HIV mortality has declined significantly faster among women than men in rural South Africa since free treatment became widely available, and a high proportion of HIV-related deaths are occurring among men who have never sought care in public clinics or hospitals, according to a new study led by a School of Public Health researcher.
In a study published in PLOS Medicine, Jacob Bor, assistant professor of global health, and colleagues from SPH and the Wellcome Trust Africa Centre for Health and Population Studies in South Africa found that the scale-up of antiretroviral therapy (ART) that began in 2004 has benefitted women more than men.
Female adult life expectancy in rural South Africa increased from 51.3 years in 2003 to 64.5 years in 2011, a gain of 13.2 years, the study found. Male adult life expectancy increased from 46.9 years in 2003 to 55.9 years in 2011, a gain of only 9.0 years. The gap between female and male adult life expectancy doubled, from 4.4 years in 2003 to 8.6 years in 2011.
HIV mortality among women declined from 1.6 deaths per 100 person-years in 2003 to 0.56 per 100 person-years in 2011. For men, HIV-related mortality declined less sharply, from 1.71 per 100 person-years to 0.76 per 100 person-years in the same period.
The research team, which includes global health research professor Sydney Rosen, said there are a number of possible explanations for the growing disparity in HIV mortality, including delayed care-seeking among men and gender differences in adherence and retention in treatment. For example, men and women have “starkly different levels” of utilization of HIV care and treatment: In 2011, more than twice as many women in the population had accessed care or initiated ART as men—16.9 percent, compared with 6.6 percent.
“We have documented that a substantial proportion of HIV-related deaths occur among people who have never sought care,” the authors wrote. “Further research is needed to understand the reasons that people dying from HIV choose not to seek free and widely available life-saving treatment.”
Given the higher risk faced by men, the researchers suggested, “population-wide interventions could be implemented to educate men about the benefits of timely ART initiation for one’s own health, economic productivity, the economic wellbeing of the household, and the health of one’s sex partners.”
Bor says that, traditionally, gender-sensitive programming has emphasized the needs of women.
“It is clear that health systems are not meeting the needs of HIV positive men in rural South Africa. Men have not benefited equally from ART rollout. Given the benefits of ART in reducing transmission, both men and women stand to benefit from targeted outreach to men,” he says.
The study is the first to document the emergence of male sex as a risk factor for HIV mortality at the population level with the scale-up of HIV treatment. Previous studies in southern Africa have found that men are less likely to get tested for HIV, less likely to link to care, and often start ART when they are already very sick and have suffered permanent immune damage. Gender differences also have been reported in health outcomes among patients who have initiated ART, with male patients experiencing higher mortality and worse recovery of immune function. However, the aggregate impact of these deficits on population-level HIV mortality had not been assessed.
Data for the study were collected on all deaths in rural KwaZulu-Natal, South Africa, from 2001 to 2011 in a large population-based surveillance cohort (52,964 women and 45,688 men, ages 15 years and older). Data on causes of death were obtained through “verbal autopsy” interviews, in which a trained nurse interviewed household members of the deceased about the events leading up to a death. Individual demographic data were linked to clinical records from the public HIV treatment program, and annual rates of HIV-related mortality were assessed for men and women separately.
Bor says that identifying barriers to men’s care-seeking was “critically important, given the high proportion of HIV-infected South African men who may not be aware they are HIV-positive or may not feel comfortable seeking care.”
He says that he hoped the study would help to underscore opportunities for future interventions “to increase uptake of ART among men, and to reduce the lingering burden of HIV mortality and HIV transmission in the context of free and widely available treatment.”