Table 1 Articles included in the systematic review

Akama E, 2018

Kenya

To evaluate the impact of a male-centred Rapid Results Initiative (RRI)* on the PMTCT cascade focusing on: -HIV testing and linkage to care for patients HIV+;-keeping mothers alive through Antiretroviral Therapy Initiation and skilled deliveries; −uptake of Early Infant Diagnosis

Package of interventions employing an RRI approach including a male invitation letter, mentor mothers and peer educators, male-friendly services, fast-tracked at the clinic

-Baseline (January to March 2013)

-During the RRI

(April–June 2013)

-Post-RRI

(July–September 2013)

Pre- and post-intervention study

Pregnant women, partner, children in 116 antenatal clinics

1. Proportion of male partners accompanying their female partners to antenatal care (MI). 2. Proportion of partners receiving HIV testing. 3. HIV prevalence for pregnant women at ANC. 3. Proportion of women receiving skilled delivery services. 4. Proportion of HIV positive women receiving skilled delivery services. 5. Proportion of HIV positive women successfully linked to care. 6. Time to linkage to care. 7. Proportion of HIV exposed infants getting HIV testing

MI in ANC: from 7.4 to 54.2%(RD = 0.47, 95% CI 0.45–0.48) and 43.4% (RD = 0.36, 95% CI 0.35–0.37)

The percent of male partners tested for HIV: from 5.4 to 50.1% (RD:0.45, 95% CI 0.43–0.46) and 38.6% (RD:0.33, 95% CI 0.32–0.34)

Male-centred RRI approach significantly contributed to increased uptake of HIV testing among male partners, earlier linkage to ART initiation among pregnant HIV-infected women, an increased proportion of women delivering in a health facility and infants. Strategies that deliberately address men’s own health needs appear promising at engaging men in PMTCT

Aluisio AR, 2016

Kenya

To assess the impact of partner ANC engagement on infant health outcomes of children born from HIV+ women

Invitation letters delivery

2009–2013

Multicentre prospective study

830 HIV positive pregnant women in 6 ANC

1.Male ANC Attendance

2.Male HIV test results per female report.

3.Infant Health Outcomes (HIV infection, infant mortality, HIV free survival)

N. of HIV-infected pregnant women: 830 (of which 11.2% reported no male partner, 25.9% refused partners participation) N. of male attended the ANC: 136 (26.2%)

Number of men failed to attend: 383 (73.8%), of which 63 (16.5%) were surveyed through female partners.

Previous male HIV test as per female report:

Male attended ANC: 56.4% HIV +

Male did NOT attend ANC: 56.4% HIV+

N. of infants born from women with ANC engagement: 132 (26.5%) Born without ANC engagement: 367 (73.5%)

Male ANC attendance was associated with improved infant HIV-free survival through six weeks of life.

Infants lacking male ANC engagement had an approximately 4-fold higher risk of death or infection compared to those born to women with partner attendance (HR = 3.95, 95% CI:1.21–12.89, p = 0.023) (aHR = 3.79, 95% CI:1.15–12.42, p = 0.028)

Aluisio AR, 2011

Kenya

To investigate the relationship between male involvement in PMTCT services and infant HIV acquisition and mortality

Word of encouragement

1999–2002

Follow up until 2005

Prospective cohort study

456 HIV positive pregnant women in ANC

1. Number of male partners involved. 2. Correlates of male partner attendance. 3. Infant Outcomes (Mother to child HIV transmission; mortality; HIV-free survival)

Female with partner attendance: 31%

Female without partner attendance: 54%

Test HIV male partners: 56% HIV+.

Association between male attendance and relationship status: women whose partners attended clinic were more likely to be in a monogamous marriage

Including men in antenatal PMTCT services with HIV testing may improve infant health outcomes. We observed a 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

Audet CM, 2016

Mozambique

To evaluate the impact of a community-based intervention on male engagement in Antenatal Care.

The intervention has four components: 1. Involving of all TBAs** in MI 2. Developing Male Champions 3.“Male-friendly” clinical environment. 4. Couples Counseling Sessions

1 June 2012-

30 March 2014

Pre- and post-intervention study

5971 pregnant women (HIV status not considered) in ANC in four rural communities. Pre:1616Post: 5971

1. Uptake of provider-initiated counselling and testing among pregnant woman. 2. Male engagement in ANC (present at first visit, always present). 3. Uptake of ART.

