Defining male support during and after pregnancy from the perspective of HIV-positive and HIV-negative women in Durban, South Africa

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

Background and Objective

Although male partners are eager to support the implementation of prevention of mother-to-child transmission (PMTCT) of HIV programs, several obstacles prevent them from participating. The purpose of this study was to explore the support of male partners of HIV-positive women in sustaining the implementation of PMTCT interventions.

Methods

This study adopted a qualitative approach. The case study research design was used to generate an in-depth understanding of the factors that hinder male participation in PMTCT interventions. Non-probability purposive sampling was used to 20 sample participants. Data was collected from two focus group discussions and analyzed using open coding. Trustworthiness was achieved by credibility, transferability, and confirmability. Adherence to ethical principles was upheld.

Results

Findings revealed two themes, perceived practices that hinder the provision of support and perceived support provided to sustain PMTCT intervention during childbirth. 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.

Conclusion and Global Health Implications

The involvement of males in the interventions of PMTCT has been found to improve the sustainability of eliminating transmission of the virus to the baby. All clinics were recommended to be men user-friendly to encourage men to accompany their partners. Men are to be actively involved during decision-making and physical examination, where possible. Workshops and information-sharing sessions for men forums and community members on PMTCT interventions to be conducted.

Money, chores and emotional support: Kenyan and Zambian fathers' perceptions of male partner involvement in maternal and infant health within the context of HIV

In sub-Saharan Africa, involving male partners in the prevention of mother-to-child transmission of HIV improves maternal and infant outcomes. Male involvement is typically conceptualised as male partners attending antenatal care, which is difficult for many men. Little is known about how men view their involvement in family health within the context of HIV, particularly outside of clinic attendance. Through interviews with 35 male partners of pregnant or postpartum women living with HIV in Kenya and Zambia, this study elicited perceptions of male involvement in maternal and infant health in families affected by HIV. Men supported the importance of clinic attendance but reported conflicts with the need to work and fulfil their role as the family's financial provider. Providing money for necessities was deemed more critical for their family's health than clinic attendance. Men's involvement was conveyed through various other supportive actions, including helping with household chores and providing emotional support (showing love and reducing women's stress). Future strategies to promote male partner involvement in the prevention of mother-to-child transmission of HIV and maternal and child health should build upon the actions men view as most meaningful to promote their family's health within their real-world life circumstances and cultural context, particularly their role as financial providers.

Young women's social support networks during pregnancy in Soweto, South Africa

BACKGROUND

Although studies from high-income countries have examined social support during pregnancy, it remains unclear what type of support is received by expectant mothers from low- and middle-income country settings.

AIM

To explore young women's social support networks during pregnancy in Soweto, South Africa.

SETTING

This study was undertaken in an academic hospital based in the Southwestern Townships (Soweto), Johannesburg, in Gauteng province, South Africa.

METHODS

An exploratory descriptive qualitative approach was employed. Eighteen (18) young pregnant women were recruited using a purposive sampling approach. In-depth interviews were conducted, and data were analysed using inductive thematic analysis.

RESULTS

Analysis of the data resulted in the development of two superordinate themes namely; (1) relationships during pregnancy and (2) network involvement. Involvement of the various social networks contributed greatly to the young women having a greater sense of potential parental efficacy and increased acceptance of their pregnancies. Pregnant women who receive sufficient social support from immediate networks have increased potential to embrace and give attention to pregnancy-related changes.

CONCLUSION

Focusing on less-examined characteristics that could enhance pregnant women's health could help in the reduction of deaths that arise because of pregnancy complications and contribute in globally accelerating increased accessibility to adequate reproductive health.Contribution: This study's findings emphasise the necessity for policymakers and healthcare providers to educate the broader community about the importance of partner, family and peer support to minimise risks that may affect pregnancy care and wellbeing of mothers.

Adverse Impact of Intimate Partner Violence Against HIV-Positive Women During Pregnancy and Post-Partum: Results From a Meta-Analysis of Observational Studies

Objectives: Intimate partner violence (IPV) against pregnant or human immunodeficiency virus (HIV)-positive women have been previously studied. However, data on the impact of IPV on HIV-positive pregnant women have not been systematically synthesized. We performed a meta-analysis to explore this issue and provide evidence regarding IPV prevention and HIV infection control. Method: The PubMed, Web of Science, Cochrane Library, and Embase databases were systematically searched. Studies that quantitatively assessed the association between IPV and its adverse impact on HIV-positive women during pregnancy and post-partum were eligible for inclusion. Pooled odds ratios (ORs) were calculated. Findings: Eight studies were identified to meet our eligibility criteria. The adverse impacts of IPV against HIV-positive pregnant women mainly included nonadherence to maternal antiretroviral treatment during pregnancy, nondisclosure of HIV-positive status to male partners, nonadherence to infant antiretroviral prophylaxis, and antenatal depression. IPV caused a 180% and 145% increase in the odds of antenatal depression and nonadherence to infant antiretroviral prophylaxis, respectively, among HIV-positive women, compared to the odds of their IPV-free counterparts [OR = 2.80, 95% confidence interval (CI): 1.66-4.74; OR = 2.45, 95% CI: 1.40-4.27]. Conclusion: Limited evidence has suggested that IPV against HIV-positive pregnant women caused maternal depression during pregnancy and led to the possible failure of HIV prophylaxis adherence in infants. Interventions to address IPV may ultimately reduce the risk of depression-related adverse birth outcomes and vertical transmission in infants exposed to maternal HIV. Prevention and control against IPV should be developed for HIV-positive pregnant women.

Understanding the meanings of male partner support in the adherence to therapy among HIV-positive women: a gender analysis

BACKGROUND

Previous literature reports that low male partner support is a barrier to women's adherence and retention in HIV care programs.

OBJECTIVE

This qualitative study explored the relationships between partners to understand what is meant by male partner support in adherence of HIV-positive women in four healthcare facilities in Southern Malawi.

METHODS

We conducted 8 semi-structured focus group discussions (FGDs) with 73 participants (40 men and 33 women) and 10 in-depth interviews (IDIs) between August 2018 to December 2019. Participants were HIV-positive patients, healthcare workers (HCWs), expert patients (EPs), and couples attending the clinic. All data were digitally recorded, transcribed verbatim, and analysed using a gender-responsive grounded theory approach.

