Abstract
In sub-Saharan Africa (SSA), male partners are rarely present during prevention of mother-to-child transmission (PMTCT) services. This systematic review aims to synthesize, from a male perspective, male partners’ perceived roles, barriers and enablers of their involvement in PMTCT, and highlights persisting gaps. We carried out a systematic search of papers published between 2002 and 2013 in English on Google Scholar and PubMed using the following terms: men, male partners, husbands, couples, involvement, participation, Antenatal Care (ANC), PMTCT, SSA countries, HIV Voluntary Counseling and Testing and disclosure. A total of 28 qualitative and quantitative original studies from 10 SSA countries were included. Men's perceived role was addressed in 28% (8/28) of the studies. Their role to provide money for ANC/PMTCT fees was stated in 62.5% (5/8) of the studies. For other men, the financial responsibilities seemed to be used as an excuse for not participating. Barriers were cited in 85.7% (24/28) of the studies and included socioeconomic factors, gender role, cultural beliefs, male unfriendly ANC/PMTCT services and providers’ abusive attitudes toward men. About 64% (18/28) of the studies reported enablers such as: older age, higher education, being employed, trustful monogamous marriages and providers’ politeness. In conclusion, comprehensive PMTCT policies that are socially and culturally sensitive to both women and men need to be developed.
Résumé
En Afrique sub-saharienne (ASS) les partenaires masculins sont rarement présents dans les services de PTME. Cette revue systématique de la littérature a pour objectif de synthétiser, du point de vue des hommes, les rôles perçus des partenaires masculins, les barrières et les facteurs facilitateurs de leur participation dans les services de PTME, et met en exergue les lacunes qui persistent. Nous avons mené une recherche systématique d'articles publiés en anglais entre 2002 et 2013 dans Google Scholar et PubMed en utilisant les mots clés: hommes, partenaires masculins, maris, couples, implication, participation, CPN, PTME, pays d'Afrique sub-saharienne, testage et conseil volontaire pour le VIH et announce des résultats. Un total de vingt-huit études originales, qualitatives et quantitatives menées dans dix pays d'ASS, ont été inclues. Le rôle perçu des hommes était analisé dans 28% (8/28) des études. Leur rôle de pourvoir aux frais des CPN/ services de PTME était cité dans 62.5% (5/8) des études. Pour d'autres hommes, les responsabilités financières semblaient être utilisées comme une excuse pour ne pas s'impliquer. Les barrières à la participation des hommes étaient citées dans 85.7% (24/28) des études et incluaient des facteurs socio-économiques, le facteur genre, les croyances culturelles, les services de CPN/PTME peu acceuillants pour les hommes et les attitudes abusives des professionnels de santé envers les hommes. Environ 64% (18/28) des études reportaients des facteurs facilitateurs de la participation des hommes comme: l’âge mûr, éducation supérieure, avoir un emploi, époux monogames et fidèles et la politesse des professionnels de santé. En conclusion, des politiques exhaustives de PTME, qui sont socialement et culturellement adaptées aux femmes aussi bien qu'aux hommes devraient être mises en place.
Introduction
Every year, an estimated 1.5 million HIV-positive women become pregnant, and 90% of total HIV infections in children that are acquired through mother-to-child transmission (MTCT) during either pregnancy, labor or breastfeeding occur in sub-Saharan African (SSA) countries (UNAIDS Citation2013). A study carried out in Zambia shows that the majority of HIV transmission is reported to occur within stable couples (Dunkle, Stephenson, Karita, Chomba, Kayitenkore, Vwalika, et al. Citation2008), the highest risk being women with low control over their sexuality (Bhagwanjee, Govender, Reardon, Johnstone, George & Gordon Citation2013; Greiga, Peacock, Jewkes & Msimang Citation2008), low risk perception for HIV acquisition and whose male sexual partners have relatively high-risk sexual behaviors (Larsson, Thorson, Nsabagasani, Namusoko, Popenoe & Ekström Citation2010). In spite of remarkable achievements in the reduction of new HIV infections from 3.4 (3.1–3.7) million in 2001 to 2.3 (1.9–2.7) million in 2012, challenges remain. In the most affected SSA countries, HIV and AIDS-related diseases are still amongst the main causes of disease and death among women and children (UNAIDS Citation2013).
