male attitudes towards participating in the prevention

MALE ATTITUDES TOWARDS PARTICIPATING IN THE PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV

by

LIVINGTON MOYO

submitted in part fulfilment of the requirements for the degree of

MASTER OF ARTS

in the subject

SOCIAL BEHAVIOUR STUDIES IN HIV/AIDS at the

UNIVERSITY OF SOUTH AFRICA Supervisor: Dr Vicci Tallis

November 2014

DECLARATION

I, Livington Moyo, do hereby declare that this dissertation is the result of my investigation and research and that this has not been submitted in part or full for any degree or for any other degree to any other university 11/05/2015 Date

______________ L. Moyo

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ACKNOWLEDGEMENTS

This dissertation has been made possible by enormous contributions from colleagues and academics from a variety of professions within the healthcare industry. Sincere appreciation goes to Dr V Tallis, my supervisor, for mentorship and guidance; her contribution was profound and is highly appreciated. She was patient and firm with me when it was difficult to continue with this study. Thank you for sticking with me even after relocation from Africa to Asia. It was frustrating to use a quote one week only to be told it was outdated two weeks later. You showed that you were well informed and up to date with the developments and research in the subject I was researching.

Further acknowledgements go to my acquaintances Mr Dumisani Msimanga and Dr Chiweni Chimbwede and my convener Mr Leon Roets for their immense contribution in helping me to shape the direction of this study. Once more I would like to thank the research participants who committed their time during the long interviews.

I would also like to thank my mentors, Dr Lewis Ndhlovu and Professor Peter Dzvimbo. They told me in an indirect and polite way that I was not well read. Then I took up the challenge: “I am not stopping here, I am going beyond your inspiration.”

I am grateful to parents, Mr Rodgers Hoko Moyo and Mrs Elita Ncube Moyo, for their upbringing in an environment that instilled in me hard work, perseverance, discipline and a positive attitude towards education and life. “I am because of you, Mom and Dad!”

Last, I would like to thank my children, Vigilance, Meluleki, Dumolwenkosi and Sinethemba. They were the true source of inspiration for me to do a master’s degree. I did this study to challenge them to surpass what I have achieved. “I have set a standard; catch me if you can my children!”

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TABLE OF CONTENTS DECLARATION ............................................................................................................................ i ACKNOWLEDGEMENTS ............................................................................................................ ii LIST OF ABBREVIATIONS .......................................................................................................viii ABSTRACT................................................................................................................................. ix CHAPTER ONE: STUDY OVERVIEW ........................................................................................ 1 1.0.

INTRODUCTION ............................................................................................................ 1

1.1.

BACKGROUND OF THE STUDY ................................................................................... 4

1.2.

THE YOU CAN COUNT ON ME CAMPAIGN ................................................................. 7

1.3.

RESEARCH AIM .......................................................................................................... 11

1.4.

RESEARCH OBJECTIVES .......................................................................................... 12

1.5.

DELINEATIONS AND LIMITATIONS ........................................................................... 12

1.6.

DEFINITIONS OF THE KEY CONCEPTS .................................................................... 15

1.7.

ASSUMPTIONS............................................................................................................ 17

1.8.

RATIONALE OF THE STUDY ...................................................................................... 18

1.9.

THEORETICAL FRAMEWORK .................................................................................... 20

1.10.

THEORIES OF MASCULINITY.................................................................................... 20

1.11.

HEGEMONIC MASCULINITY ...................................................................................... 21

1.12.

THE ROLE THEORY ................................................................................................... 23

1.13.

CONSTRUCTION OF MASCULINITIES ....................................................................... 23

1.14.

CONCLUSION .............................................................................................................. 25

CHAPTER TWO: LITERATURE REVIEW ................................................................................ 27 2.0.

INTRODUCTION .......................................................................................................... 27

2.1.

MOTHER TO CHILD TRANSMISSION OF HIV ........................................................... 27

2.1.1.

INFECTION DURING PREGNANCY ............................................................................ 28

2.1.2.

INFECTION DURING BIRTH OR DELIVERY ............................................................... 28

2.1.3.

INFECTION DURING BREASTFEEDING .................................................................... 29

2.2.

PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV ............................. 30

2.2.1.

PMTCT DURING PREGNANCY, LABOUR AND BIRTH .............................................. 31

2.2.2.

