Roles and Expectations of Male Partners from PMTCT services in Chiradzulu Malawi: A Qualitative Study

Introduction: Prevention of mother to child transmission of HIV (PMTCT) is the main measure for curbing HIV infection in children. Male involvement (MI) greatly influences uptake and adherence to PMTCT services yet the level remain low in Sub Saharan Africa. Lack of well stipulated roles for men in PMTCT is one of the main barriers to MI. Studies on MI have focused on women and Health care workers (HCW), thereby making men silent partners. The main aim of the study was to explore the roles and expectations of male partners in PMTCT services in Malawi. Methods: This was a descriptive qualitative study that involved men whose partners were either pregnant or breastfeeding a child, health care workers working in PMTCT services for over six months and traditional leaders. We conducted 9 in-depth interviews and 12 key informant interviews from January to March 2018. All interviews were audio-recorded, transcribed and translated. Thematic analysis was employed to analyze data. Results: Male partners play supportive, HIV prevention behaviour change and decision-making roles in PMTCT services. Health assessment and health promotion activities are the male specific services required in PMTCT services and these should be delivered at both health facility and community levels. Conclusion: Male partners in PMTCT have expectations that need to be met at both health facility and community levels. There is need to have male-tailored package of health services that are directly provided to men along with PMTCT services at different levels in order to promote MI. The services should be provided in an atmosphere that allows and accepts male partners to exercise their roles in PMTCT services.

of men within the programmes [3]. The lack of clarity on the roles and expectations of men in PMTCT services hinders successful male involvement [1]. Although men have knowledge of MI and PMTCT [1, 3,12], there are no stipulated roles of men in the ART/PMTCT guidelines in the country [18], which leaves both health care workers and men unaware of what men ought to access when they attend PMTCT services with their partners. Furthermore, it has been asserted that PMTCT services are for women without specific roles that are directed towards men [19]. In other instances men have been used as a mechanism to fast-track women within the antenatal clinics [1,5] with no services targeted for them.
This study was conducted to explore expectations of men in PMTCT services in a district in the southern part of Malawi. Specifically, we explored perceived roles of men and specific services that men may access within PMTCT services. The findings from this study will feed into the PMTCT services as a way including men in the services. Additionally, the identified roles and services if incorporated in policy will serve as a benchmark for assessing MI in PMTCT initiatives in the country This study was guided by the theory of reasoned action (TRA) which was developed by Fishbein et al, (1960) [20]. TRA was developed in order to appreciate the association between attitude and behavior and explains the relationship between beliefs,attitudes, intentionsand behaviour. the tenets from this theory informed some of the questions that were included in the interview guides used in the study.

Study design
A descriptive qualitative study following a phenomenological approach was conducted at two primary level health centres in the southern part of Malawi, from January to March 2018. We used In-depth interviews because they offer more time for a detailed and nuanced exploration of a phenomenon which facilitates understanding of complex issues and enable researchers to get an insight into the socio-cultural context of the participants [21,22]. The interviews allowed us to gain insights from the people who are more knowledgeable about the topic in order to understand how certain things work21].

Setting of the study
Health facility A is located to the north while Health facility B is to the South-east of the District Hospital, both are Government owned facilities and are rural health centres. Health centre A serves communities with different educational background with a number of men employed in small companies unlike Health Centre B where most men solely depend on working in farms and some informal employment. Male involvement at Health centre A health centre is voluntary while at health centre B is reinforced through the by-laws enacted by traditional leaders and the health care workers.
Both sites offer the following services: outpatient services, low risk ANC and deliveries; ART and PMTCT services; under five clinics; drug dispensing and have a referral systems to the district hospital. At Health Centre A, initial booking for ANC is done every Mondays while subsequent visits are done every Wednesdays and Fridays while at Health centre B, initial visit is done every Tuesdays, while subsequent visits are conducted on Wednesday and Thursday. There are 18 and 14 health care workers at Health centre A and Health centre B respectively.

Sample size
We conducted a total of 21 in depth interviews (IDI) among men, health care workers and Village headmen. Baker argues that qualitative samples are usually small and that by the sixth interview, one should reach 70% saturation and by the twelfth interview the information reaches 92% saturation [23]. Of the 9 men included in the study, 6 were involved in PMTCT and 3 men were not involved in PMTCT services. We also interviewed 8 health care workers and 4 village headmen. Of the men we approached, five refused participation fearing that health care workers would follow them for lack of participation in PMTCT services.

