Introduction

In South Africa, an estimated 5.6 million people were living with HIV in 2011, while AIDS-related illnesses accounted for 35% of all deaths in children less than five years of age [1, 2].

Prevention of mother-to-child transmission (PMTCT) offers a unique opportunity to reduce the number of HIV-related deaths in children under five years as well as serve as an entry point to HIV care for mothers and their families, promoting maternal and family health [3]. Similar to other African countries, South Africa`s PMTCT programme focuses on; voluntary HIV testing and counselling, antiretroviral treatment or prophylaxis for the mother and infant, modified obstetric practices, and modified infant–feeding counselling [4,5]. HIV services are integrated within primary health care, TB, maternal, new born and child health enhancing a family centred approach [6]. The South African PMTCT guidelines were revised in 2010 and are currently being implemented in almost all (98%) the health facilities in South Africa [7]. Voluntary HIV testing is provided to all pregnant mothers at first antenatal care (ANC) visit, all HIV positive women who are pregnant, breast feeding or within one year post-partum are initiated on lifelong ART irrespective of CD4 cell count. Exclusive breast feeding is recommended for infants during the first six months [6].

HIV prevalence among women accessing antenatal services is still high at 29.5% with 280,000 pregnant women requiring treatment for prevention of mother-to-child transmission of HIV in 2012 [8]. Despite the progress made in improving PMTCT coverage in South Africa, a considerable number of women report late for the first antenatal care visit, are initiated on ART late and are loss to follow up upon delivery [9,10,11]. Clouse et al, 2013 reported a median gestational age at HIV testing of 26 weeks and a high rate of loss to follow up at 57% suggesting missed opportunities in the programme

It is, therefore, important to explore different ways in which PMTCT programmes could be enhanced in order to improve outcomes for women and men accessing PMTCT services in South Africa.

Considerable attention has been drawn to the potential influence of male involvement in sexual and reproductive health in Africa [12, 13]. Male involvement has the potential to bring about change because of the social power men hold in patriarchal settings. According to Theuring et al. (2009), couple testing may serve as an entry point to women utilising PMTCT services in patriarchal communities and in settings where women have limited autonomy in decision-making [14]. Men’s role in providing emotional and material support to partners including financial support, permission to access health care, monitoring drug compliance and helping out on household chores have been identified in several studies as ways to improve women’s uptake of PMTCT services [15,16,17].

However, low levels of male HIV testing (even lower in ANC) have been reported in several studies conducted in various parts of Africa despite scale up of the provision of voluntary counselling and testing (VCT) services and educational programmes. Studies conducted in Cameroon, Ivory Coast, Kenya, Tanzania, Malawi, South Africa and Burkina Faso reported low uptake of HIV testing services by men citing a number of reasons such as; fear of knowing one`s seropositive status, time constraints, fear of stigma and using the woman’s HIV status as a criteria confirming their own status (referred to as ‘proxy testing’) [14, 18]. Lack of partner support and men’s limited knowledge about the link between antenatal care and prevention of HIV, for example, often acts as a hindrance to seeking early and effective care [19, 20]. Low levels of active male participation in antenatal care and PMTCT have been reported in South Africa [20, 21]. Although there is increasing evidence that men can make a difference in maternal health, little is known about under what conditions men choose to get involved. Furthermore, little is known about the factors that influence male participation in PMTCT programmes in South Africa, from either client or services’ perspectives. Without an understanding of the barriers and enablers to male participation in PMTCT, it will be difficult to implement PMTCT services effectively. The male partner plays a role in terms of lowering a woman`s risk of acquiring HIV, prevention of unplanned pregnancies, joint decision making on HIV testing, ART treatment and infant feeding method [22,23,24]. This study aimed to explore community members’ (men and women) and healthcare workers’ perceptions of male involvement in PMTCT in order to provide insights into possible ways of increasing male partner participation in antenatal care and improve outcomes of pregnant women accessing PMTCT services.

Methods

The study was conducted in the Khayelitsha sub-district of the Western Cape Province in South Africa. Khayelitsha is representative of many poor urban areas in South Africa, with a large proportion of the population having migrated from rural areas. The population is estimated at 500,000, with the majority of inhabitants living in informal dwellings [2, 25]. Poverty, unemployment and crime as well as sexual violence in Khayelitsha are rife. Khayelitsha has a considerably high antenatal HIV prevalence estimated at 26% in 2010 [26].

