The benefits of men's engagement in PMTCT - Extranet Systems ...

Male involvement in theprevention of mother-to-childtransmission of HIV

AcknowledgementsThis paper was written by Eric Ramirez-Ferrero (WHO consultant) and its development and finalizationwas coordinated in UNAIDS by Karusa Kiragu and in the WHO Department of Reproductive Healthand Research (RHR) by Manjula Lusti-Narasimhan. The paper was revised and updated after a Subregionalconsultation to discuss strengthening male involvement in the elimination of mother-tochildtransmission of HIV held in Kigali, Rwanda from 24-26 August, 2011, hosted by the Ministry ofHealth, Rwanda (Meeting report: http://www.who.int/entity/reproductivehealth/topics/linkages/male_involvement_PMTCT.pdf).The revised paper was further reviewed by and technical input was received from numerous colleagues inWHO/RHR and WHO/HIV and UNAIDS.WHO Library Cataloguing-in-Publication DataMale involvement in the prevention of mother-to-child transmission of HIV.1.HIV infections – transmission. 2.Infectious disease transmission, Vertical – prevention and control. 3.Men.4.Spouses. 5.Health knowledge, attitudes, practice. 6.Risk reduction behavior. 7.Africa South of the Sahara.I.World Health Organization.ISBN 978 92 4 150367 9 (NLM classification: WC 503.3)© World Health Organization 2012All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int).Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercialdistribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html).The designations employed and the presentation of the material in this publication do not imply the expressionof any opinion whatsoever on the part of the World Health Organization concerning the legal statusof any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers orboundaries. Dotted lines on maps represent approximate border lines for which there may not yet be fullagreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsedor recommended by the World Health Organization in preference to others of a similar nature that arenot mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initialcapital letters.All reasonable precautions have been taken by the World Health Organization to verify the information containedin this publication. However, the published material is being distributed without warranty of any kind,either expressed or implied. The responsibility for the interpretation and use of the material lies with thereader. In no event shall the World Health Organization be liable for damages arising from its use.« Printed by the WHO Document Production Services, Geneva, Switzerlandcover photos: top right clockwise- WHO, UNICEF, Photoshare, UNICEFii

ContentsAbbreviations and acronymsSummaryIntroduction 1Rationale and background 1Gender inequality and its impact on PMTCT 4The benefits of men’s engagement in PMTCT 5What is the nature of men’s current participation in PMTCT? 8What are the barriers to men’s participation in PMTCT? 9The evidence base: moving towards gender-transformative programmes 12How do we move towards gender-transformative programming?Suggested characteristics of male-involvement programmes in PMTCT 16The question of relationship quality: the missing piece? 22Methodological considerations, questions and resources 24Issues for consideration 26Gaps in knowledge and suggestions for further work 28References 30ivviii

Male involvement in the elimination of mother-to-child transmission of HIVAbbreviations and acronymsAIDS acquired immunodeficiency syndromeANRS National Agency for AIDS Research (France)ARTantiretroviral therapyAZTazathioprineCDCCenters for Disease ControlCHAMPION Channelling Men’s Positive Involvement in the National HIV ResponseCHTC couples HIV testing and counsellingCIconfidence intervalCOCcouple-oriented post-test HIV counsellingDALY disability-adjusted life-yearGEM Gender-Equitable Men (Scale)HTCHIV testing and counsellingHIVhuman immunodeficiency virusHPTN HIV Prevention Trials NetworkIDMT Interdepartmental Management TeamIPVintimate partner violenceJHHESA Johns Hopkins Health and Education in South AfricaMDG Millennium Development GoalMTCT mother-to-child transmissionNGO nongovernmental organizationORodds ratioPEPFAR The US President’s Emergency Plan for AIDS ReliefPMTCT prevention of mother-to-child transmissionPPTCT prevention of parent-to-child transmission of HIVSANAC South Africa National AIDS CouncilSRHsexual and reproductive healthSTIsexually transmitted infectionTBtuberculosisUNAIDS Joint United Nations Programme on HIV/AIDSUNFPA United Nations Population FundUNICEF United Nations Children’s FundUSAID United States Agency for International DevelopmentVCTvoluntary counselling and testingWHO World Health Organizationiv

Male involvement in the elimination of mother-to-child transmission of HIVvi

Male involvement in the elimination of mother-to-child transmission of HIVIntroduction1. This paper seeks to promote fruitful discussionsand deliberations to advance constructive men’sengagement in the elimination of paediatric HIVand the promotion of women’s and family health.Originally written as the background paper forthe WHO and UNAIDS sponsored subregionalexpert consultation on male involvement inPMTCT, held in Kigali, 24–26 August 2011, thepaper builds on global and regional efforts tointegrate meaningfully men’s participationinto health services and programmes. Theseefforts include the Global Task team meeting onelimination of new paediatric HIV infections (GTT)(Johannesburg, May 2011) and as well the USAID/PEPFAR consultation on FP/MNCH/HIV integration(Washington DC, April 2011). With a focus on sub-Saharan Africa, this paper highlights the currentliterature on men’s engagement in PMTCT, includingthe documented benefits of male involvement inthe PMTCT of HIV, barriers to men’s engagement,promising strategies to involve men, and conceptualand methodological issues that merit furtherconsideration and research. As a foundation forthe discussion, this paper uses the World HealthOrganization’s (WHO’s) PMTCT strategic vision, 2010–2015 (WHO 2010a) and the Joint United NationsProgramme on HIV/AIDS (UNAIDS) correspondingGlobal plan towards the elimination of new HIVinfections among children by 2015 and Keeping TheirMothers Alive, 2011–2015 (UNAIDS 2011) and theUNAIDS outcome framework: business case 2009–2011(UNAIDS 2010a) From these documents, this paperspecifically highlights integration of services andan increased focus on couples as practical andpromising strategies, opening the way for increasedmale involvement. It also deliberately problematizesour current conceptual understanding oracceptance of PMTCT (and HIV and other sexual andreproductive health services) as women’s domain.Indeed, this paper argues that to maximize thehealth outcomes of PMTCT for children, women andmen, we must move beyond seeing men as simply“facilitating factors” to enable women to accesshealth-care services (Peacock et al. 2009; Larssonet al. 2010) but as constituent parts of reproductivehealth policy and practice (Theuring et al. 2009).Rationale and background2. The statistics. In 2009, 370 000 children becameinfected with HIV globally – more than 1000 everyday (UNAIDS 2011). Nearly all of these childrenacquired HIV through mother-to-child transmission(MTCT) (McIntyre 2006; UNAIDS 2006). Sub-SaharanAfrica is disproportionately affected by paediatricHIV. About 2 million HIV-positive children below theage of 15 years live on the continent, accounting forapproximately 90% of all the HIV-infected childrenworldwide (Byamugisha et al., 2010b). Globally, HIVcontinues to wreak havoc on the health of women.HIV is the leading cause of mortality for womenof reproductive age, and in countries with a highburden of the disease, such as South Africa andZimbabwe, HIV is now the leading cause of maternalmortality (WHO, 2010a). It is estimated that in 2009between 42 000 and 60 000 pregnant woman diedbecause of HIV (UNAIDS 2011).3. Despite much progress, access and utilizationof PMTCT services are low. In high-incomecountries, MTCT of HIV has been decreased toabout 1% through preventive measures, includingeffective voluntary or routine counselling andtesting for HIV, antiretroviral therapy (ART) andthe use of safe, affordable and accessible breastmilksubstitutes (Tudor Car et al. 2011). While thisfact signals the effectiveness of efforts to halt newinfections, the reality in resource-poor countriesis starkly different. There, the coverage of womenand children with PMTCT interventions remainsunacceptably low (Gloyd et al. 2007; Johnson 2009).In 2009, an estimated 26% of pregnant womenin low- and middle-income countries were testedfor HIV, and 53% of the estimated HIV-positivepregnant women received at least some type ofART prophylaxis. Programme coverage was below1

Male involvement in the elimination of mother-to-child transmission of HIV50% in 11 of the 25 countries with the largestnumber of women needing ART to reduce motherto-childtransmission (WHO/UNAIDS/UNICEF 2010).However, it is important to recognize that since theyear 2000, many low- and middle-income countrieshave made impressive progress in the introductionand scale-up of programmes for PMTCT of HIV as anintegrated component of antenatal care.lives, reproductive rights, and needs at the centreof their national plans to scale-up interventions toprevent paediatric infection and to promote thehealth of mothers (see the programmatic frameworkof the Global plan in Table 1). This means that plansmust “be firmly grounded in the best interests of themother and child” (UNAIDS 2011:8) and that servicesmust be holistically responsive to their needs.4. Rapid scale-up of effective interventions withwomen at the centre of the global response. TheWHO’s PMTCT strategic vision, 2010–2015 (WHO2010a) and UNAIDS’s corresponding Global plantowards the elimination of new HIV infections amongchildren by 2015 and keeping their mothers alive,2011–2015 (UNAIDS 2011) and UNAIDS outcomeframework: business case 2009–2011 (UNAIDS 2010a)clearly urge countries to place the reality of women’s5. Increasing responsiveness to the reality ofwomen’s lives: HIV and sexual and reproductivehealth (SRH) integration. Creating linkagesbetween HIV and other SRH services accomplishesmany things. Integration makes “people sense” andacknowledges the realities of women’s needs. Forexample, the integration of PMTCT interventionswithin maternal and newborn health-care servicesmakes sense because these services temporallyTable 1. PMTCT and the global plan towards the elimination of new HIV infections among children by 2015and keeping their mothers aliveWhat is MTCT?The programmeframework“HIV infection transmitted from an HIV-infected mother to her child duringpregnancy, labour, delivery or breastfeeding is known as mother-to-childtransmission (MTCT).” (WHO 2010a)The implementation framework for the elimination of new HIV infectionsamong children and keeping their mothers alive will be based on a broaderfour-pronged strategy. This strategy provides the foundation from whichnational plans will be developed and implemented and encompasses a rangeof HIV prevention and treatment measures for mothers and their children,together with essential maternal, newborn and child health services, as wellas family planning, and as an integral part of countries’ efforts to achieveMillennium Development Goals (MDGs) 4 and 5, as well as 6.Prong 1 Prong 2 Prong 3 Prong 4Prevention of HIVamong women ofreproductive age withinservices related toreproductive healthsuch as antenatalcare, postpartum andpostnatal care andother health and HIVservice-delivery points,including working withcommunity structures.Providing appropriatecounselling and support,and contraceptives,to women living withHIV, to meet theirunmet needs for familyplanning and spacing ofbirths, and to optimizehealth outcomes forthese women and theirchildren.For pregnant womenliving with HIV, ensuringHIV testing andcounselling and accessto the antiretroviraldrugs needed toprevent HIV infectionfrom being passed onto their babies duringpregnancy, delivery andbreastfeeding.HIV care, treatmentand support forwomen and childrenliving with HIV, andtheir families.2

