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Range of formats may be needed to attract men to test for HIV

HIVSpecialised services to attract men to HIV testing and treatment may need to adopt several different formats in order to reach different sub-populations of men, suggesting that there is no single service innovation that will boost uptake among men in Sub-Saharan Africa, according to South African research presented at the Conference on Retroviruses and Opportunistic Infections (CROI).

Another study in rural KwaZulu-Natal found that the eligibility of household members for HIV treatment motivated men to test for the virus.

aidsmap reports that in generalised epidemics in Sub-Saharan Africa, men are less likely to test for HIV than women. The PopART study of Test and Treat in Zambia found that men were less likely to test for HIV when testing was offered through household testing campaigns, because they were away from home or out at work.

Encouraging men to test for HIV may require the provision of testing and treatment services that fit in with working patterns. Men frequently complain that clinic opening hours make it difficult for them to attend without missing paid work.

Another complaint voiced – often linked to concerns around stigma and confidentiality – is that HIV clinics are mainly geared to women and children. Attending what are commonly seen in the community as women’s services can signal that a man is HIV positive.

To address each of these barriers Médecins Sans Frontières, in partnership with the City of Cape Town and the Western Cape Department of Health, established two services in Khayelitsha township, each designed to attract men.

One clinic, the daytime clinic, opens from 8am to 4.30pm, Monday to Friday. The other clinic, a male after-hours clinic, opens from 4pm to 7.30pm on Wednesdays. Both clinics have all-male staff, offer diagnosis and treatment of sexually transmitted infections (STIs), HIV testing and counselling, point-of-care CD4 cell testing for anyone diagnosed with HIV, HIV treatment initiation and drug dispensing, and antiretroviral therapy (ART) adherence clubs.

Researchers compared uptake, treatment initiation and retention in care of the two services between the opening of the services in June 2014 and September 2016. Due to its longer opening hours, the daytime clinic had a much higher median number of visits per month (52) than the after-hours clinic (75) (p < 0.001).

Almost half of the visits (45%) to the daytime clinic included the diagnosis and treatment of an STI, indicating the importance of STI testing and treatment as a gateway for HIV testing and treatment for men. In comparison, 21% of visits to the after-hours clinic involved diagnosis and treatment of an STI.

HIV testing and counselling took place in high volumes at each clinic (291 tests per month at the day clinic and 25 tests per month at the after-hours clinic), and around half of HIV testing and counselling took place as a consequence of a visit for STI diagnosis and treatment. Prevalence was higher among attendees at the after-hours clinic (8.5% vs 5.9%, p = 0.004).

Those diagnosed with HIV at the after-hours clinic tended to have lower CD4 cell counts (330 cells/mm3 vs 384 cells/mm3) although this difference was not statistically significant, and if eligible for treatment, were more likely to start treatment after diagnosis (91% vs 70%, p < 0.001). Six months after starting treatment, retention among those who started after diagnosis at the clinics was higher among those attending the after-hours clinic (98% vs 88%).

Attendees at the after-hours clinic were much more likely to present as HIV positive (64% vs 14%). Due to its convenient opening hours, the after-hours clinic attracted a large number of men already on ART who transferred from other services – 43% of men receiving ART through the clinic had transferred from another clinic, compared to 8% of the male day clinic cohort. There was no substantial difference in retention between the two clinics among those who transferred in to the clinics from other services (91% in the day clinic and 89% in the after-hours clinic).

The other study, conducted in a large population in rural KwaZulu-Natal, found that men became more motivated to test when others in their household became eligible for HIV treatment.

The population study at the Africa Health Research Institute in the Africa Centre for Population Health in Mtubatuba, led by researchers there and at Harvard University, Boston University and Heidelberg University, is collecting demographic data and blood samples from households and linking that data to health records, in order to examine HIV testing, linkage to care and treatment initiation through health services in the district.

The study surveyed 22,965 individuals in 5,697 households between 2005 and 2013, and found that knowledge of HIV status increased by 17% among male household members if another person in the household had become eligible for antiretroviral treatment. The same effect did not hold true for women, probably because women were much more likely to know their HIV status at baseline.

The study looked at eligibility for treatment, based on having a CD4 cell count below 200 cells/mm3 (the treatment threshold in South Africa prior to 2011), rather than actual treatment history, in order to test the effect of the knowledge of treatment availability on testing behaviour.

The researchers couldn’t be sure whether the effect was due to a greater intensity of testing activity in the district, or because men updated their beliefs about their HIV status and chose to test for HIV.