Selection of Study participants
We drew apurposive sample because it allowed us to include participants with rich information on the issue that was being investigated [21]. Men who were involved in PMTCT were approached at antenatal and under-five clinics where they had accompanied their wives to access the PMTCT services. Men who were not involved in PMTCT were approached in their respective homes with the assistance of community health care workers. We included men whose partners were either pregnant or breastfeeding babies of up to 24 months of age regardless of HIV serostatus, 18 years old and above, and with an expressed willingness to participate in the study Traditional leaders were approached in their respective homes with the assistance of community health care workers. Traditional leaders were only recruited into the study if they had been in their positions for at least six months regardless of gender, 18 years old and above, willing to participate in the study. Health care workers were approached at their respective work places, with the assistance of the in-charge officers of each health centre and were specifically selected because of their active involvement in providing PMTCT services. These included 2 Nurse midwife technicians, 2 medical assistants, PMTCT coordinator for the district, 2 Health Surveillance Assistants (HSAs) and 1 HIV Diagnostic Assistant (HDAs.) Health care workers were only recruited into the study if they had worked at their respective health facilities for not less than six months,18 years old and above, and were willing to participate in the study. All participants were approached during their free time to avoid disrupting their work schedules.

Data collection
We collected data using face-to-face interviews using tools that were translated into a local language.
We used a digital audio recorder to capture all the interviews. The tools were piloted at Health Centre C within the District. The broad questions that guided the interviews were:

1.
Would you please describe the roles of male partners in PMTCT services?

2.
Would you please describe the services that are required by men in PMTCT services?
After each broad question we probed further to achieve a deeper understanding of the different opinions about the expectations of male partners in PMTCT services [21]. English. Direct quotes from the transcribed and translated data from the audio-recorded interviews are also used to clarify the responses from the participants and was captured to ascertain validity of the data [24]. Member checking was employed to ensure that the correct data was captured [25].
This was done by restating or summarizing information provided by the participant to agree on what had been discussed in the interview to ensure credibility of the findings and this was done immediately after the interview. Field notes about the characteristics of the study sites, other interesting beliefs and experiences of being in the field were collected. Since the research was part of a Master's program, the Principal Investigator and the Investigator, listened and discussed the audios at different intervals of data collection to ensure that the study achieves its objectives. Only the researcher and participant were attended the data collection session.

Data analysis
We employed a manual thematic analysis [26]. One transcript was initially coded by the two authors as a measure of ascertaining the coding framework. We manually color coded the transcripts whereby similar codes were categorized and were later rearranged into themes. The researcher read the transcribed data multiple times to have a good grasp of the depth and breadth of the data while noting ideas of interest, checking the transcripts back against the original audio recordings for accuracy [26]. Codes were inductively and deductively derived by identifying recurrent ideas as the data manifested and from the theory and objectives of the study respectively. Codes that had the same color from the manual coloring method employed were grouped together to generate an overarching theme. Different codes were sorted into potential themes and the data extracts were put within the identified themes. This involved organizing all similar coded data extracts into categories.
The themes that were realized were reviewed while paying attention to the emerging issues and any un-coded data was added at this stage bearing in mind that coding is a continual process. The process of coding was constantly discussed with the other Investigator to gain clarity and consensus [26]. We combined all themes that seemed to be related or alluding to the same idea and later named the themes influenced by the data under it.

Socio-demographic characteristics of the participants Demographic Characteristics of Male participants
The age of the men ranged from 21 to 46 years; seven were married, seven were Christians, seven were unemployed, four had some primary education and two had secondary school education.

Demographic Characteristics of Health care workers
There were eight health care workers aged 29 to 65 years, five were female, four were nurses, one medical assistant, one HIV diagnostic assistant and the PMTCT coordinator.

Demographic Characteristics of Village Headmen
These were four village head men, two from each of the study sites. They were all menwith age range of 49-70 years old. Two had attended primary school education and two never attended any formal education but were able to read and write.

Roles of male partners in PMTCT services
The roles that men play in PMTCT services were categorized into: Supportive, HIV Prevention Behavior and Decision-making Roles (Table 1).

