Vol.2, No.

1, 35-42 (2012)
http://dx.doi.org/10.4236/ojpm.2012.21006

Open Journal of Preventive Medicine

Male partner involvement in prevention of mother to

child transmission of HIV in sub-Saharan Africa:
Successes, challenges and way forward
Fatch W. Kalembo1,2*, Du Yukai1, Maggie Zgambo3, Qiu Jun1
1
Maternal and Child Health Department, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
[email protected], [email protected]
2
Faculty of Health Sciences, Mzuzu University, Mzuzu, Malawi; *Corresponding Author: [email protected]
3
University of North Carolina Project, Lilongwe, Malawi; [email protected]

Received 3 October 2011; revised 14 November 2011; accepted 27 December 2011

ABSTRACT
Sub-Saharan Africa has the highest number of
mother to child transmissions of HIV. PMTCT programme plays a big role in reducing the MTCT
nevertheless its effectiveness in sub-Saharan
Africa depends on involvement of male partners
considering the fact that men are decision makers in African families. They make important decisions that have big impact on womens health.
Male partner involvement has been seen to increase uptake of PMTCT services and their involvement underscores their importance in reducing HIV infection in children. Recently many
sub-Saharan countries adopted male partner
involvement in PMTCT programme with an aim
of increasing the uptake of PMTCT services. The
programme has made some progress in improving the effectiveness of PMTCT services.
On the other hand the strategy is facing a lot of
challenges, the biggest being low male partner
involvement. This article therefore seeks to review the successes and challenges faced by
male involvement in sub-Saharan Africa. It also
proposes the way forward in order to improve its
effectiveness. We used peer reviewed articles of
research studies conducted in sub-Saharan Africa
and other related reliable sources of data to write
the paper.
Keywords: Male Partner; Involvement; PMTCT;
HIV/AIDS; MTCT; Successes; Challenges

1. INTRODUCTION
HIV still remains a major challenge globally despite decades of advocacy, awareness raising and investing in proCopyright 2012 SciRes.

grammes to control the spread of HIV. UNAIDS estimated

that by 2009, 33.3 million people globally were living with
HIV of which 22.5 million were from sub-Saharan Africa.
UNAIDS also estimated that within the same period, about
2.5 children globally were living with HIV of which 1.8 million were from sub-Saharan Africa [1]. In sub-Saharan Africa
an estimated 60% of people living with HIV are women,
mostly in the reproductive age group. Each year approximately 1.4 million women living with HIV become pregnant.
Among antenatal clients in sub-Saharan Africa, the proportion of women living with HIV ranges from 5% to as high as
30% and HIV among childbearing women is the main cause
of infection among children [2]. Mother-to-child transmission
of HIV has been virtually eliminated in industrialized countries, but remains common in Africa. In 2008, for every one
child living with HIV in North America and Western and
Central Europe, there were nearly 800 children infected with
HIV in sub-Saharan Africa [3].
Transmission of HIV from mother to child can take place
during pregnancy, labour and delivery as well as after birth
via breastfeeding especially mixed feeding. The risk of
transmission varies at different stages ranging from 5% 10% during pregnancy, 10% - 20% during labour and
delivery, and 10% - 20% through mixed infant feeding. It
is estimated that in the absence of any intervention to prevent mother to child transmission, (MTCT) ranges from
15% - 45%. This rate can be reduced to levels below 5%
with effective interventions [4]. PMTCT was introduced as
a comprehensive package of interventions known as Prevention of mother to child transmission (PMTCT) programme with an aim of reducing MTCT. PMTCT programme consists of a range of interventions, including
improved antenatal services, opt-out HIV counseling and
testing for pregnant women, antiretroviral drug prophylaxis for HIV positive pregnant women and newborns,
referral to support groups, and counseling on options for
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safer infant feeding practices. Comprehensive PMTCT

