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Kitonsa J, Kansiime S, Kusemererwa S, Onyango M, Nayiga B, Kabarambi A, Mugisha JO, Kaleebu P, Ruzagira E. Changes in self-reported risky sexual behaviour indicators among adults receiving regular risk reduction counselling and optional initiation of pre-exposure prophylaxis in an HIV vaccine preparedness study in Masaka, Uganda. Glob Health Action 2023; 16:2242672. [PMID: 37548558 PMCID: PMC10408567 DOI: 10.1080/16549716.2023.2242672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND HIV risk reduction counselling may reduce risk-taking behaviours. Yet, concerns remain about risk compensation among individuals initiating pre-exposure prophylaxis (PrEP). OBJECTIVE We assessed changes in risky sexual behaviour indicators among HIV vaccine preparedness study participants who received regular risk reduction counselling and referral for PrEP in Masaka, Uganda. METHODS Adults (18-39 years) at high risk of HIV infection were enrolled in the study between July 2018 and December 2021. Data were collected on socio-demographic factors (baseline) and self-reported sexual risk behaviours (baseline, six monthly). HIV testing and risk-reduction counselling and referral for PrEP were done quarterly. Participants who had completed at least 1 year of follow-up were included in the analysis. Proportional differences and McNemar chi-square tests were used to assess changes in the prevalence of self-reported risky sexual behaviour indicators between baseline and 1 year. Logistic regression was used to assess the predictors of unchanged/increased HIV risk at 1 year. RESULTS Three hundred participants [132 (44%) females, 152 (51%) aged ≤24 years] were included in this analysis. Eighty-one (27%) participants initiated PrEP at 1 year. Compared to baseline, there were significant reductions in the prevalence of the following self-reported HIV risk indicators at 1 year (overall, among non-PrEP initiators, and among PrEP initiators): transactional sex, ≥6 sexual partners, unprotected sex with ≥3 partners, sex while drunk, and sexually transmitted infection diagnosis/treatment. Percentage differences ranged from 10% for individuals reporting at least six sexual partners to 30% for those reporting unprotected sex with three or fewer sexual partners. There was weak evidence of association between female gender and unchanged/increased HIV risk at 1 year (adjusted OR: 1.35, 95% CI (0.84-2.17)). No other indicators, including PrEP use, were associated with unchanged/increased HIV risk at 1 year. CONCLUSION Regular risk-reduction counselling may reduce risky sexual behaviour, while PrEP initiation may not lead to risk compensation.
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Affiliation(s)
- Jonathan Kitonsa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Sheila Kansiime
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Sylvia Kusemererwa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Martin Onyango
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Berna Nayiga
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Anita Kabarambi
- Research, International Centre for Child Health and Development (ICHAD), Masaka, Uganda
| | - Joseph O Mugisha
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
| | - Pontiano Kaleebu
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Infection Biology, London School of Hygiene and Tropical Medicine, London, UK
| | - Eugene Ruzagira
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
- Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Luseno WK, Rennie S, Gilbertson A. A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa. Int J Impot Res 2023; 35:269-278. [PMID: 34702986 PMCID: PMC8545773 DOI: 10.1038/s41443-021-00484-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022]
Abstract
Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.
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Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, NC, USA
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Rosen JG, Carrasco MA, Traub AM, Kumoji E‘K. Barriers, benefits, and behaviour: Voluntary medical male circumcision ideation in a population-based sample of Zambian men. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2021; 20:314-323. [PMID: 34905454 PMCID: PMC8994851 DOI: 10.2989/16085906.2021.2006727] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Reaching ambitious voluntary medical male circumcision (VMMC) coverage targets requires a deeper understanding of the multifaceted processes shaping men's willingness to access VMMC. Guided by the Ideation Model for Health Communication, this population-based study identifies correlates of Zambian men's future VMMC intentions. Multistage cluster sampling was used to identify households with adult men in 14 districts. Multivariable Poisson regression with robust standard errors modelled associations of future VMMC intent with ideational factors (e.g. perceived benefits and barriers) and sexual behaviours respectively. Forty per cent (40%) of uncircumcised men (N = 1 204) expressed future VMMC intentions. In multivariable analysis, VMMC intent was associated with secondary education or higher (Adjusted Prevalence Ratio [APR] 1.30, 95% Confidence Interval [95% CI]: 1.02-1.66), perceiving VMMC to increase sexual satisfaction (APR 1.45, 95% CI: 1.11-1.89), reporting distance to services as a barrier to VMMC uptake (APR = 0.54, 95% CI: 1.27-1.87), unprotected last sex (APR 1.54, 95% CI: 1.11-2.14), and ≥ 2 sexual partners in the past 12 months (APR 1.45, 95% CI: 1.05-1.99). Being aged ≥ 45 years (vs 18-24 years: APR 0.23, 95% CI: 0.13-0.40) and perceiving that circumcision: (1) is unimportant (APR 0.71, 95% CI: 0.51-0.98); (2) is incompatible with local customs (APR 0.41, 95% CI: 0.18-0.94); or (3) reduces sexual satisfaction (APR 0.10, 95% CI: 0.02-0.62) were inversely associated with future VMMC intent. Demand-creation efforts must confront salient cognitive and social barriers to VMMC uptake, including concerns around incompatibility with local customs. Simultaneously, promotional efforts should emphasise relevant VMMC benefits beyond HIV prevention that resonate with men (e.g. penile hygiene) without reinforcing harmful gender norms.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Maria A Carrasco
- Office of Family Planning and Reproductive Health, United States Agency for International Development, Washington DC, USA
| | - Ariana M Traub
- Office of HIV/AIDS, United States Agency for International Development, Washington DC, USA
| | - E ‘Kuor Kumoji
- Research and Evaluation Division, Johns Hopkins Center for Communication Programs, Baltimore, USA
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Spatial Analysis of HIV Infection and Associated Risk Factors in Botswana. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073424. [PMID: 33806151 PMCID: PMC8037802 DOI: 10.3390/ijerph18073424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/19/2021] [Accepted: 03/20/2021] [Indexed: 11/17/2022]
Abstract
Botswana has the third highest human immunodeficiency virus (HIV) prevalence globally, and the severity of the epidemic within the country varies considerably between the districts. This study aimed to identify clusters of HIV and associated factors among adults in Botswana. Data from the Botswana Acquired Immunodeficiency Syndrome (AIDS) Impact Survey IV (BIAS IV), a nationally representative household-based survey, were used for this study. Multivariable logistic regression and Kulldorf’s scan statistics were used to identify the risk factors and HIV clusters. Socio-demographic characteristics were compared within and outside the clusters. HIV prevalence among the study participants was 25.1% (95% CI 23.3–26.4). HIV infection was significantly higher among the female gender, those older than 24 years and those reporting the use of condoms, while tertiary education had a protective effect. Two significant HIV clusters were identified, one located between Selibe-Phikwe and Francistown and another in the Central Mahalapye district. Clusters had higher levels of unemployment, less people with tertiary education and more people residing in rural areas compared to regions outside the clusters. Our study identified high-risk populations and regions with a high burden of HIV infection in Botswana. This calls for focused innovative and cost-effective HIV interventions on these vulnerable populations and regions to curb the HIV epidemic in Botswana.