1.Supportive Roles
Participants stated that the role of the man in PMTCT services is to provide support and the support varied as follows:

a.Economic support
Men are expected to financially provide for their families irrespective of a wife being pregnant or not and are expected to ensure that the family has food. When a wife or partner is pregnant then men are to provide for all necessary materials in preparation of the pregnancy and delivery. "We tell men to take their babies when they fall sick and most of them do that in this community.
They are motivated because they do not wait for long hours, they are assisted early, so because of that men in this community play that role as well." (Village headman 4) Furthermore, participants expected men to offer companionship which is expressed by assisting a wife with household chores. This is illustrated in the quote below: "I don't know if men do assist but they can help the pregnant mother to wash the clothes when the pregnancy has reached term or even cooking. This has an advantage because it gives time to rest and when the mother has given birth, it helps her to have more time to breast feed her baby exclusively." (Health worker5) Male partners have a role of reminding their wives to attend antenatal care/PMTCT visits however the men who are not involved in PMTCT and the village headmen at both sites remained silent on this issue.
Health care workers and male partners described another aspect of reminders like reminding a woman on activities around PMTCT such as taking of ARV drugs and taking the baby for early infant diagnosis of HIV services and receipt of cotrimoxazole because they believe that on their own women tend to forget appointment dates "………the husband has to remind the wife, right. When it is time to take drugs, she may be hesitant, he has to make sure that his wife is taking drugs." (Health Worker 5) "… so, it is the role of the father to remind mother to take the child at for this procedure (Early Infant

Diagnosis of HIV services) in time." (Health Worker 4)
"You know women very well, they tend to forget things easily, they are fond of making mistakes. Like for my wife if I don't keep the date of her next appointment, I tell you here, she will not go and surely, she will miss that visit I tell you' how then will we know that our baby is growing well?" (Man 6, involved in PMTCT)

2.HIV Prevention Behavior Roles
In the context of PMTCT, men are expected to take up HIV prevention strategies to ensure that their families are protected. These roles include behavioral practices such as faithfulness to one's partner and using condoms in the presence of HIV Infection.

a. Faithfulness to One's Partner
Men are to remain faithful to their wives whether the woman is not pregnant, or pregnant and is breastfeeding and whether the family is HIV positive or not, the role of the man is to be faithful to

b. Initiation of condom use
Health care workers emphatically specified initiation of condom use by men as a critical role for men to avoid infection especially when a couple is HIV infected.
"So, the man has a responsibility to initiate the use of the condoms in the family when the family is HIV positive, be it during the time the wife is not pregnant, or is pregnant or is breastfeeding." (Health worker 8)

Decision making roles
Men are key in deciding on uptake of health services as follows. Participants specified various time points within PMTCT services where men make decisions. Health care workers asserted that men have to decide on the infant feeding practices a couple would follow since they provide financially for the family.
"The other role of the father is to help the mother decide on the feeding choice of her baby and decide on when she can stop breastfeeding to avoid contracting the virus." (Health worker 2)

B. Male specific services required in PMTCT programme
The specific services men require are classified under two broader themes and these are: Health Assessment and Health Promotion Services. The participants further outlined how the services can be organized and delivered at both the health facility and community level ( Table 2)

Theme 1: Health Assessment Services
The health assessment services men expected from a PMTCT service were Physical Assessment and Medical Consultation services.

a. Physical Assessments Services
Male partners and health care workers at both sites suggested that men should have targeted health care services. Such services include: checking blood pressure, body weight and blood sugar.

b. Medical Consultation Services
Health care workers reported that men expect to be attended to and be given health advice as appropriate.
"They expect to be asked if they are doing fine and given time to explain their problems that they may have. When men come at the antenatal clinic, they become our clients and we need to listen to their complaints and attend to them and refer if need arises. We always have clinicians whom we work with, those ones should also be consulted." (Health worker 2) However, some men who are both involved and not involved in PMTCT services had different opinions from other participants and emphasized that they do not require services that would benefit them directly. They insisted that they are just escorting their wives and that it is time consuming for the healthcare workers to provide some services to the men.

Delivery of Health Assessment Services
Participants further explained how the services they require could be organized and delivered at the Health Facility and Community.

Delivery of Health Assessment Services at a Health Facility
Men asserted that they expect the services and staff to be male friendly.

Delivery of Health Assessment Services at a Community Level a. Integration in other activities within a Community
Another way of providing services that was recommended by some men who are involved in PMTCT and health care workers is integrating PMTCT services in other activities, such as in sports because most men enjoy and patronize soccer events. Men who are involved in PMTCT services suggested that the information should be staggered in phases unlike the current practice where participants are loaded with information on one visit.