Male involvement in the elimination of mother-to-child transmission of HIVcoincide with pregnancy, labour, delivery andearly postpartum and because the majority ofwomen attend antenatal clinic at least once (TudorCar 2011). Integration upholds the human right toaccess primary care: “it recognizes the importanceof empowering people to make informed choicesabout their sexual and reproductive health, andthe vital role that sexuality plays in people’s lives”(UNAIDS 2010b:15). It is especially important toconsider here the human right of HIV-positiveand HIV-negative women alike to decide whetherto have children, and, if so, when, and how manyto have, given the compelling evidence of familyplanning as an effective HIV-prevention strategy(Wilcher et al. 2008). Integration acknowledgesthe epidemiological reality: both men and womenare at increased risk for acquiring HIV during thewoman’s pregnancy (Moodley et al. 2009). “Themajority of HIV infections are sexually transmittedor are associated with pregnancy, childbirth andbreastfeeding; and the risk of HIV transmissionand acquisition can be further increased dueto the presence of certain sexually transmittedinfections (STIs). Moreover, sexual and reproductiveill-health and HIV share root causes, includingeconomic inequality, limited access to appropriateinformation, gender inequality, harmful culturalnorms and social marginalization of the mostvulnerable populations” (UNAIDS 2010b:15).Integration creates synergy and can lead to costsavings: because many of the countries withthe highest burden of HIV also face the greatestchallenges in improving maternal and child healthoutcomes, utilizing the existing structures andhuman resources to extend services can serve as akey and cost-effective strategy to achieve equitableand universal access to health care and to improvethe health and survival of women and children.6. Another reality of women’s lives: men. PMTCTprogrammes focus on women, leading many tocall for an examination of men’s engagement inPMTCT to realize the programme’s objectives—notonly to reduce the incidence of infection amongwomen and infants but also to better meet theHIV prevention and care needs of the family unitas a whole. Indeed, during the last decade maleinvolvement has been recognized as a priorityfor PMTCT programmes (WHO et al. 2007). Thereason for this is clear. There is ample evidencedocumenting the impact of men’s involvement onthe various components of PMTCT programmes(Falnes et al. 2011): men play an important role interms of women’s risk of acquiring HIV (Msuya etal. 2006b), and prevention, in terms of condom usein the couple relationship (Farquhar et al. 2007;Desgrees-du-Lou et al. 2009a). Men also play arole in women’s utilization of services, includingtesting for HIV (Maman et al. 2001; Baiden et al.2005; Banjunirwe and Muzoora 2005; Peltzer et al.2008) and obtaining the follow-up results (Peltzeret al. 2008). Male partners also influence women’streatment decisions, including whether she receivesmedication (Farquhar et al. 2004; Msuya et al. 2008;Peltzer et al. 2008) and whether she adheres toinfant feeding advice (de Paoli et al. 2002, 2004b;Brou et al. 2007; Farquhar et al. 2004; Msuya et al.2008; Tijou Traore et al. 2009).7. Male involvement as part of the globalresponse. In response to this reality, and as partof its woman-centred approach, the Global plandeclares that “efforts must be taken to secure theinvolvement and support of men in all aspects ofthese programs and to address HIV and genderrelateddiscrimination that impedes service accessand uptake as well as client retention” (UNAIDS2011:8). Because SRH programmes and serviceshave been focused primarily on women, menhave often lacked information to make informeddecisions about healthy behaviours and theroles they might play in promoting overall familyhealth, including accessing HIV prevention, careand treatment services. Studies demonstrate thatwhen given the opportunity to participate in SRHprogrammes, such as family planning and thePMTCT programmes, men wish to be positivelyinvolved in promoting the health of their familiesand communities (Peacock et al. 2009). The result, asthis paper demonstrates, is that men’s constructiveengagement can and does yield positive results forthe health of women, children and families.3

Male involvement in the elimination of mother-to-child transmission of HIVGender inequality and itsimpact on PMTCT8. Historically, many PMTCT programmes haveorganized their services as if potential clients werefree to act independently. Thus, most awareness andimplementation efforts related to family planningand HIV prevention and care have been directedprimarily at women, disregarding the cultural andgender norms that may impact women’s decisionmakingregarding these issues (Peacock et al.2009). The reality is that women’s decision-makingabout their pregnancies and health are deeplyinfluenced by their partners, communities andsocial norms and beliefs regarding HIV and AIDS(UNAIDS 2011). Below, recent research illustrates theways in which patriarchal gender norms affect thevarious components of PMTCT service utilization,delivery and efficacy.9. Women may be unable to negotiate sex or safesexual practices, such as condom or contraceptiveuse, which can lead to HIV infection, STI orunplanned pregnancy. It is clear from the researchthat in most settings in sub-Saharan Africa socialand cultural norms grant men the power to decidethe nature of the sexual relationship. Across manystudies, there was a clear consensus among studyparticipants, that the decision to use a condomrested with the male partner (Farquhar et al. 2004;Desgrees-du-Lou et al. 2009b), and that men oftenassociated condom use with infidelity, and thusconsidered it not appropriate for use within thecontext of a committed relationship (Falnes et al.2011). Despite the knowledge about condoms thatwomen gained at clinics, and their subsequentfavourable view of them, many women refused toask their partners to use a condom, in fear of theirpartners’ reactions (Falnes et al. 2011).10. Fear of rejection, stigmatization, and violencemay prevent women from utilizing HIV testing andcounselling (HTC) services. Women’s fear of theirpartners’ reactions to HIV testing and the disclosureof results was a significant barrier to accessingthese services (Maman et al. 2001, 2003; Medleyet al. 2004; WHO 2004; Bajunirwe and Muzoora2005). They feared how their partners wouldreact, abandonment, loss of economic support,fear of stigmatization, rejection, discrimination,violence, upsetting family members, and avoidingaccusations of infidelity (Bor 1997, Kilewo et al.2001; Gaillard et al. 2002; de Paoli et al. 2004a;Medley et al. 2004). In fact, the strongest predictorof willingness to accept an HIV test was the woman’sperception that her husband would approve of hertesting for HIV. Women who thought their husbandswould approve were almost six times more likely toreport a willingness to be tested compared to thosewho thought their husbands would not approve(odds ratio (OR) = 5.6, 95% confidence interval(CI) = 2.8 to 11.2) (Bajunirwe and Muzoora 2005).In one study, partner’s consent was the principalreason for opting out of HIV testing (Homsy et al.2007).11. However, much of the research cited inparagraph 10 was conducted before the expandedavailability of treatment, access to ART and theintroduction of opt-out testing. Opt-out testingwas generally more acceptable to men andwomen. It is significant to note, that if the HIVtest was considered a routine part of the PMTCTprotocol, men were much more accepting of theirpartners’ testing (Falnes et al. 2011). Opt-out testingalso lessened women’s fear and made them moreaccepting of testing (Byamugisha et al. 2010a). Itwas much less acceptable for women to seek VCTif it was not a routine part of care. Men interpretedthis to mean that a woman either suspected herpartner to be unfaithful, or that she herself had beenunfaithful (Falnes et al. 2011).12. Women feel burdened by clinics’ request thattheir partners be tested (Larsson et al. 2011). Dueto the fears of testing and disclosure of results totheir male partners, women did not feel empoweredto ask their partners to undergo an HIV test. Rather,they expressed the desire that the request comefrom the clinic staff themselves (Falnes et al. 2011).13. Adherence to infant feeding was influencedby men. Infant feeding was considered to be thedomain of women, but only so long as the infant4

Male involvement in the elimination of mother-to-child transmission of HIVfeeding pattern conformed to social norms. Sinceinfant feeding is often done in public settings,how women chose to feed their babies is evidentto neighbours and family members. This choicecan inadvertently lead to a disclosure of thewoman’s HIV-positive status if it does not conformto normative cultural patterns of feeding. This, inturn, can result in the woman facing such sanctionsas, “being forced to breast feed, or even beingdivorced” (Falnes et al. 2011).14. For all of these reasons, we know that maleinvolvement and community participation arecritical elements of successful programmes: “Theprocess of developing and implementing programsmust include the meaningful participation ofwomen, especially mothers living with HIV to tacklethe barriers to services and to work as partners inproviding care. In addition, efforts must be takento secure the involvement and support of men inall aspects of these programs and to address HIVandgender-related discrimination that impedesservice access and uptake as well as client retention”(UNAIDS 2011:8).The benefits of men’sengagement in PMTCT15. Many of the studies in the last sectiondocument the effects of men’s lack of involvementin maternal and child health in Africa. It is the kindof information that fuels an often unspoken notionof men as obstacles to health instead of partnersin promoting family health. However, there is agrowing body of evidence indicating that manybenefits can accrue to the overall reproductivehealth of families when men critically examinenorms of power, acquire new knowledge and skillsand challenge prevailing gender norms (WHO2007).16. Why is it important to engage men in PMTCTand the promotion of overall family health? ACARE-Burundi staff member at a recent trainingput it quite simply: “Reproduction requires both aman and a woman. Men are half of the equation.They have to be involved”. Currently, men makemany decisions that affect private, family life. Theirconstructive involvement and support in theelimination of paediatric HIV and the promotionof women’s and family health would not onlyenable men and women to share responsibility forfamily health (currently borne disproportionatelyby women), but would also accelerate globalprogress towards the achievement of the MDGs(especially goals 3–6) that are key to nationaldevelopment (see Table 2). If we are truly interestedin creating a broad-based global response to theelimination of paediatric HIV, we cannot exclude halfthe population. We must rally men to the cause anddemonstrate the benefits of gender equality, shareddecision-making, partnership and non-violence– to themselves and their families. This sectiondocuments the effects that men’s positive andconstructive involvement can have on PMTCT.17. Men’s involvement plays a role in HIVprevention by helping to facilitate couplecommunication related to sexuality. Partnerparticipation increases spousal communicationabout HIV and sexual risk (Desgrees-du-Lou et al.2009a). This becomes especially critical in discordantcouples, where men’s involvement in testing mayenable the couple to address condom use, decreasesex with outside partners and thus help to preventHIV and other STI transmission to the uninfectedpartner (Roth et al. 2001; Allen et al. 2003). Studieshave also shown an association between men’sinvolvement and contraceptive use (Becker 1996;Sternberg and Hubley 2004). Finally, men assupportive partners can influence the family’s socialenvironment, especially with extended family, tocreate an environment that is more conducive toseeking treatment, being adherent to medicationsand clinical appointments and remaining in careboth during the pregnancy and after delivery. Thus,involving men as supportive partners can helpensure the ongoing health of both parents as well asthe prevention of perinatal transmission.18. A variety of benefits are derived from couplecounselling and testing for HIV. In one study inKenya, seropositive women who attended VCT withtheir spouse were three times more likely to adhere5

Male involvement in the elimination of mother-to-child transmission of HIVTable 2. Millennium Development Goals and the global plan (UNAIDS 2011)The central importanceof PMTCT to globalhealthThe elimination of new HIV infections among children and keeping theirmothers alive contributes directly towards achieving four of the MDGs, whereHIV currently holds back progress. Similarly, progress on achieving other MDGscontributes to HIV prevention and treatment for women and children.MDG 3 MDG 4 MDG 5 MDG 6Promote genderReduce child mortality –Improve maternal healthCombat HIV/equality andby reducing the number– through preventionAIDS, malaria andempower women – byof infants infectedof HIV among womenother diseases – bysupporting women’swith HIV; by providingand provision of familypreventing theempowermenttreatment, care andplanning for HIV-positivespread of HIV throughthrough access tosupport for uninfectedwomen of childbearingpreventing infection inHIV-preventionchildren born to mothersage; and by ensuringwomen of childbearinginformation, HIV-living with HIV andeffective care, treatmentage; preventingprevention andensuring effectiveand support for mothersHIV transmission totreatment services,linkages to life-savingliving with HIV. Strongchildren and treatingand SRH services; bytreatment for childrenhealth systems can helpmothers; and ensuringinvolving mothersliving with HIV; and,ensure that every birthstrong and effectiveliving with HIV as keyindirectly, by improvingis safe and pregnantlinkages to ongoingpartners in deliveringmaternal health andwomen are able tocare, treatment andthe plan and engagingensuring safer infantdetect HIV early andsupport for childrentheir male partners. Byfeeding practices.enrol in treatment.and mothers livingempowering women,By improving livingwith HIV. By providingthey are better ableconditions and familytuberculosis (TB)to negotiate safer sex,care practices, survivaltreatment, deathsand by eliminatingrates of children born toamong pregnantgender-based violence,women living with HIVwomen living withwomen’s vulnerabilityare increased.HIV are reduced. Byto HIV is reduced.preventing TB andmalaria, child andmaternal mortalityamong women andchildren living with HIVis reduced.6

