Men and antiretroviral therapy in Africa: our blind spot.
ABSTRACT Most antiretroviral therapy (ART)-related policies remain blind to men's treatment needs. Global and national programmes need to address this blindness urgently, to ensure equitable access to ART in Africa.
Article: Gender Differences in Survival among Adult Patients Starting Antiretroviral Therapy in South Africa: A Multicentre Cohort Study.[show abstract] [hide abstract]
ABSTRACT: BACKGROUND: Increased mortality among men on antiretroviral therapy (ART) has been documented but remains poorly understood. We examined the magnitude of and risk factors for gender differences in mortality on ART. METHODS AND FINDINGS: Analyses included 46,201 ART-naïve adults starting ART between January 2002 and December 2009 in eight ART programmes across South Africa (SA). Patients were followed from initiation of ART to outcome or analysis closure. The primary outcome was mortality; secondary outcomes were loss to follow-up (LTF), virologic suppression, and CD4+ cell count responses. Survival analyses were used to examine the hazard of death on ART by gender. Sensitivity analyses were limited to patients who were virologically suppressed and patients whose CD4+ cell count reached >200 cells/µl. We compared gender differences in mortality among HIV+ patients on ART with mortality in an age-standardised HIV-negative population. Among 46,201 adults (65% female, median age 35 years), during 77,578 person-years of follow-up, men had lower median CD4+ cell counts than women (85 versus 110 cells/µl, p<0.001), were more likely to be classified WHO stage III/IV (86 versus 77%, p<0.001), and had higher mortality in crude (8.5 versus 5.7 deaths/100 person-years, p<0.001) and adjusted analyses (adjusted hazard ratio [AHR] 1.31, 95% CI 1.22-1.41). After 36 months on ART, men were more likely than women to be truly LTF (AHR 1.20, 95% CI 1.12-1.28) but not to die after LTF (AHR 1.04, 95% CI 0.86-1.25). Findings were consistent across all eight programmes. Virologic suppression was similar by gender; women had slightly better immunologic responses than men. Notably, the observed gender differences in mortality on ART were smaller than gender differences in age-standardised death rates in the HIV-negative South African population. Over time, non-HIV mortality appeared to account for an increasing proportion of observed mortality. The analysis was limited by missing data on baseline HIV disease characteristics, and we did not observe directly mortality in HIV-negative populations where the participating cohorts were located. CONCLUSIONS: HIV-infected men have higher mortality on ART than women in South African programmes, but these differences are only partly explained by more advanced HIV disease at the time of ART initiation, differential LTF and subsequent mortality, and differences in responses to treatment. The observed differences in mortality on ART may be best explained by background differences in mortality between men and women in the South African population unrelated to the HIV/AIDS epidemic. Please see later in the article for the Editors' Summary.PLoS Medicine 09/2012; 9(9):e1001304. · 16.27 Impact Factor
Men and antiretroviral therapy in Africa: our blind spot
Morna Cornell1, James McIntyre2,1and Landon Myer1
1 School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
2 Anova Health Institute, Johannesburg, South Africa
Most antiretroviral therapy (ART)-related policies remain blind to men’s treatment needs. Global and
national programmes need to address this blindness urgently, to ensure equitable access to ART in
keywords antiretroviral therapy, gender, Africa, equity, access, men
As antiretroviral therapy (ART) becomes more widely
available, issues of access and equity within and between
populations are becoming increasingly important. In the
early years of ART, there were understandable concerns
that due to gender inequalities, men might have better
access to treatment than women (Wood et al. 2003).
However there is mounting evidence that men are at a
distinct disadvantage in the roll-out of ART in sub-Saharan
Africa. Disproportionately fewer men than women are
accessing ART across Africa (Muula et al. 2007). Men are
starting ART with more advanced HIV disease (Cornell
et al. 2009; Stringer et al. 2006), men are more likely than
women to die on ART (Cornell et al. 2010; Taylor-Smith
et al. 2010) to interrupt treatment (Kranzer et al. 2010)
and to be lost to follow-up on ART (Ochieng-Ooko et al.
Despite this evidence of gender inequity in access to
ART, most international and national ART-related policies
and programmes in Africa are still blind to men. For
example, nowhere in the UNAIDS epidemic updates or
country progress reports is men’s access to ART identified
as a gap and prioritized for urgent action. The recent 2010
Global Report on the epidemic (UNAIDS 2010) highlights
the need to ensure equitable access for children, pregnant
women and key populations at risk; men’s inequitable
access to ART is mentioned only in passing. This lack of
attention to men permeates the international funding
arena. The United States, the largest bilateral donor, has
provided funding for treatment for nearly 2.5 million
individuals through its PEPFAR programme. Although
62% of these are female, PEPFAR does not identify men’s
access to ART as an issue requiring action. The Global
Fund for HIV⁄AIDS, TB & Malaria, the largest multilat-
eral HIV⁄AIDS funding agency, identifies equitable access
to services as fundamental to its mission. Despite this, the
Fund’s comprehensive strategy document on gender
equality and HIV⁄AIDS fails to identify gender inequity in
access to ART (Global Fund to Fight TB 2008).
