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Men's heightened risk of AIDS-related death: The legacy of gendered HIV testing and treatment strategies
Abstract
Women are frequently depicted as the face of AIDS in sub-Saharan Africa (SAA) [1–3] where they comprise nearly 58% of all reported HIV infections [4]. Donor dollars, policies, and HIV programs have followed suit, resulting in a near-exclusive focus on women [e.g. 5]. Although African women are represented as particularly vulnerable to HIV infection [6], it is men, not women, who are more likely to die of AIDS [7–9]. AIDS prevalence may have the face of a woman, but AIDS mortality has the face of a man.
... Therapy (ART) in the mid-2000s and the consequent decline in mortality within sub-Saharan Africa, eastern and southern Africa is the hardest hit region by HIV, with more than 54% (20.7 million) of the total number of people living with the disease, including 7.3 million HIV positive males [4,5]. Men and women in the region are prone to contracting HIV, however men are less likely to test for HIV, more likely to be diagnosed with advanced stages of the disease and more likely to be associated with HIV related deaths because of their poorer testing uptake and treatment [6][7][8][9][10][11][12]. HIV testing is a crucial approach in reducing HIV associated morbidity and mortality outcomes [13][14][15]. ...
... Consequently, emphasis ought to be placed in understanding the challenges men face in testing for HIV. Studies on drivers of never having tested for HIV among men in Uganda indicate among others; fear of being tested, older age, fear of knowing HIV status, absence of testing interest, men's view of clinics as places for females, culture, facilities, fear of testingrelated gossip, distrust of HIV testing methods, peer and economic influence [10,32,[44][45][46][47][48][49][50][51][52][53][54][55][56], without examining determinants of never having tested for HIV among sexually active men (15 -54 years) across regions of Uganda. In Uganda, regional differences in never having tested for HIV among men exist, for instance; highest in Karamoja region (60%), trailed by Bukedi region (42%) and lowest in Greater Kampala (14%), betwixt availability of HIV testing services [20,57]. ...
... Notably, sexual activity is a key aspect through which HIV is transmitted [58]. Out of the 15 regions that were captured in the 2016 UDHS, the present study grouped the regions into four (4) administrative regions of Uganda; central, eastern, northern and western region (10). Study approval by the Institutional Review Board (IRB) was not applicable, since the research utilized secondary data. ...
Background
HIV testing among men is paramount in the prevention, diagnosis, and treatment of HIV. There is limited literature in understanding the socio-economic and demographic factors associated with never having tested for HIV among sexually active men aged 15 – 54 across the four administrative regions of Uganda. The purpose of this study is to investigate the socio-economic and demographic factors associated with never having tested for HIV among sexually active men aged 15 – 54 across the four administrative regions in the country.
Methods
The study used a cross-sectional research design to examine factors associated with never having tested for HIV among 4,168 sexually active men (15 – 54 years) across four administrative regions of Uganda using data from 2016 Uganda Demographic and Health Survey (UDHS). Frequency distributions, Pearson chi-square tests, and multivariable logistic regression were used to establish the association between never having tested for HIV among sexually active men (15 – 54 years) and selected independent variables across regions.
Results
About 20% of sexually active men (15 – 54 years) never tested for HIV across regions of the country. The major correlates amidst variability of never testing for HIV among sexually active men across regions were; educational level and marital status. Age, religious status, wealth quintile, worked in the last 12 months, circumcised, and one sexual partner in the last 12 months were only correlates of never having tested for HIV among respondents in particular regions of the country.
Conclusion
Findings in the study suggest promotion of male education, and suggest further investigation into the relationship between HIV non-testing among sexually active men (15 – 54 years) and being married across regions of the country. The study also proposes appreciation of regional differences in the outcome of HIV non-testing and suggests that efforts be focused on addressing regional differences in order to attain high HIV testing among sexually active men (15 – 54 years) across regions of Uganda, and thus reduce HIV related morbidity and mortality.
... Despite the body of evidence on heterosexual men's inequitable access to HIV prevention, testing and antiretroviral therapy (ART) [1,2], and poorer viral suppression in sub-Saharan Africa (SSA), public health responses to address this gap remain surprisingly sparse [3]. Gender stereotypes prevail, implicitly blaming men for infecting women with HIV, and for their own health outcomes due to "poorer health-seeking behaviour" [4]. ...
... The gendered nature of health services in SSA has been well described [1,[3][4]6,7]. Given women's biological and social vulnerability to HIV infection, research, programmes and policies have primarily focused on the needs of women [8]. ...
... transmitting HIV), and the health outcomes of women and children have been prioritized [9]. Consequently, the health needs of men in SSA and generally across the world have been largely ignored [1,3,10]. There are two compelling reasons why the health and HIV risks of heterosexual men should be addressed urgently: like women, men have the right to health; and to reach the ambitious UNAIDS targets of 90:90:90, we need a response that is based on public health and gender inclusiveness rather than gender bias. ...
... One reason for men's inadequate engagement in the HIV prevention and treatment cascades is the structure of health systems. Healthcare systems often prioritize mother and child health, passively excluding men from care [4] and HIV testing and treatment is primarily targeted at women in antenatal settings [4]. Furthermore, studies suggest men may feel healthcare spaces are 'women's spaces' limiting men's willingness to seek HIV care [5,6]. ...
... One reason for men's inadequate engagement in the HIV prevention and treatment cascades is the structure of health systems. Healthcare systems often prioritize mother and child health, passively excluding men from care [4] and HIV testing and treatment is primarily targeted at women in antenatal settings [4]. Furthermore, studies suggest men may feel healthcare spaces are 'women's spaces' limiting men's willingness to seek HIV care [5,6]. ...
Men's engagement in HIV prevention and treatment is suboptimal, including in South Africa. We sought to address this through adapting an evidence-based intervention, Stepping Stones and Creating Futures (SSCF), to strengthen its HIV content and provide a more scal-able (shorter) intervention in rural South Africa. We then conducted a mixed methods pre-test of the intervention among young men aged 18-35 years. To adapt SSCF, we reviewed the current evidence base and worked with male Peer Navigators to update the SSCF theory of change (ToC) and manual. The revised intervention was~45 hours (9 sessions) as opposed to~63 hours and included a greater focus on HIV prevention and treatment technologies. Overall, 64% (n = 60) of men approached agreed to participate in the intervention, uptake (attending one session) among those who agreed was n = 35(58%) and retention (attending 6 or more sessions) was n = 25(71%). Qualitative data emphasized the intervention was acceptable, with young men describing it as something they liked. The qualitative data also broadly supported the intervention ToC, including the normalization of HIV in men's lives, and the importance of health for men in achieving their life goals. However, it also highlighted the need to focus more on HIV-related stigma and fear, and the importance of HIV self-testing kits in encouraging testing. We revised the ToC and manual in light of this data. The adapted SSCF is acceptable and supports the ToC. Next steps is an evaluation to look at effectiveness of the intervention.
... Norms asserting that men should be self-reliant, strong, and emotionally inexpressive amplify HIV stigma [13][14][15][16][17][18][19][20][21], leading to poor HIV care engagement [11,12,22,23]. As such, the onus of responsibility for change has mostly been at the individual level; however, there is also evidence that gender inequities embedded in the broader health system influence HIV outcomes [24][25][26]. More research is needed that critically examines the delivery of health services to inform institutional interventions to reduce gender disparities in the provision of HIV treatment. ...
... For example, womenspecific HIV services are multidimensional, often including the integration of services to meet multiple medical and social needs, inclusion of peer and social support services, and tailored counseling and services to address their unique barriers to HIV prevention and care, such as gender-based violence [37]. Although HIV programs similarly tailored to address men's specific needs is needed and recognized [24], the health system's historically gendered organization has systematically excluded men, resulting in a lack of HIV services tailored to their needs [25,26]. ...
Background
Antiretroviral treatment (ART) is the most effective clinical intervention for reducing morbidity and mortality among persons living with HIV. However, in Uganda, there are disparities between men and women in viral load suppression and related HIV care engagement outcomes, which suggests problems with the implementation of ART. Gender norms are a known driver of HIV disparities in sub-Saharan Africa, and patient-provider relationships are a key factor in HIV care engagement; therefore, the role of gender norms is important to consider in interventions to achieve the equitable provision of treatment and the quality of ART counseling.
Methods
The overall research objective of this study is to pilot test an implementation strategy (i.e., methods to improve the implementation of an evidence-based intervention) to increase providers’ capacity to provide gender-responsive treatment and counseling to men and women on HIV treatment in Uganda. Delivered to HIV providers, this group training adapts evidence-based strategies to reduce gender biases and increase skills to deliver gender-specific and transformative HIV counseling to patients. The implementation strategy will be piloted through a quasi-experimental controlled trial. Clinics will be randomly assigned to either the intervention or control conditions. The trial will assess feasibility and acceptability and explore barriers and facilitators to implementation and future adoption while gathering preliminary evidence on the implementation strategy’s effectiveness by comparing changes in patient (N = 240) and provider (N = 80–140) outcomes across intervention and control clinics through 12-month follow-up. Quantitative data will be descriptively analyzed, qualitative data will be analyzed through thematic analysis, and these data will be mixed during the presentation and interpretation of results where appropriate.
Discussion
This pilot intervention trial will gather preliminary evidence on the acceptability, feasibility, and potential effect of a novel implementation strategy to improve men and women’s HIV care engagement, with the potential to reduce gender disparities in HIV outcomes.
Trial registration
Clinicaltrials.gov NCT05178979, retrospectively registered on January 5, 2022
... That these effects are for men is especially important: men in Malawi are less likely than women to seek treatment for HIV and more likely to die of AIDS (Dovel et al. 2015). ...
... Our sample consists of men from Zomba who are at high risk of HIV infection. We focus on men because they are less likely than women to be tested and treated for HIV, and more likely to die of AIDS (Dovel et al. 2015). 15 Despite the fact that most Malawian men report a fairly recent clinic visit, more than half have not been tested for HIV in the past year (Dovel et al. 2020a). ...
Health behaviors are plagued by self-control problems, and commitment devices are frequently proposed as a solution. We show that a simple alternative works even better: appointments. We randomly offer HIV testing appointments and financial commitment devices to high-risk men in Malawi. Appointments are much more effective than financial commitment devices, more than doubling testing rates. In contrast, most men who take up financial commitment devices lose their investments. Appointments address procrastination without the potential drawback of commitment failure, and also address limited memory problems. Appointments have the potential to increase demand for healthcare in the developing world.
... Men also start treatment at later stages of disease progression, have worse adherence and higher loss-to-follow-up when on treatment, and are more likely to die from AIDS than their female counterparts [12][13][14][15]. Given men's higher AIDS-related morbidity and mortality in this context, HIV-positive men represent another vulnerable population [16]. This situation needs to be addressed urgently if we are to curb HIV transmission in sub-Saharan Africa. ...
... This excluded men who knew their HIV positive status. Socio-demographic variables included age categories in years (15)(16)(17)(18)(19)(20)(21)(22)(23)(24), and 50 years and older), sex (male and female), race (Black Africans and Other which include White, Coloured or mixed race, and Asian or of Indian origin collapsed into one group due to small numbers), marital status (married and never married), educational level completed (no education/primary, secondary, and tertiary), employment status (not employed and employed), and locality type (urban, rural informal/tribal areas, and rural formal/farms). ...
We investigated HIV prevalence and associated factors among men ≥ 15 years in South Africa using data from a 2017 nationwide cross-sectional survey. HIV prevalence was 10.5% among 6 646 participants. Prevalence increased from 4.1% in the younger men (15–24 years), 12.5% in young men (25–34 years) to 12.7% in older men (≥ 35 years). Odds of being infected with HIV were lower among younger men who had secondary level education and those who reported poor/fair self-rated health. Young and older men of other race groups had lower odds of HIV infection. Odds of infection were lower among young men who had moderate/high exposure to HIV communication programmes. Men not aware of their HIV status had higher odds of HIV infection, including older men who never married. Improved access to education, behavioral change programmes, and awareness of HIV status are necessary to reduce the risk of HIV infection among Black African men.
... This included 10 993 ART initiators after the UTT policy change in September 2016. Median age at ART initiation was 30 years (interquartile range, [25][26][27][28][29][30][31][32][33][34][35][36][37][38]. The ART regimen at initiation was tenofovir disoproxil fumarate, emtricitabine, and efavirenz in 98% individuals. ...
... Moreover, Health workers may have selectively conducted baseline CD4 tests among individuals they perceived to be at risk of advanced HIV, thereby diluting the impact of UTT on CD4 count at ART initiation. Third, the historical policy focus on maternal and child health may have contributed to sex disparities in access to care [26,27]. Inconvenient clinic operating hours or clinics being perceived as less "men friendly" [28] may have been additional factors. ...
Background:
South Africa implemented universal test and treat (UTT) in September 2016 in an effort to encourage earlier initiation of antiretroviral therapy (ART).
