In resource-limited settings, it is important to reduce both infant HIV infection and mortality. Programs are beginning to achieve lower vertical transmission rates however, infant mortality remains high5,18
making interventions addressing both of these public health issues necessary to improve infant outcomes. This study demonstrated that infants of HIV-infected women with male partner involvement had a significantly lower risk of HIV infection and greater HIV free survival compared to infants born to women without male involvement. The associations retained significance after adjusting for maternal viral load and infant feeding modality, two of the most important predictors of infant survival and HIV acquisition.19,20
These outcomes are consistent with earlier studies, which have demonstrated enhanced utilization of PMTCT services with partner involvement.8–12
A major difference between this report and previous studies is that rather than assessing a surrogate endpoint (intervention uptake), we evaluated infant HIV-infection and mortality. Thus, our finding of a more than 40% reduction in both the risk of vertical transmission and the composite risk of infant HIV infection or mortality provides key new evidence that male involvement may represent an under-utilized public health intervention.
In sub-Saharan Africa PMTCT guidelines encourage partner HIV testing, but do not specifically promote antenatal attendance for partners of HIV-infected pregnant women.21
Consequently, men rarely present to participate in antenatal education or counseling. This is illustrated in previous studies where fewer than 20% of men attended antenatal clinics with their HIV-infected partners.12,22
Research has shown that partners of HIV-infected pregnant women in sub-Saharan Africa are not averse to participating in PMTCT or HIV testing services.23
However, health systems barriers exist that prevent male participation and will need to be addressed to achieve the benefits of male involvement for infant health.
In this analysis, women whose partners had been previously tested for HIV had a trend for better adherence to zidovudine and were significantly more likely to formula feed their infants, both of which may have contributed to reduced risk of vertical transmission. Further, the lower infant mortality risk associated with male attendance may stem from increased financial, physical and/or psychosocial support for the HIV-infected pregnant woman and her infant. It is plausible that males who take part in healthcare processes (antenatal PMTCT or HIV testing) have more knowledge of, and involvement in, their families’ health and subsequently better support women to prevent infant HIV infection and mortality. Our data provide impetus to further characterize male involvement within maternal and child health programs in order to harness the benefits that partner involvement provides.
We observed 63% less mortality risk among HIV-uninfected infants born to women whose partners attended clinic compared to those born to women whose partners did not attend. With rising rates of antenatal HIV testing and effective PMTCT interventions, HIV-exposed uninfected infants comprise the majority of children born to HIV-infected mothers. Thus, reducing mortality in this group would have major public health benefits. However, we also observed a concerning trend toward greater mortality risk among HIV-infected infants born to women with partner attendance. It is possible that knowledge of infant HIV infection impacted support for maternal and child care, particularly at the time of this study when prognosis with infant HIV-infection was poor, and this merits additional investigation. With the known importance of preventing HIV infection for infant survival in sub-Saharan Africa6
, and with improved access to pediatric antiretroviral therapy the possible trend toward greater risk may be less of an issue.
This study has limitations. For example, we did not assess for any potential negative effects of male involvement. However, domestic violence has been studied by our group in a different antenatal cohort and was not increased with disclosure of HIV serostatus.24
Nonetheless, partner violence in sub-Saharan Africa is highly prevalent and there has been concern that promotion of serostatus disclosure may result in abuse.25,26
While current evidence suggests that benefits outweigh risks, monitoring for domestic violence is warranted in future studies. A second limitation is that there may have been response bias when women answered sensitive questions regarding partner serostatus disclosure and testing. Previous partner HIV testing was reported by 52% of women, which is higher than census rates during the period of this study.27
This type of misclassification would bias towards the null and any beneficial relationship between previous testing and improved infant health would be an underestimation of the association, further strengthening the evidence for promoting male involvement.
Considering the time elapse since this cohort was accrued, it is possible that secular changes in PMTCT and HIV testing may alter the applicability of the observed associations. However, given the dynamic nature of the HIV pandemic and prevention efforts in Africa, this concern applies to all longitudinal research. The significant association in improvement in infant health outcomes with male partner involvement is valid in the setting of this study and, our findings underscore an important proof-of-concept regarding the beneficial role of partner involvement on infant HIV and mortality. These findings extend and are consistent with previously identified benefits of partner involvement on intermediate markers such as PMTCT intervention uptake.8–12,28,29
. Further studies to support the generalizability and better define the impact of male involvement in PMTCT services will be important.
In conclusion, these data suggest that incorporating men into PMTCT programs with associated HIV testing may improve infant health outcomes by reducing both vertical transmission and mortality among uninfected infants. There remains a need to define specific male partner factors associated with enhanced infant health and to address barriers to partner testing and participation in the antenatal setting. With better understanding of these issues, public health programs facilitating male involvement may augment PMTCT services and improve overall infant health, while promoting couple counseling and testing, as well as treatment and prevention efforts in at-risk populations.