Data for this study was collected using exploratory qualitative methods: focus group discussions and in-depth interviews between July and October 2010. The inclusion criteria consisted of men and women aged 18–40 years living in Khayelitsha. Men of unknown HIV status and HIV-positive women who were accessing PMTCT services at the time of the study or who had accessed/utilised the PMTCT service in the last 2 years prior to the study were eligible to participate. We did not ask if any of their children were HIV positive. Key informants involved in PMTCT service provision such as doctors, mid-wives, counsellors, non–governmental organisations and community health workers were also recruited to participate in the study.

Two focus group discussions were held with 25 men of unknown HIV status aged between 18–40 years living in Khayelitsha. The men were sampled using convenience sampling from Town Two, a neighbourhood in Khayelitsha, through a research assistant and community leader. Eligible men and women were approached at different times of the day at home, church, tavern and clinic and invited to participate in the study. The men were divided into two age categories: younger men (18–29 years) and older men (30–40 years) and discussions were held separately with each group on different days. The separation of young and old groups was to allow participants to freely express themselves [27].

One focus group discussion was held with 12 HIV-positive women, aged between 30–47 years. The women were selected purposively based on criteria of being HIV positive and were either currently accessing PMTCT services or had accessed PMTCT services not more than 2 years prior to this study.

In-depth interviews were also held with four couples with known HIV status. Key Informant interviews were held with five service providers including a nurse, midwife, doctor and two PMTCT counsellors, directly involved in PMTCT work at a clinic in Khayelitsha.

Key informant interviews with service providers were conducted and transcribed in English by the researcher and verified by two senior researchers as a form of quality check. Using semi-structured interview guide, responses were elicited from participants and tape recorded on a range of topics including: HIV testing, knowledge on MTCT, men`s role in PMTCT, experiences at antenatal clinics and infant feeding.

As this was an exploratory study of one community context, the purpose of the focus groups, couples interviews, and interviews with healthcare workers was to generate a broad description of men’s involvement in PMTCT and antenatal care, and explore what kinds of factors might enable or hinder that involvement (SI File). The number of focus groups and interviews were determined through saturation although the bar for saturation was set fairly low given the broad scope of the research objectives.

Focus group discussions were conducted in isiXhosa and transcribed verbatim into English. In-depth interviews were conducted in English and isiXhosa, transcribed verbatim by the researcher and a fieldworker, respectively. All interviews transcribed in English from isiXhosa were further verified by an experienced research assistant as a form of quality check.

Data was analysed using thematic analysis and summative content analysis [28, 29]. Transcripts were analysed using a four-step analysis as described in Dawson and Manderson, (1993). Individual transcripts were read and coded to reflect participant’s key responses. A log book was generated to group together similar/divergent topics from which themes were derived and further ideas for reflection and iterative analysis (S1 File). Results were written based on the log book and interpretation of the findings done in relation to study objectives and relevant contextual factors.

Emerging findings were reviewed by two senior researchers with extensive experience in HIV and PMTCT research in South Africa, and this particular field site. Data collected from men, women and key informants in the focus group discussions and individual and couple interviews were also triangulated to improve validity and reliability and refine the analysis. Access to data was restricted to only the researchers involved in the study and reference numbers were allocated to all FGD`s and interviews for confidentiality purposes.

Ethical approval for this study was obtained from the Research Ethics Committee of University of Cape Town and from the Provincial Department of Health of the Western Cape (REC REF: 142/2010). Participants provided written informed consent before the commencement of the study.

Results

Table 1 describes the socio-demographic characteristics of participants in the focus group discussions. All men and women in the FGDs were Xhosa-speaking residents of Khayelitsha. Three women were pregnant at the time of the discussion, while two women had their babies present during the discussion. Demographic characteristics of the participants for in-depth interviews were as follows; Of the four couples interviewed, three couples were actively involved in a support group and employed as community volunteers, and were hence knowledgeable about HIV, PMTCT, and male involvement. Three couples were in a stable relationship and one couple was married.

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Table 1.

https://doi.org/10.1371/journal.pone.0133239.t001

The main findings from the study are presented and organized into three broad themes: 1) attitudes towards male involvement and PMTCT, 2) enablers, and 3) barriers to male involvement in PMTCT.

Discussion

This study showed that both community members`(men, women) and health care providers were receptive of male involvement in PMTCT services. However, there were differences in perceptions of what constituted male involvement amongst men, women and health care providers.

