HIV services in sub-Saharan Africa: the greatest gap is men.
About: This article is published in The Lancet.The article was published on 2021-06-01. It has received 10 citations till now.
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TL;DR: In this paper , the authors examined adherence and viral non-suppression (viral load > 400 copies/mL) of participants with (20,743, 38%) and without (33,635, 62%) mental health diagnoses.
Abstract: Abstract We followed adolescents and adults living with HIV aged older than 15 years who enrolled in a South African private-sector HIV programme to examine adherence and viral non-suppression (viral load > 400 copies/mL) of participants with (20,743, 38%) and without (33,635, 62%) mental health diagnoses. Mental health diagnoses were associated with unfavourable adherence patterns. The risk of viral non-suppression was higher among patients with organic mental disorders [adjusted risk ratio (aRR) 1.55, 95% confidence interval (CI) 1.22–1.96], substance use disorders (aRR 1.53, 95% CI 1.19–1.97), serious mental disorders (aRR 1.30, 95% CI 1.09–1.54), and depression (aRR 1.19, 95% CI 1.10–1.28) when compared with patients without mental health diagnoses. The risk of viral non-suppression was also higher among males, adolescents (15–19 years), and young adults (20–24 years). Our study highlights the need for psychosocial interventions to improve HIV treatment outcomes—particularly of adolescents and young adults—and supports strengthening mental health services in HIV treatment programmes.
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TL;DR: In this article , the authors conducted a cross-sectional study with 211 couples in southern Malawi with at least one partner on ART to test for associations between ART adherence and relationship dynamics (intimacy, trust, relationship satisfaction, unity, commitment, and partner support).
Abstract: Couple relationships can be leveraged to improve adherence to antiretroviral therapy (ART), but few studies have identified relationship factors to target in interventions in sub-Saharan Africa. We conducted a cross-sectional study with 211 couples in southern Malawi with at least one partner on ART to test for associations between ART adherence and relationship dynamics (intimacy, trust, relationship satisfaction, unity, commitment, and partner support). We measured ART adherence through subjective measures (patient and partner reports) and an objective measure (ART drug levels in hair) and hypothesized that more positive relationship dynamics (e.g., higher intimacy) would be associated with better adherence. Multi-level logistic and linear regression models were used to evaluate study hypotheses, controlling for the clustering of individuals within couples. High levels of adherence were found by all three measures. Unity, satisfaction, and partner support were associated with higher patient and partner reports of adherence, and additional relationship dynamics (intimacy, trust) were associated with higher partner reported adherence. No associations were found between relationship dynamics and drug levels in hair, although drug levels were high overall. Future studies should perform longitudinal assessments of relationship dynamics and objective metrics of adherence, and examine these associations in populations with lower adherence levels such as young women or individuals starting ART.
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TL;DR: In this article , an individually randomized control trial (RCT) was conducted to investigate the impact of three-month home-based ART (hbART) on viral suppression among men who were not engaged in care.
Abstract: Background Men experience twice the mortality of women while on ART in sub-Saharan Africa (SSA) largely due to late HIV diagnosis and poor retention. Here we propose to conduct an individually randomized control trial (RCT) to investigate the impact of three-month home-based ART (hbART) on viral suppression among men who were not engaged in care. Methods and design A programmatic, individually randomized non-blinded, non-inferiority-controlled trial design (ClinicalTrials.org NCT04858243). Through medical chart reviews we will identify “non-engaged” men living with HIV, ≥15years of age who are not currently engaged in ART care, including (1) men who have tested HIV-positive and have not initiated ART within 7 days; (2) men who have initiated ART but are at risk of immediate default; and (3) men who have defaulted from ART. With 1:1 computer block randomization to either hbART or facility-based ART (fbART) arms, we will recruit men from 10–15 high-burden health facilities in central and southern Malawi. The hbART intervention will consist of 3 home-visits in a 3-month period by a certified male study nurse ART provider. In the fbART arm, male participants will be offered counselling at male participant’s home, or a nearby location that is preferred by participants, followed with an escort to the local health facility and facility navigation. The primary outcome is the proportion of men who are virally suppressed at 6-months after ART initiation. Assuming primary outcome achievement of 24.0% and 33.6% in the two arms, 350 men per arm will provide 80% power to detect the stated difference. Discussion Identifying effective ART strategies that are convenient and accessible for men in SSA is a priority in the HIV world. Men may not (re-)engage in facility-based care due to a myriad of barriers. Two previous trials investigated the impact of hbART on viral suppression in the general population whereas this trial focuses on men. Additionally, this trial involves a longer duration of hbART i.e., three months compared to two weeks allowing men more time to overcome the initial psychological denial of taking ART.
1 citations
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TL;DR: In this article , the authors analyzed reimbursement claims and vital registration data from South African medical insurance scheme beneficiaries aged 15-85 years and estimated excess life years lost associated with organic, substance use, psychotic, mood, anxiety, eating, personality, developmental or any mental disorders.