Programs to curtail mother-to-child HIV transmission (PMTCT) have been in place for almost 15 years worldwide. In most affected SSA countries, PMTCT is a component of antenatal care. Currently, there is increased access to free anti-retroviral drugs for PMTCT globally, which are also more effective, with simpler dosing and easy storage (WHO Citation2012). Taking advantage of anti-retroviral drugs availability, countries with a high HIV and AIDS burdens are escalating the provision of PMTCT interventions to respond to demands in underserved areas. The expansion needs innovation in order to strengthen the traditional PMTCT approach, which addresses only women and children, such as to include male partners. There is overwhelming evidence that male partners’ participation in PMTCT is fundamental (Reece, Hollub, Nangami & Lane Citation2010; Semrau, Kuhn, Vwalika, Kasonde, Sinkala, Kankasa, et al. Citation2005; Theuring, Mbezi, Luvanda, Jordan-Harder, Kunz & Harms Citation2009), is strongly recommended by World Health Organization and has been contemplated in strategies of many MTCT control programs.
Male partner involvement is an important factor in reducing PMTCT refusal by women, as well as delayed enrollment and dropout rates (Conkling, Shutes, Karita, Chomba, Tichacek, Sinkala, et al. Citation2010; Kalembo, Zgambo, Mulaga, Yukai & Ahmed Citation2013; Theuring et al. Citation2009). Their involvement also increases male partners’ opportunities for HIV testing and eventually early initiation of anti-retroviral treatment. Despite these benefits, male partner attendance in PMTCT is still very low (Falnes, Moland, Tylleskär, De Paoli, Msuya, & Engebretsen Citation2011; Kiarie, Farquhar, Richardson, Kabura, John, Nduati, et al. Citation2006; Larsson et al. Citation2010; Msuya, Mbizvo, Hussain, Uriyo, Sam & Stray-Pedersen Citation2008; Orne-Gliemann, Tchendjou, Miric, Gadgil, Butsashvili, Eboko, et al. Citation2010; Semrau et al. Citation2005; Theuring et al. Citation2009) and seems to be promoted exclusively to improve PMTCT uptake and outcomes benefitting women and children.
From a social perspective, traditional systems in both rural and urban settings in most SSA communities are deeply rooted in male authority over women's health, particularly in its sexual and reproductive aspects (Larsson et al. Citation2010; Orne-Gliemann et al. Citation2010)., Therefore, in these SSA settings, with the predominance of HIV heterosexual transmission, safeguarding current achievements and furthering PMTCT improvements demand combined actions that include women and their male partners as actors toward interruption of MTCT of HIV infection.
Review aims
This systematic review aims to identify and synthesize men's perceived role, barriers and enablers regarding their involvement in PMTCT in SSA countries and highlight persisting gaps.
Methods
To be well informed on the subject of this study, we carried out a systematic search in English on Google Scholar, and PubMed. Additional searches were carried out on WHO, UNAIDS, UNICEF, UNFPA publications and local gray literature. However, the systematic presentations here were limited to published articles in peer-reviewed journals, between January 2002 and December 2013. The terms used in the search included: men, male, husbands, couples involvement, participation Antenatal Care (ANC), PMTCT, SSA countries, HIV Voluntary Counseling and Testing (VCT), VCT, HIV Testing, HIV Disclosure, in different combinations accordingly. Published articles reporting on male involvement with PMTCT, HIV counseling and testing and sero-status disclosure were sought after. Specifically, the main outcomes sought were men's perceived role, barriers, obstacles, facilitators, predictors and enablers to PMTCT. Studies were identified through their titles, retrieved and screened abstracts and full texts, and lastly, the articles were assessed for eligibility and inclusion in this systematic review. Duplicated studies were eliminated. To be eligible for this review, the study was required to be an original qualitative or quantitative study carried out in SSA, addressing men's involvement in PMTCT, HIV counseling and testing and sero-status disclosure from a male perspective. Studies were excluded if not carried out in SSA, not related to PMTCT, reported women's perspectives, and did not include meńs perspectives. Each abstract and/or full paper selected was read several times, data were extracted regarding, country, authors, study aim, study site and population, male partner PMTCT attendance, HIV counseling and testing, sero-status disclosure, perceived male role, barriers (obstacles, hindrances) and enablers (predictors, facilitators). RM analyzed and summarized the data. MS and OD reviewed the processes of studies selection and data extraction analyses ().
Fig. 1. Procedures used for the selection of articles for the systematic review.
