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Ntshiqa T, Musekiwa A, Manesen R, Mdose H, Ngoma N, Kuonza L, Dlamini T, Reddy C, Williams S. Knowledge, Attitudes, Practices, and Acceptability of Medical Male Circumcision among Males in Traditionally Circumcising Rural Communities of Alfred Nzo District, Eastern Cape, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7091. [PMID: 38063521 PMCID: PMC10706319 DOI: 10.3390/ijerph20237091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023]
Abstract
Male circumcision (MC) reduces HIV transmission risk by up to 60% in heterosexual men. However, uptake of medical male circumcision (MMC) is low in traditionally circumcising communities of South Africa. We assessed knowledge, attitudes, and practices to identify factors predicting acceptability of MMC among males in the Alfred Nzo District. A cross-sectional study was conducted among males aged 15-49 years in this district. Logistic regression was used to identify factors predicting acceptability of MMC. We interviewed 343 males who had a median age of 19 years (interquartile range (IQR): 16-25 years). Of these, 77% (95% confidence interval (CI): 72-82) were circumcised: 77% (95% CI: 71-82) were circumcised in a traditional setting and 21% (95% CI: 16-26) in a medical setting. The median score of knowledge about the benefits of MMC was 62.5% (IQR: 37.5-75.0), with 59% (95% CI: 53-64) demonstrating a positive attitude towards MMC and 68% (95% CI: 63-73) accepting involvement of health workers in MC. Excellent knowledge (adjusted odds ratio (aOR): 3.07, 95% CI: 0.99-9.58, p = 0.053), awareness (aOR: 3.26, 95% CI: 1.08-9.86, p = 0.037), and positive attitude towards MMC (aOR: 2.35, 95% CI: 1.30-4.25, p = 0.005) were associated with acceptability of MMC. Participants demonstrated good knowledge and acceptance of the MMC programme. Knowledge, attitude, and awareness were significant predictors of MMC acceptability.
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Affiliation(s)
- Thobani Ntshiqa
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- South African National Aids Council, Pretoria 0002, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
- The Aurum Institute, Johannesburg 2193, South Africa;
| | - Alfred Musekiwa
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Riyadh Manesen
- The Aurum Institute, Johannesburg 2193, South Africa;
- GERMS-SA, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa
- Epidemiology Unit, Eastern Cape Department of Health, Bisho 5605, South Africa;
| | - Hetani Mdose
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Nqobile Ngoma
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Lazarus Kuonza
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Thomas Dlamini
- Epidemiology Unit, Eastern Cape Department of Health, Bisho 5605, South Africa;
| | - Carl Reddy
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
- TEPHINET Secretariat, The Task Force for Global Health, Decatur, GA 30030, USA
| | - Seymour Williams
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- Centers for Disease Control and Prevention, Atlanta, GA 30328, USA
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Voluntary Medical Male Circumcision for HIV Prevention: a Global Overview. Curr HIV/AIDS Rep 2022; 19:474-483. [PMID: 36348186 DOI: 10.1007/s11904-022-00632-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW With the promise of HIV prevention, there has been a scale-up of voluntary medical male circumcision (VMMC) in high HIV incidence/low circumcision prevalence nations worldwide. Nonetheless, debates over the implementation and the effectiveness and safety of the VMMC in real-world settings persist. We revisit the role of VMMC in HIV prevention to inform health professionals, policymakers, and advocates or opponents in this new era. RECENT FINDINGS There has been substantial progress on VMMC scale-up to date, but this has varied considerably by region. The evidence of solid and direct protection of VMMC is available for heterosexual men and older adolescent boys in sub-Saharan Africa. The protective effect in men who have sex with men is suggested by systematic reviews but is not confirmed by clinical trials. Sexual partners, including women, likely benefit indirectly from the increased VMMC coverage through a decreased risk of exposure to infected male partners. Fortunately, the preponderance of studies does not suggest higher sexual risk behaviors among circumcised men, so-called risk compensation. VMMC requires health systems strengthening and continued promulgation of other evidence-based HIV prevention strategies to be successful. Health authorities in high HIV incidence areas that have low circumcision coverage should implement VMMC within a context of complementary biomedical and behavioral prevention strategies.
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Lin Y, Gao Y, Sun Y, Turner D, Zou H, Vermund SH, Qian HZ. Does Voluntary Medical Male Circumcision Reduce HIV Risk in Men Who Have Sex with Men? Curr HIV/AIDS Rep 2022; 19:522-525. [PMID: 36520379 DOI: 10.1007/s11904-022-00637-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW To review the evidence on the effect of voluntary medical male circumcision (VMMC) on reducing HIV risk among men who have sex with men (MSM) and assess the limitations of available evidence. RECENT FINDINGS Individual studies have shown conflicting results, but recent meta-analyses have consistently suggested that VMMC was associated with 7 to 23% reductions in HIV prevalence or incidence in MSM, particularly among a subgroup of men who predominantly practice insertive role in anal sex. Mathematical models have also suggested a moderate population-level impact of VMMC intervention. All original studies have been observational and are subject to confounding and bias. Randomized clinical trials (RCTs) are needed to provide strong evidence of assessing the efficacy of VMMC on HIV risk among MSM. VMMC is a promising HIV risk reduction tool for MSM. RCTs are needed to evaluate the efficacy of VMMC intervention.
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Affiliation(s)
- Yidie Lin
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yanxiao Gao
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, China
| | - Yue Sun
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - DeAnne Turner
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, China
| | - Sten H Vermund
- School of Public Health, Yale University, Suite 501, 300 George Street, New Haven, CT, USA
| | - Han-Zhu Qian
- School of Public Health, Yale University, Suite 501, 300 George Street, New Haven, CT, USA.
- GlaxoSmithKline Plc, Rockville, MD, USA.
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Johnson LF, Meyer-Rath G, Dorrington RE, Puren A, Seathlodi T, Zuma K, Feizzadeh A. The Effect of HIV Programs in South Africa on National HIV Incidence Trends, 2000-2019. J Acquir Immune Defic Syndr 2022; 90:115-123. [PMID: 35125471 DOI: 10.1097/qai.0000000000002927] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent studies have shown HIV incidence declines at a population level in several African countries. However, these studies have not directly quantified the extent to which incidence declines are attributable to different HIV programs. METHODS We calibrated a mathematical model of the South African HIV epidemic to age- and sex-specific data from antenatal surveys, household surveys, and death registration, using a Bayesian approach. The model was also parameterized using data on self-reported condom use, voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral treatment (ART). Model estimates of HIV incidence were compared against the incidence rates that would have been expected had each program not been implemented. RESULTS The model estimated incidence in 15-49 year olds of 0.84% (95% CI: 0.75% to 0.96%) at the start of 2019. This represents a 62% reduction (95% CI: 55% to 66%) relative to 2000, a 47% reduction (95% CI: 42% to 51%) relative to 2010, and a 73% reduction (95% CI: 68% to 77%) relative to the incidence that would have been expected in 2019 in the absence of any interventions. The reduction in incidence in 2019 because of interventions was greatest for ART and condom promotion, with VMMC and behavior change after HIV testing having relatively modest impacts. HIV program impacts differed significantly by age and sex, with condoms and VMMC having greatest impact in youth, and overall incidence reductions being greater in men than in women. CONCLUSIONS HIV incidence in South Africa has declined substantially since 2000, with ART and condom promotion contributing most significantly to this decline.
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Affiliation(s)
- Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA
| | - Rob E Dorrington
- Centre for Actuarial Research, School of Management Studies, University of Cape Town, Cape Town, South Africa
| | - Adrian Puren
- Division of Virology, School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Thapelo Seathlodi
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Khangelani Zuma
- Human Sciences Research Council, Pretoria, South Africa ; and
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Frisch M, Simonsen J. Non-therapeutic male circumcision in infancy or childhood and risk of human immunodeficiency virus and other sexually transmitted infections: national cohort study in Denmark. Eur J Epidemiol 2021; 37:251-259. [PMID: 34564796 PMCID: PMC9110485 DOI: 10.1007/s10654-021-00809-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 09/12/2021] [Indexed: 12/14/2022]
Abstract
Whether male circumcision in infancy or childhood provides protection against the acquisition of human immunodeficiency virus (HIV) or other sexually transmitted infections (STIs) in adulthood remains to be established. In the first national cohort study to address this issue, we identified 810,719 non-Muslim males born in Denmark between 1977 and 2003 and followed them over the age span 0–36 years between 1977 and 2013. We obtained information about cohort members’ non-therapeutic circumcisions, HIV diagnoses and other STI outcomes from national health registers and used Cox proportional hazards regression analyses to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status (i.e., circumcised v. genitally intact). During a mean of 22 years of follow-up, amounting to a total observation period of 17.7 million person-years, 3375 cohort members (0.42%) underwent non-therapeutic circumcision, and 8531 (1.05%) received hospital care for HIV or other STIs. Compared with genitally intact males, rates among circumcised males were not statistically significantly reduced for any specific STI. Indeed, circumcised males had a 53% higher rate of STIs overall (HR = 1.53, 95% CI: 1.24–1.89), and rates were statistically significantly increased for anogenital warts (74 cases in circumcised males v. 7151 cases in intact males, HR = 1.51; 95% CI: 1.20–1.90) and syphilis (four cases in circumcised males v. 197 cases in intact males, HR = 3.32; 95% CI: 1.23–8.95). In this national cohort study spanning more than three decades of observation, non-therapeutic circumcision in infancy or childhood did not appear to provide protection against HIV or other STIs in males up to the age of 36 years. Rather, non-therapeutic circumcision was associated with higher STI rates overall, particularly for anogenital warts and syphilis.
