Men can be encouraged to test for HIV by other men and healthcare services targeted towards them, but men are often overlooked for HIV testing when they do attend healthcare facilities, studies from Zambia and Malawi presented at the 23rd International AIDS Conference (AIDS 2020:Virtual) this week show.
Men with HIV are consistently less likely to be diagnosed with HIV, demographic studies show, and less likely to take an HIV test. Understanding the factors that encourage men to test for HIV or make testing more accessible might help to improve testing uptake and HIV diagnosis in men in sub-Saharan Africa.
Zambia: Factors encouraging men to test in the PopART study
Mwelwa Phiri and colleagues in the PopART study team looked at what factors had encouraged HIV testing during the door-to-door testing campaign in the PopART study, focusing specifically on the third round of testing in Zambia.
PopART, also known as HPTN 071, was a large community-randomised trial carried out in Zambia and KwaZulu Natal, South Africa. The study tested the impact on HIV incidence of household-based HIV testing and linkage to care by community HIV care providers (CHiPs), and immediate initiation of antiretroviral treatment delivered through routine healthcare services. The strategy led to a 30% reduction in HIV infections, investigators reported in 2019, and demonstrated that it was possible to rapidly achieve 90-90-90 targets for testing, treatment and viral suppression in rural and urban areas.
The study also reported high uptake of home-based HIV testing, but found challenges in contacting men for testing.
During the third round of door-to-door testing, investigators evaluated which household or community health worker factors were most strongly associated with acceptance of HIV testing in men who had not tested before. They identified 9172 men who were previously untested and who lived in areas covered by community healthcare workers offering testing. Seventy-two per cent of these men consented to take an HIV test.
Testing acceptance was strongly associated with acceptance by other members of the household. Compared to households where no one else was tested, men were almost 15 times more likely to accept testing if another adult in the household agreed to a test and 21 times more likely to test if another man in the household agreed to a test.
Community health worker characteristics had a modest impact on testing acceptance. Community health workers who were at least five years older than the male participant had a greater influence than health workers of a similar age (adjusted odds ratio 2.28 [1.82-2.87]).
Malawi: Lack of testing offers for men
In the absence of household testing, how can health facilities encourage men to test? A study from Malawi suggests that a good first step might be to ask them if they want an HIV test.
The study assessed the use of health facilities and HIV testing in 1116 men in 36 villages in Malawi who had not tested HIV-positive. Fifty-five per cent had never tested for HIV or had tested at least one year previously, and of this group, 65% had attended a health facility in the previous year and 82% in the previous two years. Only 7% said they were offered an HIV test during a visit in the previous year and 45% said that they had not been offered a test. Forty-one percent had visited the health facility as a guardian or to support another person during a healthcare visit. The lack of testing was most pronounced in young men aged 15-24 years.
The lack of testing of men in health facilities represents a major missed opportunity, said Dr Kathryn Dovel of David Geffen School of Medicine, University of California.
“Our findings challenge prominent narratives that men do not attend health facilities,” she said.
“A surprising portion of men’s health visits were as guardians. These findings provide important information to any health service intervention trying to reach men – the majority of men can be reached during routine health visits they are already making.”
Zambia: Men feel shut out from health care and fear stigma
A qualitative study of health-seeking behaviour among young men aged 20-34 in Zambia found that men’s attitudes to health care and HIV testing were conditioned by fear of stigma and discrimination, and of undignified death from AIDS. They also felt shut out from the health system and unwelcome in health facilities, unable to obtain care from male healthcare providers and concerned about having to share facilities with women and children. Bad experiences in healthcare facilities tended to be shared with other men, discouraging them from seeking health care.
“So, we need a clinic specifically just for men… if it is possible, even just create rooms where men can go and lock themselves away from others,” one service user in Lusaka said.
Malawi: Dolutegravir roll-out closes the gender gap in viral suppression
Lower viral suppression rates in men on HIV treatment have been reported in some countries, due to non-adherence. These gender differences tend to be more pronounced in younger people. Monitoring of the roll-out of dolutegravir as a replacement for efavirenz in Malawi shows that the transition to dolutegravir has closed the gender gap in viral suppression.
The transition to dolutegravir in Malawi began in January 2019. Comparison of viral load measurements in April 2019 and April 2020 shows that viral suppression increased in all male age groups, although the greatest increase was seen in age groups under 20. Viral suppression equalised in men and women.
It’s unclear if the improvement in viral suppression is due to improved adherence resulting from better tolerability of dolutegravir, or a lower likelihood of viral rebound when doses are missed.
Chikuma-Macleod M et al. Zambia male characterization study: Insights to inform HIV programming to increase men's HIV service utilization. 23rd International AIDS Conference, abstract OAD0202, 2020.
Hamisi T et al. Transition to dolutegravir-based regimens improves overall viral-load suppression in the national ART cohort in Malawi and closes the gender gap. 23rd International AIDS Conference, abstract OAE0502, 2020.
Dovel K et al. "Missing men" or missed opportunity? Men's frequent use of health services in Malawi. 23rd International AIDS Conference, abstract OAE0503, 2020.
Phiri M et al. Factors encouraging men to test for HIV for the first time in HPTN 071(PopART) communities in Zambia. 23rd International AIDS Conference, abstract OAE0504, 2020.
Full image credit: Community Health Workers Riding to Visit Patients in Need. Baylor College of Medicine Children's Foundation–Malawi / Chris Cox. Available at www.flickr.com/photos/usaid_images/14929179975/ under a Creative Commons licence CC BY-NC-ND 2.0.