Methods:
We therefore conducted an interrupted time series (ITS) analysis to assess the impact of UTT on mean CD4 count at ART initiation among adults ≥16 years old attending 17 public sector primary care services in rural South Africa between July 2014 and March 2019.
Results:
Among 20,599 individuals (69% women), CD4 counts were available for 74%. Mean CD4 at ART initiation increased from 317.1 cells/μL (95% confidence interval, CI, 308.6 to 325.6)-one to eight months prior to UTT-to 421.0 cells/μL (95% CI 413.0 to 429.0) one to twelve months after UTT, including an immediate increase of 124.2 cells/μL (95% CI 102.2 to 146.1). However, mean CD4 count subsequently fell to 389.5 cells/μL (95% CI 381.8 to 397.1) 13 to 30 months after UTT, but remained above pre-UTT levels. Men initiated ART at lower CD4 counts than women (-118.2 cells/μL, 95% CI -125.5 to -111.0) throughout the study.
Conclusions:
Although UTT led to an immediate increase in CD4 count at ART initiation in this rural community, the long-term effects were modest. More efforts are needed to increase initiation of ART early in HIV infection, particularly among men.
... Masculine ideals that emphasize strength and independence may tacitly discourage health seeking behaviors and are commonly perceived as incompatible with HIV testing. Other research suggest that men's low testing uptake is not entirely about individual choices but rather a reflection of the differential positioning of men and women within HIV programs [4]. The most evident example is the routine testing of all pregnant women while failing to engage their male partners. ...
... The most evident example is the routine testing of all pregnant women while failing to engage their male partners. Furthermore, several studies suggest that the gendered structuring of HIV testing has led to the perspective among some men that HIV clinics are "female spaces" which may negatively influence their test seeking behaviors [4][5][6][7]. ...
We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng’ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections – providing a test yield of 5.3% (95% Confidence interval [CI] 3.3–8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6–2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.
... 15 We also know from research in Malawi and elsewhere that while most women will have regular opportunities during late adolescence and adulthood for engagement with health services related to family planning, pregnancy, and childbirth, men generally lack such a routine "universal access point" for engaging with the health services. 16,17 Although most interventions to improve men's engagement with HIV services have to date focused on increasing men's awareness and motivation through demand creation strategies, there have been some efforts to address the supply side of the equation. Most supply-side strategies have focused on creating more male-friendly services through, for example, hiring more male staff, providing gender sensitization training to staff, extending clinic hours, opening male-friendly or male-only clinics, and integrating HIV services with other services likely to engage men (such as tuberculosis [TB], substance use, or voluntary male circumcision programs). ...
... This engagement cannot be reduced to simply an issue of restrictive gender norms (as important as these may be). 17 This means that the avenues for improving this engagement must also be multidimensional. It is also clear that many HWs, despite their somewhat negative assessments of men's health-seeking practices, also really want to better engage men. ...
Men generally fare worse than women across the HIV cascade. While we know much about how men perceive the health services, we know little about how health workers (HWs) themselves have experienced engaging with men and what strategies they have used to improve this engagement. We interviewed 12 HWs in public health care services in Cape Town to better understand their experiences and perspectives. Health workers felt there were significant gaps in men’s engagement with HIV care and identified masculine gender norms, the persistent impact of HIV stigma, and the competing priorities of employment as key barriers. They also highlighted a number of health service-related challenges, including a poor perception of the patient–provider relationship, frustration at low service quality, and unrealistic expectations of the health services. Health workers also described several strategies for more effectively engaging men and for making the health services both more male friendly and more people friendly.
... Although women and men presented earlier to HIV care over time based on first CD4 cell count values, the trend was more pronounced in women. Whereas our findings in the earlier periods concur with other studies which have found men less likely to access HIV care in similar settings [23,24], we observed a narrowing of this differential in later periods of this study, approaching what would be expected based on sex-specific HIV prevalence estimates. Men continued to present with lower CD4 cell counts and have a larger proportion of TB co-infection, which seems to be increasing over time. ...
... Men continued to present with lower CD4 cell counts and have a larger proportion of TB co-infection, which seems to be increasing over time. In addition, numerous studies have found that women, via reproductive health services, have more opportunities to test for HIV and therefore present earlier for care and treatment while not otherwise symptomatic [23][24][25]. This study's results validate that finding, showing pregnant women were 38% more likely to access ART in comparison to men not infected with TB. ...
Introduction
Few studies have systematically described population‐level differences comparing men and women across the continuum of routine HIV care. This study quantifies differentials in HIV care, treatment and mortality outcomes for men and women over time in South Africa.
Methods
We analysed population‐wide linked anonymized data, including vital registration linkage, for the Western Cape Province, from the time of first CD4 count. Three antiretroviral therapy guideline eligibility periods were defined: 1 January 2008 to 31 July 2011 (CD4 cell count <200 cells/µL), 1 August 2011 to 31 December 2014 (<350 cells/µL), 1 January 2015 to 31 August 2016 (<500 cells/µL). We estimated care uptake based on service attendance, and modelled associations for men and women with ART initiation and overall, pre‐ART and ART mortality. Separate Cox proportional hazard models were built for each outcome and eligibility period, adjusted for tuberculosis, pregnancy, CD4 count and age.
Results
Adult men made up 49% of the population and constituted 37% of those living with HIV. In 2009, 46% of men living with HIV attended health services, rising to 67% by 2015 compared to 54% and 77% of women respectively. Men contributed <35% of all CD4 cell counts over 10 years and presented with more advanced disease (39% of all first presentation CD4 cell counts from men were <200 cells/µL compared to 25% in women). ART access was lower in men compared to women (AHR 0.79 (0.77 to 0.80) summarized for Period 2) over the entire study). Mortality was greater in men irrespective of ART (AHR 1.08 (1.01 to 1.16) Period 3) and after ART start (AHR 1.15 (1.05 to 1.20) Period 3) with mortality differences decreasing over time.
Conclusions
Compared to women, men presented with more advanced disease, were less likely to attend health care services annually, were less likely to initiate ART and had higher mortality overall and while receiving ART care. People living with HIV were more likely to initiate ART if they had acute reasons to access healthcare beyond HIV, such as being pregnant or being co‐infected with tuberculosis. Our findings point to missed opportunities for improving access to and outcomes from interventions for men along the entire HIV cascade.
... A growing literature documents the ways in which hegemonic masculine norms as well as other social and economic barriers inhibit men's HIV testing, initiating treatment, adherence to antiretroviral therapy (ART), and access to biomedical and psychosocial care and support (Colvin, Robins, and Leavens 2010;Jewkes et al. 2007;MenEngage Africa 2015). Institutional supply-side barriers, such as the services that are available to men, and when and how they are delivered are also a significant factor in men's poorer HIV-related health outcomes (Dovel et al. 2015). There is an increasing acknowledgement that men and boys must be better engaged in HIV prevention, treatment and care initiatives (UNAIDS 2017). ...
... Studies have documented a strong preference on the part of South African men to go to men only, or male-friendly clinics where they can be seen by male nurses and counsellors (Leichliter et al. 2011;Faull 2010). The rationale for male-friendly spaces includes the commonly held perception that public clinics are for women, long wait times, inconvenient hours and lack of confidentiality, which deter men from visiting (Faull 2010;Leichliter et al. 2011;Orner et al. 2008;Dovel et al. 2015). In addition, male clients have complained of poor treatment by clinic staff including rude and judgemental female nurses (Faull 2010;Colvin, Robins and Leavens 2010;Levack 2005;Leichliter et al. 2011). ...
The HIV epidemic is strongly gendered. Women and girls are more likely to contract HIV for biological and social reasons in Sub-Saharan Africa and men living with HIV are more likely to be lost to follow-up and die on antiretroviral therapy (ART) than women. Care work is also gendered, with women shouldering the burden of HIV care-related work. This paper considers the potential of male delivered community health work to improve men’s HIV-related health outcomes and shift gendered norms related to care work. It describes the experiences and perspectives of eight HIV community health workers and their clients from the Cape Town area, and reviews current evidence on male-focused HIV and sexual and reproductive health services, gender transformation and men and care. Findings suggest that meaningfully involving more men in HIV care work may be a way to shift damaging hegemonic masculine norms related to care and health, and that South Africa’s roll-out of National Health Insurance could be an opportunity to do so. Barriers to engaging men in this feminised profession are also explored.
... These 'safe spaces' are not provided in South African health settings, or do not are considered hostile and contentious for all parties involved Health workers might feel blamed for not providing timely services for patients, having hostile attitudes or the stock-out of medication, even though this is largely out of their control [55,56]. Patients or community representatives might be accused of irresponsible health decisions or non-adherence, without getting the opportunity to unpack this behaviour [55][56][57]. Presenting health information during these already uncomfortable conversations between community and health systems stakeholders, can potentially increase hostility instead of starting constructive dialogues on how to collectively improve health services. Therefore, building trust between participants and compassionate discussion leaders are key to facilitate discussion, rather than using the information to pinpoint persistent problems in the health system or problematic patient behaviour. ...
The access to, use, and exchange of health information is crucial when strengthening public health services and improving access to care. However, many health system stakeholders, including community groups are perpetually excluded from accessing and using health information. This is problematic as community groups, themselves end-users of care, are well-positioned to keep the health system accountable, provide feedback on the quality of services, and identify emerging health concerns. Using qualitative, ethnographic methods, this paper investigates different strategies used by the Movement for Change and Social Justice (MCSJ)–a local health activism group–to collect, use and distribute health information to improve health care in Gugulethu, a low-income neighbourhood in Cape Town, South Africa. Through participant observation, shadowing, informal conversations and semi-structured interviews that were analysed using iterative thematic analysis, findings revealed that MCSJ effectively collected, used and exchanged health information to develop short-term health campaigns. To get access to the needed health information, they used innovative strategies, including cultivating allies in the health system, finding safe spaces, and using community brokers to effectively mobilise community members to keep the health system accountable. MCSJ’s strategies highlight that stakeholders’ engagement with health information is not only a technical exercise, but a complex social process that requires constant negotiation and relationship building. Therefore, to make meaningful improvements to health services and create adaptive and responsive health systems, we need to include community groups as active stakeholders in the health system, provide relevant, up-to-date and locally relevant health information, and facilitate opportunities to socially engage with health information and those who produce it.
... Men's comparatively lower rates of HIV testing are often explained by structural barriers in the HIV service system. Gendered HIV programs throughout sub-Saharan Africa have historically tended to focus more on women and children, often sidelining men and amplifying men's reluctance to use HIV services [58]. The somewhat recent adoption of "Treatment for All" policies in the region and the expansion of community-based HIV testing sites [59,60] address many of the structural barriers to men's use of HIV testing services. ...
Despite an upward trend in HIV testing across sub-Saharan Africa, men continue to lag women in the use of HIV testing services. Inequitable gender attitudes held by some men may be implicated in their suboptimal HIV testing behaviors. We sought to ascertain the relationship between men?s endorsement of intimate partner violence (IPV), which is one manifestation of inequitable gender attitudes, and their lifetime and recent HIV testing, using nationally representative Demographic and Health Survey data from 23 sub-Saharan African countries. In a pooled analysis, we found that a unit increase in the IPV index scale is associated with 8% lower odds of lifetime HIV testing, and 6% lower odds of recent HIV testing. The strength of this relationship, however, varied across countries and regions. Our findings suggest that efforts to increase men?s HIV testing in the region should address the inequitable gender attitudes underpinning men?s endorsement of IPV, but that it is important to consider contextual variation.
... Engaging men is a priority for the HIV response in sub-Saharan Africa [1], home to over half of the world's people living with HIV [2]. Men are more likely than women to die of AIDS-related illnesses, and less likely to test for HIV or initiate antiretroviral therapy (ART) [1,3,4], a pattern mirrored in men's lower life expectancies and poorer health-related practices worldwide [5,6]. Recent research also shows a pattern of transmission whereby heterosexual men contribute to disproportionately high HIV incidence among adolescent girls and young women (AGYW) [7,8] who, for example, constitute 10% of the world's population but one-quarter of new infections [2]. ...
Objective:
To assess trends in men's HIV risk factors and service use, and their experiences with prevention programming, during an intensive HIV response for adolescent girls and young women and their male partners.
Design:
Independent cross-sectional surveys in 2016-2017 and 2018 with men in Eswatini (20-34 years-old, n = 1391) and Durban, South Africa (20-40 years-old; n = 1665), complemented by 74 in-depth interviews (IDIs) with men exposed to HIV services/prevention programming.
Methods:
Survey recruitment was primarily at hot-spot venues. We assessed Round 1-2 trends in HIV risk factors and service use, overall and by HIV risk profiles. IDI respondents were identified via survey responses or program partners.
Results:
HIV risk factors were prevalent in both countries at each survey round, although there were reductions over time among the highest risk profiles in South Africa. Most men were engaged in HIV services (e.g. nearly two-thirds tested for HIV in the last year at round 2, with large increases in Eswatini). Qualitative data suggest HIV service uptake was facilitated by increased convenience and supportive information/messaging about HIV treatment efficacy. Men described eagerly receiving the information and support offered in HIV prevention programming, and effects on HIV risk reduction and newly engaging in HIV services. However, less than 15% of survey respondents reported being reached by such programming.