Male involvement in the elimination of mother-to-child transmission of HIVto their treatment regimen during pregnancy andat the time of delivery, and five times more likelyto adhere to prescribed breastfeeding protocolsthan those who were individually counselled(Farquhar et al. 2004). In another study, the odds ofa woman having a record of facility-based deliverywere 28% higher for a woman counselled andtested with her partner than for a woman whotested alone (Conkling et al. 2010). Health-facilitybaseddelivery is helpful to ensure compliance toinfant antiretroviral dosing but also to ensure thepractice of modified obstetric practices that havebeen shown to reduce MTCT. Women tested withtheir partners were less likely to be lost to followupthan those tested alone (Conkling et al. 2010).When couples received pre- or post-test counsellingtogether, greater use of alternative feeding methods(Farquhar et al. 2004) and greater acceptance of HIVtesting (Semrau et al. 2005) were observed amongwomen.19. There is an association between partnerdisclosure and HIV prevention. Women whodisclosed their HIV status to their partners weremore likely to return for post-test counselling,accept antiretroviral prophylaxis, modify infantfeeding practices and increase condom use in thepostpartum period than those who did not (Kiarieet al.. 2006; Farquhar et al. 2004; Semrau et al.2005; Msuya et al. 2006a). In multivariate analysis,it was found that women who had disclosed theirHIV status and who reported less HIV-relateddiscrimination were more adherent to antiretroviralprophylaxis to prevent MTCT. Similarly womenwhose male partner was involved in antenatal carewere more adherent to both the maternal and infantnevirapine doses (Peltzer et al. 2011).20. Men’s involvement positively impacts infantfeeding practices and mortality. When men knewthat their spouse was HIV-positive and involved inthe PMTCT project, they played an active role inapplying the advice received, particularly related toexclusive breastfeeding and early weaning (TijouTraore et al. 2009). The greatest impact of partnerparticipation in one study in Tanzania (Msuya etal. 2008) was on infant feeding practices. In thisstudy, of those with participating partners whochose exclusive breastfeeding, 64% successfullydid not mix-feed and stopped breastfeeding at4–6 months compared to 28% among those whosepartners did not participate. For those who choseformula feeding, where the partner attended, 80%adhered to the method compared with 29% wherethe partner did not attend. Another study (Aluisioet al. 2011b) in Kenya found that including men inantenatal PMTCT with HIV testing had an impacton infant health outcomes. The authors found thatthe combined risk of HIV acquisition and infantmortality was lower with male attendance andreport of prior male HIV testing, when adjusting formaternal viral load and breastfeeding.21. Beyond the health benefits, there is someevidence suggesting that male involvement mayalso be a cost-effective strategy in the preventionof HIV. An early paper (Postma et al. 1999)concerned with HIV infection acquired by womenduring their pregnancy, focused on estimating thecost–effectiveness of expanded antenatal HIVtesting in London within the framework of universalvoluntary HIV screening in early pregnancy. Thescenario analysis was based on data from a Frenchstudy, which enumerated the numbers of childrenborn HIV-positive despite HIV testing in earlypregnancy. The research revealed that screeningpregnant women for HIV can avert the lifetimecost of caring for an HIV-positive child (estimatedto be $296 905, using a 5% discount rate for timepreference for 1995-6 prices), and could also leadto gains in life-years for both mother and child. Thepaper concluded that universal, voluntary, antenatalHIV screening is a cost-effective intervention withcost saving potential in areas in which there is ahigh prevalence of HIV infection among pregnantwomen. One author of the paper, presenting at thesubregional consultation on male involvement inPMTCT in Kigali, arrived at a further conclusion: thatuniversal/selective repeat HIV testing of woman’spartners, in addition, would be even more costeffectiveif it could avert HIV infection of both themother and father, in addition to the child. A recentmodelling exercise using Rwandan data (Ndagije2011) reached similar conclusions. In Rwanda,7

Male involvement in the elimination of mother-to-child transmission of HIV56% of couples where at least one partner isinfected with HIV are serodiscordant. This translatesinto approximately 133 000 HIV discordant couplesin the country. Using assumptions from the peerreviewedliterature about the effectiveness ofcouple HIV counselling and testing in reducingboth horizontal and vertical transmission, themodel estimates that national rollout of couples HIVtesting and counselling (CHTC) could prevent 31 691infections at a cost of $1136 per infection averted.CHTC had 91 infections averted and 2861 disabilityadjustedlife-years (DALYs) saved – more infectionsaverted and DALYs saved than was observed withthe standard HTC option (88 infections avertedand 2772 DALYs saved). The author concluded thatCHTC is a cost-effective HIV-prevention method fordiscordant couples and for the prevention of HIVtransmission to babies.What is the nature of men’scurrent participation inPMTCT?22. Participation by men in antenatal HIVtesting and counselling is very low. Despite themany benefits of male involvement, studies fromeastern and southern Africa have found testing ratesranging from 8% to 15% (Chandisarewa et al. 2007;Farquhar et al. 2004; Msuya et al. 2008; Katz et al.2009). Falnes et al. (2011) found a lower male testingrate at the antenatal clinic, at 3%, in the UnitedRepublic of Tanzania (Kilimanjaro Region).23. Even so, men’s perceptions about the benefitsof PMTCT are positive and, in general, men aresupportive of their partners’ participation in PMTCTprogrammes (Maman et al. 2003; Medley et al. 2004;WHO 2004; Theuring et al. 2009). However, there isa contradiction between men’s positive attitudes andtheir low participation rates in PMTCT sites, whichrequires explanation (Theuring et al. 2009). 124 . Men who participate in PMTCT are generallyin more committed relationships and reportmore communication with their partners aboutHIV. In a study from Nairobi, men who presentedto the antenatal clinic for HCT were more likelyto be in monogamous marriages and live withtheir partners. They were also more likely to havepreviously discussed HIV testing with their partner(27% versus 19%, P = 0.001) and willing to confidein their partner if they tested HIV seropositive(68% versus 59%, P = 0.004) than men who did notpresent to the clinic. In multivariate analysis, livingwith and reporting having previously discussed HIVtesting with female partners remained significantlyassociated with male attendance at the antenatalclinic (OR (95% CI) = 4.34 (1.05 to 18.0) and 1.49 (1.12to 1.97), respectively). In addition, women whosepartners presented to the antenatal clinic weresignificantly less likely to test HIV seropositive thanwomen whose partners did not present to clinic (10versus 16%, respectively; P = 0.015) (Katz et al. 2009).Other factors associated with men’s participationinclude education level, knowing their serostatusand having heard about PMTCT (Byamugisha et al.2010b). If they had heard about PMTCT, men weretwo times more likely to become involved thanthose who had not.Men’s participation: the chicken or the egg?The evidence is not clear. Is it PMTCTprogrammatic efforts to promote maleinvolvement that are responsible for men’sutilization of services? Or is it men whoare already constructively involved in theirpartners’ lives that utilize PMTCT services (seeBakari et al. 2000; Msuya et al. 2006a; Katz et al.2009 ; Larsson et al. 2010)?1See one possible explanation for this under the section, “Thequestion of relationship quality: the missing piece?” in this paper.8

Male involvement in the elimination of mother-to-child transmission of HIVWhat are the barriers tomen’s participation inPMTCT?25. As illustrated below, there are a varietyof facility-based (supply) and social (demand)factors that serve as barriers to the meaningfulparticipation of men in PMTCT services. Yet perhapsthe most important barriers are the conceptual andpolicy barriers that inadvertently support men’sexclusion from PMTCT and other reproductivehealth services. See Greene and Biddlecom (2000)for an expanded and thoughtful discussion of thisissue. Examples of these barriers are describedbelow.26. Increased international focus and resourceshave led many countries to concentrate theirefforts on the proximate determinants ofpaediatric infection. Since vertical transmission ofHIV to an infant can only occur from an HIV-infectedmother, PMTCT programmes focus on women.Women are encouraged to get tested for HIV andare provided with ARV prophylaxis to preventmother-to-child HIV transmission, if found to beHIV-positive. This emphasis makes biological senseand is in conceptual alignment with the theory andpractice of global reproductive health in recentdecades, which has made women the centrepiece ofits efforts. The global health challenges – populationgrowth, maternal and infant mortality, as examples– that continue to threaten to derail efforts atnational development – have been identified andtied to women. No equivalent urgent health issuehas been identified with men to the same degree(Gutmann 2007). In addition, the “women anddevelopment” model which saw women as goodinvestments in terms of development resources,meant that governments and nongovernmentalorganizations (NGOs) prioritized the participationof women in many development schemes. Howeverthis comes at a cost. The singular focus on womenignores the context of women’s lives as members ofa partnership, family and community and precludesa broader focus on overall family health, includingmen (Betancourt et al. 2010; Njeru et al. 2011).27. Beyond the professional realm of publichealth, the social or cultural milieu in which welive has also traditionally associated reproductionwith the domestic sphere, or women – a sentimenthighlighted repeatedly in the literature by menwho view health clinics as woman’s spaces, and byproviders who may also hold negative attitudestowards male involvement in traditionally femaleservices. Both public health and the cultures inwhich it operates have conspired unwittingly tocreate a system of thinking that associates SRH withwomen.28. This institutionalization of women’s healthhas led to particular antenatal and maternitystructures, which has certainly benefitedwomen and families, but it has also served toexclude men from participating in importanthealth arenas. Interventions to protect the rightsof women are important in their own right incontributing to reproductive health equity. Inaddition, interventions that involve men can furtherstrengthen reproductive health equity. “It must berecognized that the ever existent cultural/traditionalbarrier to male involvement in reproductive healthservices has been exacerbated by the tendency ofhealth systems to structurally segregate men fromreproductive issues” (Theuring et al. 2009:S99).29. One obvious implication of this system oflogic is that HIV testing is usually proposed tomen and women separately, and on very differentoccasions. This does not facilitate communicationbetween couples regarding HIV, their status, orthe adoption of preventive behaviours (Desgreesdu-Louand Orne-Gliemann 2008). As Theuringand her colleagues exhort: “male partners needto be viewed and treated not only as a powerfulinfluencing factor, but as a constituent partof reproductive health, and can no longer beexcluded from any debate surrounding issues likepregnancy or HIV/AIDS” (Theuring et al. 2009:S100).30. There are other, more concrete barriersto men’s participation in PMTCT services thatcan be organized into the following categories:factors related to HIV knowledge, stigma and9

