Gender inequality: Bad for men's health

Abstract

FORUMMen's increased risk of death in ART programmes in sub-Saharan Africa is widely reported but poorly understood. Some studies have attributed this risk to men's poorer health-seeking behaviour, which may prevent them from accessing ART, being adherent to treatment, or remaining in care. In a multicentre analysis of 46 201 adults starting ART in urban and rural settings in South Africa, these factors only partly explained men's increased mortality while receiving ART. Importantly, the gender difference in mortality among patients receiving ART (31% higher for men than women) was substantially smaller than that among HIVnegative South Africans, where men had twice the risk of death compared with women. Yet, this extreme gender inequality in mortality, both within and outside of ART programmes, has not given rise to widespread action. Here it is argued that, despite their dominance in society, men may be subject to a wide range of unfair discriminatory practices, which negatively affect their health outcomes. The health needs of men and boys require urgent attention. Sub-Saharan Africa is the centre of the HIV epidemic, with an estimated 68% of all people HIV-infected.[1] Over the past 10 years, largely through international aid programmes, there has been a dramatic increase in the number of HIV-infected individuals who have started antiretroviral therapy (ART) in the region. Despite early concerns that women may be disadvantaged in ART programmes, disproportionately more women than men have accessed ART in Southern Africa.[2] In South Africa, for example, 60% of eligible women were receiving ART by mid-2011 compared with 41% of eligible men. [3] Men have a higher mortality than women when receiving ART. [4][5][6][7][8] Although the reasons for this are poorly understood, a number of possible explanations have been suggested; some implicitly blame men for their own poorer outcomes. For example, numerous studies have suggested that men's poorer 'health-seeking behaviour' may prevent them from accessing ART services, being adherent to treatment or remaining in care. But, is this based on evidence or is it an assumption that has gained currency through widespread usage?To date, there has been no systematic attempt to understand the phenomenon of gender differences on ART. In the past year, we explored the issue in an analysis including 46 201 adults initiating ART in 8 large urban and rural South African cohorts between 2002 and 2009.[5] As 60% of our patients had civil identification (ID) numbers, it was possible to confirm their vital status through linkage to the National Population Register, estimated to capture over 90% of deaths nationally. [9] We were also able to track patients with IDs after they were lost to follow-up (LTF) and confirm whether they were alive or dead. Men's increased mortality on ART unrelated to HIV/AIDSAt the start of treatment, on average men had lower CD4+ cell counts and more advanced HIV disease than women. After we adjusted for such gender differences at ART initiation, men still...

A cross-sectional, facility based study of comorbid non-communicable diseases among adults living with HIV infection in Zimbabwe

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