Letters to the Editor
To the Editors:
We appreciate the letter by Montgomery et al in response to our study that showed an association between male partner involvement and improved infant outcomes (HIV-free survival) in Kenya.1 As was highlighted by the authors, male involvement in prevention of mother-to-child transmission of HIV (PMTCT) is recommended by multiple public health advisory bodies,2 including the World Health Organization, which states that there is a need to “increase the involvement of male partners in PMTCT services (eg, couples counseling, partner testing).”3 Most national guidelines in sub-Saharan Africa are similar,4,5 yet what comprises involvement is not well defined.
As was recommended in this letter, there is a need for research to define clear objectives for male involvement in PMTCT. To date there is a paucity of studies on partner participation in prevention of vertical transmission programs. Rates of male HIV testing in the antenatal setting have been historically low. With few exceptions, partner testing rates are consistently less than 30% in research settings.6 There are also minimal data from men themselves on their perceived barriers to antenatal clinic attendance and HIV testing in that setting. One of the few studies thatm provides information obtained directly from men on barriers to involvement found that the most frequently reported reason for failure of participation in PMTCT was a lack of knowledge regarding the existence of services or the necessity for men to take part in them.7 Therefore, in addition to clarifying definitions of male involvement in PMTCT, further research is needed to determine the self-perceived roles of, and barriers to, involvement of male partners.
As was discussed by Montgomery et al, confounding and bias may have existed in our observational study, similar to other studies on male involvement that have investigated surrogate end points such as antiretroviral prophylaxis and feeding choice.8-12 We agree with the authors that randomized controlled trials are needed to rigorously evaluate if varying forms of male involvement improve outcomes. Appropriate trial design will be crucial to ensure equipoise13 and it may be beneficial to randomize participants to comparative forms of male involvement rather than a control that excludes men from participating in their family's healthcare.
In conclusion, we concur with the recommendations by Montgomery et al regarding the need for more robust study designs aimed at delineating beneficial forms of male involvement. In addition, we stress the need for such work to focus on men themselves with the immediate aims of understanding perceptions of their roles in prevention programs and barriers to their involvement in PMTCT settings.
Adam Aluisio, MS*
Barbra A. Richardson, PhD, MS†
Rose Bosire, MBChB, MPH‡
Grace John-Stewart, MD, PhD§
Dorothy Mbori-Ngacha, MBChB, MMed, MPH‖
Carey Farquhar, MD, MPH§
*Stony Brook University Medical Center Stony Brook, NY; †Departments of Biostatistics and Global Health, University of Washington, Seattle, WA; and, Vaccine and Infectious Disease Division Fred Hutchinson Cancer Research Cancer Seattle, WA; ‡Kenya Medical Research Institute, Nairobi, Kenya; §Department of Medicine and Global Health, University of Washington, Seattle, WA; ‖Department of Paediatrics, University of Nairobi, Nairobi, Kenya
1. Aluisio A, Richardson BA, Bosire R, 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
2. WHO. The Interagency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. Guidance on Global Scale-Up of the Prevention of Mother-to-Child Transmission of HIV
. Geneva: WHO; 2007.
3. World Health Organization.PMTCT Strategic Vision 2010-2015
. Geneva: WHO; 2010.
4. Ministry of Health, Republic of Kenya. Guidelines for Prevention of Mother to Child Transmission (PMTCT) of HIV/AIDS in Kenya
. Nairobi: National AIDS and STI Control Programme (NASCOP) Ministry of Health; 2009.
5. National Department of Health, South Africa; South African National AIDS Council. Clinical Guidelines: PMTCT (Prevention of Mother-to-Child Transmission)
. Pretoria: National Department of Health; 2010.
6. Auvinen J, Suominen T, Valimaki M. Male participation and prevention of human immunodeficiency virus (HIV) mother-to-child transmission in Africa. Psychol Health Med
7. Theuring S, Mbezi P, Luvanda H, et al. Male involvement in PMTCT services in Mbeya region, Tanzania. AIDS Behav
. 2009 Mar 24 [Epub ahead of print].
8. Kiarie JN, Richardson BA, Mbori-Ngacha D, et al. Infant feeding practices of women in a perinatal HIV-1 prevention study in Nairobi, Kenya. J Acquir Immune Defic Syndr
9. Matovu A, Kirunda B, Rugamba-Kabagambe G, et al. Factors influencing adherence to exclusive breast feeding among HIV positive mothers in Kabarole district, Uganda. East Afr Med J
10. Msuya SE, Mbizvo EM, Hussain A, et al. Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: implications for preventive programs. AIDS Care
11. Farquhar C, Kiarie JN, Richardson BA, et al. Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission. J Acquir Immune Defic Syndr
12. Bii SC, Otieno-Nyunya B, Siika A, et al. Infant feeding practices among HIV infected women receiving prevention of mother-to-child transmission services at Kitale District Hospital, Kenya. East Afr Med J
13. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med