The intervention was associated with increases in (post-intervention): (1) male engagement in ANC (5% vs. 34%; p < 0.001); (2) uptake of ART (8% vs. 19%; p < 0.001)

(2) uptake of provider-initiated counselling and testing among pregnant woman (81% vs 92%; p < 0.001)

The study highlights the impact of increased male partner engagement on maternal testing. Therefore the adherence of women is higher with supportive male partners

Byamugisha R, 2011

Uganda

To evaluate the effectof a written invitation letter delivered to the spouses of women attending their first antenatal visit on couple attendance

Intervention group: invitation letter Control group: information letter or leaflet

October 2009–February 2010

A randomized, parallel-group, health facility-based intervention trial

1060 pregnant women enrolled: 530 for each group

Women attending the subsequent antenatal visits Intervention group: 290 Control group: 310

Primary outcome: proportion of pregnant women who attended ANC with their partners during a follow-up period of four weeks. Secondary outcome: proportion of men who accepted routine antenatal HIV testing.

Intervention group:

Couple antenatal attendance: 16.2% (intention to treat analysis).

Partner accepted HIV test: 95.3%

Control group:

Couple antenatal attendance: 14.2% (intention to treat analysis).

Partner accepted HIV test: 90.7%

The effect of the intervention and the control on couple antenatal attendance was similar in both arms. The majority (more than 90%) of the male partners who attended ANC accepted HIV counselling and testing

Ezeanolue E, 2017

Nigeria

To assess the effect of intervention Healthy Beginning Initiative (HBI) on the rate of HIV testing among male partners of pregnant women during pregnancy

Health Beginning Initiative is a congregation-based intervention. Intervention group: (1) community encouragement to participate in antenatal care, (2) education about the antenatal risk of HIV, (3) integrated testing to reduce stigma, (4) testing at convenient locations and (5) free testing. Control group: patients were referred for HIV testing at the nearest healthcare facility

Enrollment period: January 2013–September 2013. Follow-up of enrolled participants ended in August 2014.

Cluster randomized controlled trial

3047 pregnant women of which 2809 were married or partnered.

Partners enrolled in 40 churches were 2498: − 1297 Intervention group − 1201 Control group

Completed HIV testing for male partners of pregnant women

Verified HIV testing rate among male partners was significantly higher in IG (84.0%) compared to CG (37.7%)

The study showed that the intervention arm was more effective than standard of care: male partners of pregnant women enrolled in the Intervention Group were 12 times more likely to have tested respect control Group.

Jefferys LF, 2015

Tanzania

To assess the acceptability and effectiveness of written invitations for male partners to attend Antenatal Care

Written invitation letter

March 2013–June 2013.

Prospective, longitudinal cohort

318 pregnant women

1. Association of socio-demographic indices with partner attendance rate. 2. Acceptability and effectiveness of invitation letters

−29% of women reported that they did not know their HIV status. -98% of women have delivered the letter to their partner. Partner attendance rate: 53% Of these, 81% proceeded to counseling. Of 170 male attending ANC: 79% did so after the first visit and 21% after the second invitation

This study demonstrated that written invitations for male partners to attend joint ANC and CVCT were well accepted by women attending ANC in Mbeya Region, Tanzania with significant differences in male attendance between our urban and rural settings. More than half of the women returned with their partner at a subsequent ANC visit

Krakowiak D, 2016

Kenya

To compare the effectiveness of scheduled home visits with pregnant women and their partners to written invitations encouraging men to return to the clinic for the next

antenatal visit CVTC

Intervention group: invitation letter encouraging the male partner to attend the clinic at six months postpartum

Control group:

Scheduled home-based partner education and HIV testing visit

September 2013–June 2014

Randomized clinical trial

601 pregnant women Control group: 306 patients Intervention group: 295 patients

HIV testing outcomes (%)-Male partners HIV tested -Women knowing male partner status -No. of couples attending couple testing and counselling -Sero-discordant couples identified Maternal and Child Health Outcomes-Facility deliveries -Exclusive breastfeeding at 6-weeks postpartum -Family planning uptake

Male partners were more than twice [RR = 2.10; 95% CI: 1.81–2.42] as likely to have been HIV tested in the CG versus IG (87% versus 39%).

