The role of men as partners and fathers in the prevention of mother-to-child transmission of HIV and in the promotion of sexual and reproductive health

Abstract

Abstract

Despite ample evidence documenting the positive impact of men on the prevention of mother-to-child transmission (PMTCT) and other sexual and reproductive health programs, men’s engagement remains very low. This paper examines the current level and nature of male involvement and identifies opportunities for the advancement of men’s constructive engagement in PMTCT and sexual and reproductive health. Conceptual and policy barriers have encouraged the inadvertent exclusion of men from PMTCT and other reproductive health services. The historic institutionalization of reproductive health as women’s health has generally resulted in health services that are not welcoming of men and has undermined efforts to engage couples. This paper argues that to maximize the health outcomes of PMTCT and sexual and reproductive health programs for women and men, we must move beyond seeing men as simply “facilitating factors” that enable women to access health-care services. Men need to instead be recognized as a constituent part of reproductive health policy and practice. The paper proposes strategies for policy makers and program leaders to engage men and couples to foster communication and shared decision-making. This approach can both help to achieve health goals and engender more equitable relationships between men and women.

Résumé

En dépit de nombreuses données documentant l’impact positif qu’ont les hommes sur la prévention de la transmission mère-enfant (PTME) et d’autres programmes de santé sexuelle et génésique, leur engagement demeure très faible. Cet article examine le niveau actuel et la nature de la participation masculine, et identifie les possibilités de faire avancer l’engagement constructif des hommes dans la PTME et la santé génésique. Des obstacles conceptuels et politiques ont encouragé l’exclusion involontaire des hommes de la PTME et d’autres services de santé génésique. L’institutionnalisation historique de la santé génésique comme santé de la femme a généralement abouti à des services de santé peu accueillants pour les hommes et a miné les efforts pour y associer les couples. L’article avance que pour maximiser les résultats sanitaires de la PTME et des programmes de santé sexuelle et génésique pour les femmes et les hommes, nous ne devons plus voir les hommes comme de simples « facilitateurs » qui permettent aux femmes d’avoir accès aux services de santé. Les hommes doivent plutôt être reconnus comme partie prenante de la politique et la pratique de santé génésique. L’article propose des stratégies pour les décideurs et les directeurs de programmes afin d’inciter les hommes et les couples à favoriser la communication et la prise de décision partagée. Cette approche peut aider à atteindre les objectifs de santé et engendrer des relations plus équitables entre hommes et femmes.

Resumen

A pesar de existir abundancia evidencia que documenta el impacto positivo de los hombres en la prevención de la transmisión materno-infantil (PTMI) y en otros programas de salud sexual y reproductiva, la participación de los hombres continúa siendo muy baja. En este artículo se examina el nivel actual y la naturaleza de la participación de los hombres y se identifican oportunidades para promover su participación constructiva en los programas de PTMI y de salud sexual y reproductiva. Las barreras conceptuales y políticas han fomentado la exclusión involuntaria de los hombres de los servicios de PTMI y otros servicios de salud reproductiva. La histórica institucionalización de la salud reproductiva como salud de la mujer generalmente ha producido servicios de salud que no acogen a los hombres y ha socavado los esfuerzos por motivar la participación de parejas. Se argumenta que para maximizar los resultados de salud de los programas de PTMI y de salud sexual y reproductiva para mujeres y hombres, debemos ir más allá de ver a los hombres simplemente como “factores facilitadores” que les permiten a las mujeres obtener servicios de salud. Al contrario, debemos reconocer a los hombres como una parte constituyente de las políticas y prácticas de salud reproductiva. En este artículo se proponen estrategias para que formuladores de políticas y líderes de programas puedan motivar la participación de hombres y parejas para fomentar comunicación y compartir la responsabilidad de tomar decisiones. Este enfoque puede ayudar a lograr los objetivos de salud y a engendrar relaciones más equitativas entre hombres y mujeres.

Key Words:

• prevention of mother-to-child transmission of HIV
• gender relations
• engaging men in sexual and reproductive health

Much of the published research on the sexual and reproductive health and rights of HIV-positive people focuses on the reproductive intentions of HIV-positive women. What about the men who are their partners and potentially the fathers of their children, who also need to consider their own reproductive futures and the role they can play in decisions about having children or not? In the context of sub-Saharan Africa, in particular, we are concerned that despite overwhelmingly positive attitudes toward the prevention of mother-to-child transmission of HIV (PMTCT) among men, their engagement in PMTCT efforts remains very low.

