Leaving No Man Behind: Improving HIV Services for Men
July 22, 2015
Over the past decade, the South African government has made progress in tackling HIV, and now provides over three million patients with access to life-saving antiretroviral therapies (ARTs). Nearly seventy percent of the recipients are women. In May, I had the opportunity to discuss this gender disparity with Dr. Lynne Wilkinson outside the Ubuntu Clinic in Khayelitsha, South Africa – an impoverished township of Cape Town. Dr Wilkinson is the Project Coordinator for Médecins Sans Frontières (MSF)-Khayelitsha and according to her, men are being left behind. In response, MSF is piloting a new approach to improve male access to HIV services, with potential lessons for other areas with HIV high-prevalence.
Part of the gender disparity stems from the fact that over 60 percent of HIV positive patients in South Africa are women, but other factors play a significant role. One key reason more women access HIV services is that HIV testing has become a widespread part of antenatal care, as a way to prevent transmission of HIV from mother to child. HIV positive men, on the other hand, have fewer entry points to the public health system. As a result, men tend to have worse outcomes in terms of access to care, treatment initiation, and mortality. Studies shows that only 30 – 40 percent of HIV positive men attend clinics for treatment; and those that do often present at more advanced stages of disease and are more likely to be lost to follow-up, raising their risk of dying by approximately 31 percent. These gender disparities have been evident since the start of South Africa’s ART program, but Dr. Wilkinson argues the government and international donors have not taken adequate steps to address the issue.
To ascertain ways to improve linkages to HIV care for males and increase retention, MSF conducted a survey in 2012 with the Anova Health Institute. Out of 200 men polled, 99 percent of men said they prefer attending male-only clinics for ART services, even if it means longer waiting times. Over 95 percent said they preferred clinics that were closer to major public transport hubs and open after work. Surprisingly, nearly half of male patients admitted to avoiding primary health care services because of the presence of female staff, despite feeling welcome at those clinics. The entrenched gender norms deter men from discussing their sexual health with women. “Men will walk into clinics…but leave when I or other women try to talk about sexual health,” laments Dr. Wilkinson.
MSF’s survey highlights the need for male-centered services, and the organization is building on those findings to develop solutions to increase the number of men who access and remain in HIV care. The questionnaire does have its limitations, notably that the sample size comprised of a small, relatively well-educated and working class population specific to Khayelitsha (out of 200 men questioned, 78.5 percent were regularly employed and 88 percent had completed grade 10 or higher). In addition, “preferring” a male-centered model of care does not guarantee men would actually show up.
However, MSF and the City of Cape Town have each piloted two different male-oriented models, both of which have been successful. The Male After Hours Service program at MSF’s Ubuntu ART Clinic leverages a pre-existing ART clinic to provide after-hour services only to men by male health care workers. As a result, the model is efficient and easily replicable. Admittedly, it places an added burden on already overworked male health care workers, but Dr. Wilkinson argues that the staff are more than willing to volunteer their time. The City of Cape Town took a different approach by building a Site B male clinic which is near a transportation hub, open all day, and staffed by only by men. It is separate, standalone facility, which makes it costly and difficult to replicate.
Both male-oriented models faced an additional challenge: mobilizing male attendance. To galvanize the community, the MSF staff placed a radio ad, socialized the services at transport hubs and taverns, and even hosted two football tournaments with other organizations to galvanize awareness. These efforts required heavy, upfront time and resource investments, but are paying off: more than 50 percent of male HIV testing happens at the male only clinics in Khayelitsha, with patient retention rates reaching those of regular clinics, says Dr. Wilkinson. If proven successful, Cape Town might expand ART services to their other HIV/STI male clinic in Khayelitsha.
The South African government, on the other hand, has no plans to specifically target men. In a recent article published in the Mail and Guardian, the National Deputy Director General for Health, Yogan Pillay, is cited saying a male-oriented model will not work because it “excludes other groups like sex workers and youth.” Despite neglecting the presence of both male sex workers and youth in his statement, Dr. Pillay recognizes the need to reach men. However, he proposes “[going] to men in their communities instead of waiting for them to [attend male clinics].” This allows improved HIV services for men, while avoiding the costs associated with clinics. It seems the government is relying on their future National Health Insurance (NHI) scheme to resolve these gender inequities, because it features District Clinical Specialist teams designed to conduct the community health outreach that Dr. Pillay envisions. However, rollout of the NHI has been stalled, and progress remains to be seen.
Since visiting Khayelitsha, I have spoken to health experts who have echoed MSF’s message: health delivery systems will have to adapt to meet the needs of HIV positive men. In South Africa’s case, the government seems to have recognized the gender disparities in male HIV care, but has yet to propose robust solutions to address the issue. This is problematic because HIV positive men are a major contributor to new infections, especially among adolescent girl, and consequently help drive the epidemic. In order to contain and reverse the country’s AIDS crisis, it is crucial that their programs also address the specific realities faced by HIV-positive males.