Couples tested: CG arm was three times (RR = 3.17; 95% CI: 2.53–3.98) as likely to have been tested as a couple as the IG arm (77% versus 24%)

Home-based partner education and testing resulted in a more than 2-fold increase in male partner testing and HIV status disclosure and a higher than 3-fold increase in couple HIV testing and identification of HIV discordant couples when compared with partner invitation to attend antenatal care.

The intervention did not result in higher uptake of maternal child health outcomes.

Mphonda SM, 2014

Malawi

To increase the number of couples attending an antenatal clinic and accessing PMTCT services

Intervention: Period 1 (January 2007–June 2008): health talks performed by peer educators on the importance of involving men. Period 2 (July 2008–September 2009): drama was introduced into patient waiting areas to deliver the same message. Period 3 (October 2009–December 2009): male-friendly maternity wing.

January 2007–June 2008; July 2008–September 2009; October 2009–December 2009

Not defined (three interventions one after the other in the same hospital)

30,066 pregnant women:

 -period 1: 14,585

 -period 2: 12,700

 -period 3: 2781

-Percentage of pregnant females presenting as a couple-Male partners HIV status-Couples HIV status

-period 1: 0.7% (96) presented with male partner -period 2: 5.7% (732) presented with male partner -period 3: 10.7% (300) presented with male partner.

The proportion of women attending ANC with a male partner increased from 0.7 to 5.7% to 10.7% over the three periods

Uptake remained sub-optimal, and are needed strategies community-based as a complementary to any facility-based component. Authors recommended the expansion of peer counselling programs with drama and structural changes in all facilities in Malawi

Nyondo AL, 2015

Malawi

To evaluate the efficacy and feasibility of an invitation card to the male partners as a strategy for male involvement in PMTCT services

Intervention group: invitation letter Control group: women use “word of mouth” to involve male partners. The message was similar

Recruitment period: 14 June- 17 December 2013.

Follow up activities completed on 24 February 2014

Randomized open-label controlled trial

462 pregnant women attending antenatal care without a male partner

IG:230

CG: 232

Primary outcome:

proportion of pregnant women who reported to the study clinic with their partners, for PMTCT services following use of an invitation card after two visits.

Of the 462 women: 109/462 (23.59%) came back with their partners at one visit. Concerning each study group reported with their partners: IG: 65/230 (28.26%) CG: 44/232 (18.97%)

Invitation card increases the proportion of women who are accompanied by their male partners for the PMTCT

Rosenberg NE, 2015

Malawi

To compare two strategies for recruiting male partners for Couple HIV Testing and Counseling:

invitation-only versus invitation plus tracing

Intervention group:

Invitation card plus partner’s tracing if he did not present within one week. A community health worker can make three phone attempts, followed by three community attempts. Control group:

Invitation card

March 2014–October 2014

Unblended, randomised, controlled trial

200 HIV-positive pregnant women were enrolled and randomly assigned to IG: 100

CG: 100

Primary outcomes: Proportion of couples who presented to the clinic together and received CHTC^§.Secondary outcomes: -HIV status of men-Proportion of HIV-positive men newly diagnosed -Proportion of newly diagnosed HIV-positive men linked to care

Intervention group:

74% (74/100) couples presented for CHTC

46% (15/33) new HIV+ men linked to care

Control group:

52% (52/100) couples presented for CHTC

19% (5/26) new HIV+ men linked to care

Invitation plus tracing results highly effective at increasing CHTC uptake

Weiss SM, 2014

South Africa

To determine whether men’s participation in the intervention would significantly impact PMTCT uptake compared to male attendance at antenatal visits only

Intervention group:

Partner Plus intervention consisted of a couples’ behavioural HIV risk reduction intervention: 4 weekly session utilizing a cognitive-behavioural skill training approach

Recruitment: January 2010–July 2011

Randomized control trial (pilot study)

478 participants (238 pregnant women and 239 men)

-Baseline and post-intervention data about HIV serostatus. -Male Attendance

-HIV and PMTCT knowledge.-PMTCT-specific knowledge

Male attendance (involvement) increased in both conditions, but no significant difference between the intervention and control conditions were found (t _201.5 = 1.76, p = .08). No difference in the number of visits attended by men (t ₂₂₃ = 1.3, p = .18)

Male attendance at antenatal visits was high in both experimental and control conditions, but only the experimental group demonstrated significant improvements in PMTCT outcomes, confirming the need for psychoeducational programs to actively engage both HIV-seropositive pregnant women and their male partners in the PMTCT process.