PMTCT DURING BREASTFEEDING ........................................................................... 32 iii

2.3. CHALLENGES FACING WOMEN LIVING WITH HIV ...................................................... 33 2.4. MALE PARTICIPATION IN PMTCT .................................................................................. 35 2.5. BARRIERS TO POSITIVE MALE INVOLVEMENT IN PMTCT ......................................... 36 2.6. BENEFITS OF MALE INVOLVEMENT IN PMTCT ........................................................... 39 2.7. CULTURAL ISSUES AND PMTCT ................................................................................... 40 2.8. CONCLUSION .................................................................................................................. 43 CHAPTER THREE: RESEARCH METHODOLOGY ................................................................. 44 3.0. INTRODUCTION .............................................................................................................. 44 3.1. POPULATION SAMPLE ................................................................................................... 44 3.2. SAMPLING TECHNIQUES ............................................................................................... 45 3.3. DATA COLLECTION METHODS...................................................................................... 45 3.4. DATA ANALYSIS AND INTERPRETATION ..................................................................... 46 3.5. AUTHENTICITY AND TRUSTWORTHINESS OF DATA FINDINGS................................ 47 3.6. ETHICAL RESPONSIBILITY AND SENSITIVITY ............................................................. 47 CHAPTER FOUR: STUDY FINDINGS AND DISCUSSIONS .................................................... 49 4.0. INTRODUCTION .............................................................................................................. 49 4.1. DEMOGRAPHIC CHARACTERISTICS ............................................................................ 50 4.1.1. ETHNIC GROUP ............................................................................................................. 50 4.1.2. MARITAL STATUS .......................................................................................................... 51 4.1.3. EDUCATIONAL LEVEL .................................................................................................. 52 4.1.4. SEXUAL PARTNERS ..................................................................................................... 53 4.1.5. NUMBER OF CHILDREN ............................................................................................... 54 4.1.6. MARITAL STATUS ......................................................................................................... 55 4.2.

KNOWLEDGE OF AND ATTITUDE TO HIV AND STIS ................................................. 55

4.3.

KNOWLEDGE OF AND ATTITUDES TO PMTCT .......................................................... 57

4.4.

ATTITUDE TO PARTICIPATION IN HIV, STIS AND PMTCT ACTIVITIES .................... 59

4.5.

ATTITUDES OF HEALTHCARE WORKERS TO MALE INVOLVEMENT IN PMTCT .... 62

4.6.

THE ACCESSIBILITY OF ANTENATAL CARE FACILITIES BY MEN ........................... 63

4.7.

SOCIOCULTURAL PRACTICES AND MALE INVOLVEMENT IN PMTCT .................... 64

4.8.

BARRIERS TO MALE PARTICIPATION IN THE PMTCT PROGRAMMES ................... 67

4.9.

STRATEGIES TO IMPROVE MALE INVOLVEMENT IN PMTCT................................... 69

4.10. DISCUSSION.................................................................................................................. 70 iv

4.11. CONCLUSION ................................................................................................................ 75 CHAPTER FIVE: RECOMMENDATIONS ................................................................................. 76 SOURCE LIST ........................................................................................................................... 80 APPENDIX 1: INTERVIEW SCHEDULE ................................................................................... 99 APPENDIX 2: INFORMED CONSENT .................................................................................... 102 APPENDIX 3: ETHICAL CLEARANCE .................................................................................... 105

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LIST OF TABLES Table 1: Demographic characteristics of respondents ............................................................... 50 Table 2 Distribution of respondent participation in PMTCT activities ........................................ 59

vi

LIST OF FIGURES Figure 1: Summary of findings ................................................................................................... 49 Figure 2: Ethnic group................................................................................................................ 51 Figure 3 Categories of marital status of respondents ............................................................... 52 Figure 4: Distribution of educational qualifications of the respondents ...................................... 53 Figure 5: Distribution of the number of sexual partners for each respondent ............................. 54 Figure 6: Distribution of the number of children per respondent ................................................ 54

vii

LIST OF ABBREVIATIONS

AED: Academy for Educational Development AIDS: Acquired Immunodeficiency Syndrome ANC: Antenatal care ART: Antiretroviral therapy ARVs Antiretroviral AZT: Zidovudine CCM: Constant Comparative Analysis Method CD4: CD4 count/ Cell Divider 4 CDC: Centre for Disease Control and Prevention UNICEF CRC: Children’s Rights Centre DOH: Department of health HIV: Human Immunodeficiency Virus ICPD: International Conference on Population and Development IEC: Information, Education, and Communication MDGs: Millennium Development Goals MiM: Men in Maternity MTCT: Mother to child transmission NHMRC: National Health and Medical Research Council NSP: National Strategic Plan for HIV and AIDS and STIs PEPFAR: United States President’s Emergency Plan for AIDS Relief PMTCT: Prevention of mother to child transmission of HIV SAHARA: Social Aspects of HIV/AIDS Research Alliance SOB: Save Our Babies STI: Sexually transmitted infections TAC: Treatment Action Campaign VCT: voluntary counselling and testing WHO: World health organization

