Male partners’ involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: A systematic review

Figures & data

Fig. 1. Procedures used for the selection of articles for the systematic review.

Fig. 2. Factors influencing man involvement in PMTCT.

Table 1. Selected quantitative studies and components.

Study authors and country	Study aim	Study design	Population of interest	Age	Recruitment	Data collection	Role	Barriers	Enables
(Brou et al. 2007) Ivory Coast	To investigate among women tested for HIV within PMTCT the key moments for disclosure of their own HIV status to their partner and the impact on partner HIV testing	Cohort	184 (19.6%) partners were tested for HIV		ANC	Individual questionnaire and HIV testing	Not stated	Not stated	Partners of HIV-positive women, were more likely to be tested if they were educated (46.3% versus 16.7% Informed of their wife's HIV infection (37.7% versus 10.5%) Living in a monogamous couple (27.6% versus 6.7%), had previous HIV testing experience (100% versus 22%)
(Byamugisha et al. 2010) Uganda	To determine the level of participation of male partners in PMTCT	Mixed	388 men	32 years 199 (51%) were in the 25–34 age	ANC	Individual interviews Use ad hoc male involvement index from 0 to 6	Stated in the qualitative components	Knowledge: men with fear of disclosure of their HIV sero-status results to their spouses (OR: 0.4, 95% CI: 0.2–0.8), and men who were drivers had less male involvement index	Higher education (OR: 1.9, 95% CI: 1.1–3.3; knowing wife HIV sero-status and having heard about PMTCT
(Conkling et al. 2010) Rwanda and Zambia	To explore the feasibility of establishing CVCT at ANC	Prospective cohort	1940 women 956(49%) male partners in CVCT; Lusaka: 1685 women 663(39% ) in CVCT	Not identified	ANC	Individual interview.	Not stated	Not stated	CVCT offered on weekends was feasible
(Harms et al. 2005) Uganda, Tanzania	To analyze the status of awareness and knowledge about HIV MTCT and preventive measures of transmission in different population groups and health staff	Cross-sectional	Uganda 440 clients of ANC and outpatient clinics 239 villagers Tanzania 574 persons: 410 clients of ANC and outpatient clinics, 93 villagers	Not identified	ANC and rural and urban villages	Individual interviews Open-ended and closed questions	Not stated	Health systems: lack of HIV/AIDS treatment	Not identified
(Katz et al. 2009) Kenya	To describe male attitudes toward antenatal VCT and correlate with accompanying female partner	Prospective cohort	1993 women come with (16%) 313 of their partners	19–53 yrs	ANC	Individual interviews	Not stated	Not identified	Monogamous Married (>99%), Employed (98%), Monogamous marriages (97%) and lived with their partners (98%), and more than half (55%) had at least one living child
(Kiarie et al. 2006) Kenya	To determine the prevalence of life-time domestic violence before HIV-1 testing and its impact on the uptake of (PMTCT)	Prospective cohort	2231 (71%) women counseled; 313 (10%) came with partners 301 men (96%) accepted HIV-1 testing	Not identified	ANC	Individual Interviews.	Not Stated	Violence Barriers: Partners post-secondary education; Formal marriage; House rent above US$20 per month	Violence enablers : Polygamous marriage; House with more than three people
(Koo et al. 2013b) South Africa	To examine factors associated with men testing during pregnancy and to elicit men's and women's appropriate ANC/PMTCT invitation card	Cross-sectional	124 men	25–60 (33.9) yrs	ANC	Individual interviews	Not stated	Communication partners	P < .05 Discussed HIV if married to her (52.6% vs. 23.3%, and described his relationship as ‘exclusive’ (96.5% vs. 83.7) Knowing women's HIV status; Prior discussion of testing in PMTCT, knowing the female partner had tested Disclosure of her test result Would accept partner's invitation; Male testing is important
