Findings that appeared in PLOS Medicine suggest the gender differences in deaths of people on antiretrovirals in South Africa are not related to the HI virus.
The study, which analysed data from about 46 200 adults who started antiretroviral treatment between 2002 and 2009, found that the gender differences in the death rates of South Africans on antiretroviral programmes were smaller than those in the HIV-negative population.
Several international studies, including the PLOS study, have highlighted that males on HIV treatment are almost a third more likely to die than females. Such research has concluded that men with HIV generally access antiretrovirals at a later stage of their disease than women, making them more vulnerable to death. They are also more likely to leave antiretroviral programmes than female patients and this affects survival rates because patients have to take antiretrovirals for the rest of their lives for the drugs to be effective.
In addition, significantly fewer men than women access antiretrovirals. In South Africa, for instance, about 55% of HIV-infected people are women, yet more than two-thirds of patients receiving public sector antiretrovirals are female.
Bad health-seeking behaviour
Some researchers believe that the reason for HIV-positive men's higher death rate is their "bad health-seeking behaviour" – they choose to access healthcare late or not at all.
One study, published in the journal AIDS Care in 2010, noted that the fathers of HIV-infected men often negatively influence their sentiments about antiretroviral treatment, but no such profound influence was seen in fathers and their HIV-positive daughters.
According to the PLOS study's lead researcher, Morna Cornell, the answer is far more likely to lie in factors that pertain to the general male population. "In our study, HIV-positive men's health-seeking behaviour patterns alone could not fully explain their higher death rate. We were devastated to find that the difference in mortality rates for men and women in the HIV-negative South African population was bigger. I don't think it's a case of men not wanting to use health services. I think it has something to do with the way men are being treated, rather than them being responsible for their own mortality," Cornell said.
It is not only in Africa that more HIV-negative men die than women. According to a recent study in the Journal of Epidemiology and Community Health, men in the richest fifth of the world are twice as likely to die as women.
"Without fail, men have an increased mortality, yet in some ways we've become blind to gender inequities pertaining to men because it's unpopular to argue for men's rights – it's often perceived as arguing 'against' or 'undermining' women's rights. It's like the elephant in the room," Cornell said.
Risk of death
A study published earlier this year in the journal AIDS reviewed the mortality risk of men and women on antiretrovirals and once again confirmed that men face an increased risk of death. It warned that the study "should not be used to argue in favour of men's rights, but rather to promote equal access to treatment and care, regardless of gender".
Cornell said she was concerned that "such a message creates the impression that, because it is about men, we fail to apply the same kind of objective, rational critique to the situation. We see men and women as opposing populations and I don't know why."
Studies have shown that African men are generally more "mobile" than women, resulting in them spending more time away from their families and healthcare facilities while looking for jobs or taking up employment. Organisations including the United Nations have argued that African health services are mostly women-orientated, focusing on maternal and child health. This gives women more opportunities to access healthcare services, including HIV testing and treatment, because they are more frequently in contact with clinics and hospitals, for example, when they take babies for immunisation.
Men are also more likely to die in car accidents, from violence, or tuberculosis not related to HIV.
Cornell argued that these assumptions might help to explain why men die sooner and access healthcare less frequently than women, but "they don't paint the full picture and need to be explored further if we want to intervene to reduce gender differences in death".
Despite evidence of gender inequity in access to drugs for HIV, most antiretroviral-related policies and programmes in Africa are still blind to men. "For example, nowhere in the UNAids epidemic updates or country progress reports is men's access to antiretroviral treatment identified as a gap and prioritised for urgent action," Cornell said.
"South Africa has a detailed strategic plan to address HIV. Yet, despite mounting evidence that men are at a distinct disadvantage in the roll-out of antiretrovirals, the plan does not identify male access as a gap or plan to address it."
Mia Malan works for the Discovery Health Journalism Centre at Rhodes University.