Conclusion:
Important inroads have been made to engage men in HIV services and prevention programming in the two countries, including among the high-risk profiles. Still, improving coverage of comprehensive HIV prevention programming is critical, particularly for men most at risk.
... Interestingly, we did not find differences in gender regarding ART adherence or retention in the responses. In other low-and middle-income settings, men have higher rates of AIDS-related mortality, due at least partially to maintaining traditional masculinity [19]. Some of the factors related to traditional masculinity include the perspective that HIV and clinical care affect men´s traditional roles such as physical strength, risk-taking and the perspective that medical clinics are feminine spaces [20]. ...
Introduction:
Panama's HIV epidemic is far from under control. One of the populations with the fastest-growing epidemic among the Indigenous peoples of the Comarca Ngäbe-Buglé (CNB). The CNB is an administratively autonomous Indigenous region in Western Panama that is home to over 200,000 individuals of Ngäbe and Buglé ethnicities. This population is unique and, in several ways, represents the early stages of the AIDS epidemics in high-income countries. The CNB is the most impoverished region in Panama and is relatively isolated from outside influences, with limited roads, electricity, and an internet connection, including medical assistance. Around 1.5% of all rapid HIV tests are positive, compared to a national prevalence of 0.9%; in CNB, diagnosis tends to be late. In CNB, 56.3% of individuals had an initial CD4 count of <350 cells/mm3. Antiretroviral treatment (ART) dropout in this region is five times higher than the national average; there is high early mortality due to opportunistic infections. Using the Social-Ecological Theory for Health as a framework, this study aims to describe the facilitators and barriers associated with ART adherence and retention in HIV care among people living with HIV (PLHIV) in the CNB. A better understanding of factors that obstruct adherence could lead to more effective HIV care and prevention in CNB.
Methods:
We conducted 21 semi-structured interviews with PLHIV who reside across all three regions of the CNB and have attended an antiretroviral (ART) clinic at least once. Deductive thematic analysis was used to uncover themes related ART adherence and retention in HIV care at the individual, social and structural levels.
Discussion:
This unique, isolated population of rural Indigenous peoples has high infection rates, late diagnosis, poor ART adherence, and high AIDS-related death rates. The CNB is an important region to examen ART adherence and retention in care. We determined that psychological health, social support, and discrimination acted as individual-level facilitators and barriers to adherence and retention. Notably, structural barriers included difficult access to ART care due to travel costs, ART shortages, and uncooperative Western/Traditional medical systems. Recommended interventions used in other Low- and Middle-Income settings include increasing peer and family-level support and community knowledge and understanding of HIV infection. Additionally, our study suggests structural interventions, including decreasing the cost and distance of traveling to the ART clinic, by decentralizing services, decreasing food scarcity, and increasing collaboration between Western and Traditional providers.
... Poverty, low status of women, and gender-based violence contribute to this disparity [37]. However, the gender disparity of HIV is the opposite: men have a 25% higher risk of death from HIV than their female counterparts [41]. ...
South Africa has long grappled with one of the highest HIV and tuberculosis (TB) burdens in the world. The COVID-19 pandemic poses challenges to the country’s already strained health system. Measures to contain COVID-19 virus may have further hampered the containment of HIV and TB in the country and further widened the socioeconomic gap. South Africa’s handling of the pandemic has led to disruptions to HIV/TB testing and treatment. It has, furthermore, influenced social risk factors associated with increased transmission of these diseases. Individuals living with HIV and/or TB also face higher risk of developing severe COVID-19 disease. In this case study, we contextualize the HIV/TB landscape in South Africa and analyze the direct and indirect impact of the COVID-19 pandemic on the country’s efforts to combat these ongoing epidemics.
... (52,53) Despite the overall progress recorded against the pandemic, the resultant inadequate access to healthcare is a threat to achieving an AIDS-free generation and ending AIDS by 2030. (52,54,55) There is a dearth of data on HIV infection among LGBT people in many countries. HIV /AIDS infection among lesbians in the UK and several other countries is not subject to surveillance. ...
... Finally, findings from this study highlight features of health facilities that reinforce and institutionalize the gender divide in norms and practices around accessing HIV services. This was exemplified in participants' testimonies that most women have regular access to HIV testing, care, and treatment due to the integration of these services into family planning and antenatal services, while men do not-as other research has also found [4,52,53]. This disparity in access to services was described to fuel the perception that the health system was designed for women and reinforced the gendered belief that women prioritize health more than men. ...
Background
Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa.
Methods
We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach.
Results
We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men’s fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men’s expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family’s health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner’s results. Facility-level barriers such as long wait times continued to prevent some men from accessing care.
Conclusions
Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men’s and women’s engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.
... Verticalization of care and reproductive health services, which traditionally reach women, limit how and whether men access care and contribute to HIV-and reproductive health-related stigma and discrimination for men [24]. Men often express reproductive goals [25,26] but are less likely to access HIV testing and treatment, and are more likely to be lost to follow-up relative to women [27][28][29][30][31][32][33][34]. Given gender norms about reproductive roles and stigma towards PLWH having children, MLWH are the least likely to be offered reproductive health counselling [34][35][36][37][38][39]40]. ...
Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.
... As illustrated in several studies, men tend to access HIV services at a late stage [11][12][13] and consequently delay initiating ARVs [14]. A delay in the initiation of ARVs creates a missed opportunity to prevent transmission of HIV [12] and increases the mortality rate in men consequent to initiating ART in an advanced AIDS state [11,15]. ...
Background
Gender disparities exist in the scale-up and uptake of HIV services with men being disproportionately under-represented in the services. In Eastern and Southern Africa, of the people living with HIV infection, more adult women than men were on treatment highlighting the disparities in HIV services. Delayed initiation of antiretroviral treatment creates a missed opportunity to prevent transmission of HIV while increasing HIV and AIDS-associated morbidity and mortality. The main objective of this study was to assess the strategies that men prefer for Antiretroviral Therapy (ART) initiation in Blantyre, Malawi.
Methods
This was a qualitative study conducted in 7 Health facilities in Blantyre from January to July 2017. We selected participants following purposive sampling. We conducted 20 in-depth interviews (IDIs) with men of different HIV statuses, 17 interviews with health care workers (HCWs), and 14 focus group discussions (FGDs) among men of varying HIV statuses. We digitally recorded all the data, transcribed verbatim, managed using NVivo, and analysed it thematically.
Results
Restructuring the delivery of antiretroviral (ARVs) treatment and conduct of ART clinics is key to optimizing early initiation of treatment among heterosexual men in Blantyre. The areas requiring restructuring included: Clinic days by offering ARVs daily; Clinic hours to accommodate schedules of men; Clinic layout and flow that preserves privacy and establishment of male-specific clinics; ARV dispensing procedures where clients receive more pills to last them longer than 3 months. Additionally there is need to improve the packaging of ARVs, invent ARVs with less dosing frequency, and dispense ARVs from the main pharmacy. It was further suggested that the test-and-treat strategy be implemented with fidelity and revising the content in counseling sessions with an emphasis on the benefits of ARVs.
Conclusion
The success in ART initiation among men will require a restructuring of the current ART services to make them accessible and available for men to initiate treatment. The inclusion of people-centered approaches will ensure that individual preferences are incorporated into the initiation of ARVs. The type, frequency, distribution, and packaging of ARVs should be aligned with other medicines readily available within a health facility to minimize stigma.
... Poor or reduced access and other barriers to health care can act as deterrents. This includes for instance, lack of extended opening hours and facilities-based health care for men who work outside their communities during the day [19][20][21]. In some settings, recommended health services and estimated visits required across the reproductive lifespan (between 15 and 44 years) show that women attend the health facility between 176 and 433 times and men to attend just 30 times [22,23]. ...
Background:
Self-care interventions are influencing people's access to, expectation and understanding of healthcare beyond formal health delivery systems. In doing so, self-care interventions could potentially improve health-seeking behaviours. While many men proactively engage in maintaining and promoting their health, the focus on men's health comes from the recognition, at least partially, that male socialization and social norms can induce men and boys to have a lower engagement in institutionalized public health entities and systems around their sexual and reproductive health and rights, that could impact negatively on themselves, their partners and children.
Main text:
A research agenda could consider the ways that public health messaging and information on self care practices for sexual and reproductive health and rights could be tailored to reflect men's lived realities and experiences. Three examples of evidence-based self-care interventions related to sexual and reproductive health and rights that men can, and many do, engage in are briefly discussed: condom use, HIV self-testing and use of telemedicine and digital platforms for sexual health. We apply four core elements that contribute to health, including men's health (people-centred approaches, quality health systems, a safe and supportive enabling environment, and behaviour-change communication) to each intervention where further research can inform normative guidance.
Conclusion:
Engaging men and boys and facilitating their participation in self care can be an important policy intervention to advance global sexual and reproductive health and rights goals. The longstanding model of men neglecting or even sabotaging their wellbeing needs to be replaced by healthier lifestyles, which requires understanding how factors related to social support, social norms, power, academic performance or employability conditions, among others, influence men's engagement with health services and with their own self care practices.
... ABYM, especially those who have sex with other boys or men (Cornell and Dovel, 2018), continue to be left behind in efforts to achieve the 90-90-90 goals (UNAIDS, 2017a). Studies in many ESA countries have shown that HIV testing rates are sub-optimal among 15-24-year-old ABYM (9% ever tested vs 13% of girls the same age) (United Nations Children's Fund (UNICEF), 2018), as are initiation of and adherence to antiretroviral therapy (Ochieng-Ooko et al., 2010), retention in HIV care (Koole et al., 2014;Dovel et al., 2015Dovel et al., , 2016, and viral suppression. ...
... These findings are in accordance with previous studies looking at partner notification services that identify fear of the repercussions of notification in general and fear of violence in particular, as major barriers to APN participation for index clients [5,22,41]. Interviews with health workers highlight that fear of violence is experienced differently by men and women, a discrepancy stemming from gender roles and inequalities in relationships that have previously been shown to impact decisions surrounding HIV testing and disclosure [5,[72][73][74][75][76][77]. ...
Background:
Assisted partner notification (APN) for HIV was introduced in refugee settlements in West Nile Uganda in 2018 to facilitate testing of sexual partners. While APN is an effective strategy recommended by the World Health Organization, its safety has not been evaluated in a refugee settlement context in which participants have high prior exposure to interpersonal violence. The extent to which interpersonal violence influences APN utilization and the frequency with which post-APN interpersonal violence occurs remains unknown.
Methods:
To explore the relationship between APN and interpersonal violence, a cross-sectional mixed-methods study was conducted at 11 health centers in refugee settlements in West Nile Uganda. Routinely collected index client and sexual partner data were extracted from APN registers and semi-structured interviews were conducted with health workers.
Results:
Through APN, 1126 partners of 882 distinct index clients were identified. For 8% (75/958) of partners, index clients reported a history of intimate partner violence (IPV). For 20% (226/1126) of partners, index clients were screened for post-APN IPV; 8 cases were reported of which 88% (7/8) concerned partners with whom index clients reported prior history of IPV. In qualitative interviews (N = 32), health workers reported HIV disclosure-related physical, sexual and psychological violence and deprivation or neglect. Incidents of disclosure-related violence against health workers and dependents of index clients were also reported. Fear of disclosure-related violence was identified as a major barrier to APN that prevents index clients from listing sexual partners.
Conclusions:
Incidents of interpersonal violence have been reported following HIV-disclosure and fear of interpersonal violence strongly influences APN participation. Addressing HIV perception and stigma may contribute to APN uptake and program safety. Prospective research on interpersonal violence involving index clients and sexual partners in refugee settlements is needed to facilitate safe engagement in APN for this vulnerable population.
... Literature indicates that social protection might reduce the social and economic drivers of HIV risk, improve utilization of prevention technologies and improve adherence to ART for AYP (Cluver et al., 2015). Further examples of protective factors include gendered HIV testing and treatment strategies, provision of HIV-related education and changing patterns of HIV-related stigma (Delany-Moretlwe et al., 2015;Dovel et al., 2015). These strategies could be used in combination with each other to offset risk, foster accurate and consistent SRH use for both male and female AYP and build youth capacity, involvement and leadership (Cluver et al., 2018;Denison et al., 2017). ...
Despite efforts to address HIV-infection, adolescents and young peoples’ (AYP) engagement in interventions remain suboptimal. Guided by a risk protection framework we describe factors that support positive and negative experiences of HIV and SRH interventions among AYP in rural KwaZulu-Natal, South Africa, using data from: community mapping; repeat semi-structured individual interviews (n = 58 in 2017, n = 50 in 2018, n = 37 in 2019–2020); and group discussions (n = 13). AYP who had appropriate and accurate HIV-and SRH-related information were reported to use health-care services. Responsive health-care workers, good family and peer relationships were seen to be protective through building close connections and improving self-efficacy to access care. In contrast to cross-generational relationships with men, alcohol and drug use and early pregnancy were seen to put AYP at risk. Policies and interventions are needed that promote stable and supportive relationships with caregivers and peers, positive social norms and non-judgemental behaviour within clinical services.
