Centers for Disease Control & Prevention (CDC) Lower Levels of Antiretroviral Therapy Enrollment Among Men with HIV Compared with Women — 12 Countries, 2002–2013 Author(s): Andrew F. Auld, Ray W. Shiraishi, Francisco Mbofana, Aleny Couto, Ernest Benny Fetogang, Shenaaz El-Halabi, Refeletswe Lebelonyane, Pilatwe Tlhagiso Pilatwe, Ndapewa Hamunime, Velephi Okello, Tsitsi Mutasa-Apollo, Owen Mugurungi, Joseph Murungu, Janet Dzangare, Gideon Kwesigabo, Fred Wabwire-Mangen, Modest Mulenga, Sebastian Hachizovu, Virginie Ettiegne-Traore, Fayama Mohamed, Adebobola Bashorun, Do Thi Nhan, Nguyen Huu H ... Source: Morbidity and Mortality Weekly Report , Vol. 64, No. 46 (November 27, 2015), pp. 1281-1286 Published by: Centers for Disease Control & Prevention (CDC) Stable URL: https://www.jstor.org/stable/10.2307/24856902 REFERENCES Linked references are available on JSTOR for this article: https://www.jstor.org/stable/10.2307/24856902?seq=1&cid=pdf- reference#references_tab_contents You may need to log in to JSTOR to access the linked references. JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org. Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at https://about.jstor.org/terms Centers for Disease Control & Prevention (CDC) is collaborating with JSTOR to digitize, preserve and extend access to Morbidity and Mortality Weekly Report This content downloaded from 197.255.69.76 on Thu, 14 Sep 2023 11:08:38 +00:00 All use subject to https://about.jstor.org/terms Morbidity and Mortality Weekly Report Weekly / Vol. 64 / No. 46 November 27, 2015 World AIDS Day — Lower Levels of Antiretroviral December 1, 2015 Therapy Enrollment Among Men with HIV Compared with Women — World AIDS Day, observed on December 1, draws atten­ 12 Countries, 2002–2013 tion to the current status of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) Andrew F. Auld, MBChB1; Ray W. Shiraishi, PhD1; Francisco Mbofana, 2 epidemic worldwide. This year’s theme is World AIDS MD ; Aleny Couto, MD 2; Ernest Benny Fetogang, PhD3; Shenaaz El-Halabi, MPH3; Refeletswe Lebelonyane, MD3; Pilatwe Tlhagiso 2015: The Time to Act is Now. Pilatwe, MSc3; Ndapewa Hamunime, MD4; Velephi Okello, MD5; The first cases of AIDS were reported more than 30 years Tsitsi Mutasa-Apollo, MBChB6; Owen Mugurungi, MD6; Joseph ago, in the June 5, 1981 issue of MMWR. At the end of Murungu, MD6; Janet Dzangare, MSc6; Gideon Kwesigabo, MD7; Fred Wabwire-Mangen, MD8; Modest Mulenga, MD9; Sebastian Hachizovu, 2014, approximately 36.9 million persons worldwide were MBChB9; Virginie Ettiegne-Traore, MD10; Fayama Mohamed, MSAE11; living with HIV infection (1). Although AIDS-related Adebobola Bashorun, MD12; Do Thi Nhan, MD13; Nguyen Huu Hai, deaths have decreased by 42% since 2004, an estimated MD13; Tran Huu Quang, MSc14; Joelle Deas Van Onacker, MD15; 1.2 million persons died from AIDS in 2014 (1). Kesner Francois, MD 15; Ermane G. Robin, MD15; Gracia Desforges, MD15; Mansour Farahani, MD16; Harrison Kamiru, DrPH17; Harriet Global efforts, including the U.S. President’s Emergency Nuwagaba-Biribonwoha, MBChB17; Peter Ehrenkranz, MD18; Julie A. Plan for AIDS Relief (in which CDC is a principal Denison, PhD19; Olivier Koole, MD20; Sharon Tsui, MPH19; Kwasi 21 agency), have resulted in approximately 13.5 million Torpey, PhD ; Ya Diul Mukadi, MD 22; Eric van Praag, MD23; Joris Menten, MSc20; Timothy D. Mastro, MD24; Carol Dukes Hamilton, persons in low- and middle-income countries receiving MD24; Oseni Omomo Abiri, MPH25; Mark Griswold, MSc26; Edna antiretroviral therapy (ART) for HIV infection in 2014 Pierre, MD26; Carla Xavier, MSc27; Charity Alfredo, MD27; Kebba (2). Globally, approximately 15 million persons are on Jobarteh, MD27; Mpho Letebele, MD28; Simon Agolory, MD29; Andrew L. Baughman, PhD29; Gram Mutandi, MBChB29; ART (1). An estimated 1.2 million persons in the United Peter Preko, MD25; Caroline Ryan, MD30; Trong Ao, ScD30; Elizabeth States and Puerto Rico are living with HIV infection (3) Gonese, MPH31; Amy Herman-Roloff, PhD31; Kunomboa A. Ekra, MD32; and approximately 50,000 persons become infected with HIV each year (4). References INSIDE 1. Joint United Nations Programme on HIV/AIDS. How AIDS 1287 Scale-up of HIV Viral Load Monitoring — changed everything. MDG6: 15 years, 15 lessons of hope from the Seven Sub-Saharan African Countries AIDS response. