Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men.

John S Lambert,Elisa Lopez-Varela,Orvalho Augusto,Paula Vaz,Denise Naniche,Isabelle Casavant,Esmeralda Karajeanes,Charfudin Sacoor,Ariel Nhacolo,Laura Fuente-Soro

doi:10.1371/journal.pone.0245461

Abstract

HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique. This analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI). Among 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (p<0.001). MI did not significantly modify all-age HIV-prevalence for men but did decrease prevalence estimates in women from 36.4%to 33.0%. Estimated proportion of HIV-infected individuals aware of their status was 75.9% for men and 88.9% for women. In individuals <25 years, we observed up to 22.2% disparity in awareness of serostatus between genders. Among individuals eligible for ART, similar proportions of men and women initiated treatment (81.2% and 85.9%, respectively). Fourfold more men than womenwere in WHO stage III/IV AIDS at first clinical visit. Once on ART, men had a twofold higher 18-month loss to follow-up rate than women. The contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement.

Highlights

In 2014, UNAIDS set the ambitious global strategy of reaching the 90-90-90 targets to end the HIV epidemic by 2020: 90% of people living with HIV (PLWHIV) will know their HIV status, 90% of those will be on antiretroviral therapy (ART), and of those, 90% will reach viral suppression
Health demographic surveillance systems (HDSS) can provide crucial metrics and identification of outcomes such as loss to followup (LTFU), death, and silent transfers, all of which are challenging in many regions of subSaharan Africa that lack updated census and tracking systems
In Manhica, achievement of the first 90 target in men and women was higher than the UNAIDS estimates for Mozambique of 59% based on back-calculation of HIV national prevalence

Summary

Introduction

In 2014, UNAIDS set the ambitious global strategy of reaching the 90-90-90 targets to end the HIV epidemic by 2020: 90% of people living with HIV (PLWHIV) will know their HIV status, 90% of those will be on antiretroviral therapy (ART), and of those, 90% will reach viral suppression. According to the most recent UNAIDS global HIV data report on the progress towards these targets, men are lagging behind at 75-74-85 compared to 84-81-87 for women [2,3]. The incidence of new HIV infections in sub-Saharan Africa is higher in women, HIV-positive men have a 41% higher risk of dying than HIV-positive women [4,5,6]. In South Africa, estimates show that 51% of women living with HIV receive ART compared to 37% of men [7]. In Mozambique, according to the latest HIV prevalence survey, 78.2% of self-reported HIV-positive women receive ART compared to 68% of men [8]. HIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. By gender, the first two UNAIDS 90 targets in rural southern Mozambique

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