Impact of inter-partner HIV disclosure patterns in Malawi’s PMTCT program: A mixed-method study

PLoS ONE, Volume 14, No. 7, Year 2019

Interpretation

Background Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women. Methods A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014–2016, all (34,637) mothers attending 54 under-5 clinics with their 4–26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were excluded. Data collected included socio-demographics, partner disclosure, maternal ART uptake, and adherence. Between 2016–2017, in-depth interviews and focus group discussions were conducted with adult mothers (n = 53) and their spouse/cohabiting partners (n = 19), adolescent mothers (n = 13), lost-to-follow up (LTFU) mothers (n = 22), community leaders (n = 23) and healthcare workers (n = 154). Results Of 3153 known HIV-infected mothers, 2882 (91.4%) reported having a spouse/cohabiting partner. Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART (aOR 4.7; 95%CI 2.5–8.8), suboptimal treatment adherence (aOR 1.8; 95%CI 1.1–2.8) and MTCT (aOR 2.1; 95%CI 1.1–4.1). Women’s fear of blame by partners was central to decisions not to disclose within couples and when starting new relationships. LTFU mothers struggled to accept and disclose their status, hindering treatment initiation; some were unable to hide ART and feared involuntary disclosure. Conclusion Partner disclosure seems to play an important role in women’s decisions regarding ART initiation and adherence. Inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence and MTCT. Implementation of the Malawi integrated PMTCT/ART guidelines began in July 2011, giving all pregnant and breastfeeding women identified as HIV-infected in antenatal and maternal clinics access to life-long ART. At time of HIV status ascertainment, HIV-infected women receive 6 weeks of nevirapine prophylaxis with instruction to give this to their infants from birth, and were advised to bring their infants at six-weeks of age for virological testing at an under-5 clinic [18]. This is a cross-sectional mixed-methods study using baseline data of known HIV-infected mothers at 4–26 weeks postpartum who were enrolled for longitudinal follow up within the National Evaluation of the Malawi PMTCT Program (NEMAPP); NEMAPP methods are described in detail elsewhere [19]. Briefly, between October 2014 and May 2016, all mothers (or guardians, if the mother had died) with infants 4–26 weeks old attending an under-5 clinic in 54 randomly selected health facilities across 10 districts and four regional sampling zones (North-Central rural, North-Central urban, South rural and South urban) were screened for inclusion in the NEMAPP study. This age group was selected as it was determined from population based surveys and Malawi Ministry of Health data that it would allow the study to capture almost all infants attending for the first immunization visit; those missed at a first visit would still be identified at a subsequent visit. Eligibility criteria for the mother-infant pair included confirmed HIV exposure in infants, infant age between 4 and 26 weeks at time of screening, and mother present at screening, or confirmed dead by legal guardian. Following national guidelines, a positive HIV rapid test in the mother or infant (if the mother had died) indicated infant HIV exposure [18]. Out of 34,637 mothers (or guardians) and their infant approached, 33,980 (98.1%) were screened for HIV, including 236 (0.7%) guardians of infants whose mothers were confirmed dead. A total of 30,281 were confirmed HIV-negative, 133 had inconclusive test results and 10 were excluded as a result of missing infant HIV test results (n = 2) or concerns about clerical errors in infant HIV test results (n = 8). HIV-exposure was confirmed in 3,566/33,980 (10.5%). A total of 3456 mothers (or guardians) with HIV-exposed infants were enrolled for the NEMAPP longitudinal follow up. Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were therefore excluded. Between July 2016 and September 2017, a representative sample of 13 out of the 54 health facilities was selected to conduct a longitudinal qualitative sub-study implemented over 15 months. Sites were identified across 4 geographical strata and were included in the NEMAPP 48-month extended cohort. Data were collected through two waves of data collection at 8-month intervals for all the study sites with the same individuals; In-depth interviews were conducted with a subgroup of adult mothers (n = 53) and their partners (n = 19), adolescent (10–19 year old) mothers (n = 13), and mothers who were lost-to-follow up (LTFU, i.e., more than two months overdue after a scheduled appointment and all efforts to locate the woman had been exhausted; n = 22). The larger study (from which data are not presented in this paper) also included the views of community leaders (n = 23) andfocus group discussions (FGDs) were conducted in each of the 13 health facilities with healthcare workers (HCWs) (n = 154). For the quantitative study, mothers were interviewed by trained health facility staff at a private location in the clinic. Mothers were interviewed at enrolment on age, parity, time from when mother knew her HIV-positive status, partner’s HIV-status and