On the 30th June 2015, Cuba became the first country to eliminate mother-to-child transmission of HIV and syphilis. Cuba’s achievement demonstrates that it is possible to end the AIDS epidemic and brings hope to many other affected countries. However, universally HIV remains an exceptional challenge and an estimated 1.4 million women living with HIV become pregnant every year. Mother-to-child transmission (MTCT) is the most most common way that children contract HIV, which is why its successful eradication in Cuba represents such a major global health breakthrough.
At the end of 2013, the World Health Organization (WHO) found that there were approximately 3.2 million children living with HIV, with the largest proportion found in sub-Saharan Africa. The majority of these children will have contracted HIV from their mother at some stage during pregnancy, childbirth or breastfeeding; rates of MTCT range from 15-45% in the absence of intervention. Nevertheless efficacious treatments such as antiretroviral medicines can decrease the risk of HIV transmission to 1%. Such interventions fall under the umbrella of ‘prevention of mother-to-child transmission’ (PMTCT), a generally used term for programmes, policies and treatments developed to reduce the risk of MTCT of HIV.
The WHO has included PMTCT as one of its main approaches in preventing HIV infections in infants. Yet in sub-Saharan Africa, the region most in need of effective strategies to target HIV transmission to children, drawbacks to the provision of PMTCT services are numerous. A key challenge is the lack or absence of male participation in PMTCT; in recent reports male partner involvement in these services has been identified as a promising factor and a priority in improving the effectiveness of PMTCT programs.
One reason for this is that in many sub-Saharan African countries men are the principal decision makers in their families. In sexual and reproductive health, male partners tend to have the upper hand when it comes to decision making; typically fathers play a crucial part in the many stages of family life from family planning to pregnancy and childbirth. Fathers also play an important role in the financial and emotional support of the family. However, men are rarely included in PMTCT interventions, with too many program designs essentially ignoring half of the equation.
As a result of men’s exclusion from programs many pregnant women are avoiding HIV testing, as consent from their husband is needed. The women that do get tested without consent often do not reveal their status to their partner for fear of the assumption of infidelity, an accusation leading to divorce. Other HIV positive women are faced with abuse and as such aren’t allowed to be included in further PMTCT interventions; one study found that abandonment, violence and stigmatization were commonplace for pregnant women who revealed their HIV status in Ivory Coast. Another paper found that in sub-Saharan Africa women’s increased susceptibility to HIV is associated with husband dependency, low socioeconomic status and traditional male dominance. These influences limit women’s capability to discuss the use of condoms and fidelity with their male partners. Unsurprisingly, a Tanzanian study found there is increased risk of HIV transmission among women whose male partners practice polygamy; all these issues lead to fewer HIV positive women using PMTCT services.
Male participation is crucial then, as uptake and adherence to PMTCT interventions by most women is greatly influenced by male involvement. A study in 2012 discovered that women who’s partner approved were six times more willing to be tested for HIV than those who’s partner was against it. There is also a need for good communication amongst husband and wife, as PMTCT programs can include difficult decision-making; men’s knowledge about HIV prevention will be increased if they are involved in PMTCT and this will allow them to communicate with their partners about preventive methods. For example, rates of condom use improved drastically among HIV positive women in Ivory Coast after they began communicating with their partners about HIV prevention. Correspondingly a strong association is also found between partner participation in voluntary counselling and testing (VCT) and improvement of acceptance and utilization of HIV preventative strategies. For example in Nairobi, seropositive women had a higher probability of following their treatment protocol during pregnancy and delivery when they attended VCT with their partners. What’s more, woman counselled with their spouse were 28% more likely to have a facility-based delivery than individually counselled women. It has also been found that levels of abuse, discrimination and desertion also decrease with greater male partner understanding of HIV.
Nevertheless, men’s current participation in PMTCT services is very limited despite the clear benefits. Recent studies show male proportions to be a mere 8%-15% for HIV testing and counselling in eastern and southern Africa. But why? Recent research has found that the main obstacles to male participation in PMTCT are stigma, socio-economic factors, poor information access, weak health systems, and cultural barriers to ‘female-orientated’ health programmes. Structural barriers can also play a part; in Tanzania it was discovered that service providers would frequently refuse men who approached antenatal clinics with their spouses, and in Malawi PMTCT services have been dubbed a “divorce program”. Predictably, even men who are willing to engage will often feel marginalized or of secondary importance. Other pertinent obstacles include public ridicule of men participating in PMTCT, the misunderstanding that their spouse’s HIV status is a proxy of their own, and the reluctance of men to get HIV tested.
In the last decade there has been significant investment and determination to reduce mother-to-child transmission of HIV in sub-Saharan Africa through PMTCT services, and men must undoubtedly play a part. One of the main focuses for policymakers should be to tackle the misconception that PMTCT services are women-orientated and are thus only a woman’s responsibility. In a recent WHO report there was a mention of possibly changing the term PMTCT to ‘prevention of parent-to-child transmission’ (PPTCT) of HIV. This new term, suggesting more of a couple or family-orientated strategy, could plausibly promote further male involvement.
If effective eradication of infant acquired HIV is to be accomplished, then male participation should be expanded to all phases of care, treatment, and delivery. Male inclusion should be a top priority in future PMTCT research and projects, and it is imperative that changes to policy and practices be applied to welcome men into any HIV-preventative health care service.
Featured image © Jon Rawlinson
Apolline Lambert is a trainee at the European Medicines Agencee and holds a Master’s degree in Global Health and Development from University College London (UCL). Her main interests are in health policy and diplomacy, health and human rights, communicable diseases, and access to medicines.