Perspectives on male partner notification and treatment for syphilis among antenatal women and their partners in Kampala and Wakiso districts, Uganda

Syphilis is a cause of preventable morbidity and mortality in infants in Sub-Saharan Africa (SSA) where 2.5–17% of pregnant women are infected with syphilis [1, 2]. It is estimated that 53–82% of women with untreated syphilis have adverse birth outcomes compared to only 10–21% among uninfected women [3]. Untreated partners of women are a source of reinfection. Increasing partner uptake of syphilis screening and treatment should decrease the risk of re-infection and protect subsequent pregnancies from syphilis re-infection [4]. Uganda’s Ministry of Health (MoH) has a partner notification program as part of the management of STD and syphilis. Free partner notification and treatment is provided with provision of a numbered notification slip. An earlier study showed excellent uptake of syphilis screening, but a minority of partners came in for testing and treatment [5].

The “Comparison of Different Partner Notification Strategies after Antenatal Syphilis Screening” also known as “Syphilis Treatment of Partners (STOP) Trial” was conducted from August 2014 to November 2015 at the Infectious Diseases Institute (IDI), Makerere University. In the STOP trial after one year of study, only 18% of male partners returned for the treatment which was not different by three study arms, where participants received either a paper slip to give to their partner, paper slip plus weekly SMS reminders, or paper slip plus weekly phone calls. We conducted a qualitative study to understand the socio-cultural factors that influenced the male partner compliance with syphilis testing and treatment.

In the pathway model framework detailed by Axel Kroege [6], and guided by the World Health Organization for studies on STD management (https://​www.​who.​int/​hiv/​topics/​en/​HealthcareSeekin​g.​pdf), investigators examine or investigate pathway processes to the desired health seeking behavior and the factors that are barriers to or support these processes. The general areas of; i) characteristics of the subject ii) characteristics of the disease, and iii) characteristics of the health service give the overarching areas under which factors considered as barriers to or facilitators to the use of the health seeking behavior of interest are examined. In this study the health behavior of interest is male partners’ return to clinics after notification and receiving syphilis treatment after partner notification. We adapted the framework to the local context supported by a literature review in the area as well as based on WHO guidelines regarding protocols in STD research that seek to understand the behavior of health seeking of STD care.

We conducted an exploratory study among women participants enrolled in the STOP trial and their male partners who consented to participate from May to November 2016. The study involved persons enrolled from three study sites in the STOP study; the Infectious Disease Institute (IDI) Sexual and Reproductive Health (SRH) Clinic, Mulago National Referral Hospital; Antenatal and the STD Clinics in Kampala and the Kasangati Health Center IV Antenatal Clinic in Wakiso District. We enrolled women and men aged 18 years and above from the STOP Trial participant register who consented to the study. In the design of the study, we used parts of the model described by Axel Kroeger, which we tried to adapt to the local context and literature review in the area as well as on the WHO guidelines regarding protocols in STD research that seek to understand the health seeking behavior of people for STD care.

A number of perspectives were shared by both men and women participants regarding the reasons for the low proportion of partners who came to the clinic after syphilis notification in the Syphilis Treatment of Partners (STOP) trial. Reasons cited for not-returning of partners after partner notification by women were; inadequate knowledge about syphilis infection and its treatment, none-notification of partners by the participant women because of fear of violence and fear of conflict with the male partner, limited communication skills with their male partners and lack of proximity to partners (e.g. not living in same household). Other factors influencing male partners’ non-attendance to clinic after notification for syphilis treatment were; busy work schedules, fear of the painful syphilis treatment injection and the associated stigma of syphilis with HIV. These findings are generally similar to a recent systematic review who found fear, stigma and socio-cultural issues were barriers to partner notification of STIs in developing countries [7, 8].

Among partners who reported after notification, knowledge about syphilis as a communicable disease, that treatment was available, desire for own better health, perceptions of male role as a responsible parent with concern for the unborn child’s health and love of their women partners, were facilitators that increased their capacity to make good health choices and come for treatment after notification. Persons who understood syphilis as a transmissible disease were also more likely to come for treatment after notification.

STD services factors like; access to good hospital services, having men friendly clinic hours that were open when needed, professional staff, painless drugs and fast and respectful STD treatment services were reported by men to affect their clinic attendance for syphilis treatment after notification.

In our study, the majority of women interviewed reported experiencing domestic violence. In a study by Decker and colleagues, intimate partner violence (IPV) was a clear barrier to partner notification of STI [9]. Decker’s study suggested that an assessment of intimate partner violence be included in order to minimize harm from partner notification. If a significant risk of IPV is detected, health care workers can provide mechanisms to address related fears concerning partner notification in order to improve effectiveness of STI control and minimize violence to the partner.

Poor communication between partners was reported as a barrier to notification and attendance. Either women were not able to communicate to their partner about the notification, or when communicating they conveyed the message in a way which did not facilitate the men to attend. Some men participants suggested communication training for women and their partners. This finding is backed by the quantitative work of the STOP trial, which showed that only 69 of 81 women whose partner returned were aware that their male partner had attended a clinic for treatment. There is evidence that training in communication skills makes notification easier [8]. Structural health system reasons for not attending the clinic after notification included reports from a few men that they attended the clinic but did not get treatment, or that they were unable to locate the clinics. Similarly, a review found that in developing countries, limited access to the few STD clinics hampered return of notified partners and led to non-treatment [7].

Strategies are needed that address knowledge gaps among men regarding syphilis, that reduce intimate partner violence, target and reduce communication gaps between sexual partners and improve infrastructure and services for STD clinics (including clear directions. Other strategies that increase information on syphilis and sexual health targeted to men with the use of modern technological methods could achieve this efficiently.

