The Joint United Nations Programme on HIV/AIDS (UNAIDS) states that approximately 1.3 million Zimbabweans are living with human immunodeficiency virus (HIV), with about 31 000 new infections per year (UNAIDS 2020). The Zimbabwean National AIDS Council (ZNAC) report (2017) confirms De Walque’s (2007) point that HIV serodiscordancy (a mixed HIV status where one partner tests seropositive and the other tests seronegative) among heterosexual people in stable unions is generally high in sub-Saharan Africa (SSA). On average, serodiscordant couples were responsible for about 30% of the new HIV infections in SSA in 2012 (Chemaitelly et al. 2013, 2014).

Given the high rate of serodiscordancy and as a means for the prevention of mother-to-child transmission (PMTCT) of HIV, couple HIV counselling and testing (CHCT) is deemed to be a crucial intervention to prevent HIV from mother-to-child transmissions (Bwambale et al. 2008; Hughes et al. 2020; Sibanda et al. 2017). Zimbabwe, like many other countries, provides a CHCT service to two people who are, or who intend to be, in a sexual relationship (Nakiire et al. 2020). A primary benefit attached to CHCT is that it encourages couples to test together and facilitates disclosure of their HIV test results (Thirumurthy et al. 2016). In addition, they can jointly make informed decisions regarding HIV prevention and their reproductive health (World Health Organization [WHO] 2012). Various studies also acknowledge that couple counselling and testing is an opportunity for a couple to learn their status together, and it promotes safer sexual behaviour (Bhushan et al. 2019; Crankshaw et al. 2014; Njau et al. 2012).

In the context of the PMTCT of HIV, these services are provided to couples so as to facilitate collective efforts towards ensuring that their child is prevented from being infected with HIV. One of the primary advantages of CHCT is that after obtaining, for example, a positive test result, they will immediately be provided services for HIV treatment, care and support, which are all directed towards the PMTCT of HIV (Lolekha et al. 2014; WHO 2012). Another positive consequence of HIV couple counselling and testing is that it serves as an effective means of social support, especially for pregnant women who have been diagnosed as HIV positive (Bhushan et al. 2019; Maman, Van Rooyen & Groves 2014).

In order to increase the uptake and utilisation of CHCT services, many countries introduced various measures such as motivating male partners by including them with verbal or written invitations (Rosenberg et al. 2015; Theuring et al. 2016). Using similar methods of invitation, South Africa has within the past 5 years documented progress with increasing rates of couples who received HIV counselling and testing by its various stakeholders (Davey & Wall 2017). In a pilot study conducted between May and June 2017 which aimed at improving case finding and antiretroviral therapy initiation, approximately 63% of the people who tested were couples (Davey & Wall 2017). In other African settings, promotional strategies such as door-to-door outreaches by community workers, the use of incentives and extended weekend CHCT services in antenatal clinics were useful in increasing the number of couples testing for HIV (Kululanga, Sundby & Chirwa 2011; Theuring et al. 2016).

However, despite the efforts made towards increasing the rates of CHCT, its uptake is still suboptimal in many sub-Saharan countries (Hailemariam et al. 2020; Rosenberg et al. 2015; Sibanda et al. 2017). Reasons for the uptake hesitancy include the fear of stigmatisation, the fear of divorce or rejection by partners, intimate partner violence and the fear of accusations of infidelity (McMahon et al. 2017; Njau et al. 2012).

In addition to the slow uptake, a number of studies conducted in various African countries found that very few couples sought HIV testing together (Crankshaw et al. 2014; Kelley et al. 2011; Makoni et al. 2016). The majority of studies also indicated that the proportion of pregnant women who test alone is phenomenally higher than those who test with partners (Hailemariam et al. 2020; Krakowiak et al. 2016). Research clearly showed that women prefer to test without partners because of gender-based violence, abandonment and abuse if the HIV result is positive (McMahon et al. 2017; Njau et al. 2012). A systematic review and meta-analysis study on CHCT among heterosexual partners in SSA revealed that because of the fear of possible adverse effects resulting from CHCT, individual women in a dyad preferred to test alone before they made the decision to test together with their partner (Hailemariam et al. 2020).

