Differences Between HIV-Infected Men and Women in Antiretroviral Therapy Outcomes -- Six African Countries, 2004-2012

November 29, 2013

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Editorial Note

Equitable access to ART for both men and women is a principle endorsed by most African governments and international donors, including the U.S. President's Emergency plan for AIDS Relief and the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria.2,3 However, in Africa, proportionally more HIV-infected women are accessing ART services than men.4 Evaluating differences in ART enrollment characteristics and treatment outcomes between men and women might help program managers understand these differences in ART enrollment and identify opportunities for ART program improvement.

This report has two main findings: 1) among representative samples of adult ART enrollees in six African countries, men were more likely than women to initiate ART with advanced HIV disease, and 2) men had higher attrition risk than women after ART initiation. However, differences between men and women in rate of attrition varied by country, being larger and statistically significant in western and southern African cohorts, but smaller and not statistically significant in cohorts from eastern Africa (Uganda and Tanzania).


As in other reports from African ART programs,2,5-7 men initiated ART at more advanced HIV disease stages than women. Late initiation of ART among men has commonly been attributed to sex differences in health-seeking behavior, with men considered more likely to delay access to health care for various reasons, including stigma, male norms that discourage admitting ill health, and employment responsibilities.2 However, some have proposed that the prioritization of maternal and child health services by global and national public health organizations in Africa has resulted in inequitable access to health services, including ART.2,3 Recent reports suggest that whereas nearly all African countries include initiatives focused on women in their national AIDS strategies, only 10% of countries are effectively engaging men and boys in the national AIDS response.8 To address delayed enrollment in ART among men, increased attention from national governments and international donors to identify and implement evidence-based strategies that achieve earlier HIV testing and ART among men might be needed.2,3

As in other studies from western and southern Africa,2,5,6,9 adjusting for possible baseline predictors of ART outcomes, including CD4 count, WHO HIV disease stage, age, and ART regimen, did not fully account for the increased rate of attrition among men in Côte d'Ivoire, Swaziland, Mozambique, and Zambia. This suggests unmeasured factors are contributing to either increased rates of death or loss to follow-up among men.2 Some reports have suggested sex differences in health-seeking behavior, biologic differences in response to ART, increased male risk for opportunistic infections, worse adherence to ART pill-taking among men, or background differences in mortality rates by sex in the general population are responsible for higher attrition rates among men taking ART.2

In this analysis, although rates of attrition were marginally higher among men than women in Uganda and Tanzania, the effect of sex on attrition risk was smaller than that observed in cohorts from western and southern Africa. This might indicate variations in the effect of sex on attrition risk by country or region. One possible explanation is that internal and cross-border migration patterns vary by country and region. Historically, cross-border migration for work, which is more common among men than women, varies by region in Africa, being most common in western10 and southern Africa, where South Africa is a hub for migrant labor from surrounding countries.10 Further research into variations in the effect of sex on attrition risk by country or region might inform interventions to reduce rates of male attrition.

The findings in this report are subject to at least two limitations. First, missing data for certain covariates of interest at ART initiation might have introduced some measurement error, and might have affected estimates of hazard ratios. Second, because of differences in cohort size, there was greater power to detect differences in outcomes between men and women in Swaziland, Mozambique, and Côte d'Ivoire than in Zambia, Uganda, and Tanzania, which limits ability to make conclusions about country variations in the effect of sex on attrition risk.

Across six countries in Africa, men initiated ART with more advanced disease and had statistically significant higher attrition in western and southern African cohorts. Reasons for differences between men and women in ART enrollment are not fully understood but might include lack of emphasis by donors and national governments on the importance of engaging men early in ART.3 Higher attrition rates among men are not fully explained by traditional predictors of poor outcomes (e.g., low CD4 count and advanced WHO HIV disease stage). Identifying and implementing evidence-based interventions to improve male enrollment and retention in ART programs is important to reduce male AIDS-related mortality and might contribute to prevention of new HIV infections in female partners.3


  1. Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 1994;81:515-26.
  2. Cornell M, Schomaker M, Garone DB, et al. Gender differences in survival among adult patients starting antiretroviral therapy in South Africa: a multicentre cohort study. PLoS Med 2012;9(9)e1001304.
  3. Cornell M, McIntyre J, Myer L. Men and antiretroviral therapy in Africa: our blind spot. Trop Med Int Health 2011;16:828-9.
  4. Muula AS, Ngulube TJ, Siziya S, et al. Gender distribution of adult patients on highly active antiretroviral therapy (HAART) in Southern Africa: a systematic review. BMC Public Health 2007;7:63.
  5. Auld AF, Mbofana F, Shiraishi RW, et al. Four-year treatment outcomes of adult patients enrolled in Mozambique's rapidly expanding antiretroviral therapy program. PLoS One 2011;6(4)e18453.
  6. Stringer J, Zulu I, Levy J, et al. Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. JAMA 2006;296:782-93.
  7. Mosha F, Muchunguzi V, Matee M, et al. Gender differences in HIV disease progression and treatment outcomes among HIV patients one year after starting antiretroviral treatment (ART) in Dar es Salaam, Tanzania. BMC Public Health 2013;13:38.
  8. Joint United Nations Programme on HIV/AIDS. UNAIDS report on the global AIDS epidemic. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2012.
  9. Toure S, Kouadio B, Seyler C, et al. Rapid scaling-up of antiretroviral therapy in 10,000 adults in Côte d'Ivoire: 2-year outcomes and determinants. AIDS 2008;22:873-82.
  10. African Development Bank. Migration patterns, trends and policy issues in Africa. Tunis, Tunisia: African Development Bank; 2010.

What is already known on this topic?

Evaluating differences between human immunodeficiency virus (HIV)-infected men and women in antiretroviral therapy (ART) enrollment characteristics and treatment outcomes can help program managers understand why proportionally more women than men are accessing ART.

What is added by this report?

This retrospective cohort study of six African countries found lower median CD4 counts and more World Health Organization stage IV HIV disease in men at enrollment in all six countries. In addition, the risk of attrition during ART was significantly higher in men in western and southern African countries, even after controlling for possible baseline predictors of ART outcomes. This finding suggests that unidentified factors are contributing to this higher attrition risk in these countries. In eastern Africa, risk for attrition did not differ significantly between men and women.

What are the implications for public health practice?

Further research on country-specific reasons for differences between HIV-infected men and women in ART enrollment and in attrition while on ART are needed. The results of such studies could potentially identify strategies to improve early diagnosis and treatment among men and improve program outcomes.

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This article was provided by U.S. Centers for Disease Control and Prevention. It is a part of the publication Morbidity and Mortality Weekly Report. Visit the CDC's website to find out more about their activities, publications and services.

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