Introduction
Prevention of mother to child transmission (PMTCT) of Human Immunodeficiency virus (HIV) infection should be prioritized in sub-Saharan Africa [
1]. Barriers hindering uniform implementation of this highly successful prevention strategy need to be identified and addressed. According to the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Children’s Fund (UNICEF) an estimated 390,000 infants contracted HIV during the perinatal and breastfeeding period in 2010 [
1]. Nearly all these infections, in principle, should have been prevented. The most common route of transmission for these infants is transmission from mother to child (MTCT) which occurs in up to 90% of cases [
1]. In sub-Saharan Africa, women comprise more than half the number of people living with HIV and the majority of these HIV positive women were infected by their stable partners [
2‐
8]. Since husbands play a pivotal role in decision-making within the home, and are often the main bread winners, establishing their buy-in and support for PMTCT activities and interventions is critical [
9‐
14]. A husband’s role is a likely determinant for the successful implementation of PMTCT guidelines/standards in Sub-Saharan Africa [
15,
16].
Male participation in child-bearing decisions is crucial and also has a positive impact on the acceptability of PMTCT interventions [
17‐
24]. Providing suitable medical information to men has several important consequences related to PMTCT interventions [
18]. First, well-informed men will be more likely to participate positively in the decision making for the well-being of the couple [
25,
26]. Second, women with supportive partners will be more motivated to undergo HIV testing, to return for the HIV test result and to disclose the HIV result to their partner [
19,
23]. Third, well-informed couples may be more likely to adopt a low risk behavior and increase mutual support, regardless of the test result [
27‐
29]. Studies have shown that in countries with high HIV prevalence there is also a high incidence of HIV infection in women during pregnancy or in the post-partum period. Indeed in this period women are particularly vulnerable to become HIV infected [
30‐
32]. Therefore it is very important that partners of pregnant women are also tested for HIV and that antiretroviral treatment is considered if they are found to be HIV infected [
30‐
41]. Fourth, decisions regarding the choice of a family planning method as well as the newborn feeding method can be made together [
14]. Finally, if an HIV positive mother is pregnant and eligible for Antiretroviral Treatment (ART), she should start treatment as soon as possible. If she is not eligible for ART, antiretroviral (ARV) prophylaxis needs to be initiated as early as 14 weeks of gestational age [
15,
16]. Thus male involvement is very likely to lead to better adoption of HIV prevention practices by a well-informed couple [
30‐
41].
There is also a strong inverse relationship between low male participation in PMTCT services and high MTCT risk in exposed infants. A study conducted in Nairobi/Kenya between 1999 and 2005 found that MTCT risk in exposed children was significantly associated with low male participation in Maternal and Child Health (MCH) services. In women whose male partners had come to the antenatal care (ANC) clinic, there was less MTCT compared with women whose partners did not take part in the PMTCT interventions (aHR =0.52; 95% CI: 0.32 - 0.84; p=0.008) [
17]. Male involvement in PMTCT improves ARV prophylaxis uptake, adherence and promotes compliance for family planning, and optimal infant nutrition [
5,
21,
22].
The objective of this paper is to review the literature about determinants of male partners’ involvement in MCH activities, with a focus on PMTCT services in low-income countries, specifically sub-Saharan Africa.
Methods
Participants, interventions and outcome
Participants in this review were male partners of pregnant women attending antenatal and under five clinics. The male partner may be the baby’s father or not. Our research focused on interventions tailored to have an impact on PMTCT, HIV counseling, couple counseling, reproductive health education, family planning and safe delivery. The outcome of this review was male involvement in these interventions.
Search strategy
The following electronic data bases were used to identify the articles: Pub med/MEDLINE; CINAHL; EMBASE; Cochrane Library and Psych INFO. We limited our search strategy to articles published between January 1990 and October 2011. The websites of the International AIDS Society (IAS), the International AIDS Conference and the International Conference on AIDS in Africa (ICASA) 2011, WHO, UNICEF and UNFPA were used to find relevant abstracts and documents.
Search terms consisted of the following key words: “HIV testing”; “prevention”; “mother”; “child”; “male partner *”; “counseling”; “involvement”; “participation”, sub-Saharan Africa”. And the grouped terms“ PMTCT and partners”; “VCT and acceptability in PMTCT”; “barriers and/or factors”;“ Male involvement in PMTCT”; “Male involvement in reproductive health”.
Screening and papers selection criteria
The first screening round of publications was carried out based on the titles. The second screening round of the remaining papers was conducted using the abstracts. In the final round, the remaining publications were assessed using the full texts.