The slow uptake of CHCT can also be attributed to various factors that specifically affect male partners. One of the factors is male partners’ hesitance to take part in CHCT within antenatal and postnatal care settings, because the health care services focus mainly on maternal and child health, and it is thus viewed as a female domain (Boniphace et al. 2021; Ramirez-Ferrero & Lusti-Narasimhan 2012). Other factors that influence men’s utilisation of the couple counselling and testing services that are offered within the PMTCT of HIV programmes in particular are usually linked to social constructions of gender which define pregnancy and childcare as ‘women’s’ work (Boniphace et al. 2021; Wamoyi et al. 2017).

Like many other countries in SSA, Zimbabwe is among the worst affected by HIV and AIDS, with approximately 84 000 children between 0 and 14 years living with HIV (UNAIDS 2020). However, PMTCT of HIV is one of the strongest programmes responding to HIV in the country, with about 875 sites since 2002 (Musarandega et al. 2020). In an effort to eliminate mother-to-child transmission of HIV, the country adopted the recommendations of the WHO to guide the implementation of HIV programmes. The aim of the guidelines is to facilitate the uptake of HIV counselling and testing services and to enable the provision of antiretroviral therapy among serodiscordant couples (WHO 2012). However, evidence shows that the uptake of couple HIV counselling is generally low as compared to individual testing (Dube et al. 2017), particularly in rural areas (Sibanda et al. 2017).

Given that the uptake of CHCT is low in rural Zimbabwe, the current study sought to explore the voices of adult men and women from a rural district of Zimbabwe on their views regarding the feasibility of CHCT and to identify the possible challenges that are associated with the practice for the PMTCT of HIV.

The study was guided by the gender and development (GAD) theory. In describing the characteristics of the gender and development theory, Parpart, Connelly and Barriteau (2000) stated that:

The gender and development theory takes into consideration the historical social constructions of gender which prescribed men as superior to women (Moser 1993). The aim of the gender and development theory is to rise above the limitations of the previous developmental programmes such as the Women in Development (WID) programme, in which women were integrated into development without any fundamental changes to gender inequalities (Asante 2000). The gender and development theory seeks to ensure that holistic equality between men and women is realised and that gender inequalities are addressed. In support of this approach, Tolhurst et al. (2012) also suggest that gender mainstreaming in heath programmes must ensure that hegemonic masculinities be addressed in a way that benefits men and women equally. The main strength of the gender and development theory is that it takes a transformative approach in reserving gender equality by promoting positive masculinities. This entails engaging men and boys in programmes that advocate positive behaviour change so as to promote women’s economic empowerment and reduce gender-based violence (Bapolisi et al. 2020). The same approach is supported strongly by Ratele, whose work aims to advance gender equality and contribute to the construction of progressive masculinities (Ratele 2014, 2015). Applied to this study, the gender and development theory facilitates the unpacking of the gender relations and roles between men and women, and specifically how these influence the utilisation of HIV counselling and testing by women and men.

This study was conducted using qualitative research methods and a phenomenological design. The rationale for opting for a phenomenological design was that it sought to understand the subject under investigation from the lived experiences of the participants (Creswell & Poth 2016). The use of the phenomenological approach enabled the study participants to describe, narrate and explain their views and experiences pertaining to CHCT as lived by them.

In order to gather the views and experiences on the subject, the study used focus group discussions (FGDs) and in-depth interviews (IDIs) as the sources of data. The rationale for using FGDs was that they facilitated the production of data from a group of individuals who had homogenous characteristics or demographics (Kitzinger 1995). In qualitative research, FGDs are a method of data collection that focuses on the discussing and exchanging of ideas, views, feelings and experiences with the study participants on the research subject (Kitzinger 1995; Muijeen, Kongvattananon & Somprasert 2020). On the other hand, the IDIs enabled an exploration of the personal experiences and perceptions of CHCT for PMTCT of HIV by individual women. According to Boyce and Neale (2006), IDIs can be used when a researcher wants to distinguish individual opinions from those of the group about a specific topic.

The study was restricted to the Gokwe North district in the Midlands province of Zimbabwe. According to Gender Links (GL 2019), the population of the district was approximately 244 976 by 2019. The district is located in the remote rural areas and is governed by traditional chiefs and village headmen who oversee the management of the various villages and clusters within the district. Subsistence farming is the main source of livelihood.

Participants were selected using a nonprobability purposive sampling technique. For the IDIs, participants were drawn from the two main hospitals in the district, as they had large numbers of women admitted for antenatal and postnatal care. These participants were considered because they were assumed to have had direct experiences with their partners in terms of HIV counselling and testing. With regard to recruitment of the participants, the researcher approached the management of the hospitals, who subsequently instructed the nurses in charge of the maternity wards to facilitate the recruitment processes. The nurses in charge facilitated by organising meetings with women who had no ailments, so as to explain the overall purpose of the study and to request their participation. Individual women who consented to take part in the study met with the researcher and scheduled the time and date they could avail themselves for their interviews. A total of eight women were interviewed, whose ages were between 18 and 38 years.