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Affiliation(s)
- Morten Frisch
- Department of Epidemiology Research, Statens Serum Institut, 2300, Copenhagen S, Denmark. .,Department of Clinical Medicine, Center for Sexology Research, Aalborg University, 9000, Aalborg, Denmark.
| | - Jacob Simonsen
- Department of Epidemiology Research, Statens Serum Institut, 2300, Copenhagen S, Denmark
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Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male circumcision: A systematic review. J Evid Based Med 2019; 12:263-290. [PMID: 31496128 PMCID: PMC6899915 DOI: 10.1111/jebm.12361] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/03/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To systematically evaluate evidence against male circumcision (MC). METHODS We searched PubMed, Google Scholar, EMBASE and Cochrane databases. RESULTS Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. CONCLUSIONS Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.
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Affiliation(s)
- Brian J Morris
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | - John N Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattleWashington
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Gray RH. Male Circumcision for HIV and STI Prevention: A Reflection. Clin Chem 2019; 65:15-18. [PMID: 30602469 DOI: 10.1373/clinchem.2018.286542] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Ronald H Gray
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD.
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Morris BJ, Hankins CA, Banerjee J, Lumbers ER, Mindel A, Klausner JD, Krieger JN. Does Male Circumcision Reduce Women's Risk of Sexually Transmitted Infections, Cervical Cancer, and Associated Conditions? Front Public Health 2019; 7:4. [PMID: 30766863 PMCID: PMC6365441 DOI: 10.3389/fpubh.2019.00004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Male circumcision (MC) is proven to substantially reduce men's risk of a number of sexually transmitted infections (STIs). We conducted a detailed systematic review of the scientific literature to determine the relationship between MC and risk of STIs and associated conditions in women. Methods: Database searches by "circumcision women" and "circumcision female" identified 68 relevant articles for inclusion. Examination of bibliographies of these yielded 14 further publications. Each was rated for quality using a conventional rating system. Results: Evaluation of the data from the studies retrieved showed that MC is associated with a reduced risk in women of being infected by oncogenic human papillomavirus (HPV) genotypes and of contracting cervical cancer. Data from randomized controlled trials and other studies has confirmed that partner MC reduces women's risk not only of oncogenic HPV, but as well Trichomonas vaginalis, bacterial vaginosis and possibly genital ulcer disease. For herpes simplex virus type 2, Chlamydia trachomatis, Treponema pallidum, human immunodeficiency virus and candidiasis, the evidence is mixed. Male partner MC did not reduce risk of gonorrhea, Mycoplasma genitalium, dysuria or vaginal discharge in women. Conclusion: MC reduces risk of oncogenic HPV genotypes, cervical cancer, T. vaginalis, bacterial vaginosis and possibly genital ulcer disease in women. The reduction in risk of these STIs and cervical cancer adds to the data supporting global efforts to deploy MC as a health-promoting and life-saving public health measure and supplements other STI prevention strategies.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW, Australia
| | - Catherine A. Hankins
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- London School of Hygiene and Tropical Medicine, Bloomsbury, London, United Kingdom
| | | | - Eugenie R. Lumbers
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine and Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Adrian Mindel
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey D. Klausner
- Division of Infectious Diseases and the Program in Global Health, Fielding School of Public Health, University of California Los Angeles Care Center, Los Angeles, CA, United States
| | - John N. Krieger
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States
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Nagelkerke N, Abu-Raddad LJ, Awad SF, Black V, Williams B. A signature for biological heterogeneity in susceptibility to HIV infection? Infect Dis Model 2018; 3:139-144. [PMID: 30839921 PMCID: PMC6326230 DOI: 10.1016/j.idm.2018.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 07/12/2018] [Accepted: 08/31/2018] [Indexed: 11/29/2022] Open
Abstract
Data on female sex workers and sero-discordant couples indicate a pattern of waning of the risk of HIV infection with longer duration of exposure to infected partners. Understanding risk of HIV acquisition and transmission is critical to understanding HIV epidemiology and informing prevention interventions. Informed by empirical data, we aimed to develop a statistical model to explain these observations. In our proposed model, the time to infection for each individual is exponentially distributed, but the marginal (population averaged) distribution of time to infection follows a Weibull distribution with shape parameter of about 0.5, and with the Lévy distribution being the mixing distribution. Simulations based on this model demonstrated how HIV epidemics are destined to emerge rapidly, because of the rapid sero-conversion upon exposure, but also simultaneously destined to saturate and decline rapidly after emergence, just as observed for the HIV epidemics in sub-Saharan Africa. These results imply considerable individual variability in infection risk, probably because of biological heterogeneity in the susceptibility to HIV infection. Factoring this variability in mathematical models, through the methodology provided here, could be critical for valid estimations of impact of HIV interventions and assessments of cost-effectiveness.
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Affiliation(s)
- Nico Nagelkerke
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laith J. Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
- Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, USA
| | - Susanne F. Awad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
- Population Health Research Institute, St George's, University of London, London, UK
| | - Vivian Black
- Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, South Africa
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Brian Williams
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
- South African Centre for Epidemiological Modeling and Analysis (SACEMA), Stellenbosch, South Africa
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Abstract
BACKGROUND Our objective was to assess the population-level association between herpes simplex virus 2 (HSV-2) and HIV prevalence. METHODS Reports of HSV-2 and HIV prevalence were systematically reviewed and synthesized following PRISMA guidelines. Spearman rank correlation ((Equation is included in full-text article.)) was used to assess correlations. Risk ratios (RRHSV-2/HIV) and odds ratios (ORHSV-2/HIV) were used to assess HSV-2/HIV epidemiologic overlap. DerSimonian-Laird random-effects meta-analyses were conducted. RESULTS In total, 939 matched HSV-2/HIV prevalence measures were identified from 77 countries. HSV-2 prevalence was consistently higher than HIV prevalence. Strong HSV-2/HIV prevalence association was found for all data ((Equation is included in full-text article.) = 0.6, P < 0.001), all data excluding people who inject drugs (PWID) and children ((Equation is included in full-text article.) = 0.7, P < 0.001), female sex workers ((Equation is included in full-text article.) = 0.5, P < 0.001), and MSM ((Equation is included in full-text article.) = 0.7, P < 0.001). No association was found for PWID ((Equation is included in full-text article.) = 0.2, P = 0.222) and children ((Equation is included in full-text article.) = 0.3, P = 0.082). A threshold effect was apparent where HIV prevalence was limited at HSV-2 prevalence less than 20%, but grew steadily with HSV-2 prevalence for HSV-2 prevalence greater than 20%. The overall pooled mean RRHSV-2/HIV was 5.0 (95% CI 4.7-5.3) and ORHSV-2/HIV was 9.0 (95% CI 8.4-9.7). The RRHSV-2/HIV and ORHSV-2/HIV showed similar patterns that conveyed inferences about HSV-2 and HIV epidemiology. CONCLUSION HSV-2 and HIV prevalence are strongly associated. HSV-2 prevalence can be used as a proxy 'biomarker' of HIV epidemic potential, acting as a 'temperature scale' of the intensity of sexual risk behavior that drive HIV transmission. HSV-2 prevalence can be used to identify populations and/or sexual networks at high-risk of future HIV expansion, and help prioritization, optimization, and resource allocation of cost-effective prevention interventions.
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Awad SF, Chemaitelly H, Abu-Raddad LJ. Estimating the annual risk of HIV transmission within HIV sero-discordant couples in sub-Saharan Africa. Int J Infect Dis 2017; 66:131-134. [PMID: 29129712 DOI: 10.1016/j.ijid.2017.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To estimate the annual risk of HIV transmission (ϕ) within HIV sero-discordant couples in 23 countries in sub-Saharan Africa (SSA), by utilizing newly available national population-based data and accounting for factors known to potentially affect this estimation. METHODS We used a recently developed pair-based mathematical model that accommodates for HIV-dynamics temporal variation, sexual risk-behavior heterogeneity, and antiretroviral therapy (ART) scale-up. RESULTS Estimated country-specific ϕ (in absence of ART) ranged between 4.2% (95% uncertainty interval (UI): 1.9%-6.3%) and 47.4% (95% UI: 37.2%-69.0%) per person-year (ppy), with a median of 12.4%. ϕ was strongly associated with HIV prevalence, with a Pearson correlation coefficient of 0.92, and was larger in high- versus low-HIV-prevalence countries. ϕ increased by 1.31% (95% confidence interval: 1.00%-1.55%) ppy for every 1% increase in HIV prevalence. CONCLUSIONS ϕ estimates were similar to earlier estimates, and suggested considerable heterogeneity in HIV infectiousness across SSA. This heterogeneity may explain, partly, the differences in epidemic scales.
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Affiliation(s)
- Susanne F Awad
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; Population Health Research Institute, St George's, University of London, London, UK.
| | - Hiam Chemaitelly
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar.