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2015. Available at http://www.unaids. 1291 Vital Signs: Estimated Percentages and Numbers org/sites/default/files/media_asset/MDG6Report_en.pdf. of Adults with Indications for Preexposure 2. World Health Organization. HIV/AIDS fact sheet no. 360. Geneva, Prophylaxis to Prevent HIV Acquisition — Switzerland: World Health Organization; 2015. Available at http:// United States, 2015 www.who.int/mediacentre/factsheets/fs360/en/. 3. CDC. Monitoring selected national HIV prevention and care 1296 Vital Signs: Increased Medicaid Prescriptions for objectives by using HIV surveillance data—United States and Preexposure Prophylaxis Against HIV infection — 6 dependent areas, 2013. HIV surveillance supplemental report; New York, 2012–2015 2015:20(2). Available at http://www.cdc.gov/hiv/pdf/library/reports/ 1303 QuickStats surveillance/cdc-hiv-surveillancereport_vol20_no2.pdf. 4. Estimated HIV incidence in the United States, 2007–2010. HIV surveillance supplemental report; 2012:17(4). Available at http:// www.cdc.gov/hiv/pdf/statistics_hssr_vol_17_no_4.pdf. Continuing Education examination available at http://www.cdc.gov/mmwr/cme/conted_info.html#weekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention This content downloaded from 197.255.69.76 on Thu, 14 Sep 2023 11:08:38 +00:00 All use subject to https://about.jstor.org/terms Morbidity and Mortality Weekly Report Joseph S. Kouakou, MD32; Solomon Odafe, MD33; Dennis Onotu, estimates for the female-to-male ratio among HIV-infected MD33; Ibrahim Dalhatu, MD33; Henry H. Debem33; Duc B. Nguyen, MD34; Le Ngoc Yen, MD34; Abu S. Abdul-Quader, PhD34; Valerie adults by 23%–83%. In six African countries and Haiti, Pelletier, MD35; Seymour G. Williams, MD36; Stephanie Behel, MPH1; the ratio of women to men among new adult ART enrollees George Bicego, PhD1; Mahesh Swaminathan, MD1; E. Kainne Dokubo, increased more sharply over time than the estimated UNAIDS MD1; Georgette Adjorlolo-Johnson, MD37; Richard Marlink, MD16; 38 female-to-male ratio among adults with HIV in the general David Lowrance, MD ; Thomas Spira, MD1; Robert Colebunders, MD20; David Bangsberg, MD39; Aaron Zee, MPH1; Jonathan Kaplan, population. Increased ART coverage among men is needed MD1; Tedd V. Ellerbrock, MD1 to decrease their morbidity and mortality and to reduce HIV incidence among their sexual partners. Reaching more men Equitable access to antiretroviral therapy (ART) for men and with HIV testing and linkage-to-care services and adoption of women with human immunodeficiency virus (HIV) infection test-and-treat ART eligibility guidelines (i.e., regular testing is a principle endorsed by most countries and funding bod­ of adults, and offering treatment to all infected persons with ies, including the U.S. President’s Emergency Plan for AIDS ART, regardless of CD4 cell test results) could reduce gender (acquired immunodeficiency syndrome) Relief (PEPFAR) (1). inequity in ART coverage. To evaluate gender equity in ART access among adults (defined Three approaches to sampling and analysis were employed for this report as persons aged ≥15 years), 765,087 adult ART in the 12 studied countries (Table). In Botswana, Haiti, patient medical records from 12 countries in five geographic Mozambique, and Namibia, where large, centralized, electronic regions* were analyzed to estimate the ratio of women to ART patient monitoring systems are employed, all available men among new ART enrollees for each calendar year during data from 2002–2013 were analyzed. In each of these coun­ 2002–2013. This annual ratio was compared with estimates tries, 67%–100% of all ART patients and 58%–100% of all from the Joint United Nations Programme on HIV/AIDS ART facilities were captured in the electronic system. In Côte (UNAIDS)† of the ratio of HIV-infected adult women to men d’Ivoire, Nigeria, Swaziland, Vietnam, and Zimbabwe, nation­ in the general population. In all 10 African countries and Haiti, ally representative samples of ART facilities were selected, the most recent estimates of the ratio of adult women to men with probability of selection proportional to size. In Tanzania, among new ART enrollees significantly exceeded the UNAIDS Uganda, and Zambia, health facilities were purposively selected by investigators to represent the range of ART facilities in each * East Africa: Tanzania, Uganda; Southern Africa: Botswana, Mozambique, country and ensure that the study remained feasible. Among Namibia, Swaziland, Zambia, Zimbabwe; West Africa: Côte d’Ivoire, Nigeria; Caribbean: Haiti; Southeast Asia: Vietnam. the eight sample-based surveys, a sample frame of study-eligible † Additional information available at http://aidsinfo.unaids.org/. ART patients was created at each selected facility, and simple The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30329-4027. Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2015;64:[inclusive page numbers]. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director Harold W. Jaffe, MD, MA, Associate Director for Science Joanne Cono, MD, ScM, Director, Office of Science Quality Chesley L. Richards, MD, MPH, Deputy Director for Public Health Scientific Services Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services MMWR Editorial and Production Staff (Weekly) Sonja A. Rasmussen, MD, MS, Editor-in-Chief Martha F. Boyd, Lead Visual Information Specialist Charlotte K. Kent, PhD, MPH, Executive Editor Maureen A. Leahy, Julia C. Martinroe, Jacqueline Gindler, MD, Editor Stephen R. Spriggs, Moua Yang, Teresa F. Rutledge, Managing Editor Visual Information Specialists Douglas W. Weatherwax, Lead Technical Writer-Editor Quang M. Doan, MBA, Phyllis H. King, Soumya Dunworth, PhD, Teresa M. Hood, MS, Teresa C. Moreland, Terraye M. Starr, Technical Writer-Editors Information Technology Specialists MMWR Editorial Board Timothy F. Jones, MD, Chairman William E. Halperin, MD, DrPH, MPH Jeff Niederdeppe, PhD Matthew L. Boulton, MD, MPH King K. Holmes, MD, PhD Patricia Quinlisk, MD, MPH Virginia A. Caine, MD Robin Ikeda, MD, MPH Patrick L. Remington, MD, MPH Katherine Lyon Daniel, PhD Rima F. Khabbaz, MD Carlos Roig, MS, MA Jonathan E. Fielding, MD, MPH, MBA Phyllis Meadows, PhD, MSN, RN William L. Roper, MD, MPH David W. Fleming, MD Jewel Mullen, MD, MPH, MPA William Schaffner, MD 1282 MMWR / November 27, 2015 / Vol. 64 / No. 46 US Department of Health and Human Services/Centers for Disease Control and Prevention This content downloaded from 197.255.69.76 on Thu, 14 Sep 2023 11:08:38 +00:00 All use subject to https://about.jstor.org/terms Morbidity and Mortality Weekly Report TABLE. Study designs for antiretroviral therapy (ART) cohort evaluations — 12 countries, 2002–2013 Stage 1: selection of study sites Stage 2: selection of study patients Estimated no. study- Patient eligible sampling adult ART technique No. No. enrollees at Age at at eligible study- No. adult study- Site No. ART ART selected Planned medical Dates of Assessment No. eligible clinic eligible sampling clinics initiation enrollment study sample records data Region Country year clinics clinics* enrollees clinics technique selected (yrs) years clinics size* analyzed collection East Africa Tanzania 2007 210 85 41,920 37,728 Purposive 6 ≥18 2004–2009 SRS 1,500 1,457† 04–07/2010 Uganda 2007 286 114 45,946 41,351 Purposive 6 ≥18 2004–2009 SRS 1,500 1,466§ 04–07/2010 Southern Botswana 2014 302 176 247,856 217,082 Census 176 ≥15 2002–2013 Census 217,082 217,082 10/2013 Africa Mozambique 2014 288 170 456 055 306,335 Census 170 ≥15 2004–2013 Census 306,335 306,335 04/2014 Namibia 2013 213 213 140,224 138,054 Census 213 ≥15 2003–2012 Census 138,054 138,053¶ 12/2013 Swaziland 2009 31 31 50,767 50,767 PPS 16 ≥15 2004–2010 SRS 2,500 2,510 11/2011– 02/2012 Zambia 2007 322 129 65,383 58,845 Purposive 6 ≥18 2004–2009 SRS 1,500 1,214** 04–07/2010 Zimbabwe 2008 104 70 103,806 93,811 PPS 40 ≥15 2007–2009 SRS 4,000 3,896†† 01–06/2010 West Africa Côte d’Ivoire 2007 124 78 36,943 36,110 PPS 34 ≥15 2004–2007 SRS 4,000 3,682 11/2009– 03/2010 Nigeria§§ 2009 178 139 168,335 167,438 PPS 35 ≥15 2004–2011 SRS 3,500 3,496 12/2012– 08/2013 Caribbean Haiti 2013 149 149 52,120 78,317 Census 149 ≥15 2002–2013 Census 78,317 78,317 04/2014 Southeast Vietnam 2009 173 120 28,090 25,000 PPS 30 ≥15 2005–2009 SRS 7,587 7,579¶¶ 01–06/2010 Asia Total 2,380 1,474 1,385,325 1,250,838 881 765,875 765,087 Abbreviations: PPS = probability-proportional-to-size; SRS = simple random sampling. * To keep sample-based