testing was highly acceptable to male partners during early pregnancy (93% of 80 men) and 6 months postpartum (98% of 230 men). Therefore, uptake of paired syphilis and HIV testing uptake was also high (91% during pregnancy and 96% postpartum). Introducing syphilis testing did not adversely affect HIV testing as uptake remained high before (96%) and after (95%) syphilis testing was introduced. After receiving home-based education and testing during their partners’ pregnancy, 75 of 80 (94%) men intended to seek clinic-based services for STI consultation if testing was positive. By 6 months postpartum, among 525 women exiting the study, we reached 487 (93%) of their male partners in the intervention (n=247) and control arms (n=240). Men who received home-based couple education and testing were 59% more likely to have sought STI consultation during the study period than men in the control arm (n=47 of 247 vs. 16 of 240, respectively; RR=1.59; 95% CI: 0.50-0.96). However, at 6 months postpartum, one-time home-based education and testing did not have an impact on HIV prevention or treatment as medical circumcision among eligible uncircumcised men and linkage to HIV care among newly diagnosed HIV-positive men remained low in both intervention and control arms. Similarly, home-based couple education and testing did not affect HIV viral suppression in HIV-positive pregnant women in the intervention or control arms at 6 months postpartum. Despite women commencing lifelong antiretroviral therapy, 22 (30%) of 73 HIV-positive women who provided dried blood spots were not virally suppressed at 6 months postpartum. Of these women with unsuppressed HIV, 17 (81%) of 22 were breastfeeding and 8 (38%) of 22 had HIV-negative male partners. These findings indicate continued risk of HIV transmission to young infants and male partners and highlight continuing gaps in the HIV care and treatment cascade. These results show that syphilis testing is as acceptable as HIV testing and that home-based couple education and testing can be effective in increasing male partners seeking STI consultation and treatment. However, one-time home-based education and testing for HIV appeared insufficient to convince men to obtain medical circumcision or to increase linkage to HIV care among newly diagnosed HIV-positive male partners. HBT also did not have an effect on HIV viral suppression of women at 6 months postpartum. The inherent and social differences between STIs such as syphilis (short-term curative treatment, less stigma) and HIV (long-term non-curative treatment, high stigma) necessitate a recurrent and longer-term approach for linkage and continued engagement in HIV care and treatment. Providing home-based education and POC testing for HIV and other STIs to men and women as equal and contributing members of a family can help make a family health approach to sexual and reproductive health more holistic, accessible and sustainable.