Men are absent across the HIV continuum of care in a rural area of southern Mozambique Laura Fuente-Soro, Elisa Lopez-Varela, Orvalho Augusto , Charfudin Sacoor, Ariel Nhacolo, Edson Bernardo, Esmeralda Karajeanes, Paula Vaz , Denise Naniche 25.07.2017

No conflicts of interest to declare Conflict of Interest No conflicts of interest to declare

BACKGROUND Loss-to-follow up along the HIV continuum of care increases morbidity and mortality HIV-infected men experience substantially worse outcomes than women: HIV diagnosis and initiation of treatment are delayed, treatment adherence is reduced and mortality is higher Adolescent girls and young women aged 15–24 years are at particularly high risk of HIV infection and are often infected by older men This analysis aimed to assess the sex differences in linkage and retention in HIV care in the Manhiça District, southern rural Mozambique

Health Demografic Surveillance System METHODS Prospective cohort study conducted between May 2014-June 2016 in the Manhiça District Enrolling adults with a new HIV diagnoses through 3 testing strategies: VCT Voluntary counseling and testing PICT Provider initiated counseling and testing HBT Home-based counseling and testing Health Demografic Surveillance System See poster TUPED1233 Elisa López-Varela et al. We assessed different steps of the cascade: HIV diagnosis for HBT group Linkage, initiation of ART, retention and mortality for all groups

Difference between female and male achievement of the first 90 target RESULTS A . Progress in reaching the first 90 target Age-specific community HIV prevalence according to sex and population distribution (N=10897) Difference between female and male achievement of the first 90 target Men <45 significantly lagged behind women of the same age in reaching the first 90 target Of the PLWHIV* found, 76.8% men were aware about their serostatus as compared to 89.0% of the women (p<.0001) < 25 25-34 35-44 45-64 All Age categories -10 -5 5 10 15 20 25 30 35 40 Gap Female Male(%) (Positive values favour females) 85 - + 0.0 0.0 75 - 84 Males 8.8 2.3 Females 65 - 74 9.2 10.1 55 - 64 17.5 22.5 45 - 54 25.3 34.4 35 - 44 26.6 39.6 25 - 34 17.9 32.3 18 - 24 4.4 13.9 1600 1400 1200 1000 800 600 400 200 200 400 600 800 1000 1200 1400 1600 Total sampled individuals Community HIV prevalence was estimated to be 33.6% (95%CI 32.5-34.6) and varied significantly by sex and age *PLWHIV - People living with HIV

B . Progress in reaching the second 90 target among new HIV diagnoses RESULTS B . Progress in reaching the second 90 target among new HIV diagnoses Out of the 1122 new HIV diagnosis enrolled: - Men were less likely to be linked to care and receive a CD4 result (58.9% vs. 66.2%, p=0.016) - Five-fold more men were in WHO stages III/IV at first clinical visit (10% vs. 2%, p<0.001) - Among ART eligible individuals, similar proportions of men and women initiated (81.2% vs 85.9% respectively p=0.4) Proportion of loss to follow up over 18 months after ART initiation. * aSHR: Sub-hazard ratios adjusted by age and testing venue aSHR* 2.7, 95% CI 1.4-5.5 Male Female After an HIV diagnosis, men were less likely than women to be linked to care and receive a CD4 result (58.9% vs. 66.2%, p=0.016). Fivefold more men than women were in WHO stages III/IV of AIDS at first clinical visit (10% vs. 2%, p<0.001), and 20.6% men had advanced immunosuppression with CD4 below 100 cells/uL as compared to 11.2% of women (p<0.0001). Among individuals with criteria for ART initiation, similar proportions of men and women initiated (81.2% vs 85.9% respectively p=0.4).   However if we incorporated the losses at each step including home contact, HIV testing, and linkage to care, we can conclude that: of a random list of individuals sought out for community testing, 25.3% of men and 36% of women successfully initiated C . Mortality among new HIV diagnoses One-year mortality was almost twice as high in men as compared to women (5.9% vs. 3.2%, p=0.028)

CONCLUSSION Decreasing mortality in men and achieving the 90-90-90 objectives will require male-specific strategies Male-friendly approaches for testing, linkage and retention across the continuum care may improve clinical outcomes in HIV-infected men as well as decrease transmission to young women

ACKNOWLEDGEMENTS To all the people that made this study possible, especially participants. This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of Scaling-up HIV counseling & testing services in a rural population by strengthening the health demographic surveillance system, in Manhiça, Mozambique – CoAg GH000479. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the CDC