Male involvement in the elimination of mother-to-child transmission of HIVdiscrimination; clinic or supply-side factors; logisticalor access challenges; and barriers related to gendernorms.would cause in the relationship, further challengingmen’s desire to support their wives and even toparticipate in services (Reece et al. 2010).31. HIV-related knowledge, stigma anddiscrimination. It is clear that much remains to bedone to increase knowledge among men about HIVtesting and counselling. Some studies showed thatmen were well aware of media efforts to promotetheir involvement in testing, but they said that thesemedia campaigns did a less effective job of explainingwhy men should be tested and what benefits theywould derive from testing (e.g. Larsson et al. 2010).Other studies showed that there was simply a lotof fear: in one study of men’s perceptions aboutPMTCT, it was shown that 88.5% of sampled menthought that other men did not participate inPMTCT because they feared knowing their HIVstatus (Katz et al. 2009). In another study, womensaid that engaging their partners in PMTCT wouldbe particularly challenging if men were unawareof their status, refused to be tested, or were indenial about their HIV status (Reece et al. 2010).There also seems to be a gap in knowledge relatedto discordancy. Some men questioned the need fortesting if their partners had already been tested,believing that they would have the same test resultsas their partners (Falnes et al. 2011). Men also feareddiscordancy because of the anger and bitterness it32. More work needs to be done to reducestigma and discrimination in communities, topromote positive preventive behaviours. Therewas a feeling among men that their involvement inPMTCT services would create the perception thatone or both partners was living with HIV (Peacock2003) and they feared the stigmatizing nature ofHIV care (Larsson et al. 2010). Women said that HIVrelatedstigma was a significant factor in getting thesupport of their partners for basic activities, such asgoing to clinics to get infant feeding formula. As aresult, women said they were less likely to adhere toa formula-based regimen (Reece et al. 2010). Menalso stated that it was difficult to remain engagedin PMTCT infant feeding regimens due to the socialstigma from friends and family if feeding practicesdeviated from local norms, particularly regardingformula use (Reece et al. 2010).33. Health-facility factors serve as a strongdeterrent to utilization of services. Many of thestudies reviewed for this paper relied on men’sperceptions regarding their involvement in PMTCTservices. Participants spoke with particular virulenceabout the kind of services they experienced atThe HIV Preventions Trial Network study 052In May 2011, the HIV Prevention Trials Network (HPTN), showed that early – as opposed to delayed—initiation of antiretroviral therapy for the HIV-positive partner in a serodiscordant couple could reducethe risk of HIV transmission to the uninfected partner by 96%. These findings highlight the significanceof scaling-up public awareness about the importance of knowing one’s HIV status. They also callattention to the need to identify serodiscordant couples through improved partner and couples HIVtesting and counselling programs and linking individuals diagnosed as HIV-positive to HIV care andtreatment servicesThe literature review for this paper showed that men were aware of media attempts to get them to test,but understood less well the benefits of testing (Katz et al. 2009; Byamugisha et al. 2010b; Reece et al.2010). Awareness campaigns that educate men and couples about HIV serodiscordancy are urgentlyneeded so that more men will be motivated to seek HIV testing for themselves instead of using theirpartner’s status as a proxy measure of their own status.10

Male involvement in the elimination of mother-to-child transmission of HIVhealth facilities. Men mentioned the negativeattitudes of staff members (Theuring et al. 2009;Reece et al. 2010), staff members’ lack of commoncourtesy, their “rough handling” of pregnant women,and health-care workers not allowing men to enterthe antenatal clinic with their partners (Theuringet al. 2009; Byamugisha et al. 2010b; Larsson et al.2010). In fact, men experienced health-care workerswho were reluctant to encourage male attendancein antenatal care at all (Misiri et al. 2004). Many menfelt unwelcomed and disrespected (Larsson et al.2010), and thought it was clear that services weredesigned without taking their particular needsinto consideration (Orne-Gliemann et al. 2010). Thecharging of unofficial user fees was another barriercited (Byamugisha et al. 2010b; Larsson et al. 2010).The lack of integration of services was mentionedas discouraging men from getting tested, since theyfelt they would be “exposed” through special clinicsor opening hours (Larsson et al. 2010).34. Male clients’ concerns about their receptivityat health facilities seem to be well grounded,based on self-identified barriers to men’sparticipation on the part of health-care providers.Health-care providers seem to share the sameideas about gender as their fellow residents inthe communities in which they live and work.This is not surprising, since health professionstraining programmes seldom address gender,and specifically men’s involvement in SRH. Forexample, some providers feared accusations ofincompetence. Female providers feared sexualassault from their male clients, and all practitionersexpressed discomfort about counselling men witha positive HIV result (Aluisio 2011b; Shemsanga2011). Despite their universal expression of supportfor the idea of male involvement, no providersdescribed their services as “male friendly” in oneTanzanian study (Kapata et al. 2010). There is a lackof appreciation of the benefits of male involvementin services, and many practitioners lack knowledgeabout men’s specific SRH concerns and have hadno specialized training regarding the integration ofmen into services (Shemsanga 2011). Infrastructuralchallenges (e.g. low pay and morale, burnout,personnel shortages, etc.) seem to leave providerswith little motivation to take on the additionaldemand of providing services to men and couples(Aluisio 2011a; Shemsanga 2011) or to adopt newprovider guidelines for services. But even if therewas the desire to do so, policy guidelines for maleinvolvement simply do not exist in many places. Inthe United Republic of Tanzania, for example, men’sinclusion in the National Multi-Sectoral Frameworkon HIV/AIDS is notable, but no clear strategy existson how, when or by whom the framework’s visionfor male involvement is to be realized (Katapa et al.2010).HPTN study 052 and male-friendly servicesSince the results of the HPTN study 052 maygive greater personal and interpersonalmotivation to seek testing, larger numbersof men will likely utilize both stand-aloneHTC sites as well as PMTCT facilities. Greaterparticipation by men may serve both as animpetus to make services more male friendly,and to make men’s involvement in PMTCTmore accepted or normative, thus decreasingstigma and discrimination.35. Male involvement in PMTCT clearly goesagainst prevailing gender norms in many placesin sub-Saharan Africa. Reproductive healthseekingwas seen by men as “women’s work”. Mensaw the antenatal clinic as women’s space, and thedefinition and organization of the programme asfundamentally female oriented (Reece et al. 2010).Predictably, men thought that antenatal clinicactivities fell outside their area of responsibility(Peacock 2003; Orne-Gliemann et al. 2010; Falneset al. 2011). Consequently, men perceived thatattending the antenatal clinic would be “unmanly”(WHO 2003; Montgomery et al. 2006; Chinkonde etal. 2009). They felt uncomfortable at being the onlyman present in the clinic (Falnes et al. 2011) andfeared stigmatization by other men (Byamugishaet al. 2010b; Reece et al. 2010; Falnes et al. 2011).In PMTCT programmes, access to men is gainedthrough women clients, but many men felt thatwomen should not be telling men what to do,11

Male involvement in the elimination of mother-to-child transmission of HIVeven if the request comes through the doctor(Falnes et al. 2011) and that a man in this contextis not supposed to follow his wife; he is supposedto take the lead. Thus, in many men’s minds, theirparticipation in PMTCT would signal weakness andlack of masculinity and power to other men.Language: PMTCT or PPTCT?At the subregional consultation to discussstrengthening male involvement in theelimination of mother-to-child transmissionof HIV, held in Kigali, Rwanda in August2011, participants discussed whether itwould be appropriate to continue to use theterm PMTCT, or to switch to PPTCT – for theprevention of parent-to-child transmission ofHIV.One group of participants felt that PMTCTsimply reflects the biological reality: thatdespite the behavioural interventionsundertaken or the language used, ultimatelythe goal is to prevent the biologicaltransmission of the virus from the mother tothe child.Another group of participants felt that sincemen’s level of involvement in antenatalcare and HIV counselling and testing affectstransmission and the well-being of bothwomen and infants, the use of PPTCT notonly reflects the social reality of couples andfamilies in the dynamics of transmission, butalso helps men to feel more welcomed athealth-care facilities.Both groups seemed to agree that the locallanguage used in the delivery of servicesshould not serve as a deterrent to men’sparticipation. In other words, in the translationof these terms to local languages, it isimportant that men feel that PMTCT servicesare inclusive of them, and not designed forwomen only.36. Access or logistical challenges on the part ofmen. Men consistently cited a series of challengesof daily life that prevented them from participatingin PMTCT programmes. Men talked about theirperceived principal responsibilities as providers.Thus, time spent at clinics and away from workor other income-generating activities was clearlyperceived as a barrier to their participation in PMTCTprogrammes (Byamugisha et al. 2010b; Larsson et al.2010; Orne-Gliemann et al. 2010; Reece et al. 2010;Falnes et al. 2011). Distance, the cost of transportand clinic operation hours were also mentionedwith some frequency (Larsson et al. 2010; Reeceet al. 2010). Men felt that it was complex to ask anemployer for time off, not only because PMTCT ortesting was related to HIV, which might bring upissues of serostatus, but also because these issueswere deemed to be primarily women’s concerns(Reece et al. 2010). Efforts to address many of theselogistical barriers of access and employment byoffering weekend clinic hours have achieved mixedresults. Although the clinic was well utilized at onesite in Nairobi, it did not have a measurable impacton the proportion of men who sought services(Katz et al. 2009). In contrast, other programs havebeen successful in achieving greater participation ofcouples during expanded weekend hours (Allen etal. 2003).The evidence base:moving towards gendertransformativeprogrammes37. Before we examine PMTCT programmesand assess their success in integrating maleinvolvement, it is important for us to define whatwe mean by “success”. Historically in the field ofSRH, when programmes sought to integrate andaddress gender concerns, they did so utilizinga variety of approaches. Some programmesthought that simply including the opposite sexin their efforts was enough, without taking intoconsideration the special needs or concerns ofmen or women. Other programmes have eveninadvertently exploited power differences toachieve programme goals, such as taking advantage12

Male involvement in the elimination of mother-to-child transmission of HIVof men’s decision-making power to increaseutilization of family planning, even if it meant lesssay for women. On the positive end of the spectrum,some programmes have not only included bothsexes and addressed their special needs, buthave also sought to transform the nature of therelationship of power between men and women tohave a long-lasting impact.38. Table 3 highlights some of the diverseapproaches that have been taken in achievinggender integration in programming, and placesthem in continuum – from exploitative (harmful) totransformative (helpful) approaches. The continuumis useful because it can help public healthpolicy-makers and practitioners and programmedecision-makers to be more intentional about thestrategies/activities they undertake to achieveeffective and sustainable results.39. WHO’s PMTCT Strategic Vision (WHO 2010a)and UNAIDS’s Global plan and outcome framework:business case (UNAIDS 2011) explicitly understandgender equality as a foundational condition that,if achieved, would lead to better health outcomesfor women, children and men. By taking a womancentredapproach, these global documents promotethe full involvement of women in decision-makingabout family health and development of integratedreproductive and HIV services that address theneeds of the entire family.40. It is the understanding of these documents,too, that PMTCT programmes have the strategicopportunity to influence gender equality andpromote shared decision-making and thus have abroad and sustainable impact on women, familiesand the communities in which they live. Sharedpower and decision-making between men andTable 3Continuum of approaches for achieving gender integration in programming (Gupta 2001)Integration ApproachGender-exploitative/unequal programmesGender-blind programmesGender-accommodating/specific programmesProgrammatic CharacteristicsTake advantage of rigid gender norms and existing imbalances of power.Can result in harmful consequences and undermine a programme’s intendedobjective.Give little or no recognition to different gender norms and relations inprogramme or policy design, implementation or evaluation.Acknowledge the role of gender norms and inequities.Develop activities to adjust to and/or compensate for them.Do not actively aim to change norms, but strive to limit the impact ofharmful gender norms.Can provide a sensible first step towards gender-transformativeprogramming.Gender-transformativeprogrammesActively strive to examine, question and change rigid gender norms.Examine the vulnerabilities and costs of rigid gender norms for both menand women, for health, and social, economic, political life.Promote the position of women and equality, generally.Challenge the distribution of resources and allocation of duties.Address imbalances in power and promote equitable relationships in diversesettings.13