Similarly, participants for the FGDs were also selected using purposive sampling but with the aid of the chain referral technique. Participants for the FGDs were men and women reached through key organisations that existed in the district. These included churches, humanitarian organisations, health care centres and those belonging to community projects. The leaders of the various groups were the entry points who facilitated participation by identifying and inviting potential participants from their respective groups. The participants had to have been residents of the district for at least a year. The understanding was that after staying in the district for a period of a year, any new resident would have been familiar with the lifestyle, community norms and practices. A total of eight FGDs were conducted. Of these, two consisted only of men, two had women only, while the other four had a combination of both men and women. The age range of the participants was between 18 and 72 years.

Interviews and participant observations were used for collecting the data. Separate semistructured interview guides punctuated with probes were used for the FGDs and IDIs. The IDIs were conducted by the principal investigator, while the FGDs were moderated by a trained research assistant. Focus group discussions took about 90 min to complete, while the IDIs lasted for a minimum of 45 min to about an hour on average. Interviews were audio recorded, and notes were captured so as to document significant observations. Participants were provided an option to choose their preferred language as the medium of communication. Most of the participants chose to use the ChiShona language, while a few professionals preferred to use English. However, some of the participants in the FGDs switched between the English and ChiShona languages. The audio recordings were transcribed and subsequently translated into English.

The data were analysed using thematic analysis, which involved thorough reading of the transcripts and notes so as to facilitate familiarisation with the data. NVivo software was used to identify and arrange the themes that emerged from the transcripts. All quotes or statements were organised into their respective categories or subthemes by combining the quotes that had a common meaning. In order to ensure that no information was lost, original quotes were extracted from the interviews and were used for illustrations in the presentation of the findings.

Participants in the study generally agreed that HIV couple counselling could be a challenging practice because of the patriarchal tendencies that were evident in men’s sexual behaviour as they brought HIV into their marriages and relationships. In addition, social constructions around gender roles in childcare influenced men’s decisions to partake in CHCT in the PMTCT settings. Some of the religious sectors enforced doctrines that forbade the use of any medical or traditional approaches to healing; this made CHCT practices impossible in these sectors. Also, the practice of CHCT was found complex in situations where pregnancy resulted from extramarital unions. However, some of the approaches to increase the uptake of CHCT included the running of men’s forums in organisations that engaged with men and the wide dissemination of information surrounding CHCT.

Patriarchal behaviour, which traditionally makes it appropriate for men to have multiple sexual partners as well as unprotected sex outside marriages or relationships, negatively impacts the success of CHCT interventions. Such patriarchal behaviour and beliefs which consider and expect men to be ‘sexually competent’ put the couples at risk of HIV as the men engage in sex with multiple partners. The results in this study portrayed most of the female participants blaming men for bringing HIV infection between couples. It appeared that most women participants thought that their partners were not faithful to them and were involved in extramarital affairs which subsequently exposed them to HIV. The following quotes displayed the views from some participants that put the blame of HIV infection on men:

The results revealed that CHCT was highly stigmatised, based on two views. Firstly, men who were seen to be taking part in PMTCT programmes, including in HIV testing, were described as ignorant of their roles as men according to what was prescribed by culture and tradition. The study found that CHCT was a practice commonly known to happen among couples who wanted to have a child or those who were pregnant. The aim of couples testing for HIV together was to receive health care services for the PMTCT of HIV. Participants, however, argued that men’s participation in antenatal care seemed to be unusual and improper, because the gender roles they were accustomed to defined women as the ones responsible for children’s care and welfare. This view was shared across various FGDs and IDIs:

Secondly, people who were living with HIV were stigmatised for having been ‘promiscuous’. Hence, couples who received CHCT were most likely to be labelled as HIV positive. Mary, a participant from the IDI, stated that, ‘They will query why we are going together to the clinic and will conclude that we are HIV positive’ (IDI, 19 years of age). Other participants concurred with the same view, as demonstrated by the following quotes:

Certain religious groups and denominations do not allow the use of medicine for healing or for any other health-related matters. Their belief is in the use of faith-based artefacts which are deemed to be solemn and have healing powers vested in them. In the context of HIV or any other life-threatening diseases, members of these church groups are prohibited from visiting health care facilities and seeking medical attention. Results from the FGDs and individual interviews showed that in these churches and communities, the goals of CHCT would not be achieved given that the church members belonging to such groups did not visit health care facilities for health care support. The following quote illustrates this view:

In another FGD, a similar view was highlighted, showing that CHCT could generally be a difficult practice. The participants pointed to the need for action to be taken towards transforming the churches’ understanding regarding medicine and interventions for HIV prevention and care. One of the participants illustrated this view:

In addition, it was impossible to conduct any interviews or FGDs among members of one of the religions that did not believe in the use of any form of medicine. In a consultation with the leaders of the sector, it was learnt that any engagement which was linked to medicine and traditional or modern health care practices was an interference with their religious norms. As a result, collection of data among this group was not successful.

The study found that CHCT was central to preventing and eliminating mother-to-child transmission (MTCT) of HIV. However, participants indicated that this practice was not always feasible in a situation where a pregnancy occurred as a result of an extramarital affair because of the societal morals and values attached to marriages, as illustrated in the following quotes:

These results showed that CHCT would not be applicable to all situations; hence, health care providers needed to be sensitive when dealing with matters of marital unions.

The study participants identified possible ways in which couples could be encouraged to participate in HIV counselling and testing. These results showed that there was room to motivate for, sensitise and encourage communities to support HIV testing for couples. One of the means that participants discussed was sharing of their experiences so as to empower other couples who were facing HIV challenges. Some of the following quotations extracted from different FGDs and IDIs expressed these views:

The use of mass media in sharing experiences meant that this information was not only going to benefit the community where the research was conducted but was also expected to benefit the country, because this was to be broadcasted on television and radio stations:

Other than the use of mass media, participants suggest that organisations that engaged with men in various community projects could facilitate the uptake by reaching out to men and sensitising them about HIV matters, which included CHCT. The quote below expressed this view:

Organisations that provided male-oriented services and programmes could therefore play a vital role in communities by engaging, educating and sensitising men on the need of HIV prevention services, including their role in CHCT for protecting themselves, their partners and their children against HIV.

The study aimed at exploring the prospects of CHCT in the Gokwe North rural district in Zimbabwe. Results showed that communities understood the value and benefits that came with CHCT, namely PMTCT of HIV, regardless of the challenges leading to its full realisation. The study participants recommended specific measures in support of the idea of CHCT through mass-media campaigns and engagement with organisations that conducted men’s forums. However, challenges that were found to be a hindrance to CHCT included patriarchal practices that put couples at risk of HIV infection, HIV-related stigma, religion and extramarital affairs.

Stigmatisation of HIV in general and especially against those living with HIV was identified as a great cause of concern amid the developments made in terms of services such as antiretroviral therapy and care for people infected with HIV. In this study, anticipated community HIV stigma was a demotivating factor in CHCT, thereby leading to adverse health outcomes for individuals that could benefit from such interventions. These findings concurred with studies conducted in the past pertaining to the impacts of HIV-related stigma (Helms et al. 2017; Turan et al. 2016; Zhang et al. 2020). For people living with HIV, some impacts included low antiretroviral adherence, depression and poor health (Sweeney & Vanable 2016; Turan et al. 2014). The major impact related to this study was that the anticipated community stigma could potentially discourage couples from testing together, for obvious reasons such as discrimination and fear of being labelled. Previous studies suggested that in communities which were experiencing high levels of HIV stigmatisation, HIV testing services needed to be strengthened through awareness campaigns so as to target the challenges of HIV-related stigma, fear and discrimination (Ncitakalo et al. 2021). In addition, a Kenyan study proposed a home-based CHCT model to combat HIV stigma, and it was proven to have multiple benefits, as it offered privacy and convenience and was cost-effective and less stigmatising (Kwena et al. 2021).

One of the major setbacks in the uptake of CHCT was patriarchal behaviour, which made it traditionally acceptable for men to engage in extramarital unions. These findings confirmed what previous studies observed, namely that such male sexual behaviour made women vulnerable and susceptible to HIV (Madiba & Ngwenya 2017; Naidoo, Taylor & Mabaso 2016). These social constructions surrounding men and masculinities made it culturally acceptable for men to have multiple sexual partners so as to prove their virility (Carey et al. 2010; Fleming, DiClemente & Barrington 2016), while on the contrary, in many settings, these norms dictated that women had to be passive in sexual relationships (Madiba & Ngwenya 2017; WHO 2009). These results highlighted that gender transformation was a necessary requirement for the attainment of successful CHCT initiatives. Scholars such as Morrell, Jewkes and Lindegger (2012) and Ratele (2015) are in strong support of the idea of deconstruction of dominant masculinities and engaging young boys in activities that lead to the construction of progressive masculinities. The study showed the existing gender inequalities in the Gokwe rural district which were counter-progressive among couples or relationships.