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medicine-Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; Department of Healthcare Policy and Research, Weill Cornell Medicine, Cornell University, New York, NY, USA.
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Zhou B, Ning C, McCann CD, Liao Y, Yang X, Zou Y, Jiang J, Liang B, Abdullah AS, Qin B, Upur H, Zhong C, Ye L, Liang H. Impact of Educational Interventions on Acceptance and Uptake of Male Circumcision in the General Population of Western China: A Multicenter Cohort Study. Sci Rep 2017; 7:14931. [PMID: 29097659 PMCID: PMC5668315 DOI: 10.1038/s41598-017-13995-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/05/2017] [Indexed: 12/15/2022] Open
Abstract
To compare different intervention models for promoting male circumcision (MC) to prevent HIV transmission in Western China. A total of 1690 male participants from multiple study sites were cluster randomly allocated to three-stage (Model A), two-stage (Model B), and one-stage (Model C) educational interventions. In all three interventions models, knowledge about MC significantly increased and the reported willingness to accept MC increased to 52.6% (255/485), 67.0% (353/527), and 45.5% (219/481) after intervention, respectively (P < 0.05). Rate of MC surgery uptake was highest (23.7%; 115/485) among those who received Model A intervention, compared to those who received Model B (17.1%; 90/527) or Model C (9.4%; 45/481) interventions (P < 0.05). Multivariable Cox regression analysis identified that Model A or Model B had twice the effect of Model C on MC uptake, with relative risks of 2.4 (95%CI, 1.5-3.8) and 2.2 (95%CI, 1.3-3.6), respectively. Model B was the most effective model for improving participants' willingness to accept MC, while Model A was most successful at increasing uptake of MC surgery. Self-reported attitude towards MC uptake was not strongly correlated with actual behavior in this study focusing on the general male population in Western China.
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Affiliation(s)
- Bo Zhou
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China
| | - Chuanyi Ning
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China
| | - Chase D McCann
- Department of Microbiology & Immunology University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yanyan Liao
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China
| | - Xiaobo Yang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China
| | - Yunfeng Zou
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China
| | - Junjun Jiang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China
| | - Bingyu Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China
| | - Abu S Abdullah
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China.,Department of Medicine, Boston Medical Center, Boston University Medical Campus, Boston, United States of America
| | - Bo Qin
- The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Halmurat Upur
- School of Public Health, Xinjiang Medical University, Xinjiang, China
| | - Chaohui Zhong
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Li Ye
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China.
| | - Hao Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Guangxi, China.
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Miiro G, DeCelles J, Rutakumwa R, Nakiyingi-Miiro J, Muzira P, Ssembajjwe W, Musoke S, Gibson LJ, Hershow RB, Francis S, Torondel B, Ross DA, Weiss HA. Soccer-based promotion of voluntary medical male circumcision: A mixed-methods feasibility study with secondary students in Uganda. PLoS One 2017; 12:e0185929. [PMID: 29016651 PMCID: PMC5633183 DOI: 10.1371/journal.pone.0185929] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/21/2017] [Indexed: 11/18/2022] Open
Abstract
The Ugandan government is committed to scaling-up proven HIV prevention strategies including safe male circumcision, and innovative strategies are needed to increase circumcision uptake. The aim of this study was to assess the acceptability and feasibility of implementing a soccer-based intervention (“Make The Cut”) among schoolboys in a peri-urban district of Uganda. The intervention was led by trained, recently circumcised “coaches” who facilitated a 60-minute session delivered in schools, including an interactive penalty shoot-out game using metaphors for HIV prevention, sharing of the coaches’ circumcision story, group discussion and ongoing engagement from the coach to facilitate linkage to male circumcision. The study took place in four secondary schools in Entebbe sub-district, Uganda. Acceptability of safe male circumcision was assessed through a cross-sectional quantitative survey. The feasibility of implementing the intervention was assessed by piloting the intervention in one school, modifying it, and implementing the modified version in a second school. Perceptions of the intervention were assessed with in-depth interviews with participants. Of the 210 boys in the cross-sectional survey, 59% reported being circumcised. Findings showed high levels of knowledge and generally favourable perceptions of circumcision. The initial implementation of Make The Cut resulted in 6/58 uncircumcised boys (10.3%) becoming circumcised. Changes made included increasing engagement with parents and improved liaison with schools regarding the timing of the intervention. Following this, uptake improved to 18/69 (26.1%) in the second school. In-depth interviews highlighted the important role of family and peer support and the coach in facilitating the decision to circumcise. This study showed that the modified Make The Cut intervention may be effective to increase uptake of safe male circumcision in this population. However, the intervention is time-intensive, and further work is needed to assess the cost-effectiveness of the intervention conducted at scale.
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Affiliation(s)
- George Miiro
- Uganda Virus Research Institute, Entebbe, Uganda
| | - Jeff DeCelles
- Grassroot Soccer, Cape Town, South Africa
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - Rwamahe Rutakumwa
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Jessica Nakiyingi-Miiro
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | | | | | - Lorna J. Gibson
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rebecca B. Hershow
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - Suzanna Francis
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Belen Torondel
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David A. Ross
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Swizterland
| | - Helen A. Weiss
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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Johnson LF, Dorrington RE, Moolla H. HIV epidemic drivers in South Africa: A model-based evaluation of factors accounting for inter-provincial differences in HIV prevalence and incidence trends. South Afr J HIV Med 2017; 18:695. [PMID: 29568631 PMCID: PMC5843035 DOI: 10.4102/sajhivmed.v18i1.695] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 06/01/2017] [Indexed: 01/24/2023] Open
Abstract
Background HIV prevalence differs substantially between South Africa’s provinces, but the factors accounting for this difference are poorly understood. Objectives To estimate HIV prevalence and incidence trends by province, and to identify the epidemiological factors that account for most of the variation between provinces. Methods A mathematical model of the South African HIV epidemic was applied to each of the nine provinces, allowing for provincial differences in demography, sexual behaviour, male circumcision, interventions and epidemic timing. The model was calibrated to HIV prevalence data from antenatal and household surveys using a Bayesian approach. Parameters estimated for each province were substituted into the national model to assess sensitivity to provincial variations. Results HIV incidence in 15–49-year-olds peaked between 1997 and 2003 and has since declined steadily. By mid-2013, HIV prevalence in 15–49-year-olds varied between 9.4% (95% CI: 8.5%–10.2%) in Western Cape and 26.8% (95% CI: 25.8%–27.6%) in KwaZulu-Natal. When standardising parameters across provinces, this prevalence was sensitive to provincial differences in the prevalence of male circumcision (range 12.3%–21.4%) and the level of non-marital sexual activity (range 9.5%–24.1%), but not to provincial differences in condom use (range 17.7%–21.2%), sexual mixing (range 15.9%–19.2%), marriage (range 18.2%–19.4%) or assumed HIV prevalence in 1985 (range 17.0%–19.1%). Conclusion The provinces of South Africa differ in the timing and magnitude of their HIV epidemics. Most of the heterogeneity in HIV prevalence between South Africa’s provinces is attributable to differences in the prevalence of male circumcision and the frequency of non-marital sexual activity.
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Affiliation(s)
- Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Rob E Dorrington
- Centre for Actuarial Research, University of Cape Town, South Africa
| | - Haroon Moolla
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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Sousa JD, Temudo MP, Hewlett BS, Camacho RJ, Müller V, Vandamme AM. Male Circumcision and the Epidemic Emergence of HIV-2 in West Africa. PLoS One 2016; 11:e0166805. [PMID: 27926927 PMCID: PMC5142780 DOI: 10.1371/journal.pone.0166805] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/03/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Epidemic HIV-2 (groups A and B) emerged in humans circa 1930-40. Its closest ancestors are SIVsmm infecting sooty mangabeys from southwestern Côte d'Ivoire. The earliest large-scale serological surveys of HIV-2 in West Africa (1985-91) show a patchy spread. Côte d'Ivoire and Guinea-Bissau had the highest prevalence rates by then, and phylogeographical analysis suggests they were the earliest epicenters. Wars and parenteral transmission have been hypothesized to have promoted HIV-2 spread. Male circumcision (MC) is known to correlate negatively with HIV-1 prevalence in Africa, but studies examining this issue for HIV-2 are lacking. METHODS We reviewed published HIV-2 serosurveys for 30 cities of all West African countries and obtained credible estimates of real prevalence through Bayesian estimation. We estimated past MC rates of 218 West African ethnic groups, based on ethnographic literature and fieldwork. We collected demographic tables specifying the ethnic partition in cities. Uncertainty was incorporated by defining plausible ranges of parameters (e.g. timing of introduction, proportion circumcised). We generated 1,000 sets of past MC rates per city using Latin Hypercube Sampling with different parameter combinations, and explored the correlation between HIV-2 prevalence and estimated MC rate (both logit-transformed) in the 1,000 replicates. RESULTS AND CONCLUSIONS Our survey reveals that, in the early 20th century, MC was far less common and geographically more variable than nowadays. HIV-2 prevalence in 1985-91 and MC rates in 1950 were negatively correlated (Spearman rho = -0.546, IQR: -0.553--0.546, p≤0.0021). Guinea-Bissau and Côte d'Ivoire cities had markedly lower MC rates. In addition, MC was uncommon in rural southwestern Côte d'Ivoire in 1930.The differential HIV-2 spread in West Africa correlates with different historical MC rates. We suggest HIV-2 only formed early substantial foci in cities with substantial uncircumcised populations. Lack of MC in rural areas exposed to bushmeat may have had a role in successful HIV-2 emergence.