... yet the PrEP focus in Sub-Saharan Africa is on women rather than men [4] and echoes a general gender trend in HIV interventions in Africa [5,6]. Despite the fact that men who have sex with women (MSW) have been lagging behind in the use of HIV testing services [3,6], presented late with HIV [7][8][9] and experienced worse health outcomes and higher rates of HIV-related deaths than women [10][11][12][13][14][15][16][17][18], they are rarely seen as an HIV risk group in their own right [6,19,20]. ...
Abstract
Few studies on HIV Pre-Exposure Prophylaxis (PrEP) have focused on men who have sex with women. We present findings from a mixed-methods study in Eswatini, the country with the highest HIV prevalence in the world (27%). Our findings are based on risk assessments, in-depth interviews and focus-group discussions which describe men’s motivations for taking up or declining PrEP. Quantitatively, men self-reported starting PrEP because they had multiple or sero-discordant partners or did not know the partner’s HIV-status. Men’s self-perception of risk was echoed in the qualitative data, which revealed that the hope of facilitated sexual performance or relations, a preference for pills over condoms and the desire to protect themselves and others also played a role for men to initiate PrEP. Trust and mistrust and being able or unable to speak about PrEP with partner(s) were further considerations for initiating or declining PrEP. Once on PrEP, men’s sexual behavior varied in terms of number of partners and condom use. Men viewed daily pill-taking as an obstacle to starting PrEP. Side-effects were a major reason for men to discontinue PrEP. Men also worried that taking anti-retroviral drugs daily might leave them mistaken for a person living with HIV, and viewed clinic-based PrEP education and initiation processes as a further obstacle. Given that men comprise only 29% of all PrEP users in Eswatini, barriers to men’s uptake of PrEP will need to be addressed, in terms of more male-friendly services as well as trialing community-based PrEP education and service delivery.
... Disparities between women and men exist across the region, with lower testing rates among men (1). This disparity is due in part to women accessing HIV testing in antenatal care (ANC) and other reproductive health care settings, and men having fewer opportunities to interact with the healthcare system for HIV testing services (2). HIV testing barriers among couples and individuals are widely documented and include stigma and discrimination, challenges at facilities such as long waiting times, not knowing the benefits of HIV testing and economic and opportunity costs (3,4,5). ...
Objectives: To generate evidence on willingness to use HIV self-test kits and willingness to pay among antenatal care clients in public and private facilities in Cote d'Ivoire and Tanzania. Methods: Cross-sectional survey data was collected from 414 clients recruited from 35 high-volume facilities in Cote d'Ivoire and from 385 clients in 33 high-volume facilities in Tanzania. Surveys covered willingness to use HIV self-test kits, prices clients were willing to pay, advantages and disadvantages, and views on specific qualities of HIV self-tests. Market data on availability of proxy self-testing products (e.g. pregnancy and malaria tests) and attitudes of pharmacists toward HIV self-test kits were collected from 51 pharmacies in Cote d'Ivoire and 59 in Tanzania. Results: Willingness to use HIV self-test kits was 65% in Cote d'Ivoire and and 69% in Tanzania. Median ideal prices women would pay ranged from USD 1.77 in Cote d'Ivoire to USD 0.87 in Tanzania. Proxy self-test kits were available in pharmacies and interest was high in stocking HIV self-test kits. Conclusions: Implications for national HIV self-test policy and planning include keeping prices low, providing psychological and HIV counseling, and ensuring linkage to HIV care and treatment services. Private pharmacies will play a key role in providing access to HIV self-test kits.
... Our findings that men were almost twice as likely as women to enter care with advanced HIV disease, and that the prevalence of advanced HIV disease increases with age, add to extensive regional data demonstrating the failure of HIV services to adequately engage men and those of working age [15,18,20,21]. Developing strategies to find and engage these groups is therefore essential for successful implementation of Treat All programmes. ...
Objective(s):
To determine the proportion of individuals linking to HIV-care with advanced HIV-disease (CD4 ≤200 cells/μL) in the Botswana Combination Prevention Project, describe the characteristics of these individuals, and examine treatment outcomes.
Design:
A sub-analysis of a cluster-randomized HIV-prevention trial. HIV status was assessed in 16-64-year-olds through home and mobile testing. All HIV-positive persons not on antiretroviral-therapy (ART) were referred to local Ministry of Health and Wellness clinics for treatment.
Methods:
Analysis was restricted to the 15 intervention clusters. The proportion of individuals with advanced HIV disease was determined; associations between advanced HIV disease and sex and age explored; and rates of viral suppression determined at 1-year. Mortality and retention in care were compared between CD4 strata (CD4 ≤200 cells/μL vs. > 200 cells/μL).
Results:
Overall, 17.2% (430/2,499; 95% confidence interval [CI] 15.7-18.8%) of study participants had advanced HIV disease (CD4 ≤200 cells/μL) at time of clinic linkage. Men were significantly more likely to present with CD4 ≤200 cells/μL than women (23.7% versus 13.4%, adjusted odds ratio [aOR] 1.9, 95% CI 1.5-2.3). The risk of advanced HIV disease increased with increasing age (aOR 2.2, 95% CI 1.4-3.2 > 35 years versus < 25 years). Patients with CD4 ≤200 cells/μL had significantly higher rates of attrition from care during follow-up (hazards ratio 1.47, 95% CI 1.1-2.1).
Conclusions:
Advanced HIV disease due to late presentation to or disengagement from ART care remains common in the Treat All era in Botswana, calling for innovative testing, linkage, and treatment strategies to engage and retain harder-to-reach populations in care.
... Disparities between women and men exist across the region, with lower testing rates among men [1]. This disparity is due in part to women accessing HIV testing in antenatal care (ANC) and other reproductive healthcare settings, and men having fewer opportunities to interact with the healthcare system for HIV testing services [2]. HIV testing barriers among couples and individuals are widely documented and include stigma and discrimination, challenges at facilities such as long waiting times, not knowing the benefits of HIV testing and economic and opportunity costs [3][4][5]. ...
Objectives
To generate evidence on willingness to use HIV self‐test kits and willingness to pay among antenatal care clients in public and private facilities in Cote d’Ivoire and Tanzania.
Methods
Cross‐sectional survey data was collected from 414 clients recruited from 35 high‐volume facilities in Cote d’Ivoire and from 385 clients in 33 high‐volume facilities in Tanzania. Surveys covered willingness to use HIV self‐test kits, prices clients were willing to pay, advantages and disadvantages, and views on specific qualities of HIV self‐tests. Market data on availability of proxy self‐testing products (e.g. pregnancy and malaria tests) and attitudes of pharmacists toward HIV self‐test kits were collected from 51 pharmacies in Cote d’Ivoire and 59 in Tanzania.
Results
Willingness to use HIV self‐test kits was 65% in Cote d’Ivoire and and 69% in Tanzania. Median ideal prices women would pay ranged from USD 1.77 in Cote d’Ivoire to USD 0.87 in Tanzania. Proxy self‐test kits were available in pharmacies and interest was high in stocking HIV self‐test kits.
Conclusions
Implications for national HIV self‐test policy and planning include keeping prices low, providing psychological and HIV counseling, and ensuring linkage to HIV care and treatment services. Private pharmacies will play a key role in providing access to HIV self‐test kits.
... Health institutions, like other social organizations, are shaped by dominant social norms and social inequalities [16]. The few studies that have explored how health institutions are organized have found that men in various regions had fewer opportunities than women to engage with health institutions, and with HIV testing services more specifically [17][18][19][20]. We build on this work by examining the gendered organization of health institutions across multiple levels in Malawi, and whether institutions are structured to facilitate health services utilization for one gender over the other. ...
Introduction
Men in sub‐Saharan Africa are less likely to use HIV testing services than their female counterparts. Norms of masculinity are frequently cited as the main barrier to men’s use of HIV testing services, but very little is known about how health institutions are organized to facilitate or impede men’s care. We examined the organization of health institutions in Malawi, and implications for men’s use of HIV testing services.
Methods
A mixed methods ethnography was conducted in Malawi between October 2013 and September 2014. National Ministry of Health guidelines from 2012 to 2014 were analysed, counting the frequency of recommended preventative services by sex. In‐depth interviews were conducted with 18 healthcare workers and 11 national key informants (29 total). Five rural health facilities participated in direct observation and 52 observational journals were completed to document the structure and implementation of HIV services within local facilities. All data were analysed using the theory of gendered organization. Findings were grouped into one of the three theoretical levels of organization: (1) organizational policy; (2) organizational practice; and (3) structure of gendered expectations.
Results
Health institutions were gendered across three levels. Organizational policy : National guidelines omitted young and adult men’s health during reproductive years (176‐433 recommended visits for women vs. 32 visits for men). Health education strategies focused on reproductive and child health services, with little education strategies targeting men. Organizational practice : HIV testing was primarily offered during reproductive and child health services and located near female‐focused departments within health facilities. As these departments were women’s spaces, others could easily tell that men were using HIV services. Structure of gendered expectations : Clients who successfully accessed HIV testing services were perceived as exemplifying characteristics that were traditionally considered feminine: compliance (obeying instructions without explanation); deference (respecting providers regardless of provider behaviour); and patience (“waiting like a woman”).
Conclusions
Health institutions in Malawi were organized in ways that created substantial, multilevel barriers to men’s HIV testing and reinforced perceptions of absent, difficult men. Future research should prioritize a gendered organization framework to understand and address the complex realities of men’s constrained access to HIV services.
... However, these goals may be compromised by disparities in engagement in HIV services among certain subpopulations. Men in sub-Saharan Africa in particular continue to be less engaged in services [3][4][5]. Despite impressive increases in knowledge of HIV status across the region, uptake of HIV testing remains low among men. ...
Introduction
Without significant increases in uptake of HIV testing among men, it will be difficult to reduce HIV incidence to disease elimination levels. Secondary distribution of HIV self‐tests by women to their male partners is a promising approach for increasing male testing that is being implemented in several countries. Here, we examine male partner and couples testing outcomes and sexual decision making associated with this approach in a cluster randomized trial.
Methods
We examined data from women at higher risk of HIV participating in the intervention arm of an ongoing pair‐matched cluster randomized trial in Kenya. HIV‐negative women ≥18 years who self‐reported ≥2 partners in the past month were eligible. Participants received self‐tests at enrolment and three‐monthly intervals. They were encouraged to offer tests to sexual partners with whom they anticipated condomless sex. At six months, we collected data on self‐test distribution, male partner and couples testing, and testing and sexual behaviour in the three most recent transactional sex encounters. We used descriptive analyses and generalized estimating equation models to understand how sexual behaviour was influenced by self‐test distribution.
Results
From January 2018 to April 2019, 921/1057 (87%) participants completed six‐month follow‐up. Average age was 28 years, 65% were married, and 72% reported income through sex work. Participants received 7283 self‐tests over six months, a median of eight per participant. Participants offered a median three self‐tests to sexual partners. Of participants with a primary partner, 94% offered them a self‐test. Of these, 97% accepted the test. When accepted, couples testing was reported among 91% of participants. Among 1954 transactional sex encounters, 64% included an offer to self‐test. When offered self‐tests were accepted by 93% of partners, and 84% who accepted conducted couples testing. Compared to partners with an HIV‐negative result, condom use was higher when men had a reactive result (56.3% vs. 89.7%, p < 0.01), were not offered a self‐test (56.3% vs. 62.0%, p = 0.02), or refused to self‐test (56.3% vs. 78.3, p < 0.01).
Conclusions
Providing women with multiple self‐tests facilitated male partner and couples testing, and led to safer sexual behaviour. These findings suggest secondary distribution is a promising approach for reaching men and has HIV prevention potential.
Clinical Trial Number: NCT03135067.
... The datasets generated during and/or analyzed during the present study are available from the corresponding author on reasonable request. stigma, [20][21][22][23] programmatic focus on women to reduce motherto-child transmission of HIV, [23][24][25] and background gender differences in mortality independent of HIV [9,26] undoubtedly contribute to the observed differences and may be fully explanatory. ...
Evidence for why antiretroviral therapy (ART) outcomes differ by gender in developing countries has been inconclusive. In this first study to assess 10-year survival on ART in Kenya, our objective was to compare gender differences in survival for those who began ART as adults and as children. Kakamega County Referral Hospital (KCRH) is a tertiary rural hospital that has provided public ART to Kenyans since 2004. All patients enrolled in ART at KCRH who died between July 2004 and March 2017 and a sample of living patients were included in a survival analysis that bootstrapped sampled data. Case-cohort regressions identified adjusted hazard ratios. In total, 1360 patients were included in the study. Ten-year survival was 77% (95% confidence band [CB] 73-81%), significantly different for men (65%; 95% CB: 45-74%) and women (83%; 95% CB: 78-86%) who began therapy as adults. Ten-year survival was intermediate with no significant gender difference (76%; 95% CB: 69-81%) for patients who began therapy as children. Hazard of death was increased for men (hazard ratio [HR] 1.56; 95% confidence interval [CI] 1.13-2.17), infants (HR 2.87; 95% CI 1.44-5.74), patients with consistently poor clinic attendance (HR 3.94; 95% CI 3.19-4.86), and divorced patients (HR 2.25; 95% CI 1.19-4.25). Tuberculosis, diarrheal illnesses, human immunodeficiency virus (HIV) wasting syndrome, and malaria were leading causes of death. Survival was significantly lower for men than for women in all time periods, but only for patients who began therapy as adults, indicating against biological etiologies for the gender mortality difference.