RESULTS

This study confirms previous literature, which suggests male partner support is expressed by providing access to transport to the clinic and accompaniment to appointments. However, we found that men can also control access to resources and decision-making. Support is more complex than previous literature reported and, in some cases, gender norms significantly limit women's capacity to engage in care independently of male support since women need male partner permission to access the resources to attend clinics.

CONCLUSIONS

This paper suggests that restrictive male-partner gender norms limit women's power to engage in care. Most importantly, the gender analysis reveals that what previous literature describes as male partner support can sometimes hide male partner control in permitting access to resources to attend health facilities. For this reason, policies enhancing male support should consider the gender power relationship between partners to avoid reinforcing gender inequality.

Towards a global framework for assessing male involvement in maternal health: results of an international Delphi study

PURPOSE

Currently, no standard instrument exists for assessing the concept of male involvement in maternal health, hampering comparison of results and interpretation of the literature. The aim of this study was to construct the key elements of a global multidimensional male involvement framework, based on the latest evidence and input of experts in the field.

METHODS

For this purpose, a Delphi study, including an international panel of 26 experts, was carried out. The study consisted of three rounds, with 92% of respondents completing all three surveys. Experts were asked to rate indicators within six categories in terms of validity, feasibility, sensitivity, specificity and context robustness. Furthermore, they were encouraged to clarify their rating with open text responses. Indicators were excluded or adapted according to experts' feedback before inclusion. A 85% agreement was used as threshold for consensus.

RESULTS

A general consensus was reached for a global framework for assessing male involvement in maternal health, consisting of five categories: involvement in communication, involvement in decision-making, practical involvement, physical involvement and emotional involvement.

CONCLUSIONS

Using the male involvement framework as a tool to assess the concept of male involvement in maternal health at local, national, and international levels could allow improved assessment and comparison of study findings. Further research is needed for refining the indicators according to context and exploring how shared decision-making, gender equality and women's empowerment can be assessed and facilitated within male involvement programmes.

Male involvement in promotion of safe motherhood in low- and middle-income countries: A scoping review

BACKGROUND

Maternal health programmes that focus on the woman alone are limiting in LMICs as pregnant women often relate to maternity services through a complex social web that reflects power struggles within the kinship and the community.

METHODS

A scoping review was conducted to explore the rationale for male involvement in maternal health in LMICs. This review was guided by the question: What is the current state of knowledge regarding the inclusion of men in maternal health services in LMICs? The literature search was conducted using mySearch, Bournemouth University`s iteration of the EBSCO Discovery Service (EDS) tool. The review process used the Preferred Reporting Items for Systematic Reviews to select papers for inclusion.

FINDINGS

Thirty three studies met the inclusion criteria. Findings describe the rationale for involving men in maternity care, alongside the criticisms and challenges inherent in engaging with men in maternal health. Involving men in maternity services can improve health outcomes for women and infants. Health strategies aimed at educating men are relevant in equipping men with knowledge and skills that help men to be supportive of women`s wellbeing during pregnancy and childbirth.

CONCLUSION

Men can serve as advocates for women and reinforce their partner`s choices in accessing skilled care and infant feeding. Further research is required to examine the effect of male involvement on women`s autonomy and to assess health education interventions aimed at mitigating harmful outcomes of involving men in maternity services.

Associations of Father and Adult Male Presence with First Pregnancy and HIV Infection: Longitudinal Evidence from Adolescent Girls and Young Women in Rural South Africa (HPTN 068)

This study, a secondary analysis of the HPTN 068 randomized control trial, aimed to quantify the association of father and male presence with HIV incidence and first pregnancy among 2533 school-going adolescent girls and young women (AGYW) in rural South Africa participating in the trial between March 2011 and April 2017. Participants' ages ranged from 13-20 years at study enrollment and 17-25 at the post-intervention visit. HIV and pregnancy incidence rates were calculated for each level of the exposure variables using Poisson regression, adjusted for age using restricted quadratic spline variables, and, in the case of pregnancy, also adjusted for whether the household received a social grant. Our study found that AGYW whose fathers were deceased and adult males were absent from the household were most at risk for incidence of first pregnancy and HIV (pregnancy: aIRR = 1.30, Wald 95% CI 1.05, 1.61, Wald chi-square p = 0.016; HIV: aIRR = 1.27, Wald 95% CI 0.84, 1.91, Wald chi-square p = 0.263) as compared to AGYW whose biological fathers resided with them. For AGYW whose fathers were deceased, having other adult males present as household members seemed to attenuate the incidence (pregnancy: aIRR = 0.92, Wald 95% CI 0.74, 1.15, Wald chi-square p = 0.462; HIV: aIRR = 0.90, Wald 95% CI 0.58, 1.39, Wald chi-square p = 0.623) such that it was similar, and therefore not statistically significantly different, to AGYW whose fathers were present in the household.

Systematic review of the concept 'male involvement in maternal health' by natural language processing and descriptive analysis

INTRODUCTION

Experts agree that male involvement in maternal health is a multifaceted concept, but a robust assessment is lacking, hampering interpretation of the literature. This systematic review aims to examine the conceptualisation of male involvement in maternal health globally and review commonly used indicators.

METHODS

PubMed, Embase, Scopus, Web of Science and CINAHL databases were searched for quantitative literature (between the years 2000 and 2020) containing indicators representing male involvement in maternal health, which was defined as the involvement, participation, engagement or support of men in all activities related to maternal health.

RESULTS

After full-text review, 282 studies were included in the review. Most studies were conducted in Africa (43%), followed by North America (23%), Asia (15%) and Europe (12%). Descriptive and text mining analysis showed male involvement has been conceptualised by focusing on two main aspects: psychosocial support and instrumental support for maternal health care utilisation. Differences in measurement and topics were noted according to continent with Africa focusing on HIV prevention, North America and Europe on psychosocial health and stress, and Asia on nutrition. One-third of studies used one single indicator and no common pattern of indicators could be identified. Antenatal care attendance was the most used indicator (40%), followed by financial support (17%), presence during childbirth (17%) and HIV testing (14%). Majority of studies did not collect data from men directly.