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Affiliation(s)
- João Dinis Sousa
- KU Leuven—University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, B-3000, Leuven, Belgium
- Center for Global Health and Tropical Medicine, Unidade de Microbiologia Médica, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Marina Padrão Temudo
- Department of Natural Resources, Environment, and Land, CEF, School of Agriculture, University of Lisbon, Lisbon, Portugal
| | - Barry Stephen Hewlett
- Department of Anthropology, Washington State University Vancouver, Vancouver, Washington, United States of America
| | - Ricardo Jorge Camacho
- KU Leuven—University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, B-3000, Leuven, Belgium
| | - Viktor Müller
- Institute of Biology, Eötvös Loránd University, Budapest, Hungary
- Parmenides Center for the Conceptual Foundations of Science, Pullach/Munich, Germany
| | - Anne-Mieke Vandamme
- KU Leuven—University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, B-3000, Leuven, Belgium
- Center for Global Health and Tropical Medicine, Unidade de Microbiologia Médica, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
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16
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Impact and Cost of Scaling Up Voluntary Medical Male Circumcision for HIV Prevention in the Context of the New 90-90-90 HIV Treatment Targets. PLoS One 2016; 11:e0155734. [PMID: 27783681 PMCID: PMC5082670 DOI: 10.1371/journal.pone.0155734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 05/03/2016] [Indexed: 01/07/2023] Open
Abstract
Background The report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for World AIDS Day 2014 highlighted a Fast-Track Strategy that sets ambitious treatment and prevention targets to reduce global HIV incidence to manageable levels by 2020 and end the AIDS epidemic by 2030. The 90-90-90 treatment targets for 2020 call for 90% of people living with HIV to know their HIV status, 90% of people who know their status to receive treatment, and 90% of people on HIV treatment to be virally suppressed. This paper examines how scale-up of voluntary medical male circumcision (VMMC) services in four priority countries in sub-Saharan Africa could contribute to ending the AIDS epidemic by 2030 in the context of concerted efforts to close the treatment gap, and what the impact of VMMC scale-up would be if the 90-90-90 treatment targets were not completely met. Methods Using the Goals module of the Spectrum suite of models, this analysis modified ART (antiretroviral treatment) scale-up coverage from base scenarios to reflect the 90-90-90 treatment targets in four countries (Lesotho, Malawi, South Africa, and Uganda). In addition, a second scenario was created to reflect viral suppression levels of 75% instead of 90%, and a third scenario was created in which the 90-90-90 treatment targets are reached in women, with men reaching more moderate coverage levels. Regarding male circumcision (MC) coverage, the analysis examined both a scenario in which VMMCs were assumed to stop after 2015, and one in which MC coverage was scaled up to 90% by 2020 and maintained at 90% thereafter. Results Across all four countries, scaling up VMMC is projected to provide further HIV incidence reductions in addition to those achieved by reaching the 90-90-90 treatment targets. If viral suppression levels only reach 75%, scaling up VMMC leads to HIV incidence reduction to nearly the same levels as those achieved with 90-90-90 without VMMC scale-up. If only women reach the 90-90-90 targets, scaling up VMMC brings HIV incidence down to near the levels projected with 90-90-90 without VMMC scale-up. Regarding cost, scaling up VMMC increases the annual costs during the scale-up phase, but leads to lower annual costs after the MC coverage target is achieved. Conclusions The scenarios modeled in this paper show that the highly durable and effective male circumcision intervention increases epidemic impact levels over those of treatment-only strategies, including the case if universal levels of viral suppression in men and women are not achieved by 2020. In the context of 90-90-90, prioritizing continued successful scale-up of VMMC increases the possibility that future generations will be free not only of AIDS but also of HIV.
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Kankaka EN, Murungi T, Kigozi G, Makumbi F, Nabukalu D, Watya S, Kighoma N, Nampijja R, Kayiwa D, Nalugoda F, Serwadda D, Wawer M, Gray RH. Randomised trial of early infant circumcision performed by clinical officers and registered nurse midwives using the Mogen clamp in Rakai, Uganda. BJU Int 2016; 119:164-170. [PMID: 27597563 DOI: 10.1111/bju.13589] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the safety and acceptability of early infant circumcision (EIC) provided by trained clinical officers (COs) and registered nurse midwives (RNMWs) in rural Uganda. SUBJECTS AND METHODS We conducted a randomised trial of EIC using the Mogen clamp provided by newly trained COs and RNMWs in four health centres in rural Rakai, Uganda. The trial was registered with clinicaltrials.gov # NCT02596282. In all, 501 healthy neonates aged 1-28 days with normal birth weight and gestational age were randomised to COs (n = 256) and RNMWs (n = 245) for EIC, and were followed-up at 1, 7 and 28 days. RESULTS In all, 701 mothers were directly invited to participate in the trial, 525 consented to circumcision (74.9%) and 23 were found ineligible on screening (4.4%). The procedure took an average of 10.5 min. Adherence to follow-up was >90% at all scheduled visits. The rates of moderate/severe adverse events were 2.4% for COs and 1.6% for RNMWs (P = 0.9). All wounds were healed by 28 days after circumcision. Maternal satisfaction with the procedure was 99.6% for infants circumcised by COs and 100% among infants circumcised by RNMWs. CONCLUSIONS EIC was acceptable in this rural Ugandan population and can be safely performed by RNMWs who have direct contact with the mothers during pregnancy and delivery. EIC services should be made available to parents who are interested in the service.
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Affiliation(s)
| | - Teddy Murungi
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | | | - Frederick Makumbi
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | | | - Stephen Watya
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | | | | | - Daniel Kayiwa
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | - Fred Nalugoda
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,College of Health Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Maria Wawer
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ronald H Gray
- Rakai Health Sciences Program, Kalisizo, Rakai, Uganda.,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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18
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Mati K, Adegoke KK, Salihu HM. Factors associated with married women's support of male circumcision for HIV prevention in Uganda: a population based cross-sectional study. BMC Public Health 2016; 16:696. [PMID: 27484177 PMCID: PMC4971618 DOI: 10.1186/s12889-016-3385-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the protective effect of male circumcision (MC) against HIV in men, the acceptance of voluntary MC in priority countries for MC scale-up such as Uganda remains limited. This study examined the role of women's sociodemographic characteristics, knowledge of HIV and sexual bargaining power as determinants of women's support of male circumcision (MC). METHODS Data from the Uganda AIDS Indicator Survey, 2011 were analyzed (n = 4,874). Bivariate and multivariate logistic regression analyses with random intercept were conducted to identify factors that influence women's support of MC. RESULTS Overall, 67.0 % (n = 3,276) of the women in our sample were in support of MC but only 28.0 % had circumcised partners. Women who had the knowledge that circumcision reduces HIV risk were about 6 times as likely to support MC than women who lacked that knowledge [AOR (adjusted odds ratio) = 5.85, 95 % CI (confidence interval) = 4.83-7.10]. The two indicators of women's sexual bargaining power (i.e., ability to negotiate condom use and ability to refuse sex) were also positively associated with support of MC. Several sociodemographic factors particularly wealth index were also positively associated with women's support of MC. CONCLUSIONS The findings in this study will potentially inform intervention strategies to enhance uptake of male circumcision as a strategy to reduce HIV transmission in Uganda.
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Affiliation(s)
- Komi Mati
- Department of Epidemiology and Biostatistics, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL USA
| | - Korede K. Adegoke
- Department of Epidemiology and Biostatistics, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL USA
| | - Hamisu M. Salihu
- Department of Family and Community Health, Baylor College of Medicine, Houston, TX USA
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Mbonye M, Kuteesa M, Seeley J, Levin J, Weiss H, Kamali A. Voluntary medical male circumcision for HIV prevention in fishing communities in Uganda: the influence of local beliefs and practice. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2016; 15:211-8. [PMID: 27450591 DOI: 10.2989/16085906.2016.1179652] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Local beliefs and practices about voluntary medical male circumcision (VMMC) may influence uptake and effectiveness. Data were gathered through interviews with 40 people from four ethnically mixed fishing communities in Uganda. Some men believed that wound healing could be promoted by contact with vaginal fluids while sex with non-regular partners could chase away spirits - practices which encouraged unsafe sexual practices. Information given by providers stressed that VMMC did not afford complete protection from sexually-transmitted infections, however, a number of male community members held the view that they were fully protected once circumcised. Both men and women said that VMMC was good not just for HIV prevention but also as a way of maintaining hygiene among the men. The implementation of VMMC in high-HIV prevalence settings needs to take account of local beliefs about circumcision, working with local religious/social group leaders, women and peers in the roll-out of the intervention.
