Written evidence submitted by the DFID
Funded Research Programme Consortium (RPC) on Research & Capacity
Building in Sexual & Reproductive Health and HIV in Developing
Countries (SRH&HIV) of the London School of Hygiene and Tropical
Medicine, the MRC Social & Public Health Sciences, Glasgow
and other collaborators[31]
30 September 2009
EVIDENCE PROVIDED
FOR: "PROGRESS
TOWARDS THE
COMMITMENT TO
UNIVERSAL ACCESS
TO ANTI-RETROVIRAL
TREATMENT (ART) AND
ITS IMPACT
ON THE
EFFECTIVENESS OF
CARE AND
TREATMENT, PARTICULARLY
FOR WOMEN"
1. This document is written from the perspective
of the academic communities at the London School of Hygiene and
Tropical Medicine (LSHTM) and the MRC Social and Public Health
Sciences Unit (SPSHU), Glasgow and collaborators in Ghana, Tanzania,
South Africa, and others in the UK. For this particular inquiry
of the International Development Committee, we have focused on
one aspect of provision of ART care in Uganda, based on work conducted
by RPC Partner MRC SPSHU with the MRC/UVRI Uganda Research Unit
on AIDS (a partner from our wider RPC network), who are jointly
supervising a doctoral study to investigate how masculine identity
affects the take-up of ART in Uganda.
2. When antiretroviral therapy (ART) first
became widely available in low income countries, there were policy
concerns that it would be accessed primarily by men, since they
have greater control of economic resources and more confidence
to make use of services. International observers and agencies,
and feminist commentators have consistently emphasised the need
to ensure that women are not forgotten in the expansion of AIDS
treatment and care. The theory that gender inequities often affect
women's access to and interaction with health services (eg Braitstein
et al, 2008; Silvester et al, 2005) has prompted
arguments in support of more affirmative action with regard to
women's and girls' access to ART as well. Although, the 2006 WHO/UNAIDS
progress report on global access alluded to the absence of evidence
of systematic gender bias in access to ART, it nonetheless acknowledged
the existence of gender inequities, with women receiving more
in some countries and men in other countries.
3. Emerging evidence now suggests that men
may in fact be more disadvantaged with regard to accessing ART
in most low and middle income countries. According to the WHO/UNAIDS/UNICEF
2008 global report on the HIV epidemic, in most of these countries,
women are receiving more than the expected coverage of antiretroviral
therapy. At the end of 2007, 56% of those receiving antiretroviral
therapy were women, while they represented 52% of people in need.
In sub-Saharan Africa, data from 32 countries revealed that 61%
of the people receiving antiretroviral therapy in this region
were female, while they represent 57% of the people in need (WHO/UNAIDS/UNICEF,
2008). In east and southern Africa, it had earlier been observed
that in those areas where ART has been made widely available at
low cost or at no cost, women utilise ART at greater rates than
men (UNAIDS/UNFPA/UNIFEM, 2004).
4. The trend towards gender discrepancy
in ART uptake is evident in the ART roll out programme in Uganda,
with men tending to be fewer. In a recent survey of 336 facilities
providing ART across the country, the data from a sub set of 175
facilities that had sex disaggregated data for their 69,058 clients
showed that 37% (25,929) were males and 63% (43,129) were female
(MoH, 2008). The findings reported in a 2008 article by Braitstein
et al provide further useful insights into gender patterns
of access to ART in Uganda and other resource limited settings.
Of the 22 HAART centres they surveyed in SSA, women were over
represented in 13 centres compared to the UNAIDS estimated proportions
of HIV infected adults who are women. They found that in 2 of
the 5 centres covered by the survey in Uganda, women were overrepresented
compared to the UNAIDS estimated proportions of HIV infected adults
who are women (Braitstein et al, 2008). Men are also likely
to access ART later in the disease progression than women. Braitstein
and colleagues further report that at initiation to ART, women
were less likely than men to have AIDS; suggesting that men might
be delaying to seek care for symptoms.
5. The variations in uptake of ART in Uganda
do not seem to be due to substantially different rates of testing
among women and men. In the 2004-05 Uganda sero-behaviour survey,
it was found that 11% of men and 13% of women aged 15-49 have
ever been tested for HIV and received their results. But in the
12 months preceding this survey, an equal percentage (4%) of men
and women had been tested for HIV and received their test results.
Although during the sero-behaviour survey itself women were slightly
more likely to be tested for HIV compared to men, the main reason
for the difference could have been the higher percentage of eligible
women who were interviewed in the survey (MoH/ORC Macro, 2006).
This survey also reports that overall, 25% of men who are HIV
positive know their status compared to 15% of women who are HIV
positive. Earlier studies have also reported that women are significantly
less likely to receive voluntary counselling and testing (VTC)
than men (Nyblade et al, 2001).
6. There are several possible explanations
for greater take-up of ART by women than men, amongst those infected
with HIV:
— it might reflect men's general treatment
seeking behaviour for most illnesses;
— women may be more familiar with medical
treatment, due to child-bearing, and therefore more ready to access
treatment;
— women's responsibilities for dependents
might give them greater motivation to maintain their health;
— men might be more reluctant to publicly
acknowledge that they are HIV +ve, which might relate to greater
vulnerability to HIV/AIDS related stigma;
— HIV/AIDS health promotion, and HIV testing,
might take place primarily in female-dominated contexts and therefore
exclude men (WHO/UNAIDS, 2006; Baker & Ricardo, 2005; Bila
and Egrot, 2009), for instance women may be accessing treatment
from sites offering prevention of mother to child (PMTCT) services;
— men might avoid testing because they
anticipate that they would be blamed for their infection whereas
women's infection would be attributed to their male spouses; and
— it might reflect a different age profile
of those in need of treatment, women generally being younger and
therefore having more reason to want to prolong their lives.
7. Therefore, even though wider access to
ART is now increasingly realistic, there is a need to pay greater
attention to the dynamics of access and factors that may prevent
use of ART by men. In their progress report on global access to
ART, WHO/UNAIDS (2006) called for continued monitoring of gender
and ART to both identify gender bias and improve understanding
of how and why individuals access treatment. In view of the emerging
evidence suggesting male under representation in ART treatment
programmes, it seems as if male socialisation, traditional ideas
about masculinity and gender roles could present barriers to men
in accessing treatment for HIV/AIDS (Bila and Egrot, 2009; Braitstein
et al, 2008; Greig et al, 2008).
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31 Contributors to this piece: Mr Godfrey Siu and Daniel
Wight, MRC Social and Public Health Sciences Unit, Glasgow (danny@msoc.mrc.gla.ac.uk) Back
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