In rural Malawi it is not uncommon for neighbours to see a skeletal man being pushed in a wheelbarrow by his son or his brother. The frail man is being taken to the nearest clinic because he is too sick from HIV to walk. When they arrive, he is given anti-retroviral medication. But it is likely to be too late. So instead of being sent home, he is sent to the men’s ward nicknamed the “death ward”.

On the other hand, most women in rural Malawi regularly walk to the clinic. They receive dedicated services for their pregnancies and for their young children and are routinely tested for HIV. If they are found to be infected they are immediately started on anti-retroviral medication. This enables them to live many more years with HIV and blocks the transmission of HIV to their children.

It is well known that there are more HIV positive women than men in sub-Saharan Africa. While women are more likely to be infected, men account for 60% of all HIV-related deaths. Most are related to poor use of HIV testing and treatment.

In eastern and southern Africa, the regions most affected by HIV, over 65% of men who are HIV positive have never started treatment. HIV is a manageable disease when treated well. If it is not treated, or treated too late, it becomes a death sentence.

Why aren’t men tested and treated for HIV? The standard response is that men refuse to admit that they need help. Alternatively, they refuse to attend a clinic considering health care a woman’s activity. It is a common and perhaps universal stereotype: the macho man who refuses to see a doctor, opting instead to “man up”.

But is a macho ideal of manhood really to blame?

A focus on women, but what about the men?

International organisations regularly examine factors outside of women’s control that limit their use of health services. Gender inequality, poverty and the distance they have to travel to access a health centre are often to blame.

The international community has thus channelled money and other resources to remove barriers to testing and treatment for women. There is a logic to this approach. Focusing on women means that we can prevent new infections in utero and during birth, thus saving the lives of children.

Baylor College of Medicine Children's Foundation–Malawi / Chris Cox

As a result, HIV services are tailored to women of childbearing age and their children. Pregnant women are routinely tested and women are exposed to HIV prevention messages during most family planning, antenatal, or child wellness visits.

In a growing number of countries, pregnant and breastfeeding HIV positive women are automatically started on HIV treatment for life. This happens regardless of whether they meet the standard eligibility criteria.

Despite these successes for women, HIV policymakers have not fully understood why men are not using services. Answering this question is critical to understand the problem of missing men.

Our research found that the way HIV testing and treatment is offered makes a big difference for men’s use of care. Unlike women, men are not targeted by HIV policies to ensure they are tested and treated. As a result, heterosexual men have become a marginalised group when it comes to HIV services. They are systematically disadvantaged in their access to care.

We found that in southern Malawi there are limited options available for men to test and start treatment. They must seek out HIV services for themselves and are not actively recruited as is the case with pregnant women.

Men who do choose to get tested can go to a public or private clinic. Both scenarios present problems.

Public clinics are typically tailored to women. They are inevitably crowded with women waiting to see a nurse, increasing waiting times for services and making public clinics “woman’s spaces” that men believe are not intended for them. In smaller public facilities, HIV services may only be available during hours when pregnant women are served. This again limits men’s access to care. When HIV services are so focused on women, can we expect men to access them?

Private clinics provide a more male-friendly alternative, but paying for care is a luxury most cannot afford.

The alternative is to forego testing altogether. For many, this will mean an untimely death.

Turning the tide

There is good justification to prioritise services for women and the children they bear and care for. But to stem the tide of the HIV pandemic, men must be included.

We are not advocating that there needs be an equal number of health services for men. Instead, we propose that more must be done for men than is currently offered.

The international community has done a great deal to keep women and their children alive through the AIDS epidemic. It should not continue to overlook their husbands and fathers.

Dedicated male-friendly HIV services are needed. The alternative scenario is dismal. Sons will continue to wheel their skeletal fathers to “death wards”, where they die of something that could have been managed. Men’s use of health services can be improved – we have seen it happen for women.