programme also includes continued follow-up and treatment for HIV positive mothers and their children, especially for the first 18 months of the childs life [4,5].
The 1994 international conference on Population and development in Cairo and the 1995 international conference
on women in Beijing organized by UN called global attention to the importance of involving men in reproductive
health programs because of their influence on womens
health [6,7]. In 2002 the World Health Organization (WHO)
formulated recommendations advising couple HIV testing
in settings with high HIV prevalence [8]. WHOs 20102015 PMTCT Strategic Vision, emphasizes the need to involve male partners in scaling up PMTCT services in
sub-Saharan Africa. WHO introduced the policy guidelines
based on the assumption that couple testing would help increase spousal support for women to use prevention of
mother to child transmission (PMTCT) services, create opportunities for secondary prevention by counseling both
men and women about HIV, and increase the uptake of
testing and identification of HIV infected persons [9].
In PMTCT programme men are encouraged to accompany their pregnant wives to antenatal clinic in order to be
counseled and tested for HIV together. Men are also encouraged to be supportive to their pregnant wives if found
HIV positive and to encourage them to adhere to all PMTCT protocols. Before the introduction it was observed
that a lot of pregnant women were shunning HIV testing
because they had no consent from their husbands. Those
who had courage to go for test, if tested positive were afraid
to disclose their sero status to their husbands because
they thought their husbands would accuse them of infidelity or even face divorce. Some HIV positive women
who had courage to inform their husbands, faced divorce,
violence or accused of infidelity, some were not even
allowed to continue with PMTCT interventions. This
resulted in low uptake of PMTCT services by HIV positive women. Male partner involvement in PMTCT was
then introduced with an aim of combating these problems
and consequently increasing uptake and adherence to
PMTCT interventions by HIV infected women [5,9].
Since its introduction in sub Saharan Africa, male partner involvement has made an impact in reducing Maternal to child transmission of HIV nevertheless it has its
own challenges. This review therefore seeks to establish
the impact of male partner involvement in PMTCT in
terms of progress made by exploring successes and challenges of the program and suggesting recommendations to
improve the programme in sub-Saharan Africa. It uses peer
reviewed articles of research studies conducted in subSaharan Africa and other reliable sources of data such as
WHO, UNICEF and UNAIDS.
Copyright 2012 SciRes.

2. PMTCT PROGRESS IN SUB-SAHARAN

AFRICA
2.1. HIV Testing and Counseling
By the end of 2009, six countries in sub-Saharan Africa
provided HIV tests to less than one third of all pregnant
women: Nigeria (13%), the Democratic Republic of the
Congo (9%), Ethiopia (16%), Chad (6%), Angola (26%)
and Sudan (3%). In these countries, considerably greater
investments are needed to increase HIV testing and counseling among pregnant women in order to effectively prevent mother-to-child transmission of HIV and to enroll eligible women living with HIV in appropriate care and treatment. Four countries reported to have provided HIV testing and counseling to over 80% of pregnant women in
their countries: South Africa (>95%), Zambia(>95%), Botswana (93%) and Namibia (88%) [10].

2.2. Antiretroviral Prophylaxis HIV Pregnant

Mothers
In sub-Saharan Africa, coverage of antiretroviral drugs
for preventing mother-to-child transmission reached 54%
in 2009, from 45% in 2008. However, there were considerable differences between sub regions: whereas 68% of
pregnant women received antiretroviral drugs for preventing mother-to-child transmission in Eastern and Southern
Africa. In West and Central Africa the comparable figure
was 23%. Botswana, Namibia, Swaziland and South Africa (the country with the largest number of pregnant women living with HIV) have already reached the target set
at the United Nations General Assembly Special Session
(UNGASS) on HIV/AIDS of providing 80% of pregnant
women in need with antiretroviral drugs for reducing the
risk of mother-to-child transmission of HIV [10].
The overall gap in reaching the target of 80% coverage
of antiretroviral prophylaxis for preventing mother-to-child
transmission is becoming more concentrated in a handful
of countries, with 14 countries comprising more than 80%
of the global gap. Nigeria alone now contributes to 32%
of the gap, with the Democratic Republic of the Congo
next, contributing 7% of the gap [11].