disclosure status between partners, uptake of and adherence to maternal ART and uptake of infant nevirapine prophylaxis for HIV-exposed infants, using structured questionnaires. Quantitative data was based on self-reports and verified through health booklets and clinical records were possible. The sample of respondents engaged in the qualitative sub-study were interviewed on women’s barriers and facilitators to start and continue ART, disclosure, and family dynamics. Interviews and FGDs were conducted in private locations and audio recorded. Dried blood spot (DBS) specimens from infants were tested in a reference laboratory. A qualitative HIV-1 DNA polymerase chain reaction test (COBAS AmpliPrep/COBAS TaqMan Qualitative Assay, version 2.0, Roche Diagnostics, Indianapolis, IN, USA) was performed on all HIV-exposed infant DBS samples to determine whether the infant was HIV-infected. All mothers were asked whether they currently had a spouse or cohabiting male partner, and among those with a partner, whether they had disclosed their HIV status to their partner and if they knew his HIV status. ‘Both partners disclosed (any status)’ was defined as the mother disclosed her HIV-positive status to her partner and knew his HIV status. ‘One partner disclosed (any status)’ was defined as the mother disclosed her HIV-positive status to the partner but did not know his HIV status or the mother did not disclose her HIV-positive status to the partner, but knew his HIV status. ‘Neither partner disclosed’ was defined as the mother did not disclose her HIV-positive status to her partner and did not know his HIV status. Current uptake of and adherence to maternal ART were recorded as reported by the mother. Whenever possible, interviewers checked the mothers’ health booklets to check the accuracy of the mothers’ responses. Among those on ART, and in alignment with the Malawi Ministry of Health guidelines, optimal treatment adherence was defined as self-reported missing none or one day of once daily fixed-dose combination antiretrovirals (ARVs), and suboptimal treatment adherence as self-reported missing ≥2 days of ARVs in the last month. Uptake (any number of days given from birth) and missing nevirapine prophylaxis syrup for exposed infants was recorded as reported by the mother. We calculated MTCT ratios at 4–26 weeks postpartum as the percentage of infants tested for HIV-1 DNA who were positive. Descriptive statistics were used to characterize study participants and estimate the proportion of each outcome. Characteristics were described with numbers and proportions or medians with interquartile ranges (IQR). To get further insight in the complex dynamics between partner disclosure, partner’s HIV and ART status, and their respective impacts on PMTCT outcomes, we explored the following associations: i) having a partner or not, ii) being in a relationship in which the mother disclosed or not, iii) being in a relationship in which the partner disclosed or not, iv) being in a relationship with a partner whose HIV status is positive, negative, or unknown/non-disclosed, and v) being in a relationship in which both, one, or neither partner(s) disclosed their HIV status, separately with missing uptake of maternal ART, suboptimal treatment adherence, and MTCT. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI) for each model and with adjustment for geographic region, age, parity, and time from when mother knew her HIV-positive status (prior to, during, or after the index pregnancy). We also adjusted for uptake of maternal ART and infant nevirapine prophylaxis in the models for MTCT. All variables were simultaneously entered in the logistic regression model as the first step and tested for removal one by one (p-value cut-off 0.05). Analyses were conducted using IBM SPSS Statistics 24 (IBM, Armonk, NY, USA). Overall MTCT, and MTCT ratios among mothers who were in a relationship where both, one, or neither of the partners disclosed were reported with 95% CI. Qualitative data were fully transcribed and translated from Chichewa to English. All data were coded using NVivo11 (QSR International, Melbourne, Australia). Four coders, including one investigator and three field researchers, coded the qualitative data and reached consensus on a common analysis framework and associated coded extracts. Inductive and deductive analyses were used to identify common themes across the different categories of informants, which were organized through a content analysis approach to compare responses between two waves of data collection at 8-month interval. The framework analysis followed emerging categories from the dataset in relation to decision making and patient agency; barriers and facilitators to uptake and retention; perception of ART; experience of breastfeeding and pregnancy; health staff perception; and disclosure of HIV status. Ethical approval for the study was provided by Malawi’s National Health Sciences Research Committee (#1262 and #1381), the Centers for Disease Control and Prevention (CDC) Center for Global Health Associate Director of Science (#2014-054-7 and #2016–133), and the University of Toronto Research Ethics Board (#30448). All participants provided written or witnessed thumbprint informed consent.