Results
Included studies
Twenty-one studies were retrieved from the systematic review process and seven from studies’ references (). Thirteen (46%) were qualitative, 11 (39%) quantitative (6 cohort, 5 cross sectional) and 4 (14%) mixed (cross-sectional with qualitative components). The studies were from: Uganda 6 (21%), Tanzania 5 (17%), Kenya 5 (17%), Zambia 4 (14%), South Africa 3 (10%), Cameroon 2 (7%), Malawi 2 (7%), Ivory Coast 1 (3%), Democratic Republic of Congo 1 (3%), and Rwanda 1 (3%).
Fig. 2. Factors influencing man involvement in PMTCT.
In 50% (14/28) of the studies, men were recruited indirectly through their female partners at ANC/PMTCT clinics. Outside PMTCT clinic settings, recruitment of men was mostly done directly, through letters to them at their homes (Falnes et al. Citation2011; Karamagi, Tumwine, Tylleskar & Heggenhougen Citation2006; Larsson et al. Citation2010), at social spaces (Falnes et al. Citation2011; Larsson et al. Citation2010), farms (Falnes et al. Citation2011; Larsson et al. Citation2010; Nkuoh, Meyer, Tih & Nkfusai Citation2010), work places (Semrau et al. Citation2005), sports venues, churches, (Falnes et al. Citation2011; Semrau et al. Citation2005), bars (Semrau et al. Citation2005), in communities (Duff, Rubaale & Kipp Citation2012; Falnes et al. Citation2011; Harms, Schulze, Moneta, Baryomunsi, Mbezi & Poggensee Citation2005; Koo, Makin, & Forsyth Citation2013b; Kwambai, Dellicour, Desai, Ameh, Person, Achieng, et al. Citation2013; Mohlala, Gregson & Boily Citation2012; Tweheyo, Konde-Lule, Tumwesigye & Sekandi Citation2010), agricultural exhibitions and public events (Theuring et al. Citation2009).
(1) Male partners’ perceived roles on PMTCT were cited in (28%) 8/28 studies. We identified men's perceived direct and indirect roles. The direct role most frequently stated was financial support (Byamugisha, Tumwine, Semiyaga, & Tylleskär Citation2010; Kwambai et al. Citation2013; Larsson et al. Citation2010; Nkuoh et al. Citation2010; Theuring et al. Citation2009), followed respectively by decision-making, responsibility over women's health (Koo, Makin, & Forsyth Citation2013a; Kwambai et al. Citation2013; Larsson et al. Citation2010; Theuring et al. Citation2009) and help with housework throughout pregnancy (Kwambai et al. Citation2013; Nkuoh et al. Citation2010; Theuring et al. Citation2009). One study referred to indirect support through improvement of communication between couples (Aarnio, Aarnio, Olsson, Chimbiri & Kulmala Citation2009), faithfulness during pregnancy and support to HIV-positive women (Aarnio et al. Citation2009). Financial support was stated in 62.5% (5/8) of the studies ( and ). Most men reported believing that their main role was that of a breadwinner (Larsson et al. Citation2010; Musheke, Bond & Merten Citation2013) and provider of money for health expenses, ANC/PMTCT clinic fees, food and family well-being (Larsson et al. Citation2010; Nkuoh et al. Citation2010; Theuring et al. Citation2009). Nevertheless, the meńs role of guaranteeing family income and having to work is often used as an excuse to not accompany their wives to ANC/PMTCT clinics (Kwambai et al. Citation2013; Larsson et al. Citation2010; Musheke et al. Citation2013). According to some men's statements, as part of their responsibility (Aarnio et al. Citation2009; Theuring et al. Citation2009) and in spite of their awareness of women's financial dependence, they assume that women need their permission to go to ANC/PMTCT sessions because only male partners can decide which clinic to attend and which ANC/PMTCT care they can afford (Kwambai et al. Citation2013; Theuring et al. Citation2009). Other men perceive that they have to persuade women and sometimes obligate them to attend ANC/PMTCT clinics or see a traditional birth attendant in reaction to women's careless health conduct, ignorance or laziness (Kwambai et al. Citation2013). Few men see their role as extending to sharing responsibility during pregnancy, childbirth and child care (Nkuoh et al. Citation2010), as well as helping with cooking and housework (Kwambai et al. Citation2013; Nkuoh et al. Citation2010; Theuring et al. Citation2009) and improving women's diets (Kwambai et al. Citation2013).
Table 1. Selected quantitative studies and components.
Table 2. Selected qualitative studies and components.
(2) Perceived barriers for male partners involvement in PMTCT were present in 85% (24/28) of the studies, and comprised socioeconomic constraints, health system factors, cultural beliefs, gender inequity, limited knowledge of ANC/PMTCT, mistrustful marriages and inadequate couples’ communication patterns.