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Affiliation(s)
- Martin Mbonye
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda
| | - Monica Kuteesa
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda
| | - Janet Seeley
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda.,b Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , United Kingdom
| | - Jonathan Levin
- c School of Public Health, Faculty of Health Sciences , University of Witwatersrand , Johannesburg , South Africa
| | - Helen Weiss
- d MRC Tropical Epidemiology Group , London School of Hygiene & Tropical Medicine , London , United Kingdom
| | - Anatoli Kamali
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda.,e Faculty of Epidemiology and Population Health , London School of Hygiene & Tropical Medicine , London , United Kingdom
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20
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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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21
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Esra RT, Olivier AJ, Passmore JAS, Jaspan HB, Harryparsad R, Gray CM. Does HIV Exploit the Inflammatory Milieu of the Male Genital Tract for Successful Infection? Front Immunol 2016; 7:245. [PMID: 27446076 PMCID: PMC4919362 DOI: 10.3389/fimmu.2016.00245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/10/2016] [Indexed: 12/16/2022] Open
Abstract
In many parts of the World, medical male circumcision (MMC) is used as standard prevention of care against HIV infection. This is based on seminal reports made over 10 years ago that removal of the foreskin provides up to 60% protection against HIV infection in males and seems currently the best antiretroviral-free prevention strategy yet against the global epidemic. We explore the potential mechanisms by which MMC protects against HIV-1 acquisition and that one of the oldest, albeit re-invented, rituals of removing a foreskin underscores the exploitative nature of HIV on the anatomy and tissue of the uncircumcised penis. Furthermore, foreskin removal also reveals how males acquire HIV, and in reality, the underlying mechanisms of MMC are not known. We argue that the normal sequelae of inflammation in the male genital tract (MGT) for protection from sexually transmitted infections (STI)-induced pathology represents a perfect immune and microbial ecosystem for HIV acquisition. The accumulation of HIV-1 target cells in foreskin tissue and within the urethra in response to STIs, both during and after resolution of infection, suggests that acquisition of HIV-1, through sexual contact, makes use of the natural immune milieu of the MGT. Understanding immunity in the MGT, the movement of HIV-1 target cells to the urethra and foreskin tissue upon encounter with microbial signals would provide more insight into viral acquisition and lay the foundation for further prevention strategies in males that would be critical to curb the epidemic in all sexual partners at risk of infection. The global female-centric focus of HIV-1 transmission and acquisition research has tended to leave gaps in our knowledge of what determines HIV-1 acquisition in men and such understanding would provide a more balanced and complete view of viral acquisition.
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Affiliation(s)
- Rachel T. Esra
- Department of Pathology, Division of Immunology, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Abraham J. Olivier
- Department of Pathology, Division of Immunology, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann S. Passmore
- Department of Pathology, Division of Virology, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Cape Town, South Africa
| | - Heather B. Jaspan
- Department of Pathology, Division of Immunology, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Rushil Harryparsad
- Department of Pathology, Division of Immunology, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Clive M. Gray
- Department of Pathology, Division of Immunology, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Services, Cape Town, South Africa
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Morris BJ, Barboza G, Wamai RG, Krieger JN. Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe. Glob Public Health 2016; 13:1889-1899. [PMID: 27043484 DOI: 10.1080/17441692.2016.1164737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A meta-analysis by Van Howe of 109 populations confirms the well-known association of male circumcision (MC) with reduced HIV prevalence. He then performed meta-regression adjusting for location, risk and MC prevalence. When one or two of these adjustments in combination were applied MC appeared protective, but when all three were introduced the association remained significant in high-risk populations, but not in general populations within Africa with a hypothetical MC prevalence of <25% or elsewhere with hypothetical MC prevalence of <75%. However, many MC prevalence values given differed from those reported in references cited (including all US studies). This and other problems invalidate his adjustments for MC prevalence, undermining most of his meta-regression results. Meta-regression is a highly sophisticated statistical tool and is prone to error if not applied correctly. The study contained a high risk of bias arising from confounding. We also question his use of crude, rather than adjusted, odds ratios and his inclusion of unpublished data, so precluding replication by others. Flawed statistics, opaque presentation of results and inclusion of previously repudiated arguments downplaying a role for MC in HIV prevention programmes should lead readers to be sceptical of the findings and conclusions of Van Howe's study.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute , University of Sydney , Sydney , Australia
| | - Gia Barboza
- b Department of African-American Studies , Northeastern University , Boston , MA , USA.,c School of Criminology and Criminal Justice , Northeastern University , Boston , MA , USA
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- d University of Washington School of Medicine and VA Puget Sound Health Care System, Section of Urology , Seattle , WA , USA
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Rasmussen DN, Wejse C, Larsen O, Da Silva Z, Aaby P, Sodemann M. The when and how of male circumcision and the risk of HIV: a retrospective cross-sectional analysis of two HIV surveys from Guinea-Bissau. Pan Afr Med J 2016; 23:21. [PMID: 27200126 PMCID: PMC4856489 DOI: 10.11604/pamj.2016.23.21.7797] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/20/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Male circumcision (MC) reduces the risk of HIV, and this risk reduction may be modified by socio-cultural factors such as the timing and method (medical and traditional) of circumcision. Understanding regional variations in circumcision practices and their relationship to HIV is crucial and can increase insight into the HIV epidemic in Africa. Methods We used data from two retrospective HIV surveys conducted in Guinea-Bissau from 1993 to 1996 (1996 cohort) and from 2004 to 2007 (2006 cohort). Multivariate logistical models were used to investigate the relationships between HIV risk and circumcision status, timing, method of circumcision, and socio-demographic factors. Results MC was protective against HIV infection in both cohorts, with adjusted odds ratios (AORs) of 0.28 (95% CI 0.12-0.66) and 0.30 (95% CI 0.09-0.93), respectively. We observed that post-pubertal (≥13 years) circumcision provided the highest level of HIV risk reduction in both cohorts compared to non-circumcised. However, the difference between pre-pubertal (≤12 years) and post-pubertal (≥13 years) circumcision was not significant in the multivariate analysis. Seventy-six percent (678/888) of circumcised males in the 2006 cohort were circumcised traditionally, and 7.7% of those males were HIV-infected compared to 1.9% of males circumcised medically, with AOR of 2.7 (95% CI 0.91-8.12). Conclusion MC is highly prevalent in Guinea-Bissau, but ethnic variations in method and timing may affect its protection against HIV. Our findings suggest that sexual risk behaviour and traditional circumcision may increases HIV risk. The relationship between circumcision age, sexual behaviour and HIV status remains unclear and warrants further research.
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Affiliation(s)
- Dlama Nggida Rasmussen
- Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Bissau, Guinea-Bissau; Department of Infectious Diseases, Odense University Hospital, DK-5000 Odense, Denmark; Center for Global Health, Institute of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
| | - Christian Wejse
- Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, DK-8200 Aarhus, Denmark; Center for Global Health, Department of Public Health, Aarhus University, DK-8000 Aarhus, Denmark
| | - Olav Larsen
- Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Bissau, Guinea-Bissau; Department of Infectious Diseases, Odense University Hospital, DK-5000 Odense, Denmark
| | - Zacarias Da Silva
- Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Bissau, Guinea-Bissau
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Bissau, Guinea-Bissau; Statens Serums Institute, DK-2300 Copenhagen, Denmark
| | - Morten Sodemann
- Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Bissau, Guinea-Bissau; Department of Infectious Diseases, Odense University Hospital, DK-5000 Odense, Denmark; Center for Global Health, Institute of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark
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Barone MA, Li PS, Awori QD, Lee R, Goldstein M. Clinical trials using the Shang Ring device for male circumcision in Africa: a review. Transl Androl Urol 2016; 3:113-24. [PMID: 26816759 PMCID: PMC4708291 DOI: 10.3978/j.issn.2223-4683.2014.01.09] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Male circumcision (MC) reduces the risk of HIV and other sexually transmitted infections (STIs), including human papillomavirus (HPV) and herpes simplex virus type 2 (HSV-2), and is recommended as an important component of a comprehensive package of HIV prevention interventions. While computer modeling has demonstrated that substantial reductions in HIV could be achieved with rapid scale-up of MC services in sub-Saharan Africa, scale-up has lagged due to scarcity of trained providers coupled with relative technical difficulty of recommended surgical MC techniques. Simplified techniques, such as devices, have the potential to allow for a more rapid roll-out of MC. One such device is the Shang Ring, a novel disposable MC device that eliminates the need for suturing and has been on the Chinese market since 2005. Results from Chinese studies have demonstrated that the Shang Ring is both safe and easy to use. Since 2008, a series of studies using the Shang Ring for adult MC have been carried out in Kenya, Uganda and Zambia, according to guidelines established by World Health Organization (WHO) for clinical evaluation of new devices for adult MC. These include a proof of concept study, a study of delayed removal of the Shang Ring, two studies comparing Shang Ring circumcision to conventional surgical approaches, and a large field trial to evaluate safety of Shang Ring circumcision during routine service delivery. Results from these studies demonstrate that the Shang Ring has an excellent safety profile and that Shang Ring circumcision is relatively easy to teach and learn, making Shang Ring MC an appealing technique for use in sub-Saharan Africa where doctors are in short supply and non-physician providers such as nurses and clinical officers are playing a major role in providing MC through task shifting. Shang Ring MC and device removals were uneventfully performed by trained nurses and clinical officers, who preferred the Shang Ring to conventional surgical techniques. Adverse event rates were similar to those observed with conventional surgical circumcision and were managed with, at most, minor interventions, resolving with no long-term sequale. Perhaps one of the biggest advantages of the Shang Ring is the relatively short 3-6 minutes procedure time. Importantly, men also preferred the Shang Ring compared to conventional circumcision and satisfaction with cosmetic appearance of their circumcised penis was very high. The vast majority of participants in studies in Africa as well as China have reported few problems and little disruption to daily life while wearing the device. The Shang Ring holds great promise as an innovative technology that has the potential to facilitate the safe and effective scale-up of circumcision services in settings where MC is not widely used and where the burden of HIV-disease is high.
