Public health blindness towards men in HIV programmes in Africa

For some years, concerns have been raised about the blindness towards men in HIV and antiretroviral therapy (ART) services in Africa 1-12. Compared to women in African ART programmes, men are less likely to be diagnosed with HIV 13, 14, less likely to start ART 11, 15, more likely to start ART with advanced HIV disease and at older ages 4, 6, 16 and have shorter life expectancy and higher mortality rates on ART 17-19. Recently, the Strategic Timing of AntiRetroviral Treatment (START) study announced that in studies in 35 countries worldwide, early ART reduced the risk of death or serious adverse events by 57% and reduced the risk of HIV transmission 20. On this basis, the new WHO ART guidelines will recommend ART initiation for all with a confirmed HIV diagnosis, increasing the estimated number of individuals eligible for ART from 28 to 37 million 21. Such a dramatic expansion of access to ART may exacerbate existing gender disparities in HIV programmes unless men's access to HIV services is increased substantially. One way to reach men is by adapting HIV services to their needs. In 2007, a male-only walk-in HIV/STI screening clinic open until 6 pm was established at a taxi rank in Khayelitsha, a large township near Cape Town 22. The number of men receiving HIV testing and counselling (HTC) grew rapidly – 27% of all men tested per year in Khayelitsha tested in this clinic alone. Men testing positive were referred to a nearby health centre for ART. However, despite the increased rate of HTC, the proportion of men initiating ART did not increase from 2007 to 2012 23. Men initiated ART with more advanced HIV disease than women 22, and in unreported data from the same analysis, among those starting ART with CD4 cell counts <50 cells/ml, the proportion of males increased from 41% in 2007 to 49% in 2011/2012. The low ART uptake, together with men's more advanced HIV disease at ART initiation, suggested that men experienced barriers in accessing ART despite their willingness to test for HIV. To explore male preferences regarding ART services, MSF and Anova Health Institute undertook a survey at the aforementioned clinic 24. The responses were enlightening: among 200 male clients, 99% would prefer attending a male clinic for ART services and 96% requested extended clinic hours and close proximity to home or public transport hubs. Informed by this survey, a once weekly male after-hours service was started in an existing large ART clinic in Khayelitsha. Since its inception in late 2014, the clinic has seen a monthly increase in men accessing HCT and ART services between 4 and 8 pm. Linking men to HIV care may have additional benefits beyond reducing HIV-related male mortality. In a study of >46 000 South African adults, men had a 31% higher risk of death than women over 36 months, after adjusting for gender differences in age and stage of disease at ART initiation 4. Of note, this difference was smaller than the age-standardised death rates in a hypothetical cohort of HIV-negative South Africans, where men were twice as likely to die as women. Simply being in care appeared to be protective for men, possibly through access to other preventive and curative services that could reduce non-HIV mortality. We call for widespread targeted HTC campaigns and HIV and ART services for men. Such public health HIV strategies could both reduce the gender difference in mortality in ART programmes and reduce community transmission between men and women.