Direct health worker engagement with men, disclosure of status by women and HIV testing, enhances increased male participation in maternal and child health. This finding is similar to a qualitative study conducted in Vietnam that showed that men who had tested for HIV and/or disclosed their HIV status were more supportive of partners throughout pregnancy and childbirth [30]. Men’s participation could also be shaped by the role of health workers who provide information on HIV/PMTCT and describe men’s roles in family care in ways that extend beyond meeting material needs to supporting the pregnant partner in monitoring ART compliance, infant feeding compliance, and emotional support. The role of health workers in persuading men`s uptake of PMTCT services has been documented elsewhere [31].

Men who regularly attended some sort of support group were more likely to attend antenatal clinics with partners. Peers within a support group often encouraged and motivated each other to support their partners during pregnancy and child birth. The support group’s women attend such as those run by the NGO mother2mothers, create a bond among the pregnant women accessing PMTCT. Support groups are like family and often they refer to each other as ‘comrades’ providing support to members. The role of peer to peer support has been documented in studies conducted in Uganda and Zambia [32, 33].

HIV-positive women also had weak social ties with family members but stronger social ties with members of the support group they belonged to. This finding is similar to a study conducted among HIV-positive women and men in Soweto, South Africa that showed that HIV placed a tremendous strain on familial relationships [34]. Overall, men were knowledgeable about PMTCT and the potential roles they could play in the programme. A discrepancy exists in this study, however, between what men know and consider as their roles in PMTCT and what their actions concerning their involvement depict. This discrepancy was elucidated in a study conducted in rural Uganda that cited reasons for men`s non-participation in HIV testing despite being knowledgeable such as mistrust in marriages, rude health workers, lack of motivation and convincing messages to warrant their involvement [32,35]. Men’s roles in PMTCT need to be clearly defined and appropriate programs expanded to reach out to men in all spheres of life to embrace these new roles in family care.

The findings suggest three kinds of men; men who are or would be actively involved in PMTCT, men who are not involved but could be motivated, and men who are resistant to getting involved in any kind of support for their partners (except perhaps for financial support). The men who are involved in PMTCT are more likely to have tested for HIV, are knowledgeable about HIV/AIDS, and are generally positive about their involvement in the partner’s pregnancy. Men who are not involved and uninterested were more likely to resist intervention messages and/or discussing reproductive health, HIV/AIDS or PMTCT with their partners. However, for the men in the middle, they may be less concerned about or aware of PMTCT but may not necessarily resist intervention messages. There is a possibility of them being actively involved if reached out to appropriately. Social relationships of care and decision-making are changing and men are finding themselves in situations where they are being asked to do more in the family than before [36]. The demands on men to be actively involved in family care are increasing in light of urbanization, gender equality movements, and the HIV/AIDS epidemic in South Africa [19]. Men’s roles in Africa are increasingly extending beyond the traditional roles of being the ‘bread winner’ in the family to attending antenatal care visits, making birth plans, caring for babies and monitoring ART and infant feeding options for the mother and the baby [15,20,21]. Older men in this study resisted these new care-giving roles more strongly than younger men claiming it would make them lose respect from their peers. In contrast, Ditekemena et al reported that men who were older and in monogamous relationships were more likely to embrace the care-giving roles accrued to them [37].

Conclusion

Support groups and direct health worker engagement with men increases male involvement in PMTCT services. Using men in the media and community to reach out to fellow men with prevention messages tailored to suit specific audiences may reduce perceptions of antenatal care as being a woman`s domain. Promote the benefits of male participation in the media using couples as flag bearers of PMTCT information to encourage family-centred care.

Limitations of the study

This study explored perceptions of community members’ (men and women) and healthcare workers on male involvement in ANC and PMTCT services that provided an opportunity to compare different views and opinions from participants. The views and opinions expressed in this study may not be generalised nationally, although useful insights can be drawn from it to improve existing PMTCT interventions. The study used a Xhosa-speaking facilitator enabling participants to express themselves candidly though translating the interviews into English may have affected the originality of the field data collected and limited the researcher`s ability to probe.

Supporting Information

Acknowledgments

The authors are greatly indebted to the study participants for their participation in this study and would also like to thank Lihle Lekker and Gladwell Nganga for the tireless efforts invested in data collection, transcription of field interviews and proof reading sections of this work respectively.