Increased mortality among HIV-positive men on antiretroviral therapy: survival differences between sexes explained by late initiation in Uganda

Abstract

BackgroundWe aimed to assess the relationship between gender and survival among adult patients newly enrolled on antiretroviral therapy (ART) in Uganda. We also specifically examined the role of antenatal services in favoring women’s access to HIV care.MethodsFrom an observational cohort study, we assessed survival and used logistic regression and differences in means to compare men and women who did not access care through antenatal services. Differences were assessed on measures of disease progression (WHO stage and CD4 count) and demographic (age, marital status, and education), behavioral (sexual activity, disclosure to partner, and testing), and clinical variables (hepatitis B and C, syphilis, malaria, and anemia). A mediational analysis that considered gender as the initial variable, time to death as the outcome, initial CD4 count as the mediator, and age as a covariate was performed using an accelerated failure time model with a Weibull distribution.ResultsBetween 2004 and 2011, a total of 4775 patients initiated ART, and after exclusions 4537 (93.2%) were included in analysis. Men initiating ART were more likely to have a WHO disease stage III or IV (odds ratio: 1.46, 95% confidence interval [CI]: 1.29–1.66), and lower CD4 cell counts compared to women (median baseline CD4 124 cells/mm3, interquartile range [IQR]: 43–205 versus 147 cells/mm3, IQR: 68–212, P-value < 0.0001). Men were at an increased risk of death compared to women (hazard ratio: 1.38, 95% CI: 1.03–1.83). Baseline CD4 cell counts accounted for 43% of the increased risk of death in men (95% CI: 22%–113%). Access to care via antenatal services did not explain differences in outcomes.ConclusionIn this cohort there is a marked increase in risk of mortality for men and approximately half of it can be attributed to their later engagement in care. More effort is required to engage men in care in a timely manner.

Epidemiological profile of individuals diagnosed with HIV: results from the preliminary phase of case-based surveillance in Kenya

“…Delayed diagnosis has a major impact on morbidity, mortality and on continued disease transmission (Chadborn, Delpech, Sabin, Sinka, & Evans, 2006; Chaisson, Keruly, & Moore, 2000; Dybul et al, 2002; Mocroft et al, 2013; Sabin et al, 2004; WHO, UNAIDS, UNICEF, 2010). Late presentation to care for males in Africa has been found in previous studies (Diero, Shaffer, & Kimaiyo, 2006; Drain, Losina, & Parker, 2013; Geng, Hunt, & Diero, 2011; Kanters, Nansubuga, & Mwehire, 2013; Kigozi, Dobkin, & Martin, 2009; Siika et al, 2008), which is consistent with our findings. As delayed diagnosis was more common in males and those aged 35–54 years, targeting testing for these groups should occur to promote earlier diagnosis and health care systems should address barriers in access to care.…”

Effectiveness of four antiretroviral regimens for treating people living with HIV

“…In the multivariate analysis of our data, females presented a higher chance of virologic response, thereby corroborating an observational cohort conducted in Uganda from 2004 to 2011 with 4537 participants [15]. Adherence may explain these differences [16].…”

Perceived Cost Advantages and Disadvantages of Purchasing HIV Self- Testing Kits among Urban Tanzanian Men: An Inductive Content Analysis

“…As a consequence, a high proportion of HIV-positive men are unaware of their HIV status, and may engage in sexual risk behaviors that lead to HIV transmission [ 1 ]. The low rate of HCTS uptake among men compared to women also results in earlier mortality among HIV-positive men due to late-stage diagnosis, initiating antiretroviral therapy (ART) with lower CD4 cell counts, and having more advanced disease [ 6 – 9 ]. Unknown HIV status as a result of low uptake of HCTS additionally impedes use of prevention technologies for men, such as medical male circumcision, rectal microbicides, pre-exposure prophylaxis, and early ART initiation [ 10 ].…”