What stops men from being more involved? Many men are afraid of finding out their HIV status, and also fear the stigma and discrimination of a positive diagnosis. But perhaps the most significant obstacles are the conceptual and policy barriers that inadvertently result in the exclusion of men from PMTCT and other sexual and reproductive health services. The historic institutionalization of reproductive health, and particularly maternal health, as a women-only realm has yielded health services that are not welcoming of men or indeed couples, contributing to men’s perception of clinic spaces as “women’s spaces” and reproductive health as “women’s health.” We argue that to maximize the health outcomes of sexual and reproductive health services and PMTCT for children, women and men alike, we must move beyond the currently popular view of men as one of the “facilitating factors” enabling women to access health care services. Men must instead be viewed as a constituent part of reproductive health policy and practice for their own sake too.

Studies documenting men’s lack of involvement have fuelled an often unspoken notion of men as obstacles to health, or as irrelevant. Yet a growing body of evidence indicates that there can be many benefits to the health of families when men critically examine norms of power, acquire new knowledge and skills, challenge prevailing gender ideologies and become actively involved in learning about and addressing health issues.^1–6 Efforts to involve men in the promotion of their own, women’s and their family’s health not only enable men and women to share responsibility for family health (currently borne disproportionately by women), but also help to lay the groundwork for sustainable change – through example – regarding social expectations about men’s participation in family and community health. If we are truly interested in creating a broad-based global response to HIV, supporting women and eliminating pediatric HIV infection, we cannot exclude half of the population. We must rally men to the cause, in policy circles and communities, and demonstrate the benefits of gender equality, shared decision-making, partnership and non-violence.

The following points support this recommendation:

•	Men’s involvement plays a role in HIV prevention by helping to facilitate couple communication related to sexuality. First, partner participation increases spousal communication about HIV and sexual risk.7 This becomes especially critical in HIV-discordant relationships. In these situations, men’s involvement in testing may encourage the couple to address condom use and decrease sex with outside partners, thus helping to prevent the transmission of HIV and other sexually transmitted infections to partners and offspring.8,9 Second, studies have also shown an association between men’s involvement and contraceptive use.10–12 For example, a study examining the uptake of family planning among HIV-infected men and women found lower rates of contraceptive usage among women in couples where fertility intentions and HIV status were not discussed.12 Finally, men as supportive partners can influence family dynamics, especially among extended family members, to create a social environment that is more conducive to contraceptive use; reproductive choice, including abortion; seeking HIV treatment; being adherent to medications and clinic appointments; and remaining in care during pregnancy and after delivery, termination or loss.
•	A variety of benefits are derived from couple HIV counseling and testing. In one study in Kenya, seropositive women who attended voluntary counseling and testing with their spouses were three times more likely to report adhering to their treatment regimen during pregnancy and delivery than those who were counseled individually. They were also five times more likely to report adhering to prescribed breastfeeding protocols.13 In another study, the odds of a woman having a record of facility-based delivery were 28% higher for women counseled and tested with their partners than for women who were counseled and tested alone.14 In addition to giving a woman access to clinical interventions and strategies that can reduce her risk of death, health facility-based delivery helps promote compliance to infant antiretroviral dosing and other measures that can be taken during the intrapartum period to reduce mother-to-child transmission of HIV. Women tested with their partners also were less likely to be lost to follow-up than those tested alone.14 When couples received pre-or post-test counseling together, greater use of alternative feeding methods13 and greater acceptance of HIV testing15 were observed among women. Couple counseling enables communication and cooperation required for shared decision-making regarding risk reduction, care and treatment, including PMTCT, ultimately benefitting the health of women, men and children.
•	An association exists between partner disclosure and HIV prevention. There is surprisingly little recent literature on the preventive effects of HIV disclosure by heterosexual men to their female partners, beyond the associated positive outcomes relating to personal stress and social adjustment.16 There is more literature on the connection between women’s HIV disclosure to male partners and HIV prevention. Women who disclosed their HIV status to their male partners were more likely to return for post-test counseling, accept antiretroviral prophylaxis, modify infant feeding practices and increase condom use in the postpartum period than those who did not.13,15,17,18 In multivariate analysis, it was found that women who had disclosed their HIV status and who reported less HIV-related discrimination were more likely to adhere to antiretroviral prophylaxis for PMTCT. Similarly, women whose male partners were involved in antenatal care were more likely to adhere to both the maternal and infant nevirapine doses in a PMTCT protocol.19 This is not to say that disclosure is unproblematic; women’s fears of abandonment, violence and accusations of being carriers of infection remain significant barriers to disclosure. However, in one study conducted in Uganda, HIV-positive women generally experienced positive responses by their partners to their disclosure.20 Another study with high disclosure rates showed that disclosure was rarely accompanied by negative reactions on the part of partners.21 Even so, the Ugandan study emphasizes that disclosure remains extremely difficult for women. The authors highlighted the need to strengthen support services for both HIV-positive and HIV-negative women to maximize opportunities for HIV prevention.20
•	Men’s involvement positively impacts infant feeding practices and survival. When men knew that their spouses were HIV-positive and involved in a PMTCT program, they played an active role in implementing advice received from health professionals, particularly related to exclusive breastfeeding and early weaning.22 The greatest impact of partner participation in one study in Tanzania was on infant feeding practices.23 In this study, 64% of exclusively breastfeeding women with participating partners successfully avoided mixed feeding and stopped breastfeeding at four to six months, while only 28% of exclusively breastfeeding women who did not have partner participation were able to achieve these outcomes. Among study participants who instead chose formula feeding, 80% of women with participating partners adhered to the formula feeding protocol, compared to 29% of women who did not have partner participation. A study in Kenya found that including men in antenatal PMTCT with HIV testing had an impact on infant health outcomes.24 The authors found that after adjusting for maternal viral load and breastfeeding, the combined risk of HIV acquisition and infant mortality was lower with male attendance and self-report of prior male HIV testing.

