CROI 2016: HIV trial data raises the question of how to end an epidemic when men are “missing but in action . . .”

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Science Speaks is in Boston this week covering the Conference on Retroviruses and Opportunistic Infections

Science Speaks is in Boston this week covering the Conference on Retroviruses and Opportunistic Infections

Where are the men?

In HIV responses across the countries hardest hit by the pandemic, the subject of men comes up often — as sugar daddies who drive HIV acquisition among school girls, as partners of pregnant women living with HIV, and as men who beat their wives — or, as it is more often put in some circles, as perpetrators of “GBV.”

But their numbers — among people living with HIV who have been diagnosed, are in care and receiving life-saving and virus suppressing antiretroviral treatment — reflect neither the impact of HIV among them, or the role of their disproportionate absence from the treatment rolls in driving ongoing incidence, presentations here have highlighted.

On Thursday, a presentation at the 2016 Conference on Retroviruses and Opportunistic Infections examining the impact of antiretroviral treatment coverage on HIV incidence in South Africa noted findings in one study showing the overwhelming majority of people who didn’t know their partners’ HIV status were women. The reason for this knowledge gap, Catherine Oldenberg who presented those findings, noted, is the greatly lower numbers of men who have been tested.

The day, before findings from the Pop ART (or HPTN 072) trial examining the impacts of full coverage in South Africa and Zambia communities of intensive HIV interventions — including combination prevention, testing, and treatment on infection rates —  had highlighted some of the reasons for that. In that trial, community workers offering access to those services found a gap — while 90 percent of women in the eligible population reached accessed those services, only 77 percent of men did.

The difference wasn’t because fewer men wanted services, Helen Ayles of the London School of Hygiene and Tropical Medicine said, but because fewer men were found.

Women not only visit health facilities more frequently than men, for antenatal care and other reproductive health services, but also are likelier to benefit from community-based door-to-door outreach because they are likelier to be at home. Ayles, who is lead investigator of Pop ART in Zambia noted some of the other reasons — including the marginalization and stigma driven by messages portraying of men as vectors of disease, and as part of the problem rather than part of the solution — which further discourages men from seeking health care, and programs from meeting their needs.

And while men lag behind women in accessing health care, their rates of premature mortality, from HIV as well as other causes, greatly exceed those of women, Ayles noted.

Ayles pointed to findings from other studies that already have yielded insights on how to reach more men. Researchers from the SEARCH collaboration of University of California, San Francisco and Makerere University investigators found testing campaigns reached more men when they broadened their range of settings, and that more men were found on weekends than weekdays. Another study, she said, found young men in Malawi welcomed self-testing.

She also pointed to some of the insights yielded by asking men what they wanted. Male-only clinics would be nice, some said — not an extraordinary request, given the number of solely or primarily female-oriented health settings. Extended after-work hours would help. A clinic near a transport hub would be used more by men, answers indicated. And men wanted other services, outside of HIV, including eye exams, she said.

In a discussion after the presentation, Dr. Renee Ridzon, an infectious diseases physician and consultant for Akeso Associates, pointed out settings already exist where men can get both HIV testing and greater protection against the virus: clinics that provide medical circumcision.

And as a number of presentations highlighted throughout the conference, streamlined and cost effective services — that provide direct and immediate links to antiretroviral treatment and allow patients to travel to clinics less often to get treatment — will knock down barriers standing between care and the people who need it.

“Equity means providing both genders what they need,” Ayles said. She had already noted in a press conference prior to her presentation, “Unless we reach everyone, we’re never going to end the epidemic.”

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