Abstract 998
In large African antiretroviral therapy (ART) programs, disproportionately fewer men initiate ART, and at more advanced age and disease stage than women. Identifying and overcoming gender-specific barriers, at the individual and service delivery level, are critical to improving HIV/STI services for men. Previous research in Khayelitsha, a large, high HIV-prevalence township near Cape Town, found that despite increased male access to HIV counseling and testing (HCT), the proportion of men accessing treatment did not increase. MSF, the City of Cape Town and the Western Cape Provincial Department of Health, piloted two male services in Site B, Khayelitsha: Site B Male Clinic (SBMC) and a male after-hours clinic (MAC). Both facilities have all-male staff and offer HIV/STI services, including testing and treatment. SBMC is open daily 8:00-16:00 and MAC is open on Wednesdays 16:00-19:30. We compare the characteristics and outcomes of these two clinics.
Those on ART who initiated at another clinic are referred to as transfers-in (TFI) while known HIV-positives tested positive at another service before presenting. Summary statistics of patient characteristics and outcomes are presented, contrasting the two clinics where relevant.
Between June 2014 and June 2016, 14193 visits took place; median: 588/month (IQR: 509-659). Most (88%) of these visits took place at SBMC. Compared to MAC, patients at SBMC were more likely to seek STI treatment(45% vs 21%). Over half of the HCT occurred at an STI-related visit and HCT yielded a 6.2% positivity rate. The median CD4 counts were 376 (IQR:260-505) cells/µL at testing. Of those found eligible for ART, 91% (42/46) ever initiated at MAC compared to 69% at SBMC (203/295). Compared with SBMC, a far higher proportion of MAC patients presented as known HIV-positive or TFIs (64% vs 14%). TFIs at MAC were on ART longer (median:3.3yrs[IQR:2.1-5.2] vs 1.9yrs[IQR:1-2.4] at SBMC) with similar retention in care 6 months after TFI(86%). Among new initiates 6-month retention in care was 95%(35/37) at MAC and 88%(140/159) at SBMC.
STI care is an excellent opportunity to link men to HIV services. While SBMC had more patients, MAC attracted a different patient population, and had higher initiation and retention rates. Given these contrasting successes, further research should investigate whether aspects of both services could be rolled out to attract more men to HIV services.

Authors
Tali Cassidy, Amir Shroufi, Sarah Jane Steele, Morna Cornell, Virginia de Azevedo, David Binza, Rodd Gerstenhaber

Abstract 960
A crucial first step toward obtaining HIV care is knowing one's own HIV status. A large proportion of HIV-infected persons in South Africa do not know their status, and men are typically less likely than women to be aware of their serostatus. Expansion of HIV treatment may increase disclosure, reduce stigma, and increase testing. We estimate how a person's ART eligibility affects their household member's HIV status knowledge.
We conducted a regression discontinuity analysis that exploits the CD4 count threshold for ART eligibility in South Africa to evaluate the causal intent-to-treat (ITT) effect of ART eligibility on the patient's household members. Using data from 2007-2012 in a large population-based cohort in rural South Africa run by the Africa Health Research Institute, we compared outcomes among household members of patients who had a CD4 count just below the 200-cell threshold (and were thus eligible for ART) with household members of patients with CD4 counts just above the cut-off (and were thus less likely to be eligible for ART). We assessed effects on self-reported knowledge of HIV status and conducted sub-group analyses by the gender of the patient and the gender of household members.
ART led to a large increase in HIV status knowledge among the patient's male household members (ITT causal effect of 17 percentage points, 95% CI 12, 22). This effect represents a three-fold increase in the likelihood that a male household member reported knowing their HIV status relative to the baseline rate of 7%. The effect was concentrated among men living in households where women became eligible for ART, and there was no effect for female household members. The results for men were robust to sensitivity analyses including variation in bandwidths and inclusion of covariates.
Living with someone who is eligible for ART increased men's likelihood of reporting that they knew their HIV status. This effect may be due to increased testing, or to updating of beliefs about HIV status based on partner's status even in the absence of test results. In designing the next generation of ART programs, such household-level spillover effects could be harnessed to increase HIV status knowledge and ART uptake among men. Although prior studies have noted a correlation between ART expansion and testing rates, this study is among the first to causally link ART initiation to increased awareness of HIV status among household members.

Authors
Ellen Moscoe, Jacob Bor, Frank Tanser, Deenan Pillay, Till Baernighausen

[link url="http://www.aidsmap.com/Finding-men-with-HIV-and-keeping-them-in-treatment/page/3125268/"]Aidsmap material[/link]
[link url="http://www.croiconference.org/sessions/art-initiation-and-retention-after-hour-versus-daily-male-health-clinics"]CROI 2017 abstract 998[/link]
[link url="http://www.croiconference.org/sessions/does-hiv-treatment-availability-encourage-people-learn-their-hiv-status’"]CROI 2017 abstract 960[/link]

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