studies feasible, in Côte d’Ivoire, Nigeria, Vietnam, and Zimbabwe, only facilities with ≥50 adults on ART were eligible for sampling, whereas in Tanzania, Uganda, and Zambia only facilities that had enrolled ≥300 adults on ART were eligible. † In Tanzania, record of one patient was excluded from 1,458 sampled because of missing age data at ART initiation. § In Uganda, records of six patients were excluded from 1,472 sampled because of missing age data at ART initiation. ¶ In Namibia, among those adults enrolled on ART during 2003–2012, one patient with missing gender information was excluded from analysis. ** In Zambia, 243 of 1,457 records sampled were excluded because of noncompliance with simple random sampling procedures at one site. †† In Zimbabwe, 23 selected patients with either missing gender (n = 12) or missing outcome (n = 11) were excluded from analysis. §§ In Nigeria, implicit stratification was used in the sampling approach. ¶¶ In Vietnam, among observations from 7,587 records sampled, four were excluded because of lack of gender information and four because of lack of outcome date. random sampling was used to select the sample of records. available online at http://stacks.cdc.gov/view/cdc/35684.) Eligibility criteria included initiation of ART ≥6 months before In all countries except Vietnam, the most recent estimates of data abstraction, during 2002–2013, and at age ≥15 years. the female-to-male ratio among new ART enrollees, and the Data were abstracted from ART records onto standardized ratio of women to men currently enrolled in ART exceeded abstraction forms by trained study personnel. the UNAIDS female-to-male ratios among persons with HIV. For each of the 12 countries, the ratio of women to men who In addition, in seven countries (Botswana, Côte d’Ivoire, were newly enrolled in ART during 2002–2013 was compared Haiti, Nigeria, Mozambique, Swaziland, and Zambia), point with the current ratio of women to men among cumulative estimates of the ratio of female-to-male new ART enrollees ART patients who were alive on ART by the end of each cal­ increased more sharply over time than did the UNAIDS endar year and with UNAIDS estimates of the ratio of women female-to-male ratios among persons with HIV. The trends in to men among adults living with HIV for each calendar year. female-to-male ratios of current ART enrollees closely paral­ To assess a country’s ART program accessibility to women with leled the new ART enrollee ratio trends. HIV compared with men with HIV, the percent difference In east Africa, the most recent female-to-male new ART between the most recently available female-to-male new ART enrollee ratios were 2.10 in both Tanzania and Uganda for enrollee ratio and the UNAIDS estimate of the ratio of women 2009; in contrast, the 2009 UNAIDS female-to-male ratios to men among persons with HIV in the general population among adults with HIV were 1.38 and 1.31, respectively. for the same calendar year was calculated. Data were analyzed Compared with males, adult females with HIV were approxi­ using statistical software, and study design was controlled for mately 53% and 60% more likely to access ART in Tanzania during analyses. and Uganda, respectively (Figure). Across the 12 countries, 765,087 adult ART patient In southern Africa, the most recent female-to-male new records were analyzed. (Graphs of data for all countries are ART enrollee ratios were 1.95 in Botswana (2013); 2.73 in US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / November 27, 2015 / Vol. 64 / No. 46 1283 This content downloaded from 197.255.69.76 on Thu, 14 Sep 2023 11:08:38 +00:00 All use subject to https://about.jstor.org/terms Morbidity and Mortality Weekly Report FIGURE. Percent difference between female-to-male new antiretroviral therapy enrollee ratios and corresponding UNAIDS ratios of females to males among all persons with HIV, by country* — 12 countries, 2002–2013 100 80 60 40 20 0 -20 Tanzania Uganda Botswana Mozam- Namibia Swaziland Zambia Zimbabwe Côte Nigeria Haiti Vietnam bique d’Ivoire Country Abbreviations: AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; UNAIDS = Joint United Nations Programme on HIV/AIDS. * East Africa: Tanzania, Uganda; Southern Africa: Botswana, Mozambique, Namibia, Swaziland, Zambia, Zimbabwe; West