The study revealed that some religious groups did not believe in the use of any medical therapies, and such doctrines hindered the utilisation of health care services such as CHCT and other health services. Such practices were unique to certain Apostolic churches in the country. The findings of this study confirmed evidence from the previous studies which demonstrated how the most popular Apostolic church in Zimbabwe, the Johanne Marange Apostolic Church (JMC), and other similar groups resisted medical health care in favour of what they defined as spiritual healing (Musevenzi 2017). In describing JMC’s health care seeking behaviours, Musevenzi (2017) stated:

In a study to explore the contribution of JMC’s healing practices to pregnant mothers’ health, Kutsira (2013) found that the majority of pregnant women decided to seek health care services at hospitals regardless of the punishment they would receive from their church leaders for breaching the church’s doctrines (Kutsira 2013). The authors also argue that most of these churches are also led by men who may have patriarchal tendencies in terms of their governance. The unequal power and gender relations often put women in a difficult position, as they may be unable to negotiate with their partners for CHCT. These results were in agreement with the current study, which demonstrated deprivation of the right to access health care services by individuals in these sectors. In unison with previous studies, this study suggests that as much as it is important for believers within these religious sects to live by their faith in matters of health, it is highly recommended that in the context of HIV, they make use of holistic approaches to healing that include visiting health care facilities.

Couple counselling and testing for HIV can be one of the mechanisms through which couples in stable relationships can receive support towards the PMTCT of HIV. However, this study found that the occurrence of extramarital affairs in stable relationships made it impossible for couples to maintain the practice of CHCT. The challenge was evident in situations where a woman fell pregnant from a married man or a man who was in another relationship. Interestingly, the results of this study showed a similar challenge of extramarital affairs, but they differed from previous studies in that men viewed CHCT as unhelpful because of the adverse results they experienced after testing, as this subsequently brought mistrust and instability into their marriages and relationships (Hannaford et al. 2020; Larsson et al. 2010). What could be learnt from these studies was that where extramarital affairs occurred, CHCT was not always given because of the negative social implications it had for marriages and the individuals involved. Based on these findings, it can be suggested that as much as CHCT is critical for PMTCT of HIV, health care workers should consider the dynamics that exist for the pregnant women in terms of their marital status or that of their partners, as not all women may be able to produce their partner. This will ensure that all pregnant single mothers get their desired health care services without having to explain about their private affairs.

Although the study revealed the obstacles that hindered the practice of CHCT, positive responses demonstrated the possibility of its success through the use of media and by engaging men in health-related organisations and initiatives that ran men’s forums. The reasons for focusing specifically on men in an effort to mobilise CHCT and for HIV testing in general are well documented (Bwambale et al. 2008; Camlin et al. 2016; Hlongwa et al. 2020). The findings of this study concurred with previous studies that considered various ways of encouraging male-partner involvement in CHCT in their settings, such as actively engaging men in sensitising their fellow men, ensuring that health care facilities were less stigmatising and that they provided male-oriented services, as well as conducting dialogues among health care workers and community members (Larsson et al. 2010). This study suggests that while it is necessary to learn from other communities on measures that they are taking towards the utilisation of CHCT services, use of locally acceptable approaches can be an asset in increasing the utilisation of this service, especially in the PMTCT of HIV, treatment, care and support.

The study highlighted the influence of patriarchal behaviour in shaping HIV responses among couples. Societal norms and practices that made it acceptable for men to have multiple sexual partners exposed women to HIV. This study challenged these patriarchal practices as they hindered the overall aim of PMTCT of HIV through CHCT. Another challenge that influenced full utilisation of CHCT was the stigmatisation of HIV. Stigmatisation of HIV has the potential of reversing the gains that could be achieved through identification, treatment and care of HIV-positive individuals. In this study, the use of awareness campaigns and other forms of education in communities were shown to be instrumental in increasing the uptake of CHCT. Hence, such methods could be used in interventions that were committed to challenging the patriarchal as well as religious norms that hindered the uptake of health care services and CHCT in particular.