A Male Friendly Approach to Prevention of Mother to Child Transmission of HIV: Men’s Perspectives from Mashonaland East, Zimbabwe V Chitiyo 1, K Webb 1, T Ndoro 1, D Patel 1, S Page-Mtongwiza 1, Mbetu P 1, B Engelsmann 1 1 Organisation for Public Health Interventions and Development, Harare, Zimbabwe

Background: Context Estimated children in 21 Global Plan priority countries in sub-Saharan Africa became infected with HIV in 2013 (90% of global infections).[1] In Zimbabwe, infants tested HIV positive using DNA PCR in [2] Urgent need to effectively implement PMTCT interventions towards virtual elimination of mother to child transmission of HIV.. 1.UNAIDS Progress Report on the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Geneva: UNAIDS MOHCC Prevention of Mother To Child Transmission of HIV 2013 Annual report. Harare. Ministry of Health and Child welfare Zimbabwe

Prevention of mother to child transmission (PMTCT) of HIV interventions: integrated within maternal and child health services, specifically antenatal care (ANC), which traditionally focused on women.[3] Yet, the role of male partners of pregnant and breastfeeding women for PMTCT is critical. Men are decision makers in many of African countries Prevention of sexual and hence vertical transmission of HIV Integral part of family planning decisions Influence the uptake of and adherence to PMTCT interventions Male participation in ANC and PMTCT services increases uptake and adherence to PMTCT interventions among women.[4-5] Background: PMTCT 3. WHO et al Towards elimination of mother to child transmission of HIV. Geneva, Switzerland. World Health Organization. 4. Aluisio, A et al "Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV free survival". Journal of Acquired Immune Deficiency Syndrome, 58(1): Farquhar, C et al "Antenatal couple counselling increases uptake of interventions to prevent HIV-1 transmission". Journal of Acquired Immune Deficiency Syndrome, 37(5):

PMTCT Challenge Low male partner participation in PMTCT services offered in ANC settings: – Sub-Sahara Africa reported range 12.5%- 18.7%. [6] – In Zimbabwe - 17% in [2] Common barrier that emerged from studies: ANC environment is “unfriendly” to male partners.[6] 6. Kalembo F.W., Yukai D., Zgambo M., et al Male partner involvement in prevention of mother to child transmission of HIV in sub-Saharan Africa: Successes, challenges and way forward. Open Journal of Preventive Medicine. 2(1):

Study Objective To explore men’s experiences, attitudes and perceptions of a “male friendly” ANC/PMTCT environment to provide insights into feasible, acceptable and evidence-based strategies for increased male participation.

Methods December 2013 to March 2014, 309 male partners of pregnant or breastfeeding women who had received ANC/PMTCT services at twelve health facilities in Mashonaland East Province were selected for participation. Data were collected using open ended sections of pre-tested questionnaires. Six focus group discussions were conducted at community level with 59 men. The thematic approach was used to analyse the qualitative data. Picture 1. Men participating in Focus Group Discussions

Results Socio-demographics (N=368) Median age: 31 years. 246 (67%) rural areas, while 122 (33%) resided in urban areas. 324 (88%) had secondary or higher education. Perceptions and behaviour Acceptance of the PMTCT program 99% (306/309). 95% (295/309): importance of men’s participation for a successful PMTCT. But: 34% (44/129) reported ever attending ANC and PMTCT services with their partners during the last pregnancy (partners followed up in community with at least 1 CEB). Picture 2. Couple going for ANC

Minimal service waiting times. Service availability: Availability of services during non-working hours. Gender balanced healthcare worker composition: It is important to have more male service providers. Improve staff complement: To reduce waiting times and improve quality of service. Results continued “A male friendly clinic is one where less time is taken” On Clinic service times for friendly environment “… many of us go to work by the time we come back from work the clinics will be closed.” ” Even if I decided to come after hours because I will be at work I should get help including weekends…… Those are things they are not considering as the health service providers.” Men’s Perspectives for Health facility based Approaches for “Male Friendly” environment

Results continued Men’s Voices on Health Worker Composition for a “Male Friendly” Environment “..have more male nurses in ANC to encourage men to feel comfortable during PMTCT services” “There should be gender balance in terms of male and female nurses at the clinics” “The other problem is when pregnant women attend ANC they go there early at the time the clinic is opened but the nurses are few so they come back home late because of the long queues. ” “…nurses are too few when we come to be treated. We take more time in the long queues and not receive adequate education or procedures because the nurses will be running out of time.”

Healthcare worker skills: trained, competent and welcoming staff who are able to provide quality and timely services. Privacy and confidentiality: specifically for HTC and HIV test results. Importance of staff rotation: To improve men’s confidence in the confidentiality of patient medical histories. Results continued On Confidentiality: “Healthcare providers should avoid leaking information to our communities.” “There should be confidentiality especially with our test results”, “….these people (nurses) have to rotate. If I get infected with an STI, the whole village will end up knowing about it because of nurses relationships after staying for too long.” Men’s Perspectives for Health facility based Approaches for “Male Friendly” environment

Results continued “This information should be brought to our communities so that more people can hear about PMTCT, especially at the ward meetings.” Most men come to these ward meetings because issues that affect us in the villages are discussed. I say this because I first heard about PMTCT at our village meeting. “As men we can access program information at their convenience and we discuss as peers” “Provide information through different media so that men know and understand the benefits of PMTCT.” Community Based Approaches: reaching men through health education & promotion in non-health related contexts: Education at community meetings e.g. ward and agricultural meetings. Using mobile phone messaging to promote male engagement in PMTCT. IEC materials - in public places e.g. bars, churches or shops.

Conclusion Gap in acceptance of PMTCT program among men and participation - missed opportunities for uptake and support for PMTCT interventions. A “Male-friendly” approach can improve male participation in PMTCT services offered in ANC settings. Interventions need to address: -Processes – to improve service quality and timeliness -Service availability – through extending hours of operation and weekends to accommodate working male partners -Interpersonal relationships – for improved confidence and confidentiality, specifically HIV test results -Knowledge and awareness gap, specifically at community level

Acknowledgements MOHCC National PMTCT and Pediatric HIV unit, Provincial, District and Health Care site level staff, Men who participated in the study. This research has been supported the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID under the terms of Families and Communities for Elimination of Pediatric HIV in Zimbabwe (AID-613-A ).

Thank You! Tatenda! Siyabonga!