Authors: Bevis Phiri, Trevor Mwamba & Simret Habtezgi ; Mentors: Victor Chalwe, Albertina Moraes, Kutha Banda & Douglas Mushinge
Supported by: NHRA
- 25% of adult men have not been tested for HIV compared to only 15% of adult women in Zambia by 2018.
- Men’s unawareness of their HIV status poses a major challenge across the HIV treatment cascade.
- Early identification of HIV infected men is one of the major steps to prevent new infections.
- Scaling up HTS through male-friendly clinics will reach more than 90% of men who did not previously test.
There is a discrepancy in testing between genders, with men less likely to test for HIV than women. Zambia is one of the top 10 countries with the highest HIV prevalence of 11.1% among adults aged 15–49 years old, with 14.3% and 7.5% HIV prevalence between women and men respectively (ZDHS, 2018). There exists gender variations in national testing rates with more women testing (93%) than men (87%) according to estimates (NAC 2015, ZDHS 2018). Several gender analysis studies highlight specific explanations for men’s lower rates of testing. Many reported that men underestimate their risk of HIV infection compared to women, they fear a positive test, worry about disclosure, stigma and discrimination, and often feel shut out of the health system (Okal et. al).
Awareness of HIV status among men is substantially lower than among women, with 25% (120,000) of men having not been tested for HIV and received their results, compared to only 15% of adult women in Zambia by 2018 (ZDHS, 2018, UNAIDS, 2020). Men’s uptake of HTS has increased over the past, but they are still not testing at a high enough rate to significantly reduce the number of men living with HIV who are unaware of their HIV status (ZDHS,2018). This unawareness of their HIV status poses a major challenge in the HIV care cascade, which leads to the late linkage, initiation to treatment, and low viral suppression, culminating into high HIV related mortality (Bhatia et. Al, 2017). Nationally, there are an estimated 480,000 men (above the age of 15) living with HIV, with only 78% of them receiving life-saving ART, leaving a 22% gap (UNAIDS, 2020). In addressing some of these challenges, intervention strategies in Zambia have been implemented such as VCT, Provider initiated testing and conselling (PITC), couple’s testing during (ANC), and HIV self-testing and contact tracing (Lasry et al, 2016).
Policy Options to address low uptake of HTS amongst men in Zambia
Achieving the first-90 of the UNAIDS ‘90-90-90’ target amongst men requires the use of innovative strategies to deliver HIV testing services to reach individuals previously not tested and encourage re-testing amongst those testing HIV-negative. Proposed policy option to achieve this include;
- Conventional HTS at a facility (Status Quo)
- Scaling up HTS through male-friendly clinics
- Community based assisted self-testing (HIVST)
Option 1: Conventional HTS at facilities (Status quo)
What: Leave things the way they are and continue routine HIV testing for all women, men and children together. There is a poor outcome in reaching men due to an unfavourable environment at health facilities that is usually congested with women and children.
Why: 25% of men having not been tested for HIV and received their results, compared to only 15% of adult women in Zambia by 2018 (ZDHS, 2018).
Feasibility: High Health facilities already have health care workers to attend to men, women and children who visit the health facility, and the standards of care have already been established.
Option 2: Scaling up HTS through male-friendly clinics
Men’s clinics provide a male-friendly environment that encourages men to get tested for HIV and therefore be identified as HIV positive and linked to HIV care and treatment services. This is an effort to improve service uptake among men, as currently there are 25% of HIV-positive males that do not know their status.
What: Identify space in existing government health facilities to establish male-friendly clinics, and recruit male nurses and counsellors who would provide services to men in an environment where they feel comfortable, and extended clinic hours and weekend clinics for men working longer day hours.
Why: Even though men are less likely to utilize existing health facility-based HIV services, they account for a significant proportion of new HIV infections and subsequent onward transmission (PEPFAR, 2018). The services in the men’s clinics will offer benefits that include flexible appointment schedules, longer working hours, weekend clinics, service delivery by staff trained in providing male-friendly services, multi-disease consultations, one-stop-shop for consultation and drug dispensing (e.g. ARV drug refills), short waiting times, and focus on male health care needs. Studies have shown that more than 90% of men accept HTS in a male-friendly clinic (PEPFAR 2018).