(Mulongo et al. 2010) DR of Congo	To analyze couples’ attitudes toward HIV testing after prenatal HIV testing offered to pregnant women and analyze the males’ behavior with regard to their own HIV testing	Cross-sectional	143 male partners	30 yrs (SD, 5.9)	ANC	Individual interviews	Not stated	Lack of time Fear of HIV positive results Knowledge: HIV sero-status equal to their wives	Not stated
(Msuya et al. 2008) Tanzania	To test whether the high rate of intention to notify partners (90%) translated into actual male partner HCT	Prospective cohort study	A total of 332 (12.5%) male partners came		ANC	Individual interviews	Not identified	Not identified	Older age (trend p .005); married or cohabiting (p .001); 30 USD/month (p .001) and collected their own HIV/STI test results (p .001)
(Nkuoh et al. 2010) Cameroon	To present the barriers to men participating in HIV testing and ANC with their wives	Cross-sectional	252 men	18–60 yrs.	House to house and farm to farm	KAP Questionnaire	To pay ANC/delivery fees; Financial Support; Support in pregnancy; Assistance in cooking and caring	Knowledge: Lack of sickness; Faithful; knowledge of their wives sero-status; Fear of HIV results; lack of time, and money; Where to test Cultural beliefs and gender roles: Pregnancy is a woman's affair; not good; Shameful; Not their custom; community does not think it is normal; if man goes to ANC no one to care for the house	Younger age; Community receptiveness; Free HIV testing. More education on HIV/AIDS
(Semrau et al. 2005) Zambia	To test woman's acceptance of HIV testing and compliance with NVP in a PMTCT program influenced by VCT/CVCT	Prospective cohort	Nine percent (868) of 9409 women were couple counseled 798 (92%) of the men accepted HIV testing	Not identified	ANC HIV testing was promoted by community and male outreach workers at men venues Churchs; Workplaces; Taverns, Sports; Saturday clinics	Individual interviews	Not stated	Not stated	Not stated
(Theuring et al. 2009) Tanzania	To fill the gap on male research and learn men's perspective on improving male participation at ANC	Mixed	124 men	22–59 yrs	Agricultural exhibition and community event	Individual interviews	Stated in qualitative components	Knowledge: Unclear concept father Involvement; Cultural beliefs and gender roles: ANC /PMTCT not for men ANC for women and children; Fear of HIV testing and results; Work conflicts Health Systems: Waiting time Wait outside; Why being called to ANC	CVCT; kind reception; Politeness; Value of the services
(Tweheyo et al. 2010) Uganda	To investigate the level, perceived benefits and factors associated with male partner Attendance of skilled ANC in a peri-urban community recovering from two decades of civil conflict	Cross-sectional	331 married men	31.9 [SD 8.2]	Community	Individual interviews using semi-structured questionnaire		Male partners intending their spouse to carry another pregnancy (adj. PRR 0.83; 95% CI 0.71, 0.97) Health systems: Living more than 5 km from a health facility (adj. PRR 0.83, 95% CI 0.70, 0.98) Long waiting time (41.7%), lack of, transport means (35.8%), Fear of being tested for HIV (29.7%). Non-invitation, Cultural beliefs and gender roles: No importance to their attendance Work: having a concurrent task or job demand	Knowledge of 3 or more ANC services (adj. PRR 2.77; 95% CI 2.24, 3.42), obtaining health information from facility health workers (adj. PRR 1.14; 95%CI 1.01, 1.29) and if spouse had skilled attendance at last childbirth (adj. PRR 1.31; 95% CI 1.04–1.64)

