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Background: Within the context of a cluster randomized prevention of mother-to-child HIV transmission (PMTCT) trial, we evaluated the impact of disclosure on selected PMTCT continuum of care measures. Methods: In 12 rural matched-pair clinics randomly assigned to an intervention package versus standard-ofcare, we enrolled 372 HIV-infected pregnant women from April 2013 to March 2014. This secondary analysis included 327 (87.9%) women with unknown HIV status or who were treatment naïve at presentation to antenatal care. We employed mixed effects logistic regression to estimate impact of disclosure on facility delivery and postpartum retention in HIV care at 6 and 12 weeks. Results: Fully 86.5% (283/327) of women disclosed their HIV status to their partner, more in the trial intervention arm (OR 3.17, 95% CI 1.39-7.23). Adjusting for intervention arm, maternal age, education and employment, women who disclosed were more likely to deliver at a health facility (OR 2.73, 95%CI 1.11-6.72). Participants who disclosed also had a trend towards being retained in care at 6 and 12 weeks’ postpartum (OR 2.72, 95% CI 0.79-9.41 and 2.46, 95% CI 0.70-8.63, respectively). Conclusions: HIV status disclosure at 6 weeks’ postpartum was positively associated with facility-based delivery, but not with early postpartum retention. Facilitating HIV status disclosure to partners can increase utilization of facility obstetric services.
We assessed the determinants of HIV status disclosure at 6 weeks postpartum in a cluster-randomized PMTCT implementation science trial.19,20 The trial was conducted in 12 health facilities in rural Niger state in north-central Nigeria. The sites were supported by Friends in Global Health (FGH), Vanderbilt University’s implementation partner for the U.S. President’s Plan for AIDS Relief (PEPFAR). Twelve sites were matched based on antenatal care (ANC) volume, HIV patient volume, urbanization of the area, and site accessibility, then randomized within matched pairs to intervention (n=6) or control (n=6) (Fig. (Fig.11). Flow chart depicting trial activities, Niger state, Nigeria. Participants in the full trial included women with HIV presenting for ANC and/or delivery who met one of the following inclusion criteria: unknown HIV status at time of presentation; history of antiretroviral prophylaxis or treatment, but not on prophylaxis/treatment at the time of presentation; or known HIV status but had never received treatment (treatment naïve). Permission to participate was obtained by research staff in the form of informed consent. The intervention sites received an integrated package of PMTCT services that included: transition of decentralized PMTCT tasks to trained midwives (task shifting); point-of-care CD4+ cell count and CD4% testing; integrated mother-infant care services; active influential family member (male partner); and community involvement. For the control arm, we referred women testing HIV-positive to nearby FGH-supported comprehensive clinics for clinical and laboratory evaluation, and antiretroviral therapy (ART) initiation. HIV clinical management was performed in accordance with current Nigeria PMTCT guidelines, as described elsewhere.19 The PMTCT continuum of care refers to a cascade of essential steps that are required for both the mother and her child to achieve the desired outcome of a HIV-free infant as well as optimal maternal retention, adherence and viral load suppression.22 For the purpose of this study we focused on two continuum of care measures: HIV status disclosure to the spouse and facility delivery. HIV status disclosure by the women enrolled in the trial to their partners was ascertained once, after enrollment, either during the 6 week postpartum visit or at home by a study coordinator if that 6 week visit was missed. Thus, disclosure was assessed many weeks after the ANC intervention period. HIV disclosure in the intervention arm was also completely voluntary. An important first stage of the male partner engagement component of the trial was entirely dependent on the woman—we provided personalized invitation letters to the HIV-positive woman who presented to antenatal care to give to her partner, encouraging the partner to accompany the woman to the next antenatal visit.19 The option of giving the letter to the partner was entirely at the discretion of the woman. In addition, the community component involved training spouses of HIV-infected women enrolled in the study as peer mentors so that they could educate other men, share their own experience and solicit the support of community leaders through one-on-one interactions and community forums. Peer mentors did not have access to information on the HIV status of other women and their role did not include liaising with other women with HIV. Study data were collected and managed using Research Electronic Data Capture (REDCap), a secure, web-based application hosted at Vanderbilt University.23 Only HIV-infected women who had unknown HIV status or who were treatment naïve at presentation to ANC were eligible for the trial, and among these only married women were included in this study of disclosure. Participant characteristics (e.g., age, education) and outcomes were summarized using descriptive statistics, including frequency and percentage for categorical variables with median and IQR for continuous variables. The χ2 and Wilcoxon rank-sum tests were used to compare characteristics across disclosure status at 6 weeks postpartum, ignoring effects of clustering. To estimate factors independently associated with disclosure, we used mixed effects logistic regression with a random effect for matched pairs to account for clustering. Potential determinants of disclosure status were identified a priori and ordered by importance based on literature and input from trial leadership. We considered that up to four covariates would be included in the final, multivariable model to prevent model overfitting, given our sample size. The top four covariates were intervention, age, education and employment. No stepwise model selection was performed. We performed post hoc adjustment for ethnicity, as this factor was on the original covariate listing and was associated with disclosure. We also used mixed effects logistic regression to assess the association between disclosure and postpartum retention of mother-infant pairs at 6 and 12 weeks, and with in-facility delivery. We adjusted models for maternal age, education, employment status, and study arm. For each of the three models, we tested for an interaction effect between study arm and disclosure status at 6 weeks postpartum and for mediation of the intervention effect through disclosure.24 For the retention analyses, mother–infant pairs were excluded if the mother or infant died or was transferred or relocated within 14 weeks of delivery. For the delivery analyses, one mother was excluded who had miscarried. An intent-to-treat approach was used for all analyses. R-software version 3.3.1 (www.r-project.org) was used for data analyses.
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