We read with interest the recent systematic review and meta-analysis which summarized the published evidence that, in many settings of sub-Saharan Africa, men receiving antiretroviral therapy (ART) appear to experience greater mortality on treatment compared with women .
We concur with the authors that their finding conflicts with current views on sex inequality in Africa. For the most part, funding agencies, governments, researchers and the general public have struggled to acknowledge that, contrary to the general discourse on sex inequality in the HIV epidemic, in fact men appear to be widely disadvantaged in their access to and outcomes on ART . However, we are concerned that some of the remarks of Druyts et al. seem to propagate the dominant messages of women's disempowerment. Despite reporting overwhelming evidence for male sex inequity in ART programme outcomes, the authors conclude that their findings ‘should not be used to argue strongly in favour of men's rights, but rather to promote equal access to treatment and care, regardless of sex’. We question the implicit assumption that advocating for men's rights in a situation of sex inequity automatically undermines the rights of women.
In recent years, there has been a plethora of studies reporting elevated risk for men compared with women in ART programmes [3–7]. Many such studies have concluded that this may be due to individual level risk factors related to men's poorer ‘health-seeking behaviour’. Researchers have suggested, for example, that men are less likely to seek care for HIV ; that when they seek care they do so at a later stage than women ; that they may be less likely to adhere to treatment ; and that they are more likely lost to follow-up  and consequently to die.
We recently explored these explanations in a study on sex and survival on ART among 46 201 adults in a large multicentre analysis of South African adult ART programmes . We found that none of the mechanisms fully explained men's elevated risk of mortality on ART. Indeed, it appeared that the reasons may be unrelated to ART and even to HIV: whereas men in these programmes had a 31% higher risk of death than women, in an age-standardized hypothetical cohort of HIV-negative individuals, men had twice the risk of death compared with women. Although these findings are intriguing, our study was not designed to explore non-HIV mortality and we would welcome research that sheds light on the mechanisms which increase men's general risk of mortality compared with women.
So men are indeed more likely than women to die on ART but this sex difference may be even greater outside ART programmes than within. Surely we should be trying to understand the factors that increase men's mortality risk rather than pitting the interests of men and women against each other?
Conflicts of interest
There are no conflicts of interest.
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