-
The following criteria were used to exclude ineligible papers:
-
studies not addressing the issue of determinants of male involvement in PMTCT;
-
studies not conducted in sub- Saharan Africa;
-
published in languages other than English;
-
comments, debates, reviews, personnel opinions;
-
theses and dissertations;
-
reports of activity implementations;
-
studies published before 1990;
-
papers related to the tools/instrument developments;
Data was extracted from the full texts and abstracts. The extracted information consisted of: authors, year of publication, research question, study settings, purpose and study objectives; study design, study population, participants number, participants type, interventions type, study outcomes, study results, male participation barriers, male participation factors, male participation definitions, study timeline and study limitations.
Discussion
This review showed that different definitions of male involvement in PMTCT are used in different studies resulting in difficulties when comparing data between these studies. Determining a consensus definition of male involvement may be a necessary first step to measure efficacy and enhance comparability across programs [
16]. In most of the studies we reviewed male involvement was considered as male participation in HIV testing during ANC. Other studies considered male involvement as male participation in HIV couple counseling.
Some authors classify MIP in two categories: “positive MIP” and “negative MIP” [
19,
39‐
42]. “Positive MIP” increases the engagement of women in PMTCT activities [
19,
36‐
40]. Positive MIP includes discussing HIV testing with the partner, being supportive regardless of the HIV result, participation in couple counseling and willingness to accompany the pregnant women to the ANC [
18,
19,
30,
31]. “Negative MIP” includes violence towards the partner, not discussing HIV testing with the partner and even prohibiting the partner to be HIV tested [
19,
39‐
42].
Byamugisha et al. scored male involvement using 6 variables: the male partner accompanying his wife during ANC services; knowing the ANC schedule; discussing the ANC interventions with the female partner; supporting the ANC fees; knowing what happens at the ANC; and using a condom with the female partner during the current pregnancy. Scores between 0–3 were considered weak male involvement and scores of 4 and above were considered as high male involvement. While this scoring system is a useful first step, it remains to be validated [
11].
We speculate that adoption of a uniform definition of MIP and further studies specifically focused on metrics assessing male involvement in PMTCT services will be useful tools for monitoring and evaluation of HIV and MCH-related programs and research.
Most studies reported that older age, cohabiting and monogamy were associated with male involvement [
8,
10‐
13,
42‐
44]. An explanation for this could be that older men may have a higher risk perception and that cohabiting men and women may have more time to harmonize their time schedules and to communicate. It is unclear why polygamous men in Cameroon were more likely to be involved in MCH services [
13]. A possible explanation is that such men by virtue of having more than one partner are invited more frequently to the health facility. An alternative explanation could be that they are more financially secure, and thus more able and willing to pay for and wait with their partners to receive MCH services.
Many explanations for provider harshness and lack of respectful care to patients have been suggested. These include provider low salaries, lack of a functioning health infrastructure and a critical shortage of health care providers [
11]. While these are certainly realities working in sub-Saharan Africa, it is clear that further training in nursing, midwifery and medical schools on the principles of family-centered care, combined with improved customer care communications are urgently needed.
When there is limited physical space to accommodate male partners, providers will have difficulties incorporating male partners [
11]. This situation is worsened when health care workers are understaffed, underpaid and overworked.
Given that the staffing and financial situations in many health care systems in sub-Saharan Africa are unlikely to improve overnight, alternative models of care, targeted at men, are imperative if men are to participate in MCH activities. These may include the following: implementation of systems improvement strategies to improve patient attendance and flow through the health system; use of an appointment system and/or letter of invitation by the health provider; broadening services to the evenings and weekends; and consideration of multiple venues not traditionally associated with health care provision such as bars, bus stops and churches [
10,
47,
48]. Access to health services for male partners should be prioritized [
56]. In addition, in order to maximize the PMTCT uptake, a family centered approach is important since others members of mother‘s family such as mother’s father, brother, brothers and others male friends also may have an impact on the PMTCT uptake. Actions should be taken as well to involve those peoples [
57‐
61].
Limitations of this review
Many of the studies were conducted in countries with a different cultural context and used different study designs. We speculate that a harmonized international study regarding the MIP would be more comprehensive and generalizable across countries.
Conclusion
There are many challenges to increase male involvement/participation in MCH and PMTCT services. So far very few interventions addressing these challenges have been evaluated scientifically. Capacity reinforcement of health providers through training and adequate salary support is needed. Improving accessibility, affordability, availability, accommodation and acceptability (5 A’s) of ANC service venues will make them more attractive for male partners. Additionally, health education campaigns to improve beliefs and attitudes of men are absolutely needed.
Competing interests
All the authors declare that they have no competing interests.
Authors’ contributions
JD, OK, CE, RM, AT, RR and RC had significant intellectual contribution and input in the conception and design of this review, draft writing, and final approval of the manuscript. All authors read and approved the final manuscript.