AI Digest

Study Justification:

This study aims to investigate the impact of inter-partner HIV disclosure patterns on the prevention of maternal-to-child transmission of HIV (PMTCT) outcomes in Malawi. The justification for this study is based on the evidence suggesting that partner disclosure of HIV status may influence maternal antiretroviral therapy (ART) uptake and adherence, as well as the transmission of HIV from mother to child. Understanding the factors influencing partner disclosure and its association with PMTCT outcomes is crucial for improving the effectiveness of HIV prevention programs.

Study Highlights:

1. The study included a nationally representative sample of HIV-infected mothers attending under-5 clinics in Malawi.
2. The study collected both quantitative and qualitative data to provide a comprehensive understanding of partner disclosure patterns and their impact on PMTCT outcomes.
3. The study found that inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence, and increased risk of MTCT.
4. Women’s fear of blame by partners was a significant barrier to disclosure within couples and when starting new relationships.
5. Lost-to-follow-up mothers faced challenges in accepting and disclosing their HIV status, hindering treatment initiation.

Recommendations:

1. Strengthen counseling and support services for HIV-infected women to encourage partner disclosure and address fears of blame or stigma.
2. Develop targeted interventions to improve partner communication and promote mutual disclosure within couples.
3. Enhance efforts to identify and engage lost-to-follow-up mothers, providing them with necessary support and resources to initiate and adhere to ART.
4. Conduct further research to explore the long-term impact of partner disclosure on PMTCT outcomes and the effectiveness of interventions aimed at improving disclosure rates.

Key Role Players:

1. Ministry of Health: Responsible for implementing and coordinating HIV prevention and PMTCT programs.
2. Healthcare Workers: Provide counseling, testing, and treatment services to HIV-infected individuals.
3. Community Leaders: Play a crucial role in promoting awareness, reducing stigma, and supporting HIV-infected individuals and their families.
4. Non-Governmental Organizations (NGOs): Provide additional support, resources, and advocacy for HIV prevention and PMTCT programs.

Cost Items for Planning Recommendations:

1. Training and capacity building for healthcare workers on counseling and support services: Includes workshops, materials, and ongoing supervision.
2. Development and dissemination of educational materials and communication campaigns: To raise awareness about the importance of partner disclosure and reduce stigma.
3. Outreach and community engagement activities: To reach lost-to-follow-up mothers and provide them with necessary support.
4. Monitoring and evaluation: To assess the effectiveness of interventions and track progress in improving partner disclosure rates and PMTCT outcomes.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is a cross-sectional mixed-method study, which provides valuable insights into the relationship between partner disclosure and PMTCT outcomes. The study includes a large sample size and uses both quantitative and qualitative data collection methods. The results show a clear association between inter-partner non-disclosure and negative PMTCT outcomes. However, to improve the evidence, the study could have included a longitudinal design to establish causality and control for confounding factors. Additionally, the study could have used more objective measures, such as medical records, to verify self-reported data. Overall, the evidence is strong, but these suggested improvements would further enhance its validity.