KAP, knowledge, attitudes and practices; NVP, nevirapine; RPR, rapid plasma reagin (rapid test for syphilis).

Table 2. Selected qualitative studies and components.

Study authors and country	Study aim	Study design	Population of interest	Age	Recruitment	Data collection	Role	Barriers	Enablers
(Aarnio et al. 2009) Malawi AB	Was to explore married men's perceptions of HIV in pregnancy and male involvement in antenatal HIV testing and counseling	Qualitative	Not stated	Not stated	ANC	11FGD	Men perceived husbands’ role as participation in the process indirectly through spousal communication; being faithful during pregnancy; supporting the wife if found HIV+	Cultural beliefs and gender roles: Men feel problematic to attend female-oriented care at ANC/PMTCT Knowledge: Men are mostly unaware of availability of ANC HIV testing and counseling; Reluctance to learn their HIV status Fear of the threat HIV can pose to marriage	Inclusion of men on ANC/PMTCT; Refocusing information on ANC/PMTCT to men to avoid negative social outcomes
(Auvinen et al. 2013) Zambia AB	Was to describe the views of Luba-Kasai (a Congolese tribe) men on barriers inhibiting them from the prevention of mother-to-child transmission (PMTCT) of HIV and the resources they need to implement such prevention in Lusaka, Zambia	Qualitative	21 men	Not stated	Not stated	Individual interviews	Not stated	Social economics: poverty, refugee status, absence of support arrangements Health systems: Working culture in antenatal care Knowledge: Passivity, ignorance Stigma	Not stated
(Byamugisha et al. 2010) Uganda	The aim of FGD and in-depth interviews was to explore and obtain information about the factors hindering male involvement in PMTCT and its influence	Mixed	76 men 6 men declined 24 men absent		AIDS Support Groups	FGD	Ensure family subsistence; Struggle to look for money for families	Cultural beliefs and gender roles Negative attitude to men's presence at ANC/PMTCT; perceived to be weaklings by peers; Is not good to share privacy at ANC Work and economic difficulties: Men did not have time to attend ANC with their partners; do not have enough money for transport for two people Health systems: Rudeness and rough handling of the pregnant women by the health workers; harshness and abusive manners to pregnant women; Health workers do not allow men to enter the antenatal clinics with their pregnant women; Charging of unofficial user fees; Lack of adequate space in the antenatal clinics. Long distances from communities	Refresher courses and customer care skills for health care providers; Friendly nurses and midwives; at ANC sensitization of men about ANC and PMTCT, and their benefits; Written invitation to men; Mobilization of men for ANC/PMTCT using such as fellow male peers, churches and mosques; Provision of better wages to health workers
(Chinkonde et al. 2009) Malawi	To clarify why some women who were enrolled in a PMTCT program in Lilongwe, Malawi, did not fully participate in follow-up visits in the first six months after testing HIV-positive	Qualitative	15 men		ANC	FGDs In-depth interviews	Not stated	Knowledge: Limited information about HIV/AIDS and anti-retroviral treatment	Not stated
(Duff et al. 2012) Uganda	To describe the perceptions of married men about barriers to accessing and accepting highly active anti-retroviral therapy (HAART) by pregnant Postnatal women positive for human immunodeficiency virus (HIV)	Qualitative	48 married men	18–45 yrs	Community	4 FGD	Not stated	Knowledge: Low knowledge of HAART and low HIV testing rate among male HAART and HIV testing misconception Lack the opportunity to be taught about HIV/AIDS and HAART Communication patterns: Lack of disclosure of a positive HIV diagnosis by women to the partner and stigma Health systems: Low men involvement in the reproductive care Women's lack of trust in confidentiality when on HAART Cultural beliefs and gender roles blame and accusation of bringing the diseases. Fears of sero-status disclosure to their partners, economic dependence, fear of physical abuse, abandonment divorce Socioeconomic: Distance; lack of money for testing fees, transport and conflict with other needs Men: Positive result interfere with men capacity to work, HIV testing a nuisance and not a priority	Not stated
(Falnes et al. 2011) Tanzania	To explore acceptability of PMTCT and to identify structural and cultural challenges to male involvement	Mixed	Five FGD of with 5–12 fathers 21 in-depth interviews: • Fathers • Mothers	Not identified	Villages at outdoors, private homes, churches or school buildings	FGDs In-depth interviews	Not stated	Cultural beliefs and gender roles: ANC female oriented by Definition; Organization; Program; Female domain; Not male-friendly; Women do not have authority to invite men to ANC/PMTCT; Unwelcome invitation by wife to attend a female arena Knowledge: Same HIV result as that of wife Men: Routine testing for HIV of women at ANC highly acceptable and appreciated by men, while still some resistance for partner testing, condom use and the infant feeding recommendations; 100% of those asked accepted testing of their wives; few men had tested	Empowering women Empowering men to participate by creating a male-friendly PMTCT. Offer partner testing in arenas other than the antenatal clinic. Other than the wife invite partner to test