DISCUSSION

Researchers often focus on a single aspect of male involvement, resulting in a narrow set of indicators. Aspects such as communication, shared decision making and the subjective feeling of support have received little attention. We believe a broader holistic scope can broaden the potential of male involvement programmes and stimulate a gender-transformative approach. Further research is recommended to develop a robust and comprehensive set of indicators for assessing male involvement in maternal health.

Improving male involvement in antenatal care in low and middle-income countries to prevent mother to child transmission of HIV: A realist review

BACKGROUND

Childhood Human Immunodeficiency Virus (HIV) infection occurs almost exclusively via mother to child transmission (MTCT) during pregnancy, birth, or through breastfeeding. Recent studies have shown that male involvement (MI) in antenatal care (ANC) and HIV testing, including couples voluntary counselling and testing (CVCT), increases the likelihood that women will adhere to prevention advice and comply with HIV treatment if required during their pregnancy; hence reducing the rates of MTCT of HIV. This realist review investigates how, why, when, and for whom MI in ANC works best to provide contextual advice on how MI in ANC can be best used for prevention of mother to child transmission (PMTCT) of HIV.

METHODS

A realist review of existing evidence was conducted. Realist review seeks to explain how and why an intervention works, or does not work, in a given context. This was completed through the five stages of realist synthesis; Eliciting the program theory, search strategy, study selection criteria, data extraction, and data analysis and synthesis. Findings are presented as context-mechanism-outcome (CMO) configurations outlining the mechanisms that work in given contexts to give an outcome.

RESULTS

Three CMO configurations were developed. These describe that 1) Couples in monogamous relationships have higher levels of trust, commitment and security leading to increased uptake of PMTCT programs together; 2) ANC spaces that make 'male friendly' adaptions promote normalisation of MI in PMTCT and are more welcoming, leading to increased willingness of male partners to participate in ANC; and 3) couples and communities with higher health literacy encourage increased informed decision making, ownership, and responsibility and thus increased participation in PMTCT of HIV.

CONCLUSIONS

The CMOs developed in this review give contextual advice on how one might improve ANC services to increase MI and help reduce MTCT of HIV. We propose that MI in ANC works best where couples are monogamous and trusting, where ANC spaces actively promote being a 'male friendly space' and where there are high levels of community education programs around MTCT.

Using a Social Support Framework to Understand How HIV Positive Kenyan Men Engage in PMTCT/EID Care: Qualitative Insights From Male Partners

Greater male partner involvement in Prevention of Mother to Child Transmission (PMTCT) and Early Infant Diagnosis (EID) is associated with improved outcomes. Perceived low social support for the mother can negatively impact the uptake of PMTCT/EID services. Most research relies on women's reports of the types and quality of male partner support received versus what is desired. This qualitative study examines Kenyan male partners' reported social support provision pre- and post-partum from their own perspective. The study was embedded within intervention development studies in Kenya designed to develop and pilot a PMTCT module of a web based system to improve EID. Focus groups were conducted with male partners of pregnant women with HIV and elicited feedback on male partner involvement in maternal and child care and factors affecting participation. Interviews were analyzed within a theoretical social support framework. Participants described providing tangible support (financial resources), informational support (appointment reminders) and emotional support (stress alleviation in the face of HIV-related adversity). African conceptualizations of masculinity and gender norms influenced the types of support provided. Challenges included economic hardship; insufficient social support from providers, peers and bosses; and HIV stigma. Collaboration among providers, mothers and partners; a community-based social support system; and recasting notions of traditional masculinity were identified as ways to foster male partner support.

Towards a definition of male partner involvement in the prevention of mother-to-child transmission of HIV in Uganda: a pragmatic grounded theory approach

BACKGROUND

Male partner involvement has been shown to increase mothers' uptake of Prevention of Mother-to-Child Transmission of HIV (PMTCT) and improve maternal and infant HIV treatment outcomes. Currently, male involvement in PMTCT is measured primarily through men's attendance at HIV testing and counselling which may not be a true reflection of their engagement. This study therefore set out to explore the meaning of male partner involvement and propose a definition and theoretical model of this concept in PMTCT in Uganda.

METHODS

Eight focus group discussions and five in-depth interviews were conducted with couples at three public health facilities and community members in the health facility catchment areas in Uganda. The study employed a grounded theory approach underpinned by the pragmatic philosophical paradigm. Data were analyzed using the constant comparative method, performing three levels of open, axial, and selective coding.

RESULTS

Of the 61 participants, 29 (48%) were male and the majority 39 (63.9%) were in long term marital relationships, while about half were self-employed 29 (47.5%). Three themes emerged for the meaning of male involvement in PMTCT (a) HIV treatment support (b) economic support and (c) psychosocial support. HIV treatment support included adherence support, couples' HIV counseling and testing, and clinic attendance during and after pregnancy. Participants expressed that men were engaged in PMTCT when they offered economic support by providing basic needs and finances or when they included their female partners in financial planning for the family. Psychosocial support arose from the female participants who defined male involvement as family support, perceived societal recognition and emotional support. Emotional support also included the absence of harm resulting from women's disclosure of HIV test results to their male partner.

CONCLUSIONS

This study proposes a new definition for male partner involvement in PMTCT in Uganda. The definition extends beyond men's clinic attendance and HIV testing and counselling. Further research should seek to develop and validate tools to accurately measure male partner involvement as the next step in the development of interventions to improve PMTCT outcomes.

Men's hopes, fears and challenges in engagement in perinatal health and the prevention of mother-to-child transmission of HIV in rural Kenya

Male involvement in antenatal care has been shown to improve health outcomes for women and infants. However, little is known about how best to encourage male partners to support essential perinatal health activities. We explored men's perceptions of facilitators and barriers to involvement in antenatal care and HIV prevention including fears, hopes and challenges. Forty in-depth interviews were conducted with the male partners of HIV-positive and HIV-negative pregnant women in southwest Kenya. Most male partners believed engaging in pregnancy health-related activities was beneficial for keeping families healthy. However, thematic analysis revealed several obstacles that hindered participation. Poor couple relationship dynamics seemed negatively to influence male engagement. Some men were apprehensive that clinic staff might force them to test for HIV and disclose the results; if HIV-positive, men feared being labelled as 'victimisers' in situations of serodiscordancy, and described fears of abandonment by their wives. Some men avoided accompanying their wives, citing local culture as rationale for avoiding the 'effeminate' act of antenatal care attendance. Amidst these obstacles, some men chose to use their partners' HIV status as proxy for their own. Findings suggest that improving male engagement in essential maternal and child health-related activities will require addressing both structural and interpersonal barriers.

