1. The ugly news

2. THE UGLY Gender disparities, pathways and repercussions Chodziwadziwa Kabudula London School of Hygiene & Tropical Medicine, UK Joyce Wamoyi TAZAMA cohort study, National Institute for Medical Research, Tanzania

3. Gender disparities in HIV prevalence –HIV prevalence in reproductive ages is between 40 and 100% higher for women in eastern and southern Africa Renewed concern over (reversed) gender disparities in the uptake of services: (1) More women on ART, (2) Women start ART earlier, (3) Women have lower loss to follow up and mortality on ART But little evidence from population-based studies Gender disparities; a persistent concern Data sources: ORC Macro (2013), Shisana (2005), and CSO [Botswana] (2009) Female to male sex ratio of HIV infections

4. Use ALPHA Network data to assess gender differences in the uptake of services in successive cohorts of PLHIV Three transitions: –Seroconversion → Diagnosis (death = competing risk) –Diagnosis → ART initiation (death = competing risk) –ART initiation → Survival Repercussions of gender disparities for other mortality indices and their downstream effects on HIV incidence Pathways: a summary of evidence from qualitative interviews Gender disparities, a persistent concern

5. Male-to -female hazard ratio of HTC uptake following seroconversion (green) & death before diagnosis (grey) in successive cohorts of seroconvertors Findings: –Uptake of HTC increased for both men and women (not shown) –Women’s hazard of HTC uptake is now almost twice as high as that of men (green) –Men are now twice as likely as women to die before being diagnosed (grey) Interpretation –PMTCT programs contributed to an earlier uptake of services among women that is not matched for men Disparities in the uptake of HTC increased Notes: HRs from Cox PH models stratified for study site and adjusted for age.25.5 1 2 4 Male to Female HR 1990-'992000-'052006-'12 Infection --> Diagnosis Death before diagnosis

6. Male-to-female hazard ratio of ART uptake following diagnosis (green) & death before ART (grey) in successive cohorts of diagnosed PLHIV Findings –Uptake of ART increased for both men and women (not shown) –The progression to ART used to be slower for men, but that is no longer the case (green) –But: men are now twice more likely than women to die before initiating ART (grey) Interpretation –Men’s relatively faster progression to ART could be symptomatic of late diagnosis –Gender disparities in pre-treatment mortality increased Disparities in the uptake of ART increased Notes: HRs from Cox PH models stratified for study site and adjusted for age.25.5 1 2 4 Male to Female HR 1990-'992000-'052006-'12 Diagnosis --> ART Death before ART

7. Male/female hazard ratio of mortality (all causes) in successive treatment cohorts Findings –Survival on ART increased for both men and women (not shown) –Men’s (all-cause) mortality hazard after starting ART remains twice as high as that of women (red) –Same for TB/HIV mortality only (data from uMkhanyakude only, orange) Disparities in the survival on ART remain large Notes: HRs from Cox PH models stratified for study site and adjusted for age

8. LE gains from ART are larger for women than for men –Higher uptake services –Women are infected at younger ages –Women have lower background mortality BUT: the burden of HIV mortality remains larger for women than for men Are men the losers in the ART era ? LE gains since ART Remaining LE deficit

9. Cumulative risk of HIV acquisition, by sex and period (Rakai) HIV acquisition risk declined for men (orange), but not for women (blue) –Higher ART coverage in women protects their male partners –Male circumcision interventions Are men the losers in the ART era ?

10. Pregnant (frequently asymptomatic) women often driven by a desire to protect their unborn babies – breastfeeding encourages ART adherence – male partners supportive of partners seeking care to protect the health of unborn child What drives ART initiation and maintenance?

11. Pregnant (frequently asymptomatic) women often driven by a desire to protect their unborn babies – breastfeeding encourages ART adherence – male partners supportive of partners seeking care to protect the health of unborn child Symptomatic men and women often motivated to seek HIV care by their fear of deteriorating health – desire to restore and protect their own health to fulfil social expectations (femininity & masculinity expectations) What drives ART initiation and maintenance?

12. Pregnant (frequently asymptomatic) women often driven by a desire to protect their unborn babies – breastfeeding encourages ART adherence – male partners supportive of partners seeking care to protect the health of unborn child Symptomatic men and women often motivated to seek HIV care by their fear of deteriorating health – desire to restore and protect their own health to fulfil social expectations (femininity & masculinity expectations) ART was important for looking healthy to attract new partners – but not to protect existing partners What drives ART initiation and maintenance?

