Delayed entry to care by men with HIV infection in Kumasi, Ghana

Introduction In resource-limited settings, men may face considerable barriers to accessing HIV care as early interventions tend to focus on antenatal care settings. Methods We performed a retrospective chart review of all adult patients referred to Komfo Anokye Teaching Hospital HIV clinic in Kumasi, Ghana in 2011 to identify the differences in clinical and demographic variables by gender at presentation to care using two-sample t tests with adjusted variance and Wilcox rank sum tests for continuous variables and Pearson chi-squared tests for categorical variables. We also compared differences in clinical and demographic variables among men stratified by CD4 count at initiation of care in order to identify variables associated with later entry to care. Results Demographically, men were more likely to be older (men age 42 vs. 37, p<0.01), have a greater number of dependent children (1.8 v. 1.5, p = 0.04), to be living with or married to their partner (65.4% vs. 49.0%, p<0.01), and to have a higher level of education (tertiary education, 45.8% vs. 25.4%, p<0.01) than women. Clinically, men were more likely to have a lower CD4 count at entry to care (260 v. 311 cells/µL, p<0.01), to report clinical symptoms to the nurse during intake (p<0.01), and to have any history of alcohol use (p<0.01). Conclusion Men in Ghana are accessing treatment at a later stage of their disease than women. Efforts to test and link men to care early should be intensified.


Introduction
In resource limited settings (RLS), men have been identified as an at-risk population for delayed entry to HIV care, initiation of antiretroviral therapy (ART) and retention in care [1][2][3][4][5][6][7]. In sub-Saharan Africa, the focus of HIV treatment interventions has been on women, who are considered to be vulnerable to HIV infection due to biological factors and socio cultural factors that limit their sexual autonomy and power [1]. Recently, poorer health outcomes have been associated with male gender in the African HIV epidemic [1][2][3][4][5]7]. This phenomenon has been connected to two causal factors: 1) the international focus upon interventions for prevention of maternal to child transmission (PMTCT) and 2) cultural values surrounding masculinity in sub-Saharan Africa that emphasize the invulnerability of men to illness [8]. Currently, there are few published studies on gender disparities in entry to HIV care in Western Africa. Nonetheless, national epidemiological data casts some light upon the gender dynamics of the HIV epidemic in Ghana.
The Ghanaian HIV epidemic is predominantly driven by heterosexual transmission, which is responsible for 80% of new cases [9]. In occupation, alcohol use) that could play a role in gender disparities in entry to care or treatment adherence. In this retrospective chart review, we sought to identify the differences in clinical and demographic variables between men and women at presentation to care. We also sought to identify differences in clinical and demographic variables between men, stratified by CD4 count at presentation to care. The results of this study could serve as the basis for future in-depth research and intervention development to improve access to care for HIV-infected men. 4 statistically significant differences between these demographic variables among men with high CD4 counts compared to men with low CD4 counts, we did find differences in these variables between men and women. Older age has been associated with delayed HIV testing and entry to care as well as decreased desire for HIV testing [12][13][14][15]. Being unmarried and living in a household alone have also been tied to late presentation to care [8], and men were more likely to be cohabiting or married than women in our study. Higher education levels have been tied to increased knowledge about HIV status and increased interest in HIV testing [15,16], though our study found that men were more educated than women and delayed their engagement with HIV care.

Methods
We were unable to assess disparities in access to care based on either PMTCT interventions or men's migratory career choices due to a paucity of chart data on these variables, though both of these Men's participation in migratory careers such as mining has been tied to increased risk of HIV infection as well as difficulty in engaging with HIV care [17,18]. In our chart review, we found that men and women were equally likely to be employed in some fashion, but sample sizes within specific occupations were too small to adequately assess gender disparities by occupation ( Table 1).
There are several limitations to this analysis. The chart review utilized retrospective data from medical records. As a result, the findings allow for limited interpretation and causal factors cannot be determined. Additionally, a significant amount of 2011 data was missing (13.3% of charts, n=156), though this proportion is similar to or much smaller than the proportion measured by other studies.
As previously explained, initial CD4 counts for women entering HIV care through PMTCT interventions at this teaching hospital were often missing. i.e. primary prevention [19][20][21], but limited efforts have been made to improve treatment of HIV, i.e. secondary prevention, for this subpopulation. A small body of evidence is emerging that interventions integrated into the workplace and educational settings where men predominate may be effective in connecting men to care [22]. Efforts to test and link men to care early should be intensified.

Competing interests
The authors declare that they have no competing interests.