'Unless you come with your partner you will be sent back home': strategies used to promote male involvement in antenatal care in Southern Tanzania

Background: Male involvement in pregnancy and childbirth has been shown to improve maternal and child health. Many countries have used different strategies to promote participation of men in antenatal care services. While many strategies have been employed to promote male participation in antenatal care, few have been evaluated to provide much-needed lessons to support wider adoption.

Objective: This study aimed at describing strategies that were used by health providers and the community to promote male participation in antenatal care services and challenges associated with the implementation of these interventions in Southern Tanzania.

Methods: We used qualitative data and analytical methods to answer the research questions. The study relied on semi-structured interviews with health providers, men and women, village and community leaders and traditional birth attendants. Data were analysed using a thematic approach.

Results: The findings of this study revealed that different strategies were employed by health providers and the community in promoting participation of men in antenatal care services. These strategies included: health providers denying services to women attending antenatal care without their partners, fast-tracking service to men attending antenatal care with their partners, and providing education and community sensitisation. The implementation of these strategies was reported to have both positive and unintended consequences.

Conclusions: This study concludes that despite the importance of male involvement in pregnancy and childbirth-related services, the use and promotion of the male escort policy should not inadvertently affect access to antenatal care services by pregnant women. In addition, programmes aiming for men’s involvement should be implemented in ways that respect, promote and facilitate women’s choices and autonomy and ensure their safety. Furthermore, there is a need for sensitisation of health providers and policymakers on what works best for involving men in pregnancy and childbirth.

Influences on Exclusive Breastfeeding Among Rural HIV-Infected South African Women: A Cluster Randomized Control Trial

South African guidelines for prevention-of-mother-to-child-transmission (PMTCT) of HIV emphasize exclusive breastfeeding (EBF). This study examined the impact of a PMTCT intervention and male involvement on EBF. In a two-phase cluster-randomized trial, rural South African community health centers were randomized to offer HIV-infected pregnant women PMTCT standard of care plus either: a behavioral PMTCT intervention, or a time-equivalent attention-control condition. Phase 1 women had non-participating male partners; Phase 2 women had participating partners. Pregnant women (n = 1398) were assessed on HIV stigma, disclosure of HIV status to partner, male involvement, and family planning knowledge. Feeding practices were assessed 6 weeks postpartum (56% retained). Reduced depressive symptomatology predicted EBF 6 weeks postpartum, adjusting for attrition (AOR = 0.954, p = 0.001). Neither male involvement in antenatal care, phase, HIV stigma, disclosure, nor family planning knowledge predicted EBF. Future studies and perinatal care should address depression, which has important implications for infant health.

Prevalence and correlates of non-disclosure of maternal HIV status to male partners: a national survey in Kenya

BACKGROUND

Prevention of mother-to-child HIV transmission (PMTCT) programs usually test pregnant women for HIV without involving their partners. Non-disclosure of maternal HIV status to male partners may deter utilization of PMTCT interventions since partners play a pivotal role in decision-making within the home including access to and utilization of health services.

METHODS

Mothers attending routine 6-week and 9-month infant immunizations were enrolled at 141 maternal and child health (MCH) clinics across Kenya from June-December 2013. The current analysis was restricted to mothers with known HIV status who had a current partner. Multivariate logistic regression models adjusted for marital status, relationship length and partner attendance at antenatal care (ANC) were used to determine correlates of HIV non-disclosure among HIV-uninfected and HIV-infected mothers, separately, and to evaluate the relationship of non-disclosure with uptake of PMTCT interventions. All analyses accounted for facility-level clustering, RESULTS: Overall, 2522 mothers (86% of total study population) met inclusion criteria, 420 (17%) were HIV-infected. Non-disclosure of HIV results to partners was higher among HIV-infected than HIV-uninfected women (13% versus 3% respectively, p < 0.001). HIV-uninfected mothers were more likely to not disclose their HIV status to male partners if they were unmarried (adjusted odds ratio [aOR] = 3.79, 95% CI: 1.56-9.19, p = 0.004), had low (≤KSH 5000) income (aOR = 1.85, 95% CI: 1.00-3.14, p = 0.050), experienced intimate partner violence (aOR = 3.65, 95% CI: 1.84-7.21, p < 0.001) and if their partner did not attend ANC (aOR = 4.12, 95% CI: 1.89-8.95, p < 0.001). Among HIV-infected women, non-disclosure to male partners was less likely if women had salaried employment (aOR = 0.42, 95%CI: 0.18-0.96, p = 0.039) and each increasing year of relationship length was associated with decreased likelihood of non-disclosure (aOR = 0.90, 95% CI: 0.82-0.98, p = 0.015 for each year increase). HIV-infected women who did not disclose their HIV status to partners were less likely to uptake CD4 testing (aOR = 0.32, 95% CI: 0.15-0.69, p = 0.004), to use antiretrovirals (ARVs) during labor (OR = 0.38, 95% CI 0.15-0.97, p = 0.042), or give their infants ARVs (OR = 0.08, 95% CI 0.02-0.31, p < 0.001).

CONCLUSION

HIV-infected women were less likely to disclose their status to partners than HIV-uninfected women. Non-disclosure was associated with lower use of PMTCT services. Facilitating maternal disclosure to male partners may enhance PMTCT uptake.

