Partner-based HIV care and treatment for expectant couples

in rural Mozambique

CarolynM.AudetAssistantProfessor,HealthPolicy

VanderbiltUniversityMedicalCenter

Map of Study Sites in Mozambique

HIV Epidemic in

Mozambique

The Original Male Engagement Design

• TBAcounselsre:prenatalcareservices/HIVtesCng

• Offerstoaccompanyhertohospital/clinic

Pregnantwomengoesto

TBA

• TBAcontactsMaleChampion• MaleChampionvisitsmalepartnertocounselre:couplescounseling

MaleChampionvisitsmalepartner

• TBAaccompaniesbothparentstothehealthfacility

• Couplecounseledandtestedtogether(separateroom).

CoupleaKends1stPrenatalCarevisittogether

Male Champions give community lectures about importance of prenatal care services and support of partners during pregnancy

•  MaleChampionconductstoaddiConalhomevisits

•  TBAfollowsupwithfamilypost-deliverytoaccompanyinfanttoCCR

Home-based

follow up

Male Partner Accompaniment and Couples TesBng Uptake

• Malepartneraccompaniment2%-60%• MaternaltesCngrose76%-92%• Womenwhoarrivedwiththeirpartnerwere7xmorelikelytoreceiveanHIVtest

• Womeninmaleengagementsiteshad23%lowerhazardofbeingLTFUat6months

But what about the male partners?

•  In2016,wedoubledthenumberofmalestestedforHIVthroughMESprogram(upto68,000in2016)

• MalepartnersreferredtoAdultHIVcare

• MalestestedinANChadhighestLTFU

Couples vs. Individual HIV care

• CouplesenrolledonARTtogetherdemonstrateimproved12-monthretenConrates.

• Canweusethisstrategytoimprovemalepartneroutcomes?

NIMH R01 (2017): Couples-based Services

• HybridType2trial• Hypothesis:ExpectantcoupleswhoenrollintreatmenttogetherthroughANC&post-natalserviceswillhaveimprovedretenConincare.

•  FocusonmaternalandpaternalretenCon,MTCToutcomes,infantretenCon

•  FocusonimplementaConprocessandsustainability

ImplementaBon QuesBons

1.  Willacouple-basedcareandtreatmentintervenConbepossibleinthisextremelyresourcelimitedsebng?WillpaCentsacceptit?

2.  WhichpaCentsbenefitmostfromacouple-basedprogram?DoallpaCentsbenefitfrompeerandprofessionalcounseling?

3.  DoestheimplementaConmethod(couplescounselors&peersupporters)showpromiseinfacilitaCngcouple-basedcare?

Re-AIM framework for implementaBon assessment

QualitaCveInterviews•  HealthCareProviders(clinicians,counselors,peersupporters)

•  ParCcipants(includingthoseLTFU)QuanCtaCveData•  RecruitmentandretenConinstudy•  Clinicaloutcomes•  Broadhealthoutcomes(depression)•  Costs(topaCents,healthsystem)

Reach

Goal:TargetnewlyenrolledpaCents(orthosepreviouslyLTFU)tonotarCficiallyinflateeffectoftheintervenCon.CouplescurrentlyenrolledtogetherinadultcarewhobecamepregnantarenoteligibleAcceptance:Currentlyacceptancerateis82%amongeligiblecouples(171couplesenrolled)

Reasonsforenrollment:InJulywewillbegininterviewswithparCcipantstounderstanddecisionmakingrelatedtostudyenrollment

EffecBveness

Shouldthisinterven7onbetargetedtospecificpa7ents?:ShouldtheintervenConbetailoredforcoupleswithdepression,lowlevelsofsocialsupport,highHIVsCgma,lowcoupleempathyscores?

Howcanweimproveourprofessionalandpeercounselingstrategies?:CoupleparCcipaConinmonthlycounselingsessions,includingreasonswhyonememberdidnotparCcipate(ifapplicable);whatsupportwasrequested/provided.

AdopBon-SeWng Level

Healthfacilitystaff“resistance”:UseofqualitaCveinterviewswithstudyteammemberstounderstandclinician/counselorresistancetoimplementaCon.

-IdenCfyminimumspaceissuesrequiredtomangepaCentflow.-IdenCfyminimumCmeneededtosupportcouplevs.individualpaCent

ImplementaBon

CounselorAc7vi7es• Percentageofcounselingsessionscompletedwithin30daysacrosshealthfaciliCes.

• Percentageofphonecalls/homevisitsmadewithin3daysofmissedvisit.

• Concernswithtraining,preparaCon,anddeliveryofcounselingsessions…whatelsedotheyneedtobesuccessful?

Costs• CostofintervenCon

Maintenance

IndividualLevel:• DocouplestransiContofamilycare18monthspost-partum?SeEngLevel:•  IfprogramissCllongoingat>6monthspost-funding•  Ifandhowprogramwasadaptedlong-term(whatremainspost-funding)

IniBal Thoughts

• MinistryofHealthbuy-inishigh,butwehavealreadyencounteredresistance-mostlyduetocompeCngdesiresforspace.

•  TheintervenConhasbeenacceptabletopaCents(parCcularlythosewhoarenoteligible)butwehavesomemenleavingmedicaConpick-uptotheirfemalepartners.

• CounselorshavefeltconfidentindeliveringeducaConalandsupporCvesessions;findingpeercounselorshasprovendifficultasfewpeoplecanreadandwriteinruralareas

Special Thanks NIMHR01HoPS+Team

•  ErinGraves(StudyManager,VUMC)•  EzequielBarreto(StudyManager,Mozambique)

•  CarolineDeschacht(Physician,Mozambique)

•  SaraVanRompaey(Physician,Mozambique)

•  BryanShephard(BiostaCsCcian,VUMC)•  WuGong(BiostaCsCcian,VUMC)•  RivetAmico(Psychologist,UMichigan)•  MaKDiemer(Psychologist,UMichigan)•  AndreaCiaranello(Cost-effecCveness,Harvard)

•  HoPS+couplescounselors(24)andstudyassistants(5)!

Mentors/DSMBmembers•  StenVermund(mentor,Yale)•  MiltonWainberg(DSMB,Columbia)•  KatherineFielding(DSMB,LSHTM)•  KeithHorvath(DSMB,UMichigan)•  PeterRebeiro(DSMB,Vanderbilt)