In 2017, 36% of the nearly 7 million HIV-positive adults living in South Africa were male, but males accounted for 52% of AIDS deaths. In South Africa, ART coverage is substantially lower among adult males (58%) compared with adult females (64%). Multiple studies have shown men to have higher rates of attrition from HIV care programs than women. A meta-analysis found that among 20-year olds starting ART in low and middle-income countries, males on average live 22.9 more years (95% CI 18.4вЂ“27.5В years), compared to 33.0В years (95% CI 30.4вЂ“35.6В years) for females. Those who do are more likely to present to clinics later, with more advanced disease and have worse clinical outcomes. In most African settings, men are less likely to get tested for HIV, link to HIV care or initiate antiretroviral therapy (ART) than women. These findings support clinic-specific adaptations to create more male-friendly environments. Male-only clinics reached younger, healthier men, and had lower ART attrition than general services.

In separate analyses for each of the two male clinics, only the more established male clinic showed a protective effect. In the matched analysis (1451 person-years, 1568 patients) patients initiating ART at male clinics had lower attrition (HR 0.71 95% CI 0.60вЂ“0.85). Those initiating at male clinics had higher median CD4 counts at ART initiation. Before matching, patients from male clinics (nвЂ‰=вЂ‰784) were younger than males from general clinics (nвЂ‰=вЂ‰2726), median age: 31.2 vs 35.5В years.

Follow-up time began at ART initiation and ended at attrition, clinic transfer, or dataset closure. The association between attrition (death or loss to follow-up, defined as no visits for nine months) and clinic type was estimated using Cox proportional hazards regression. We used exposure propensity scores (generated based on baseline health and age) to match male clinic patients 1:1 to males at other clinics. We described baseline characteristics of patients initiating ART at the male and general clinics from 1 January 2014 to 31 March 2018. We compared attrition from ART care among men initiating ART at these clinics with male attrition in six general primary healthcare clinics in Khayelitsha. In Khayelitsha, a high HIV prevalence area in South Africa, two public sector primary healthcare clinics offer services, including HIV testing and treatment, exclusively to men. Men have higher rates of attrition from antiretroviral therapy (ART) programs than women.

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