"He does not have to wait under a tree": perceptions of men, women and health care workers on male partner involvement in prevention of mother to child transmission of human immunodeficiency virus services in Malawi

Background

The perception of male involvement (MI) in maternal child health services is multifaceted and differs among varying programs and populations. In the Prevention of Mother to Child Transmission (PMTCT) context, MI includes men’s attendance at antenatal care (ANC) clinics, undertaking an HIV tests within the ANC and financial and psychological support. Contexualising the definition of MI is fundamental in the development of MI in PMTCT policy and interventions. The objective of this study was to explore the perceptions of men, women and health care workers on male partner involvement in PMTCT services in Malawi.

Methods

A qualitative descriptive study was conducted at South Lunzu Health Centre (SLHC) in Blantyre, Malawi from December 2012 to January 2013. We conducted s Key Informant Interviews (KIIs) with 6 health care workers and moderated four Focus Group Discussions (FGDs) among 18 men and 17 pregnant women attending antenatal care at SLHC. We divided FGDs participants according to sex and age. We digitally recorded all FGDs and KIIs and simultaneously transcribed and translated verbatim into English. We employed thematic analysis to identify codes and themes.

Results

Men and women described MI in PMTCT as either a) Positive participation or b) Negative participation. Positive participation included total involvement of the male partner in PMTCT interventions, reminding the spouse of clinic and treatment schedules, and resource provision. Health care workers described MI as either a) Involvement along the pregnancy continuum or b) Passive Involvement. Participants’ preferred positive involvement of male partners.

Conclusions

There are multiple perceptions of MI in PMTCT with participants preferring positive involvement. There is a need to have a uniform description of MI in PMTCT to optimize development of strategies and interventions that accommodate and optimize MI in PMTCT. A uniform description will be useful in assessing a country’s progress towards achieving MI in PMTCT goals.

Relationships matter: contraceptive choices among HIV-positive women in Tanzania

Efforts to eliminate mother-to-child transmission of HIV in Tanzania are guided by a four-prong strategy advocated by the World Health Organization (WHO). Prong 2, prevention of unintended pregnancies among women living with HIV, has, however, received the least attention and contraceptive use to prevent unintended pregnancies remains low. This study explored the perceived barriers to the use of modern methods of contraception, and factors influencing contraceptive choice among HIV-positive women in urban Dar-es-Salaam, Tanzania. A qualitative multi-site study was conducted, utilising in-depth interviews and focus group discussions with 37 sexually active HIV-positive women aged between 20 and 44 years, attending three health facilities within Dar-es-Salaam. The theoretical framework was a patient centred model. Four barriers were identified: the influence of the women's spousal relationships; personal beliefs and the relationship of these in understanding her disease; the influence of the social demands on the woman and her relationships; and the importance of a woman's relationship with her healthcare provider/healthcare system. Being the bearers of bad news (HIV-positive status) the pregnant women experienced conflicts, violence, abandonment and rejection. The loss in negotiating power for the women was in relation to their intimate partners, but also in the patient-healthcare provider relationship. The role of the male partner as a barrier to contraceptive use cannot be understated. Therefore, the results suggest that healthcare providers should ensure patient-focused education and provide support that encompasses the importance of their relationships. Additional research is required to elucidate the functional association between contraceptive choices and personal and social relationships.

Psychosocial correlates of patient-provider family planning discussions among HIV-infected pregnant women in South Africa

Patient–provider family planning discussions and preconception counseling can reduce maternal and neonatal risks by increasing adherence to provider recommendations and antiretroviral medication. However, HIV-infected women may not discuss reproductive intentions with providers due to anticipation of negative reactions and stigma. This study aimed to identify correlates of patient–provider family planning discussions among HIV-infected women in rural South Africa, an area with high rates of antenatal HIV and suboptimal rates of prevention of mother-to-child transmission (PMTCT) of HIV. Participants were N=673 pregnant HIV-infected women who completed measures of family planning discussions and knowledge, depression, stigma, intimate partner violence, and male involvement. Participants were, on average, 28 ± 6 years old, and half of them had completed at least 10–11 years of education. Most women were unemployed and had a monthly income of less than ~US$76. Fewer than half of the women reported having family planning discussions with providers. Correlates of patient–provider family planning discussions included younger age, discussions about PMTCT of HIV, male involvement, and decreased stigma (p < 0.05). Depression was indirectly associated with patient–provider family planning discussions through male involvement (b = −0.010, bias-corrected 95% confidence interval [bCI] [−0.019, −0.005]). That is, depression decreased male involvement, and in turn, male involvement increased patient–provider family planning discussions. Therefore, by decreasing male involvement, depression indirectly decreased family planning discussions. Study findings point to the importance of family planning strategies that address depression and facilitate male involvement to enhance communication between patients and providers and optimize maternal and neonatal health outcomes. This study underscores the need for longitudinal assessment of men’s impact on family planning discussions both pre- and postpartum. Increasing support for provision of mental health services during pregnancy is merited to ensure the health of pregnant women living with HIV and their infants.

Male Involvement and Accommodation During Obstetric Emergencies in Rural Ghana: A Qualitative Analysis

CONTEXT

Although men potentially play an important role in emergency obstetric care in Sub-Saharan Africa, few studies have examined the ways in which men are involved in such emergencies, the consequences of their involvement or the degree to which health facilities accommodate men.

METHODS

Qualitative interviews were conducted with 39 mothers and fathers in two districts in Northern and Central Ghana who had experienced obstetric emergencies, such as severe birth complications, to obtain narratives about those experiences. In addition, interviews with six health facility workers and eight focus group discussions with community members were conducted. Transcripts were analyzed using an inductive analytic approach.

RESULTS

Although some men had not been involved at all during their partner's obstetric emergency, two-thirds had provided some combination of financial, emotional and instrumental support. On the other hand, several men had acted as gatekeepers, and their control of resources and decisions had resulted in care-seeking delays. Although many respondents reported that health facilities accommodated male partners (e.g., by providing an appropriate space for men during delivery), others found that facilities were not accommodating, in some cases ignoring or disrespecting men. A few respondents had encountered improper staff expectations, notably that men would accompany their partner to the facility, a requirement that limits women's autonomy and delays care.

CONCLUSIONS

Policies and programs should promote supportive behavior by men during obstetric emergencies while empowering women. Health facility policies regarding accommodation of men during obstetric emergencies need to consider women's and men's preferences. Research should examine whether particular forms of support improve maternal and newborn health outcomes.