(Karamagi et al. 2006) Uganda	To determine the prevalence of intimate partner violence, risk factors, partner violence and HIV prevention and PMTCT	Mixed	Not identified	Not identified	WHO/EPI cluster survey House to house	FGD 4 men	Not stated	Cultural beliefs and gender roles: Men react violently when women go for HIV testing; Disclose HIV test results; Men perceive as evidence of ‘prostitution’; Multiple partners. Consumption of alcohol	Not stated
(Koo et al. 2013a) South Africa	To explore the social and cultural factors underlying low rates of male-partner HIV testing during PMTCT	Qualitative	124 men		33 were referred by participants; 21 clinic staff, 15 community practitioners	In-depth interviews with 124 men; 5 FGD with physicians; nurses; HIV counselors; and community representatives	Decision-makers, Responsible for health of partner and children	Cultural beliefs and gender roles: Women below men; difficult to disclose, no discussion of health if no sickness; Feeling of power inversion when women give ANC/PMTCT information; Risk of losing protection because of HIV Knowledge: HIV status equal to wives, MTCT only occurs because of mother status; They are Faithfull; HIV testing is an important part of preparing for fatherhood. Communication patterns: Difficulty of disclosure; Fears of having to surrender to HIV/AIDS; health discussion only in case of sick Health Systems: ANC/PMTCT oriented only on HIV testing not general well-being; No social expectation to test during pregnancy for fathers; Clinics are for sick and dying people; ANC/PMTCT dominated by women and female staff; Gender of VCT counselor; the negative attitude of health workers. Providers’ judgment on men who seek VCT; Work Time away from work and life; Clinic schedule and waiting hours; clinics everything is slow	Special hours and spaces for men's health; Programs about fatherhood issues; Peer education and counseling in informal social spaces; More defined roles for men to support women during PMTCT More family-oriented approaches to PMTCT; measurable improvements on strategies for men involvement on ANC/MTCT
(Kwambai et al. 2013) Kenya	To provide insight into men's perceptions of maternal healthcare services and to identify factors that facilitate or constrain men's involvement in ANC and delivery care in western Kenya	Qualitative	68 married men	20–65 yrs	Community	8 FGD	Provision of financial support. Decision-makers. Helping wives to bringing flour and fetching fire wood and improve wives' diet	Cultural beliefs and gender roles pregnancy is a women and in laws responsibility. Distrustful marriages. Communication patterns: Difficulty to disclose pregnancy and related information; Wives either distorted or withheld some information Knowledge: Men are mostly unaware of availability and aims of ANC; Reluctance to learn their HIV status; Fear of unwanted HIV disclosure and the threat HIV can pose to marriage Health Systems: men are ignored, harsh and negative attitudes toward men's participation, couple unfriendly antenatal and delivery unity infrastructure.
(Larsson et al. 2010) Uganda	To examine men's own perspectives by exploring fathers' views and experiences of couple HIV testing	Qualitative	103 fathers Rural and semi-urban area	Not identified	Homes, social spaces, outside farms	FGD 10 fathers each 5 in 2008; 4 in 2009 and 13 in-depth interviews	Ensure family's financial support; Decision-makers; exercise power over their wives	Cultural beliefs and gender roles: Pregnancy is a woman's affair; Women not authorized to request husbands to test; Men resistant to women's persuasive role including HIV testing; Polygamy, Unstable and distrustful marriages; Men adultery; Couples mutually suspicious; Couple testing Knowledge: Most men may recite the broadcasted HIV testing messages but do not go to ANC/PMTCT; Men do not understand why they should be tested without symptoms; Do not understand the importance of testing. Not informed about advantages of identifying a possible HIV infection: Social stereotypes: jealousy when man escorts wife to ANC/PMTCT clinic; Health Systems : The distance and costs, waiting times; organizational problems, special clinics and hours for testing; rudeness and impoliteness of health workers; Men uncomfortable and embarrassed due to wives' mistreatment; lack of drugs; informal payment for care; Men are unwelcome to ANC/PMTCT; Stigmatization of HIV/AIDS care
(Mlay et al. 2008) Tanzania AB	The aim was to gain insight from views of Tanzanian men and women on couple voluntary counselling and testing (CVCT) for HIV at antenatal clinics (ANC) in Tanzania	Qualitative	16 men	20–34 yrs (n = 8) and 35–75 yrs (n = 8)		FGD Depth interviews	Not stated	Cultural beliefs and gender roles: Disclosure of HIV-positive status to an HIV-negative spouse could result in abandonment, divorce or violence against the woman whether she was sero-negative or –positive	Not stated