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Ledikwe JH, Mawandia S, Kleinman NJ, Ntsuape C, Ramabu NM, Semo BW, Wirth KE. Voluntary Medical Male Circumcision and Perceived Sexual Functioning, Satisfaction, and Risk Behavior: A Qualitative Study in Botswana. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:983-998. [PMID: 31997131 DOI: 10.1007/s10508-019-01589-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 06/10/2023]
Abstract
This article examines perceptions of sexual functioning, satisfaction, and risk-taking related to voluntary medical male circumcision (VMMC) in Botswana. Twenty-seven focus group discussions were conducted in four purposively selected communities with community leaders, men, and women. Discussions were analyzed using an inductive content analytic approach. Perceptions of VMMC's impact on sexual functioning and satisfaction varied. Increased satisfaction was attributed to improved penile health and increased ejaculatory latency time, whereas decreased satisfaction was attributed to erectile dysfunction and increased vaginal irritation during sex. Most participants thought sexual disinhibition occurred after circumcision; nevertheless, some women said they used male circumcision status as a marker of HIV status, thereby influencing sexual decision-making and partner selection. Messaging should emphasize that VMMC does not afford complete HIV protection. Optimizing VMMC's impact requires increasing uptake while minimizing behavioral disinhibition, with a balance between potential messaging of improved sexual functioning and satisfaction and the potential impact on sexual disinhibition.
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Affiliation(s)
- Jenny H Ledikwe
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA.
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.
| | - Shreshth Mawandia
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Nora J Kleinman
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- NJK Consulting, Seattle, WA, USA
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Nankie M Ramabu
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Bazghina-Werq Semo
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Kathleen E Wirth
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, Gaborone, Botswana
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Shi C, Li M, Dushoff J. Traditional Male Circumcision is Associated with Sexual Risk Behaviors in Sub-Saharan Countries Prioritized for Male Circumcision. AIDS Behav 2020; 24:951-959. [PMID: 30955178 DOI: 10.1007/s10461-019-02473-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To understand the sexual risk behavior of men with traditional male circumcision and medical male circumcision in the context of the World Health Organization's (WHO) campaign for voluntary medical male circumcision (VMMC) scale-up, we investigated ten countries prioritized for the scale-up from the Demographic and Health Surveys. Male respondents aged 15-49 were selected. Ordinal regression was used to analyze the relationship between three sexual risk behaviors-condom use with non-cohabiting partners, number of non-cohabiting partners, and partner type-and circumcision status (traditionally circumcised before and after the VMMC scale-up, medically circumcised before and after the scale-up, and not circumcised), while controlling for social demographic covariates. We found evidence that some sexual risky behavior, specifically lower condom use and higher number of sexual partners, was associated with traditional circumcision. This finding suggests that messages about the protective effect of male circumcision may not have reached men with traditional circumcision. We suggest that WHO's VMMC campaign should include communities where traditional male circumcision is popular. We looked for, but did not find, evidence of differences between groups circumcised at different times, which could have indicated sexual risk compensation.
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Chatsika ZJ, Kumitawa A, Samuel V, Azizi SC, Jumbe VC. Voluntary medical male circumcision and sexual practices among sexually active circumcised men in Mzuzu, Malawi: a cross-sectional study. BMC Public Health 2020; 20:211. [PMID: 32046686 PMCID: PMC7014635 DOI: 10.1186/s12889-020-8309-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/31/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Voluntary Medical Male Circumcision (VMMC) is one of the strategies being promoted to prevent sexual heterosexual transmission of HIV. It has been adopted by 14 countries with high HIV prevalence and low circumcision rates. The 60.0% protective efficacy of VMMC has come with misconceptions in some societies in Malawi, hence VMMC clients may opt for risky sexual practices owing to its perceived protective effect. The study estimated proportion of circumcised men engaging in risky sexual behaviors post-VMMC, assessed knowledge on VMMC protective effect and identified socio-demographic factors associated with risky sexual practices. METHOD A cross sectional study was conducted at two sites of Mzuzu city. Systematic random sampling was used to select 322 participants aged 18-49 who had undergone VMMC. The independent variables included age, location, occupation, religion, marital status and education. Outcome variables were non condom use, having multiple sexual partners and engaging in transactional sex. Data from questionnaires was analyzed using Pearson's chi square test and logistic regression. RESULTS Out of 322 respondents, 84.8% (273) understood the partial protection offered by VMMC in HIV prevention. Ninety-six percent of the participants self-reported continued use of condoms post VMMC. Overall 23.7-38.3% participants self-reported engaging in risky sexual practices post VMMC, 23.7% (76) had more than one sexual partner; 29.2% (94) paid for sex while 39.9% (n = 187) did not use a condom. Residing in high density areas was associated with non-condom use, (p = 0.043). Being single (p < 0.001), and residing in low density areas (p = 0.004) was associated with engaging in transactional sex. CONCLUSION Risky sexual practices are evident among participants that have undergone VMMC. Messages on safer sexual practices and limitations of VMMC need to be emphasized to clients, especially unmarried or single and those residing in low density areas.
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Affiliation(s)
- Zimveka Jones Chatsika
- College of Medicine, Public Health Department, P/Bag 360, Chichiri, Blantyre 3, Malawi. .,Malawi Defence Force, Malawi Military Health Services, Moyale Barracks, P.O Box 23, Mzuzu, Malawi.
| | - Andrew Kumitawa
- College of Medicine, Public Health Department, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Vincent Samuel
- College of Medicine, Research Support Centre, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Steven Chifundo Azizi
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Post Box 50110, Lusaka, Zambia.,Malawi Defence Force, Malawi Military Health Services, Kamuzu Barracks, Private Bag 43, Lilongwe, Malawi
| | - Vincent C Jumbe
- College of Medicine, Department of Public health, Health Systems and Policy, P/Bag 360, Chichiri, Blantyre 3, Malawi
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Mangombe K, Kalule-Sabiti I. Knowledge about male circumcision and perception of risk for HIV among youth in Harare, Zimbabwe. South Afr J HIV Med 2019; 20:855. [PMID: 31205776 PMCID: PMC6556916 DOI: 10.4102/sajhivmed.v20i1.855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 02/05/2019] [Indexed: 01/21/2023] Open
Abstract
Background Male circumcision will require high uptake among previously non-circumcising countries to realise the impact of circumcising in preventing HIV. Little is known about whether youths are knowledgeable about male circumcision and its relationship with HIV prevention and their perception of risk of HIV infection. Objective This article aimed to ascertain youth’s knowledge about male circumcision and perception of risk of HIV infection. Methods A quantitative study on 784 youth (men aged 15–35 years) was conducted in Harare, Zimbabwe, after obtaining their consent. Multivariate analysis examined the associations between background characteristics and knowledge about male circumcision and the perception of risk of HIV infection. Results The results revealed that age was a significant predictor of knowledge about male circumcision among youth in Harare, as was educational attainment and ever having tested for HIV. In addition, youth who had heard of voluntary medical male circumcision were more likely to have high knowledge of male circumcision compared to those who had never heard of it. The results also showed that male circumcision status was associated with higher knowledge about male circumcision compared to those who were not circumcised. The study also found that educational attainment, belonging to the Shona ethnic group, never having tested for HIV and disapproval of voluntary counselling and testing prior to male circumcision were associated with the perception of risk of HIV infection. Conclusion The study provides two recommendations: the need to strengthen perceived susceptibility to HIV among the youth and the need for advocacy on the health benefits of male circumcision.