... However, several South African studies have reported an increased risk of virologic failure among men [24][25][26]36]. Given the growing body of evidence that men are disadvantaged in access to, and outcomes on ART [37][38][39][40][41][42][43][44][45], our findings suggest that ACs may have a particular benefit for men who chose to be in one, and that stable men in routine care could be safely referred to ACs for ongoing care. This model of care appears to be beneficial for women as well, given that 74% of the AC cohort were women, approximately 10% higher than the proportion of HIV-positive women in South Africa [46]. ...
Introduction
In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long‐term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town.
Methods
We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed.
Results
Overall, 8058 patients were included in the analysis, contributing 16,047 person‐years of follow‐up from AC entry (median follow‐up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed.
Conclusions
This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.
... [1][2][3][4][5] Men may experience specific barriers to HIV testing and care, including hegemonic masculine norms, family or community expectations, conceptions related to care seeking, and the nature of the HIV testing and care environment. [6][7][8][9][10] Further barriers may include lack of familiarity with clinics and having work hours that limit access to care. 11 Failure to test for HIV and engage in care leads to increased morbidity and mortality for individuals living with HIV and undermines ART's promise for preserving health and preventing HIV transmission. ...
Background:
Historically, men in sub-Saharan Africa have worse outcomes along the HIV care continuum than women. Brothers for Life (BFL) is a community-based behavior change intervention for men, adapted for Côte d'Ivoire, involving group discussions that address salient gender norms and promote HIV prevention, testing, and linkage to care with support from peer navigators. The goal of this study was to describe the BFL program as implemented in Côte d'Ivoire, evaluate program implementation, and report uptake of HIV testing and treatment among BFL participants.
Setting:
Three urban and periurban sites in Côte d'Ivoire.
Methods:
The implementation evaluation assessed the fidelity and acceptability of the BFL program and the reach of program completion, testing and peer navigation using qualitative and quantitative approaches.
Results:
BFL facilitation fidelity and content fidelity were high. Semi-structured interviews with BFL participants indicated that men appreciated the format and content and that the BFL program helped some participants overcome their fears and adopt more positive attitudes and behaviors around testing and treatment. Assessments of reach showed that, of the 7,187 BFL participants, 81% tested for HIV as part of BFL and 2.3% (135) tested HIV positive. Of those, 102 (76%) accepted peer navigator support and 97% (131) initiated treatment. After six months, 100% of the 131 men who initiated treatment remained in care.
Conclusion:
The implementation of BFL in Côte d'Ivoire successfully achieved the goals of engaging participants in discussions around HIV prevention, encouraging HIV testing, and achieving linkage to care, treatment initiation, and retention.
... Men demonstrate disproportionately poor uptake and participation in HIV services, constituting 'a blind spot' in the fight against HIV and AIDS. 1 Men are more unlikely to take part in testing services, initiate antiretroviral treatment (ART) with more advanced HIV disease, show worse retention in care and adherence to treatment behaviours and, consequently, have worse health outcomes compared to women. [2][3][4][5] These differences in experiencing HIV services appear to relate more to gender norms than to health system factors. 6 Therefore, apart from the structural barriers to engagement [1] in HIV services such as distance to the facility, inconvenient hours, sigma, poverty and perceptions that facilities provide women-centred services, 8 there is strong evidence linking men's disinclination to engage in HIV care to masculinity. ...
Background:
Men demonstrate disproportionately poor uptake and engagement in HIV services with strong evidence linking men's disinclination to engage in HIV services to their masculinity, necessitating adaptive programming to accommodate HIV-positive men. Differentiated service delivery models (DSDMs) - streamlined patient-centred antiretroviral treatment (ART) delivery services - have demonstrated the potential to improve men's engagement in HIV services. However, it is unclear how and why these models contribute to men's reframing of ART-friendly masculinities - a set of attributes, behaviours and roles associated with boys and men that favour the uptake and use of ART. We sought to unveil how and why DSDMs support the formation of ART-friendly masculinities to enhance men's participation in HIV-related services.
Methods:
A theory-driven qualitative approach underpinned by critical realism was conducted with 30 adult men using 3 types of DSDMs: facility-based adherence clubs (FACs), community-based adherence clubs (CACs) and quick pharmacy pick-ups (QPUPs). Focus group discussions (FGDs) (6) and in-depth interviews (IDIs) (20) were used to elicit information from purposively selected participants based on their potential contribution to the theory development - theoretical sampling. Recordings were transcribed verbatim in isiXhosa, then translated to English and analysed thematically. Theoretical constructs (themes) related to programme context and generative mechanisms were distilled and linked by retroduction and abductive thinking to formulate explanatory theories.
Results:
Three bundles of mechanisms driving the adoption of ART-friendly masculinities by men using DSDMs were identified. (1) DSDMs instil a sense of cohesion (social support and feeling of connectedness), which enhances their reputational masculinity - having the know-how and being knowledgeable. (2) DSDMs provide a sense of assurance by providing reliable, convenient, stigma-free services, which makes men feel strong and resilient (respectability identity). (3) Through perceived usefulness, the extent to which an individual believes the model enhances their disease management, DSDMs enhance men's ability to be economically productive and take care of their family (responsibility identity).
Conclusion:
DSDMs enhance the refashioning of ART-friendly versions of masculinity, thus improving men's engagement in HIV services. Their effectiveness in refashioning men's masculinities to ART friendly masculinities can be improved by ensuring conducive conditions for group interactions and including gender-transformative education to their existing modalities.
Background: Men are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs’ buy-in for male-specific interventions.
Methods: Focus group discussions (FGDs) were conducted in 2016 with HCWs from 15 facilities across Malawi and Mozambique, and were originally conducted to evaluate barriers to universal treatment (not gender or internal bias). FGDs were conducted in local languages, recorded, translated to English, and transcribed. For this study, we focused on HCW perceptions of men as HIV clients, using inductive and deductive coding in Atlas.ti v.8, and analyzed codes using constant comparison methods.
Findings: 20 FGDs with 154 HCWs working in HIV treatment clinics were included. Median age was 30 years, 59% were female, and 43% were providers versus support staff. HCWs held strong implicit bias against men as clients. Most HCWs believed men could easily navigate HIV services due to their elevated position within society, regardless of facility-level barriers faced. Men were described in pejorative terms as ill-informed and difficult clients who were absent from health systems. Men were largely seen as “bad clients” due to assumptions about men’s ‘selfish’ and ‘prideful’ nature, resulting in little HCW sympathy for men’s poor use of care.
Interpretation: Our study highlights a strong implicit bias against men as HIV clients, even when gender and implicit bias were not the focus of data collection. As a result, HCWs may have little motivation to implement male-specific interventions or improve provider-patient interactions with men. Framing men as problematic places undue responsibility on individual men while minimizing institutional barriers that uniquely affect them. Implicit bias in local, national, and global discourses about men must be immediately addressed.
Improving men’s engagement in HIV prevention is not only essential for reducing their own HIV risk but also the risk of transmitting HIV to their female partners. We conducted a cross-sectional survey using a population-based sample of men (age 18–30) who reported being a partner of an adolescent girls and young women (AGYW) in South Africa (N = 2827). We used logit-binomial regression models to examine associations among men’s partnership characteristics, HIV risk perceptions, and HIV-related behaviors and examine differences by male partner age (younger men (18–24) vs. older men (25–30)) and age difference between partners (age-concordant (< 5 years) vs. age-disparate (≥ 5 years)). Most men reported inconsistent condom use (85%) and nearly half reported engaging in transactional sex (48%). Older men were just as likely as younger men, and men with age-disparate and age-concordant partners, to inconsistently use condoms, engage in transactional sex, and perpetrate intimate partner violence. Most men also reported a very high interest in pre-exposure prophylaxis (PrEP) (77%) and half reported having an HIV test in the past year (50%). There were no differences by male partner age or age difference between partners in PrEP interest but older men and men in age-discordant relationships were more likely than younger men and men in age-concordant relationships to have an HIV test in the past year. Male partners of AGYW in South Africa are engaging in HIV-related behaviors and need HIV prevention interventions to reduce risk for themselves and their female partners.
Despite the widespread availability of lifesaving antiretroviral drugs, demand for HIV testing is low. Antiretrovirals have a positive externality: they prevent HIV transmission. We use an experiment in Malawi to show that informing communities about this externality can shift beliefs and increase HIV testing in the short term, with a larger effect for sexually-active demographics. We also see a change in attitudes toward sexual partners taking antiretrovirals. Learning about a positive externality can increase demand for healthcare.
This article examines the meaning of health among middle‐aged and older adults in a rural South African setting, where 72 percent of adults aged 40 and over are living with a major chronic condition, and 81 percent report good or very good health. We draw on a unique mixed‐methods dataset that includes a population‐based survey with disease biomarkers (hypertension, diabetes, HIV), self‐assessments of health including self‐rated health, functional ability and medication use, as well as nested qualitative life history interviews with survey participants including questions about lived experiences of health. We conduct survey trend analysis and ordinal logistic regression, as well as inductive and deductive coding of qualitative interviews, and triangulate findings across data sources. Overall, we find that self‐rated health and functional ability are not associated with biometric disease indicators; however, we find that gendered familial expectations, life course stage, and the socioepidemiological context work together to regulate the salience of illness as people age. The study highlights the utility of research with multiple measures of health in illuminating the challenges of aging amidst the complex epidemiological transitions that increasingly characterize low‐ and middle‐income countries.
Objective: To estimate association between ageing process markers (clinical conditions necessitating total abdominal hysterectomy) and immune functions (i.e. HIV-risk) among adult non-gravid female humans.
Materials & Methods: We did a secondary data analysis, from a prospective, observational, hospital-based study conducted in Dar es Salaam, Tanzania between March-October 2017. The primary study population included all women planned for Total Abdominal Hysterectomy (TAH). Target population was all women who underwent total abdominal hysterectomy. Data were analysed using a generalized linear model via SAS statistical software version 9.4.
Results: We analysed 40981 women-hours of follow-up. None of the participant seroconverted against HIV, making an HIV-incidence of 0/40981 women-hours. All participants were black Africans (median age 42 [IQR: 37–47] years). We found a statistically significant drop (aOR: 0.687) in HIV-risk after age 45. Serial correlation between age and HIV-serostatus was evident (γ = 0.514, p = 0.000). HIV and marital stata had a barely statistically significant association (χ2 = 8.0176, df = 3).
Conclusion: We observed a statistically significant reduced HIV-risk after age 45 among hysterectomised women up and above the known behavioural/clinical factors. Participants who reported married had the highest HIV-seropositivity rate.
Recommendations: These findings reflect antagonistic pleiotropy theory of ageing. Analyses on potential biological mechanism(s) against HIV in post-menopausal females is/are warranted.
Background
Men in Sub-Saharan Africa are less engaged than women in accessing HIV testing and treatment and, consequently, experience higher HIV-related mortality. Reaching men with HIV testing services is challenging, thus, increasing the need for innovative ways to engage men with low access and those at higher risk. In this study, we explore men’s perceptions of drivers and barriers of workplace-based HIV self-testing in Uganda.
Methods
An exploratory study involving men working in private security companies employing more than 50 men in two districts, in central and western Uganda. Focus group discussions and key informant interviews were conducted. Data were analyzed using inductive content analysis.
Results
Forty-eight (48) men from eight private security companies participated in 5 focus group discussions and 17 key informant interviews. Of the 48 men, 14(29.2%) were ages 26–35 years. The majority 31(64.6%) were security guards. The drivers reported for workplace-based HIV self-testing included convenience, autonomy, positive influence from work colleagues, the need for alternative access for HIV testing services, incentives, and involvement of employers. The barriers reported were the prohibitive cost of HIV tests, stigma, lack of testing support, the fear of discrimination and isolation, and concerns around decreased work productivity in the event of a reactive self-test.
Conclusions
We recommend the involvement of employers in workplace-based HIV self-testing to encourage participation by employees. There is need for HIV self-testing support both during and after the testing process. Both employers and employees recommend the use of non-monetary incentives, and regular training about HIV self-testing to increase the uptake and acceptability of HIV testing services at the workplace.
