Date Published: April 11, 2017
Publisher: Public Library of Science
Author(s): Monisha Sharma, Ruanne V. Barnabas, Connie Celum
Abstract: Monica Sharma and colleagues discuss evidence-based approaches to improving HIV services for men in sub-Saharan Africa.
Partial Text: The successful scale-up of antiretroviral therapy (ART) in sub-Saharan Africa (SSA) will require policy makers to address the gender gap in HIV testing and treatment access. Men in SSA are less likely than women to undergo HIV testing and more likely to start ART at advanced disease stages and interrupt or drop out of ART . These disparities have resulted in a life expectancy gap of up to 10 years between HIV-positive men and women [2–5]. Low male testing and treatment rates also increase HIV transmission to female partners. For example, pregnant women in SSA have high HIV testing coverage through antenatal care (ANC) yet have twice the HIV incidence of nonpregnant women . This can be partially attributable to low testing rates in their male partners. In Kenya during 2013, 88% of pregnant women were tested for HIV compared to 4.5% of their male partners [7,8].
Accurate HIV prevalence estimates are crucial for designing and evaluating prevention programs. However, HIV surveillance programs such as Demographic and Health Surveys (DHS) are expensive to implement. Instead, much of SSA relies on prevalence estimates extrapolated from ANC data, which exclude men altogether . Countries with DHS tend to have more accurate HIV prevalence estimates. However, measuring male HIV prevalence can be difficult as disproportionately more men decline DHS participation (although nonparticipation is an issue for both sexes). Studies show that DHS often underestimate HIV prevalence, indicating nonparticipation is related to knowledge of HIV status [15–17]. An analysis of 12 DHS found that 10 of the 12 surveys underestimated male HIV prevalence, with bias-corrected estimates up to 9% higher than original DHS prevalence estimates . Another study evaluating DHS in Zambia found that the sex gap in HIV prevalence disappeared after correcting for nonparticipation, with prevalence in men increasing from 12% to 21% . Underestimating HIV prevalence can lead to prevention policies that do not adequately address the male HIV burden. Advanced methods to adjust HIV prevalence for nonparticipation including instrumental variables and Heckman-type selection models can generate more accurate estimates [15,17,18]. These methods will become increasingly important as knowledge of HIV status increases in SSA, which can increase the bias in DHS estimates . Additionally, bias correction is one of the few viable options for obtaining accurate HIV prevalence estimates in settings such as the Swaziland HIV Incidence Measurement Survey (SHIMS), which had lower response rates for men (65%) compared to women (81%) despite up to nine repeated home visits to reduce nonparticipation in the survey .
Facility-based HTC has achieved limited coverage in men. Studies highlight men’s desire to test outside clinics , with some men preferring to test at home , while others have concerns about the confidentiality of home testing  and consider mobile HTC to be more private . As there is no one-size-fits-all approach, a variety of community-based HTC strategies will likely be needed to achieve high testing coverage (Table 1). Meta-analyses find that community HTC achieves higher population coverage than facility testing , with home and mobile HTC increasing coverage in men (mobile having a larger effect than home HTC) . Community HTC reaches more first-time testers, suggesting expanded coverage to persons who may not otherwise undergo facility testing . Additionally, community HTC identifies asymptomatic HIV-positive men at higher cluster of differentiation 4 (CD4) cell counts . This can facilitate earlier linkage to ART, preventing morbidity, mortality, and transmission.
The success of HTC strategies depends on their ability to link and engage HIV-positive individuals in care. Extra support may be needed to ensure linkage in community-based modalities, as they are conducted outside of health care systems . Community HTC with facilitated linkage (e.g., counsellor follow-up) has achieved higher linkage than HTC without such support . However, facility linkage rates after community HTC remain lower than what is needed for epidemic control [33,61]. Although community HTC reduces barriers to receiving an HIV test, individuals still must travel and wait at a clinic to obtain treatment. Community-based ART initiation is a convenient alternative to facility linkage. An RCT in Malawi found higher ART uptake with optional home ART initiation compared to facility initiation, with no difference in retention at 6 months . Notably, a recent systematic review found no current or planned trials evaluating community-based ART initiation in men in SSA; likewise, there is a lack of interventions for MSM .
More work remains to be done to reduce the gender disparity in HIV testing, linkage, and retention in care in SSA. Multicomponent interventions are needed to reduce stigma and address issues of masculinity and health-seeking behavior. Additionally, leveraging social support and providing poverty alleviation can change norms around testing and treatment while addressing other factors contributing to low engagement in care (e.g., food insecurity and poverty). Community-based testing, and potentially community-based ART initiation and medication resupply, can overcome barriers associated with clinics and strengthen male engagement across the care cascade. A variety of community HTC modalities can be implemented simultaneously to achieve maximum coverage. Targeted messaging to motivate men (e.g., protection of one’s sexual partner and future children, and restoration of health through ART) can increase testing uptake and linkage . Community-based “test and treat” strategies may reduce loss to follow-up associated with clinic-based ART initiation. Further, an integrated approach combining testing and treatment with other HIV interventions (VMMC and PrEP) and chronic disease screening can increase intervention program efficiency while reducing stigma. Further research is needed on community-based interventions that motivate male engagement in care, particularly later in the cascade (i.e., ART initiation and retention).