Abstract

Implementation of the Malawi integrated PMTCT/ART guidelines began in July 2011, giving all pregnant and breastfeeding women identified as HIV-infected in antenatal and maternal clinics access to life-long ART. At time of HIV status ascertainment, HIV-infected women receive 6 weeks of nevirapine prophylaxis with instruction to give this to their infants from birth, and were advised to bring their infants at six-weeks of age for virological testing at an under-5 clinic [18]. This is a cross-sectional mixed-methods study using baseline data of known HIV-infected mothers at 4–26 weeks postpartum who were enrolled for longitudinal follow up within the National Evaluation of the Malawi PMTCT Program (NEMAPP); NEMAPP methods are described in detail elsewhere [19]. Briefly, between October 2014 and May 2016, all mothers (or guardians, if the mother had died) with infants 4–26 weeks old attending an under-5 clinic in 54 randomly selected health facilities across 10 districts and four regional sampling zones (North-Central rural, North-Central urban, South rural and South urban) were screened for inclusion in the NEMAPP study. This age group was selected as it was determined from population based surveys and Malawi Ministry of Health data that it would allow the study to capture almost all infants attending for the first immunization visit; those missed at a first visit would still be identified at a subsequent visit. Eligibility criteria for the mother-infant pair included confirmed HIV exposure in infants, infant age between 4 and 26 weeks at time of screening, and mother present at screening, or confirmed dead by legal guardian. Following national guidelines, a positive HIV rapid test in the mother or infant (if the mother had died) indicated infant HIV exposure [18]. Out of 34,637 mothers (or guardians) and their infant approached, 33,980 (98.1%) were screened for HIV, including 236 (0.7%) guardians of infants whose mothers were confirmed dead. A total of 30,281 were confirmed HIV-negative, 133 had inconclusive test results and 10 were excluded as a result of missing infant HIV test results (n = 2) or concerns about clerical errors in infant HIV test results (n = 8). HIV-exposure was confirmed in 3,566/33,980 (10.5%). A total of 3456 mothers (or guardians) with HIV-exposed infants were enrolled for the NEMAPP longitudinal follow up. Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were therefore excluded. Between July 2016 and September 2017, a representative sample of 13 out of the 54 health facilities was selected to conduct a longitudinal qualitative sub-study implemented over 15 months. Sites were identified across 4 geographical strata and were included in the NEMAPP 48-month extended cohort. Data were collected through two waves of data collection at 8-month intervals for all the study sites with the same individuals; In-depth interviews were conducted with a subgroup of adult mothers (n = 53) and their partners (n = 19), adolescent (10–19 year old) mothers (n = 13), and mothers who were lost-to-follow up (LTFU, i.e., more than two months overdue after a scheduled appointment and all efforts to locate the woman had been exhausted; n = 22). The larger study (from which data are not presented in this paper) also included the views of community leaders (n = 23) andfocus group discussions (FGDs) were conducted in each of the 13 health facilities with healthcare workers (HCWs) (n = 154). For the quantitative study, mothers were interviewed by trained health facility staff at a private location in the clinic. Mothers were interviewed at enrolment on age, parity, time from when mother knew her HIV-positive status, partner’s HIV-status and disclosure status between partners, uptake of and adherence to maternal ART and uptake of infant nevirapine prophylaxis for HIV-exposed infants, using structured questionnaires. Quantitative data was based on self-reports and verified through health booklets and clinical records were possible. The sample of respondents engaged in the qualitative sub-study were interviewed on women’s barriers and facilitators to start and continue ART, disclosure, and family dynamics. Interviews and FGDs were conducted in private locations and audio recorded. Dried blood spot (DBS) specimens from infants were tested in a reference laboratory. A qualitative HIV-1 DNA polymerase chain reaction test (COBAS AmpliPrep/COBAS TaqMan Qualitative Assay, version 2.0, Roche Diagnostics, Indianapolis, IN, USA) was performed on all HIV-exposed infant DBS samples to determine whether the infant was HIV-infected. All mothers were asked whether they currently had a spouse or cohabiting male partner, and among those with a partner, whether they had disclosed their HIV status to their partner and if they knew his HIV status. ‘Both partners disclosed (any status)’ was defined as the mother disclosed her HIV-positive status to her partner and knew his HIV status. ‘One partner disclosed (any status)’ was defined as the mother disclosed her HIV-positive status to the partner but did not know his HIV status or the mother did not disclose her HIV-positive status to the partner, but knew his HIV status. ‘Neither partner disclosed’ was defined as the mother did not disclose her HIV-positive status to her partner and did not know his HIV status. Current uptake of and adherence to maternal ART were recorded as reported by the mother. Whenever possible, interviewers checked the mothers’ health booklets to check the accuracy of the mothers’ responses. Among those on ART, and in alignment with the Malawi Ministry of Health guidelines, optimal treatment adherence was defined as self-reported missing none or one day of once daily fixed-dose combination antiretrovirals (ARVs), and suboptimal treatment adherence as self-reported missing ≥2 days of ARVs in the last month. Uptake (any number of days given from birth) and missing nevirapine prophylaxis syrup for exposed infants was recorded as reported by the mother. We calculated MTCT ratios at 4–26 weeks postpartum as the percentage of infants tested for HIV-1 DNA who were positive. Descriptive statistics were used to characterize study participants and estimate the proportion of each outcome. Characteristics were described with numbers and proportions or medians with interquartile ranges (IQR). To get further insight in the complex dynamics between partner disclosure, partner’s HIV and ART status, and their respective impacts on PMTCT outcomes, we explored the following associations: i) having a partner or not, ii) being in a relationship in which the mother disclosed or not, iii) being in a relationship in which the partner disclosed or not, iv) being in a relationship with a partner whose HIV status is positive, negative, or unknown/non-disclosed, and v) being in a relationship in which both, one, or neither partner(s) disclosed their HIV status, separately with missing uptake of maternal ART, suboptimal treatment adherence, and MTCT. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI) for each model and with adjustment for geographic region, age, parity, and time from when mother knew her HIV-positive status (prior to, during, or after the index pregnancy). We also adjusted for uptake of maternal ART and infant nevirapine prophylaxis in the models for MTCT. All variables were simultaneously entered in the logistic regression model as the first step and tested for removal one by one (p-value cut-off 0.05). Analyses were conducted using IBM SPSS Statistics 24 (IBM, Armonk, NY, USA). Overall MTCT, and MTCT ratios among mothers who were in a relationship where both, one, or neither of the partners disclosed were reported with 95% CI. Qualitative data were fully transcribed and translated from Chichewa to English. All data were coded using NVivo11 (QSR International, Melbourne, Australia). Four coders, including one investigator and three field researchers, coded the qualitative data and reached consensus on a common analysis framework and associated coded extracts. Inductive and deductive analyses were used to identify common themes across the different categories of informants, which were organized through a content analysis approach to compare responses between two waves of data collection at 8-month interval. The framework analysis followed emerging categories from the dataset in relation to decision making and patient agency; barriers and facilitators to uptake and retention; perception of ART; experience of breastfeeding and pregnancy; health staff perception; and disclosure of HIV status. Ethical approval for the study was provided by Malawi’s National Health Sciences Research Committee (#1262 and #1381), the Centers for Disease Control and Prevention (CDC) Center for Global Health Associate Director of Science (#2014-054-7 and #2016–133), and the University of Toronto Research Ethics Board (#30448). All participants provided written or witnessed thumbprint informed consent.