HIV testing is the entry point to the cascade of services within HIV care. Although Malawi has made positive strides in HIV testing, men are lagging at 65.5% while women are at 81.6%. This study explored the preferences of men on the avenues for HIV testing in Blantyre, Malawi. This was a descriptive qualitative study in the phenomenological tradition in seven public health facilities in Blantyre, Malawi, among men and health-care workers (HCWs). We conducted 20 in-depth interviews and held 14 focus group discussions among 113 men of varying HIV statuses. All our participants were purposively selected, and data were digitally recorded coded and managed through NVivo. Thematic analysis was guided by the differentiated service delivery model. Men reported a preference for formal and informal workplaces such as markets and other casual employment sites; social places like football pitches, bars, churches, and "bawo" spaces; and outreach services in the form of weekend door-to-door, mobile clinics, men-to-men group. The health facility was the least preferred avenue. The key to testing men for HIV is finding them where they are. Areas that can be leveraged in reaching men are outside the routine health system. Scaling up HIV testing among men will require targeting avenues and operations outside of the routine health system and leverage them to reach more men with services. This suggests that HIV testing and counseling (HTC) uptake among men may be increased if the services were provided at informal places.
Purpose of review:
The global pandemic caused by the severe acute respiratory virus coronavirus 2 (SARS-CoV-2) has a male bias in mortality likely driven by both gender and sex-based differences between male and female individuals. This is consistent with sex and gender-based features of HIV infection and overlap between the two diseases will highlight potential mechanistic pathways of disease and guide research questions and policy interventions. In this review, the emerging findings from SARS-CoV-2 infection will be placed in the context of sex and gender research in the more mature HIV epidemic.
Recent findings:
This review will focus on the new field of literature on prevention, immunopathogenesis and treatment of SARS-CoV-2 referencing relevant articles in HIV for context from a broader time period, consistent with the evolving understanding of sex and gender in HIV infection. Sex-specific features of epidemiology and immunopathogenesis reported in COVID-19 disease will be discussed and potential sex and gender-specific factors of relevance to prevention and treatment will be emphasized.
Summary:
Multilayered impacts of sex and gender on HIV infection have illuminated pathways of disease and identified important goals for public health interventions. SARS-CoV-2 has strong evidence for a male bias in disease severity and exploring that difference will yield important insights.
Background. Young South Africans experience high rates of HIV infection. While nationally scaled medical male circumcision (MMC) can help to curb HIV infection rates in countries such as South Africa (SA), MMC uptake has not been consistent or universal, suggesting variable acceptability among men. Both MMC and traditional male circumcision (TMC) are practised in SA. For male circumcision to be most effective for HIV prevention, it should be performed prior to sexual debut with complete removal of the foreskin.
Objectives. The MACHO (Male Adolescent Choices for HIV Prevention Options) study investigated uptake of and preference for MMC v. TMC in two culturally distinct settings in SA.
Methods. This observational, longitudinal, cohort study investigated circumcision preferences and uptake in 100 males (aged 14 - 17 years) and their legal guardians in Cape Town (Western Cape Province) and Soweto (Gauteng Province). Data were collected via surveys administered every 4 months over a 24-month period.
Results. A total of 100 uncircumcised adolescent boys (Cape Town n=50, Soweto n=50; mean (interquartile range) age 15 (14 - 16) years) and their guardians were enrolled. At baseline, 42 boys from Soweto (84%) and none from Cape Town expressed a preference for MMC over TMC. Sowetan participants were more likely to elect circumcision (MMC n=11 (22%), TMC n=1 (2%)) than those from Cape Town (TMC n=1 (2%), MMC n=0) over 13.6 months of follow-up (hazard ratio 18.9; 95% confidence interval 2.37 - 150.71; p=0.006).
Conclusions. MMC was the preferred option for young men in Soweto compared with those in Cape Town, and this translated into practice. Despite knowledge of the benefits of early MMC, many participants delayed uptake, potentially reducing the MMC benefits before sexual debut. Programmes promoting circumcision should consider the influence of local practices. To realise full HIV prevention benefits, efforts should be made to ensure that circumcision is promoted, and that all circumcision is safe, performed prior to sexual debut, and contextually responsive.
Objectives:
Despite free access to antiretroviral therapy (ART) from 1996 onward, and treatment for all people living with HIV (PLWHIV) from 2013, mortality in Brazil has not homogeneously decreased. We investigated to what extent delayed ART, hepatitis coinfections and sociodemographic factors predict all-cause mortality in Brazilian PLWHIV.
Design:
We included PLWHIV ≥18 years, with complete CD4 count data, followed up between 2007 and 2015 in Brazil.
Methods:
After multiple imputation, an extended Cox model helped estimate the effects of fixed and time-varying covariates on mortality.
Results:
The study population (n = 411,028) were mainly male (61%), Caucasian (55%), ≤40 years (61%), heterosexually HIV-infected (71%), living in the Southeast region (48%) and had basic education (79%). HCV and HBV coinfection prevalences were 2.5% and 1.4%, respectively. During a 4-year median follow-up, 61,630 deaths occurred and the mortality rate was 3.45 [95% confidence interval (CI): 3.42-3.47] per 100 person-years. Older age, male gender, non-Caucasian ethnicity, illiteracy/basic education and living outside the Southeast and Central-West regions were independently associated with increased mortality. The main modifiable predictors of mortality were delayed ART (i.e., CD4 < 200 cells/mm at ART initiation) (adjusted population attributable fraction: 14.20% [95% CI: 13.81-14.59]), being ART-untreated (14.06% [13.54-14.59]), and ART-treated with unrecorded CD4 at ART initiation (5.74% [5.26-6.21]). HCV and HBV coinfections accounted for 2.44% [2.26-2.62] and 0.42% [0.31-0.53] of mortality, respectively.
Conclusions:
This study demonstrates that besides early ART and coinfection control, actions targeting males, non-Caucasians and illiterate people and those with basic education are important to reduce avoidable deaths among Brazilian PLWHIV.
Objectives
The number needed to test (NNT) to identify a child infected with HIV remains high in the context of the implementation of the blanket provider-initiated testing and counselling (bPITC) strategy. This study assessed the predictors of HIV seropositivity among outpatient children/adolescents (6 weeks-19 years) in Cameroon. This information is needed to improve the yield of bPITC and reduce the current gap in pediatric and adolescent ART coverage in this country and beyond.
Study Design
Cross-sectional study conducted in 3 hospitals in Cameroon.
Methods
Through biological parents and guardians we systematically invited children and adolescents visiting the outpatient departments for any reason to test for HIV (bPITC) in a 6-month period. Children and adolescents were tested for HIV following the national guidelines and the predictors of HIV seropositivity were assessed using multivariate logistic regression at 5% significant level.
Results
A total of 2729 eligible children/adolescents were enrolled. Among these, 90.3% (2465/2729) were tested for HIV. Out of these, 1.6% (40/2465) tested HIV-positive, corresponding to a NNT of 62. In multivariate analysis, HIV seropositivity was 2.5, 3.3, and 5 times more likely to be reported among children/adolescents of the female sex [aOR=0.4 (0.2-0.8), p=0.008]; whose fathers had no formal school education [aOR=0.3 (0.1-0.6), p=0.004] and those whose mothers had died [aOR=0.2 (0.0-0.9), p=0.041], respectively.
Conclusions
Focusing HIV testing among female children/adolescents of the female sex, whose fathers had no education level and whose mothers had died could reduce the NNT, improve the yield of bPITC and increase the pediatric and adolescent ART coverage.
Background:
Men in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized.
Methods and findings:
We evaluated HIV-positive adults ≥18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/μl, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/μl) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those <30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/μl (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men <30 years old compared to women of the same age, while women ≥50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (<30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records.
Conclusions:
In this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.
The Joint United Nations Programme on HIV and AIDS (UNAIDS) and the Public Health Agency of Canada wish to reach, test and treat at least 90 percent of undiagnosed people living with HIV. Fourteen percent (9,090 of 63,100) of Canadians living with HIV were unaware of their status by the end of 2016. Evidence about barriers before and after reaching testing is required to inform policy and practice in planning more equitable HIV testing interventions. We conducted face-to-face semi-structured interviews among twenty young heterosexual African migrants from HIV-endemic countries between May and October 2017. Participants included fourteen men and six women aged 18–29 years to identify barriers to reaching HIV testing services in Ottawa. We used Grounded Theory informed by a socio-ecological framework and a framework of access to care. Participants described access barriers and enablers at the testing stages of approachability, acceptability, and availability. Participants were, however, often unable to recognize the need for HIV testing, unable to actively seek and choose HIV testing and reach HIV testing at the intrapersonal, interpersonal, organizational, community, and policy levels. Lack of outreach programs and inability to obtain required information about HIV testing options was a major access barrier among young men in this study. Young heterosexual African women experienced unique barriers even after reaching testing, such as, not being taken seriously by healthcare providers. Our analysis showed multi-level determinants influence our populations HIV testing, both before and after reaching testing services. These determinants have practical implication for researchers, policymakers, affected communities and patients.
Newly diagnosed HIV positive children may be unique index cases to identify undiagnosed parents. Data was used from the Pediatric Urgent Start of HAART (NCT02063880) trial, which enrolled hospitalized, ART-naïve, HIV positive children ages 0–12 years in Kenya. Exact McNemar’s tests were used to compare proportions of mothers and fathers tested for HIV, linked to care, and on ART at baseline and 6 months. This analysis included 87 newly diagnosed children with HIV who completed 6 months of follow-up. Among 83 children with living mothers, there were improvements in maternal linkage to care and treatment comparing baseline to 6 months (36% vs. 78%; p < 0.0001 and 22% vs. 52%; p < 0.0001). Among 80 children with living fathers, there were increases from baseline to 6 months in the number of fathers who knew the child’s HIV status (34% vs. 78%; p < 0.0001), fathers ever tested for HIV (43% vs. 65%; p < 0.0001), fathers ever tested HIV positive (21% vs. 43%; p < 0.0001), fathers ever linked to care (15% vs. 35%; p < 0.0001), and fathers ever initiated on ART (11% vs. 23%; p = 0.0039). Newly diagnosed HIV positive children can be important index cases to identify parents with undiagnosed HIV or poor engagement in care.
Antiretroviral medications can reduce rates of mother-to-child transmission of human immunodeficiency virus (HIV) to less than 5%. However, in 2011, only 57% of HIV-infected pregnant women in low- and middle-income countries received a World Health Organization (WHO)-recommended regimen for prevention of mother-to-child transmission (PMTCT), and an estimated 300,000 infants acquired HIV infection from their mothers in sub-Saharan Africa; 15,700 (5.2%) of these infants were born in Malawi. An important barrier to PMTCT in Malawi is the limited laboratory capacity for CD4 cell count, which is recommended by WHO to determine which antiretroviral medications to start. In the third quarter of 2011, the Malawi Ministry of Health (MOH) implemented an innovative approach (called "Option B+"), in which all HIV-infected pregnant and breastfeeding women are eligible for lifelong antiretroviral therapy (ART) regardless of CD4 count. Since that time, several countries (including Rwanda, Uganda, and Haiti) have adopted the Option B+ policy, and WHO was prompted to release a technical update in April 2012 describing the advantages and challenges of this approach as well as the need to evaluate country experiences with Option B+. Using data collected through routine program supervision, this report is the first to summarize Malawi's experience implementing Option B+ under the direction of the MOH and supported by the Office of the Global AIDS Coordinator (OGAC) through the President's Emergency Plan for AIDS Relief (PEPFAR). In Malawi, the number of pregnant and breastfeeding women started on ART per quarter increased by 748%, from 1,257 in the second quarter of 2011 (before Option B+ implementation) to 10,663 in the third quarter of 2012 (1 year after implementation). Of the 2,949 women who started ART under Option B+ in the third quarter of 2011 and did not transfer care, 2,267 (77%) continue to receive ART at 12 months; this retention rate is similar to the rate for all adults in the national program. Option B+ is an important innovation that could accelerate progress in Malawi and other countries toward the goal of eliminating mother-to-child transmission of HIV worldwide.
In Lesotho, men have lower HIV testing rates, less contact with HIV clinical settings and less knowledge of HIV prevention than women. However, women's HIV prevalence has consistently remained higher than men's. This paper explores gender norms, sexual decision-making and perceptions of HIV among a sample of Basotho men and women in order to understand how these factors influence HIV testing and prevention. A total of 200 women and 30 men were interviewed in Lesotho between April and July 2011. Participants reported reluctance among women to share information about HIV prevention and testing with men, and resistance of men to engage with testing and/or prevention services. Findings demonstrate a critical need for educational initiatives for men, among other strategies, to engage men with HIV testing and prevention. This study highlights how gender issues shape perceptions of HIV and sexual decision-making and underlines the importance of engaging men along with women in HIV prevention efforts. More studies are needed to determine the most effective strategies to inform and engage men.