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Affiliation(s)
- Mark A Barone
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Philip S Li
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Quentin D Awori
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Richard Lee
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Marc Goldstein
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
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Afonso LA, Cordeiro TI, Carestiato FN, Ornellas AA, Alves G, Cavalcanti SMB. High Risk Human Papillomavirus Infection of the Foreskin in Asymptomatic Men and Patients with Phimosis. J Urol 2016; 195:1784-9. [PMID: 26796413 DOI: 10.1016/j.juro.2015.12.096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE There has been increasing interest in understanding the natural history of HPV and the diseases that it causes in men. HPV infection is strongly associated with penile cancer, lack of neonatal circumcision and phimosis. We investigated the incidence of HPV infection in asymptomatic men and patients with phimosis. MATERIALS AND METHODS We assessed 110 asymptomatic men and 30 patients who underwent circumcision due to phimosis. DNA was extracted from swabbed samples collected from asymptomatic men and from foreskin samples collected at circumcision. Polymerase chain reaction using consensus primers for detecting HPV-MY09/11 was performed to detect generic HPV DNA. HPV genotyping was done by polymerase chain reaction amplification with primers for the E6 gene DNA sequences HPV6, HPV11, HPV16, HPV18, HPV31, HPV33, HPV35, HPV45 and HPV58. RESULTS HPV was present in 46.66% of patients with phimosis, of whom 50% had high risk HPV genotypes. Of asymptomatic cases 16.36% were HPV positive but only 1 sample showed high risk HPV. We detected a significantly high rate of HPV genital infection in patients presenting with phimosis compared with asymptomatic men (p = 0.00167). The prevalence of high risk HPV genotypes in patients with phimosis was also statistically significant (p = 0.0004). CONCLUSIONS We found a robust association between phimosis and the genital HPV prevalence in men and a significant frequency of high risk HPV. Other studies are needed to investigate the occurrence of factors that can increase the incidence of penile carcinoma and determine its impact on female genital infection in cervical cancer.
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Affiliation(s)
- Larissa A Afonso
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
| | - Thaissa I Cordeiro
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
| | - Fernanda N Carestiato
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
| | - Antonio Augusto Ornellas
- Department of Urology, Brazilian National Institute of Cancer and Hospital Mário Kröeff, Rio de Janeiro, Brazil.
| | - Gilda Alves
- Department of Urology, Research Coordination, Brazilian National Institute of Cancer and Circulating Biomarkers Laboratory, Department of Pathology, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sílvia M B Cavalcanti
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
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Hu M, Patel SK, Zhou T, Rohan LC. Drug transporters in tissues and cells relevant to sexual transmission of HIV: Implications for drug delivery. J Control Release 2015; 219:681-696. [PMID: 26278511 PMCID: PMC4656065 DOI: 10.1016/j.jconrel.2015.08.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 01/11/2023]
Abstract
Efflux and uptake transporters of drugs are key regulators of the pharmacokinetics of many antiretroviral drugs. A growing body of literature has revealed the expression and functionality of multiple transporters in female genital tract (FGT), colorectal tissue, and immune cells. Drug transporters could play a significant role in the efficacy of preventative strategies for HIV-1 acquisition. Pre-exposure prophylaxis (PrEP) is a promising strategy, which utilizes topically (vaginally or rectally), orally or other systemically administered antiretroviral drugs to prevent the sexual transmission of HIV to receptive partners. The drug concentration in the receptive mucosal tissues and target immune cells for HIV is critical for PrEP effectiveness. Hence, there is an emerging interest in utilizing transporter information to explain tissue disposition patterns of PrEP drugs, to interpret inter-individual variability in PrEP drug pharmacokinetics and effectiveness, and to improve tissue drug exposure through modulation of the cervicovaginal, colorectal, or immune cell transporters. In this review, the existing literature on transporter expression, functionality and regulation in the transmission-related tissues and cells is summarized. In addition, the relevance of transporter function for drug delivery and strategies that could exploit transporters for increased drug concentration at target locales is discussed. The overall goal is to facilitate an understanding of drug transporters for PrEP optimization.
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Affiliation(s)
- Minlu Hu
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Sravan Kumar Patel
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Tian Zhou
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Lisa C Rohan
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA; School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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27
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Tapela NM, Mpunga T, Karema N, Nzayisenga I, Fadelu T, Uwizeye FR, Hirschhorn LR, Muhimpundu MA, Balinda JP, Amoroso C, Wagner CM, Binagwaho A, Shulman LN. Implementation Science for Global Oncology: The Imperative to Evaluate the Safety and Efficacy of Cancer Care Delivery. J Clin Oncol 2015; 34:43-52. [PMID: 26578617 DOI: 10.1200/jco.2015.61.7738] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The development of cancer care treatment facilities in resource-constrained settings represents a challenge for many reasons. Implementation science-the assessment of how services are set up and delivered; contextual factors that affect delivery, treatment safety, toxicity, and efficacy; and where adaptations are needed-is essential if we are to understand the performance of a treatment program, know where the gaps in care exist, and design interventions in care delivery models to improve outcomes for patients. METHODS The field of implementation science in relation to cancer care delivery is reviewed, and the experiences of the integrated implementation science program at the Butaro Cancer Center of Excellence in Rwanda are described as a practical application. Implementation science of HIV and tuberculosis care delivery in similar challenging settings offers some relevant lessons. RESULTS Integrating effective implementation science into cancer care in resource-constrained settings presents many challenges, which are discussed. However, with carefully designed programs, it is possible to perform this type of research, on regular and ongoing bases, and to use the results to develop interventions to improve quality of care and patient outcomes and provide evidence for effective replication and scale-up. CONCLUSION Implementation science is both critical and feasible in evaluating, improving, and supporting effective expansion of cancer care in resource-limited settings. In ideal circumstances, it should be a prospective program, established early in the lifecycle of a new cancer treatment program and should be an integrated and continual process.
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Affiliation(s)
- Neo M Tapela
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA.
| | - Tharcisse Mpunga
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Nadine Karema
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Ignace Nzayisenga
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Temidayo Fadelu
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Frank R Uwizeye
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Lisa R Hirschhorn
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Marie Aimee Muhimpundu
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Jean Paul Balinda
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Cheryl Amoroso
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Claire M Wagner
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Agnes Binagwaho
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
| | - Lawrence N Shulman
- Neo M. Tapela and Temidayo Fadelu, Brigham and Women's Hospital; Neo M. Tapela, Temidayo Fadelu, Lisa R. Hirschhorn, and Agnes Binagwaho, Harvard Medical School; Lisa R. Hirschhorn, Ariadne Labs; Claire M. Wagner and Lawrence N. Shulman, Dana-Farber Cancer Institute, Boston, MA; Tharcisse Mpunga and Agnes Binagwaho, Rwandan Ministry of Health; Marie Aimee Muhimpundu and Jean Paul Balinda, Rwanda Biomedical Center, Kigali; Neo M. Tapela, Nadine Karema, Ignace Nzayisenga, Temidayo Fadelu, Frank R. Uwizeye, and Cheryl Amoroso, Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Claire M. Wagner, Union for International Cancer Control, Geneva, Switzerland; Agnes Binagwaho, Geisel School of Medicine, Dartmouth College, Hanover, NH; and Lawrence N. Shulman, Abramson Cancer Center, Philadelphia, PA
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Morris BJ, Wamai RG, Krieger JN, Banerjee J, Klausner JD. Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby. Glob Public Health 2015; 12:1315-1333. [PMID: 26564989 DOI: 10.1080/17441692.2015.1104371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute, University of Sydney , Sydney , NSW , Australia
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- c Section of Urology, University of Washington School of Medicine and VA Puget Sound Health Care System , Seattle , WA , USA
| | - Joya Banerjee
- d Jhpiego, an affiliate of Johns Hopkins University , Washington , DC , USA
| | - Jeffrey D Klausner
- e Division of Infectious Diseases, Department of Medicine , David Geffen School of Medicine, University of California Los Angeles , CA , USA
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Morris BJ, Klausner JD. In developed countries male circumcision prevalence is inversely related to HIV prevalence. Isr J Health Policy Res 2015; 4:40. [PMID: 26269739 PMCID: PMC4533798 DOI: 10.1186/s13584-015-0034-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 07/14/2015] [Indexed: 01/10/2023] Open
Abstract
A study by Chemtob and co-workers found significantly lower prevalence of HIV amongst heterosexual men and women in Israel compared with the Netherlands and France. Risk factors for heterosexual HIV infection in these countries were similar, apart from one, namely, a strikingly higher prevalence of male circumcision (MC) in Israel compared with the Netherlands and France. It is now well established that MC protects heterosexual men against becoming infected with HIV during sexual intercourse with an infected woman. In epidemic settings, such as countries in sub-Saharan Africa, in which heterosexual contact is the primary driver for HIV infection, MC is being implemented to reduce HIV prevalence. The results of the new study by Chemtob and co-workers support the evidence and recent polices in the United States advocating MC to reduce the spread of HIV. While prevalence in developed countries is generally low, it is rising. In the long term, neonatal MC is the most desirable option, since not only is it simpler, safer, cheaper and more convenient than MC later, it provides immediate protection from infections, penile inflammation, genital cancers and physical problems. It is also cost-effective. European countries have not supported MC for its public health benefits. The new findings add to calls for European and other countries with low MC prevalence to consider developing evidence-based policies favoring MC in order to reduce HIV and other infections and diseases and at the same time reduce suffering, mortality and the cost of treating these.
