Male involvement in PMTCT and associated factors among men whom their wives had ANC visit 12 months prior to the study in Gondar town, North west Ethiopia, December, 2014

Introduction Globally, male involvement has been recognized as a priority focus area to be strengthened in PMTCT but, testing male partners for HIV in the context of preventing mother-to-child transmission remains a challenge in most low- and middle-income countries including Ethiopia. In Ethiopia even though male involvement is one of the guiding principle in testing and counseling of HIV, the magnitude of male involvement in PMTCT is not well known. The objective was to assess the magnitude of male involvement in PMTCT and associated factors among men whom their wives have ANC visit 12 months prior to the study in Gondar town, North west Ethiopia. Methods A community-based cross-sectional survey was conducted from December 1- 20, 2014 among men whose wives had ANC follow up in the last 12 months prior to study period in Gondar town. Cluster sampling was used to get the total of 802 participants. Results From all participants, only 20.9% of men had high involvement index in prevention of mother to child transmission of HIV/AIDS. Men with secondary and post secondary education (AOR=3.59, 95%CI: 1.36, 9.44), government employment by occupation (AOR=2.23, 95%CI: 1.53, 4.02) men who were married and in union (AOR=4.37, 95%CI: 1.85, 10.32), and men who have heard about PMTCT (AOR=1.74, 95%CI=1.21, 2.49) were more likely to have high involvement index in PMTCT. Conclusion Male involvement in PMTCT programme was low in the study area. Having information about PMTCT, attending Secondary and post secondary education, being government employer and living in union with partner were factors significantly associated with male involvement in PMTCT. Improving male involvement by creating husband’s awareness regarding benefit of PMTCT through provision of balanced information for all male partners is recommended.


Introduction
Human Immunue Deficiency Virus (HIV) is transmitted from an HIVinfected mother to her child during pregnancy, labor, delivery or breastfeeding is known as mother-to-child transmission (MTCT) and preventing HIV transmission in pregnant women and their children often referred to as prevention of mother-to-child transmission (PMTCT) [1,2]. These PMTCT become a crucial intervention in the global fight against this epidemic [2]. To prevent the transmission of HIV from mother to baby, the World Health Organization (WHO) promotes a comprehensive approach, which include preventing HIV transmission from a woman living with HIV to her infant [3,4]. An estimated 430,000 children were newly infected with HIV in 2008, over 90% of them through mother-to-child transmission (MTCT).
Without treatment, about half of these infected children will die before their second birthday [5]. MTCT is the primary cause of all HIV infections in children under fifteen years of age [6]. Without intervention, the risk of MTCT ranges from 20% to 45%. With specific interventions in non-breastfeeding populations, the risk of MTCT can be reduced to less than 2%, and to 5% or less in breastfeeding populations [7,8]. Globally, male involvement has been recognized as a priority focus area to be strengthened in PMTCT [8] but testing male partners for HIV in the context of preventing mother-to-child transmission remains a challenge in most low-and middle-income countries. In 2008, 57 countries documented the number of male partners of pregnant women attending antenatal care who received an HIV test. The proportion of pregnant women attending antenatal care whose male partners were tested for HIV was 5% in 2008 versus 2% in 2007 [9].
Studies have shown that the utilization of PMTCT services by the pregnant women is influenced both by factors related to the health system such as accessibility of VCT services, and by individual factors such as fear of disclosure of HIV results, lack of male partner support, fear of domestic violence, abandonment and stigmatization [2,5,10]. Couple VCT was shown to have greater benefits than accompanying the female partner for individual VCT [11].
Unfortunately, few men accompany their partners to antenatal clinics and even fewer participate in couple counseling when it is available [12,13]. There is evidence that lack of partner support is associated with poor uptake of antiretroviral medication and the inability to modify infant feeding practices [7,14]. Sexual abstinence and condom use have also been shown to be more common among postpartum women who reveal HIV-positive results to partners [15,16]. These associations between partner involvement and uptake of interventions underscore the importance of involving the male partner in HIV-1 prevention efforts initiated in the antenatal setting [17]. Low rates of HIV testing among women in antenatal setting have several implications for PMTCT programmes as the optimal uptake and adherence to such programmes is difficult for women whose partners are either unaware or not supportive of their participation. So, to improve utilization of HIV testing among women in ANC, assessing magnitude of male involvement in PMTCT and associated factors will have important implications to address the perspective issues.