Male involvement in reproductive, maternal and child health: a qualitative study of policymaker and practitioner perspectives in the Pacific

BACKGROUND

The importance of involving men in reproductive, maternal and child health programs is increasingly recognised globally. In the Pacific region, most maternal and child health services do not actively engage expectant fathers and fathers of young children and few studies have been conducted on the challenges, benefits and opportunities for involving fathers. This study explores the attitudes and beliefs of maternal and child health policymakers and practitioners regarding the benefits, challenges, risks and approaches to increasing men's involvement in maternal and child health education and clinical services in the Pacific.

METHODS

In-depth interviews were conducted with 17 senior maternal and child health policymakers and practitioners, including participants from five countries (Cook Island, Fiji, Papua New Guinea, Solomon Island, and Vanuatu) and four regional organisations in the Pacific. Qualitative data generated were analysed thematically.

RESULTS

Policymakers and practitioners reported that greater men's involvement would result in a range of benefits for maternal and child health, primarily through greater access to services and interventions for women and children. Perceived challenges to greater father involvement included sociocultural norms, difficulty engaging couples before first pregnancy, the physical layout of clinics, and health worker workloads and attitudes. Participants also suggested a range of strategies for increasing men's involvement, including engaging boys and men early in the life-cycle, in community and clinic settings, and making health services more father-friendly through changes to clinic spaces and health worker recruitment and training.

CONCLUSIONS

These findings suggest that increasing men's involvement in maternal and child health services in the Pacific will require initiatives to engage men in community and clinic settings, engage boys and men of all ages, and improve health infrastructure and service delivery to include men. Our findings also suggest that while most maternal and child health officials consulted perceived many benefits of engaging fathers, perceived challenges to doing so may prevent the development of policies that explicitly direct health providers to routinely include fathers in maternal and child health services. Pilot studies assessing feasibility and acceptability of context-appropriate strategies for engaging fathers will be useful in addressing concerns regarding challenges to engaging fathers.

Improving men's participation in preventing mother-to-child transmission of HIV as a maternal, neonatal, and child health priority in South Africa

Wessel van den Berg and colleagues outline how increasing male partner involvement in efforts to reduce mother-to-child HIV transmission in South Africa may improve maternal and infant outcomes.

Invitation cards during pregnancy enhance male partner involvement in prevention of mother to child transmission (PMTCT) of human immunodeficiency virus (HIV) in Blantyre, Malawi: a randomized controlled open label trial

Introduction

Male involvement (MI) is vital for the uptake of Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) interventions. Partner notification (PN) is among the strategies identified for MI in PMTCT services. The purpose of this randomized controlled trial was to evaluate the efficacy of an invitation card to the male partners as a strategy for MI in PMTCT services by comparing the proportion of pregnant women that were accompanied by their partners between the intervention and the non-intervention study groups.

Methods

Pregnant women attending antenatal care without a male partner at South Lunzu and Mpemba health centres in Blantyre, Malawi, were enrolled in the study from June to December 2013. In an intention-to-treat analysis, we compared all participants that were randomized in the invitation card group with the standard of care (SoC) group. Risk ratios (RR) with 95% confidence intervals (CI) were computed to assess the efficacy of the invitation card.

Results

Of the 462 randomized women, 65/230 (28.26%) of the women in the invitation card group reported to the antenatal care clinic with their partners compared to 44/232 (18.97%) women in the SoC group. In an unadjusted intention-to-treat analysis women in the invitation card group were 50% more likely to be accompanied by their male partners than those in the SoC group RR: 1.49 (95% CI: 1.06-2.09); p = 0.02. Our random effects analysis showed that there was no clustering by site of recruitment with an inter cluster correlation coefficient (ICC) of 1.98x 10^-3, (95% CI: 1.78 x10^-7 - 0.96 x 10^-1); p =0.403.

Conclusion

An invitation card significantly increased the proportion of women who were accompanied by their male partners for the PMTCT services. An invitation card is a feasible strategy for MI in PMTCT.

Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission

Introduction

Prevention of mother-to-child transmission (PMTCT) has the potential to eliminate new HIV infections among infants. Yet in many parts of sub-Saharan Africa, PMTCT coverage remains low, leading to unacceptably high rates of morbidity among mothers and new infections among infants. Intimate partner violence (IPV) may be a structural driver of poor PMTCT uptake, but has received little attention in the literature to date.

Methods

We conducted qualitative research in three Johannesburg antenatal clinics to understand the links between IPV and HIV-related health of pregnant women. We held focus group discussions with pregnant women (n=13) alongside qualitative interviews with health care providers (n=10), district health managers (n=10) and pregnant abused women (n=5). Data were analysed in Nvivo10 using a team-based approach to thematic coding.

Findings

We found qualitative evidence of strong bidirectional links between IPV and HIV among pregnant women. HIV diagnosis during pregnancy, and subsequent partner disclosure, were noted as a common trigger of IPV. Disclosure leads to violence because it causes relationship conflict, usually related to perceived infidelity and the notion that women are “bringing” the disease into the relationship. IPV worsened HIV-related health through poor PMTCT adherence, since taking medication or accessing health services might unintentionally alert male partners of the women's HIV status. IPV also impacted on HIV-related health via mental health, as women described feeling depressed and anxious due to the violence. IPV led to secondary HIV risk as women experienced forced sex, often with little power to negotiate condom use. Pregnant women described staying silent about condom negotiation in order to stay physically safe during pregnancy.

Conclusions

IPV is a crucial issue in the lives of pregnant women and has bidirectional links with HIV-related health. IPV may worsen access to PMTCT and secondary prevention behaviours, thereby posing a risk of secondary transmission. IPV should be urgently addressed in antenatal care settings to improve uptake of PMTCT and ensure that goals of maternal and child health are met in sub-Saharan African settings.

