Gender Considerations Along the HIV Treatment Cascade: An Evidence Review with Priority Actions

"Expanding access to ART while considering equity and human rights is urgently needed..."

This brief provides policymakers and programme implementers with evidence about the impact of gender dynamics on treatment access and adherence and the gender-related gaps in treatment research and programming. It also raises questions for implementation science in order, by 2020, to achieve the global goals set out by the Joint United Nations Programme on HIV/AIDS (UNAIDS): 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy (ART) will have viral suppression. The brief draws from What Works For Women and Girls: Evidence for HIV Interventions and uses the World Health Organization (WHO) treatment cascade framework to identify and analyse major gender considerations in providing ART to those living with HIV in low- and middle-income countries.

With regard to knowing one's HIV status, it is noted that women must navigate a number of hurdles in accessing testing. For example, stigma, gender inequalities, and fear of negative outcomes following disclosure (e.g., ostracism by household or community) are significant barriers. Gender norms affect men as well in this arena. For instance, focus group discussions (FGDs) with young men in Malawi and Uganda found that norms such as equating masculinity with invulnerability and sexual conquest were the reasons they would not access HIV testing and counseling. Priority actions for programming and policy are outlined and include, among other approaches, creating programmes to reach men as independent users of health services rather than exclusively through their female partners and strengthening couples testing by revising national and local guidelines to feature: a context-appropriate definition of a "couple", gender-sensitive ways to engage men and women in counseling, and linkages to available gender-based violence (GBV) services.

With regard to enrollment in ART and treatment care, though women constitute a higher proportion of those receiving ART than men, "structural factors and traditional gender norms can jeopardize women's adherence, retention in care or ability to reduce transmission." These include the focus on attention to women with the goal of prevention of vertical transmission (leading to high dropout rates from treatment programmes, postpartum) and the complexities of so-called "Option B+" (see page 4 for a discussion). Harmful gender norms (e.g., viewing seeking health care as weakness) frequently cause men to delay presentation for treatment. One study found that men used their economic and decision-making power to informally access ART (e.g., by stealing their wives' antiretrovirals, or ARVs) in order not to be seen at clinics, which are seen as a woman's space. There are also cases of inequitable access to ART due to age (e.g., inadequate treatment access for adolescent women) and social status (e.g., stigma, discrimination, and marginalisation faced by transgender people and sex workers). Priority actions are outlined, such as ensuring that all service providers are trained in the principles of non-discrimination and creating both an inclusive atmosphere as well as physical space within clinics where men can initiate ART with follow-up within communities and with male peer support.

With regard to ART retention, there are gender differences in predictors of adherence. For example, female sex workers in Vietnam reported they were not allowed to join networks of people living with HIV who gained access to valuable support and information services because they were seen as "social evils" rather than "innocent wives getting the disease from their husband". Also in that country, men, even if they injected drugs, reported better quality of life on ART (which can have side effects) than did women, as women cared for the men. FGDs in South Africa with men living with HIV on ART who had disclosed to their partners found they wanted to access male-only support groups with guarantees that their HIV status would not be disclosed outside of the support group setting. "Non-judgmental, non-stigmatizing interventions both within the health sector and outside the health sector, such as transforming gender norms, reducing violence against women, [and] revising laws that criminalize non-disclosure of HIV...need to be implemented in order to support safer sexual behavior once someone knows his or her positive serostatus." Priority areas include strengthening training for counselors and other healthcare workers that provides guidance on safe disclosure for both men and women (separate guidance for each that addresses gender issues for each).

With regard to achieving viral suppression, factors such as drug resistance, drug interactions, and biological differences may also be subject to gender-related challenges. Furthermore, there may be sex differences in ART efficacy, yet this is an understudied area of inquiry, with women underrepresented in clinical trials.

The brief concludes with an argument that all ART programming must include respect for human rights. For example: "Requiring people living with HIV to disclose their serostatus to sexual partners and/or community members in order to receive treatment, care or support is a human rights violation. Similarly, coercing women to accept contraception in order to access treatment violates women's rights to make their own fertility choices." The authors note that there are few evaluated interventions demonstrating what works to overcome gender-related barrier to ART treatment. Future studies should ask questions such as "how can ART availability and accessibility be partnered with informed consent about the risks and benefits of treatment so that all people living with HIV may decide for themselves how best to stay healthy and live full, productive lives?"