Methods
A community based cross-sectional study was conducted in Gondar town from December 1-20, 2014. Gondar town is found in North Gondar zone of Amhara regional state and is located 750 km Northwest of Addis Ababa. According to the 2007 Ethiopian census report, Gondar has a total population of 206, 987 and adolescents aged 15-19 years are estimated to be (25,128) 12% of the total population. Administratively, the town is divided into 12 administrative areas. The health system in the town is represented by one referral hospital, eight health centers and two governmental youth center. In addition, there are five higher clinics, one hospital, twenty two medium clinics; nineteen lower clinic owned by private sectors and two NGO clinics. The study populations were men whose wives had ANC follow up in the last 12 months prior to study period in the selected clusters. Cluster sampling technique was used to select the study units. By taking admistrative area as cluster, 4 out of 12 admistrative areas were selected. Then, all eligible men in the selected administrative area were included in the study. The sample size was determined by using a single population proportion formula considering the following assumptions: Magnitude of male involvement in PMTCT 50% (p= 0.5) as there was no previous study, 5% level of significance (a = 0.05), 5% marginal error (d= 0.05). The final sample size was adjusted by using design effect of 2 and 5% non-response. Finally the sample size determined was 808.
Data was collected by face to face interview using a structured and pre-tested questionnaire. Ten diploma nurses were used to collect data. Three Midwives from University of Gondar teaching Hospital were assigned to supervise the data collection process. Training was given for both data collectors and supervisors. The level of male involvement in PMTCT programme was measured using six Page number not for citation purposes 3 questions adapted from similar study conducted in Uganda (17).
The questions were modified to local context and include: whether the man attends antenatal care with his partner, whether the man knows the partner's antenatal appointment, whether the man discusses antenatal interventions with his Partner, whether the man supports his partner's antenatal visits financially, whether the man has sought permission to use a condom during the current pregnancy and whether the man tested for HIV with his partner.
The involvement score for each respondent range from 0 = no involvement to 6 = involved in all 6 activities. A total score of 4-6 was considered as a 'high' male involvement score and 0-3 as 'low' male involvement. Data entry was done by using EPI

Socio demographic characteristics
A total of 802 male whom their wives had ANC follow up in the last 12 months were interviewed; out of these 641(79.9%) were Orthodox religion followers. The mean age of the respondents was  Table 1).

Level of male involvement in PMTCT programmed
The level of male involvement in PMTCT was assessed using six variables shown in Table 2 (Table 2).

Programme
As depicted in the bivariate models, male involvement in PMTCT times more likely to have high involvement index than those who were widowed or separated. Men whose occupation was government employee were about 2 times more likely to be involved in PMTCT as compared to self employer (Table 3).

Discussion
The study results revealed that only one in four men (20.9%) had high PMTCTC involvement index in the study area. This finding is similar with study report from Mekele town health facilities, Ethiopian in which 20% of men had high PMTCTC involvement index [17] . The finding is higher than study conducted in Nairobi antenatal clinic, Kenya in which only 15% of male involved in VCT with their wives [11]. But this finding is lower when compared with the study from eastern Uganda 26% and Addis Ababa, Ethiopia 28.1% [16,18]. The difference between our findings and other studies might be due to the difference of socio-economical and accessibility and availability of health care. In this study we have  [19].
Similarly study conducted in Addis Ababa revealed that those men's who had knowledge on PMTCT were more likely to have high PMTCT involvement index [18]. The possible explanation for this might be having information about PMTCT will help the partners to know the benefit of PMTCT programme for themselves as well as their new born thereby increase their involvement. Men's who attended secondary education and above were more like to have high PMTCT involvement index than those who were unable to read and write. This finding is in agreement with other study conducted in Uganda [16] and Zambia [20] where level of men's education had significant association with involvement in PMTCT. These might be due to the fact that educated men's had better awareness about the benefits of preventive health care including PMTCT. They might also have higher receptivity to new health related information. This study also revealed that men's whose occupation was government employee were about 2 times more likely to involve in PMTCT as compared to self employer. This finding is similar with the study finding of Addis Ababa [18] where government employer were more likely to involve in PMTCT than private employer. Study conducted in Uganda [16] also showed occupation of the husband had significant association with male involvement in PMTCT. The possible explanation for this might be that those government employers were more educated and had more awareness about health related issues than private employers like daily laborer.
Those men's who are married and in union were about 4 times more likely to have high involvement index than those who were widowed or separated. These finding is comparable with study conducted in northern Tanzania where partners living together were more likely involved in PMTCT [21]. These might be due the fact that partners who live together had a penchant to discuss about health and related issue that can increase men's involvement in PMTCT.

Conclusion
In conclusion, this study revealed that the proportion of men who had high PMTCT involvement index in the study area was low.
Having had information about PMTCT, Secondary and post secondary education, being government employer and living in union with partner were factors significantly associated with male involvement in PMTCT. Improving male involvement by creating husband's awareness regarding benefit of PMTCT through provision of balanced information for all male partners is recommended.
What is known about this topic  Magnitude of male involvement in PMTCT is low;  Known factors for high PMTC involvement index was having had information on PMTCT and being employed.
What this study adds  Attending secondary and above level of education, and being married contribute to high PMTC involvement index.

Competing interests
The authors declare no competing interests.

Authors' contributions
AA wrote the proposal, participated in data collection, analyzed the data and drafted the paper. AM approved the proposal with some revisions, participated in data analysis and revised subsequent drafts of the paper. All authors read and approved the final manuscript.

Acknowledgments
We are very grateful to the University of Gondar for approval of ethical clearance, technical and financial support of this study. Then, we would like to thank all men who participated in this study for their commitment in responding to our interviews. Finally, we are also grateful to the North Gondar zone health department and Gondar woreda health offices for their assistance and permission to undertake the research.
Page number not for citation purposes 5 Tables   Table 1: socio-demographic characteristics of the study participants, Gondar Town North West Ethiopia, December, 2014