Involvement of Male Partners in Sustaining Interventions for Preventing Mother-to-Child Transmission of HIV Among Women with HIV

Research Design

This study adopted a qualitative approach in their natural settings with the aim of comprehending and interpreting phenomena in terms of the subjective interpretations of individuals.^[16] The case study research design was used to generate an in-depth understanding of support provided by male partners to their HIV-positive female partners to sustain PMTCT interventions. The study was conducted in 2018 at the Tshitamboni male’s forum center in Vhembe District in Limpopo province.

Population and Sampling

The population comprised more married than single men and members of the Tshitamboni men’s forum and those in relationship with their HIV-positive partners. Purposive and convenience sampling was used to 20 sample participants who volunteered to participate in the study.

Ethical Considerations

Ethical standards were ensured by obtaining ethical clearance (Ref: SHS/16/PDC/05/1306) from the University of Venda Ethics Committee and permission to conduct the study from Board members of the forum and the participants. Participants were coded as P and a number from a specific group as focus group discussion (FGD) 1 or 2. The participants gave verbal and written informed consent and were informed of their right to withdraw from the study without penalty. Ethics principles of fairness, privacy, confidentiality, anonymity, and participants’ rights to voluntarily participate in the study were adhered to.

Data Collection

The researchers developed an interview guide that lists the questions to be explored during the interview. Data was collected through focus group discussion to gain a detailed narrative of the perceived support and risks to MTCT by male partners of HIV-positive women and what support was provided during childbirth. Data was collected at the Tshitamboni Center. Two focus groups, each comprising ten participants, were conducted [Table 1]. The researchers used focus group discussions to get data from participants who were attending the men’s forum. This method allowed for the observation of participant’s body language, which provided valuable insights into their self-reports. The questions asked were (1) what are the perceived practices that hinder your support to your HIV-positive partner as this could contribute to MTCT risks and (2) what support will you provide to your partner to sustain PMTCT interventions during this period?

The researchers conducted further investigation to uncover more intricate information by providing clarification and elaboration on previous answers. The investigation primarily centered around the following topics: regular use of condoms, infant feeding practices, administration of traditional and over-the-counter medication, adherence to antiretroviral drugs (ARVs), providing expressed breast milk to the baby, and general beliefs regarding the prevention of childhood illnesses.

Data Analysis

Data analysis began while data was being collected and transcribed. A linguist converted the data from Tshivenda/Xitsonga to English verbatim after it was first translated. Tesch’s eight-step open coding data analysis process was employed.^[16,17,18] To avoid omissions, transcriptions of the data was compared to the recorded information, and field notes as verbal cues were coded and categorized. Creswell and Creswell^[17] open coding data analysis was used, which included a series of steps: First, thoroughly analyze the data in order to obtain a full understanding. Next, record any interpretations or significance that arose during the reading process. Construct codes based on the reduced data that was collected. Examine the transcriptions again and carefully study them, while also asking questions regarding the importance of the collected data. Abbreviate topics that arose as codes; Categorize interconnected subjects to provide significance to the main themes and subthemes; subsequently, elaborate on the themes and subthemes.

Trustworthiness

Trustworthiness was established by the credibility gained from prolonged engagement during the data collection process. The researchers and the moderator interacted with participants during the visit and data collection, establishing trust and rapport.^[19] Additionally, the credibility was strengthened by the time spent with participants during the interviews, where active listening and observation took place. The two focus groups were conducted to the point where no new data was being obtained. A verification process was performed to validate the accuracy and confirm the findings. The voice recorder was used to ensure the reliability of the information. To ensure the feasibility to apply the research technique, detailed and comprehensive descriptions of the research methodology were provided. The recorded interviews were transcribed verbatim, and the nonverbal cues were enclosed in brackets in the transcripts to ensure their authenticity.

Presentation of Qualitative Results

From the raw narratives following data analysis, the following themes emerged:

• Perceived practices that hinder the provision of support, and

• Perceived support provided to sustain PMTCT intervention during childbirth.

Childbirth in this study referred to the participation support by a male partner of an HIV-positive partner during pregnancy, labor, and early postnatal. The sustaining PMTCT interventions included how the male partner adheres to interventions that prevent the transmission of the virus, like consistent condom use, especially during breastfeeding, support in exclusive breastfeeding, adherence to ART, and limiting the use of cultural practices. The identified theme and subthemes are presented below. Direct quotes from participants supported the themes that emerged.

Perceived Practices that Hinder the Provision of Support

In most African societies, there is the perception that pregnancy and child-rearing are women’s responsibilities.^[20] The role played by male partners in PMTCT is treasured. However, male partners were often socialized from a young age not to involve themselves in issues related to childbirth, which may hinder their ability to support their wives and children. This study revealed that male partners faced hindrances supporting their female partners, whether HIV-positive or negative. They reported that they wanted to support their wives and children, but society seems to be not yet ready for that since those trying are shunned; for example, they are said to be given a substance to stay soft (muti to make a man quiet).

Male partners indicated they wish to support their female partners, but it is not traditionally acceptable. The study’s findings concurred that traditionally men are oriented not to be involved with issues of supporting women during the postnatal period.^[21] This was not concurring with the guidelines of the South African Department of National Health^[13] because components 3 and 4 require the full support of a male partner, to prevent transmission of HIV from an HIV-infected woman to her infant during pregnancy, labor, childbirth, and breastfeeding if engaging in unprotected sex. Additionally, both partners are encouraged to undergo HIV counseling and testing, support one another when taking ARVs, even for prophylaxis and a male partner to create opportunities to support the HIV-positive partner.

