The above results demonstrate that cultural factors, availability of HIV-related information and health system factors constitute the main barriers to male involvement in PMTCT activities. Specifically the most pertinent barriers noted include: the cultural perception of antenatal care as a woman’s place; the societal norm that men should not participate in ANC/PMTCT; the societal ridicule of men participating in ANC/PMTCT; the reluctance of men to learn their HIV status; the misconception by men that their partner’s HIV status is a proxy of theirs; the unawareness of ANC PMTCT services; time conflicts with ANC/PMTCT; long waiting times at the clinics; and the male unfriendliness of ANC/PMTCT services. Accordingly, many of the actions shown to facilitate male involvement in PMTCT have taken place at these levels. The most notable amongst these include: inviting men to ANC/PMTCT; offering routine voluntary couple counselling, the provision of services during non-working hours; offering HIV counselling and testing at other locations; community sensitization activities; open discussions for free prenatal HIV testing for partners; increased male knowledge concerning HIV and the perceived benefits of PMTCT.
The blend between minimizing these barriers and optimizing facilitators in a context-specific manner would help optimize the benefits of male involvement in PMTCT. The results imply a need not only for amendments but also context-specific adaptations if we are to achieve the public health benefits of male PMTCT involvement.
At the level of the health system these findings imply there is a need for reinforcement of the strategies used, if any, to improve male involvement in PMTCT. There is a need to actively invite and involve men in PMTCT activities through different means. These efforts of engaging men should consider the health and other needs of men rather than simply portray them as tools for women’s or infant’s health outcomes .
Furthermore, health service changes rendering ANC and PMTCT services more male-friendly  are necessary. These could include the implementation of couple antenatal counselling and testing as a routine within the health service [19, 24, 47], the reorientation of services towards both sexes , the possibility of couple/individual testing , the strengthening of couple counselling outside routine antenatal care , and the creation of male-friendly spaces within the ANC premises  amongst others.
Also within the health system, capacity reinforcement and motivation of the health service providers could improve the quality of services and minimize long waiting times within antenatal care [44, 45]. Most often than not, resources are usually in short supply and antenatal clinics especially in developing countries are usually inadequately staffed . Efforts need to be made to target the best use of available resources. One option may be the differential counselling for HIV infected women to bring along their husbands . Another may be the selective counselling of men presenting at delivery wards . Irrespective of the methods chosen, such selective measures may not only minimize time wastages, but may also ensure that limited resources and manpower are concentrated upon the population most likely to benefit from the interventions.
Still within the health system, the offering of VCT during non-working hours has been identified as a means to improve male uptake of PMTCT interventions [38, 45]. The use of alternative but acceptable HIV testing sites was also suggested . The implication of these suggestions within the health system is the careful consideration of the cost-effectiveness and acceptability of any interventions before implementation.
Cultural barriers represent the most pertinent barriers to male involvement in PMTCT. This is a multi-faceted barrier, the strongest elements being the recognition of antenatal care as the woman’s place P[19, 23, 38–41, 43, 44, 48], and the associated discomfort for all men found within these settings [19, 32, 44]. Other cultural barriers focused on the power dynamics within the home [39, 44]. A possible way forward may be to initiate diverse community-based initiatives to address underlying gender norms and societal attitudes towards male involvement in PMTCT activities. Men could be brought to realize it is unacceptable to preserve outdated cultural norms at the risk of losing their lives , and endangering infants. In so doing, we must however recognise the values that every society places in its culture and heritage. It is therefore important to work with community leaders to build upon and expand the present cultural expectations, such that additional social support is provided to women, and men be encouraged to participate in ANC/PMTCT activities . Hence community-based programs that would normalize male ANC/PMTCT participation and minimize associated stigma need to be initiated.
The implications of our results for policy makers are numerous. The gap between global health policies and local realities must be addressed. The problem of finances is a recurrent problem, and the fear of the burden of care is enough to dissuade men from ANC/PMTCT interventions. Therefore, addressing health system financing mechanisms is a major step towards encouraging couples to seek care. Furthermore, the lack of concern for the local context of infant feeding has been identified as a limitation to the success of PMTCT programs in sub-Saharan Africa . The policy implications of these findings should include universal free HIV testing , and free access to HIV care within the health service . Also, whenever possible artificial milk should be provided freely to HIV-infected mothers who opt not to breastfeed.
Policy on the general organization of health services need to be addressed. Establishment of a widely disseminated health policy on HIV testing could minimize the fear of HIV testing . A way forward could be to strengthen the policy on routine HIV testing in antenatal care to incorporate partners. Other measures could include the provision of pre and post-test counselling services for HIV on the same day , the availability of rapid HIV-testing at the clinic and increased confidentiality at every level of the ANC/PMTCT program.
Policies directly addressing PMTCT may also need to be addressed. Aspects such as the integration of domestic violence screening into the PMTCT programmes should be considered in order to minimize this obstacle within the community . Furthermore, PMTCT programs should consider granting women the possibility to test more than once as this may provide multiple opportunities for getting partners involved . Moreover, PMTCT models should also consider integrating discussion of finances within the family . Family health budgets should have provisions for male care.
The lack of knowledge about HIV and the importance of male involvement in PMTCT have direct implications for information, education and communication initiatives. It highlights the need to increase male education on HIV/PMTCT and target information for men by various means [20, 41, 44]. Examples of these sensitization activities include the pasting of flyers and posters in areas frequented by men, and use of the media to discuss and encourage male participation in HIV/PMTCT . The knowledge barrier also calls for increased training of health educators and the revision of educational messages provided by health counselors so far. Hence, counselling messages within ANC/PMTCT services should address spousal communication regarding sexual risks . It should also encourage women to discuss VCT with their spouses before testing , and help them to elaborate plans to involve their partners early in PMTCT . The message that a woman’s HIV status is not a proxy measure of that of her partner should be emphasized.
This review has some limitations. The major limitation is that only English reports were considered. Our findings are also limited to the databases we searched and may not provide a complete picture of the barriers and facilitators to male partner participation in PMTCT. Furthermore, most of the studies included in this review were from resource limited settings hence these results may not be applicable in higher resource settings. In addition, most of the included studies were conducted in urban settings in resource limited areas, thus limiting the applicability of some of these findings in rural settings.