2.3. Antiretroviral Prophylaxis for Infants

Born to Mothers Living with HIV
The 2010 WHO guidelines recommend that all infants
born to HIV-positive mothers should receive antiretroviral
prophylaxis [10]. About a third of infants in sub-Saharan
Africa were reached with antiretroviral prophylaxis (31%
in 2008 and 35% in 2009). In Eastern and Southern Africa, 45% of infants received antiretroviral prophylaxis in
2009. Swaziland, Namibia and Botswana, coverage among
children was 70% or higher while in West and Central Africa, only 12% did. Only Benin and Gambia reached over
40% of children in need with antiretroviral therapy [10,11].
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3. CHALLENGES AND OBSTACLES TO

SCALE-UP PMTCT IN SUB-SAHARAN
AFRICA
There are a lot of challenges and obstacles to scale up
PMTCT services in sub-Saharan Africa. Most PMTCT programs in sub-Saharan Africa focus only on medical intervention, leaving out the others that address the social drivers of MTCT including primary prevention, male involvement, family planning and other reproductive health measures [3]. PMTCT services continue to suffer from low
counseling uptake and low testing proportions. Furthermore, loss to follow-up is high, as mothers may either not
return for delivery or deliver in a health facility which does
not offer a PMTCT service [12].
HIV testing of men also remains challenging, with an estimated 6.1% of men in sub-Saharan Africa having ever
been tested for HIV and receiving the results [13]. Further
challenges include large proportions of home deliveries,
shortages of personnel, inadequate supplies of test kits, varying distribution and availability of PMTCT service delivery points, lack of supplementary feeds for women who
may opt for non-breastfeeding for their infants, and logistical and social implications after testing HIV positive, such
as a lack of spousal support and sometimes violence [14].
Some countries have been slow to revise national policy to reflect global guidance on PMTCT and peadiatrics
treatment and care, in particular recent guidance that recommends use of a combination of drugs for ARV prophylaxis in pregnant women. Policies are not always disseminated well. Health workers at clinic facilities are often unaware of existing policies and guidelines and unclear
about what advice to give to mothers living with HIV
about infant feeding. Failure to promote exclusive breastfeeding, unless in circumstances where replacement feeding is acceptable, feasible, affordable, sustainable and safe
is also putting infants at increased risk of HIV and of
other infections as a result of mixed feeding or early
cessation of breastfeeding. There is often a lack of standard operational guidelines to support the implementation
of comprehensive PMTCT and ensure that services are
integrated. Weak health systems are a significant challenge, in particular shortages of key cadres of health
workers, inadequate equipment and poor procurement and
supply management. Scale-up is difficult when health
services lack staff that can provide HIV counseling and
testing, administer ARVs and advise women about family.
Follow-up treatment and care for mothers and children is
still limited in many countries, Pregnant women may be
deterred from finding out their HIV status and accessing
PMTCT services in contexts where HIV is highly stigmatized and male involvement is limited. Data on infant
feeding choices and the quality of follow up treatment,
care and support for women and infants is not available
Copyright 2012 SciRes.

from many of the sub-Saharan Africa countries surveyed

[14,15].