Exploring the relevance of male involvement in the prevention of mother to child transmission of HIV services in Blantyre, Malawi

Background

Male involvement (MI) in Prevention of mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services remains low despite the progress registered in the implementation of the PMTCT program. Male involvement in PMTCT is a fairly new concept in Malawi that has not been fully implemented within PMTCT service provision despite its inclusion in the PMTCT guidelines. One of the reasons for the limited MI is the lack of knowledge on both its relevance and the role of men in the program. Currently, men have been encouraged to participate in PMTCT services without prior research on their understanding of the relevance and their role in PMTCT. This information is vital to the development of programs that will require MI in PMTCT. The objective of this study was to explore the views of men, pregnant women and health care providers on the importance and roles of MI in PMTCT services in Blantyre Malawi.

Methods

An exploratory descriptive qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) and its catchment area in Blantyre, Malawi. We conducted 6 key informant interviews (KIIs) with health care workers and 4 focus group discussions (FGDs) with 18 men and 17 pregnant women. Interviews and discussions were digitally recorded and simultaneously transcribed and translated into English. Data were analyzed using framework analysis approach.

Results

The major themes that emerged on the relevance of MI in PMTCT were a) uptake of interventions along the PMTCT cascade b) support mechanism and c) education strategy. Lack of MI in PMTCT was reported to result into non-disclosure of HIV test results and non-compliance with PMTCT interventions.

Conclusions

Male involvement is paramount for the uptake of interventions at the different cascades of PMTCT. The absence of male involvement may compromise compliance with PMTCT interventions.

Challenges with couples, serodiscordance and HIV disclosure: healthcare provider perspectives on delivering safer conception services for HIV-affected couples, South Africa

INTRODUCTION

Safer conception interventions should ideally involve both members of an HIV-affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa.

METHODS

We conducted six semistructured individual interviews per site (a total of 12 interviews) as well as a focus group discussion at each clinic site (a total of 13 additional participants). All interviews were coded in Atlas.ti using a grounded theory approach to develop codes and to identify core themes and subthemes in the data.

RESULTS

Managing the clinical and relationship complexities related to serodiscordant couples wishing to conceive was flagged as a concern by all categories of health providers. Providers added that, in the HIV clinical setting, they often found it difficult to balance their professional priorities, to maintain the health of their clients, and to ensure that partners were not exposed to unnecessary risk, while still supporting their clients' desires to have a child. Many providers expressed concern over issues related to disclosure of HIV status between partners, particularly when managing couples where one partner was not aware of the other's status and expressed the desire for a child. Provider experiences were that female clients most often sought out care, and it was difficult to reach the male partner to include him in the consultation.

CONCLUSIONS

Providers require support in dealing with HIV disclosure issues and in becoming more confident in dealing with couples and serodiscordance. Prior to implementing safer conception programmes, focused training is needed for healthcare professionals to address some of the ethical and relationship issues that are critical in the context of safer conception care.

[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]

OBJECTIVE

The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit.

METHODS

We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS.

RESULTS AND CONCLUSIONS

The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).

Assessment of strategies for male involvement in the prevention of mother-to-child transmission of HIV services in Blantyre, Malawi

Background

Despite the documented benefits of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) services, the uptake remains low in sub-Saharan Africa. The lack of male involvement (MI) may be one of the reasons for this. However, there are limited data on strategies for MI in PMTCT.

Objective

The objective of this study was to identify strategies that may promote MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi.

Study design

An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face-to-face key informant interviews (KIIs) with healthcare workers and four focus group discussions (FGDs) with 18 men and 17 pregnant women attending ANC at SLHC. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analyzed using thematic content analysis.

Results

Three major themes with several subcategories emerged. Theme 1 was a gatekeeping strategy with two subcategories: (1) healthcare workers refusing service provision to women accessing antenatal clinic without their partners and (2) women refusing ANC attention in the absence of a partner. Theme 2 comprised extending invitations and had six subcategories: (1) word of mouth, (2) card invites, (3) woman's health passport book invites, (4) telephonic invites, (5) use of influential people, and (6) home visits. Theme 3 was information education and communication, such as health education forums and advertisements. Of all the strategies, an invitation card addressed to the male partner was most preferred by study participants.

Conclusions

There are several strategies by which men may be involved in PMTCT. Healthcare workers should offer a pregnant woman all strategies available for MI for her to select the appropriate one. Further research and consultations with men should continue to achieve higher levels of MI.

Women's attitudes toward their partners' involvement in antenatal care and prevention of mother-to-child transmission of HIV in Cameroon, Africa

INTRODUCTION

Although the HIV epidemic has stabilized worldwide, it remains a public health challenge in sub-Saharan Africa. The key strategy to prevention and control of HIV remains voluntary counseling and testing. In sub-Saharan Africa, 76% of pregnant women have at least one antenatal visit. Therefore, antenatal care is a venue through which women can access HIV testing, and, if infected, obtain care for prevention of mother-to-child transmission (PMTCT). Public health organizations have promoted increasing HIV testing of men by incorporating partner testing into antenatal care. Recent studies have shown that African women may not be receptive to their partner's involvement in obstetric care secondary to cultural attitudes and traditional beliefs.

METHODS

A quality improvement project surveyed women to identify their attitudes and beliefs concerning antenatal care, PMTCT, and partner's participation in antenatal care and testing.

RESULTS

Women viewed antenatal care as important to having a positive pregnancy outcome and the primary venue through which they accessed HIV testing. Most women (83.8%) were receptive to their partners' involvement in antenatal care and identified increased partner participation over the past 5 years. Women (98.2%) said men's primary role was payment for obstetric care. Cultural and gender-based attitudes and beliefs were identified as barriers to HIV testing of men.

DISCUSSION

Women viewed antenatal care as important to a positive pregnancy outcome with access dependent on their families' finances and their partners' ability and willingness to pay for their care. Although pregnancy has traditionally been viewed as a women's affair, the majority of women wanted their partners to participate in their care, including receiving HIV counseling and testing. Women identified men's involvement as an individual belief, saying that many in their community were not supportive of male participation in antenatal care. Multiple options, including couples testing in antenatal clinics, should be available to increase HIV testing in men.