Male involvement in the elimination of mother-to-child transmission of HIVwomen about SRH can lead to benefits for theentire family – beyond PMTCT – including increasedfamily planning utilization, prevention of the sexualtransmission of HIV and other STIs, reduction inmaternal and infant mortality, and the preventionof gender-based violence. This requires thatgovernments and programmes move from seeingmen solely as enablers of women’s positive healthseekingbehaviours, to viewing them as integralpartners in promoting gender equality and healthand as clients of SRH services.41. Our measure of success, then, is gendertransformativeprogrammes that:• intentionally and thoughtfully involve bothwomen and men – either simultaneously orsequentially under the same programmaticumbrella (i.e. gender-synchronizedprogramming as clients (not simply enablers)(see Population Reference Bureau (2010) for anoverview of gender-synchronized programmingand its benefits)• address the specific needs of men as well aswomen• create opportunity for constructive dialoguebetween men and women• actively strive to examine, question and changegender norms that increase vulnerability to HIVand other adverse reproductive health outcomes• address imbalances in power and promoteequitable relationships in diverse settings,including the wider community• achieve a demonstrable health outcome orimpact.42. There are a few programmes focusingspecifically on PMTCT and male involvement thathave resulted in specific behavioural or healthoutcomes:43. Couple voluntary counselling and testing(CVCT) is “the shared participation of a couple inHIV counselling and testing [and] constitutes afoundation for all further decisions undertakenjointly with regard to HIV and PMTCT, like thedecision to enrol in the PMTCT intervention”(Theuring et al. 2009). An excellent article byDesgrees-du-Lou and Orne-Gliemann (2008) reviewswhat is known about CVCT since the 1990s. Thereview covers CVCT efforts in both PMTCT and non-PMTCT sites. In PMTCT sites (Zambia and Kenya),where pregnant women were offered individualor couple HIV counselling, the couple counsellingimproved the uptake of HIV testing, antiretroviralprophylaxis and alternatives to prolonged andmixed breastfeeding, and no increased risk ofadverse social events was reported compared withindividual counselling (Farquhar et al. 2004; Semrauet al. 2005). The results of studies in non-PMTCT siteswere equally positive. Rates of partner disclosurewere high, and rarely accompanied by negativereactions on the part of the partner. CVCT also hada dramatic impact on rates of condom use and hasbeen shown to reduce risk among couples (Allenet al. 1992, 2007; Van der Straten et al. 1995; Painter2001).44. Family-centred approach. In alignment withWHO’s PMTCT strategic vision 2010–2015 (WHO2010a) and its focus on integration and creating acontinuum of care, the family-centred approachtakes a holistic look at the household unit, withthe assumption that HIV-affected families are atrisk for a broad range of negative outcomes, whichcan have a cascading effect on the health of allhousehold members (Betancourt et al. 2010). Aholistic approach is achieved by taking traditionalPMTCT interventions, and “extending” thoseservices to reach additional members of the family.For example, as part of antenatal care, servicesmight be extended to other members throughhousehold HIV testing and counselling, or throughrisk assessments for gender-based violence. Oneset of studies reviewed for effectiveness soughtto extend HIV testing and counselling to partnersof pregnant women attending antenatal care.The review shows that “partner participation wasassociated with positive outcomes, such as greateruse of antiretrovirals and higher acceptance ofpost-test counselling among pregnant women, aswell as increased spousal communication about HIV14

Male involvement in the elimination of mother-to-child transmission of HIVand sexual risk. Moreover, when couples receivedpre- or post-test counselling together, greater use ofalternative feeding methods and greater acceptanceof HIV testing were observed among women.Partner participation was also often utilized as anentry point for the provision of additional PMTCTservices to both male and female participants”. It isimportant to note that the paper by Betancourt etal. also reviewed a second set of studies that focusedon extending ART to partners and other familymembers, finding high adherence to ART amongall members. A third category of studies critiquedcomprehensive PMTCT models. The authors choseto highlight two as model programmes, whichhad attained impressive results: (1) the MTCT-PlusInitiative, which addresses the health need of themother and infant and which recognizes that themother’s family should also be brought into care;and (2) The Centers for Disease Control (CDC)-Uganda, Global AIDS Programme, which focuses onextending HIV testing and counselling through ahome-based approach.45. Intrapartum HIV testing and counselling. Astudy conducted by Homsy et al. (2006) in a 200-bedhospital in rural Uganda compared the acceptability,feasibility and uptake of routine opt-out antenatalPMTCT services with routine opt-out intrapartumHIV testing and counselling (i.e. during onset ofchildbirth and delivery) in the maternity ward. Theresults obtained were impressive. The acceptanceof HTC was 97% (3591/3741) among women and97% (104/107) among accompanying men in theantenatal clinic and 86% (522/605) among womenand 98% (176/180) among their male partnersin the maternity ward. Thirty-four women werefound to be HIV seropositive through intrapartumtesting, representing a 12% (34/278) increase indetection of HIV infection. Over the study period,the percentage of women discharged from thematernity ward with documented HIV statusincreased from 39% (480/1235) to 88% (1395/1594).Only 2.8% of undocumented women had their malepartners tested in the antenatal clinic, in contrastto 25% in the maternity ward. Of all male partnerswho presented to either unit, only 48% (51/107)came together and were counselled with theirwife in the antenatal clinic, as compared with 72%(130/180) in the maternity ward. Couples counselledtogether represented 2.8% of all persons tested inthe antenatal clinic, as compared with 37% of allpersons tested in the maternity ward. The studythus demonstrates that intrapartum HIV counsellingand testing may be an acceptable and feasible wayto increase individual and couple participation inPMTCT interventions.46. On the “continuum of approaches for achievinggender integration in programming”, the positionof these programmes most likely falls in thegender-accommodating/specific category. Theseinterventions intentionally involve both men andwomen. Through couple counselling, they createthe opportunity for dialogue between men andwomen. There is some evidence that the dynamicsof power in relationships and gender norms mayalso be challenged through the interventions. Forexample, in their review of CVCT, Desgress-du-Lou and Orne-Gliemann (2008) found that in theUnited Republic of Tanzania, less partner violencewas reported among women who disclosed theirtest results compared to women who did notshare their results. On the other hand, none ofthese interventions focus explicitly on changingharmful gender norms among men, women andcommunities, which can enhance the ability of aprogramme to increase male involvement, preventHIV infection, STI and unwanted pregnancies, andfacilitate women’s uptake of PMTCT services. Inaddition, despite the many documented benefitsof CHTC, acceptability remains low. This raises thequestion of how CHTC is conducted and whetherthe service indeed addresses men’s specific needsor concerns. In other words, do these programmesview men as simply enablers of positive healthseekingbehaviour on the part of women, or aremen recognized for the expanded roles they canplay beyond being supportive partners—as clientsthemselves and as advocates for social change?15

Male involvement in the elimination of mother-to-child transmission of HIVHow do we move towardsgender-transformativeprogramming? Suggestedcharacteristics of maleinvolvement programmesin PMTCT47. Broadly speaking, the WHO study (2007),Engaging men and boys in changing gender-basedinequity in health: evidence from programmeinterventions, aimed to examine the evidenceregarding the effectiveness of programmes engagingmen and boys in reproductive health programmes.While some programmatic efforts within eachof the intervention categories examined (e.g.group education, health services and communitymobilization and engagement) showed significantresults, those programmes that combined differenttypes of intervention, particularly with communityoutreach, mobilization and mass media campaigns,were most effective in producing behavioural orhealth outcomes (e.g. increased condom usage,delayed sexual debut, decreased violence, lowerrates of STIs, etc.).48. The WHO study identified critical elements ofsuccessful male-involvement programming, whichhave been subsequently confirmed by anotherstudy (Pulerwitz et al. 2010). They included:• critical reflections about what it means to bemen• reinforcing messages in well-designedcommunity and mass media campaigns• engaging girls, women, the community andservice providers• engaging community allies• acknowledging men’s needs as well as their needto support and accept women’s rights.49. Suggested characteristics drawn both fromthe WHO male involvement study (WHO 2007)and the current literature on PMTCT are discussednext. These characteristics can be roughlygrouped into clinic, or supply-side factors, andcommunity, or demand factors. In keeping with therecommendations of the WHO study on engagingmen and boys (WHO 2007), it is important toconsider how supply and demand factors canbe addressed together and coherently to notonly increase men’s engagement in PMTCT, butalso transform gender norms to foster sustainedpositive social change and equality.50. Facility-based or supply-side strategies forpromoting male involvement. Men can play avariety of roles that contribute to the overall SRHof families and to development. One role is menas clients (for a complete discussion on men’sinvolvement see Green et al. (1991)). In this role,men are encouraged to seek out services not onlyto improve their own health, but also as way toshare equal responsibility and to participate injoint decision-making with their partners, withoutnecessarily controlling those decisions, and tocontribute to overall family health.51. To promote positive health-seeking behaviourand men’s participation in PMTCT programmes,it is critical both that services are welcoming tomale clientele and that their staff are competentto meet their needs. The ability to increase men’sutilization of HIV and reproductive health servicesand support for partners utilizing services topromote family health will rest largely on a site’scapacity to address organizational and attitudinalbarriers that may exist when initiating, providing, orexpanding services that are inclusive of men.52. Trained, competent and male-friendly staffare essential. Suggestions for how to improve staffand the quality of care they provide come from avariety of sources. Staff members themselves feltthat refresher courses, including customer care,and better remuneration for staff were important(Byamugisha et al. 2010b). Men suggested teachingstaff how to better meet men’s needs, and makeservices more male friendly and less stigmatizing(Larsson et al. 2010). One author suggested thattraining for service providers on the importanceof partner integration and couple testing andcounselling would represent an important strategyin increasing men’s participation (Walston 2005;16