Cultural practices often perpetuate stereotypes, leading to the perception that a male partner supporting his female partner in child-rearing may weaken his manhood. The community also contributed to the discouragement of male partner involvement by stigmatizing and devaluing men who support their wives, portraying them as submissive or lacking masculinity. Traditionally, grandmothers were regarded as highly experienced and knowledgeable about the issues of childbirth and taking care of a newborn baby; however, Negin et al.^[22] said that the family-centered aspect was ignored. Male partners were hindered from providing support to their female partners following the birth of the infant, which disrupted the implementation and continuation of the PMTCT interventions. Healthcare professionals need to be involved in creating opportunities for male partners. The success of PMTCT of HIV depends on cooperation between parties, as a male partner has a strong influence on the PMTCT sustainability.^[23]

Participants also mentioned that health facility-related factors were obstacles to the involvement of male partners’ participation. The nurses and security guards at the health facility have been observed discouraging male companions from entering the consultation room or even the facility area with the woman. Furthermore, the male partner may have been discouraged by the longer period of the waiting. This was supported by Gourlay et al.,^[15] who reported that male partners were prevented from accompanying their wives to the clinic due to long waiting periods. Midwives tell the male partner to wait outside when the women enter the cubicle to be examined. The same findings by Kalembo et al.^[24] corroborated that healthcare workers excluded the male partners from the session where their wives were examined and instructed them to wait outside without any information about what was happening to their pregnant wives. Midwives were reported to display hostile behavior toward male partners who try to support their wives.^[15] The health professional was cited as noncaring and very slow when rendering care. Gourlay et al.^[15] further maintained that health workers had been reported as barriers to involvement for support in PMTCT sustainability. The mistreatment of the spouses of HIV-positive women and partners by healthcare workers made them feel uncomfortable and embarrassed.^[25] Most healthcare facilities were planned long ago before PMTC programs were initiated and were not built in a way that they may accommodate family consultation. Male partners were offended by the space, sitting arrangement, and accommodation of mothers and their spouses as it is still a challenge, especially with old infrastructures.^[25–27] The security services and long waiting hours were reported to contribute to male partners’ failure to support their wives.^[28]

Perceived Support Provided to Sustain PMTCT Intervention During Childbirth

As in most African countries, male partner involvement in PMTCT interventions is crucial in family settings where men are the primary decision-makers. As the head of the household, the husband dramatically influences the woman’s ability to seek healthcare or implement health practices and interventions. In the context of HIV, male partners have a role in the women’s risk of acquiring HIV and in their uptake of HIV testing and MTCT prevention programs. In this study, participants cited the instances that could increase the chances of MTCT, like engaging in unprotected sexual relations. Tilahun and Mohamed^[29] indicated that male partners are unwilling to use condoms during sexual intercourse. Male partners were reported to use violence, withdrawal of financial support, resentment, and control behaviors to force their wives to have sex without a condom. This was also a problem because female partners who did not disclose their HIV-positive status found it difficult to negotiate condom use, thus exposing them to reinfection and risk of MTCT to their babies.^[15]

The lack of support from male partners causes female partners not to disclose their HIV-positive status to their partners.^[30] Nonuse of condoms with infected women while breastfeeding is one of the identified causes of MTCT.^[31] This information was also confirmed by the focus group of male partners who verbalized that they don’t use condoms in marriage, fearing the issue of trust in their relationship. Participants verbalized that when they have condoms, it is like confirming to their suspicious wives that they are having extramarital affairs; they also reported that female partners are compassionate to seeing male partners with the condom. Participants stated that if they bring a packet of condoms, the wife will count them; if one pack is missing, they will have to explain to the point of sleepless nights. They said they may use a condom with their girlfriends but not their wives. Men were also likely to have more than three sexual partners in their lifetime.

Multiple concurrent sexual partners have been identified as one of the drivers fueling the HIV epidemic and the hindrance of family support to PMTCT interventions. Men who have multiple sexual partners were reported not wanting to accompany their pregnant women because they do not want to be seen by their concubines. Extramarital relationships or multiple sexual partners were cited as barriers to male partners’ involvement in family support in PMTCT sustainability.^[32,33] From the study’s findings, it became clear that males need detailed information on the risks of MTCT and the importance of their participation in the sustainability of PMTCT interventions. Male involvement in PMTCT improves sustainability and promotes positive attitudes toward adherence to PMTCT interventions. This was also confirmed by Ditekemena et al.^[34] who said that male participation in child-bearing decisions is crucial and also has a positive impact on the acceptability of PMTCT interventions.

Limitations

This study was conducted with one men’s forum in one district (Vhembe) of Limpopo Province and cannot be generalized to another district. The focus group method may have limited the participants’ information sharing, as the minority of participants may dominate the entire group during the discussion. This was not ignored as the setting up and moderating the groups attempted to reduce these limitations.

Key Message

• Support from a male partner is linked to improved maternal HIV testing during pregnancy, better initiation and adherence to maternal antiretroviral medication, and less vertical transmission, with an accompanying rise in HIV-free baby survival.