The study by Augustine Choko and colleagues1Choko AT Fielding K Johnson CC et al.Partner-delivered HIV self-test kits with and without financial incentives in antenatal care and index patients with HIV in Malawi: a three-arm, cluster-randomised controlled trial. has shown that the secondary distribution of HIV self-testing (HIVST) kits, by pregnant women attending antenatal care to their male partners and by index patients attending general health care to their sexual contacts, can increase the number of men testing for HIV. Choko and colleagues reported that the mean proportion of partner testing in the antenatal care cohort was 35·0% (SD 10·0) in the standard care group versus 73·0% (13·1) in the HIVST only group and 65·2% (11·6) in the HIVST plus financial incentive group. However, the authors found no difference in the geometric mean number of new HIV-positive sexual partners per cluster between the HIVST only group and the standard care group (unadjusted incidence rate ratio 1·38, 95% CI 0·45–4·16) in the index cohort.1Choko AT Fielding K Johnson CC et al.Partner-delivered HIV self-test kits with and without financial incentives in antenatal care and index patients with HIV in Malawi: a three-arm, cluster-randomised controlled trial. Therefore, secondary distribution appears to improve the accessibility of HIV diagnosis, treatment, and care. This study makes an important contribution to implementation strategies aimed at increasing the uptake of HIV testing and other HIV services by male partners and sexual contacts in low-income and middle-income countries.We endorse this study's recommendation to integrate the secondary distribution of HIVST kits into routine services for prevention of mother-to-child transmission, as an approach to increase HIV testing in male partners. A persistent combination of male partner factors has been reported to derail the progress in HIV prevention and treatment, including the elimination of mother-to-child transmission.2Belato DT Mekiso AB Begashaw B Male partners involvement in prevention of mother-to-child transmission of HIV services in Southern Central Ethiopia: in case of Lemo District, Hadiya Zone. For example, it is widely reported in many studies done in Africa that the difficulty of getting men to test for HIV has been one of the major challenges of reaching the 95-95-95 goals for controlling the epidemic. Many studies have shown that men not only did not turn up to access HIV testing and treatment services for themselves but they also created barriers for their pregnant and breastfeeding partners to access HIV testing services, start HIV treatment, and adhere to treatment and care.3Shapiro AE van Heerden A Krows M et al.An implementation study of oral and blood-based HIV self-testing and linkage to care among men in rural and peri-urban KwaZulu-Natal, South Africa. Furthermore, despite the progress made in reducing mother-to-child transmission, there is evidence that some of the new HIV infections that occur during pregnancy and breastfeeding come from infected male partners, most of whom are not aware of their HIV status.4Risk of HIV acquisition during pregnancy and postpartum: a call for action.Although the secondary distribution of HIVST kits might help to increase male partner HIV testing, there are some key considerations for policy makers as they adopt the recommendations from the Article. It is important to recognise that men's struggles in accessing HIV services are linked to deep social structures associated with the performance of hegemonic masculinities in a patriarchal society.5Mweemba O Dixey R Bond V White A The influence of social constructs of hegemonic masculinity and sexual behaviour on acceptability of vaginal microbicides in Zambia. Therefore, secondary distribution of HIVST kits might not completely overcome the barriers for men in accessing HIV prevention and treatment.6Sileo KM Fielding-Miller R Dworkin SL Fleming PJ What role do masculine norms play in men's HIV testing in sub-Saharan Africa? A scoping review. For example, some studies have shown that men struggle to seek health services, especially in a traditionally female space, because it goes against the masculine notion that they are physically strong, aggressive, and healthy.7Blackstone SR Nwaozuru U Iwelunmor J Antenatal HIV testing in sub-Saharan Africa during the implementation of the millennium development goals: a systematic review using the PEN-3 cultural model. Some men might also struggle to follow up with confirmatory tests, and receive and adhere to appropriate treatment because of conflicting and equally demanding masculine roles, such as being the breadwinner.8Korte JE Kisa R Vrana-Diaz CJ et al.HIV oral self-testing for male partners of women attending antenatal care in central Uganda: uptake and linkage to care post-test in a randomized trial. In a similar vein, some HIV-positive women might be reluctant to distribute HIVST kits to their male partners because they fear a discordant test result, intimate partner violence, divorce, and loss of economic support. In agreement with these possibilities, four temporary marital separations occurred during the study by Choko and colleagues.1Choko AT Fielding K Johnson CC et al.Partner-delivered HIV self-test kits with and without financial incentives in antenatal care and index patients with HIV in Malawi: a three-arm, cluster-randomised controlled trial. These concerns need addressing in the implementation of services, including special support systems from health workers.9Kumwenda MK Johnson CC Choko AT et al.Exploring social harms during distribution of HIV self-testing kits using mixed-methods approaches in Malawi.It is also important to note that the secondary distribution of HIVST kits through antenatal services might not reach particular groups at high risk of HIV, such as married adolescents and single mothers, who are known to avoid maternal and child health services because of stigma from health workers and the community.10Bwalya BC Sitali D Baboo KS Zulu JM Experiences of antenatal care among pregnant adolescents at Kanyama and Matero clinics in Lusaka district, Zambia. Additionally, there is also a question as to whether the secondary distribution of HIVST kits puts pressure on already overburdened pregnant women due to the demands from maternal and child health services. The provision of financial incentives to men to encourage them to seek HIV services could further exacerbate the unjust distribution of burdens and benefits of HIV services. Social science and economic evaluation studies are needed to understand the social effects of implementing such an intervention, including burdens and costs, from the perspective of women.

We declare no competing interests.

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Reprod Health. 15: 124Article InfoPublication HistoryIdentification

DOI: https://doi.org/10.1016/S2214-109X(21)00257-6

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