'If there is joy'¦I think it can work well' ' Investigating relationship factors impacting HIV self-testing acceptability among pregnant women and male partners in Uganda

BACKGROUND: Secondary distribution of HIV self-test (HIVST) kits from pregnant women to their male partners may promote HIV couples testing and disclosure, and is being scaled up in sub-Saharan Africa. Understanding couple-level barriers and facilitators influencing HIVST uptake is critical to identifying strategies for strengthening clinical guidelines for HIVST distribution.
METHODS: We conducted gender-stratified focus group discussions (N=14) and in-depth interviews (N=10) with pregnant women, and male partners of pregnant women, in Uganda from April 2019 to February 2020 (N=122 participants). We purposely sampled men and pregnant women living with HIV to assess how perspectives differed from those without HIV. Interview topics included acceptability and barriers for HIV testing and HIVST, and perspectives on disclosure and gender roles impacting HIVST use. Transcripts were transcribed and translated from Luganda to English and analyzed thematically by two coders using NVIVO. We adapted the Interdependence Model of Communal Coping and Health Behavior Change to explore factors impacting HIVST acceptability.
RESULTS: Participants felt that relationships characterized as having facilitating predisposing factors, such as trust and open communication, would have a higher likelihood of women delivering HIVST kits to their partners and subsequently exhibiting communal coping behaviors such as couples self-testing and disclosure. Conversely, participants mentioned that relationships with breaches of trust, infidelity, or intimate partner violence were more likely to experience negative consequences of disclosure, such as violence and/or relationship dissolution, and would be hesitant to distribute/use HIVST. Pregnancy was described as a critical motivator for self-testing, while gender dynamics served as a barrier to HIVST acceptability, with for example some women mentioning concerns about asking their partners to use HIVST. Generally, participants felt HIV-negative women were more likely to give HIVST to their partners, while HIV-positive women would have concerns, particularly in navigating discordant relationships and disclosure without a counselor.
CONCLUSIONS: While HIVST generally had high acceptability, a subset of participants, particularly those with negative predisposing factors, may benefit from targeted counseling and disclosure support before and after HIVST distribution to increase uptake. Results may help support policy guidelines regarding HIV self-testing of pregnant women and their partners, and recommendations for counseling support.