Evidence shows that men are significantly underrepresented in HIV and AIDS testing and treatment services – both in sub-Saharan Africa and globally. HIV policies within sub-Saharan Africa also have insufficient focus on ensuring national HIV responses encourage men to test, access anti-retroviral treatment and support the disproportionate burden of HIV care on women. Addressing these challenges is important for everyone's sake and must be approached within a context of addressing power differentials between men and women at all levels. This includes challenging the broader patriarchal power structures in which gender plays out, such as the assumption that care work is ‘women's work’ and therefore less valued, and the rigidity of gender norms that encourage men to participate in risk-taking behaviours that put their life and the life of those around them in jeopardy.
The evidence is encouraging that men and boys can be engaged in health interventions with a gender perspective and that they change attitudes and behaviour as a result, but most of the programmes
are small in scale and short in duration.
Background
Impressive achievements have been made towards achieving universal coverage of antiretroviral therapy (ART) in sub-Saharan Africa. However, the effects of rapid ART scale-up on delays between HIV diagnosis and treatment initiation have not been well described.
Methods
A retrospective cohort study covering eight years of ART initiators (2004–2011) was conducted at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. The time between most recent positive HIV test and ART initiation was calculated and temporal trends in delay to initiation were described. Factors associated with time to initiation were investigated using multivariate regression analysis.
Results
From 2004–2011, there were 15,949 ART initiations at QECH (56% female; 8% children [0–10 years] and 5% adolescents [10–20 years]). Male initiators were likely to have more advanced HIV infection at initiation than female initiators (70% vs. 64% in WHO stage 3 or 4). Over the eight years studied, there were declines in treatment delay, with 2011 having the shortest delay at 36.5 days. On multivariate analysis CD4 count <50 cells/μl (adjusted geometric mean ratio [aGMR]: aGMR: 0.53, bias-corrected accelerated [BCA] 95% CI: 0.42-0.68) was associated with shorter ART treatment delay. Women (aGMR: 1.12, BCA 95% CI: 1.03-1.22) and patients diagnosed with HIV at another facility outside QECH (aGMR: 1.61, BCA 95% CI: 1.47-1.77) had significantly longer treatment delay.
Conclusions
Continued improvements in treatment delays provide evidence that universal access to ART can be achieved using the public health approach adopted by Malawi However, the longer delays for women and patients diagnosed at outlying sites emphasises the need for targeted interventions to support equitable access for these groups.
Poor rates of linkage from HIV diagnosis to ART initiation are a major barrier to universal coverage of ART in sub-Saharan Africa, with reasons for failure poorly understood. In the first study of this kind at primary care level, we investigated the pathway to care in the Malawian National Programme, one of the strongest in Africa.
A prospective cohort study was undertaken at two primary care clinics in Blantyre, Malawi. Newly diagnosed HIV-positive adults (>15 years) were followed for 6-months to assess completion of eligibility assessments, initiation of ART and death. Two hundred and eighty participants were followed for 82.6 patient-years. ART eligibility assessments were problematic: only 134 (47.9%) received same day WHO staging and 121 (53.2%) completed assessments by 6-months. Completion of CD4 measurement (stage 1/2 only) was 81/153 (52.9%). By 6-months, 87/280 (31.1%) had initiated ART with higher uptake in participants who were ART eligible (68/91, 74.7%), and among participants who received same-day staging (52/134 [38.8%] vs. 35/146 [24.0%] p = 0.007). Non-completion of ART eligibility assessments (adjusted hazard ratio: 0.11, 95% CI: 0.06-0.21) was associated with failure to initiate ART. Retention in pre-ART care for non-ART initiators was low (55/193 [28.5%]). Of the 15 (5.4%) deaths, 11 (73.3%) occurred after ART initiation.
Although uptake of ART was high and prompt for patients with known eligibility, there was frequent failure to complete eligibility assessment and poor retention in pre-ART care. HIV care programmes should urgently evaluate the way patients are linked to ART. In particular, there is a critical need for simplified, same-day ART eligibility assessments, reduced requirements for hospital visits, and active defaulter follow-up.
Ed Mills and colleagues argue that a more balanced approach to gender is needed so that both men and women are involved in HIV treatment and prevention.
Objective
To understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees.
Methods
All clinic attendances and episodes of HTC were recorded at two clinics in Blantyre. A cohort of newly diagnosed HIV-positive adults (>15 years) was recruited and exit interviews undertaken. Logistic regression models were constructed to investigate factors associated with referral to start ART. Qualitative interviews were conducted with providers and patients.
Results
There were 2398 episodes of HTC during 18 021 clinic attendances (13.3%) between January and April 2011. The proportion of clinic attendees undergoing HTC was lowest in non-pregnant women (6.3%) and men (8.5%), compared with pregnant women (47.2%). Men had more advanced HIV infection than women (79.7% WHO stage 3 or 4 vs. 56.4%). Problems with WHO staging and access to CD4 counts affected ART eligibility assessments; only 48% completed ART eligibility assessment, and 54% of those reporting WHO stage 3/4 illnesses were not referred to start ART promptly. On multivariate analysis, HIV-positive pregnant women were significantly less likely to be referred directly for ART initiation (adjusted OR: 0.29, 95% CI: 0.13–0.63).
Conclusions
These data show that provider-initiated testing and counselling (PITC) has not yet been fully implemented at primary care clinics. Suboptimal ART eligibility assessments and referral (reflecting the difficulties of WHO staging in primary care) mean that simplified eligibility assessment tools are required to reduce unnecessary delay and attrition in the pre-ART period. Simplified initiation criteria for pregnant women, as being introduced in Malawi, should improve linkage to ART.
Counselling is considered a prerequisite for the proper handling of testing and for ensuring effective HIV preventive efforts. HIV testing services have recently been scaled up substantially with a particular focus on provider-initiated models. Increasing HIV test rates have been attributed to the rapid scale-up of the provider-initiated testing model, but there is limited documentation of experiences with this new service model. The aim of this study was to determine the use of different types of HIV testing services and to investigate perceptions and experiences of these services with a particular emphasis on the provider initiated testing in three selected districts in Kenya, Tanzania, and, Zambia.
A concurrent triangulation mixed methods design was applied using quantitative and qualitative approaches. A population-based survey was conducted among adults in the three study districts, and qualitative data were obtained from 34 focus group discussions and 18 in-depth interviews. The data originates from the ongoing EU funded research project "REsponse to ACountable Priority Setting for Trust in Health Systems" (REACT) implemented in the three countries which has a research component linked to HIV and testing, and from an additional study focusing on HIV testing, counselling perceptions and experiences in Kenya.
Proportions of the population formerly tested for HIV differed sharply between the study districts and particularly among women (54% Malindi, 34% Kapiri Mposhi and 27% Mbarali) (p < 0.001). Women were much more likely to be tested than men in the districts that had scaled-up programmes for preventing mother to child transmission of HIV (PMTCT). Only minor gender differences appeared for voluntary counselling and testing. In places where, the provider-initiated model in PMTCT programmes had been rolled out extensively testing was accompanied by very limited pre- and post-test counselling and by a related neglect of preventative measures. Informants expressed frustration related to their experienced inability to 'opt-out' or decline from the provider-initiated HIV testing services.
Counselling emerged as a highly valued process during HIV testing. However, counselling efforts were limited in the implementation of the provider-initiated opt-out HIV testing model. The approach was moreover not perceived as voluntary. This raises serious ethical concerns and implies missed preventive opportunities inherent in the counselling concept. Moreover, implementation of the new testing approach seem to add a burden to pregnant women as disproportionate numbers of women get to know their HIV status, reveal their HIV status to their spouse and recruit their spouses to go for a test. We argue that there is an urgent need to reconsider the manner in which the provider initiated HIV testing model is implemented in order to protect the client's autonomy and to maximise access to HIV prevention.
To determine the incidence of loss to follow-up in a treatment programme for people living with human immunodeficiency virus (HIV) infection in Kenya and to investigate how loss to follow-up is affected by gender.
Between November 2001 and November 2007, 50 275 HIV-positive individuals aged ≥ 14 years (69% female; median age: 36.2 years) were enrolled in the study. An individual was lost to follow-up when absent from the HIV treatment clinic for > 3 months if on combination antiretroviral therapy (cART) or for > 6 months if not. The incidence of loss to follow-up was calculated using Kaplan-Meier methods and factors associated with loss to follow-up were identified by logistic and Cox multivariate regression analysis.
Overall, 8% of individuals attended no follow-up visits, and 54% of them were lost to follow-up. The overall incidence of loss to follow-up was 25.1 per 100 person-years. Among the 92% who attended at least one follow-up visit, the incidence of loss to follow-up before and after starting cART was 27.2 and 14.0 per 100 person-years, respectively. Baseline factors associated with loss to follow-up included younger age, a long travel time to the clinic, patient disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV disease, and rural clinic location. Men were at an increased risk overall and before and after starting cART.
The risk of being lost to follow-up was high, particularly before starting cART. Men were more likely to become lost to follow-up, even after adjusting for baseline sociodemographic and clinical characteristics. Interventions designed for men and women separately could improve retention.
For patients in all health-care settings HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines. The nation's physicians and other health care providers should assume a much more active role in promoting HIV testing. The aim of this study was to investigate the extent to which missed opportunities for earlier HIV testing and diagnosis occur in the health facilities of north east Ethiopia.
A confidential client exit interview and medical record review was made on 427 clients who attended health facilities of Dessie town between November-December 2008. Data collection was done by counselors trained on Provider Initiated Counseling and Testing (PICT) and data collection tool included demographics, reason for visit to health facilities, HIV test initiation by service providers, clients self risk perception, clients willingness and acceptance of HIV test, HIV test result and review of client medical records.
Among 427 clients, missed opportunities for HIV testing were found in 76.1% (325) of clients. HIV test initiation was made by data collecting counselors during interview period and 80.0% (260) of clients not initiated by service providers were found to be willing to have HIV test. Large number, 43.0% (112), of the willing clients actually tested for HIV. Of the tested clients, 13.4% (15) were found to be HIV positive. Most, 60% (9), of HIV positive clients who lost the opportunities of diagnosis felt themselves as having no risk for HIV infection. Missed opportunities for HIV diagnosis of 51.7% (15), overall HIV test acceptance rate of 36.5% (154) and positivity rate of 6.9% (29) were found.
The missed opportunities for earlier HIV test and diagnosis of patients attending health facilities were found to be high and frequent. Testing only clients with HIV risk misses large number of HIV positive patients. Asking clients' willingness for HIV testing should be conducted by all service providers irrespective of the clients' risk behaviors for HIV infection or the type of services they need.
Most HIV prevention literature portrays women as especially vulnerable to HIV infection because of biological susceptibility and men's sexual power and privilege. Conversely, heterosexual men are perceived as active transmitters of HIV but not active agents in prevention. Although the women's vulnerability paradigm was a radical revision of earlier views of women in the epidemic, mounting challenges undermine its current usefulness. We review the etiology and successes of the paradigm as well as its accruing limitations. We also call for an expanded model that acknowledges biology, gender inequality, and gendered power relations but also directly examines social structure, gender, and HIV risk for heterosexual women and men.
Voluntary HIV counselling and testing (VCT) is one of the key strategies in the prevention and control of HIV/AIDS in Uganda. However, the utilization of VCT services particularly among men is low in Kasese district. We therefore conducted a study to determine the prevalence and factors associated with VCT use among men in Bukonzo West health sub-district, Kasese district.
A population-based cross-sectional study employing both quantitative and qualitative techniques of data collection was conducted between January and April 2005. Using cluster sampling, 780 men aged 18 years and above, residing in Bukonzo West health sub-district, were sampled from 38 randomly selected clusters. Data was collected on VCT use and independent variables. Focus group discussions (4) and key informant interviews (10) were also conducted. Binary logistic regression was performed to determine the predictors of VCT use among men.
Overall VCT use among men was 23.3% (95% CI 17.2-29.4). Forty six percent (95% CI 40.8-51.2) had pre-test counselling and 25.9% (95%CI 19.9-31.9) had HIV testing. Of those who tested, 96% returned for post-test counselling and received HIV results. VCT use was higher among men aged 35 years and below (OR = 2.69, 95%CI 1.77-4.07), the non-subsistence farmers (OR = 2.37, 95%CI 2.37), the couple testing (OR = 2.37, 95%CI 1.02-8.83) and men with intention to disclose HIV test results to sexual partners (OR = 1.64, 95%CI 1.04-2.60). The major barriers to VCT use among men were poor utilization of VCT services due to poor access, stigma and confidentiality of services.
VCT use among men in Bukonzo West, Kasese district was low. In order to increase VCT use among men, the VCT programme needs to address HIV stigma and improve access and confidentiality of VCT services. Among the more promising interventions are the use of routine counselling and testing for HIV of patients seeking health care in health units, home based VCT programmes, and mainstreaming of HIV counselling and testing services in community development programmes.
The Zambian Ministry of Health has scaled-up human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care and treatment services at primary care clinics in Lusaka, using predominately nonphysician clinicians.
To report on the feasibility and early outcomes of the program.
Open cohort evaluation of antiretroviral-naive adults treated at 18 primary care facilities between April 26, 2004, and November 5, 2005. Data were entered in real time into an electronic patient tracking system.