Materials

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or text messaging services to provide pregnant women with information about maternal health, including HIV prevention and treatment options. These platforms can also be used to send reminders for medication adherence and clinic appointments.

2. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women, including information about HIV prevention, partner disclosure, and the importance of antiretroviral therapy (ART) uptake and adherence.

3. Peer Support Groups: Establish peer support groups for HIV-infected pregnant women, where they can share experiences, receive emotional support, and learn from each other about strategies for partner disclosure and ART adherence.

4. Integration of Services: Strengthen the integration of HIV prevention and treatment services with maternal health services, ensuring that pregnant women have easy access to both HIV testing and antenatal care.

5. Addressing Stigma and Fear: Develop interventions to address the fear of blame and stigma associated with HIV status disclosure. This could include community awareness campaigns, counseling services, and support groups for both HIV-infected women and their partners.

6. Male Involvement: Implement strategies to engage male partners in the maternal health care process, including encouraging partner testing, promoting partner disclosure, and providing education on the importance of ART for preventing mother-to-child transmission of HIV.

7. Task Shifting: Train and empower non-specialist healthcare providers, such as nurses and midwives, to provide comprehensive maternal health care, including HIV testing, counseling, and ART initiation.

8. Health System Strengthening: Improve the capacity of health facilities to provide high-quality maternal health services, including adequate staffing, essential supplies, and infrastructure for HIV testing and treatment.

These innovations can help improve access to maternal health services, increase partner disclosure rates, and enhance ART uptake and adherence among HIV-infected pregnant women, ultimately reducing the risk of mother-to-child transmission of HIV.

AI Innovations Description

The study titled “Impact of inter-partner HIV disclosure patterns in Malawi’s PMTCT program: A mixed-method study” examines the relationship between partner disclosure of HIV status and maternal antiretroviral therapy (ART) uptake, adherence, and mother-to-child transmission (MTCT) of HIV among postpartum HIV-infected women in Malawi. The study found that partner disclosure plays a significant role in women’s decisions regarding ART initiation and adherence. Non-disclosure by either partner was associated with no ART uptake, suboptimal treatment adherence, and increased risk of MTCT.