viii

ABSTRACT

Men have traditionally been absent in programmes that offer services for the prevention of mother to child transmission of HIV (PMTCT). The factors that influence participation or non-participation of men in the reproductive health of women include cultural prohibitions and prescriptions, accessibility of maternal health facilities to men, attitude of healthcare workers to men and knowledge of HIV and AIDS, STIs and PMTCT. A qualitative research methodology was used in this research to obtain specific information about the values, beliefs, attitudes and behaviours of the research participants from their social contexts. Key to the research design was the manner in which the research participants interpreted their lived experiences when participating or not participating in the reproductive health of women and the meaning they attached to those experiences.

Power disparities between men and women, influenced by the understanding and experiences of masculinity were perceived as a barrier to significant male participation in the prevention of paediatric infections of HIV owing to cultural differences and modernisation. The cultural dynamics, which included cultural prohibitions during and after delivery and often misconstrued as a lack of willingness to participate in PMTCT by men, explained the modalities of male participation in the reproductive health of women from a black African man’s cultural perspective. Cultural or ethnic orientation influenced the level of male participation in the reproductive health of women including PMTCT. Men’s involvement or their reluctance to participate in PMTCT was perceived as relative. This meant that male involvement or lack of male participation could not be generalised; it could only be perceived and defined from a specific cultural context.

The evidence that male participation in the PMTCT process increased adherence and led to better outcomes for the child was compelling. This research explored barriers to male participation and put forward some suggestions to reduce the barriers and increase involvement.

ix

CHAPTER ONE: STUDY OVERVIEW

1.0.

INTRODUCTION

Men have traditionally been absent from programmes that offer reproductive services women, including the prevention of mother to child transmission of HIV (PMTCT) ((Greene, Mehta, Pulerwitz, Wulf, & Bankole 2006) . In South Africa, as in most other African countries, family planning, pregnancy and childbirth have been regarded as exclusively women’s affairs and men generally do not accompany their partners to family planning, antenatal or postnatal care services and are not expected to attend the birth of their children ( Mullick, Kunene, & Wanjiru 2005). A lack of culturally appropriate programmes, cultural proscriptions and prescriptions influences men's willingness or reluctance to participate in the reproductive health of women. An understanding of male participation in PMTCT should be cognisant of the cultural practices that prohibit men from being present during childbirth and after the first few days of life, a custom that is sometimes misinterpreted as a lack of interest in involvement in the reproductive health of women including PMTCT. The need to involve men in women’s reproductive health services started to attract a lot of interest after the 1994 International Conference on Population and Development (ICPD) in Cairo and the 1995 Women’s Conference in Beijing after a realisation by stakeholders of the role that men could play in the success of these services (Greene et al 2006). Since then, there has been an increase in research and programming (Byamugisha, Tumwine, Semiyaga, & Tylleskär, 2010; Pularwitz et al 2010; Boniphace 2010: Katz, Kiarie, John-Stewart, Richardson, John, & Farquhar 2009; Aluisio, Richardson, Bosireg, John-Stewart, Mbori-Ngachah, & Farquhar 2011; Berg 2004; and Cullinan 2002 among others) on male participation in the reproductive health of women which has focused on understanding the impact of male involvement in women’s reproductive health, with most researchers exploring the factors that influence male participation in PMTCT and the reproductive health of women. Increased knowledge of women’s reproductive health issues among men led to a scaling up of programmes designed to promote male involvement in PMTCT as well as to promote increased health-seeking behaviours among men (Boniphace 2010).