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Affiliation(s)
- Kudzaishe Mangombe
- Department of Sociology and Social Anthropology, Faculty of Social Sciences, Great Zimbabwe University, Masvingo, Zimbabwe
| | - Ishmael Kalule-Sabiti
- Department of Population Studies and Demography, Faculty of Humanities, North-West University, Mmabatho, South Africa
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Risk Compensation Following Medical Male Circumcision: Results from a 1-Year Prospective Cohort Study of Young School-Going Men in KwaZulu-Natal, South Africa. Int J Behav Med 2018; 25:123-130. [PMID: 28688094 DOI: 10.1007/s12529-017-9673-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE This study sought to assess risk compensation following voluntary medical male circumcision of young school-going men. Risk compensation is defined as an inadvertent increase in sexual risk behaviors and a corresponding decrease in self-perceived risk for contracting HIV following the application of a risk reduction technology. METHODS This study documented the sexual practices of circumcised (n = 485) and uncircumcised (n = 496) young men in 42 secondary schools at three time points (baseline and 6 and 12 months) in a sub-district of KwaZulu-Natal, South Africa. Study participants were aged from 16 to 24 years old. RESULTS At the end of the study period, there was no significant difference between the two cohorts concerning learners' perceptions of being at risk of contracting HIV (interaction effect: b = -0.12, p = 0.40). There was also no significant difference in the number of sexual partners in the previous month (interaction effect: b = -0.23, p = 0.15). The proportion of learners who have never used a condom decreased significantly over time (time effect: b = -0.27, p = 0.01), and there was no difference between the circumcised and uncircumcised learners (interaction effect: b = -0.09, p = 0.91). CONCLUSIONS Risk compensation, as evidenced in this study over a 1-year period, was not associated with undergoing voluntary medical male circumcision (VMMC) in our sample of young school-going men. However, it is of concern that at the end of this study, less than half of the sexually active sample in a high-HIV-prevalence community used condoms consistently in the previous month (39% for both study cohorts). The latter underscores the need to view VMMC as a potential entry point for planned HIV and sexuality education interventions targeting young men in this community.
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Cockcroft A, Marokoane N, Kgakole L, Kefas J, Andersson N. The Inter-ministerial National Structural Intervention trial (INSTRUCT): protocol for a parallel group cluster randomised controlled trial of a structural intervention to reduce HIV infection among young women in Botswana. BMC Health Serv Res 2018; 18:822. [PMID: 30376834 PMCID: PMC6208099 DOI: 10.1186/s12913-018-3638-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background Wide recognition that structural factors are important in the HIV epidemic has not generated much evidence of impact of structural interventions. Few randomised controlled trials of structural interventions for HIV prevention have an HIV endpoint, and most of those did not show a significant impact. It has proved difficult to prevent new HIV infections in Botswana, especially among young women, many of whom are unable to act on HIV preventive choices. Proposed by a government think tank in Botswana, the Inter-ministerial National Structural Intervention trial (INSTRUCT) tests whether addressing social and economic factors, including gender inequality, gender violence, poverty, and poor access to education, can lower HIV infection rates among young women. Focussed on increasing access by marginalised young women to government support programs, the intervention seeks to change their structural position, reducing their vulnerability to transactional sex, and thus to HIV infection. Methods This parallel group cluster randomised controlled trial compares HIV rates among young women in districts with and without the structural interventions. The 30 administrative districts in the country, stratified by HIV prevalence and development status, will be randomly assigned to 5-district implementation waves. The intervention in the first-wave districts will include: (i) recruiting and preparing vulnerable young women to apply to government support programs, (ii) making the support programs more accessible to young women by engaging local program officers and young women in co-evaluation of programs and co-design of solutions; and (iii) generating an enabling environment for change in communities through an audio-drama edutainment program. In year five, an impact survey will measure HIV rates among vulnerable young women (15–29 years) in a random sample of communities in the five intervention districts and in the five second-wave (control) districts. Fieldworkers will undertake rapid HIV screening and interview young women and young men, collecting information on secondary outcomes of attitudes and behaviours. Discussion This is the first step in a planned stepped-wedge design that will roll out the intervention, modified as necessary, to all districts. Strong government commitment provides an important opportunity to reduce new HIV cases in Botswana, and guide prevention efforts in other countries. Trial registration Registration number: ISRCTN 54878784. Registry: ISRCTN. Date of registration: 11 June 2013.
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Affiliation(s)
- Anne Cockcroft
- Department of Family Medicine, McGill University, Montreal, Canada. .,CIET Trust Botswana, PO Box 1240, Gaborone, Botswana.
| | | | | | - Joseph Kefas
- National AIDS Coordinating Agency, Gaborone, Botswana
| | - Neil Andersson
- Department of Family Medicine, McGill University, Montreal, Canada.,Centro de Investigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero, Acapulco, Mexico
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Reynolds Z, Gottert A, Luben E, Mamba B, Shabangu P, Dlamini N, Dlamini M, Mathur S, Pulerwitz J. Who are the male partners of adolescent girls and young women in Swaziland? Analysis of survey data from community venues across 19 DREAMS districts. PLoS One 2018; 13:e0203208. [PMID: 30216356 PMCID: PMC6157821 DOI: 10.1371/journal.pone.0203208] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 08/16/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Adolescent girls and young women (AGYW, ages 15-24) are at high risk of HIV in Swaziland. Understanding more about their male sexual partners can inform HIV prevention efforts for both. METHODS Using the PLACE methodology across all 19 DREAMS implementation districts, 843 men ages 20-34 were surveyed between December 2016-February 2017. Surveys were conducted at 182 venues identified by community informants as places where AGYW and men meet/socialize. Descriptive and multivariate analyses examined characteristics and risk behaviors of male partners of AGYW. RESULTS Men's average age was 25.7. Sixty-three percent reported female partners ages 15-19, and 70% reported partners ages 20-24 in the last year; of those, 12% and 11% respectively had five or more such partners. Among the 568 male partners of AGYW, 36% reported consistent condom use with their current/last partner. Forty-two percent reported testing for HIV in the last year; 6% were HIV-positive, and of those, 97% were currently on treatment. One-third (37%) reported being circumcised; among uncircumcised, 81% were not considering it. In multivariate analyses, men who reported three or more AGYW partners in the last year were more likely to be HIV-positive (aOR 3.2, 95% CI 1.1,8.8). Men were also less likely to disclose their HIV status to adolescent versus older partners (aOR 0.6, 95% CI 0.4,0.9) and partners more than 5 years younger than themselves (aOR 0.6, 95% CI 0.4,0.9). Results also revealed relatively high unemployment and mobility, substantial financial responsibilities, and periodic homelessness. CONCLUSIONS Most men identified through community venues reported relationships with AGYW, and these relationships demonstrated substantial HIV risk. Challenging life circumstances suggest structural factors may underlie some risk behaviors. Engaging men in HIV prevention and targeted health services is critical, and informant-identified community venues are promising intervention sites to reach high-risk male partners of AGYW.