Those meeting criteria for antiretroviral therapy (ART) received drugs according to Zambian national guidelines.
Survival, regimen failure rates, and CD4 cell response.
We enrolled 21,755 adults into HIV care, and 16,198 (75%) started ART. Among those starting ART, 9864 (61%) were women. Of 15,866 patients with documented World Health Organization (WHO) staging, 11,573 (73%) were stage III or IV, and the mean (SD) entry CD4 cell count among the 15,336 patients with a baseline result was 143/microL (123/microL). Of 1142 patients receiving ART who died, 1120 had a reliable date of death. Of these patients, 792 (71%) died within 90 days of starting therapy (early mortality rate: 26 per 100 patient-years), and 328 (29%) died after 90 days (post-90-day mortality rate: 5.0 per 100 patient-years). In multivariable analysis, mortality was strongly associated with CD4 cell count between 50/microL and 199/microL (adjusted hazard ratio [AHR], 1.4; 95% confidence interval [CI], 1.0-2.0), CD4 cell count less than 50/microL (AHR, 2.2; 95% CI, 1.5-3.1), WHO stage III disease (AHR, 1.8; 95% CI, 1.3-2.4), WHO stage IV disease (AHR, 2.9; 95% CI, 2.0-4.3), low body mass index (<16; AHR,2.4; 95% CI, 1.8-3.2), severe anemia (<8.0 g/dL; AHR, 3.1; 95% CI, 2.3-4.0), and poor adherence to therapy (AHR, 2.9; 95% CI, 2.2-3.9). Of 11,714 patients at risk, 861 failed therapy by clinical criteria (rate, 13 per 100 patient-years). The mean (SD) CD4 cell count increase was 175/microL (174/microL) in 1361 of 1519 patients (90%) receiving treatment long enough to have a 12-month repeat.
Massive scale-up of HIV and AIDS treatment services with good clinical outcomes is feasible in primary care settings in sub-Saharan Africa. Most mortality occurs early, suggesting that earlier diagnosis and treatment may improve outcomes.
HIV and AIDS are significant and growing public health concerns in southern Africa. The majority of countries in the region have national adult HIV prevalence estimates exceeding 10 percent. The increasing availability of highly active antiretroviral therapy (HAART) has potential to mitigate the situation. There is however concern that women may experience more barriers in accessing treatment programs than men.
A systematic review of the literature was carried out to describe the gender distribution of patients accessing highly active antiretroviral therapy (HAART) in Southern Africa. Data on number of patients on treatment, their mean or median age and gender were obtained and compared across studies and reports.
The median or mean age of patients in the studies ranged from 33 to 39 years. While female to male HIV infection prevalence ratios in the southern African countries ranged from 1.2:1 to 1.6:1, female to male ratios on HAART ranged from 0.8: 1 to 2.3: 1. The majority of the reports had female: male ratio in treatment exceeding 1.6. Overall, there were more females on HAART than there were males and this was not solely explained by the higher HIV prevalence among females compared to males.
In most Southern African countries, proportionally more females are on HIV antiretroviral treatment than men, even when the higher HIV infection prevalence in females is accounted for. There is need to identify the factors that are facilitating women's accessibility to HIV treatment. As more patients access HAART in the region, it will be important to continue assessing the gender distribution of patients on HAART.
OBJECTIVE: To determine the incidence of loss to follow-up in a treatment programme for people living with human immunodeficiency virus (HIV) infection in Kenya and to investigate how loss to follow-up is affected by gender. METHODS: Between November 2001 and November 2007, 50275 HIV-positive individuals aged > 14 years (69% female; median age: 36.2 years) were enrolled in the study. An individual was lost to follow-up when absent from the HIV treatment clinic for 3 months if on combination antiretroviral therapy (cART) or for 6 months if not. The incidence of loss to follow-up was calculated using Kaplan-Meier methods and factors associated with loss to follow-up were identified by logistic and Cox multivariate regression analysis. FINDINGS: Overall, 8% of individuals attended no follow-up visits, and 54% of them were lost to follow-up. The overall incidence of loss to follow-up was 25.1 per 100 person-years. Among the 92% who attended at least one follow-up visit, the incidence of loss to follow-up before and after starting cART was 27.2 and 14.0 per 100 person-years, respectively. Baseline factors associated with loss to follow-up included younger age, a long travel time to the clinic, patient disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV disease, and rural clinic location. Men were at an increased risk overall and before and after starting cART. CONCLUSION: The risk of being lost to follow-up was high, particularly before starting cART. Men were more likely to become lost to follow-up, even after adjusting for baseline sociodemographic and clinical characteristics. Interventions designed for men and women separately could improve retention.
Background:
HIV/AIDS has historically had a sex and gender-focused approach to prevention and care. Some evidence suggests that HIV-positive men have worse treatment outcomes than their women counterparts in Africa.
Methods:
We conducted a systematic review and meta-analysis of the effect of sex on the risk of death among participants enrolled in antiretroviral therapy (ART) programs in Africa since the rapid scale-up of ART. We included all cohort studies evaluating the effect of sex (male, female) on the risk of death among participants enrolled in regional and national ART programs in Africa. We identified these studies by searching MedLine, EMBASE, and Cochrane CENTRAL. We used a DerSimonian-Laird random-effects method to pool the proportions of men receiving ART and the hazard ratios for death by sex.
Results:
Twenty-three cohort studies, including 216 008 participants (79 892 men) contributed to our analysis. The pooled proportion of men receiving ART was 35% [95% confidence interval (CI): 33-38%]. The pooled hazard ratio estimate indicated a significant increase in the risk of death for men when compared to women [hazard ratio: 1.37 (95% CI: 1.28-1.47)]. This was consistent across sensitivity analyses.
Interpretation:
The proportion of men enrolled in ART programs in Africa is lower than women. Additionally, there is an increased risk of death for men enrolled in ART programs. Solutions that aid in reducing these sex inequities are needed.
To determine the relationship between sex and antiretroviral therapy (ART) outcomes in an urban Tanzanian setting.
Longitudinal analysis of a cohort of HIV-infected adult men and women on ART enrolled at the Management and Development for Health (MDH)-President's Emergency Plan For AIDS Relief (PEPFAR) HIV care and treatment program in Dar es Salaam, Tanzania.
Clinical and immunologic responses to ART were compared between HIV-infected men and women enrolled from November 2004 to June 2008. Cox regression analyses were used to study sex differences with regard to mortality, immunologic failure (WHO, 2006) and loss to follow-up, after adjusting for other risk factors for the outcomes.
Four thousand, three hundred and eighty-three (34%) men and 8459 (66%) women were analyzed. Men were significantly more immunocompromised than women at enrollment in terms of stage IV disease (27 vs. 23%, P < 0.001) and mean CD4⁺ cell count (123 vs. 136 cells/μl, P < 0.001). In multivariate analyses, men had a significantly higher risk of overall mortality [hazard ratio 1.19, 95% confidence interval (CI) 1.05-1.30, P < 0.001], immunologic nonresponse defined as CD4 cell count less than 100 cells/μl after at least 6 months of initiating ART (hazard ratio 1.74, 95% CI 1.44-2.11, P < 0.001) and loss to follow-up (hazard ratio 1.19, 95% CI 1.10-1.30, P < 0.001) than that in women. Associations did not change significantly when restricting analyses to the period of good adherence for all patients.
Nonadherence to care and advanced immunodeficiency at enrollment explained only 17% of the inferior mortality in HIV-infected men in this resource-limited setting. Additional study of behavioral and biologic factors that may adversely impact treatment outcomes in men is needed to reduce these sex disparities.
With increasing calls for linking HIV-infected individuals to treatment and care via expanded testing, we examined sociodemographic and behavioral characteristics associated with HIV testing among men and women in Soweto, South Africa.
We conducted a cross-sectional household survey involving 1539 men and 1877 women as part of the community-randomized prevention trial Project ACCEPT/HPTN043 between July 2007 to October 2007. Multivariable logistic regression models, stratified by sex, assessed factors associated with HIV testing and then repeated testing.
Most women (64.8%) and 28.9% of men reported ever having been tested for HIV, among whom 57.9% reported repeated HIV testing. In multivariable analyses, youth and students had a lower odds of HIV testing. Men and women who had conversations about HIV/AIDS with increasing frequency and who had heard about antiretroviral therapy were more likely to report HIV testing, and repeated testing. Men who had ≥ 12 years of education and who were of high socioeconomic status, and women who were married, who were of low socioeconomic status, and who had children under their care had a higher odds of HIV testing. Women, older individuals, those with higher levels of education, married individuals, and those with children under their care had a higher odds of reporting repeated HIV testing. Uptake of HIV testing was not associated with condom use, having multiple sex partners, and HIV-related stigma.
Given the low uptake of HIV testing among men and youth, further targeted interventions could facilitate a test and treat strategy among urban South Africans.
To investigate antiretroviral treatment (ART) interruption in a long-term treatment cohort in South Africa.
All adults accessing ART between 2004 and 2009 were included in this analysis. Defaulting was defined as having stopped all ART drugs for more than 30 days. Treatment interrupters were patients who defaulted and returned to care during the study, whereas loss to follow-up was defined as defaulting and not returning to care. Kaplan-Meier estimates and Poisson regression models were used to analyze rates and determinants of defaulting therapy and of treatment resumption.
Overall rate of defaulting treatment was 12.8 per 100 person-years (95% confidence interval: 11.4 to 14.4). Risk factors for defaulting were male gender, high baseline CD4 count, recency of ART initiation, and time on ART. The probability of resuming therapy within 3 years of defaulting therapy was 42% (event rate = 21.4 per 100 person-years). Factors associated with restarting treatment were female gender, older age, and time since defaulting.
Defaulting treatment need not be an irreversible event. Interventions to increase retention in care should target men, less immunocompromised patients, and patients during the first 6 months of treatment. Resumption of treatment is most likely within the first year of interrupting therapy.
This critique talks about the evidence that indicates we are doing a poor job of providing men with the medical assistance they need in the fight against HIV/AIDS. Addressing these issues effectively means moving beyond laying blame and starting to develop interventions to encourage uptake of prevention testing and treatment for men—for everyone’s sake.
In sub-Saharan Africa 12-13 women are infected by HIV for every 10 men, and the average rate of infection for teenage girls in some countries is five times higher than that for teenage boys.1 Most of these infections occur through unprotected heterosexual interactions. Women are limited in their ability to control these interactions because of their low economic and social status and because of the power that men have over women's sexuality.
Most of the world's women are poor and most of the world's poor are women. Women make up almost two thirds of the world's illiterate people and are often denied property rights or access to credit. They earn 30-40% less than men for the same work, and most of those who are working are employed outside the formal sector in jobs characterised by income insecurity and poor working conditions.2 Women's economic vulnerability and dependence on men increases their vulnerability to HIV by constraining their ability to negotiate the use of a condom, discuss …
The recording of outcomes from large-scale, simplified HAART (highly active antiretroviral therapy) programmes in sub-Saharan Africa is critical. We aimed to assess the effectiveness of such a programme held by Médecins Sans Frontières (MSF) in the Chiradzulu district, Malawi.
We scaled up and simplified HAART in this programme since August, 2002. We analysed survival indicators, CD4 count evolution, virological response, and adherence to treatment. We included adults who all started HAART 6 months or more before the analysis. HIV-1 RNA plasma viral load and self-reported adherence were assessed on a subsample of patients, and antiretroviral resistance mutations were analysed in plasma with viral loads greater than 1000 copies per mL. Analysis was by intention to treat.
Of the 1308 patients who were eligible, 827 (64%) were female, the median age was 34.9 years (IQR 29.9-41.0), and 1023 (78%) received d4T/3TC/NVP (stavudine, lamivudine, and nevirapine) as a fixed-dose combination. At baseline, 1266 individuals (97%) were HAART-naive, 357 (27%) were at WHO stage IV, 311 (33%) had a body-mass index of less than 18.5 kg/m2, and 208 (21%) had a CD4 count lower than 50 cells per muL. At follow-up (median 8.3 months, IQR 5.5-13.1), 967 (74%) were still on HAART, 243 (19%) had died, 91 (7%) were lost to follow-up, and seven (0.5%) discontinued treatment. Low body-mass index, WHO stage IV, male sex, and baseline CD4 count lower than 50 cells per muL were independent determinants of death in the first 6 months. At 12 months, the probability of individuals still in care was 0.76 (95% CI 0.73-0.78) and the median CD4 gain was 165 (IQR 67-259) cells per muL. In the cross-sectional survey (n=398), 334 (84%) had a viral load of less than 400 copies per mL. Of several indicators measuring adherence, self-reported poor adherence (<80%) in the past 4 days was the best predictor of detectable viral load (odds ratio 5.4, 95% CI 1.9-15.6).
These data show that large numbers of people can rapidly benefit from antiretroviral therapy in rural resource-poor settings and strongly supports the implementation of such large-scale simplified programmes in Africa.
Unequal benefits from ART: a growing male disadvantage in life expectancy in rural South Africa
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