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In sub-Saharan Africa, a number of organisations have engaged in programmes that address challenges related to mother to child transmission of HIV and male involvement in the reproductive health of women. Some organisations that developed and implemented programmes promoting male participation in the reproductive health of women include Men as Partners; Brothers for Life; Kagiso TV and Communication in South Africa; the National PMTCT programme in Tanzania; the Ugandan Programme for Human and Holistic Development (UPHOLD) in Uganda; the Pathfinder International in Nigeria; Men’s Forum on Gender in Zimbabwe and others. Despite the above efforts to increase the uptake of PMTCT services by men, coverage is still lower in most developing countries than in developed countries (Brusamento, Ghanotakis, Car, Velthoven, Majeed & Car 2012.) because of the perception that antenatal care (ANC) and PMTCT are a woman’s responsibility (Peltzer, Jones, Weiss, & Shikwane 2011) This is also viewed as a major barrier for women to access those services (Brusamento et al 2012). Men were found to be key players in influencing, both positively and negatively, directly and or indirectly, the reproductive health outcomes of their wives and children (Singh & Faujdar 2009). Research by Nkuoh, Meyer, Tih and Nkfusai (2010) shows that when men participate in the prevention of mother to child transmission of HIV programmes, their knowledge of HIV increases; their behaviour towards PMTCT becomes positive and supportive; their responsiveness to HIV testing increases and enhances the effectiveness of reproductive health services for women (Nkuoh, Meyer, Tih and Nkfusai 2010). Therefore, ensuring men’s involvement in reproductive and maternal health matters promotes a better outcome for the prevention of mother to child transmission of HIV (Singh & Faujdar 2009). Men’s involvement in their own health in general, and women’s health specifically, was relatively new in most societies and was mostly influenced by the advent of the HIV epidemic. A critical question was whether men were both capable of, and willing to be active participants in the reproductive health of their partners, especially within a patriarchal society in which men and boys had been (in most cultures) socialised into roles which encouraged attitudes and behaviours that undermined women’s sexual and reproductive health (Women’s Commission for Refugee Women and Children 2005). There was a need for men to be informed about the importance of pre-natal and natal care, that the upbringing of children was a shared responsibility of both men and women and that the issues surrounding pregnancy and childbirth should be seen as the collective responsibility of both parents (Singh et al 2009). Globalisation, feminism, and modernisation are gradually reshaping perceptions about masculinity and creating the notion that 2

men can be responsive and accommodating if they discover the benefits of participating in the reproductive health of their partners (Brown, Sorrell & Raffaelli 2005).

Research shows that men have played an important role in the uptake of antenatal voluntary counselling and testing (VCT) and mother to child transmission (MTCT) prevention programmes (Katz, Kiarie, John-Stewart, Richardson, John, & Farquhar 2009). In a study undertaken between 1999 and 2005 in Nairobi, Kenya by Adam Aluisio and colleagues, the researchers found that partner involvement in the prevention of mother to child transmission (PMTCT) services reduces the risks of vertical transmission and infant mortality by more than 40% (Aluisio et al 2011). In another study by Dutki (2010) it was discovered that male involvement improves women’s uptake of core PMTCT services; contributes to community acceptance and support of PMTCT; is linked to greater uptake of testing and antiretroviral medications; increased condom use; increased communication; support for infant feeding choices; and the prevention of unintended pregnancies (Dutki 2010).

It is important for both men and women to be aware of the positive and significant impact that male involvement in PMTCT can yield. Increasing male participation as a method to enhance the implementation of PMTCT and increased uptake of and commitment to the medical protocol for pregnancy and new-born care are identified as critical strategies for PEPFAR funded countries (Peltzer, Jones, Weiss, & Shikwane 2011). In a study in Ecuador, 89% of women who participated in a PMTCT research expressed a greater need for joint partner decision making on reproductive health issues (Muwa, Mugume, Buzaalirwa, Nsabagasani & Kintu 2008). At the Reproductive Health Research Unit (RHRU) of the University of the Witwatersrand, an operations research study showed that both men and women are interested in men’s involvement during maternity care, though there remains a number of health service delivery challenges that need to be addressed within the South African context before maternity services become more male friendly (Mullick et al. 2005). Involving men in PMTCT promotes communication between men and women, empowers men on reproductive health matters, makes them more sensitive to women’s needs and supportive to efforts that enhance women’s socio-health status (Dutki 2010).

This study explored factors that influence or hinder male participation in the reproductive health of women. Some of the factors include cultural proscriptions, the structure of maternal health facilities in public health institutions, and the attitude of healthcare workers to men who attend 3

antenatal care with their partners. An assessment of the influence of men’s knowledge of HIV and AIDS, STIs and PMTCT was also examined. The nature of male involvement in the reproductive health of women including PMTCT has a cultural or an ethnic orientation.

1.1.

BACKGROUND OF THE STUDY

With an estimated 5.6 million (5.4 – 5.8 million) people living with HIV (2010), South Africa’s epidemic remains the largest in the world (UNAIDS 2011). In Africa there is a disproportionate burden of HIV between women and men with more women than men living with HIV. Currently, young women aged 15 to 24 years are as much as eight times more likely to be HIV positive than men of the same age group (UNAIDS 2010). Though the estimated National HIV prevalence among women in South Africa has remained stable over four years (29.1% in 2006; 29.4% in 2007; 29.3% in 2008; 29.4 in 2009), there was a rise of 0.8% to 30.2% in 2010 (DOH 2011). In the 2012 National survey, female HIV prevalence continued to increase, peaking at 30 to 34 years where prevalence reached a record high of 36.0% (DOH 2012).