Men can be involved in the promotion of sexual and reproductive health in a variety of ways: as supporters of their partners, encouraging and enabling women’s utilization of and access to services; as clients of health services, to help ensure their own reproductive health and that of their partners; and as change agents in their communities, challenging restrictive gender norms that hinder service utilization, family health and women’s equality.²⁵ As mentioned, however, there is a contradiction between men’s positive attitudes and their low participation rates in PMTCT and other sexual and reproductive health programs. The nature of their participation is also unclear. Do men participate because of outreach efforts conducted by HIV programs and other sexual and reproductive health programs? Or is it that the men who participate are the ones who already feel a sense of commitment and have good communication with their partners?

Studies seem to support the latter conclusion. Bakari et al²⁶ found that for Zambian couples, the pre-existing level of communication around sexual and reproductive health issues influenced the acceptability of prenatal HIV counseling and testing. In a Tanzanian study, women were less likely to collect their HIV test results if they had never discussed reproductive health matters with their partners.¹⁸ A Kenyan study concluded that greater commitment to a female partner increases a man’s motivation to participate in voluntary HIV counseling and testing and in antenatal care, and that having discussed HIV in the past may motivate or simplify HIV test-seeking.²⁷ In another Kenyan study, both men and women thought that good and open communication would support them in seeking routine HIV testing, discussing the challenges of living with HIV and being more supportive of their HIV-infected partners.²⁸

So if good communication among men and women is important, why do we know so little about couples and their relationships in the context of HIV? If public health institutions and the cultures in which they operate have conspired unwittingly to sustain a paradigm that associates sexual and reproductive health with women, and have inadvertently excluded men, so too have couples been excluded. When couples have been considered, it is still primarily with a focus on the proximate determinants of pediatric HIV infection in mind, i.e. men as supportive partners, helping women to adhere to prevention and treatment guidelines to eliminate pediatric HIV. What is missing is a consideration of the nature and quality of relationships between men and women, including the “entanglement between sexual behavior and affective relations.”²⁹ The impact of these nuanced relationships on a constellation of reproductive health outcomes must be considered. Researchers have begun to note the paucity of literature on relationships and the need for more information to strengthen public health programming for couples. This includes couple communication on sexual risk; the evolution of preventive behaviors over time; and gender issues including with respect to negotiation and violence.²¹

Most HIV infections in sub-Saharan Africa occur in stable relationships, either due to one of the partners being infected previously or because of infidelity.^30–32 Thus, the lack of focus on couples on the part of health professionals reveals not only the bias of equating reproductive health with women’s health, but also a failure to recognize the significance of HIV serodiscordancy. Data from large-scale surveys in Burkina Faso, Cameroon, Ghana, Kenya and Tanzania show that at least two-thirds of couples in each country with at least one HIV-positive partner were HIV-serodiscordant.²¹

There is also a lack of awareness on the part of the public that serodiscordancy is possible, let alone common. For example, the literature review conducted for this article revealed that men sometimes did not seek HIV testing and counseling because they knew their partners’ HIV status and assumed that their own HIV status would be the same.³³ It follows that if both partners believe they have the same HIV serostatus, it will not seem logical to adopt practices to prevent HIV transmission during sexual intercourse.²¹

Moreover, condom use remains low in “committed” relationships.^34,35 Condom use in many contexts in sub-Saharan Africa is associated with casual partners, infidelity and distrust.^36,37 This makes it difficult for both women and men^37,38 to suggest or adopt preventive behaviors with their regular partners unless those behaviors are proposed as contraception. Low levels of condom use in populations with high levels of serodiscordancy may result in many opportunities for sexual transmission of HIV, as well as risking subsequent perinatal HIV infection.