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Affiliation(s)
- Zahra Reynolds
- MEASURE Evaluation, University of North Carolina at Chapel Hill, Chapel Hill, N.C., United States of America
- * E-mail:
| | - Ann Gottert
- Population Council, HIV and AIDS Program, Washington, D.C., United States of America
| | - Erin Luben
- MEASURE Evaluation, University of North Carolina at Chapel Hill, Chapel Hill, N.C., United States of America
| | - Bheki Mamba
- Institute for Health Measurement, Mbabane, Swaziland
| | | | - Nsindiso Dlamini
- National Emergency Response Council on HIV and AIDS, Mbabane, Swaziland
| | - Muhle Dlamini
- Swaziland National AIDS Programme, Mbabane, Swaziland
| | - Sanyukta Mathur
- Population Council, HIV and AIDS Program, Washington, D.C., United States of America
| | - Julie Pulerwitz
- Population Council, HIV and AIDS Program, Washington, D.C., United States of America
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Nakyanjo N, Piccinini D, Kisakye A, Yeh PT, Ddaaki W, Kigozi G, Gray RH, Kennedy CE. Women's role in male circumcision promotion in Rakai, Uganda. AIDS Care 2018; 31:443-450. [PMID: 30010413 DOI: 10.1080/09540121.2018.1500009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Medical male circumcision (MMC) has expanded in sub-Saharan Africa, yet uptake remains sub-optimal. We sought to understand women's perceptions of and influence on MMC in Rakai, Uganda. We conducted in-depth interviews with 27 women in fishing and trading communities, including women married to circumcised and uncircumcised men, single women, and sex workers. Data analysis followed a team-based framework approach. All female participants preferred circumcised men because of perceived reduced HIV and sexually transmitted infection (STI) risk, improved penile hygiene, and increased sexual pleasure. Perceived negative aspects included abstinence during wound healing, potentially increased male sexual risk behaviors, fear of being blamed for HIV acquisition, and economic insecurity due to time off work. Participants felt women could persuade their partners to be circumcised, accompany them to the clinic, refuse sex with uncircumcised men, and participate in community MMC activities. Findings support women's important role in MMC acceptance.
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Affiliation(s)
- Neema Nakyanjo
- a Social and Behavioral Sciences Department , Rakai Health Sciences Program, Research Directorate , Kalisizo , Uganda
| | - Danielle Piccinini
- b Center for Communications Programs , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Alice Kisakye
- c Rakai Health Sciences Program, Programs Directorate , Kalisizo , Uganda
| | - Ping Teresa Yeh
- d Department of International Health, Social and Behavioral Interventions Program , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - William Ddaaki
- a Social and Behavioral Sciences Department , Rakai Health Sciences Program, Research Directorate , Kalisizo , Uganda
| | - Godfrey Kigozi
- e Rakai Health Sciences Program, Research Directorate , Kalisizo , Uganda
| | - Ronald H Gray
- f Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Caitlin E Kennedy
- d Department of International Health, Social and Behavioral Interventions Program , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Kanda L, Mash R. Reasons for inconsistent condom use by young adults in Mahalapye, Botswana. Afr J Prim Health Care Fam Med 2018; 10:e1-e7. [PMID: 29943592 PMCID: PMC6018458 DOI: 10.4102/phcfm.v10i1.1492] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 12/28/2017] [Accepted: 02/07/2018] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Botswana is one of the countries significantly affected by the HIV and AIDS epidemic. Despite an extensive preventive campaign, the incidence of HIV remains high.Condoms are an important contributor to prevention of new HIV infections, although they are not consistently used by young adults. AIM The aim of this study was to explore the reasons why condoms are not consistently usedby young adults. SETTING Mahalapye District Hospital and Airstrip Clinic, Botswana. METHOD This was a phenomenological qualitative study using individual in-depth interviews.Eleven participants were purposively selected, including six males and five females. Data were transcribed and analysed using the framework method. RESULTS All participants acknowledged the importance of utilising condoms to prevent unplanned pregnancies and sexually transmitted infections. Reasons not to use condoms were a need to have a child,implied lack of trust or faithfulness, long-term relationships need toplease the partner and decreased pleasure. Other contributing factors were lack of knowledge of benefits, less fear of contracting HIV and AIDS as it can now be controlled with medication,influence of tradition, alcohol and drug abuse, peer pressure, power and gender issues and the refusal of the partner. The female condom was largely rejected by young adults in general and by women in particular because of its size and the perception that it is complicated to insert. CONCLUSION The current preventive campaign against HIV and AIDS needs to take cognisance of the factors affecting decisions on the use of condoms by young adults and the obstacles to their use, particularly the new belief that HIV and AIDS is no longer a significant concern.
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Affiliation(s)
- Luhaka Kanda
- Division of Family Medicine and Primary Care, Stellenbosch University.
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Greevy C, King R, Haffejee F. Male circumcision for HIV prevention: female risk compensatory behaviour in South Africa. AIDS Care 2018; 30:1083-1089. [PMID: 29779415 DOI: 10.1080/09540121.2018.1476658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
South Africa promotes male circumcision (MC) as an HIV prevention method and implemented a national plan to scale-up MC in the country from 2012 to 2016. Literature has suggested that female risk compensatory behaviours (RCBs) are occurring in countries where these programmes have been implemented. Behaviours such as decreased condom use, concurrent sexual partners and sexual activity during the circumcision wound-healing period have the potential to jeopardise the campaigns' objectives. Literature has shown that directly providing women with MC information results in correct knowledge however, previous studies have not directly sought women's views and ideas on engagement with the information. This study aims to identify and explore female RCBs in relation to MC campaigns in South Africa, and to identify interventions that would result in greater female involvement in the campaigns. Snowball sampling was used to conduct twelve qualitative vignette-facilitated semi-structured interviews with women residing in a municipal housing estate in Durban, Kwa-Zulu Natal, South Africa. Interviews were audio-recorded, verbatim transcribed and analysed using framework analysis. MC knowledge and understanding varied, with some participants mistaking MC as direct HIV protection for females. Despite a lack in knowledge, the majority of women did not report signs of RCBs. Even with a lack of evidence of RCBs, misinterpretation of the MC protective effect has the potential to lead to RCBs; a concept acknowledged in the literature. Several women expressed that MC campaigns are directed to males only and expressed a keenness to be more involved. Suggested interventions include couple counselling and female information sessions in community clinics. Exploring women's attitude towards involvement in MC campaigns fills in a research knowledge gap that is important to international health, as women have a vital role to play in reducing the transmission of HIV.
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Affiliation(s)
- Clare Greevy
- a Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences , University of Leeds , Leeds , UK
| | - Rebecca King
- a Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences , University of Leeds , Leeds , UK
| | - Firoza Haffejee
- b Department of Basic Medical Sciences , Durban University of Technology , Durban , South Africa
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Ferraz D, Paiva V. Sex, human rights and AIDS: an analysis of new technologies for HIV prevention in the Brazilian context. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2017; 18 Suppl 1:89-103. [PMID: 26630300 DOI: 10.1590/1809-4503201500050007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 01/22/2015] [Indexed: 11/22/2022] Open
Abstract
Worldwide, HIV prevention is challenged to change because clinical trials show the protective effect of technologies such as circumcision, preexposure prophylaxis, and the suppression of viral load through antiretroviral treatment. In the face of demands for their implementation on population levels, the fear of stimulating risk compensation processes and of increasing riskier sexual practices has retarded their integration into prevention programs. In this article, following a narrative review of the literature on risk compensation using the PubMed database, we offer a critical reflection on the theme using a constructionist approach of social psychology integrated to the theoretical framework of vulnerability and human rights. The use of biomedical technologies for prevention does not consistently induce its users to the increase of riskier practices, and variations on the specificity of each method need to be carefully considered. Alternatives to the theories of sociocognitive studies, such as social constructionist approaches developed in the social sciences and humanities fields, indicate more comprehensive interpretations, valuing the notions of agency and rights. The critical analysis suggests priority actions to be taken in the implementation process: development of comprehensive programs, monitoring and fostering dialog on sexuality, and technical information. We highlight the need to implement a human rights-based approach and to prioritize dialog, stressing how complementary these technologies can be to meet different population needs. We conclude by stressing the need to prioritize sociopolitical changes to restore participation, dialog about sexuality, and emphasis on human rights such as core elements of the Brazilian AIDS policy.