Africa: Côte d’Ivoire, Nigeria; Caribbean: Haiti; Southeast Asia: Vietnam. Mozambique (2013); 1.61 in Namibia (2012); 1.91 (95% women with HIV were 32% more likely to access ART in confidence interval [CI] = 1.70–2.13) in Swaziland (2010); 2013. Finally, in Vietnam in 2009, the female-to-male new 1.57 in Zambia (2009); and 1.76 (95% CI = 1.53–1.99) in ART enrollee ratio was 0.34 (95% CI = 0.27–0.41), which was Zimbabwe (2009); whereas the corresponding calendar year similar to the UNAIDS female-to-male ratio among persons UNAIDS female-to-male ratios among adults with HIV for with HIV (0.39). these countries were 1.30, 1.49, 1.13, 1.43, 1.05, and 1.43, respectively. Compared with males living with HIV in southern Discussion Africa, females living with HIV were 23%–83% more likely This analysis of 765,087 adult ART patient records from to access ART (Figure). 12 countries is the most up-to-date and comprehensive In west Africa, the most recent female-to-male new ART assessment of disproportionate ART enrollment among adult enrollee ratios were 2.21 (95% CI = 1.77–2.64) in Côte d’Ivoire women with HIV compared with men, in resource-limited (2007) and 2.34 (95% CI = 1.86–2.83) in Nigeria (2011); the settings (2). In 10 African countries and Haiti (countries with corresponding calendar year UNAIDS female-to-male ratios generalized HIV epidemics) women with HIV were more among adults with HIV were 1.28 and 1.34, respectively. likely to access ART than men with HIV. In addition, in six Compared with men, adult women with HIV were about African countries and Haiti, gender-related disparities in ART 73% and 75% more likely to access ART in Côte d’Ivoire and coverage appear to be increasing over time. The adult ART Nigeria, respectively. program sex distribution was largely reflective of the UNAIDS In Haiti in 2013, the female-to-male new ART enrollee female-to-male ratio among persons with HIV in only one ratio was 1.89, and the UNAIDS female-to-male ratio among country, Vietnam. persons with HIV was 1.43. Compared with men, adult 1284 MMWR / November 27, 2015 / Vol. 64 / No. 46 US Department of Health and Human Services/Centers for Disease Control and Prevention This content downloaded from 197.255.69.76 on Thu, 14 Sep 2023 11:08:38 +00:00 All use subject to https://about.jstor.org/terms Percent diffe rence (%) Morbidity and Mortality Weekly Report Higher ART coverage among adult women with HIV in the African countries and Haiti could occur for a number of Summary potential reasons. First, HIV testing and counseling is a part What is already known on this topic? of routine antenatal care, which provides an early entry point Equitable access to antiretroviral therapy (ART) for human to ART for women with HIV. Second, ART eligibility crite­ immunodeficiency virus (HIV)-infected men and women is a principle endorsed by most countries and funding bodies, including ria are currently more inclusive for adult women with HIV the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). than men because, to prevent mother-to-child transmission What is added by this report? (PMTCT) for pregnant women with HIV, all 12 countries except Nigeria§ have adopted guidelines recommending uni­ To evaluate gender equity in ART access, 765,087 adult ART patient medical records from 12 countries were analyzed to esti­ versal, lifelong ART, regardless of the results of the CD4 cell mate the female-to-male new ART enrollee ratio for each calen­ count test (referred to as PMTCT Option B+). Third, differ­ dar year during 2002–2013. This annual ratio was compared with ences between men and women in health-seeking behavior corresponding Joint United Nations Programme on HIV/AIDS might also play a role, with men considered more likely to (UNAIDS) estimates of adult female-to-male ratios among all delay access to health care for reasons that include stigma, persons with HIV. In all 10 African countries and Haiti, the most recent estimate of the ratio of women to men newly enrolled in male norms that discourage admitting ill health, and employ­ ART significantly exceeded the UNAIDS estimate of the ratio of ment responsibilities, which might involve within-country and women to men among persons with HIV by 23%–83%. cross-border migration (3). What