Finding men with HIV – and keeping them in treatment

Specialised services to attract men to HIV testing and treatment may need to adopt several different formats in order to reach different sub-populations of men, suggesting there is no single service innovation that will boost uptake among men in sub-Saharan Africa, research from South Africa presented at last month’s Conference on Retroviruses and Opportunistic Infections (CROI) shows.

In generalised epidemics in sub-Saharan Africa, men are less likely to test for HIV than women. The PopART study of Test and Treat in Zambia found that men were less likely to test for HIV when testing was offered through household testing campaigns, because they were away from home or out at work.

Encouraging men to test for HIV may require the provision of testing and treatment services that fit in with working patterns. Men frequently complain that clinic opening hours make it difficult for them to attend without missing paid work.

Another complaint voiced – often linked to concerns around stigma and confidentiality – is that HIV clinics are mainly geared to women and children. Attending what are commonly seen in the community as women’s services can signal that a man is HIV positive.

To address each of these barriers, MSF (Medecins Sans Frontieres), in partnership with the City of Cape Town and the Western Cape Department of Health, established two services in Khayelitsha township, each designed to attract men.

One clinic, the daytime clinic, opens from 8am to 4.30pm, Monday to Friday. The other clinic, a male after-hours clinic, opens from 4pm to 7.30pm on Wednesdays. Both clinics have all-male staff, offer diagnosis and treatment of sexually transmitted infections (STIs), HIV testing and counselling, point-of-care CD4 cell testing for anyone diagnosed with HIV, HIV treatment initiation and drug dispensing, and antiretroviral therapy (ART) adherence clubs.

Researchers compared uptake, treatment initiation and retention in care of the two services between the opening of the services in June 2014 and September 2016.

Due to its longer opening hours, the daytime clinic had a much higher median number of visits per month (529) than the after-hours clinic (75) (p < 0.001). Almost half of the visits (45%) to the daytime clinic included the diagnosis and treatment of an STI, indicating the importance of STI testing and treatment as a gateway for HIV testing and treatment for men. In comparison, 21% of visits to the after-hours clinic involved diagnosis and treatment of an STI.

HIV testing and counselling took place in high volumes at each clinic (291 tests per month at the day clinic and 25 tests per month at the after-hours clinic), and around half of HIV testing and counselling took place as a consequence of a visit for STI diagnosis and treatment. Prevalence was higher among attendees at the after-hours clinic (8.5% vs 5.9%, p = 0.004).

Those diagnosed with HIV at the after-hours clinic tended to have lower CD4 cell counts (330 cells/mm³ vs 384 cells/mm³) although this difference was not statistically significant, and if eligible for treatment, were more likely to start treatment after diagnosis (91% vs 70%, p < 0.001). Six months after starting treatment, retention among those who started after diagnosis at the clinics was higher among those attending the after-hours clinic (98% vs 88%).

Attendees at the after-hours clinic were much more likely to present as HIV positive (64% vs 14%). Due to its convenient opening hours, the after-hours clinic attracted a large number of men already on ART who transferred from other services. Forty-three per cent of men receiving ART through the clinic had transferred from another clinic, compared to 8% of the male day clinic cohort. There was no substantial difference in retention between the two clinics among those who transferred in to the clinics from other services (91% in the day clinic and 89% in the after-hours clinic).

Another study, conducted in a large population in rural KwaZulu-Natal in South Africa, found that men became more motivated to test when others in their household became eligible for HIV treatment. The Africa Health Research Institute population study in the Hlabisa district of KwaZulu-Natal province is collecting demographic data and blood samples from households and linking that data to health records, in order to examine HIV testing, linkage to care and treatment initiation through health services in the district.

The population study surveyed 22,965 individuals in 5697 households between 2005 and 2013, and found that knowledge of HIV status increased by 17% among male household members if another person in the household had become eligible for antiretroviral treatment. The same effect did not hold true for women, probably because women were much more likely to know their HIV status at baseline. The study looked at eligibility for treatment, based on having a CD4 cell count below 200 cells/mm³ (the treatment threshold in South Africa prior to 2011), rather than actual treatment history, in order to test the effect of the knowledge of treatment availability on testing behaviour.

The researchers couldn’t be sure whether the effect was due to a greater intensity of testing activity in the district, or because men updated their beliefs about their HIV status and chose to test for HIV.