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Affiliation(s)
- Brian J. Morris
- />School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, New South Wales Australia
| | - Jeffrey D. Klausner
- />Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, USA
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Chemtob D, Op de Coul E, van Sighem A, Mor Z, Cazein F, Semaille C. Impact of Male Circumcision among heterosexual HIV cases: comparisons between three low HIV prevalence countries. Isr J Health Policy Res 2015; 4:36. [PMID: 26244087 PMCID: PMC4524174 DOI: 10.1186/s13584-015-0033-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/11/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Studies performed in high-HIV prevalence countries showed a strong epidemiological association between male circumcision (MC) and the prevention of HIV transmission. We estimated the potential impact of MC on the general heterosexual population in low-HIV prevalence countries. METHODS Cross-national comparisons, including data on newly diagnosed HIV cases among heterosexuals living in Israel (where almost all males undergo MC), to similar data from the Netherlands and France (where <10 % of males are circumcised) were performed. National data from HIV registers and Bureaus of Statistics for the period of 2004-2010, global rates, rates by sex, age, and year of HIV-diagnosis were compared. MC and potential biases were examined. RESULTS Annual rates of new HIV diagnoses per 100,000 were significantly lower in Israel compared to the Netherlands and France (for men: 0.26-0.70, 1.91-2.28, and 2.69-3.47, respectively; for women: 0.10-0.34, 1.10-2.10 and 2.41-3.08, respectively). Similarly, HIV-rates were much lower in Israel when comparing by age groups. Although Gross National Income per capita in 2010 was lower in Israel compared to the Netherlands and France, access to HIV testing and treatment were not different between countries. Also, the number of sexual-partners and condom-use in the general population showed a high similarity between the countries. CONCLUSIONS The lower rate of HIV among heterosexuals in Israel compared to the Netherlands and France might be explained by MC routinely practiced in Israel, since other parameters of influence on HIV transmission were rather similar between the countries. However, recommendation for systematic MC in low HIV prevalence countries requires further investigations.
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Affiliation(s)
- Daniel Chemtob
- />Department of Tuberculosis and AIDS, Ministry of Health, P.O.B. 1176, Jerusalem, 944727 Israel
| | - Eline Op de Coul
- />Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | | | - Zohar Mor
- />Department of Tuberculosis and AIDS, Ministry of Health, P.O.B. 1176, Jerusalem, 944727 Israel
| | - Françoise Cazein
- />HIV/AIDS-STI-Hepatitis B and C Unit, Department of Infectious Diseases, Institut de Veille Sanitaire, Saint Maurice, France
| | - Caroline Semaille
- />HIV/AIDS-STI-Hepatitis B and C Unit, Department of Infectious Diseases, Institut de Veille Sanitaire, Saint Maurice, France
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Ikwegbue JN, Ross A, Ogbonnaya H. Rural Zulu women's knowledge of and attitudes towards medical male circumcision. Afr J Prim Health Care Fam Med 2015; 7:775. [PMID: 26245595 PMCID: PMC4656926 DOI: 10.4102/phcfm.v7i1.775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 03/06/2015] [Accepted: 12/17/2014] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Medical male circumcision (MMC) is a key strategy in the South African HIV infection prevention package. Women may have a potentially powerful role in supporting such a strategy. Circumcision is not a traditional part of Zulu society, and Zulu women may have limited knowledge and ambivalent or negative attitudes towards MMC. AIM This study employs quantitative data to expand insight into rural Zulu women's knowledge of and attitudes towards MMC, and is important as women could potentially yield a powerful positive or negative influence over the decisions of their partners and sons. SETTING A hospital-based antenatal clinic in rural KwaZulu-Natal. METHODS Participants were 590 pregnant, mostly isiZulu-speaking women. Data on their knowledge of and attitude towards MMC were collected using a questionnaire and were analysed descriptively. RESULTS The majority of the women supported MMC; however, knowledge of the potential benefits was generally poor. Most would encourage their partners and sons to undergo MMC. The preferred place for the procedure was a hospital. CONCLUSION Zulu participants supported MMC and would support their partners and children being circumcised. Knowledge around potential benefits was worryingly poor, and further research into disseminating information is essential. The findings highlight the need for an expanded campaign of health education for women, and innovative means are suggested to enhance information accessibility. Reasons for preferring that MMC be carried out in hospital need to be explored further.
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George G, Strauss M, Chirawu P, Rhodes B, Frohlich J, Montague C, Govender K. Barriers and facilitators to the uptake of voluntary medical male circumcision (VMMC) among adolescent boys in KwaZulu-Natal, South Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 13:179-87. [PMID: 25174635 DOI: 10.2989/16085906.2014.943253] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Epidemiological modelling has concluded that if voluntary medical male circumcision (VMMC) is scaled up in high HIV prevalence settings it would lead to a significant reduction in HIV incidence rates. Following the adoption of this evidence by the WHO, South Africa has embarked on an ambitious VMMC programme. However, South Africa still falls short of meeting VMMC targets, particularly in KwaZulu-Natal, the epicentre of the HIV/AIDS epidemic. A qualitative study was conducted in a high HIV prevalence district in KwaZulu-Natal to identify barriers and facilitators to the uptake of VMMC amongst adolescent boys. Focus group discussions with both circumcised and uncircumcised boys were conducted in 2012 and 2013. Analysis of the data was done using the framework approach and was guided by the Social Cognitive Theory focussing on both individual and interpersonal factors influencing VMMC uptake. Individual cognitive factors facilitating uptake included the belief that VMMC reduced the risk of HIV infection, led to better hygiene and improvement in sexual desirability and performance. Cognitive barriers related to the fear of HIV testing (and the subsequent result and stigmas), which preceded VMMC. Further barriers related to the pain associated with the procedure and adverse events. The need to abstain from sex during the six-week healing period was a further prohibiting factor for boys. Timing was crucial, as boys were reluctant to get circumcised when involved in sporting activities and during exam periods. Targeting adolescents for VMMC is successful when coupled with the correct messaging. Service providers need to take heed that demand creation activities need to focus on the benefits of VMMC for HIV risk reduction, as well as other non-HIV benefits. Timing of VMMC interventions needs to be considered when targeting school-going boys.
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Affiliation(s)
- Gavin George
- a Health Economics and HIV and AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
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Jewell BL, Cremin I, Pickles M, Celum C, Baeten JM, Delany-Moretlwe S, Hallett TB. Estimating the cost-effectiveness of pre-exposure prophylaxis to reduce HIV-1 and HSV-2 incidence in HIV-serodiscordant couples in South Africa. PLoS One 2015; 10:e0115511. [PMID: 25616135 PMCID: PMC4304839 DOI: 10.1371/journal.pone.0115511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/25/2014] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To estimate the cost-effectiveness of daily oral tenofovir-based PrEP, with a protective effect against HSV-2 as well as HIV-1, among HIV-1 serodiscordant couples in South Africa. METHODS We incorporated HSV-2 acquisition, transmission, and interaction with HIV-1 into a microsimulation model of heterosexual HIV-1 serodiscordant couples in South Africa, with use of PrEP for the HIV-1 uninfected partner prior to ART initiation for the HIV-1 1infected partner, and for one year thereafter. RESULTS We estimate the cost per disability-adjusted life-year (DALY) averted for two scenarios, one in which PrEP has no effect on reducing HSV-2 acquisition, and one in which there is a 33% reduction. After a twenty-year intervention, the cost per DALY averted is estimated to be $10,383 and $9,757, respectively--a 6% reduction, given the additional benefit of reduced HSV-2 acquisition. If all couples are discordant for both HIV-1 and HSV-2, the cost per DALY averted falls to $1,445, which shows that the impact is limited by HSV-2 concordance in couples. CONCLUSION After a 20-year PrEP intervention, the cost per DALY averted with a reduction in HSV-2 is estimated to be modestly lower than without any effect, providing an increase of health benefits in addition to HIV-1 prevention at no extra cost. The small degree of the effect is in part due to a high prevalence of HSV-2 infection in HIV-1 serodiscordant couples in South Africa.