(2.1) Socioeconomic barriers cited in 39.2% (11/28) of the studies consisted of:
(2.1.1) Distance and financial burdens: Clinics were too centralized (Byamugisha et al. Citation2010) and far from communities and work places (Byamugisha et al. Citation2010; Duff et al. Citation2012; Larsson et al. Citation2010; Nkuoh et al. Citation2010; Reece et al. Citation2010). Other reasons included the inability to afford transportation particularly for two people (Byamugisha et al. Citation2010; Duff et al. Citation2012; Koo et al. Citation2013a; Larsson et al. Citation2010; Nkuoh et al. Citation2010; Orne-Gliemann et al. Citation2010; Reece et al. Citation2010), lack of transport (Tweheyo et al. Citation2010), the need to pay for HIV testing (Duff et al. Citation2012), pay for care and drugs (Larsson et al. Citation2010; Reece et al. Citation2010), pay illegal extra charges (Larsson et al. Citation2010; Orne-Gliemann et al. Citation2010; Reece et al. Citation2010), and financial conflicts with other urgent household needs (Duff et al. Citation2012).
(2.1.2) Work commitments: Overlap of clinic appointment schedules and working hours (Duff et al. Citation2012; Koo et al. Citation2013a; Orne-Gliemann et al. Citation2010; Reece et al. Citation2010; Theuring et al. Citation2009; Tweheyo et al. Citation2010), sporadic jobs and casual labor, jobs with little control of assignments (Reece et al. Citation2010) were frequently cited. The belief that ANC/PMTCT was only for women and children had negative impact at meńs workplace leading them not to request leave to attend PMTCT clinics (Theuring et al. Citation2009). Accompanying women to PMTCT was a stigma for men, as they feared not being authorized by their employers to attend PMTCT with their spouses, and worried with confidentiality issues linked to HIV/PMTCT (Reece et al. Citation2010).
(2.1.3) Time constraints: Time away from job including the waiting time at the clinic (Byamugisha et al. Citation2010; Duff et al. Citation2012; Nkuoh et al. Citation2010; Theuring et al. Citation2009; Tweheyo et al. Citation2010) as well as the time needed for HIV testing, including receiving counseling, testing and returning for results were seen as barriers (Koo et al. Citation2013a; Reece et al. Citation2010). Some men said that they were unable to spend the entire day alongside their partners at clinics (Koo et al. Citation2013a) and that all of the procedures were time consuming (Koo et al. Citation2013a) and a nuisance for them (Tweheyo et al. Citation2010).
(2.2) Health systems related barriers found in 39% (11/28) studies were as follows:
(2.2.1) PMTCT targets and scope: Men perceive ANC/PMTCT clinics as unfriendly (Koo et al. Citation2013a; Kwambai et al. Citation2013; Larsson et al. Citation2010; Orne-Gliemann et al. Citation2010), dominated by women as both clients and care providers (Koo et al. Citation2013a) and they feel totally ignored (Kwambai et al. Citation2013). ANC/PMTCT interventions were focused on HIV and neglected general wellness, fatherhood and father's roles, a common unmet need particularly expressed by young fathers (Koo et al. Citation2013a; Larsson et al. Citation2010; Theuring et al. Citation2009). HIV testing was not mandatory for male partners within PMTCT (Koo et al. Citation2013a). The few accompanying male partners were frequently asked to wait outside the room (Byamugisha et al. Citation2010; Orne-Gliemann et al. Citation2010; Theuring et al. Citation2009). In this regard, male partners wonder why they should accompany their partners to ANC/PMTCT visits (Byamugisha et al. Citation2010; Theuring et al. Citation2009).
(2.2.2) PMTCT settings: The crowded state of the clinics and excess of clients in waiting (Byamugisha et al. Citation2010; Koo et al. Citation2013a; Orne-Gliemann et al. Citation2010; Reece et al. Citation2010), lack of space to accommodate couples in consultation rooms (Byamugisha et al. Citation2010; Koo et al. Citation2013a; Reece et al. Citation2010), uneasiness related to sitting next to unknown women, (Byamugisha et al. Citation2010; Koo et al. Citation2013a; Reece et al. Citation2010), cleanliness and confidentiality issues contributed to lack of male participation (Byamugisha et al. Citation2010). On the other hand, special facilities, days or hours for HIV testing were embarrassing for some men because others might question their HIV sero-status (Falnes et al. Citation2011; Larsson et al. Citation2010). For others, clinics were conceptualized as a place for sick and dying people and they perceived themselves as healthy and in no need to visit clinics (Koo et al. Citation2013a).
