Strengthening male involvement in prevention of mother-to-child transmission of HIV in Enugu State, Nigeria

Nigeria has the second highest HIV prevalence in Sub-Saharan Africa and  the risk of mother-to-child transmission of HIV in children below the age of 15 is between 25-40% . In 2010, the Nigerian government committed to achieving a 50% reduction in mother-to-child transmission of HIV and 50% improvement in HIV counselling and testing.

Prevention of mother-to-child transmission (PMTCT) services offered to women in Nigeria include: ante-natal care, basic information about HIV transmission and prevention; HIV counselling and testing; prevention of unintended pregnancy; and antiretroviral treatment. Efforts to improve uptake of PMTCT have been hindered by the lopsided focus on medical interventions and neglect of the social factors that contribute to mother-to-child transmission . In particular, lack of male involvement is considered a key challenge to the uptake of PMTCT services.

Our research explored the extent of male involvement in PMTCT in Enugu state, Nigeria and its effects on women’s access to and use of PMTCT services. The findings showed that only a few men accompanied their wives to antenatal care. Men’s attendance with their partners to educational sessions on prevention of unintended pregnancies and HIV counselling and testing was also reported to be low. Women were said to come for their antiretroviral treatments alone and on some occasions would also collect medicine for their partners.

Factors affecting men’s participation in PMTCT

Factors which contributed to the limited participation of men in PMTCT included individual and relationship factors, gendered community norms and expectations, and health system factors.

Individual and relationship factors

Individual and relationship factors, included: time constraints, poor spousal communication, and non-disclosure of status to one’s partner.

 “The reason why it is difficult for men to participate in PMTCT services is just because of time. Because the work men do, keep them busy, like if a man is a driver, he will not be at home at the time his wife may want to go and access the PMTCT services. So, time is the main problem we have”(P8 FGD Male support Group Nsukka).

“Most of them will confide in you, “my husband is negative, he doesn’t know I’m going to this place; please, I don’t want him to know”. That is what they will tell you. And others will tell you, I am positive, I don’t know about my husband” (Health worker 2, at Facility A)

“…Because maybe, he has no clear knowledge of what the woman is passing through, the issue of PMTCT, the need to assist her during that period. If he has clear knowledge of the situation, definitely he will make time to accompany her” (P1 FGD Male support group Enugu).

“Well, I have never asked him to accompany me” (Female HIV client 3 at Facility B)

Gendered community norms

Gendered community norms and expectations included: pregnancy being perceived as a woman’s responsibility, male dominance in household decision making, and ridiculing of men who accompany women to ante-natal care visits.

“…What happens to men all the time is that they feel that family planning is always for the women… that it is the women that need such services…that is why I don’t follow my wife to go for it” (P6, FGD male support group, Nsukka).

“They see it as a woman’s work to go for her PMTCT service especially this ANC” (Health worker 3 at Facility B)

“For the man, it will look as if the woman now rules him” (P3, FGD Female support group Nsukka)

Health system factors

Health system factors included: ante-natal care services that were only woman-centred, unwelcoming attitudes of health workers to men who accompany their partners, and that appointments for anti-retroviral treatment for partners were scheduled separately (meaning separate visits to the health care centre).

“The attitude of the nurses at times contributes a lot to why some don’t like to follow their wives for antenatal.” (P2, FGD Male support group Enugu)

“We designed it (ante-natal care, PMTCT, post-natal care) in such a way that men are excluded here.” (Health worker 4 at Facility A)

“The date of appointment differs. Because my wife will be coming next week and my own falls today. So, there is no way we can come together” (P3, FGD, male support group, Nsukka).

Effects of male involvement (or lack of) on access and use of PMTCT by women

The perceived benefits of male partner participation in PMTCT included: male partners understanding and accepting the programme, women being more free to access the programme, reduction of the effects of male dominance on access to and uptake of PMTCT, male partners being better positioned to support their female partners emotionally and financially, couples being more able to work together towards preventing unintended pregnancies, and the promotion of adherence to treatment.

 “So what I think that men do which is cultural for us is to ensure that the woman has the means of transportation to the clinic. And that is precisely the same thing that those whose wives are HIV infected do. The key male involvement in PMTCT is trying to understand that this woman needs to take her drugs everyday whether they are concordant positive, or discordant” (Health worker 4 at facility A)

“… I receive my ART drugs in the same facility with my wife. And I normally make sure every morning, at 8 o’clock, I take the drug, my wife takes hers too, and in the night we take our drugs at the same time” (P5 FGD Male support group Enugu)

Lack of men’s involvement in PMTCT was found to contribute to: difficulty in breastfeeding properly or as recommended for a HIV positive woman, difficulty with keeping to scheduled ante-natal care appointments, inability to discuss outcome of counselling visits, inability to discuss prevention of unwanted pregnancies, and poor adherence to antiretroviral treatment.

Conclusion

The findings of this study have highlighted various factors that affect men’s effective involvement in PMTCT services. As the constraints identified within this study have implications for successful implementation of PMTCT services in Nigeria, policy measures need to be put in place to deal with these constraints if effective up take of PMTCT services is to be achieved.

Photo Credit: © 2004 Rachel Hoy, Courtesy of Photoshare