"I expect a healthy baby, being born without HIV. But our concern is that the information is given just once when we come for the first visit, the information is not repeated when we return and we wonder
if we are doing the right things that the health care workers expect us to do, for us to have a child who is not HIV infected." (Man 2, involved in PMTCT) Another health care worker shared the consequences of the current practice in sharing information with men: "If we only counsel them once they will not remember for the whole nine months, until the 24th month." (Health worker 2) The healthcare workers at both sites asserted that sharing expectations with the male partners can bring behavior change among men, because they would know what is expected of them within PMTCT services. The quote below illustrates this: "If we just leave them without telling them our expectations, they behave ignorantly and they don't like it because they feel out of place." (Health worker 6)

Delivery of Health Promotion Services at a Health Facility a. Audio and visual Messages
The health care workers and men who are involved in PMTCT at both sites suggested sharing information using leaflets, brochures or charts so that men could be reading when they are at the waiting area in the antenatal clinic. Additionally, men and health care workers recommended sharing of information on PMTCT services through television or a radio that are located within a health facility. This approach was deemed inclusive because it would cater for men that cannot read on their own.
"… If there is a radio or television, I see others like at the district hospital in children's ward there is a radio or television. When they wait to be attended to, they could be watching or listening that, then they will be enticed, for those who can read then we can make some charts so they can read, as they wait to be assisted." (Health worker 2) b

. Health Education Sessions in all areas men patronize at a health facility
Giving health talks about the PMTCT services in areas where most men patronize, such as at Antiretroviral clinics and Outpatient Department is another way of delivering health promotional services. This approach was suggested by health care workers who noted that in most cases PMTCT education services are offered at the antenatal or under-five clinics where only a few men are inattendance.
"In every opportunity that we have to meet men, at the hospital we should be able to give them the information. We can also find a way of spreading information about PMTCT, through OPD or ART. We tend to meet a lot of men in these areas at this hospital." (Health worker 7)

Delivery of Health Promotion Services at a Community Level a. Creation of peer support groups
Village headmen and men involved in PMTCT services recommended creation of peer support groups as a mechanism for peer-education to fellow men on PMTCT services in the villages. The participants stated that peer-education is effective in relaying information to others.
"People love to learn from the people that they know, so if we agree to train some few men about PMTCT services so that they can be trained and trained individuals … they will help the chief in advocating for this in the villages with other men. Then they will be helping the village headmen, I think this will be good if added." (Village headman 2)

b. Stakeholders' mapping and collaboration
Another form of sharing of information suggested was through collaboration with the community leaders such as traditional leaders, influential institutions such as religious leaders, family clan and employers to facilitate sensitization in community gatherings with the village headmen and existing community healthcare workers. This approach was suggested because cultural beliefs regarding pregnancy, child caring and roles of men towards the care of pregnancy are the ones hindering men from participating in PMTCT services hence the need to work with opinion leaders and key people within a community.

Discussion
The findings of this study show that male partners have specific roles they render and expectations from PMTCT services. The roles of men in PMTCT services are supportive, HIV prevention behavior change and decision-making roles. Men expect health assessment and promotion services from PMTCT programme. The services expected are to be provided at facility and community levels. The services should be provided in an atmosphere that allows and accepts male partners to exercise their roles in PMTCT programme.