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Affiliation(s)
- Dulce Ferraz
- Escola FIOCRUZ de Governo, Diretoria Regional de Brasília da Fundação Oswaldo Cruz, Brasília, DF, Brazil
| | - Vera Paiva
- Study Group for the Prevention of AIDS, Universidade de São Paulo, São Paulo, SP, Brazil
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Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized Sub-Saharan countries. PLoS One 2017; 12:e0175928. [PMID: 28441458 PMCID: PMC5404849 DOI: 10.1371/journal.pone.0175928] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/03/2017] [Indexed: 11/19/2022] Open
Abstract
Background WHO and UNAIDS prioritized 14 eastern and southern African countries with high HIV and low male circumcision prevalence for a voluntary medical male circumcision (VMMC) scale-up in 2007. Because circumcision provides only partial protection against HIV infection to men, the issue of possible risk compensation in response to VMMC campaigns is of particular concern. In this study, we looked at population-level survey data from the countries prioritized by WHO for a VMMC scale-up. We compared the difference in sexual risk behaviours (SRB) between circumcised and uncircumcised men before and after the WHO’s official VMMC promotion. Materials and methods Ten countries (Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe) participating in the WHO’s VMMC scale-up had available data from the Demographic and Health Surveys (DHS). We used cumulative-link mixed models to investigate interactions between survey period and circumcision status in predicting SRB, in order to evaluate whether the difference between the behavior of the two groups changed before and after the scale-up, while controlling for socio-demographic and knowledge-related covariates. The main responses were condom use at last sex and number of non-cohabiting sexual partners, both in the last 12 months. Results There was little change in condom use by circumcised men relative to uncircumcised men from before the VMMC scale up to after the scale up. The relative odds ratio is 1.06 (95% CI, 0.95–1.18; interaction P = 0.310). Similarly, there was little change in the number of non-cohabiting partners in circumcised men (relative to uncircumcised men): the relative odds ratio of increasing the number of partners is 0.95 (95% CI, 0.86–1.05; interaction P = 0.319). Age, religion, education, job, marital status, media use and HIV knowledge also showed statistically significant association with the studied risk behaviours. We also found significant differences among countries, while controlling for covariates. Conclusions Overall, we find no evidence of sexual risk compensation in response to VMMC campaigns in countries prioritized by WHO. Changes in relative partner behaviour and the relative odds of condom use were small (and of uncertain sign). In fact, our estimates, though not significant, both suggest slightly less risky behavior. We conclude that sexual risk compensation in response to VMMC campaigns has not been a serious problem to date, but urge continued attention to local context, and to promulgating accurate messages about circumcision within and beyond the VMMC context.
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Masese RJ, Chimango JL, Mbirimtengerenji ND. Overcoming Barriers to Uptake of Voluntary Medical Male Circumcision in a Traditionally Circumcising Community in Machinga District, Malawi. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/wja.2017.71005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Lower HIV Risk Among Circumcised Men Who Have Sex With Men in China: Interaction With Anal Sex Role in a Cross-Sectional Study. J Acquir Immune Defic Syndr 2016; 71:444-51. [PMID: 26413852 DOI: 10.1097/qai.0000000000000856] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain. METHODS Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed. RESULTS Among 1155 participants (242 were seropositive and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by examination) was associated with 47% lower odds of being HIV seropositive [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.27 to 1.02] after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR: 0.38; 95% CI: 0.09 to 1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR: 0.54; 95% CI: 0.25 to 1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR: 0.15; 95% CI: 0.04 to 0.65). Circumcision was not associated clearly with lower syphilis risk (aOR: 0.91; 95% CI: 0.51 to 1.61). CONCLUSIONS Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed.
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Haberland NA, Kelly CA, Mulenga DM, Mensch BS, Hewett PC. Women's Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia. PLoS One 2016; 11:e0149517. [PMID: 26937971 PMCID: PMC4777382 DOI: 10.1371/journal.pone.0149517] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/02/2016] [Indexed: 12/04/2022] Open
Abstract
Women's perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women's health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men's risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman's HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women's misperception regarding MC. Programs should address women's informational needs and continue to emphasize that condoms remain critical, regardless of male partner's circumcision status.
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Affiliation(s)
| | | | | | | | - Paul C. Hewett
- Population Council, Washington DC, United States of America
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Morris BJ, Wamai RG, Henebeng EB, Tobian AAR, Klausner JD, Banerjee J, Hankins CA. Estimation of country-specific and global prevalence of male circumcision. Popul Health Metr 2016; 14:4. [PMID: 26933388 PMCID: PMC4772313 DOI: 10.1186/s12963-016-0073-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 02/12/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Male circumcision (MC) status and genital infection risk are interlinked and MC is now part of HIV prevention programs worldwide. Current MC prevalence is not known for all countries globally. Our aim was to provide estimates for country-specific and global MC prevalence. METHODS MC prevalence data were obtained by searches in PubMed, Demographic and Health Surveys, AIDS Indicator Surveys, and Behavioural Surveillance Surveys. Male age was ≥15 years in most surveys. Where no data were available, the population proportion whose religious faith or culture requires MC was used. The total number of circumcised males in each country and territory was calculated using figures for total males from (i) 2015 US Central Intelligence Agency (CIA) data for sex ratio and total population in all 237 countries and territories globally and (ii) 2015 United Nations (UN) figures for males aged 15-64 years. RESULTS The estimated percentage of circumcised males in each country and territory varies considerably. Based on (i) and (ii) above, global MC prevalence was 38.7 % (95 % confidence interval [CI]: 33.4, 43.9) and 36.7 % (95 % CI: 31.4, 42.0). Approximately half of circumcisions were for religious and cultural reasons. For countries lacking data we assumed 99.9 % of Muslims and Jews were circumcised. If actual prevalence in religious groups was lower, then MC prevalence in those countries would be lower. On the other hand, we assumed a minimum prevalence of 0.1 % related to MC for medical reasons. This may be too low, thereby underestimating MC prevalence in some countries. CONCLUSIONS The present study provides the most accurate estimate to date of MC prevalence in each country and territory in the world. We estimate that 37-39 % of men globally are circumcised. Considering the health benefits of MC, these data may help guide efforts aimed at the use of voluntary, safe medical MC in disease prevention programs in various countries.
