A 1:1 unmatched case control study design was used to determine factors associated with male partner involvement in PMTCT. Socio-cultural (history of couple HTC and fear of knowing HIV status), health service related factors (staff friendly and welcoming, ever heard about PMTCT) and knowledge) were found to be associated with male involvement in PMTCT.
Previous couple HIV testing and counseling was associated with male involvement in PMTCT. Couples who are aware of their status are not afraid of HIV testing and counselling unlike those who are not aware. This implies that promoting couple HIV testing and counselling in all other HTC entry points might enhance male involvement in PMTCT. Similar findings were reported by Morfaw et al. in sub Saharan Africa in 2013 . Being afraid of knowing HIV status was associated with male partners less likely to be involvement in PMTCT.
Men who had more than one sexual partner were less likely to be involved in PMTCT. In a study by Ditekemena et al. in Kinshasa, it was found out that men with one sexual partner were twice more likely to be involved in PMTCT . Similar findings were reported by Kang’oma et al. in Malawi where they found that fear of HIV testing among men who engaged in extra marital affairs was the main reason why men did not participate in PMTCT services . Men who engage in multiple unprotected sexual relationships are at a higher risk of acquiring HIV. About 45 % (n = 100) of the male partners interviewed in this study reported that they engaged in extra marital affairs. Majority of these men refused to accompany their wives for PMTCT due to the fear of knowing their HIV status which might result in stigma, discrimination, domestic violence or abandonment by wife if positive. From the qualitative data, it was also highlighted by three quarters of the respondents that the fear of HIV test results was the main barrier to male involvement in PMTCT. Men who perceive themselves at risk of HIV refuse to go for couple HTC. This implies the need for more HIV and AIDS educational and behaviour change communication programs for male partners in order to address issues to do with culture and the benefits of knowing one’s HIV status.
Having time to accompany wife for PMTCT was associated with male involvement in PMTCT. Male partners who could get time were more likely to accompany their wives than those who were always busy with other commitments. Men are usually limited by shortage of time due to various commitments mainly in urban settings. Eighty three percent of the respondents were either formally or informally employed. However it is still possible for a male partner to take a day off considering that in Zimbabwe, workers in the formal sector get twelve days annual leave and a number of other leave days. Men in the informal sector need to plan their time so that they can accompany their wives for PMTCT.
Similar findings were reported in a systematic review by Morfaw et al. in sub Saharan Africa in 2013 where lack of time and the non-invitations to the health facility were the main reasons for low male participation . It is interesting to note that in this study being employed was associated with the likelihood of male partners being involved in PMTCT. This was contrary with other studies were the association was found to be significant [13, 14].
Men who reported to be comfortable being tested at their local clinic were more likely to be involved in PMTCT. HIV testing at the local clinic may be associated with stigma and discrimination thereby hindering male partners from accompanying their wives for PMTCT. Men would prefer to be tested elsewhere outside their nearest health facility. Similar findings were reported by Ditekemena et al. in a randomized control study which was conducted in Kinshasa, DRC. It was found that the majority of male partners preferred to be tested for HIV in non-health service settings like churches . This implies that sensitizing and referring men for PMTCT in all other entry points might improve their involvement. Similar findings were reported by Ncube et al. in Bulawayo, Zimbabwe, where they found out that being comfortable testing at the clinic where partner goes for ANC was one of the predictors of male participation in PMTCT .
Male partners who received feedback from their wives on ANC issues were significantly more likely to be involved in PMTCT than those who did not receive any feedback. Giving feedback to a partner might imply good couple communication and hence acceptance by the male partner to be involved in PMTCT despite other limiting factors. In other studies barriers to male involvement in PMTCT programs included lack of couple communication and the unwillingness of women to have their male partners involved because they feared domestic violence, stigmatization and divorce if HIV positive. Other studies reported poor communication on ANC services and the importance of couple HTC between partners was associated with poor male involvement in PMTCT [10, 16].
Having ever heard about PMTCT was significantly associated with male involvement in PMTCT. However, the association was overestimated by the fear of knowing one’s HIV status. Male partners who heard about PMTCT appreciated the importance of their involvement in the program and were more likely to participate. In this study it was found out that men who had never heard about PMTCT did not appreciate it as an important service, hence did not participate. The main sources of information highlighted by the respondents were the clinic/health worker, family/friend and the radio and television. Nsagha et al. also reported the clinic/health worker and television as the main sources of PMTCT information in Cameroon .