(2.2.3) Health workers' attitudes: Health workers’ attitudes were described by men as embarrassing, rude, and harsh (Koo et al. Citation2013b). Use of abusive words either to pregnant women alone or in the presence of their partners and others (Byamugisha et al. Citation2010; Koo et al. Citation2013b; Kwambai et al. Citation2013; Larsson et al. Citation2010), as well as the worrisome maneuvers over pregnant women's abdomens, potentially hurting them, also contributed to meńs lack of participation (Byamugisha et al. Citation2010).
(2.3) Cultural beliefs and gender roles cited in 60% (17/28) of studies: Some traditions considered women as inferior to men in social status (Koo et al. Citation2013b) and they were not allowed to lead their male partners (Falnes et al. Citation2011; Larsson et al. Citation2010; Nkuoh et al. Citation2010), or tell them what to do (Falnes et al. Citation2011). Both inviting them to a female gathering and giving their partners ANC/PMTCT information (Koo et al. Citation2013a; Larsson et al. Citation2010) might be interpreted as handing over power to women. Men use their authority to devalue women's demands for their involvement in ANC/PMTCT (Falnes et al. Citation2011; Larsson et al. Citation2010). In some situations, women's HIV testing is considered an indication of prostitution or adultery (Duff et al. Citation2012; Falnes et al. Citation2011; Karamagi et al. Citation2006; Larsson et al. Citation2010; Walcott, Hatcher, Kwena & Turan Citation2013) and sometimes, regardless of the results, could lead to domestic violence (Aarnio et al. Citation2009; Duff et al. Citation2012; Falnes et al. Citation2011; Mlay, Lugina & Becker Citation2008). Cases of sero-discordance, involving positive woman can culminate in divorce. If the man is positive, the consequences are lighter often involving quarrels and denial (Kiarie et al. Citation2006; Larsson et al. Citation2010).
Some communities perceived male presence at ANC/PMTCT clinics as abnormal (Larsson et al. Citation2010; Nkuoh et al. Citation2010; Theuring et al. Citation2009), making men susceptible to criticism and doubt about their masculinity, their power over their wives, and a sign of weakness (Byamugisha et al. Citation2010), bewitchment (Nyondo, Chimwaza & Muula Citation2014), jealousy (Larsson et al. Citation2010), and serving as an unwelcome example for other couples. Fearing peers’ hostility (Falnes et al. Citation2011; Larsson et al. Citation2010; Orne-Gliemann et al. Citation2010) and shame (Nkuoh et al. Citation2010) to be the only male present (Falnes et al. Citation2011)), men generally do not go to ANC/PMTCT clinics. Meńs visit to clinics could be eventually justified if accompanying their sick wives (Falnes et al. Citation2011; Mohlala et al. Citation2012).
(2.4) Men's inadequate knowledge stated in 50% (14/28) of the studies included: Some men believing their HIV status would always be the same as that of their wives (Falnes et al. Citation2011; Katz, Kiarie, John-Stewart, Richardson, John & Farquhar Citation2009; Koo et al. Citation2013a), but MTCT as only the mother's responsibility (Koo et al. Citation2013a). Others were unaware of the availability of ANC HIV testing and counseling (Aarnio et al. Citation2009), felt insufficiently involved (Duff et al. Citation2012; Kwambai et al. Citation2013), unclear on the concept of the father's involvement in ANC/PMTCT (Theuring et al. Citation2009) and felt that there was a lack of opportunity to learn about HIV/AIDS and Highly Active Antiretroviral Therapy (HAART) (Chinkonde, Sundby & Martinson Citation2009; Duff et al. Citation2012). Some could repeat broadcasted HIV testing messages while still not going for HIV testing (Larsson et al. Citation2010). Some did not understand the role of ANC/PMTCT if the mother and baby were well (Mohlala et al. Citation2012) or see the advantages of testing where there were no symptoms (Auvinen, Kylmä, Välimäki, Bweupe & Suominen Citation2013; Larsson et al. Citation2010; Theuring et al. Citation2009).