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Affiliation(s)
- Brian J Morris
- />School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006 Australia
| | - Richard G Wamai
- />Department of African-American Studies, Northeastern University, Boston, MA 02115 USA
| | | | - Aaron AR Tobian
- />Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287 USA
| | - Jeffrey D Klausner
- />Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095 USA
| | - Joya Banerjee
- />Jhpiego, an affiliate of Johns Hopkins University, Washington, DC 20009 USA
| | - Catherine A Hankins
- />Department of Global Health, Academic Medical Centre and Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, 1105 AZ The Netherlands
- />Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
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Maughan-Brown B, Godlonton S, Thornton R, Venkataramani AS. What Do People Actually Learn from Public Health Campaigns? Incorrect Inferences About Male Circumcision and Female HIV Infection Risk Among Men and Women in Malawi. AIDS Behav 2015; 19:1170-7. [PMID: 25155700 DOI: 10.1007/s10461-014-0882-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Qualitative studies and polling data from sub-Saharan Africa indicate that many individuals may mistakenly believe that male circumcision directly protects women from contracting HIV. This study examines whether individuals who learn that male circumcision reduces female-to-male HIV transmission also erroneously infer a reduction in direct male-to-female transmission risk (i.e. from an HIV-positive man to an uninfected woman). We used data on Malawian men (n = 917) randomized to receive information about voluntary medical male circumcision (VMMC) and HIV risk in 2008 and a random sample of their wives (n = 418). We found that 72 % of men and 82 % of women who believed that male circumcision reduces HIV risk for men also believed that it reduces HIV risk for women. Regression analyses indicated that men randomly assigned to receive information about the protective benefits of circumcision were more likely to adopt the erroneous beliefs, and that the underlying mechanism was the formation of the belief that male circumcision reduces HIV risk for men. The results suggest the need for VMMC campaigns to make explicit that male circumcision does not directly protect women from HIV-infection.
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Affiliation(s)
- Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, Private Bag, Rondebosch, Cape Town, 7701, South Africa
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Sgaier SK, Baer J, Rutz DC, Njeuhmeli E, Seifert-Ahanda K, Basinga P, Parkyn R, Laube C. Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies. GLOBAL HEALTH, SCIENCE AND PRACTICE 2015; 3:209-29. [PMID: 26085019 PMCID: PMC4476860 DOI: 10.9745/ghsp-d-15-00020] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 04/27/2015] [Indexed: 11/29/2022]
Abstract
By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits.
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Affiliation(s)
- Sema K Sgaier
- Bill & Melinda Gates Foundation, Global Development Program, Integrated Delivery, Seattle, WA, USA, and University of Washington, Department of Global Health, Seattle, WA, USA. Now with Surgo Foundation, Seattle, WA, USA, and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - James Baer
- Bill & Melinda Gates Foundation, Independent Consultant, London, UK
| | - Daniel C Rutz
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Emmanuel Njeuhmeli
- US Agency for International Development, Division of Global HIV/AIDS, Washington, DC, USA
| | | | - Paulin Basinga
- Bill & Melinda Gates Foundation, Global Development Program, Integrated Delivery, Seattle, WA, USA
| | | | - Catharine Laube
- US Department of State, Office of the US Global AIDS Coordinator, Washington, DC, USA
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Peltzer K, Onoya D, Makonko E, Simbayi L. Prevalence and acceptability of male circumcision in South Africa. AFRICAN JOURNAL OF TRADITIONAL, COMPLEMENTARY, AND ALTERNATIVE MEDICINES 2014; 11:126-30. [PMID: 25392591 DOI: 10.4314/ajtcam.v11i4.19] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objectives of the current national study were to determine the rates of self-reported circumcision among South African men and, more importantly, evaluate the acceptability of male circumcision in South Africa by uncircumcised adult men and all adult women. MATERIALS AND METHODS The study based on a population-based survey included a nationally representative subgroup of 6654 men aged 15 years and older who where included in the analysis on male circumcision prevalence, and a subgroup of 6796 women aged 15 to 49 years who were included in the analysis on male circumcision acceptance. RESULTS An overall prevalence of self-reported male circumcision of 42.8% was found. Among the Black African population group the prevalence of male circumcision was 48.2%, 32.1% were traditionally and 13.4% were medically circumcised. Among males not circumcised 45.7% of 15-24 years olds indicated that they would consider being circumcised compared to 28.3% among 25-49 years olds. In multivariate analysis among non-circumcised men Black African and Coloured population groups and having heard of the HIV protective effect of male circumcision were significant predictors for male circumcision acceptability, and among women with a non-circumcised sexual partner, Black African and Coloured population groups and higher education were predictors for male circumcision acceptability. CONCLUSION The study found high rates and high acceptability of male circumcision. Findings associated with the acceptability of male circumcision can be used to increase awareness of the benefits of male circumcision for HIV prevention.
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Affiliation(s)
- Karl Peltzer
- HIV/AIDS/STI and TB Research Programme, Human Sciences Research Council, Cape Town, South Africa ; Department of Psychology, University of Limpopo, Turloop, South Africa ; ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand
| | - Dorina Onoya
- HIV/AIDS/STI and TB Research Programme, Human Sciences Research Council, Cape Town, South Africa
| | - Elias Makonko
- HIV/AIDS/STI and TB Research Programme, Human Sciences Research Council, Cape Town, South Africa
| | - Leickness Simbayi
- HIV/AIDS/STI and TB Research Programme, Human Sciences Research Council, Cape Town, South Africa
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L’Engle K, Lanham M, Loolpapit M, Oguma I. Understanding partial protection and HIV risk and behavior following voluntary medical male circumcision rollout in Kenya. HEALTH EDUCATION RESEARCH 2014; 29:122-130. [PMID: 24293524 PMCID: PMC3894669 DOI: 10.1093/her/cyt103] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 10/27/2013] [Indexed: 06/02/2023]
Abstract
In the midst of scaling up voluntary medical male circumcision (VMMC) in Kenya, there is concern that men do not adequately understand that circumcision provides only partial protection against HIV. The study goal was to determine men's understanding of partial protection, perceptions of HIV risk before and after VMMC and use of protective measures following VMMC. In-depth interviews with 44 men aged 18-39 years recently circumcised or planning to undergo VMMC were conducted in two urban and rural districts in Nyanza Province, Kenya. Participants described partial protection as the need to continue using other HIV protective measures such as condoms, with numbers such as a '60 percent protection' or 'not 100 percent protection', and described how circumcision reduces HIV transmission such as reduced penile bruising or bleeding. Most said their HIV risk before VMMC was high and that VMMC would reduce their risk moderately. Participants demonstrated good understanding of partial protection and there was little suggestion of risk compensation following VMMC.
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Affiliation(s)
- K. L’Engle
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
| | - M. Lanham
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
| | - M. Loolpapit
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
| | - I. Oguma
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
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Layer EH, Beckham SW, Momburi RB, Peter M, Laizer E, Kennedy CE. 'He is proud of my courage to ask him to be circumcised': experiences of female partners of male circumcision clients in Iringa region, Tanzania. CULTURE, HEALTH & SEXUALITY 2014; 16:258-272. [PMID: 24400819 DOI: 10.1080/13691058.2013.873481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Male circumcision programmes in Tanzania seek to increase demand among older, married clients who are more likely to have steady female sexual partners. Understanding women's roles throughout their partners' circumcision and any resultant changes in relationship dynamics are important considerations as efforts are made to scale up male circumcision. We conducted interviews with 32 wives of male circumcision clients from November 2011 to February 2012 in Iringa, Tanzania. Transcripts were digitally recorded, transcribed and translated into English and codes were developed based on emerging themes. Women were instrumental in convincing their husbands to be circumcised, but early resumption of sexual activity was common and a minority of women reported their husbands' emotional abuse or risk compensation following circumcision. These findings suggest that married women play a key role in their husbands' decisions to be circumcised, but women's needs for information and education are not being met and gender inequalities further decrease women's abilities to reduce their risk of HIV in this context. Strategies to more meaningfully engage women in male circumcision programmes are needed.
