Overall, there were 12 infant infections, with 1 (0.8%) among infants born to mothers with male ANC involvement versus 11 (3.0%) infections among infants born to mothers without male ANC involvement (P = 0.197). The corresponding incidence of infection for infants born to women with male attendance was 6.7/100 person-years (95% CI: 0.9 to 47.7) versus 28.0/100 person-years (95% CI: 15.5 to 50.6) among those born to mothers without partner attendance (P = 0.136) (Tables 2 and 3).
Infant survival at 6 weeks of life is depicted in the Kaplan–Meier survival plot (Fig. 2A) and was significantly greater for those children born to mothers with male ANC involvement (P = 0.049). In Cox regression models, infants born to women without male attendance showed a trend toward reduced survival (HR = 3.83, 95% CI: 0.90 to 16.33; P = 0.070), which was maintained when adjusting for maternal and infant ARV use (aHR = 3.73, 95% CI: 0.87 to 15.94; P = 0.077).
HIV-free survival was significantly greater with male partner ANC involvement. For the combined outcome, there were 3 (2.3%) events occurring in the group of infants born to mothers with male ANC attendance versus 32 (8.7%) for those born to mothers lacking partner participation (Table 2). This resulted in an incidence of 20.2/100 person-years (95% CI: 6.5 to 62.5) in the male involvement group as compared with 81.5/100 person-years (95% CI: 57.6 to 115.3) for infants born to women without male ANC participation through 6 weeks postpartum (Table 3).
Although progress toward virtual elimination of MTCT has been made, a substantial burden of infant HIV infection and mortality persists in Sub-Saharan Africa.3,5,6,36 Male partner engagement in ANC/PMTCT services may improve these outcomes.9,30 In this study, infants born to HIV-infected women with male partner ANC attendance had greater HIV-free survival through 6 weeks postpartum than infants born to women without male involvement. Men were more likely to participate in ANC programs if they had previously been exposed to HIV testing services. These findings support investment in programs aimed at enhancing male HIV testing and ANC engagement to improve child health outcomes.
The observation of improved infant survival with male involvement concurs with the larger body of data supporting the beneficial association between male ANC participation and PMTCT service utilization by women living with HIV.9,12–14 In this study, however, there were no differences in PMTCT utilization between women with and without male engagement. Neither ARV utilization nor EBF adherence differed significantly between groups. The mechanism of improved survival among infants with male ANC attendance is unclear. It may reflect male partners who subsequently are more involved with infant care and provide access to medical services when needed. Male ANC attendance was associated with factors potentially indicative of greater partnership commitment and communication. Specifically, women in monogamous relationships and those reporting that their male partners had disclosed being previously tested for HIV had a greater likelihood of male ANC engagement. Thus, infant survival benefits may stem from more supportive male–female partnerships. As the reported data did not allow for delineation of these potential mechanisms, further research, likely using mixed methods, to identify and explore these beneficial partnership characteristics is needed.
In this study, the likelihood of male ANC engagement was enhanced with previous exposure to HIV testing services. This is consistent with earlier work from similar settings showing increased ANC attendance with previous HIV testing and serostatus awareness among male partners.19,22 These findings support the public health impetus to improve coverage of HIV testing, especially in settings with high HIV prevalence and infant mortality. Consistent with previous studies from Africa, overall male ANC engagement was low in this cohort.16,19,22–24 Considering the persistent suboptimal levels of participation in concert with recognition that HIV testing improves attendance, exploration of novel male testing and engagement strategies is needed. A trial from western Kenya that randomized women attending the ANC to home visits versus written invitations for their male partners found significantly increased uptake in male HIV testing with home visits at 85% as compared with 36% in the clinic-based invitation arm.30 Research exploring novel methods such as home-based testing and education to engage men during pregnancy and postpartum will continue to be important given the benefits observed.
This study has limitations. The design was not randomized which may have resulted in selection bias, and this could reduce the generalizability of the findings. For women lacking male ANC involvement only a subset of men were sampled, and characteristics of this subset were used in analyses for correlates of male ANC attendance. Among men who failed to attend antenatally, differences between those who completed postnatal data collection and those who did not were assessed based on female partner data, and only male employment status was found to be significantly different between the subgroups (see Supplemental Digital Content, http://links.lww.com/QAI/A823). Given the homogeneity of the nonattending group, it is likely that the subset sampled is representative of that larger population of nonengaged partners; however, there may have existed unmeasured confounders, and this limitation must be considered.
Infant follow-up was only performed through 6 weeks postpartum which could restrict the application of these results to longer survival times. Although most vertical HIV transmission events occur peripartum, later transmission accounts for a substantial proportion of infant HIV infections.38–40 However, in consideration of the previous infant health benefits documented in a similar population through one year postpartum, the proportional survival advantage with male involvement would likely have been maintained with longer follow-up.19 The pragmatic design of this study used national standard PCR testing to diagnose vertical transmission events.34 Although PCR is a highly accurate diagnostic assay, the lack of serial testing may have resulted in imperfect sensitivity and imprecise timing of infant infection.41 In addition, mortality event time was partially based on maternal report, which may have suffered from recall bias. Either of these factors could have resulted in misclassification of outcomes. If this did occur, the error would be nondifferential and bias toward the null, and any beneficial relationship between male ANC attendance and improved HIV-free survival would be an underestimation of the strength of the association.
Finally, data from this work did not directly evaluate participants' perceived barriers to male partner ANC attendance, and this is a limitation. Although there is literature showing that both male and female partners in many Sub-Saharan African contexts are not averse to male participation in antenatal settings, sociocultural and systems barriers persist and impede achievement of recommended levels of engagement.42–44 Thus, research addressing barriers in conjunction with studies assessing novel mechanisms to engage the male partner population in Sub-Saharan Africa would be informative to the knowledge base.
This prospective cohort study demonstrated an association between male ANC attendance and improved infant HIV-free survival through 6 weeks of life. In light of these findings, further interventional trials are warranted to more robustly assess the role of male ANC involvement in relation to infant outcomes. In addition, male attendance was more likely among men exposed to previous HIV testing, and research evaluating novel mechanisms to achieve higher male HIV testing and improve engagement is needed. Although international guidelines call for male participation in ANC/PMTCT services, achieving consistent male engagement has been difficult in high-burden regions. Considering the findings from this study, the low levels of male involvement may preclude attainment of virtual elimination of vertical transmission goals and inhibit improving overall infant survival.10,45
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