Feasibility: High Male friendly clinics leverage on existing infrastructure and personnel to provide a separate space, or in some cases dedicated times, to allow only men to access primary health care services. This is intended to address sociocultural barriers impeding men from visiting health care facilities.
Option 3: Community based assisted self-testing (HIVST)
Targeted community distribution of HIV self-testing (HIVST) kits for men has the potential to increase uptake of HIV testing services.
What: Exapnd community based targeted assisted HIVST for men
Why: Studies show that HIVST delivered in people’s communities/homes by community-based volunteers (CBVs) is acceptable, including to harder to reach individuals especially men (Bwalya et. al. 2020). The introduction of the HIVST in communities has the potential of improving men’s uptake in HIV testing services, thereby contributing to addressing the first cascade of the 90–90-90. Evidence shows that 90% of men are comfortable with using HIVST (Hlongwa et. al).
Feasibility: Medium; The approach of offering Universal Routine HIV Testing, including HIVST, gives a window to provide immediate treatment and care to all HIV infected individuals through the “test and treat” strategy. However, this implementing this strategy will require training of additional CBVs on HIVST promotion and use, hence requiring more resources. In addition, individuals who test positive on the HIVST kit will still need to do a confirmatory test at the health facility.
Cost effectiveness comparison of policies
Male friendly clinic HIV Testing Services in the facility are more cost-effective compared to HIV Self- Testing Services (HIVST) in the Community, and to Routine HIV Testing at the facility. The results show that HTS through male friendly clinics costs the least to initiate, which is $275 per an additional individual identified as HIV positive. These clinics provide a Differntiated Service Delivery (DSD) model for adult males who are less likely to be reached by provider-initiated and community-based HIV testing approaches that are widely used in Zambia.
Recommendations and next steps
Based on our analysis, scaling up HIV Testing Services (HTS) through male-friendly clinics in facilities is the most feasible option to increase uptake of HIV testing services among men. Male friendly clinics at health facilities make testing easier for men as they also provide flexible working hours and address confidentiality concerns. Studies have shown that more than 90% of men will accept HTS in a male-friendly environment.Scaling up HIV Testing Services through male-friendly clinics at the facilities to reach more men coupled with targeted testing through Index testing and social network testing will ensure case identification of more HIV positive men.
This intervention will need to introduce outreach activities in areas where men are more likely to be found e.g. busy city markets, taxi ranks, bus stops, and mines. With existing guidance on universal routine HIV testing and treatment in all public and private health facilities in Zambia, there is a need to design an implementation scale-up plan for expanding male-friendly clinics with relevant stakeholders. There is a need for all health facilities to have designated spaces for male-friendly clinics offering HTS, with male HCWs trained on provision of male friendly services, away from spaces with women and children. MoH will also have to work closely with other stakeholders and implementing partners that have successfully worked on DSD models such as after-hour clinics. The sustainability of this model will be strengthened through the use of MoH staff to provide services in the male clinics.
- Bwalya, C., Simwinga, M., Hensen, B. et al. Social response to the delivery of HIV self-testing in households: experiences from four Zambian HPTN 071 (PopART) urban communities. AIDS Res Ther 17, 32 (2020). https://doi.org/10.1186/s12981-020-00287-y
- Okal J, Lango D, Matheka J, Obare F, Ngunu-Gituathi C, Mugambi M, et al. (2020) “It is always better for a man to know his HIV status” – A qualitative study exploring the context, barriers and facilitators of HIV testing among men in Nairobi, Kenya. PLoS ONE 15(4): e0231645. https://doi.org/10.1371/journal.pone.0231645
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J Int AIDS Soc. 2020 Jun; 23(Suppl 2): e25520. Published online 2020 Jun 26. doi: 10.1002/jia2.25520
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