(2.5) Men's fearful attitudes regarding PMTCT: The fear of positive results (Aarnio et al. Citation2009; Koo et al. Citation2013a; Kwambai et al. Citation2013; Mulongo, Schirvel, Mukalay wa Mukalay & Dramaix Citation2010; Theuring et al. Citation2009), unwanted HIV disclosure (Kwambai et al. Citation2013), stigma (Auvinen et al. Citation2013; Chinkonde et al. Citation2009; Duff et al. Citation2012; Larsson et al. Citation2010; Musheke et al. Citation2013; Walcott et al. Citation2013) and marital disharmony after HIV results were factors also mentioned (Aarnio et al. Citation2009; Auvinen et al. Citation2013; Duff et al. Citation2012; Kwambai et al. Citation2013; Larsson et al. Citation2010; Musheke et al. Citation2013).
(2.6) Distrustful marriages and couples’ communication patterns: Some men described their marriages as unstable and distrustful (Auvinen et al. Citation2013; Larsson et al. Citation2010; Reece et al. Citation2010; Walcott et al. Citation2013) with mutual suspicions of extra-marital relationships, but particularly among men (Koo et al. Citation2013a; Larsson et al. Citation2010). On the other hand, some traditional norms prohibit women to initiate HIV and reproductive health conversations (Larsson et al. Citation2010), others intentionally neglect information provided by wives (Larsson et al. Citation2010). These situations contribute to turning communication around HIV infection into a sensitive and intricate subject, told in the third person (Koo et al. Citation2013a; Larsson et al. Citation2010; Orne-Gliemann et al. Citation2010; Reece et al. Citation2010). Other men suspect that their wives have either distorted or withheld some information (Chinkonde et al. Citation2009; Musheke et al. Citation2013) and feel forced into getting tested by their partners, with the collusion of health workers(Musheke et al. Citation2013), some have never been requested to attend ANC/PMTCT sessions and thought they were not needed (Mohlala et al. Citation2012).
(3) Male enablers to participating in PMTCT cited in 53% (15/28) of the studies were:
(3.1) Stable marriages: men were more disposed to participate in ANC/PMTCT if living with their partners (Falnes et al. Citation2011; Katz et al. Citation2009; Larsson et al. Citation2010) as a monogamous couple (Brou, Djohan, Becquet, Allou, Ekouevi, Viho, et al. Citation2007; Katz et al. Citation2009), and to discuss HIV if married, in an exclusive relationship (Koo et al. Citation2013b) and having children (Falnes et al. Citation2011; Katz et al. Citation2009; Msuya et al. Citation2008; Reece et al. Citation2010; Tweheyo et al. Citation2010). Men were 3.5 times more likely to be tested if they were aware of their wives' sero-status (Brou et al. Citation2007; Koo et al. Citation2013a) and informed about HIV testing by their wives (Reece et al. Citation2010).
(3.2) Male-friendly PMTCT services were dependent on availability of specific information on ANC/PMTCT directed toward men (Aarnio et al. Citation2009; Byamugisha et al. Citation2010; Mohlala et al. Citation2012; Reece et al. Citation2010; Theuring et al. Citation2009), understanding of the value of the services offered, and the kindness and politeness of health workers (Reece et al. Citation2010; Theuring et al. Citation2009). Men were also keen to receive invitation letters, health information addressed directly to them from health workers and those other than their partners (Byamugisha et al. Citation2010; Mohlala et al. Citation2012; Reece et al. Citation2010; Theuring et al. Citation2009), and clinic hours during non-work period such as weekends, appointments outside ANC/PMTCT clinics, for example, at their homes or work places (Larsson et al. Citation2010; Reece et al. Citation2010). Men were also in favor of learning more about fatherhood issues, couples' VCT, existence of health products, drugs and promotion of refresher courses and customer care skills for healthcare providers (Byamugisha et al. Citation2010).
(3.3) Age: Adult men were more willing to participate in ANC/PMTCT sessions (Byamugisha et al. Citation2010; Katz et al. Citation2009; Koo et al. Citation2013a; Mlay et al. Citation2008; Mohlala et al. Citation2012; Msuya et al. Citation2008; Musheke et al. Citation2013). Figures from Cameroon show that ANC knowledge was higher among 20- to 39-year-old men favoring their participation in PMTCT (Nkuoh et al. Citation2010).
(3.4) Education: In South Africa (Koo et al. Citation2013a), men with higher levels of education were 5.8 times more likely to attend ANC clinics, and 2.7 times more likely to be tested for HIV in Ivory Coast (Brou et al. Citation2007). Data from two studies in Uganda showed that the literacy rate was high among male participants and varied from 74% (Byamugisha et al. Citation2010) to nearly 90% (Larsson et al. Citation2010).