Abstract: Background People with mental illness have a reduced life expectancy, but the extent of the mortality gap and the contribution of natural and unnatural causes to excess mortality among people with mental illness in South Africa are unknown. Methods We analysed reimbursement claims and vital registration data from South African medical insurance scheme beneficiaries aged 15-85 years. We estimated excess life years lost (LYL) associated with organic, substance use, psychotic, mood, anxiety, eating, personality, developmental or any mental disorders. Findings We followed 1 070 183 beneficiaries, of whom 282 926 (26.4%) received mental health diagnoses. Life expectancy of people with mental health diagnoses was 3.83 years (95% CI 3.58-4.10) shorter for men and 2.19 years (1.97-2.41) shorter for women. Excess mortality varied by sex and diagnosis, ranging from 11.50 LYL (95% CI 9.79-13.07) among men with alcohol use disorder to 0.87 LYL (0.40-1.43) among women with generalised anxiety disorder. Most LYL were attributable to natural causes (3.42 among men and 1.94 among women). A considerable number of LYL were attributable to unnatural causes among men with bipolar (1.52) or substance use (2.45) disorder. Interpretation The burden of premature mortality among persons with mental disorders in South Africa is high. Our findings support implementing interventions for prevention, early detection, and treatment of physical comorbidities among people with mental disorders. Suicide prevention and substance use treatment programmes are needed to reduce excess mortality from unnatural causes, especially among men. Funding Swiss National Science Foundation and National Institutes of Health
References
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TL;DR: In this paper, the authors describe 5 cases of pneumocystis carinii pneumonia occurring in homosexual men in Los Angeles California, two of whom have died, and the patients did not know each other and had no known common contacts or knowledge of sexual partners with similar illnesses.
Abstract: This article describes 5 cases of Pneumocystis carinii pneumonia occurring in homosexual men in Los Angeles California. All 5 patients had previous or current cytomegalovirus and candidal mucosal infection. The men 2 of whom have died ranged from 29-36 years of age. The patients did not know each other and had no known common contacts or knowledge of sexual partners with similar illnesses. The 5 did not have comparable histories of sexually transmitted disease. 4 had serologic evidence of past hepatitis B infection but no evidence of current hepatitis B surface antigen. 2 of the men reported frequent homosexual contact with various partners. All 5 reported use of inhalant drugs. The 3 patients in whom lymphocyte studies were performed had profoundly depressed in vitro proliferative responses to mitogens and antigens. The occurrence of pneumocystosis in these 5 previously healthy men without a clinically apparent underlying immunodeficiency is unusual but seems to reflect some association with a homosexual lifestyle or disease acquired through sexual contact. Cytomegalovirus infection has been shown to induce transient abnormalities of in vitro cellular immune function in healthy homosexual men with and without antibody and a high prevalence of cytomegalovirus infections has been reported among male homosexuals. In additon there is some evidence that seminal fluid may be an important vehicle of cytomegalovirus transmission. Although the role of cytomegalovirus infection in the pathogenesis of pneumocystosis reamins unknown the possibility of P. carinii infection should be carefully considered in previously healthy homosexuals with dyspnea and pneumonia.
1,306 citations
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TL;DR: In this paper, a relational approach to understand gender on a global scale is proposed, where gendered embodiment is seen as interwoven with the violent history of colonialism, the structural violence of contemporary globalization, and the making of gendered institutions on a world scale including the corporations, professions and state agencies of the health sector.
634 citations
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TL;DR: This work reviews the etiology and successes of the women's vulnerability paradigm, and calls for an expanded model that acknowledges biology, gender inequality, and gendered power relations but also directly examines social structure, gender, and HIV risk for heterosexual women and men.
Abstract: Most HIV prevention literature portrays women as especially vulnerable to HIV infection because of biological susceptibility and men's sexual power and privilege. Conversely, heterosexual men are perceived as active transmitters of HIV but not active agents in prevention. Although the women's vulnerability paradigm was a radical revision of earlier views of women in the epidemic, mounting challenges undermine its current usefulness. We review the etiology and successes of the paradigm as well as its accruing limitations. We also call for an expanded model that acknowledges biology, gender inequality, and gendered power relations but also directly examines social structure, gender, and HIV risk for heterosexual women and men.
420 citations
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TL;DR: This Series paper raises the parallel question of whether discrimination based on gender likewise becomes embodied, with negative consequences for health, as well as how gender-biased health research and health-care systems reinforce and reproduce gender inequalities, with serious implications for health.
417 citations
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TL;DR: It seems that gendered norms that make it difficult for men to admit weakness and seek medical attention are the main probable cause for the low proportions of men accessing HAART.
Abstract: This paper explores the gender dimensions of access to highly active antiretroviral therapy (HAART) in South Africa. It shows that women are more vulnerable to HIV infection than men, but that women access HAART in disproportionately large numbers. Regression analysis on data from the South African Demographic and Health Survey suggests that men in general access health services less readily than women. This ‘masculinity factor’ accounts for most of the difference between men and women when it comes to accessing HAART. Although men were more likely to favor traditional medicine than women, this was not a statistically significant factor, and it appears that visiting a traditional healer is complementary to, rather than a substitute for, accessing HAART. In short, it seems that gendered norms that make it difficult for men to admit weakness and seek medical attention are the main probable cause for the low proportions of men accessing HAART.
187 citations