Male involvement in the elimination of mother-to-child transmission of HIVTheuring et al. 2009). Another researcher suggestedthat the guidelines contained in WHO’s document,Integrating gender into HIV/AIDS programmes(WHO 2003) should be incorporated into the workroutine by including them into terms of referencesof health-care workers, for example (Amin et al.2007). This was felt to be especially important withantenatal care counsellors, who represent a cruciallink between policy and practice of health services,and whose attitudes and practices in giving advicewould significantly influence the intervention’soutcome (De Paoli et al. 2002; Theuring et al. 2009).53. Range of services, their structure andorganization. The literature makes a series ofrecommendations concerning the type of servicesthat could increase the active engagement ofmen. They include offering alternative HIV testingmethods such as mobile clinics, workplace testing,and door-to-door testing, which have been shownto increase uptake of services and reduce stigma(Larsson et al. 2010). CHTC was considered a goodidea because it provided an opportunity to getinformation, be tested and hear the results together.Studies suggested a diversity of opinion regardingthe preference for couple, as opposed to individual,testing for HIV (Larsson et al. 2010; Falnes et al.2011). Because of this, Katz et al. (2009) suggest thatantenatal clinics offering services to men shouldconsider including options for both couple andindividual counselling.54. Making services more male friendly. Both menand women expressed support for more initiativesthat are exclusively for men and that are led by men.They suggested that interventions such as a men’spsychosocial support group was a perfect exampleof an effort that could be helpful in engaging andretaining men in HIV-related services (Reece etal. 2010). Another suggestion was to offer service/appointments to men at the same time – presumablyto address men’s specific health concerns (Reece etal. 2010), which is in line with another suggestionto integrate HIV care into general health care tomake testing, monitoring and ART provision moresustainable, but to also help reduce stigma (Larssonet al. 2010). Women suggested that employing moremen as staff members would make their spousesmore comfortable and would help them to talkabout sensitive subjects. To lessen stigmatizationby other men, some authors suggested a malesensitiverevision of antenatal sites (Theuring et al.2009), facilities for men only, or facilities designedespecially for pregnant couples (Falnes et al.2011). Finally, having fathers directly invited to betested by health personnel, for example, by givingthem invitation letters, emerged repeatedly inthe literature as a good strategy to increase men’sparticipation in sub-Saharan Africa. Doing thismay make men feel more included in the PMTCTprogramme and therefore more likely to take action(Theuring et al. 2009; Byamugisha et al. 2010b;Falnes et al. 2011).Resource on male-friendly services:EngenderHealth’s men’s reproductive healthcurriculumThis is a three-part curriculum designed toprovide a broad range of health-care workerswith the skills and sensitivity needed towork with male clients and provide men’sreproductive health services. The curriculumincludes the following sections:• Introduction to men’s reproductive healthservices, revised edition (2008). The firstmodule of the curriculum is designed tohelp sites and health-care workers addressorganizational and attitudinal barriers thatmay exist when initiating, providing, orexpanding a men’s reproductive healthservices programme• Counselling and communicating withmen. The second module focuses onstrengthening service providers’ abilityto interact with, communicate with, andcounsel men – with or without theirpartners – on reproductive health issues• Management of men’s reproductivehealth problems. The third moduleprovides information to clinicians andother service providers in diagnosing andmanaging reproductive health disorders inmen.For more information, contact Lori Rolleri (LRolleri@engenderhealth.org) at EngenderHealth.17

Male involvement in the elimination of mother-to-child transmission of HIV55. Behaviour-change communication andcommunity engagement. Another role that mencan play is that of supportive partners (Greene et al.1991). This role recognizes the influence that mencan have on the SRH of their partners, includingin decision-making, planning and the provisionof resources for care. In reaching out to men toencourage them to play this role, it is importantto view men as allies and resources in promotingthe health of families. Men want to be supportiveto their pregnant partners, but often did not knowhow (Peacock et al. 2009), or seemed to have vagueconcepts of paternal responsibility. In response,behaviour-change communications campaignshave an unparalleled opportunity to diffusegender-transformative messages that challengethe status quo and encourage new ways ofthinking in the community about men, women andrelationships. For example, campaigns that highlightrole models of responsible fatherhood could be amajor emphasis in public information, educationand communication efforts to increase partnerinvolvement in antenatal care/PMTCT (Theuring etal. 2009). Promoting couple communication regardingHIV/AIDS through the media may increase thenumber of men accompanying their female partnersto antenatal clinics when male VCT is available.Special efforts may be necessary to reach malepartners of unmarried women seeking antenatalcare (Katz et al. 2009).A new initiative to watch: MenCare campaign in South AfricaOf all the topics discussed in engaging men in gender equality, the issue of men and caregiving,including men’s involvement in maternal health, remains conspicuously absent and underexplored.To address this void, the Sonke Gender Justice Network, Promundo and others have recently launchedMenCare to create and implement a world-wide campaign that promotes men’s greater involvement: incare work and domestic work, including in the context of HIV/AIDS; as engaged fathers; and as partnersin maternal and child health. The campaign seeks to provide policy-makers, the media, the health andsocial services sector, NGOs and community groups, and men and women with positive images ofmen’s roles as caregivers, along with concrete programme and policy examples of how to increase suchpositive involvement.“While we have talked much of the intergenerational transmission of violence, we have talked muchless of the intergenerational transmission of caregiving and gender equality.”The MenCare campaign is framed with the belief that men’s participation in caregiving and maternalhealth is positive for women, children, societies and men themselves. As such, caregiving providesa “positive hook” for engaging men in gender equality and reducing violence against women andchildren. It provides an alternative identity for men that can serve to galvanize men’s participation ingender equality in ways that have yet to be fully realized.For more information, contact Sonke Gender Justice Network (info@genderjustice.org.za).18

Male involvement in the elimination of mother-to-child transmission of HIV56. Men were clear that they preferred community-based events. Because of their specificneeds for information, men preferred community events where they would have the opportunityto ask questions. They specifically thought that it would useful to hear from men who had alreadybeen tested and who could talk about their own experiences, and from HIV-positive men so theycould learn more about the reality of their lives. They said they would also find it helpful to haveorganized discussions between health-care workers and the community, to learn more aboutservices (Larsson et al. 2010).Resource on behaviour-change communication: Brothers for LifeBrothers for Life (www.brothersforlife.org) is a national campaign targeting mainly men aged 30 yearsand over, to address the risks associated with having multiple and concurrent partnerships, sexualintercourse and alcohol, and gender-based violence, and promotes HIV testing, male involvement inPMTCT and other health-seeking behaviours. The campaign uses interpersonal communication, massmedia and advocacy to reach its audiences.Brothers for Life utilizes the Men’s Wellness Toolkit to engage men within communities around prioritytopics that continue to undermine the health of men and women. The community-level work issupported by a beautifully designed and hard-hitting mass media component. Using television andradio, the campaign draws on the concept of brotherhood to convey the importance of men’s decisionsto their own health and the health of the people who depend on them.The campaign is a collaborative effort led by South African National AIDS Council (SANAC), theDepartment of Health, the United States Agency for International Development/US President’sEmergency Plan for AIDS Relief (USAID/PEPFAR), Johns Hopkins Health and Education in South Africa(JHHESA), Sonke Gender Justice, the United Nations Children’s Fund (UNICEF), the InterdepartmentalManagement team (IDMT), the United Nations System in South Africa and more than 40 other civilsociety partners.For more information, contact Johns Hopkins Health and Education in South Africa (joinbrothers@jhuccp.co.za).57. Peer education and outreach was another strategy that was advocated for by men. Peersensitization of men (Larsson et al. 2010) could include recruiting leaders from the men’s supportgroups to serve as peer discussion leaders to deliver educational sessions to other men in theircommunities about the importance of men’s support and engagement with programmes like PMTCT(Reece et al. 2010).19

Male involvement in the elimination of mother-to-child transmission of HIVResource on a multiple intervention approach: Promundo’s Program HProgram H: Engaging Young Men in Gender Equality seeks to engage young men and theircommunities in critical reflections about rigid norms related to manhood. It includes group educationalactivities, community campaigns, and an innovative evaluation model (the Gender-Equitable men(GEM) scale) for assessing the programme’s impact on gender-related attitudes. After participating inProgram H activities, young men have reported a number of positive attitudinal as well as behaviouralchanges, from higher rates of condom use and improved relationships with friends and sexual partners,to greater acceptance of domestic work as men’s responsibility and lower rates of sexual harassmentand violence against women. In 2008, the United Nations Population Fund (UNFPA) recognized ProgramH as an effective strategy for engaging young men in the promotion of SRH in its State of the PopulationReport.For more information, contact Piotr Pawlak (p.pawlak@promundo.org.br) at Promundo.58. Men as agents of change. The final role thatmen can play is as agents of change. The criticalaspect of this role is its emphasis on questioning,challenging and actively working to changegender norms that negatively affect the healthof women, children and men. Though here theusage of the term is beyond that of its initialconceptualization (Greene et al. 1991), it is criticalthat the expectation is that men have a role beyondbeing passive recipients of new knowledge, skillsand awareness, and that they have a responsibilitybeyond being personally transformed (moregender equitable) in their relationships. Thequestion of roles and responsibilities brings usto leadership – personal, communal, nationaland global. In their roles as policy-makers,men are in a position of power to bring aboutsystemic change – from challenging conceptualbarriers with global implications to addressingnational and subnational policy development andimplementation with direct, local-level effects. Onthe international stage, policy-makers can challengerestrictive demographic thinking (with its oftenmechanistic and reductive focus on proximatedeterminants), which has supported the logic ofmen’s exclusion in reproductive health settings.Instead, by taking a health and human rightsapproach and acknowledging the social reality offamilies, decision-makers are in a unique positionto advocate for policies that reflect the dynamicsof infection in communities. It is important that abroader vision of gender equality—that is inclusiveof male involvement—is “mainstreamed” intonational HIV frameworks for action, includingsupporting implementation guidance and supportto enable action. An important action wouldbe to support policy initiatives that incentivizemen’s participation in services, promoting jointresponsibility for testing and mutual disclosureand encouraging an often unwilling partner to test.Normalizing men’s involvement would also addressmany of men’s concerns (e.g. it is women’s work,the fear of being seen by other men, etc.), becausethe expectation is that all men would participate.Perhaps the same kind of incentives can be usedto encourage men’s participation in antenatalcare, to include birth-preparedness planning andthe promotion of facility-based deliveries. But thisissue of leadership goes well beyond global ornational actors. Local leadership is critical for qualityimplementation. The Government of Rwanda hasrecognized this and has incentivized local leaders’participation in promoting men’s involvementin PMTCT by making this a criterion of their jobperformance (see the country spotlight box).Ultimately, being an agent of change is personal. Itis about commitment to equality and recognizing itsbenefits for the entire community. From this basic20

Male involvement in the elimination of mother-to-child transmission of HIVcommitment, the expectation is that action willflow – from policy formulation on the grand scale,to speaking out against gender-based violencein one’s local community and holding other menaccountable for inequitable speech and actions. Tobe “sensitized” to gender is not sufficient. To make areal change in the elimination of paediatric HIV andmaternal health, we need more than sensitive men.We need leaders.Country spotlight: RwandaIn response to an identified lack of participation of men in PMTCT, Rwanda developed the “Going forthe gold” campaign, which aims to support a family-package approach to PMTCT in line with nationalstrategies, with strong emphasis on male participation, encouraging male partners to participate in HIVcounselling and testing.Components of the campaign include:• high-level advocacy with the involvement of high-level leaders and authorities• promotion of HIV counselling and testing for couples as a national strategy• community mobilization with local authorities and community health-care workers• capacity building of health-care staff on HIV counselling and testing for couples• public awareness campaigns using mass media for couples’ testing• introduction of couples’ HIV testing indicators into the performance contract of local authoritieswith the government• couples’ HIV counselling and testing indicators integrated within a performance-based financingprogramme at health facilities and at the community level• organization of weekend HIV counselling and testing sessions for partners who are not available onweekdays• introduction of invitation letters for male partners.Results: The uptake of couples’ testing has dramatically increased from a national average of 33% in2005 to 78% in 2008, with some health-care facilities reaching 90% partner testing uptake. The numberof couples tested through the PMTCT programme has increased almost fourfold, from 58 700 in 2005to 229 200 in 2008. Within the programme, HIV testing coverage increased from 10% of the totalnumber of expected pregnant women in 2002 to 50% in 2005 and 75% in 2008. A relative decrease inthe prevalence of HIV among pregnant women and their male partners was also reported: from 9.1% in2003 to 2.98% in 2008 among pregnant women, and from 10.2% in 2003 to 3.07% in 2008 among malepartners.For more information, contact Placidie Mugwaneza (mu_placy@yahoo.fr) of the Treatment and Research on AIDSCenter/Ministry of Health.21