Condom use is higher among couples who engage in a dialogue on sexual risks.^39,40 However, the quality of relationships, as reported by research respondents, may in fact be quite poor. According to Larsson et al,⁴¹ Ugandan men thought their relationships were fundamentally unstable and marked by mistrust between partners:

“Extramarital affairs were common, especially among men. Extramarital affairs were in general tacitly accepted within a marriage, and rarely discussed between spouses. However, the ever-present suspicion that one’s partner would be unfaithful created a pervasive atmosphere of mistrust between husbands and wives.”

Not surprisingly, men in the study found the idea of couple testing at PMTCT sites unappealing because of the conflicts that this could generate in their relationships.

These insights about individuals’ perceptions of the nature and quality of their relationships are suggestive, and perhaps explain why, despite the positive outcomes of couple HIV testing and counseling programs, the promotion and acceptability of these services remains low.²¹ Couple HIV testing and counseling appears to be a great idea, but it may spur conversations and bring up issues that partners are unwilling or do not have the skills or power to successfully address.

Couples represent a wonderful but as yet unrealized opportunity to promote sexual, reproductive and family health within the context of integrated services. The HIV Prevention Trials Network (HPTN) 052 study outcome makes it all the more imperative to learn more about the quality of relationships between men and women. HPTN 052 showed that early initiation of antiretroviral therapy for the HIV-positive partner in a serodiscordant couple could reduce the risk of HIV transmission to the uninfected partner by 96%.⁴² The finding highlights the significance of scaling up efforts to educate the public about the importance of knowing one’s HIV status. HPTN 052 also calls attention to the need to involve men as an integral part of reproductive health policy and practice; identify serodiscordant couples through improved partner and couples HIV testing and counseling programs; and link individuals diagnosed as HIV-positive to HIV care and treatment services.

The key challenge is to overcome the conceptual and policy barriers that support the exclusive association between reproductive health services and women’s health services. Programs must move to not only involve men as constituent stakeholders, but also to find effective facility-and community-based modalities to foster communication among couples to increase the likelihood that they will utilize a range of sexual and reproductive health services to prevent pediatric HIV, promote maternal health and improve the well-being of the entire family. Issues of power must be addressed if we are to end the silence regarding men’s reproductive lives and the resulting non-involvement of men and couples. But how do we alter these power dynamics to bring about men’s participation as a critical part of reproductive health?

One way is through policy. Policy makers are in a position of power to bring about systemic change – from challenging conceptual barriers with global implications to addressing national and subnational policy development and implementation with direct, local-level effects. On the international stage, restrictive demographic thinking, with its often mechanistic and reductive focus on proximate determinants, has supported the logic of men’s exclusion in reproductive health settings. By replacing this paradigm with a health and human rights approach that acknowledges the social reality of families, decision-makers are in a unique position to advocate for policies that reflect the dynamics of HIV infection in communities.

In this process, it is important to learn from successful male involvement programs in the governmental and non-governmental sectors and create pathways for their expansion through policies that are integrated within a country’s existing gender equality and health policies.⁴³ It is essential that a broader vision of gender equality – one inclusive of male involvement – is mainstreamed into national HIV frameworks for action, with the accompaniment of implementation guidance and support. An important step would be to advance policy initiatives that incentivize men’s participation in services and promote joint responsibility for testing and mutual disclosure, encouraging unwilling partners to test. Normalizing men’s involvement to the extent that all men were expected to participate would also eliminate barriers such as men’s perception that reproductive health exclusively concerns women or men’s concern about how other men will perceive them. The Rwandan government has recognized this and has tried to institutionalize its efforts by incentivizing local health directors’ participation in promoting men’s involvement in PMTCT by making this a criterion of their job performance.⁴⁴ Perhaps the same kind of incentives could be used to encourage men’s participation in antenatal care, including birth-preparedness planning and the promotion of facility-based deliveries.

Programmatically, PMTCT and other sexual and reproductive health service providers must think through the implementation implications of a broader policy vision of gender equality that is inclusive of male involvement in achieving desired health outcomes. Program designers and practitioners must consider how to intentionally and thoughtfully involve both women and men in the services they offer (simultaneously or sequentially), address the specific health needs and concerns of men, and create opportunities for men and women to engage one another in dialogue about sex, their relationships and equity.⁴⁵ This should be done not only in traditional reproductive health settings but also at facility-and community-based sites that men are more likely to visit, including sexually transmitted infection clinics, tuberculosis clinics and workplace programs, and men’s participation in these programs should be encouraged. Despite the location of the service site, all of this must be done under a programmatic umbrella that is explicit about its goal to challenge power dynamics and transform societal gender norms. Facility-and community-based health settings are wonderful places to model the kind of shared decision-making among couples that can help to address imbalances in power, promote equitable relationships in diverse settings and lead to more sustainable social change.