Men missing from the HIV care continuum in sub‐Saharan Africa: a meta‐analysis and meta‐synthesis

Abstract

Introduction:Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods: We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis. Results and discussion: We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions: Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.

Linkage to HIV Care Following HIV Self-testing Among Men: Systematic Review of Quantitative and Qualitative Studies from Six Countries in Sub-Saharan Africa

“…Gender disparities are pervasive throughout the HIV care continuum in sub-Saharan Africa. Compared with women, men test, receive treatment, and achieve viral suppression at lower rates; have higher mortality rates; and have greater loss to follow up after testing and treatment [1][2][3][4][5][6][7]. Studies conducted in multiple sites throughout sub-Saharan Africa have shown that men's access to HIV-related services at healthcare clinics is adversely affected by multiple factors, including stigma, privacy and confidentiality concerns, long queues, financial barriers, and fear of testing positive [8][9][10].…”

Understanding the Unique Barriers and Facilitators that Affect Men’s Initiation and Retention in HIV Care: A Qualitative Study to Inform Interventions for Men Across the Treatment Cascade in Malawi

“…This did not emerge as an explicitly stated theme in our data, however the implicit identification of health facilities as the domain of women and children may partially explain the importance of positive facility experiences for promoting men’s engagement in ART services [ 31 ]. Client-centered care, waiting spaces that encourage discussion and socialization among clients, and male-tailored services could enhance positive experiences at facilities; these positive experiences may increase men’s attendance at HIV services [ 3 , 31 ]. Given that many patients feel healthy at the time of diagnosis, friendly interactions at ART clinics (either with facility staff or fellow clients) may be one of the few immediate benefits associated with early ART initiation [ 44 , 45 ].…”

The benefits of care: treated HIV infection and health-related quality of life among older-aged people in Uganda

“…A similar trend was seen with overall self-reported health, although this was not statistically significant. The unequal benefit of HIV care programs on well-being in the region is well known, with men being less likely to access HIV care and remain in care than with women, resulting in a widening mortality gap between the sexes Bor et al, 2015;Tsai & Siedner, 2015;Nardell et al, 2022). These differences have resulted in different life expectancy gains by gender among PWH in the region Johnson et al, 2013;Mills et al, 2011).…”