Roles of men in PMTCT Services
The supportive roles of men in PMTCT services from our study are similar to findings that earlier studies reported on the main role of men as financial providers for their family [27][28][29][30] During couple antenatal education, some of the issues considered are roles of men during perinatal period and birth preparedness which help couples to be well equipped with the requirements during the peri and postnatal period [31]. Our findings on the role of men as financial providers are contrary to what was reported earlier in Malawi where men reported that their willingness to participate in PMTCT services was impeded by their role to support their wives financially [1]. This means that there is lack of clear description of the roles of men in the services [13]. In our study men the role of men was limited to financial provision while in other studies it encompassed physical presence of a man at the clinic where PMTCT services are delivered and attending to clinic appointments and all health related issues [1,32]. The observed difference in the roles of men arises from the way men perceive and describe their role in different contexts [5]. The varying clarity on definitions and roles necessitates a deliberate effort to specify in the PMTCT guidelines on the roles of men to promote understanding across the stakeholders in PMTCT services.
Our findings on the role of men in caring for their partners from pregnancy, delivery and post-delivery resonates with a South African study that regarded accompanying partners to the antenatal clinic as a form of spousal support [5]. Although men in Malawi accompany their spouses to the antenatal clinic they usually wait outside the clinic rooms while their partner accesses services [32]. As it was reported earlier by Nkuoh et al [29], the men in our study advocated for couples attendance to PMTCT services because that enhances their understanding and uptake of the health related aspects during pregnancy. Additionally, our findings on rendering social support, remain consistent with another study that reported that by accompanying a wife, a man would encourage and support the woman during the stress and discomfort of pregnancy [33]. We suggest that men be included in all the health services activities that a woman undertakes to promote full participation [32].
Despite the positive attitudes towards the roles of men expressed in this study, cultural factors are a hindrance to the execution of the roles. Culture relegates maternal and child caring aspects to women which remains consistent with findings by Adelekan (2014) who reported that men were unwilling to participate in PMTCT because it was culturally inappropriate [34]. Although assistance with household chores was highlighted in our study and in a previous study [5], the division of roles according to gender, prohibits men from assisting a pregnant or a nursing mother, because of the prevailing norm that household chores are for women [5]. Going forward in developing guidelines for roles of men in PMTCT, it will require involvement of custodians of culture to ensure that the guidelines are culturally appropriate.
The role of men in reminding a woman on clinic activities and HIV prevention service highlighted in our study, is consistent with what was reported by earlier studies [16,35]. We therefore argue that male involvement in providing health related support falls within the pathway of achieving HIV viral load suppression among women and protection of children from contracting the virus and will impact positively on the UNAIDS 90: 90: 90 goal which Malawi adopted [36]. Furthermore, the role of men in leading in uptake of HIV prevention practices from our study supports findings from a study done by Larsson (2010) who reported that mistrust in marriage is due to lack of faithfulness between partners [27]. Focusing on HIV prevention as a role of male partners in PMTCT services would encourage adoption of desirable behaviours among men [37,38].
Men are key decision makers in a family and society [7,30,39]. Specifically, in this study, men make decisions concerning attendance in PMTCT services and couple HIV testing, place and mode of labour and delivery, and infant feeding choices. Similarly, other studies have reported that involvement of father postnatally has led to a longer breastfeeding duration [2,40]. Osoti et al. (2014) argued that when men make decisions on health related care for the mother and baby, it yields positive outcomes such as giving birth under a skilled health worker, practicing exclusive breastfeeding, uptake of effective contraceptives, and infant immunizations [41,42].