Male involvement in the elimination of mother-to-child transmission of HIVThe question of relationshipquality: the missing piece?59. In the section on obstacles to men’sparticipation in PMTCT, conceptual barriers werehighlighted. It was asserted that both public healthand the cultures in which it operates have conspiredunwittingly to sustain a paradigm that associatesSRH with women, and has served to inadvertentlyexclude men from participating in importantreproductive health areas.60. If men have largely been missing, so toohave couples – the essential biological and socialdyad of biological and social reproduction whosehealth outcomes have significant implications fornational development. When couples have beenconsidered, it is still with a focus on the proximatedeterminants of paediatric infection in mind: howdo we get men to cooperate with women to adhereto prevention and treatment guidelines to eliminatepaediatric HIV? What is missing is a consideration ofthe nature and quality of the relationship betweenmen and women, including the “entanglementbetween sexual behaviour and affective relations”(Cole and Thomas 2009). If we exclude this more“distal variable” from consideration of our work,how faithful can we be to the imperative of theglobal plan (UNAIDS 2011) to consider the realityof women’s lives as central to our response topaediatric HIV infection? How successful will we bein mobilizing programmes and services to achieveholistic family health and a continuum of care?61. Researchers have begun to note the paucityof literature on relationships and the need formore information to strengthen public healthprogramming for couples. “In sub-SaharanAfrica, there is still inadequate socio-behaviouralknowledge of HIV prevention within the dynamicsof couple relationships” (Painter 2001). Thisincludes couple communication on sexual risk;the evolution of preventive behaviours overtime (e.g. by duration of relationship and timesince VCT); and gender issues of negotiation andviolence (Desgrees-du-Lou and Gliemann 2008).In another recent multi-country study to assessthe acceptability of couple-oriented post-test HIVcounselling (COC) , the authors found that one of thekeys to men’s involvement within prenatal HIV testingand counselling is “the better understanding of couplerelationships, attitudes and communication patternsbetween men and women, in terms of HIV and sexual andreproductive health. This conjugal context needs to betaken into account in order to provide quality prenatalHIV counselling, which aims at integrated PMTCT andprimary prevention of HIV” (Orne-Gliemann et al. 2010). 2It is also important to note, however, that the types ofrelationships men and women have with one another canvary dramatically (i.e., polygamous marriages, co-residentvs. visiting relationships, the self-identification of peopleas single, etc.), and that type of relationship affects thenature and even definition of male involvement (pleasesee “Issues for Consideration: Couples” in this paper).62. Why is it important to learn about the nature ofrelationships? Simply put, because most infectionshappen in stable relationships in sub-Saharan Africa,either due to previous infection by one of the partners, orbecause of infidelity (Carpenter et al. 1999; Malamba et al.2005; Chomba et al. 2008). Data from recent large-scalesurveys in Burkina Faso, Cameroon, Ghana, Kenya and theUnited Republic of Tanzania reveal that serodiscordancyis a serious reality: at least two thirds of couples in eachcountry with at least one HIV-positive partner were HIVserodiscordant (Desgrees-du-Lou and Orne-Gliemann2008).63. One potential epidemiological reason for a lackof focus on couples is a misapprehension on thepart of professionals concerning the extent of HIVserodiscordancy, and denial on the part of the publicthat it is possible. In the literature review conducted forthis paper, it was noted on at least a few occasions thatmen did not seek testing and counselling because theserostatus of their partners was known to them and theyassumed that their HIV status would be the same as theirpartners’ (e.g. Brou et al. 2007). If both partners believethey have the same HIV serostatus, the use of preventionduring sexual intercourse will not seem logical (Desgreesdu-Louand Orne-Gliemann 2008).2Couple-oriented post-test HIV counseling (COC) is a clinic-basedbehavioral intervention which replaces standard post-test HIVcounseling delivered to a pregnant woman. “It provides the womanwith personalized information as well as tools and strategies to activelyinvolve her partner within the prenatal HIV counseling and testingprocess (Orne-Gliemann et al. 2010).22

Male involvement in the elimination of mother-to-child transmission of HIV64. Therefore, the use of condoms remains lowin “committed” relationships (United Nations2002; De Walque, 2007). We also know that thecondom is a loaded symbol, associated withcasual partners and infidelity (Bauni and Jarabi2003; Chimbiri 2007), making it difficult for bothwomen and men (Maharaj et al. 2005; Chimbiri2007) to suggest or adopt preventive behaviourswith their regular partners. Given the reality andextent of serodiscordancy, this places individualsin serodiscordant relationships at risk for infectionsubsequently, as well as risking paediatric HIVinfection.65. We know that that condom use is higherin couples where there is dialogue on sexualrisks (Zamboni et al. 2000; Desgrees-du-Lou etal. 2009b). But what we find is that the qualityof relationships, as reported by respondents instudies, is in fact quite poor. One study in Ugandareported that men thought their relationships werefundamentally unstable and distrustful. Larsson etal. (2010) found that “mistrust was widespread, andextramarital affairs were common, especially amongmen. Extramarital affairs were in general tacitlyaccepted within a marriage, and rarely discussedbetween spouses. However, the ever-presentsuspicion, that one’s partner would be unfaithful,created a pervasive atmosphere of mistrust betweenhusbands and wives”. It was no surprise then thatmen found the idea of couple testing at PMTCTsites unappealing because of the conflicts it couldgenerate in the relationship. These studies aboutindividuals’ perceptions about the nature andquality of their relationships are suggestive, andperhaps explain why, despite the positive outcomesof couple HTC programmes, the acceptability ofthese services remains low (Desgrees-du-Lou andOrne-Gliemann 2008). Couple HTC is a great idea,but may spur conversations and bring up issuesthat the couple is not interested in, or is unwilling ordoes not have the skills or power to engage, even ifto protect oneself or one’s partner.Promising initiative: CoupleConnectEngenderHealth’s CoupleConnect is aninteractive, skills-based curriculum designed toprevent HIV infection among couples from theUnited Republic of Tanzanian, which focuseson strengthening “couple connectedness”,that is, “the quality of the emotional bondbetween partners that is both mutual andsustained over time”. In line with the project’sobjectives, couples are defined as thosewho live in or near an urban area, have beenmarried within the past five years, are of lowto middle socioeconomic class, are literate, areat least 20 years old, and are non-polygamous.EngenderHealth operationalizes coupleconnectedness through the promotion ofnine key couple behaviours. A major themeof the curriculum is how gender inequalityand harmful gender norms affect the ninebehaviours that comprise the condition ofcouple connectedness. As such, the curriculumraises awareness about harmful gendernorms, questions the cost of these norms andredefines them into healthier alternativesthroughout the programme.CoupleConnect is based on the hypothesisthat couples who report a higher senseof couple connectedness are more likelyto engage in healthier sexual behaviourscompared to couples who report a lower senseof couple connectedness. CoupleConnect iscurrently in the pilot phase of implementation.For more information contact: Dr Dunstan Bishanga(DBishanga@engenderhealth.org), CHAMPIONProject, EngenderHealth, United Republic ofTanzania.23

Male involvement in the elimination of mother-to-child transmission of HIV66. We are back, then, to the chicken or the eggquestion raised earlier: do men participate inPMTCT programmes because of the good outreachefforts conducted by these programmes? Or is itmen who already feel a sense of commitment andhave good communication with their partners thatparticipate? Studies seem to support the latterconclusion:• the pre-existing level of communication withinthe couple around SRH issues influences theacceptability of prenatal HIV counselling andtesting (Bakari et al. 2000)• in an urban area of the United Republic ofTanzania, women were less likely to collecttheir test results if they had never discussedreproductive health matters with their partner(Msuya et al. 2006)• greater commitment to a female partner mayincrease a man’s motivation to participate inVCT and in antenatal care, and having discussedHIV in the past may motivate or simplify HIV testseeking (Katz et al. 2009)• both men and women in one study thought thatgood and open communication would supportthem in seeking routine HIV testing, discussingthe challenges of living with HIV, and being moresupportive of their HIV-infected partners (Reeceet al. 2010).67. Bringing women, men and integrationtogether: couples as a part of a focused globalresponse. Couples represent a wonderful, butas yet, unexploited opportunity to promotereproductive and family health within the contextof integrated services. These missed opportunitiesfor integrating the primary prevention of HIV andPMTCT should urgently be addressed. A couplecentredapproach to HIV testing and counselling,involving men, would contribute to improvingreproductive health, partner communication aboutsexuality, and the prevention of HIV and otherSTI within the relationship (Orne-Gliemann et al.2010). Now, with the advent of the HPTN study 052and its implications for serodiscordant couples,the importance of couple counselling to addressprevention and the quality of the relationshipbecomes all the more imperative. The questionbecomes: how can we foster communication incouples in our communities to predispose them toutilize a range of SRH services to prevent paediatricAIDS, promote maternal health, and improve thewell-being of the entire family?Methodologicalconsiderations, questionsand resources68. How do we define male involvement?Currently, male involvement in PMTCT is measuredprimarily through men’s attendance at HIV testingand counselling and through its associatedbehavioural and health outcomes (for example,condom usage or adherence to prescribed infantfeeding regimens). Is testing a good proxyindicator of men’s constructive involvementin PMTCT? Does a man’s participation in testingguarantee that he or the couple will adopt less riskysexual behaviours? Does it assure that the manwill support his partner in her efforts to adhere totreatment and care regimens (Ghanotakis, personalcommunication, 2011)?69. There are, in fact, many components of PMTCTservice delivery. Not all components have receivedequal attention regarding men’s engagement.Three examples are: (1) men’s involvement infamily planning among infected or discordantcouples, though the study by Wanyenze et al.(2011) is a recent and notable exception; (2) men’sparticipation more generally during pregnancy,focused antenatal care and especially in birthpreparednessplanning, including the promotion offacility-based delivery; (3) effect of antenatal syphilistesting and partner treatment in engaging men inantenatal care, including acceptance of HIV testing.70. So, what constitutes male involvement inPMTCT? What do men need to know, believe or doto be “involved”? Participation by men in which ofthe components of PMTCT constitutes involvement?24

Male involvement in the elimination of mother-to-child transmission of HIVFor example, if men have positive gender attitudesand behaviours (e.g. do not have multiple sexualpartners or commit intimate partner violence (IPV))and are supportive of their partners’ uptake ofservices (e.g. provide financial support), is it criticalfor them to attend the PMTCT facility with theirpartner? This question becomes especially salient ifhealth-care services are not male friendly, and mayin fact reinforce harmful gender norms (Ghanotakis,personal communication, 2011). The question iscritical too in the context of high prevalence ofserodiscordancy among couples.71. Two research groups (Byamugisha et al.2010b; Peltzer et al. 2011) have utilized scales orindices to gauge the level of male involvement. Forexample, the study by Byamugisha and colleaguessought to determine the level of male involvementand its determinants in a PMTCT programmein eastern Uganda. To gauge the level of maleinvolvement, the authors utilized an “ad hoc maleinvolvement index”. The index consisted of six items,with each being given equal weight in the analysis.The items consisted of the following:• the man attends antenatal care with his partner• the man knows the partner’s antenatalappointment• the man discusses antenatal interventions withhis partner• the man supports his partner’s antenatal visitsfinancially• the man has taken time to find out what goes onin the antenatal clinic• the man has sought permission to use a condomduring the current pregnancy.“The involvement score for each respondent couldrange from 0 = no involvement to 6 = involved inall six activities. A total score of 4–6 was consideredas a ‘high’ male involvement score and 0–3 as ‘low’relative to this particular population. Bivariateanalysis was performed between high maleinvolvement index as the dependent variable andeach independent variable” (Byamugisha et al.2010b). Unfortunately, there was no discussionin the article regarding the rationale for theselection of these criteria, their validity, or theirgeneralizability to other locations.72. Horizons and Promundo developedthe Gender-Equitable Men (GEM) scale toquantitatively measure change in attitudesabout gender norms and an intervention’s effectson gender norms and sexual risk behaviours.The scale is designed to provide informationabout gender norms in a community, as wellas the effectiveness of interventions that try tochange them (Pulerwitz and Barker 2008). TheGEM scale is intended to “(1) be multifaceted andmeasure multiple domains within the constructof gender norms, with a focus on support forequitable or inequitable gender norms; (2) targetprogram goals related to sexual and intimaterelationships, and sexual and reproductive healthand disease prevention; (3) be broadly applicableyet culturally sensitive, so indicators can be appliedin and compared across varied settings and besufficiently relevant for specific cultural contexts;and (4) be easily administered so that a numberof actors – including the organizations that areimplementing the interventions – can take on thistype of evaluation”. Respondents with a higherGEM scale score (indicating greater support forinequitable gender norms) were significantly morelikely to report STI symptoms and physical andsexual violence against a partner than respondentswith lower GEM scale scores” (Population Council,undated). The GEM scale has been validated forEthiopia, Kenya, India and Brazil.73. Monitoring male involvement in programmeimplementation and quality. EngenderHealth’sCHAMPION (Channeling Men’s Positive Involvementin the National HIV Response) project in the UnitedRepublic of Tanzania developed a series of standardsof performance for each of its programmatic areas(Ramirez-Ferrero et al. 2010). They were designedfor the purpose of monitoring and evaluatingCHAMPION or other male involvement programmesat the community level, principally through localpartner organizations.25