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Affiliation(s)
- Erica H Layer
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , USA
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MacLaren D, Tommbe R, Mafile’o T, Manineng C, Fregonese F, Redman-MacLaren M, Wood M, Browne K, Muller R, Kaldor J, McBride WJ. Foreskin cutting beliefs and practices and the acceptability of male circumcision for HIV prevention in Papua New Guinea. BMC Public Health 2013; 13:818. [PMID: 24015786 PMCID: PMC3846639 DOI: 10.1186/1471-2458-13-818] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 09/05/2013] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Male circumcision (MC) reduces HIV acquisition and is a key public health intervention in settings with high HIV prevalence, heterosexual transmission and low MC rates. In Papua New Guinea (PNG), where HIV prevalence is 0.8%, there is no medical MC program for HIV prevention. There are however many different foreskin cutting practices across the country's 800 language groups. The major form exposes the glans but does not remove the foreskin. This study aimed to describe and quantify foreskin cutting styles, practices and beliefs. It also aimed to assess the acceptability of MC for HIV prevention in PNG. METHODS Cross-sectional multicentre study, at two university campuses (Madang Province and National Capital District) and at two 'rural development' sites (mining site Enga Province; palm-oil plantation in Oro Province). Structured questionnaires were completed by participants originating from all regions of PNG who were resident at each site for study or work. RESULTS Questionnaires were completed by 861 men and 519 women. Of men, 47% reported a longitudinal foreskin cut (cut through the dorsal surface to expose the glans but foreskin not removed); 43% reported no foreskin cut; and 10% a circumferential foreskin cut (complete removal). Frequency and type of cut varied significantly by region of origin (p < .001). Most men (72-82%) were cut between the ages of 10-20 years. Longitudinal cuts were most often done in a village by a friend, with circumferential cuts most often done in a clinic by a health professional. Most uncut men (71%) and longitudinal cut men (84%) stated they would remove their foreskin if it reduced the risk of HIV infection. More than 95% of uncut men and 97% of longitudinal cut men would prefer the procedure in a clinic or hospital. Most men (90%) and women (74%) stated they would remove the foreskin of their son if it reduced the risk of HIV infection. CONCLUSION Although 57% of men reported some form of foreskin cut only 10% reported the complete removal of the foreskin, the procedure on which international HIV prevention strategies are based. The acceptability of MC (complete foreskin removal) is high among men (for themselves and their sons) and women (for their sons). Potential MC services need to be responsive to the diversity of beliefs and practices and consider health system constraints. A concerted research effort to investigate the potential protective effects of longitudinal cuts for HIV acquisition is essential given the scale of longitudinal cuts in PNG.
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Affiliation(s)
- David MacLaren
- School of Medicine and Dentistry, James Cook University, McGregor Road, Smithfield, Cairns 4878, Queensland, Australia
| | - Rachael Tommbe
- School of Health Science, Pacific Adventist University, Port Moresby, National Capital District, Papua New Guinea
| | - Tracie Mafile’o
- Deputy Vice Chancellor, Pacific Adventist University, Port Moresby, National Capital District, Papua New Guinea
| | - Clement Manineng
- Faculty of Health Science, Divine Word University, Madang, Madang Province, Papua New Guinea
| | - Federica Fregonese
- Global Health Unit, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Michelle Redman-MacLaren
- School of Medicine and Dentistry, James Cook University, McGregor Road, Smithfield, Cairns 4878, Queensland, Australia
| | - Michael Wood
- School of Arts and Social Science, James Cook University, Cairns, Queensland, Australia
| | - Kelwyn Browne
- Rural Primary Health Services Delivery Project, National Department of Health, Port Moresby, Papua New Guinea
| | - Reinhold Muller
- School of Public Health, Tropical Medicine and Rehabilitation Science, James Cook University, Cairns, Queensland, Australia
- Tropical Health Solutions, Townsville, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - William John McBride
- School of Medicine and Dentistry, James Cook University, McGregor Road, Smithfield, Cairns 4878, Queensland, Australia
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Layer EH, Beckham SW, Mgeni L, Shembilu C, Momburi RB, Kennedy CE. "After my husband's circumcision, I know that I am safe from diseases": women's attitudes and risk perceptions towards male circumcision in Iringa, Tanzania. PLoS One 2013; 8:e74391. [PMID: 24009771 PMCID: PMC3756960 DOI: 10.1371/journal.pone.0074391] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/31/2013] [Indexed: 11/19/2022] Open
Abstract
While male circumcision reduces the risk of female-to-male HIV transmission and certain sexually transmitted infections (STIs), there is little evidence that circumcision provides women with direct protection against HIV. This study used qualitative methods to assess women's perceptions of male circumcision in Iringa, Tanzania. Women in this study had strong preferences for circumcised men because of the low risk perception of HIV with circumcised men, social norms favoring circumcised men, and perceived increased sexual desirability of circumcised men. The health benefits of male circumcision were generally overstated; many respondents falsely believed that women are also directly protected against HIV and that the risk of all STIs is greatly reduced or eliminated in circumcised men. Efforts to engage women about the risks and limitations of male circumcision, in addition to the benefits, should be expanded so that women can accurately assess their risk of HIV or STIs during sexual intercourse with circumcised men.
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Affiliation(s)
- Erica H Layer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Can combination prevention strategies reduce HIV transmission in generalized epidemic settings in Africa? The HPTN 071 (PopART) study plan in South Africa and Zambia. J Acquir Immune Defic Syndr 2013; 63 Suppl 2:S221-7. [PMID: 23764639 DOI: 10.1097/qai.0b013e318299c3f4] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The HIV Prevention Trials Network (HPTN) is conducting the HPTN 071 (PopART) study in 21 communities in Zambia and South Africa with support from a consortium of funders. HPTN 071 (PopART) is a community-randomized trial of a combination prevention strategy to reduce HIV incidence in the context of the generalized epidemic of southern Africa. The full PopART intervention strategy is anchored in home-based HIV testing and facilitated linkage of HIV-infected persons to care through community health workers and universal antiretroviral therapy for seropositive persons regardless of CD4+ cell count or HIV viral load. To further reduce the risk of HIV acquisition among uninfected individuals, the study aims to expand voluntary medical male circumcision, diagnosis and treatment of sexually transmitted infections, behavioral counseling, and condom distribution. The full PopART intervention strategy also incorporates promotion of other interventions designed to reduce HIV and tuberculosis transmission, including optimization of the prevention of mother-to-child HIV transmission and enhanced individual and public health tuberculosis services. Success for the PopART strategy depends on the ability to increase coverage for the study interventions whose uptake is a necessary antecedent to a prevention effect. Processes will be measured to assess the degree of penetration of the interventions into the communities. A randomly sampled population cohort from each community will be used to measure the impact of the PopART strategy on HIV incidence over 3 years. We describe the strategy being tested and progress to date in the HPTN 071 (PopART) study.
