Men make up slightly less than half of the adults living with HIV across the world. Yet they account for nearly 60% of the AIDS related deaths.
This is one of the observations from the The Lancet Commission on HIV, which looked at the global response to the pandemic. According to the report, the key driver of this gender difference in health outcomes between men and women is that men use health care services less than women.
This isn't a new observation: for more than 10 years antiretroviral therapy (ART) programmes in sub-Saharan Africa have been reporting that a disproportionately higher number of women are on treatment compared to men.
There's a simple reason for this, which my work in the last decade highlights: men's health is generally overlooked in HIV care. My studies show that women remain the focus of HIV testing and ART programmes, while men are disadvantaged in access to these.
In a recent analysis of long-term mortality in five large antiretroviral programmes in South Africa, I found that that over the last 12 years the proportion of men starting ART remained the same: between 2004 and 2006 only 31% of those enrolling in treatment programmes were men; by 2015, the figure was unchanged.
What this shows is that there needs to be a real mind shift towards men's health issues. This, in turn, should lead to health care being provided in ways that encourage men to be tested so that they can get treatment earlier than is often currently the case. For example, research shows that providing mobile clinics, or testing people at home, can make a difference.
So what are the obstacles to increasing men's access to ART?
Opportunities to access
The largest obstacle is access to HIV testing. Most testing is done through health facilities, often with a strong focus on testing pregnant women.
The average woman will have a number of encounters with the health system in her lifetime. As a young girl, she will probably go to the local clinic for family planning. When she is pregnant she will go for antenatal care. When her child is small she will go to the local clinic for vaccinations. As mothers are generally still the main caregivers, she will take her child to the clinic when the child is ill. And if she has an elderly relative, there's a chance she will accompany them to the clinic.
This means that there are several opportunities to be offered an HIV test and to start treatment. And if she starts treatment at a young age, she is likely to be healthy and have good survival prospects. So the health system seems to be doing well at engaging young women in HIV services.
In contrast there has been very little concerted effort from health services to go out and find the men.
The pattern of men's engagement with the health system is totally different. There is no easy entry point into the health system for healthy young men. Primary health care clinics offer few services targeting men. This is generally limited to treating TB and sexually transmitted infections.
The fact that men are falling outside the net of health care systems is well illustrated in data on people knowing their HIV status. In 2012 nearly a third (31.9%) of men didn't know their status compared with only 19% in the case of women. The greater proportion of men not knowing their status was particularly worrying given that the percentage of all adults with HIV who didn't know their status dropped dramatically between 2000 and 2012 - from over 80% in the early 2000s to 23.7%.
This has important implications for men as well as their sexual partners. People with HIV who are undiagnosed are likely to have high viral loads. This means they have a high risk of sickness and death, and also that they are more likely to transmit HIV.
So how do we reach more men earlier?
Finding ways of testing men as early as possible will mean changes in the way our health system delivers services.
Preliminary findings show that there is higher testing uptake among men in services that fall outside the traditional facilities. For example, research shows that providing mobile clinics, testing people at home, self-testing and offering male-only or male-friendly services can increase men's uptake of HIV testing.
These and other strategies need to be tried in different settings, and where successful, rolled out across the sub-continent.
The good news is that a change in mindset seems to be happening. After years when it seemed that they were blind to the mounting evidence, international agencies and big donors are starting to discuss the absence of men from HIV programmes. At the end of 2017, UNAIDS produced a report on this blind spot in the response to HIV.
The World Health Organisation has recently established a working group on engaging men into HIV care. And most recently, at the 2018 International AIDS Conference, PEPFAR, the US President's Emergency Plan for AIDS Relief, launched a global coalition to increase testing and access for men.
Given the huge influence that international agencies and donors have on the priorities of national programmes in sub-Saharan Africa, these are long overdue but extremely welcome new initiatives which could substantially increase access to testing and ART for men.