Missing But in Action: Where Are the Men?

In Sub-Saharan Africa men are under-represented at all stages in the cascade of HIV care. Men have a lower uptake of HIV testing, access care at later stages than women and have higher mortality than women. To realise the global targets of 90:90:90 we need to do much more to find men. In addition unless we reach near universal access we cannot hope to have any impact on reducing HIV incidence and ultimately stopping the HIV epidemic. From published and unpublished literature the gaps where men are failing to attain the 90:90:90 targets will be described and  possible reasons for this will be discussed. In particular data will be presented from the HPTN 071 trial of combination prevention and universal test and treat where population level estimates of coverage in men is available in 21 communities in Zambia and South Africa. Various initiatives have been tested to improve the involvement of men at each stage of the treatment and prevention cascades. Some of these will be reviewed and the evidence of effect analysed. In order to reach universal coverage of HIV interventions, in generalised epidemics such as in Sub-Saharan Africa, much more attention must be paid to men and their specific needs. If we fail to understand the barriers to accessing HIV care for men we will fail in our goal of ending the HIV epidemic.