13. ART: to look good and find a partner The can use their medication properly, for example now during this time, the young people can use the medication properly but stop once they start looking good and found a partner….They will not involve their partner. The AIDS patient will stop taking the medication during the marriage... they do not want the partner to know they have the disease [IDI, Male] They can use their medication properly, for example now during this time, the young people can use the medication properly but stop once they start looking good and have found a partner….They will not involve their partner. The AIDS patient will stop taking the medication during the marriage... they do not want the partner to know they have the disease [Man, Diagnosed but not in care, Tanzania]

14. Will prevention effects of ART within couples be difficult to harness? Widely assumed that HIV status can be inferred through partners’ HIV status – men using knowledge of their wife’s HIV status as a reason for not needing to undergo a HIV test – men encouraging partners to test in order to deduce their own status

15. Will prevention effects of ART within couples be difficult to harness? Widely assumed that HIV status can be inferred through partners’ HIV status – men using knowledge of their wife’s HIV status as a reason for not needing to undergo a HIV test – men encouraging partners to test in order to deduce their own status Infection between serodiscordant partners is perceived to be inevitable regardless of partners’ ART status

16. Will prevention effects of ART within couples be difficult to harness? Widely assumed that HIV status can be inferred through partners’ HIV status – men using knowledge of their wife’s HIV status as a reason for not needing to undergo a HIV test – men encouraging partners to test in order to deduce their own status Infection between serodiscordant partners is perceived to be inevitable regardless of partners’ ART status Some accounts of serosorting or ART patients seeking new partners who are also on ART (in HIV clinic waiting rooms, through peer support networks) – as a strategy to address challenges posed by needing to keep HIV & ART status a secret

17. Using partner's status as a proxy He asked me: “What were you told, by the way? What you were told is similar to mine [status]… If you were told you are safe, I am safe too. If you were told that you’re suffering from the disease, I am having the disease too.” [Woman, diagnosed but not initiated on ART, Tanzania] He asked me: “What were you told, by the way? What you were told is similar to mine [status]… If you were told you are safe, I am safe too. If you were told that you’re suffering from the disease, I am having the disease too.” [Woman, diagnosed but not initiated on ART, Tanzania]

18. Will the news get uglier? Deep-seated male reluctance to test, and to start ART until very unwell

19. Will the news get uglier? Deep-seated male reluctance to test, and to start ART until very unwell HIV testing & care-seeking is still seen as a woman’s issue, despite “couple-friendly” HIV testing policies – men unwilling to test through advice from their partners

20. Will the news get uglier? Deep-seated male reluctance to test, and to start ART until very unwell HIV testing & care-seeking is still seen as a woman’s issue, despite “couple-friendly” HIV testing policies – men unwilling to test through advice from their partners Many reasons for non-disclosure of HIV status to partners – guilt over being infected through extra-marital affairs – perceived risks of partnership breakdown & their associated consequences

21. Will the news get uglier? Deep-seated male reluctance to test, and to start ART until very unwell HIV testing & care-seeking is still seen as a woman’s issue, despite “couple-friendly” HIV testing policies – men unwilling to test through advice from their partners Many reasons for non-disclosure of HIV status to partners – guilt over being infected through extra-marital affairs – perceived risks of partnership breakdown & their associated consequences Women are better at hiding their ART taking than men

22. The doctor explained to him, “we have tested your wife and we should test you also” this was before giving us the results, he refused and said “I can’t test because I haven’t felt sick/unwell”. The doctor tried to convince him but he refused “I can’t take a test unless I feel sick/unwell”. [Woman, no longer in care, Malawi] Reluctance to test while not sick

23. Discussion Social norms and expectations concerning men and women are different and this is reflected in their patterns of accessing care As a result men have poorer outcomes across the treatment cascade – Lower uptake of HTC – Higher (x2) pre-ART mortality – Higher (x2) mortality on ART – Gender differences amplified in recent years As a result, women have gained more adult life years that men following the rollout of ART, But – Women still lose more life years to HIV than men – Lower uptake of services among men, exposes their female partners to HIV