Reducing the risk of HIV infection during pregnancy among South African women: a randomized controlled trial

Mpumalanga Province, South Africa has one of the highest HIV/AIDS diagnosis rates among pregnant women (~29.4%). This study sought to enhance male involvement in pregnancy to increase HIV disclosure, sexual communication, HIV knowledge and reduce unprotected sex. Participants attending Antenatal Clinics (ANC) completed HIV counseling and testing and were enrolled with male partners (n=239 couples, 478 individuals). Twelve ANCs were randomly assigned to provide a prevention of mother-to-child transmission (PMTCT) intervention or the standard of care, health education sessions plus PMTCT. Participants were assessed at baseline and post-intervention (approximately 6-8 weeks post-baseline) on demographics, sexual behavior, HIV-related knowledge, and conflict resolution strategies. Experimental participants increased HIV knowledge, use of negotiation, and decreased intimate partner violence. Additionally, they were more likely to have increased condom use from baseline to post-intervention (OR=5.1, 95% CI=[2.0, 13.3]). Seroconversions in the control condition exceeded experimental (6 vs. 0). HIV serostatus disclosure to partner did not increase over time for men or women within the experimental or control condition. Male involvement in pregnancy may be an important strategy to reduce sexual risk behavior and HIV transmission. Results support the utility of group interventions to enhance communication and HIV knowledge among pregnant couples.

HIV knowledge and sexual risk behavior among pregnant couples in South Africa: the PartnerPlus project

In sub-Saharan Africa, 60 % of people living with HIV are women and most are of childbearing age. Alarmingly, seroconversion rates during pregnancy are high and increase as pregnancy progresses, highlighting the importance of increasing HIV-knowledge among pregnant women and their partners. This study compared sexual risk behavior, HIV knowledge and condom use pre- to post-partum among South African couples (n = 239 couples) randomly assigned to an intervention or an enhanced standard of care with the PMTCT protocol at rural community health antenatal clinics. Consistent condom use and HIV-related knowledge increased baseline to post-intervention and was maintained at long term follow up post-partum among participants in the intervention condition. HIV knowledge mediated the relationship between the intervention and consistent condom use. Results from this pilot study provide support for the integration of HIV risk reduction interventions for both women and men into existing PMTCT services during and following pregnancy.

Women's health in urban Mali: social predictors and health itineraries

Social and marital factors may influence women's health outcomes. This is of particular relevance in sub-Saharan Africa, where women's health indicators lag behind the rest of the world. Our study examines the impact of social mediators of women's health during key events (pregnancy and illness) in urban Mali. In this cross-sectional study, we interviewed 324 women aged 15-80, living in Bamako, the capital city, in 1999. We used mixed quantitative and qualitative methods to obtain detailed histories of pregnancy and illness during specific time periods preceding the survey. We examined the role of marital factors (polygyny, widowhood), social factors (sources of support and scales derived for social network and social power), and household wealth on women's therapeutic itineraries. We compared the sociodemographic characteristics of our sample with those of the 2001 Mali Demographic and Health Survey and used their data on contraception to enrich analyses. We found that most pregnant women delivered in a health center and most women sought medical care during an illness event. Household wealth influenced illness reporting, and financial concerns were obstacles to medical care. Polygyny was associated with lower prevalence of contraceptive use, lower social power, as well as with less support received during pregnancy from women's husbands and in-laws. Widowhood appeared to increase susceptibility to illness, while decreasing resort to biomedical care. Our social composite scores highlighted differences in healthcare utilization in an urban setting with near-uniform access to biomedical care. We validate the utility of locally-derived composite scores, which may provide a deeper understanding into the social mediation of health outcomes for women.

HIV disclosure, sexual negotiation and male involvement in prevention-of-mother-to-child-transmission in South Africa

HIV-seroconversion during pregnancy is a serious concern throughout South Africa, where an estimated 35 to 40% of pregnant women have HIV/AIDS and drop-out is high at all stages of the prevention-of-mother-to-child-transmission (PMTCT) process. The likelihood of PMTCT success may be linked to partner support, yet male involvement in antenatal care remains low. This qualitative study examined the influence of pregnant couples' expectations, experiences and perceptions on sexual communication and male involvement in PMTCT. A total of 119 couples participated in a comprehensive intervention in 12 antenatal clinics throughout South Africa. Data were collected between December 2010 to June 2011 and analysed using a grounded theory approach. Findings point to the importance of sexual communication as a factor influencing PMTCT male involvement. Analysis of themes lends support to improving communication between couples, encouraging dialogue among men and increasing male involvement in PMTCT to bridge the gap between knowledge and sexual behaviour change.

Community-based approaches for prevention of mother to child transmission in resource-poor settings: a social ecological review

INTRODUCTION

Numerous barriers to optimal uptake of prevention of mother to child transmission (PMTCT) services occur at community level (i.e., outside the healthcare setting). To achieve elimination of paediatric HIV, therefore, interventions must also work within communities to address these barriers and increase service use and need to be informed by evidence. This paper reviews community-based approaches that have been used in resource-limited settings to increase rates of PMTCT enrolment, retention in care and successful treatment outcomes. It aims to identify which interventions work, why they may do so and what knowledge gaps remain.

METHODS

First, we identified barriers to PMTCT that originate outside the health system. These were used to construct a social ecological framework categorizing barriers to PMTCT into the following levels of influence: individual, peer and family, community and sociocultural. We then used this conceptual framework to guide a review of the literature on community-based approaches, defined as interventions delivered outside of formal health settings, with the goal of increasing uptake, retention, adherence and positive psychosocial outcomes in PMTCT programmes in resource-poor countries.

RESULTS

Our review found evidence of effectiveness of strategies targeting individuals and peer/family levels (e.g., providing household HIV testing and training peer counsellors to support exclusive breastfeeding) and at community level (e.g., participatory women's groups and home-based care to support adherence and retention). Evidence is more limited for complex interventions combining multiple strategies across different ecological levels. There is often little information describing implementation; and approaches such as "community mobilization" remain poorly defined.

CONCLUSIONS

Evidence from existing community approaches can be adapted for use in planning PMTCT. However, for successful replication of evidence-based interventions to occur, comprehensive process evaluations are needed to elucidate the pathways through which specific interventions achieve desired PMTCT outcomes. A social ecological framework can help analyze the complex interplay of facilitators and barriers to PMTCT service uptake in each context, thus helping to inform selection of locally relevant community-based interventions.