Persistent gender inequities in ART uptake and retention in sub-Saharan Africa – strategies needed to better engage men.

Differences Between HIV-Infected Men and Women in Antiretroviral Therapy Outcomes - Six African Countries, 2004-2012.

Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2013 Nov 29;62(47):946-52.

Evaluation of differences between human immunodeficiency virus (HIV)-infected men and women in antiretroviral therapy (ART) enrollment characteristics and outcomes might identify opportunities to improve ART program patient outcomes and prevention impact. During September 2008-February 2012, retrospective cohort studies to estimate attrition of enrollees (i.e. from death, stopping ART, or loss to follow-up) at 6-month intervals after ART initiation were completed among samples of adult men and women (defined as aged ≥15 years or aged ≥18 years) who initiated ART during 2004-2010 in six African countries: Côte d'Ivoire in western Africa; Swaziland, Mozambique, and Zambia in southern Africa; and Uganda and Tanzania in eastern Africa. Records for 13 175 ART enrollees were analyzed; sample sizes among the six countries ranged from 1 457 to 3 682. In each country, women comprised 61%-67% of ART enrollees. Median CD4 count range was 119-141 cells/µL for men and 137-161 cells/µL for women. Compared with women, a greater percentage of men initiated ART who had World Health Organization (WHO) HIV stage IV disease. In cohorts from western Africa and southern Africa, the risk for attrition was 15%-26% lower among women compared with men in multivariable analysis. However, in eastern Africa, differences between men and women in risk for attrition were not statistically significant. Research to identify country-specific causes for increased attrition and delayed initiation of care among men could identify strategies to improve ART program outcomes among men, which might contribute to prevention of new HIV infections in female partners.

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Editor’s notes: Equitable access to treatment is a widely endorsed principle in all fields of medicine. This study on gender differences in the uptake and outcomes of antiretroviral therapy (ART) provides programme managers with the evidence to assess and possibly rectify any imbalance. The study is based on clinical cohort data from six geographically diverse African countries. The study found that (1) women account for the majority of patients on ART, (2) they are less likely to enrol with advanced HIV disease, and (3) they have lower attrition rates (mortality, loss to follow up, etc.), after adjusting for possible baseline predictors of survival such as the CD4 count. The first of the three findings may be related to higher eligibility rates in women, which is difficult to assess using clinical data alone. It may also be related to the evidence in favour of higher male attrition rates that was not as strong in the two East African sites. We also need to bear in mind that higher attrition may result from causes unrelated to HIV (see Sabin CA in this issue). Aside from these caveats, the results do indeed suggest that greater effort is necessary to engage men in HIV treatment and care programmes.  This will rectify the apparent imbalance in treatment uptake and outcomes, and it will also have implications for onward transmission to their (female) partners. 

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