Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis

Druyts, Erica; Dybul, Markb; Kanters, Stevec; Nachega, Jeand; Birungi, Josephinee; Ford, Nathanf; Thorlund, Kristiang; Negin, Joelh; Lester, Richardi; Yaya, Sannia; Mills, Edward J.a,g

doi: 10.1097/QAD.0b013e328359b89b
Epidemiology and Social

Background: HIV/AIDS has historically had a sex and gender-focused approach to prevention and care. Some evidence suggests that HIV-positive men have worse treatment outcomes than their women counterparts in Africa.

Methods: We conducted a systematic review and meta-analysis of the effect of sex on the risk of death among participants enrolled in antiretroviral therapy (ART) programs in Africa since the rapid scale-up of ART. We included all cohort studies evaluating the effect of sex (male, female) on the risk of death among participants enrolled in regional and national ART programs in Africa. We identified these studies by searching MedLine, EMBASE, and Cochrane CENTRAL. We used a DerSimonian-Laird random-effects method to pool the proportions of men receiving ART and the hazard ratios for death by sex.

Results: Twenty-three cohort studies, including 216 008 participants (79 892 men) contributed to our analysis. The pooled proportion of men receiving ART was 35% [95% confidence interval (CI): 33–38%]. The pooled hazard ratio estimate indicated a significant increase in the risk of death for men when compared to women [hazard ratio: 1.37 (95% CI: 1.28–1.47)]. This was consistent across sensitivity analyses.

Interpretation: The proportion of men enrolled in ART programs in Africa is lower than women. Additionally, there is an increased risk of death for men enrolled in ART programs. Solutions that aid in reducing these sex inequities are needed.

Author Information

aFaculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada

bO’Neill Institute for National and Global Health Law, Georgetown University, Washington, District of Columbia, USA

cFaculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada

dCentre for Infectious Diseases, University of Stellenbosch, Stellenbosch, South Africa

eThe AIDS Support Organization (TASO), Kampala, Uganda

fInternational Office, Médecins Sans Frontiers, Geneva, Switzerland

gDepartment of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada

hSchool of Public Health, University of Sydney, Sydney, New South Wales, Australia

iBritish Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.

Correspondence to Edward J. Mills, Faculty of Health Sciences, University of Ottawa, 43 Templeton Street, Ottawa, ON K1N6X1, Canada. E-mail:

Received 22 June, 2012

Revised 15 August, 2012

Accepted 24 August, 2012

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© 2013 Lippincott Williams & Wilkins, Inc.