Journal of the International Aids Society: Men & HIV, insights from sub-Saharan Africa

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Guest Editors: Wole Ameyan, James Ayieko, Anna Grimsrud, Tanya Shewchuk
Supplement Editor: Marlène Bras

Thirty years into the HIV response, there is growing recognition that engaging men will be key to reaching the global UNAIDS fast‐track targets of 90‐90‐90 by the end of 2020 – whereby 90% of people living with HIV know their status, 90% of those who know they are positive are on antiretroviral therapy (ART) and 90% of those on ART are virally suppressed [1]. The most recent global HIV data through 2018 show that progress towards the 90‐90‐90 targets for men lags behind at 75‐74‐85 compared to 84‐81‐87 for women [2]. Looking at the second 90, ART coverage is considerably lower for men than women globally (68% vs. 55%), and consistently lower in all of the seven World Health Organization (WHO) regions except Latin America [3].

Since the 2017 UNAIDS publication of “Blind spot: Reaching out to men and boys,” the global trend of poorer outcomes across the HIV care cascade for men has gained traction and focus from PEPFAR programmes, national departments of health, implementing partners and global normative agencies [4-8]. Furthermore, recent guidance from the WHO does highlight gender differences in HIV outcomes, including the substantial gap in reaching men with HIV testing services [9].

Our call for abstracts for this supplement highlighted this growing attention and sought to collect and promote approaches to reaching men with HIV testing, prevention, treatment, care and support services. The interest in this topic was reflected in the over 100 abstracts that we received, which emphasized several salient points on where the gaps are and where we should be headed.

First and foremost, it is time to shift away from a narrative that looks at men from a “safe” distance, blames men for poor health‐seeking behaviour and focuses on men solely to improve the health of their partners and children. Men need and are willing and deserve to have access to services for their own health. Engaging men in health services for their own health can further provide an entry point for programmes that may have a positive impact on improving the health of their families and communities.

Our second takeaway is that the current system is not working for anyone – all populations are negatively impacted by the current gender norms. As highlighted by The Lancet in their recent series on gender, equality, norms and health, “rigid gender norms undermine the health and wellbeing of all people – girls and women, boys and men, and gender minorities” [10]. This is true in HIV where, as outlined, men are not accessing and benefiting from ART in the same way as women, while at the same time, incidence rates among adolescent years girls and young women remain unjustifiably high [11] and outcomes among key populations, including men who have sex with men and transgender people, remain disturbingly poor [3].

Thirdly, given the global HIV response and the current spotlight on men, HIV programmes may be uniquely positioned to drive a larger men’s health agenda and plans within countries that are adapted to different settings. Data highlighting worse outcomes for men compared to women are not unique to HIV. The global burden of disease data sheds light on mortality rates presenting sex‐disaggregated data across geographies and notes that improvement is less pronounced, particularly for adult males where in several countries progress in mortality was “stagnant or increasing” [12]. There is evidence of increased morbidity among men from infectious diseases including tuberculosis (TB) [1314] and other conditions including cardiovascular diseases, respiratory diseases and injuries [15]. Higher rates of co‐infection with TB were demonstrated by Osler et al . in this supplement where men living with HIV were twice as likely to have TB compared to women living with HIV [16]. The experiences of the “Khotla” male‐centred services in Lesotho highlight both the importance of having a physical space within the health system for men and that a non‐vertical, comprehensive men’s health services offering is appealing to men [17].

Despite the large number of abstracts reviewed for this supplement, there were limited data and evidence to show what works. Much of the data describes challenges or current pilot programmes (often focused on HIV testing), with few examples highlighting where men’s health has been mainstreamed and health systems have been responsive to their needs.

Despite this, there is a strong case for health systems that are people‐centred and can be sensitive and responsive to the attributes of clients [18]. Put differently, we need differentiated service delivery for different populations. There are increasing calls for “x‐friendly services” which all include integration, service hours that work for patients, are offered by educated and sensitive staff and involve peers. This is universal – for men, for adolescents, for key populations, for women – the bottom line is that people, including men, want and need services that respond to their needs. The balance is to ensure these services can be offered within a public health approach and in resource‐constrained settings.

In this supplement, four key themes emerged. First, health systems are structurally gendered to address women’s health needs. Second, while there are considerable efforts, including through the MenStar Coalition [19], to reach younger men, there is a large number of “older” men (those over 35 years old) who require HIV services. The third theme is that programmes are going to need to be more creative and strategic to access and test men who truly do not know their HIV status. Some of the interventions studied around testing may be retesting those who know their status instead of reaching men who are unaware of their HIV‐positive status. This insight underscores not only the need for testing interventions to reach those unaware of their status but also corresponding services adapted so men start and stay on treatment. Finally, as described above, it’s time for a narrative shift away from “men as the problem” to one that views men as a group that is interested in health and able to be part of the solution where health systems adapt to meet men where they are.

July 9, 2020
Year of publication
2020
Resource types
Journal and research articles
Tags
community based care, HIV self-testing, men, access to care

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