Based on the findings of this study, a recommendation to improve access to maternal health would be to implement interventions that promote partner disclosure and support women in disclosing their HIV status to their partners. This could include:

1. Education and counseling: Provide comprehensive education and counseling to HIV-infected women about the importance of partner disclosure for maternal and child health outcomes. This should include information on the benefits of ART, the role of partner support, and strategies for effective communication.

2. Peer support groups: Establish peer support groups for HIV-infected women, where they can share their experiences, receive emotional support, and learn from each other’s strategies for partner disclosure. Peer support can help reduce stigma and empower women to initiate conversations about their HIV status with their partners.

3. Couple counseling: Offer couple counseling services that focus on HIV disclosure and its impact on maternal health. Trained counselors can facilitate open and honest discussions between partners, addressing fears, concerns, and misconceptions related to HIV status disclosure.

4. Community engagement: Engage community leaders, healthcare workers, and other stakeholders to raise awareness about the importance of partner disclosure and create a supportive environment for HIV-infected women. This can be done through community dialogues, workshops, and awareness campaigns.

5. Integration of services: Ensure that HIV testing, counseling, and ART services are integrated into maternal health programs. This will facilitate early identification of HIV-infected women, promote partner testing, and provide seamless access to ART for both the mother and the child.

By implementing these recommendations, it is expected that access to maternal health services, including ART uptake and adherence, will be improved, leading to better outcomes for HIV-infected women and their children in Malawi.

AI Innovations Methodology

The study titled “Impact of inter-partner HIV disclosure patterns in Malawi’s PMTCT program: A mixed-method study” examines the relationship between partner disclosure of HIV status and prevention of maternal-to-child transmission of HIV (PMTCT) outcomes in Malawian women. The study utilizes a cross-sectional mixed-methods approach, combining quantitative data from a nationally representative longitudinal cohort study and qualitative data from in-depth interviews and focus group discussions.

The methodology used in this study involves several steps:

1. Study Population: The study includes HIV-infected mothers who were enrolled in the National Evaluation of the Malawi PMTCT Program (NEMAPP) between 2014 and 2016. Mothers attending under-5 clinics with their 4-26 week-old infants were approached for inclusion in the study.

2. Data Collection: Baseline data was collected from HIV-infected mothers who were known to be HIV-positive at the time of screening. Data collected included socio-demographics, partner disclosure, maternal antiretroviral therapy (ART) uptake, and adherence. In addition, in-depth interviews and focus group discussions were conducted with adult mothers, their partners, adolescent mothers, lost-to-follow-up mothers, community leaders, and healthcare workers.

3. Quantitative Analysis: Descriptive statistics were used to characterize study participants and estimate the proportion of each outcome. Multivariable logistic regression analysis was conducted to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI) for each model, adjusting for geographic region, age, parity, and time from when the mother knew her HIV-positive status. The analysis explored associations between partner disclosure, partner’s HIV and ART status, and PMTCT outcomes.

4. Qualitative Analysis: Qualitative data from interviews and focus group discussions were transcribed, translated, and coded using NVivo11 software. Four coders analyzed the data and identified common themes related to decision making, patient agency, barriers and facilitators to uptake and retention, perception of ART, experience of breastfeeding and pregnancy, health staff perception, and disclosure of HIV status.

5. Ethical Considerations: The study obtained ethical approval from Malawi’s National Health Sciences Research Committee, the Centers for Disease Control and Prevention (CDC), and the University of Toronto Research Ethics Board. All participants provided written or witnessed thumbprint informed consent.

The findings of this study suggest that partner disclosure plays a significant role in women’s decisions regarding ART initiation and adherence. Non-disclosure between partners was associated with no ART uptake, suboptimal treatment adherence, and increased risk of MTCT. Women’s fear of blame by partners was identified as a central barrier to disclosure.

In conclusion, this study highlights the importance of partner disclosure in improving access to maternal health services and preventing MTCT of HIV. The mixed-methods approach used in this study provides a comprehensive understanding of the complex dynamics between partner disclosure, HIV and ART status, and their impact on PMTCT outcomes.

Authors & Co-Authors

Statistics:

Citations: 8

Authors: 11

Identifiers:

DOI: 10.1371/journal.pone.0219967

Research Areas:

Community Interventions, Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Malawi

Study Design:

Cohort Study, Cross Sectional Study, Exploratory Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male & Female