Syphilis treatment world over consists of parenteral use of Benzathine penicillin, a painful injection. In cases of allergy to penicillin, other antibiotics have been used but the drug of choice remains Benzathine penicillin. Counseling targeting men’s fear of the painful injections could facilitate return and future drug development of less painful injections for syphilis is crucial as fear of a painful injection was commonly mentioned.

Strategies for improvement of men’s return to clinics for treatment after partner notification that have worked in other settings include strategies involving the partner in “home delivery of partner therapy, home sampling and providing additional information for partners” [10]. These strategies could be explored in Sub-Saharan populations to improve male partner return after notification. A review by Hogben and colleagues showed that expedited partner therapy (EPT) which is the delivery of treatment to a partner and interactive counseling improved notification [11]. although this has been criticized by some. In our study, participants similarly suggested a more active role for health workers in notifying sexual partners (calls and physical visits), suggesting it could reduce the stress associated with informing partners. Similarly, provider based referral interventions have been found to be efficacious in scientific reviews. Programs that involve clinical providers in notification can be instituted or strengthened alongside patient centered notification interventions. Notified partners, are either provided with treatment at home or are taken through an expedited process of treatment at STD clinics rather than wait for long hours in line to improve partner treatment.. In the same study, Hogben and colleagues suggested a role for modern technologies (phones, websites, messaging) in partner notification. These could be instituted in STD programs in Uganda and other developing countries where mobile phones and internet coverage is fairly high and has been found useful in improving participants’ return to clinics for other illnesses [12].

Male partners’ work schedules and work environment need to be addressed; balancing economic losses against the gains of attending clinics. Strategies to get more men to come to STD clinics after notification that take into account patient social, cultural and economic needs are needed. Counseling for women who test positive for syphilis should include improving communication skills to enable easier and more effective partner notification. Client-oriented counseling that takes into account the unique challenges of each infected partner network could be implemented [7]. Table 3 outlines suggested strategies from this study and from the literature to address this. A study in Zimbabwe by Moyo and colleagues showed that partners that received specialized (client oriented) counseling to overcome perceived barriers, [13] had improved STD partner notification. Similarly programs providing STD counseling targeting barriers to notification could be provided to women to improve likelihood to notify male partners.

Provision of information through partner -delivered brochures and the use of web based STD information services [14] was found to be acceptable. These too, could be used to improve partner notification in Uganda and other resource constrained settings.

Men who reported to clinics after notification and left without treatment constitute an important group that needs to be targeted. They illustrate system inadequacies in meeting the STD care service needs of men who have overcome other barriers to access. Targeting this gap in access to STD care, in the system efficiencies and in the capacity of clinic personnel to ensure such willing men get timely and good treatment is very important and a reachable goal for improvement. Programs to improve acceptable, timely and efficient access to STD care in clinic and hospital set-ups are crucial.

Globally it is accepted that STD and HIV partner notification is key to epidemiological and public health control of STD and HIV. Some countries have legal frameworks that support partner notification of STD and HIV. In the USA, for example, federal states have the legal authority to notify partners of STD and HIV infection of their spouses. The Ryan White CARE Act Amendments of 1996 that supports "administrative or legislative action to require that a good faith effort be made to notify a spouse of a known HIV-infected patient that such spouse might have been exposed to the human immunodeficiency virus and should seek testing, is an example. The Center for Disease Control (CDC) recommends partner services for all persons newly tested positive for HIV, gonorrhea, chlamydia and syphilis [15].

In many states in the USA, reporting of STD and HIV by physicians is mandatory though a good faith effort is first required of the index partner [16]. These requirements are not agreed upon by many but continue for the public health. Even in such countries where physicians are legally mandated to report STD infection to partners and the public health authorities, reporting is low [17].

In many resource-constrained environments like Uganda, the legal and policy framework for STD partner notification and necessary treatment is very limited. The Uganda HIV AIDS Prevention and Control Act was approved in 2014. The law requires the mandatory notification of HIV status to partners. However this law does not make a mention of STD. Developing countries like Uganda therefore still have barriers to partner notification for STDs and many lack a firm legal and policy framework that addresses the epidemiological control aspects necessary for STI control (testing and treatment of sexual partners). Treatment guidelines in Uganda, mention partner notification and contact tracing but no policies or legal frameworks to mandate treatment and follow up of infected partners exist. Programs for contact tracing are very few and have limited resources. This is a gap in the effective STI control in Uganda and other resource constrained settings. An amendment to the HIV or other communicable disease health acts that addresses STD notification and control is needed.

Our study identified intimate partner violence (IPV) as a factor negatively affecting notification. However, one of the study limitations is that the study did not delve deep enough into the area of IPV. More detailed studies on impact of IPV on STD notification in this setting are needed. Another limitation is that the study did not use more detailed theoretical frameworks in its conceptualization and protocol development. Future studies could employ the COM-B theoretical domains framework [18] to better identify barriers and facilitators of uptake of STD notification services. However the study was able to highlight significant issue in the area of STD notification in male partners and provides important data to inform public health STD control in Uganda.

In this study we found that the notification of male partners by pregnant women treated for syphilis was low due to individual characteristics (lack of adequate knowledge about syphilis as a disease, its consequences and treatment in men, fears of domestic violence, and lack of communication between partners; characteristics of the disease (signs and symptoms, type of treatment, effects). Combined with this were structural barriers (characteristics of the health services) that hindered male partner treatment. These factors threaten efforts to eliminate mother-to-child re-infection of syphilis. Improved public messaging about syphilis, especially to men, provision of communication skills to women and men regarding sexual health, improvement of access to quality STD services to men, as well as legal and policy frameworks that can support STD notification and treatment in resource-constrained settings are needed for effective STD control. Further studies will give rise to more effective strategies in the control of syphilis especially among pregnant women, and their male partners.