4. MALE PARTNER INVOLVEMENT IN

PMTCT IN SUB-SAHARAN AFRICA
4.1. Rationale for Male Partner Involvement
in PMTCT
Men are decision makers in many of the African settings where PMTCT is offered [16]. Without working with
men change would be very difficult or impossible [17].
Literature shows that risk behaviors change dramatically
among couples where partners are aware of their HIV serostatus [18]. One major factor that prevents some women
from accepting HIV testing is the need to seek their partner consent or assent [19]. Across sectional study in Uganda found that the strongest predictor of willingness to accept an HIV test was the womans perception that her husband would approve of her testing for HIV. Women who
thought their Husbands would approve were almost six
times more likely to report a willingness to be tested compared to those who thought their husbands would not approve (OR = 5.6, 95% CI 2.8, 11.2) [20].
Studies in Uganda, Malawi and Nigeria have shown that
the utilization of PMTCT services by pregnant women is
influenced by individual factors such as fear of disclosure
of HIV results, lack of male partner support, fear of violence, abandonment and stigmatization [21-23]. In Cote
dIvoire, 3.5% to 14.6% of pregnant women reported negative consequences of HIV status disclosure to their spouses [24]. In sub-Saharan Africa womens economic vulnerability and dependence on men coupled with traditional
male superiority over women increase their vulnerability
to HIV by constraining their ability to negotiate the use
of a condom, discuss fidelity with partners, or leave risky
relationships [25,26]. This means that if men are involved in PMTCT their understanding in HIV prevention
will be higher and they would cooperate with their
spouses in using condoms and other HIV preventive
measures. The rate of violence, stigmatization and abandonment can also be reduced. Men always play a leading
role in terms of initiating sex. In Malawi, men initiate
sex in 92% of relationships and women feel powerless to
refuse sex or negotiate safe sex [5]. Traditionally it is
common for men to have extra marital relationships thereby putting their spouses at risk of contracting HIV. A
study in Tanzania found that the risk for HIV was greater
among women whose male partner had other sexual
partners [27]. Another study in Tanzania found that male
partner played a role in terms of womans risk of acquiring HIV [12].
With male partner involvement in PMTCT, a couple has
a chance to make informed decisions together on living
positively with HIV, share responsibility for preventing
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HIV in the unborn child and they can discuss safer sex
practices and make informed decisions to access care and
treatment [28]. Men can play an important role of supporting HIV positive pregnant women to get to clinics or hospitals where chances of safe delivery are higher, they can
assist HIV positive pregnant women to choose safe infant
feeding method [18].

4.2. Successes of Male Partner Involvement

in PMTCT
In Zambia and Kenya, couple HIV counseling appeared to improve the acceptability of HIV testing, uptake of
ARV prophylaxis and adherence to prolonged and mixed
breastfeeding. Women who received couple counseling
did not report an increased risk of adverse social events
compared to individually counseled women [27,30,31].
Dropout among those who have discussed HIV testing
with their partners was found to be low in Burkina Faso
[32]. A study conducted in Ivory Coast revealed that men,
who were involved in PMTCT program played an active
role in applying the advice received, particularly related to
exclusive breast feeding and early weaning. Studies in
Kenya found that women accompanied by their partner
for HIV testing were three times more likely to return for
antiretroviral prophylaxis. Couple post-test counseling
was also associated with an eight-fold increase in postpartum follow up, as well as greater antiretroviral utilization and formula feeding [30,33]. In Uganda male involvement is associated with beneficial health outcomes
such as first trimester antenatal visits, abstinence from
smoking and alcohol consumption, reduction in low birth
weight infants as well as positively influence uptake of
HIV testing and preventive interventions for vertical and
sexual transmissions of HIV [34]. In another study in
Kenya the combined adverse outcome risk of vertical
transmission and infant mortality was significantly lower
with male partner involvement. The combined risk for
either vertical transmission or mortality was 45% lower
with male antenatal attendance [35].

4.3. Challenges of Male Partner Involvement

in PMTCT
Literature shows that there is low male partner involvement in PMTCT services in many sub-Saharan countries [12,36]. In sub-Saharan Africa, male participation
rate levels in hospital settings vary between 12.5% and
18.7% [37]. In Malawi, male partners do not often come
forward to test for HIV with their wives, this has contributed to drop outs and non-compliance at many levels of
PMTCT services [28,38,39]. In Tanzania, male involvement in reproductive and child health services is low,
estimated at 5% and lower in urban areas [40]. Several
factors have been found as barriers to male involvement.
These include; culture, health system, socio-economic
Copyright 2012 SciRes.