are the implications for public health practice? In many of the countries studied, gender inequity in ART Reaching more men with HIV testing and linkage-to-care coverage appears to be increasing. At the patient level, the services and adoption of test-and-treat ART-eligibility recent initiation of PMTCT B+ might explain recent dis­ guidelines could reduce gender inequity in ART coverage. proportionate accelerations in ART coverage among women Government- and donor-level policy and management shifts, in some countries (e.g., Mozambique initiated PMTCT B+ including endorsement of male-health–focused strategies, in 2013). However, at governance- and funder-levels, lack of performance-based financing that provides incentives to reach both men and women, and gender disaggregation of HIV initiatives to address gender inequities in ART coverage might treatment cohort data are also needed. Prioritizing increased result from tacitly holding men responsible for failing to access ART coverage among men with HIV could decrease male ART services, rather than assigning responsibility for improv­ morbidity and mortality and reduce HIV incidence among ing male ART coverage to global health programs (4). Recent sexual partners. data show that men’s health is often considered a lower priority than women’s health in global health programs (5). However, The findings in this report are subject to at least four limita­ this prioritization is not based on disease burden as estimated tions. First, UNAIDS estimates of female-to-male ratios among using disability-adjusted life years: HIV and the other nine top all persons with HIV are derived from epidemic models with contributors to global disability-adjusted life years are more inherent uncertainty, limiting the ability to make statistical burdensome in men than in women (5). comparisons between UNAIDS-derived and cohort-derived Of the 12 countries studied, only Vietnam had female-to­ ratios. Second, cohort data varied in size and generalizability. male new ART enrollee ratios similar to UNAIDS female-to­ Third, this study analyzed average female-to-male ratios for male ratios among persons with HIV. A possible explanation is adults; future analyses to examine effect modification across that Vietnam has a concentrated epidemic, affecting predomi­ adult age groups are needed. Finally, this analysis did not nantly male persons who inject drugs, and therefore, from the evaluate gender ratios among persons being tested for HIV beginning, the ART program in Vietnam has been focused on or linking to care, which would help explain observed ratios addressing the disease within this population (6). In Vietnam, among ART enrollees. men with HIV commonly access ART through routine HIV Increasing ART coverage among men with HIV would testing and counseling at needle and syringe exchange programs reduce morbidity and mortality in this group and contribute to and methadone maintenance therapy clinics (6). In contrast, reducing HIV incidence among their sex partners (8), includ­ women with HIV primarily access HIV testing and linkage to ing adolescent girls and young women, a priority population ART via outreach activities to female sex workers, and through for PEPFAR.¶ Strategic program changes needed to reach routine HIV testing at antenatal care clinics; this coverage was more HIV-infected men with ART include identification low in 2005, but is increasing (6,7). Continued monitoring of of routine HIV testing systems, similar to HIV testing and Vietnam’s ART program gender ratios is warranted, as women counseling for women in antenatal care settings, and adop­ account for increasing proportions of new HIV infections (6). tion of test-and-treat guidelines, which was recommended § Additional information available at http://www.hivpolicywatch.org/. ¶ Additional information available at http://www.pepfar.gov/partnerships/ppp/ dreams/index.htm. 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Corresponding author: Andrew Auld, aauld@cdc.gov, 404-639-8997. 1286 MMWR / November 27, 2015 / Vol. 64 / No. 46 US Department of Health and Human Services/Centers for Disease Control and Prevention This content downloaded from 197.255.69.76 on Thu, 14 Sep 2023 11:08:38 +00:00 All use subject to https://about.jstor.org/terms