The vulnerability of women to HIV in the childbearing age increases the risk of HIV infection to unborn children, especially in the absence of PTMTC, during pregnancy, delivery and breastfeeding, as reflected in the South African National Antenatal Sentinel HIV and Syphilis Prevalence Survey (DOH 2011). In 2012, around 260,000 children were newly infected with HIV, bringing the total number of children under the age of 15 living with HIV to 3.3 million. More than 90% of these children lived in sub-Saharan Africa (UNICEF 2012). In 2011, the overall HIV prevalence among antenatal women had decreased by 0.7% from 30.2% in 2010 to 29.5% and the number of newly infected children aged 0 to 14 years fell by 56.2%, from 66 000 in 2008 to an estimated 29 000 in 2011 (DOH 2011). One bright spot on the global horizon was the rapid decline in new HIV infections among children, largely owing to stepped-up efforts to prevent mother to child transmission of HIV and the introduction of ARVs (UNICEF 2012).

It is important to note that the HIV prevalence in South Africa decreased as the global incidence was decreasing (Shisana, Rehle, Simbayi, Zuma, Jooste, Pillay-van-Wyk, Mbelle, Van Zyl, Parker, Zungu, Pezi & the SABSSM III Implementation Team 2009). Similarly, there was a decline the transmission of mother to child infection rates at six weeks that had been observed over the 4

past few years (in South Africa), indicating that policy changes in conjunction with improved implementation of the prevention of mother to child transmission (PMTCT) programmes were effective. (Shisana, Rehle, Simbayi, Zuma, Jooste, Zungu, Labadarios, Onoya et al 2014). The HIV prevalence trends in South Africa are largely credited to the decision taken by the South African government in December 2009 to expand the access of prevention of mother to child transmission of HIV among women living with HIV and AIDS through early infant diagnosis and the roll out of paediatric treatment to HIV positive infants (UNICEF 2009).

Prior to May 2009 (before the incumbent Minister of Health Aaron Motsoaledi was appointed), owing to lack of funds and a political will, there had been a lengthy delay from government in unveiling treatment for the prevention of mother to child transmission of HIV as well as antiretroviral therapy for those with advanced HIV infection (SAHARA 2010). Significant debates (the 1994 National AIDS Plan; the Thai/Bangkok study; Minister of Health v Treatment Action Campaign (No 2) 2002 (5) SA721 (CC); The Sowetan: How Many More Babies Must Die?; Statement by Government on the Constitutional Court Judgment regarding PMTCT (5 July 2002) etc. about MTCT had emerged in 1994 in South Africa, when it was discovered that mono-therapy with the antiretroviral drug AZT reduces the risk of MTCT of HIV (Heywood 2003).

The lobbying of the minister and the Department of Health to develop policies and programmes to prevent MTCT pressured the government to implement the “steps to be taken to prevent perinatal transmission of HIV” listed in the 1994 National AIDS Plan, which included offering HIV testing at antenatal clinics on a voluntary basis and conducting research into methods of preventing perinatal transmission such as short course AZT and non-nucleoside reverse transcriptase inhibitors (National AIDS Convention of South Africa A National AIDS Plan for South Africa 1994). In 1998, the Gauteng Health Department responded to the results of the Bangkok Thailand study by announcing the establishment of five pilot sites where programmes to reduce MTCT would be introduced (Heywood 2003). On 30 April 1999, a meeting between TAC and Dr Nkosazana Zuma, the Minister of Health, led to a joint statement that the price of AZT was the major barrier to an MTCT programme and a promise was made that government would name an affordable price for the implementation of AZT to pregnant mothers and report within six weeks on the price and other issues pertaining to the prevention of mother to child transmission (Heywood 2003).

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Even after that joint statement between TAC and the government on the role out of Nevirapine, the government led by then President Thabo Mbeki declined an offer from Boehringer Ingelheim, the manufacturer of Nevirapine, for a “free” supply of the drug for five years (Heywood 2003). TAC, together with Save Our Babies (SOB), a coalition of paediatricians, and the Children’s Rights Centre (CRC) in Durban filed a constitutional claim against the government on 21 August 2001 seeking a declaration to order government to make Nevirapine available to pregnant women with HIV and to their babies in the public health institutions (Heywood 2003). The state opposed the TAC case on the grounds that the relief was unaffordable, and that the efficacy and safety of Nevirapine had not been fully proven and that its widespread use risked a public health catastrophe (Heywood 2003).

It was only from 2010, under the leadership of President Jacob Zuma, that South Africa had one of the most successful PMTCT programmes. The National Strategic Plan 2007 – 2011 set a target of