factors, lack of information, poor communication, stigma

and lack of confidentiality [38-44].
4.3.1. Cultural Factors
Traditionally in sub-Saharan Africa, support and care
are seen as womens work [29]. In Tanzania social and
religious norms that prohibits males from attending female health services and the wide spread attitude that
female reproductive health is not male responsibility was
found to inhibit male involvement in PMTCT [40]. In
Burkina Faso and Cameroon, Antenatal clinic activities
were perceived by many fathers as outside their responsibility [12,13]. In Eastern Uganda the power structure of
marriages in which men are decision makers and have
power over wives action results to men resisting womens
effort to influence them to have HIV testing [36]. A study
conducted in four countries; Cameroon, Dominican republic, Georgia and India indicated that male partner
rarely participated in antenatal care services, mainly because these are traditionally and programmatically a
womans domain [41]. Another barrier is mens perception that he will be viewed as jealous by the community if
he comes to clinic with the pregnant wife [13]. In Malawi,
in settings where a man moves to a womans village when
married, revelation of HIV positive diagnosis by his wife
leads to a husband being looked upon as the one who
brought the infection to his wifes clan and kin. The experience of blame for infecting the family of his in-laws
will commonly be so difficult to live with that husband
eventually leaves his wife and children to manage on their
own. This has led to PMTCT programme being locally
named the divorce programme [42].
4.3.2. Socio-Economic Factors
In Malawi, Men reported that due to socio-economic difficulties, they did not have time to attend ANC with their
partners since they utilize the time to source money to take
care of their families [43]. In South Africa and Uganda,
distance, poor roads, undeveloped transport system and
cost of getting to the hospital bar men from being involved
in PMTCT since most of them have few resources to travel and live along distance from the clinic or hospital [36,44].
In Uganda, charging user fee also prevent male partner from
participating in PMTCT services due to financial problems
[21,36].
4.3.3. Health System Factors
In Uganda, men reported having been forced to wait an
entire day for care at antenatal clinics, a heavy sacrifice for
someone who needs to work to support his family. They
were also excluded from the session where their wives
were examined and had to wait outside without any information about what was happening to their pregnant wives. Furthermore, health workers mistreatment of the spouOPEN ACCESS

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ses made them feel uncomfortable and embarrassed [21,36].

Lack of adequate space in the antenatal clinics coupled
with shortage of health workers and an increase in women
attending antenatal care demotivate men from attending
ANC with their spouses since they have to wait for a long
time before they are attended to [21].
4.3.4. Lack of Information, Trust and Poor
Communication
Lack of information on PMTCT and HIV testing in Tanzania has contributed to low male partner involvement in
PMTCT services [40]. Poor communication between spouses on PMTCT has also contributed to low turnout of men
in antenatal clinics in sub-Saharan Africa [45]. In a study
conducted in Cameroon most women conceded that they
avoid talking about safe sex and HIV/AIDS to their partner because they feel embarrassed if they start conversation on these issues. Some even fear that their partners
would accuse them of infidelity [41].
4.3.5. Stigma and Lack of Confidentiality
In a study conducted in rural western Uganda, AIDS
related stigma and lack of confidentiality created barriers
to seeking VCT among men. More than half of the men
feared to test for HIV because of stigma. Men were worried of being labeled HIV-infected because they would
lose their social privileges. They expressed fear of meeting familiar people in HIV testing clinics, and preferred
to test in distant clinics where they were not known by the
people and staff [46].