(Mohlala et al. 2012) South Africa	To assess pregnant women and men's attitudes, feelings, beliefs, experiences and reactions to male partners’ involvement in antenatal clinic (ANC) in Khayelitsha	Qualitative	30 men	19–49 yrs	Social networks by word of mouth and through the use of key informants, and by advertising community	Focus group discussion	Not stated	Cultural beliefs and gender roles: ANC is for women to check the baby status; Labor ward is the ‘bush’ for women; The male partner should not be allowed during birth because he will bring ‘bad spirits’ to the mother and baby if he has been with other women Knowledge: Men do not think it is necessary for men to go, to ANC/PMTCT; do not see man role at ANC/PMTCT, If all is well, it is not necessary for men to attend Health Systems :some have never been asked to attend and they thought they are not needed	ANC/PMTCT as for baby health monitoring Health/ANC facility more ‘male-friendly’; Invitations letters to men to attend ANC visits; Community support to men in attending ANCs Correction of misconceptions, challenging prevailing social norms
(Musheke et al. 2013) Zambia	To examine couple experiences of provider-initiated couple HIV testing at a public antenatal clinic and discusses policy and practical lessons	Qualitative	10 men	23–46 yrs	ANC	Open-ended in-depth interviews	Not stated	Some men feeling ‘trapped’ or ‘forced’ to test due to unclear information. Fear of abandonment	Not stated
(Orne-Gliemann et al. 2010) Cameroon (India, Georgia, Dominican Republic, Georgia	To assess the acceptability of couple-oriented post-test HIV counseling (COC) and men's involvement in prenatal care services within different sociocultural settings	Qualitative	92 key informant including accompanying their wives		ANC	Direct observations of health services; in-depth interviews with men, women	Not stated	Cultural beliefs and gender roles: Maternity is a woman's domain; men attending ANC seen as out of place; Health Systems: long waiting time; Clinic operational hours; ANC traditionally and programmatically a woman's environment; Accompanying men are not allowed to enter into the consultation room; Negative attitude of health workers; Work: professional obligations; Working hours make for men to attend ANC/PMTCT Couples communication pattern :Vague couple dialogue on HIV and usually happens after TV program or story of someone who is infected	Better understanding of: Couple relationships, attitudes and communication patterns; conjugal context for HIV counseling and testing
(Reece et al. 2010) Kenya	To assess the likelihood that male spouses will support their wives during pregnancy, and become engaged in PMTCT-related antenatal care initiatives	Qualitative	75 (51.4% ) men	Not identified	ANC/Aids support group	16 in-depth FGD;	Not stated	Cultural beliefs and gender roles: Difficulty to approach employers due to belief ANC/PMTCT is for women and children; sporadic work; Communities disapprove; HIV sero-status discordance; Couples' communication patterns: Inability to communicate; Stigma; Health Systems: Distance to clinics; Transport costs; operating hours; Time per appointment; Disrespect of health staff ; Belief in traditional healing	Tangible health-related products ex: formula and drugs; Knowledge, understanding the program; Initiatives exclusively for men and led by men; men's psychosocial support groups; Clinic hours during non-work hours (e.g. weekends); CVCT; Leaders from men's support groups as peer educators; and deliver education to other men in their communities
(Theuring et al. 2009) Tanzania	Was to fill the existing gap on male-focused research and to learn about men's perspectives in order to identify strategies for increasing partner	Mixed	124 men	22–59 yrs	Agricultural exhibition, community event, and waiting areas in the outpatient clinics	FGD and In-depth interviews	Provision of daily subsistence; Ensure family surviving; Provide food; security and health; some men women need husband's permission for ANC/PMTCT and Support in housework	Cultural beliefs and gender roles: men do not give attention ANC/PMTCT services; Is not a men role to attend ANC clinics; men attend ANC clinic only before wives sickness; ANC clinics are for women only; ANC/PMTCT is for women and children; Knowledge: The concept of father's full involvement is still vague; couple testing does not give time to prepare partner how became HIV+; women positive sero-discordancy; men are afraid of testing. Work: waiting time, conflicts with working obligations; health systems: men are invited to wait outside the room; men do not know why they are invited to the clinic; and why they should attended	CVCT, kind reception, politeness, value of the services
(Walcott et al. 2013) Kenya	To elicit feedback on three approaches for safe HIV disclosure for pregnant women and male partners in rural Kenya	Qualitative	20 men		ANC	In-depth interviews with 20 men	Not stated	Cultural beliefs and gender roles: blame of infidelity, promiscuity, bringing the diseases Distrustful marriage Stigma and discrimination	Openness and peaceful discussion between partners

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