Couples testing is an important intervention that can assist in achieving the UN goal of ending HIV by 2030. Studies have shown that women who know their partner’s status show reduced rates of mother-to-child transmission and higher rates of health facility delivery. However, couples testing was only 16 per cent in Uganda in 2011, and men continue to be a difficult segment of the population to target for HIV testing interventions. In Uganda, mother-to-child transmission of HIV is the second most common form after heterosexual transmission.
- Does providing HIVST kits to women using antenatal care, for use by their partner, increase male partner testing rates and the number of new HIV infections identified?
- Do men who test HIV positive link to care across both study arms?
- Is couple/partner HIVST acceptable among women attending ANC?
- What are the disclosure rates and positive/negative outcomes of partner HIV testing across both study arms?
- What are the coping mechanisms of serodiscordant couples?
- What are the cost impacts of male partner HIVST relative to public health benefits?
Researchers implemented a phased cluster-randomised controlled trial among pregnant women attending ANCs. Women in the control arm were given standard of care health education and were encouraged to bring their partner in for HIV testing, while women in the intervention arm were additionally given HIVST kits to take home to their partner and other adults in the household. ANC clinic days were randomly assigned to intervention or control.
Theory of change
By providing both HIVST kits to pregnant women to take home to their male partners and counselling on how to perform an HIV self-test, women would take kits home and deliver to their male partners. This is theorised to lead to the male partner deciding to take the HIV test, linking to care if positive, and thereby reducing transmission to infants, morbidity and mortality in the long run. The theory is based on the assumptions that the barriers to HIV testing such as time, financial and social costs (e.g. stigma) can be mitigated through oral HIV self-tests, which provide increased privacy, ease of access, choice of testing method and convenience.
This study was implemented in three Mildmay Uganda-supported health facilities. Researchers conducted structured interviews with women at baseline, and at one and three months post-enrolment. Men were interviewed at one and three months post-women’s enrolment. Long-term follow-up with serodiscordant couples and HIV-positive men continued at 6 and up to 24 months post-enrolment. For the qualitative portion of the evaluation, researchers also conducted key informant interviews with health care providers and in-depth interviews with selected women, their male partners, family members, HIV-positive men and serodiscordant couples.
Researchers observed a dramatic increase in male partner testing in the intervention arm, with nearly four times higher proportion of male partners testing. Overall, 626 out of 816 (76.7%) tested for HIV in the intervention group versus 278 out of 742 (37.5%) in the control group across months one and three. Furthermore, 562 (73.3%) in the intervention arm tested as couples compared to 186 (30.8%) in the control arm. The intervention comprised 42 HIV-positive men being identified in the treatment and 11 in the control group. Based on month 1 and month 3 follow-ups, researchers found that 10 out of 42 men in the intervention group and 5/11 in the control group were linked to care, respectively (p=0.09). In the extended follow-up in phase 3 of the study, in which the researchers focused on men who tested positive in the intervention arm, they found that 21 out of 42 men eventually opted for confirmatory testing.
Women affirmed that the kits encouraged men to test for HIV and helped the women learn their male partners’ HIV status. HIVST was reported to increase the number of men escorting their wives to the health facility and testing for HIV, besides improving the quality of their relationships. Two main factors enabled individuals in serodiscordant relationships to cope with their HIV serodiscordance: a) post-test counselling support from health professionals; and b) psycho-social support from relatives and close friends. Post-test counselling played a key role in supporting initiation and retention in HIV care among those that were still in care at the end of the follow-up period.
The cost per partner tested was US$30.3 for the intervention and US$31.2 for control, while the cost per HIV-infected person identified was US$462.3 for the intervention and US$582.6 for the control. Comparing intervention to control, the incremental cost per additional partner tested (incremental cost-effectiveness ratio) was US$29.8 and the ratio per additional partner testing HIV-positive was US$412.1.
Specific findings for policy and practice
HIVST should be integrated as one of the recognised approaches for HIV testing. Additional support may be required to ensure linkage to care for individuals who test HIV-positive through HIVST, including provision of home-based antiretroviral therapy initiation. Further evaluations and research with larger numbers and longer-term follow-up of newly diagnosed HIV-positive individuals are needed, to ascertain better the linkage to and retention in care and social harms following HIVST.
Based on the evidence from two HIVST pilot studies conducted in Uganda with funding support from 3ie, the Ministry of Health has developed HIVST guidelines to guide the national roll-out of HIVST in Uganda. These guidelines have been appended to the existing 2010 Uganda National HIV Counselling and Testing Policy.
National dissemination meeting was jointly organised with the Ministry of Health and held on 17th July 2017 at Hotel Africana. A total of 238 people attended the meeting.
The dissemination meeting received wide coverage in the local media, including a front-page story in the leading daily, New Vision and another story in the Monitor Newspaper. One of the Co-Investigators, Dr. Joseph Matovu, was also hosted on the morning show of one of the leading national television channels on 19th July 2017 to discuss the study findings.