4.4. Way Forward in Male Partner

Involvement in PMTCT
Innovative approaches to promote male partner involvement are urgently needed in order to enhance uptake of
PMTCT interventions [47]. Literature has suggested several strategies to improve male involvement in PMTCT.
Tanzania showed a 30% increase in male partner counseling when men were sent a letter of invitation to participate in PMTCT programs [12,48,49]. Other strategies include extending clinic hours so that men who have tight
work or business schedule can visit in late afternoon. Reducing wait times for men or couples who visit MCH clinics in order to give chance to men to return to work and
business in time. Health workers should attend ward development and other community meetings to explain the
importance of male involvement and the need for expectant parents to be tested [48,50].
PMTCT program should integrate beliefs, values and
practices of different cultural settings so that it can attract
more male partners [42]. Communication with partner plays
a vital role in the uptake of HIV testing. Encouraging women to engage in discussion about testing with their partCopyright 2012 SciRes.

ners may improve male partner participation in PMTCT

[21]. Refresher courses for midwives and nurses should be
conducted on regular basis so that they can make PMTCT
services more male friendly. Other studies suggested, Weekend clinics hours, making clinics more male or couple friendly or introducing specific clinics for pregnant couples
as effective ways to increase male involvement in PMTCT
activities [12,49]. Governments should also bring services
closer to the people for easy access. A three-arm randomized controlled trial (RCT) was conducted in DRC that offered VCT at a neighborhood health center, bar and church
to male partners of pregnant women attending a maternity unit in Kinshasa. Male participation was significantly
higher in bars (26%, P, 0.001), and higher but not statistically significant in church-based VCT (21%, P 1 4 0.163)
compared with health centre VCT (18%). Male participation in VCT associated with ANCs was higher in non-health service settings, particularly in bars [37].
Welfare of health workers should be improved so that
they are motivated to carry out their duties whole heartedly in addition to this more staff should be recruited in
the health service so that waiting time for ANC attendees
is reduced [21]. In South Africa, Uganda and Burkina Faso,
use of male nurses to motivate male partners and the use
of IEC in the community to encourage men to accompany
their wives to ANC was found to be useful [30,32,34,52].
Peer influence and role models, provision of transport to
testing site, provision testing to non-governmental organization and provision of home-based testing were also found
to be effective in improving male involvement in PMTCT
[36]. In Democratic Republic of Congo at Kingasani maternity, male participation in PMTCT was increased from
2% to 18% when men were invited to PMTCT services
between 15:00 and 20:00 hours through letters [37]. A study in Tanzania where men were asked on their approval of
different ways to overcome mens barriers, the highest affirmation was expressed for special couple voluntary counseling and testing (CVCT) hours within ANC services (91
persons, 73%), followed by a special waiting area for
men/couples (75 persons, 61%), an invitation letter from
the health facility delivered to men by their wives (58
persons, 47%) and an official letter excusing from work
for ANC attendance (53 persons, 43%). 80 interviewees
(65%) suggested to offer CVCT in ANC services not only
during working days to enable male partners to attend
[51].

5. CONCLUSION AND PERSPECTIVES

Men are decision makers in many societies and families in sub-Saharan Africa; they make important decisions
that affect the health of the family members positively or
negatively. Literature has shown that male partner involvement in PMTCT is very important for successful impleOPEN ACCESS

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F. W. Kalembo et al. / Open Journal of Preventive Medicine 2 (2012) 35-42

mentation of the programme. It can increase up take of

PMTCT services by HIV positive pregnant women. Literature has also shown that countries which are doing well
in PMTCT programme already adopted male partner involvement. The biggest challenge being faced by many
countries is low participation of male partners in PMTCT
services. Lack (or low) of male involvement implies low
uptake of PMTCT interventions and increase in maternal
to child transmission of HIV. There is need for more research studies in sub-Saharan countries to find innovative strategies that do not only consider male partners as
mere supporters of women in PMTCT services but rather
as active participants. Such strategies should also incorporate ways of changing the mind set of African men of
perceiving motherhood and PMTCT as womens domain
but rather as a collective responsibility. Some countries
in sub-Saharan Africa are silent on the role of male partners in PMTCT. There is need for research studies in
such countries to explore the feasibility and importance of
male partner involvement in PMTCT services. Few research studies have also been done to establish the rate of
male involvement in PMTCT in sub-Saharan Africa.
There is need for further research on this area in order to
determine the level of male partner involvement in
PMTCT which can be of great importance in planning for
PMTCT scale-up activities.

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