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Rosario IJ, Kasabwala K, Sadeghi-Nejad H. Circumcision as a Strategy to Minimize HIV Transmission. Curr Urol Rep 2013; 14:285-90. [DOI: 10.1007/s11934-013-0343-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mantell JE, Smit JA, Saffitz JL, Milford C, Mosery N, Mabude Z, Tesfay N, Sibiya S, Rambally L, Masvawure TB, Kelvin EA, Stein ZA. Medical male circumcision and HIV risk: perceptions of women in a higher learning institution in KwaZulu-Natal, South Africa. Sex Health 2013; 10:112-8. [PMID: 23448912 PMCID: PMC3963517 DOI: 10.1071/sh12067] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 09/04/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Medical male circumcision (MMC) reduces the risk of HIV acquisition for men in heterosexual encounters by 50-60%. However, there is no evidence that a circumcised man with HIV poses any less risk of infecting his female partner than an uncircumcised man. There may be an additional risk of HIV transmission to female partners during the 6-week healing period and if condoms are used less often after circumcision. The aim was to explore young women's perspectives on MMC, with a view to developing clear messages about the limitations of MMC in reducing women's HIV risk. METHODS We explored women's perspectives on MMC in KwaZulu-Natal, South Africa, with a sample of 30 female tertiary students via four focus groups (two for women only; two mixed gender). RESULTS In all groups, women communicated a thorough understanding of the partial efficacy of MMC, but believed that others would not understand this concept. Participants noted that MMC affords no direct benefit to women. Most thought that MMC would increase females' risk of contracting HIV, that circumcised men may engage in risky behaviours and that men would increase their number of sexual partners after circumcision. Participants believed that condom use would decrease after MMC and speculated that men would have sex during the healing period, which could further compromise women's sexual health. CONCLUSION The concerns expressed by women regarding MMC highlight the need for including women in the dialogue about MMC and for clarifying the impact of MMC on HIV risk for women.
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Affiliation(s)
- Joanne E. Mantell
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA
| | - Jennifer A. Smit
- Maternal, Adolescent and Child Health (MatCH), Department of Obstetrics and Gynaecology, Faculty of Health Research Sciences, University of the Witwatersrand, 155 Juniper Road, Overport, Durban 4091, South Africa
- School of Pharmacy and Pharmacology, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa
| | - Jane L. Saffitz
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA
- Department of Anthropology, University of California at Davis, 328 Young Hall, One Shields Avenue, Davis, CA 95616-8522, USA
| | - Cecilia Milford
- Maternal, Adolescent and Child Health (MatCH), Department of Obstetrics and Gynaecology, Faculty of Health Research Sciences, University of the Witwatersrand, 155 Juniper Road, Overport, Durban 4091, South Africa
| | - Nzwakie Mosery
- Maternal, Adolescent and Child Health (MatCH), Department of Obstetrics and Gynaecology, Faculty of Health Research Sciences, University of the Witwatersrand, 155 Juniper Road, Overport, Durban 4091, South Africa
| | - Zonke Mabude
- Maternal, Adolescent and Child Health (MatCH), Department of Obstetrics and Gynaecology, Faculty of Health Research Sciences, University of the Witwatersrand, 155 Juniper Road, Overport, Durban 4091, South Africa
| | - Nonkululeko Tesfay
- Maternal, Adolescent and Child Health (MatCH), Department of Obstetrics and Gynaecology, Faculty of Health Research Sciences, University of the Witwatersrand, 155 Juniper Road, Overport, Durban 4091, South Africa
| | - Sibusiso Sibiya
- Maternal, Adolescent and Child Health (MatCH), Department of Obstetrics and Gynaecology, Faculty of Health Research Sciences, University of the Witwatersrand, 155 Juniper Road, Overport, Durban 4091, South Africa
| | - Letitia Rambally
- Maternal, Adolescent and Child Health (MatCH), Department of Obstetrics and Gynaecology, Faculty of Health Research Sciences, University of the Witwatersrand, 155 Juniper Road, Overport, Durban 4091, South Africa
| | - Tsitsi B. Masvawure
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA
| | - Elizabeth A. Kelvin
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA
- Department of Epidemiology, Hunter College School of Urban Public Health, 2180 Third Avenue, New York, NY 10035, USA
| | - Zena A. Stein
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY 10032, USA
- GH Sergievsky Center, Joseph Mailman School of Public Health, Columbia University, 722 W. 168th Street, New York, NY 10032, USA
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Layer EH, Beckham SW, Momburi RB, Kennedy CE. Understanding the partial protection of male circumcision for HIV prevention among women in Iringa Region, Tanzania: an ethnomedical model. AIDS Care 2012; 25:1045-50. [PMID: 23216512 DOI: 10.1080/09540121.2012.748874] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Communicating the partial efficacy of male circumcision for HIV prevention is challenging. Understanding how people conceptualize risk can help programs communicate messages in a way that is understandable to local communities. This article explores women's ethnomedical model of disease transmission related to male circumcision in Iringa Region, Tanzania. We conducted in-depth interviews (IDIs) with 32 female partners of male circumcision clients and focus group discussions (FGDs) with married (n=3) and unmarried (n=3) women from November 2011 to February 2012. Interviews were digitally recorded, transcribed, and translated into English, and codes were developed based on emerging themes. While women understand that circumcised men are still at risk of HIV, risk is perceived to be low as long as both partners avoid abrasions during sexual intercourse and the man's penis is kept clean. Women said that HIV transmission only occurs when both partners have abrasions on their genitalia and mixing of blood occurs. Abrasions are thought to be the result of friction from fast or dry sex and are more likely to occur with uncircumcised men; thus, HIV can be prevented if a man is circumcised and couples have gentle, lubricated sex. In addition, women reported that the foreskin traps particles of sexually transmitted infections (STIs) including HIV, which can easily be passed on to female partners. In contrast, circumcised men are viewed as being able to clean themselves of disease particles and, therefore, do not easily acquire diseases or transmit them to female partners. These findings align with the scientific understanding of increased HIV risk associated with abrasions or microflora in the foreskin; however, the ethnomedical model differs from scientific understanding in that disease transmission can in fact occur without either of these conditions. Programs can build upon these findings to better convey risks along with the benefits of male circumcision.
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Affiliation(s)
- Erica H Layer
- Department of International Health, Johns Hopkins University, Baltimore, USA.
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Modeling the population-level effects of male circumcision as an HIV-preventive measure: a gendered perspective. PLoS One 2011; 6:e28608. [PMID: 22205956 PMCID: PMC3243682 DOI: 10.1371/journal.pone.0028608] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 11/11/2011] [Indexed: 11/29/2022] Open
Abstract
Background Evidence from biological, epidemiological, and controlled intervention studies has demonstrated that male circumcision (MC) protects males from HIV infection, and MC is now advocated as a public-health intervention against HIV. MC provides direct protection only to men, but is expected to provide indirect protection to women at risk of acquiring HIV from heterosexual transmission. How such indirect protection interacts with the possibility that MC campaigns will lead to behavior changes, however, is not yet well understood. Our objective here is to investigate the link between individual-level effects of MC campaigns and long-term population-level outcomes resulting from disease dynamics, looking at both genders separately, over a broad range of parameters. Methods and Findings We use simple mathematical models of heterosexual transmission to investigate the potential effects of a circumcision scale-up, combined with possible associated behavioral disinhibition. We examine patterns in expected long-term prevalence using a simple equilibrium model based on transmission factors, and validate our results with ODE-based simulations, focusing on the link between effects on females and those on males.We find that the long-term population-level effects on females and males are not strongly linked: there are many possible ways in which an intervention which reduces prevalence in males might nonetheless increase prevalence in females. Conclusions Since an intervention that reduces long-term male prevalence could nonetheless increase long-term female prevalence, MC campaigns should explicitly consider both the short-term and long-term effects of MC interventions on females. Our findings strongly underline the importance of pairing MC programs with education, support programs and HIV testing and counseling, together with other prevention measures.
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