Developing and Assessing a Male Engagement Intervention in Option B+ in Malawi

Study Overview
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Brief Summary
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There is promising evidence that couple-based approaches within Malawi's Option B+ prevention of mother to child transmission program could address help address 1) poor male engagement in the HIV continuum of care, 2) low male adoption of biomedical HIV prevention approaches, 3) sub-optimal female engagement in the continuum of care, and 4) poor or uncertain infant outcomes. Our team has developed an intervention to address these challenges, and will conduct a randomized controlled trial (N=500 couples) to assess intervention effectiveness at one year. Women with recent HIV infections enrolled in this trial will be compared against a cohort of 350 HIV-uninfected women to explore predictors of HIV acquisition in pregnancy in Malawi.

Detailed Description
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In sub-Saharan Africa, engaging HIV-infected men in HIV care and treatment and engaging HIV-uninfected men in prevention has proven challenging. Along all steps of the HIV care-seeking cascade, men exhibit worse care-seeking behaviors. They are less likely to seek HIV testing and counseling (HTC), initiate combination antiretroviral therapy (cART), and be retained in cART care. Poor care-seeking has resulted in a lower prevalence of viral suppression and earlier mortality. Additionally, men rarely engage in the antenatal care-seeking of their female sexual partners, leading to worse maternal and infant outcomes. This low level of engagement has been noted in Malawi's Option B+ prevention of mother to child transmission (PMTCT) program, and has been a critical barrier to female Option B+ uptake and retention, and a missed opportunity for engaging men. There is promising evidence that couple-based approaches within Malawi's Option B+ prevention of mother to child transmission program could address all of these challenges: poor male engagement in the HIV continuum of care, low male adoption of biomedical HIV prevention approaches, sub-optimal female engagement in the continuum of care, and poor or uncertain infant outcomes. Our team has designed a couples-based intervention to address these challenges, and will conduct a randomized controlled trial (N=500 couples) to assess intervention effectiveness at one year. Results from this study are expected to inform how best to address family outcomes in an Option B+ program. This study has the following aims described below: Aim 1: Determine whether the couple-based intervention increases new HIV-positive diagnoses among HIV-infected male sex partners, helps HIV-infected men engage and remain in care, and contributes to male viral suppression compared to individual standard of care. The investigators will compare the couple-based intervention to standard of care for increasing the proportion of men who are aware of being HIV-infected, the proportion of these men who initiate and remain in cART care, and the proportion of these men with viral suppression at one year. Aim 2: Determine whether the couple-based intervention identifies HIV-discordant couples and decreases the likelihood of male exposure to HIV compared to individual standard of care. The investigators will compare the intervention to standard of care for increasing the number of men with non-HIV exposure from their female partner through consistent condom use, viral suppression, abstinence, or a combination of these methods over one year. Aim 3: Determine whether the couple-based intervention improves female cART retention and viral suppression compared to individual standard of care. The investigators will compare the intervention to standard of care for female cART retention and viral suppression at one year. Aim 4: Determine whether the couple-based intervention improves infant early infant diagnosis uptake compared to individual standard of care. Explore uptake of early infant diagnosis and rates of mother-to-child transmission and child survival in the two intervention arms. Aim 5: Develop an in-depth understanding of HIV transmission dynamics in Lilongwe. Using the biomarkers and behavioral survey, we will seek to understand transmission timing, direction, and context in Lilongwe. We will compare women with recent HIV infection to a population of HIV-uninfected controls (n=350) to understand predictors of HIV acquisition in pregnancy in Malawi.

Official Title
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Developing and Assessing a Male Engagement Intervention in Option B+ in Malawi: A Randomized Controlled Trial in Lilongwe

Conditions
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Hiv

Intervention / Treatment
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* Behavioral: Enhanced Couple HIV Testing and Counseling


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria (HIV-infected Women): HIV-infected and eligible for Option B+ >18 years old or 15-17 years old and married Planning to remain in the Bwaila catchment area for the next year or notify the study team if they leave the area or change facilities Part of a heterosexual relationship for >3 months Expects the partner to be in the relevant catchment area for at least one week in the next six months. Able and willing to give locator information for this partner Willing to have study staff conduct phone and physical tracing of that partner Willing to undergo a couple-based intervention with this partner Able and willing to provide informed consent Inclusion Criteria (Male Partners of HIV-infected women) >18 years old or 15-17 years old and married In a relationship with the female partner for >3 months Willing to undergo a couples-based intervention with their female partner Able and willing to provide informed consent Inclusion Criteria (HIV-uninfected Women): HIV-uninfected >18 years old or 15-17 years old and married Part of a heterosexual relationship for >3 months Expects the partner to be in the relevant catchment area for at least one week in the next six months. Willing to receive couples-based HIV testing and counseling with this partner Able and willing to provide informed consent Exclusion Criteria (all Women and Male Partners): • Any condition that in the opinion of the study investigator would compromise the ability of the prospective participant to provide informed consent, undergo study procedures safely, or would prevent proper conduct of the study.

Ages Eligible for Study
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Minimum Age: 15 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Individual (SOC)<br>HIV-infected pregnant women enrolled in the individual arm of the study will receive Standard of Care Option B+ procedures. | |
| Experimental: Couple (Intervention)<br>In addition to receiving standard of care procedures, HIV-infected pregnant women in the couple arm will be provided with an intervention aimed at recruiting their male partners, providing enhanced couple counseling and testing, engaging their male partners in their care, and supporting male partners to receive care and treatment services. | Behavioral: Enhanced Couple HIV Testing and Counseling<br>* Participants are provided study-specific partner referral cards and encouraged to bring male partners to antenatal care for a male engagement intervention. Those who do not present on their own are then traced. Couples will receive three enhanced couple counseling sessions that include: pre-test counseling, return of joint results, and post-test counseling. HIV-infected men will be able to initiate cART at the antenatal clinic and the couple will be offered condoms from the HTC counselor. Between sessions, couple members can pick up condoms and cART for one another.<br>* Other names: male engagement intervention;|
| No Intervention: HIV-Uninfected Cohort<br>HIV-uninfected pregnant women will be invited to participate in a cross-sectional study. No intervention will be provided and no follow-up will be conducted. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Women Retained in Care | Women who presented at 12 months and reported taking at least one dose of ART in the last seven days | 12 months | 
| Number of Women With Viral Suppression | Women who presented at 12 months with a viral load <1000 copies/mL | 12 months | 
| Number of HIV-positive Male Partners Aware of Their HIV-positive Status | HIV-positive male partners who presented at 12 months and reported knowing they were HIV-positive prior to receiving the results of the HIV test conducted at the 12 month study visit | 12 months | 
| Number of HIV-positive Male Partners Retained in Care | HIV-positive male partners who presented at 12 months and reported taking at least one dose of ART in the last seven days | 12 months | 
| Number of HIV-positive Male Partners With Viral Suppression | HIV-positive male partners who presented at 12 months with a viral load <1000 copies/mL | 12 months | 
| Number of HIV-negative Men Without HIV Exposure From Their Primary Partner | HIV-negative men with a) consistent condom use in the last six months or b) a suppressed female partner or c) abstinence with primary partner | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of HIV-positive Female Participants Who Reported Early Infant Diagnosis | HIV-positive female participants who reported a live birth and uptake of early infant diagnosis | 12 months | 
| Predictors of Recent HIV Infection | Risk factor analysis to identify predictors of recent HIV infection among pregnant women | At the day of female consent | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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couple HIV testing and counseling, disclosure, Malawi