(3.5) Employment: Most men who participated in the studies included in this review were employed (Msuya et al. Citation2008). For 58 (47%) men, it was important to receive an official letter to present to their employers for permission to attend ANC/PMTCT clinics (Reece et al. Citation2010).
(3.6) Men's empowerment: Promotion of couple- and family-centered PMTCT interventions (Koo et al. Citation2013a) and mobilization of men for PMTCT using male peers, churches and mosques were found to be effective (Byamugisha et al. Citation2010). Encouraging initiatives exclusively for men, led by men, promoting men's psychosocial support groups, community education through men's support groups as peer educators are all approaches that support men to attend PMTCT sessions as well as to continue sensitizing and educating other men in their communities (Mohlala et al. Citation2012; Reece et al. Citation2010). It is important that the role of men is clearly defined to better support women at PMTCT (Koo et al. Citation2013a; Mohlala et al. Citation2012).
(3.7) Better communication among couples: Men were in favor of open and peaceful discussion between partners (Walcott et al. Citation2013) and more family-oriented approaches by health workers (Koo et al. Citation2013a). More understanding of communication patterns in the context of HIV counseling and testing can facilitate more effective services (Orne-Gliemann et al. Citation2010).
Discussion
This review reiterates the low level of male partners’ involvement in PMTCT. summarizes multiple factors that influence men's involvement in PMTCT. The need and demand for men involvement at PMTCT clinics are influenced by the prevailing understanding of PMTCT not being a men's role, but rather a women's issue (Aarnio et al. Citation2009; Duff et al. Citation2012; Larsson et al. Citation2010; Nkuoh et al. Citation2010; Theuring et al. Citation2009; Tweheyo et al. Citation2010). The role of men is perceived rather to be as provider of money for family sustenance and payment of eventual costs for care related to delivery or baby care (Falnes et al. Citation2011; Larsson et al. Citation2010; Mohlala et al. Citation2012; Nkuoh et al. Citation2010; Orne-Gliemann et al. Citation2010; Reece et al. Citation2010; Theuring et al. Citation2009). Traditional cultural concepts about gender roles (Falnes et al. Citation2011; Reece et al. Citation2010; Theuring et al. Citation2009) and social constructions (Tweheyo et al. Citation2010) favoring male partner superiority may inhibit them to assume a more active role in PMTCT. On the other hand, the perceived inferiority of women (Duff et al. Citation2012; Falnes et al. Citation2011; Larsson et al. Citation2010) and their greater responsibility over pregnancy and childbearing (Falnes et al. Citation2011; Larsson et al. Citation2010; Theuring et al. Citation2009) contribute for their greater role and eventually lonesome involvement in PMTCT.
Some men miss opportunities to participate in PMTCT because they neglect information given by their female partners (Duff et al. Citation2012; Falnes et al. Citation2011; Larsson et al. Citation2010). Nevertheless, some men express lack of knowledge and awareness for their insufficient involvement with their spouses' pregnancy and PMTCT process (Duff et al. Citation2012; Kwambai et al. Citation2013; Larsson et al. Citation2010). Men were not concerned with getting tested or with prevention of HIV infection from mother to their child even though they were able to repeat the broadcasted HIV prevention messages (Larsson et al. Citation2010). These attitudes and behaviors highlight the need for urgent improvement of men's involvement through multi-sectoral approaches, including those aimed at communities, in order to produce behavior change, decrease negative beliefs and cultural practices.
Besides work commitments (Theuring et al. Citation2009) and alleged lack of time (Aarnio et al. Citation2009; Byamugisha et al. Citation2010; Falnes et al. Citation2011; Larsson et al. Citation2010; Mulongo et al. Citation2010; Nkuoh et al. Citation2010; Theuring et al. Citation2009) reported in reviewed studies, there is also a lack of legislation ensuring fathers' greater participation at PMTCT (Orne-Gliemann et al. Citation2010; Tweheyo et al. Citation2010). This legislative gap is even worse when employers also understand PMTCT as women issue (Nkuoh et al. Citation2010; Reece et al. Citation2010) and hinder their male employees from attending PMTCT services (Larsson et al. Citation2010). Additionally, men fear to be asked by their employers to disclose their HIV status, which may also prevent them from asking permission to attend PMTCT sessions with their spouses (Reece et al. Citation2010). Money constraints may also be a real barrier for male partner PMTCT attendance (Byamugisha et al. Citation2010; Duff et al. Citation2012; Reece et al. Citation2010; Tweheyo et al. Citation2010). However, reviewed studies make no mention of increasing male partner attendance even if PMTCT services are free of charge.