Male involvement in the elimination of mother-to-child transmission of HIVStandards of performance have been developed fora number of programmatic areas, including peereducation, curriculum-based education, communityengagement, male-friendly health services,advocacy and gender-based programming (ororganizational gender mainstreaming). Programmeassessment may be completed by administrative orprogrammatic staff, or by an external organization,on a periodic basis. The standards serve threeprincipal functions:• to establish a baseline of performance and toidentify technical assistance needs;• to provide guidance to CHAMPION staff andimplementing partners, helping them identifykey areas for monitoring and for improving thequality of programming;• to evaluate, over time, the effectiveness oftechnical assistance by monitoring the numberof indicators (or standards) that have been metsince baseline.Issues for consideration74. Conceptual issues• From seeing men as obstacles and enablersto seeing them as partners, clients andagents of change. A radical (i.e. at the rootlevel) reorientation is needed to addressthe conceptual and policy barriers to maleinvolvement and integration of services – tomove beyond seeing men as simply a facilitatingfactor to enable women to access health-careservices, and toward seeing men as partners andclients of reproductive health policy and practiceand as advocates for social change• Gender is relational. Insufficient attention waspaid in this paper to a foundational assumptionof gender-transformative programming – thatgender is relational. That is, gender norms, rolesand the particular cultural vulnerabilities ofthe sexes are continually constructed throughindividual and collective interactions betweenmen and women throughout the life-cycle.“The social meanings of masculinities andfemininities – and all that happens because ofthese meanings – are constructed in contrastand relation to each other” (PopulationReference Bureau 2010). Gender-transformativeprogramming seeks to increase understandingof how everyone shapes and is shaped by socialconstructions of gender. So, if we are interestedin bringing about sustainable social changemore effectively, we must move beyond gettingmen simply to come to the health-care facility,but intentionally intersect our gender-basedprogramming work with men and women,i.e. bring together both men and womenwhen examining etc. to engage everyonein examining, questioning and challengingrestrictive constructions of masculinity andfemininity that drive inequality and hinderhealth and well-being.75. Couples• Relationship quality and its implicationsfor HIV. We need to learn more about thedynamics and qualities of the relationship ofour clients. The contradiction between men’spositive attitudes towards services and their lowparticipation rates in PMTCT sites is suggestiveof dynamics within relationships that wecurrently do not fully understand. Increasedunderstanding is imperative given the high rateof serodiscordancy, as well as the very positivepotential of couples to serve as entry points topromote whole-family health and wellness.• Diversity of relationship types and thedefinition of male involvement. It is importantto recognize the “complex spectrum of maritaltypes” that constitute the “in union” categoryin Africa (Desgrees-du-lou et al. 2009b). Maritalstatus can be difficult to define. Marriage itselfcan be imprecise, as it may not be reducibleto a single event, but rather a process that cantake years to complete. In addition there arevariables regarding cohabitation (co-residence,or visiting unions) and number of spouses withina marriage, with polygamy being frequentlypracticed in parts of Africa. Desgrees-du-louand her colleagues (2009b) conclude that the26

Male involvement in the elimination of mother-to-child transmission of HIV‘‘in union’’ category, which includes all personswho declare having a regular partner, seemsto be the most relevant category to take intoaccount in order to explore the prevention of HIVtransmission within conjugal relationships here.Even so, the temporal aspects of the formationof unions, the variety of unions, and diversity ofmarital status call into question how we definemale involvement in diverse settings. What doesit look like, for instance, in places where themajority of women attending a clinic considerthemselves single? How would our services andpolicies differ as a result?76. Integration• Family planning. Despite being a cornerstoneof the four prongs of PMTCT, the focus onfamily planning continues to get lost. This isunfortunate since there is ample evidencedocumenting family planning’s effectiveness inpreventing HIV infection, and reducing maternaland infant mortality. There is also a humanrights imperative here: family planning enablesHIV-positive and HIV-negative women, men andcouples to decide if they want to have children,and when and how many.• Sexually transmitted infection. HIV and otherSTI control efforts are not optimally integrated,even though it is widely recognized that STIcontribute to HIV acquisition and transmission,that HIV prevalence is higher among patientswith STI, and similar interventions (condoms,circumcision, and behavioural change) preventboth HIV and other STI (Fleming et al. 1999, WHO2007). Strategies for engaging male partners inPMTCT of HIV should explore potential synergieswith STI, such as the role of routine antenatalsyphilis testing and syndromic STI diagnosis inengaging male partners in antenatal care.• Gender-based violence. Gender-based violenceis an immediate sexual and reproductive healthand rights (SRHR) concern – because it speaksto the basic protection of people from physicalharm. Not only is physical injury a priorityconcern, but the implications of violence onSRH are profound. Violence in relationships hasbeen linked to increased rates of unintendedpregnancy and STI and HIV transmission,underutilization of antenatal care, depressionand low self-esteem, pregnancy and of covertcontraceptive use (Heise et al. 1999).77. Health services• Quality care. Quality of services is a significantconcern that serves as a barrier to care. The goodnews is that initiatives, such as male-friendly services,are not only a way to enhance the range of services,but they are also useful quality-improvement tools.In the provision of male-friendly services training,attention should be paid to addressing two concernsalready expressed – how to work more effectivelywith couples (see “Promising initiative” box thatfollows) in ways that challenge harmful gendernorms and promote shared decision-making, andhow to screen for IPV. A study conducted in SouthAfrica revealed a myriad of benefits to IPV screening.Not only were the questions well received byfemale clients, but it also enabled women to accesstreatment and psychosocial sources of support.Women found that simply discussing experiencesof violence was helpful. The authors report thatwomen easily made the connection between theirexperiences of violence and gender inequality(Christofides and Jewkes 2010).• Scaling-up services. Although PMTCT includes avariety of services, HIV testing and counselling arecritical, serving, as already noted, as the startingpointfor couples to make a series of decisionsregarding HIV and PMTCT. Quality services helpto ensure clients’ human rights to not only accesscouple HTC, but also to be linked to effectiveprevention, treatment and care programmes.When components are added to couple HTC, likechallenging harmful gender norms, the quality ofthat counselling becomes all the more important– and so are the challenges in terms of scale-up.Given the infrastructural problems that many healthsystems in sub-Saharan Africa face (e.g. humanresources shortage), it is important to remember thatmaintaining quality in the face of WHO’s call to scaleupeffective PMTCT programmes is not a matterof chance, but one of choice. WHO is one amonga number of organizations that provide technicalguidance on quality assurance and improvementat the national and subnational levels. A key pointof all quality-assurance and improvement efforts27

Male involvement in the elimination of mother-to-child transmission of HIVis that quality must be planned. A recent WHOtechnical brief (WHO 2011) on the topic providesa useful quality-improvement framework forpolicy-makers and public health practitioners,which includes 10 fundamental buildingblocks required to institutionalize quality HIVcounselling and testing within different contextsand settings.Promising initiative: couple-oriented posttestHIV counsellingCOC is a clinic-based behavioural interventionthat replaces standard post-test HIVcounselling delivered to a pregnant woman.“It provides the woman with personalizedinformation as well as tools and strategies toactively involve her partner within the prenatalHIV counselling and testing process” (Orne-Gliemann et al. 2010). The expanded coupleorientedcounselling components include:identification of the partner and discussionabout the type of relationship; assessment ofthe level of communication regarding SRHand HIV; discussion about disclosure, partnertesting, and couple counselling; provisionof tools and strategies to help womenaddress these issues with their partners; andanticipation of partners’ possible negativereactions, and strategies to overcome them.The COC effort is part of the French NationalAgency for AIDS Research (ANRS) 12127antenatal multisite HIV-prevention trial, whichis only now at the acceptability stage of thetrial. Even so, in their baseline assessment, theauthors found that one of the keys to men’sinvolvement within prenatal HIV counsellingand testing is “the better understandingof couple relationships, attitudes andcommunication patterns between menand women, in terms of HIV and sexual andreproductive health. This conjugal contextneeds to be taken into account in order toprovide quality prenatal HIV counselling,which aims at integrated PMTCT and primaryprevention of HIV” (Orne-Gliemann et al. 2010).Gaps in knowledge andsuggestions for further work78. Men• Most of the available information regarding menand PMTCT relates to HIV testing. More research isneeded regarding ways to involve men in the othercomponents of PMTCT.• There is hardly any mention of men’s participationin birth-preparedness planning, the promotion offacility-based deliveries and HIV transmission.• There is inadequate research on the role of routineantenatal syphilis screening in engaging men in awoman’s pregnancy, and the potential influencethat STI screening could have in increasing testingcoverage of male partners and identifying womenat increased risk of HIV acquisition.• Men’s use of women as proxies for their ownHIV testing suggests limitations in men’sunderstanding of the dynamics of transmissionand serodiscordancy.• Most of the available information we have aboutmen and PMTCT comes from women and, lessso, from men who attend clinic. There is littleinformation about men and couples who do notutilize services.79. Couples• Research on HIV risk management andprevention within couple relationships shouldbe strengthened. In sub-Saharan Africa, there isstill inadequate socio-behavioural knowledge ofHIV prevention within the dynamics of couplerelationships (Painter 2001). This includes couplecommunication on sexual risk; the evolution ofpreventive behaviours over time (e.g. by durationof relationship and time since VCT); and genderissues of negotiation and violence (Desgrees-du-Lou and Gliemann 2008).• Research on the difference between couples whoutilize services and those who do not would beuseful. What is the relationship between couplequality, utilization and male involvement? Is coupleconnectedness a confounding factor betweenutilization and health or behavioural outcomes?28

Male involvement in the elimination of mother-to-child transmission of HIV80. Integration• Further research is needed to assess the effect ofintegrating perinatal PMTCT with other healthservices regarding coverage, utilization, servicequality and health outcomes and the optimalintegration modality (Tudor Car et al. 2011).• Family-centred approaches remain largelyunderdeveloped and under-documented.There are few formal published evaluations offamily-centred PMTCT models, and almost nocomparative research in this area (Betancourt etal. 2010).29

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