The friendliness and welcoming of male partners by health workers was significantly associated with male involvement in PMTCT. Men need to feel that they are important and are part of the pregnancy when they accompany their wives for ANC. In a descriptive qualitative study conducted by Adelekam et al. in Nigeria, married men agreed that it was important to accompany their wives for ANC. However, they highlighted that before accompanying their wives, they must feel needed . Similar findings by Byamugisha et al. in Eastern Uganda, who reported that harsh treatment of men by health care providers, discouraged them from being involved in PMTCT .
In Uganda, it was found that the unwelcoming attitude of health workers and the fear of being harassed by health workers were some of the reasons contributed to low male involvement .
Men who reported that the clinic’s operating time was convenient were more likely to be involved in PMTCT that those who reported that the time was inconvenient. Most men whether formally employed, informally employed or unemployed run around working for the family during the week and would be found at home during the weekends. Men who work at least five days a week and cannot get off days from work find the clinic’s operating time inconvenient for them. This implies that if clinics would open during weekends, more men would be available to accompany their wives for PMTCT. If men are given formal invitation letters by the clinic, they can present them at their workplaces and ask for a day off.
Men who perceived delays in service provision at the health facility were significantly less likely to be involved in PMTCT. There were a number of activities that took place in ANC in Midlands province as highlighted by key informants and these included, group health education, booking, examination, weighing, paying and HTC. These activities might take an average of two hours. In a study by Byamugisha et al. in Eastern Uganda in 2010, it was found that ANC service providers take time to deliver services to clients, hence male partners are not in a position to spend more time at ANC clinics . Short waiting time of less than 30 min was found to increase male involvement in maternal health services in Uganda . This implies that attending couples first and increasing the number of nurses in ANC to avoid delays might improve male partner involvement in PMTCT. Giving first preference to those who bring their male partners is also very important in that it encourages other women to convince their partners to accompany them.
Men who perceived couple HTC for PMTCT as important were more likely to be involved in PMTCT but was not statistically significant in this study. Ncube et al. in Bulawayo City, Zimbabwe, found out that having the attitude that it was important for couples to get counseled and tested for PMTCT was significantly associated with male participation in PMTCT . The same study also found out that men who believed that it was important for them to attend HIV testing and counseling together with their female partners were more likely to participate in PMTCT . Madzima et al. found out in Zvimba district that male partners who knew the benefits of PMTCT were more likely to be involved in PMTCT . This implies that routine advocacy and social mobilization activities on the importance and benefits of male involvement in PMTCT are necessary to improve male involvement.
In this study men who were invited for couple HTC in ANC were less likely to be involved in PMTCT though not statistically significant. Men might not value verbal invitations by their wives, an initiative which was being used by all the clinics, hence the need for formal invitation letters. In a randomized control trial conducted in Zvimba district, Zimbabwe in 2010 by Madzima et al., it was found that male partners invited by a formal letter were more likely to participate in PMTCT . This implies that male partner involvement may improve if the clinics write formal invitation letters to male partners explaining the importance of their involvement. In a study by Dyogo et al. in Uganda, male partners who were invited through formal letters were significantly more likely to be involved in maternal health services .
Knowledge levels were significantly high among men who were involved in PMTCT. This might be due to the exposure to PMTCT information at the health facilities. Men who are knowledgeable about PMTCT get involved and support their wives because they understand the benefits. In this study, men who supported their wives joining the PMTCT program were more likely to be involved in PMTCT but not statistically significant. High knowledge levels enhance program acceptability an uptake. Similar findings were reported in a study by Ncube et al. in Bulawayo City where the majority of men who participated in PMTCT had good knowledge on PMTCT whilst the majority who did not participate in PMTCT had poor knowledge on PMTCT . In a study by Tshibumbu et al. in Zambia, knowledge of PMTCT was the strongest factor which was positively associated with male partner involvement in PMTCT . Similar findings were also reported in other studies [10, 19, 21, 22]. This implies that exposing men to adequate information on the importance of their involvement in PMTCT might improve their involvement. Dyogo et al. in Uganda found out from the qualitative data that lack of knowledge on the benefits and need of male involvement in maternal health care services was reported to contribute to low male involvement .
Limitation of the Study
There was a possibility of recall bias whereby both cases and controls could have forgotten about history of HIV testing and counseling as a couple. This was minimized by confirming with their wives whether they were once tested as a couple before.
There was a possibility that men who were to accompany their wives later were likely to be recruited as cases during the time the study was conducted. This was avoided by recruiting men whose wives had attended the forth, which is the last ANC visit and those who had just delivered.
Social desirability bias cannot be excluded from this study whereby cases and controls could have responded in a way to please the researcher. It can take the form of over-reporting good behavior or under-reporting bad or undesirable behavior. This bias interferes with the interpretation of average tendencies as well as individual differences. Indirect questioning was used to reduce such bias.