For the most conservative communities among the sub-SSA Countries included in this study, pregnancy and childbearing are female responsibility (Larsson et al. Citation2010; Reece et al. Citation2010; Theuring et al. Citation2009) and family provision, more a male duty. There is no culturally perceived role for male partners at PMTCT (Byamugisha et al. Citation2010; Koo et al. Citation2013a). Also, women are prohibited from discussing sexual and reproductive issues with their male partners (Koo et al. Citation2013a; Larsson et al. Citation2010), restricting therefore sharing of information and appeal for their male partners involvement at PMTCT (Duff et al. Citation2012). So, an important role has to be played by the less traditionalist community members (open-minded or unprejudiced), civil society faith-based organizations, traditional healers and traditional birth attendants in promoting reforms of community norms and taboos (Byamugisha et al. Citation2010; Larsson et al. Citation2010; Mohlala et al. Citation2012) to enhance men understanding of their parenthood role and need for their involvement in PMTCT.
Even though men acknowledge the (Koo et al. Citation2013a; Kwambai et al. Citation2013) challenges women face in directing conversations, most of them still are not receptive to discuss HIV-related issues which contributes to couples’ communication gaps and misunderstandings (Larsson et al. Citation2010; Orne-Gliemann et al. Citation2010; Reece et al. Citation2010; Villar-Loubet, Bruscantini, Shikwane, Weiss, Peltzer & Jones Citation2013). Having monogamic families (Brou et al. Citation2007), having children (Katz et al. Citation2009), stable and faithful relationships (Koo et al. Citation2013b) were all identified as enabling factors. However, polygamy and extra-marital relationships are relatively common in these settings and may interfere in males' involvement in PMTCT.
Globally and at country level, the PMTCT policies have been conceived to promote female reproductive and sexual rights. However, in more traditional settings in SSA Countries, the political focus on HIV epidemic feminization, PMTCT (Falnes et al. Citation2011) and the greater emphasis on mother and child health may reinforce some men's cultural background which tends to confer on women all responsibility for pregnancy, blame for eventual HIV infection and transmission to the child (Falnes et al. Citation2011). This seems to be one of the reasons why MCH nurses often feel not prepared to address health, sexual and reproductive needs of men (Koo et al. Citation2013a; Larsson et al. Citation2010).
We can conclude that the relationship of men with their community's cultural beliefs, social norms, work commitments, local health policies and healthcare delivery systems are some important factors influencing men's involvement in PMTCT. At global and local levels, reproductive and sexual health approaches should be revised to address men's, women's and community's roles in reproductive health and childbirth. Thus, there is a need for greater education, health and labor sector reforms that contribute to improve national policies and strategies for men's involvement in PMTCT. Innovative multi-sectoral reforms aimed at men's involvement in PMTCT should also promote free health services to diminish the financial pressure on the financially more vulnerable men. Due to the urgency of improving men's involvement in PMTCT, feasible low-cost enablers should be better explored and implemented, for instance, the involvement of male community leaders and faith-based organizations, employers, training of health workers to improve understanding of male health and reproductive needs. Innovative strategies should also see opportunities for scheduling men or couples for weekday afternoon PMTCT services.
Although the findings of this review present valuable evidence about the roles, barriers and enablers of men's involvement with PMTCT, there are some limitations to consider. The review analyzed only reported evidence from published studies retrieved from PubMED and Google Scholar, which might exclude some studies and/or evidence such as existing gray literature in SSA Countries. On the other, the SSA Countries are very diverse in terms of ethno-cultural background and thus the evidence produced in this study might not be generalizable to all diverse settings (urban, rural, etc.) and contexts in these countries.
Acknowledgements
This research project is a component of thesis work of the principal researcher, a registered PhD student at University of Gent and scholarship fellow of VRIL-UOS (Flemish University Council – University Development Cooperation), and Universidade of Eduardo Mondlane (UEM, Mozambique). Thus, we would like to thank VLIR-UOS and UEM. Also special thanks to Francisco Mbofana, Caroline Soy, Sandy McGunegill as well as Jose Estado, Mahomed Mussagy, Acacio Sabonete and administrative team of the Desafio Program at UEM for their continual support.
Funding
This work was supported by Scholarship provided jointly by University Eduardo Mondlane (UEM) and Flemish International University Coopreation (IUC).
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