Services men require in PMTCT services
The need for physical assessments and medical consultation services as suggested in this study are similar to what a Ugandan study referred to as a male health package [17] while in South Africa they were termed as free male health checkups [43]. The specific assessment reported in this study like; blood pressure, blood sugar, body weight, health education and consultation services; differed from what was recommended in Uganda as part of the male health package. In Uganda they specified deworming and offering couples first priority during ANC [17]. Deworming might not have been mentioned in our study because of lack of knowledge of the services that might benefit them and because the Malawian health system emphasizes deworming among children and antenatal women only44]. The Malawian health system has been heavily criticized for only focusing more on women and children and leaving out men which is a disservice to men [45]. Notably men are underserved because the major partners in health services are women and children and are more knowledgeable than men [45,46]. The requested services by men may be assigned to other support staff trained with the required skills to avoid overburdening the midwives. WHO (2010) recommended task shifting in order to overcome shortages of staff in hospitals [47]. Provision of such services will be in line with the Malawi Ministry of Health's (MOH) vision statement which advocates for health for all regardless of gender, race, age, disability and residing place [48].
The delivery of health assessments services could be at health facility and community levels. The specific changes to be made within a health system like stopping singing songs and clapping hands, providing couple specific structural services, providing privacy and confidentiality in service provision rooms and providing personalized and integrated services to the couple were reiterated by Nyondo et al (2014) [15]. Other studies considered making health facilities male friendly by reducing long waiting time or introducing weekend or evening services for couples [10, 13,49]. This study did not find similar sentiments and this may be due to the different settings, the previous study was done in urban areas while this study was done in rural areas where most men are not employed and may easily avail themselves during week days for clinic appointments.
Delineating a specific area for couples to access health service as reported in our study confirms what a Sub Saharan Africa systematic review a [30] and other studies that revealed that organizing specific clinics for pregnant couples would be effective ways to increase male involvement in PMTCT activities [10]. Similarly, it was noted that a lack of space to accommodate couples in consultation rooms was a barrier to MI because it made men feel uneasy when seated next to women they do not know [16,30,50]. Belato et al. (2017) advocated for separate waiting areas for men and women visiting maternal and child health clinics [51]. The current health systems of Malawi face a challenge of lack of adequate space to accommodate men in PMTCT service [13]. This suggests that there may be need to engage other partners who may help in renovating the current health facilities and create enough space that would accommodate men in PMTCT services. This finding requires careful consideration because it may discriminate women without partners or are in unstable relationships [41]. Related to space was the need for privacy which has been reported in earlier studies [13,14].
Although our study did not report what other studies highlighted that there should be a different exit for male and female partners after HIV testing to avoid being identified by other health facility users [51], our study highlighted that HIV testing rooms should be behind other service rooms so that the areas should not be crowded and albeit preserve privacy.
At community level, services can be integrated with events where most men patronize like soccer.
This approach which is builds upon community based strategies ensures that influential and men learn about their roles from health care workers in environments of comfort [14]. This approach would encourage community members to understand the new concepts which would promote behaviour change.A community's supportive attitudes towards PMTCT services will give a symbol about a changed cultural environment that permits and expects male partners to be involved in PMTCT services [14].
Men want to be taught on PMTCT services. Delivering sessions on PMTCT services as men suggested for in our study will require overcoming some barriers that may impede provision of education services, accessing the information and bringing the information to the required people [52]. At health facility level, the health promotion service messages can be delivered through audio visual aid and provision of health education sessions in all areas men patronise such as outpatient department (OPD) or ART clinics. Similarly, earlier studies in Malawi stated that there is need for health information sharing and male education about the importance of ANC and PMTCT [10,13] and IEC has a key role in promoting MI in PMTCT [15,53]. There is an association between exposure to media and uptake of HIV testing; more women and men who watched TV and women who read newspapers and listened to the radio daily took and HIV test than their counterparts who did not [53]. Information, education and communication is vital in understanding issues and has proved to improve attitudes of people on services [3,54].Provision of leaflets will not be a new thing in the health system because with voluntary medical male circumcision (VMMC) they provide leaflets or brochures that contains all the information a person might need [55]. leaders were lobbied to strengthen the capacity of those giving messages in the communities [14].
Equally, the study revealed that there is a need to collaborate with family members through the their clan to promote male participation in PMTCT. Similar suggestions were reported by Besada et al.
(2010) whereby the community members instilled powers to the people who were working in communities to sensitize the family on PMTCT with potential of the message trickling toward their family members [14]. In Uganda, the collaboration of village elders and community leaders in the elimination of mother-to-child transmission (eMTCT) of HIV was expressed as fundamental in introducing a shift in the attitude of community members towards the role of men in ANC and eMTCT [17].
Creation of peer support groups in villages can facilitate male participation in PMTCT services. Similar findings were also reported in other studies [13,14,27]. Male peer approach would be culturally appropriate for men to get information from their fellow men other than women [13]. This study did not find other support groups that have been advocated in PMTCT like expert clients are in general HIV care [57]. This is so because the focus of expert clients is for people who are living positively, while this study would want to reach all men regardless of their HIV status.

Strengths and Limitations
The study has presented the opinions and perceptions of health care workers, men and traditional leaders, which means that it provides a holistic approach to MI, however this study excluded the voice of women who are an important party in MI in PMTCT. Although some men refused to participate in the study, we searched for more men to ensure that we have a purposive sample of what we studied.
The sampling technique and study design employed does not allow for generalizations.

Conclusions
Male partners in PMTCT have expectations that need to be at both health facility and community levels. Male partners play supportive roles, health behaviour roles for HIV prevention and decisionmaking roles in PMTCT. Health assessment services and health promotion activities are the major male specific services required in PMTCT. Strengthening awareness services at both health facility and in communities is more desirable. Additionally, stipulating the roles of men in PMTCT in necessary documents would guide the health care workers in knowledge and practice which will help them to meet the needs of male partners in PMTCT services. Further studies should focus on delivering a male-tailored package of interventions within PMTCT services.
participants who were approached. The Principal Investigator read the consent form to all participants that could not read nor write in the presence of an impartial witness and participants thumb-printed on the consent form. Literate participants gave a written consent after reading the consent form.
Privacy and confidentiality were maintained by conducting interviews at a private place with assignment of identification numbers instead their real names. We conducted our in-depth interviews in Chichewa to prevent language barriers. Interviews with health care workers were conducted in both Chichewa and English depending on health care workers' preference. All data were kept in a password protected computer and consent forms were kept in a locked cabinet.

Consent for publication
This was obtained as part of informed consent