Many southern African countries have made remarkable
progress in expanding access to ART, but patients have
been disproportionately female. In South Africa, about
55% of those living with HIV are women but more than
two-thirds of patients receiving public sector ART are
female (Cornell et al. 2010). Similarly in Zambia, 54% of
those living with HIV are women yet 63% of adults
starting ART in Lusaka were female (Stringer et al. 2006).
Both countries have detailed national strategic plans yet
neither identifies male access as a gap or includes plans to
address it (National Department of Health 2007–2011,
National HIV and AIDS Council 2006).
Why are we blind to this glaring inequity in access to
treatment? One possible explanation is that public sector
health services in many parts of Africa historically have
focused on maternal and child health issues, and in turn
most health care services are often oriented to engaging
women. Another possibility is that advocacy for women’s
rights in the HIV epidemic has been highly successful and
has overshadowed the needs of men. In sexual and
reproductive health circles, men’s health issues are often
seen as secondary to those of women and men have been
described as the ‘forgotten fifty per cent’ in sub-Saharan
Africa (Varga 2001). A similar phenomenon may exist with
access to and uptake of ART.
Ensuring equitable access to ART for men should not
prejudice any other vulnerable group, or threaten the gains
made in HIV prevention and treatment for women. Global
Tropical Medicine and International Healthdoi:10.1111/j.1365-3156.2011.02767.x
volume 16 no 7 pp 828–829 july 2011
ª 2011 Blackwell Publishing Ltd
and national plans and programmes need to recognize this
as an issue requiring urgent attention. Such immediate
orientation will signal a true commitment to equity in
access to ART in Africa.
Cornell M, Technau K, Fairall LR et al. (2009) Monitoring the
South African National Antiretroviral Treatment Programme
2003–2007: The IeDEA Southern Africa Collaboration. South
African Medical Journal 99, 653–660.
Cornell M, Grimsrud A, Fairall L et al. (2010) Temporal changes
in programme outcomes among adult patients initiating anti-
retroviral therapy across South Africa 2002–2007. Aids 24,
GLOBAL FUND TO FIGHT TB, A. M. (2008) Global Fund
Gender Equality Strategy. The Global Fund to Fight TB, AIDS
& Malaria, Geneva.
Kranzer K, Lewis JJ, Ford N et al. (2010) Treatment interruption
in a primary care antiretroviral therapy program in South
Africa: cohort analysis of trends and risk factors. Journal of
Acquired Immune Deficiency Syndromes 55, e17–e23.
Muula AS, Ngulube TJ, Siziya S et al. (2007) Gender distribution
of adult patients on highly active antiretroviral therapy
(HAART) in Southern Africa: a systematic review. BMC Public
Health 7, 63.
National Department of Health (2007–2011) HIV and AIDS and
STI Strategic Plan for South Africa.
National HIV and AIDS Council (2006) Republic of Zambia
National HIV and AIDS Strategic Framework 2006–2010.
Ochieng-Ooko V, Ochieng D, Sidle JE et al. (2010) Influence of
gender on loss to follow-up in a large HIV treatment programme
in western Kenya. Bulletin of the World Health Organization
Stringer JS, Zulu I, Levy J et al. (2006) Rapid scale-up of anti-
retroviral therapy at primary care sites in Zambia: feasibility
and early outcomes. JAMA 296, 782–793.
Taylor-Smith K, Tweya H, Harries AD, Schoutene E & Jahn A
(2010) Gender differences in retention and survival on antiret-
roviral therapy of HIV-infected adults in Malawi. Malawi
Medical Journal 22, 49–56.
UNAIDS (2010) Global Report: UNAIDS Report on the Global
AIDS Pandemic: 2010. UNAIDS.
Varga CA (2001) The forgotten fifty per cent: a review of sexual
and reproductive health research and programs focused on boys
and young men in Sub-Saharan Africa. African Journal of
Reproductive Health⁄La Revue Africaine de la Sante ´ Repro-
ductive 5, 175–195.
Wood E, Montaner JSG, Bangsberg DR et al. (2003) Expanding
access to HIV antiretroviral therapy among marginalized
populations in the developed world. AIDS 17, 2419–2427.
Corresponding Author Morna Cornell, School of of Public Health & Family Medicine, University of Cape Town, Cape Town,
South Africa. E-mail: firstname.lastname@example.org
Tropical Medicine and International Healthvolume 16 no 7 pp 828–829 july 2011
M. Cornell et al. Men and ART in Africa: our blind spot
ª 2011 Blackwell Publishing Ltd