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Affiliation(s)
- Britta L. Jewell
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Ide Cremin
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Michael Pickles
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Connie Celum
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Jared M. Baeten
- Departments of Global Health, Medicine and Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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Skolnik L, Tsui S, Ashengo TA, Kikaya V, Lukobo-Durrell M. A cross-sectional study describing motivations and barriers to voluntary medical male circumcision in Lesotho. BMC Public Health 2014; 14:1119. [PMID: 25359662 PMCID: PMC4287583 DOI: 10.1186/1471-2458-14-1119] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 10/17/2014] [Indexed: 11/30/2022] Open
Abstract
Background In February 2012, the Lesotho Ministry of Health launched a national voluntary medical male circumcision (VMMC) program. To assess the motivations for seeking VMMC, a cross-sectional mixed methods study was conducted among clients aged 18 years and older at four sites. Methods A total of 161 men participated in individual survey interviews and 35 participated in four focus group discussions. Results Men sought medical circumcision for the following main reasons: protection against HIV (73%), protection from other sexually transmitted infections (62%), and improved penile hygiene (47%). Forty percent learned about VMMC through friends who had already accessed services. According to these men, perceived concerns hindering service uptake include fear of pain (57%), a female provider (18%), and “compulsory” HIV testing (15%). Conclusions The study provides important insights into the motivations of clients seeking VMMC services. Findings can be used by the national VMMC program to attract more clients and address barriers to uptake.
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Affiliation(s)
- Laura Skolnik
- Jhpiego Lesotho, Dolphin House, 23 Motsoene Road, Industrial Area, Maseru 100, Lesotho.
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Bulled NL. Hesitance towards voluntary medical male circumcision in Lesotho: reconfiguring global health governance. Glob Public Health 2014; 10:757-72. [PMID: 25300786 DOI: 10.1080/17441692.2014.962559] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention - voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the country's high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of 'partnerships' has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesotho's domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesotho's resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture.
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Affiliation(s)
- Nicola L Bulled
- a Department of Anthropology , University of Connecticut , Storrs , CT , USA
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Mavhu W, Mupambireyi Z, Hart G, Cowan FM. Factors associated with parental non-adoption of infant male circumcision for HIV prevention in Sub-Saharan Africa: a systematic review and thematic synthesis. AIDS Behav 2014; 18:1776-84. [PMID: 24980247 PMCID: PMC4125745 DOI: 10.1007/s10461-014-0835-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Infant male circumcision (IMC) may be more effective at preventing HIV than adult male circumcision as the procedure is carried out before the individual becomes sexually active. Successful scale-up will depend on identifying and overcoming parental concerns that may act as barriers for IMC. We conducted a systematic review to identify qualitative studies reporting on parental reasons for non-adoption of IMC for HIV prevention in sub-Saharan Africa. Thematic synthesis was subsequently conducted. Five descriptive themes were identified; these were later condensed into two main analytical themes: "poor knowledge" and "social constructs". While barriers and motivators are to some degree context specific, this review suggests that there are common themes that need to be addressed across the region if uptake of IMC for HIV prevention is to be widely adopted. Study findings are therefore likely to have broad implications for IMC roll out.
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Affiliation(s)
- Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe, 9 Monmouth Road, Avondale, Harare, Zimbabwe,
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Tram KH, Bertrand JT. Correlates of male circumcision in Eastern and Southern African countries: establishing a baseline prior to VMMC Scale-up. PLoS One 2014; 9:e100775. [PMID: 24955963 PMCID: PMC4067410 DOI: 10.1371/journal.pone.0100775] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 05/29/2014] [Indexed: 11/27/2022] Open
Abstract
Background Despite the importance of male circumcision (MC) prevalence to HIV prevention efforts in Eastern and Southern Africa, there has been no systematic analysis on the correlates of male circumcision. This analysis identifies correlates of MC in 12 countries in the region with available data. Methods Data from the male questionnaire of DHS surveys collected between 2006–2011 in Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe were analyzed. The dependent variable was self-reported male circumcision status. Independent variables included age, education, wealth quintile, place of residence, ethnicity, religion and region. Bivariate and multivariate analyses were conducted separately for each country. Results MC prevalence ranged from 8.2 percent in Swaziland to 92.2 percent in Ethiopia. Bivariate analyses showed a consistent positive association between age (being older) and male circumcision. Education, wealth quintile, and place of residence were either not significantly related or differed in the direction of the relationship by country. Multivariate logistic regression showed three variables consistently associated with MC status: age (being older), religion (being Muslim) and ethnicity. Discussion These data were collected prior to the scale-up of voluntary medical male circumcision (VMMC) programs in 11 of the 12 countries. As the VMMC scale-up intensifies in countries across Eastern and Southern Africa, the correlates of VMMC are likely to change, with (younger) age and education emerging as key correlates of VMMC performed in medical settings. The centuries-long tradition among Muslims to circumcise should continue to favor MC among this group. Non-circumcising ethnicities may become more open to MC if promoted as a health practice for decreasing HIV risk.
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Affiliation(s)
- Khai Hoan Tram
- Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
| | - Jane T. Bertrand
- Tulane University School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America
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Matar L, Zhu J, Chen RT, Gust DA. Medical risks and benefits of newborn male circumcision in the United States: physician perspectives. J Int Assoc Provid AIDS Care 2014; 14:33-9. [PMID: 24899259 DOI: 10.1177/2325957414535975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION In 2012, the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) published recommendations that physicians should discuss with parents the benefits and risks of newborn male circumcision. Our objective was to assess physicians' perspectives of newborn male circumcision. METHODS A self-administered, cross-sectional electronic survey of US physicians was conducted in 2008 (N = 1500). RESULTS Approximately one-third (33.2%) of the respondents reported that their current perspective was that the medical benefits outweigh the risks associated with newborn male circumcision and less than one-third (31.1%) reported they would recommend the procedure when counseling parents. CONCLUSIONS In 2008, only about one-third of the physicians surveyed thought that the benefits of male circumcision outweighed the risks and recommended it to parents of newborn sons. These attitudes may be relevant to the declining circumcision rates in the United States. Repeat surveys may be useful, given the new AAP and ACOG recommendations.
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Affiliation(s)
- Lea Matar
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Julia Zhu
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Robert T Chen
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Deborah A Gust
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Morris BJ, Hankins CA, Tobian AAR, Krieger JN, Klausner JD. Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny. ISRN UROLOGY 2014; 2014:684706. [PMID: 24944836 PMCID: PMC4040210 DOI: 10.1155/2014/684706] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 02/04/2014] [Indexed: 02/06/2023]
Abstract
We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered original data, in the case of human papillomavirus (HPV), by questionable adjustments for "sampling bias," (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health policy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia
| | - Catherine A. Hankins
- Department of Global Health, Academic Medical Centre and Amsterdam Institute for Global Health and Development, University of Amsterdam, 1100DE, Amsterdam, The Netherlands
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Aaron A. R. Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - John N. Krieger
- Section of Urology University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, WA 98108, 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
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Bertrand JT, Rech D, Omondi Aduda D, Frade S, Loolpapit M, Machaku MD, Oyango M, Mavhu W, Spyrelis A, Perry L, Farrell M, Castor D, Njeuhmeli E. Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up: adoption of efficiency elements in Kenya, South Africa, Tanzania, and Zimbabwe. PLoS One 2014; 9:e82518. [PMID: 24801374 PMCID: PMC4011576 DOI: 10.1371/journal.pone.0082518] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 10/23/2013] [Indexed: 11/18/2022] Open
Abstract
Background SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency— use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery—as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe. Methods and Findings This multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays. Conclusions SYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement.
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Affiliation(s)
- Jane T. Bertrand
- Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America
- * E-mail:
| | - Dino Rech
- Centre for HIV/AIDS Prevention Studies, Johannesburg, South Africa, Nairobi, Kenya
| | | | - Sasha Frade
- Centre for HIV/AIDS Prevention Studies, Johannesburg, South Africa, Nairobi, Kenya
| | | | | | | | - Webster Mavhu
- Zimbabwe AIDS Prevention Project, Department of Community Medicine UZ, Harare, Zimbabwe
| | - Alexandra Spyrelis
- Centre for HIV/AIDS Prevention Studies, Johannesburg, South Africa, Nairobi, Kenya
| | - Linnea Perry
- Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America
| | - Margaret Farrell
- Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America
| | - Delivette Castor
- United States Agency for International Development, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, District of Columbia, United States of America
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Morris BJ, Bailis SA, Wiswell TE. Circumcision rates in the United States: rising or falling? What effect might the new affirmative pediatric policy statement have? Mayo Clin Proc 2014; 89:677-86. [PMID: 24702735 DOI: 10.1016/j.mayocp.2014.01.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/19/2013] [Accepted: 01/02/2014] [Indexed: 02/06/2023]
Abstract
The objective of this review was to assess the trend in the US male circumcision rate and the impact that the affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circumcision practice. We searched PubMed for the term circumcision to retrieve relevant articles. This review was prompted by a recent report by the Centers for Disease Control and Prevention that found a slight increase, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the past decade. There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and 44% in Hispanic males. Because data on neonatal circumcision are equivocal, we undertook a critical analysis of hospital discharge data. After correction for underreporting, we found that the percentage had declined from 83% in the 1960s to 77% by 2010. A risk-benefit analysis of conditions that neonatal circumcision protects against revealed that benefits exceed risks by at least 100 to 1 and that over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin. Other analyses show that neonatal male circumcision is cost-effective for disease prevention. The benefits of circumcision begin in the neonatal period by protection against infections that can damage the pediatric kidney. Given the substantial risk of adverse conditions and disease, some argue that failure to circumcise a baby boy may be unethical because it diminishes his right to good health. There is no long-term adverse effect of neonatal circumcision on sexual function or pleasure. The affirmative 2012 American Academy of Pediatrics policy supports parental education about, access to, and insurance and Medicaid coverage for elective infant circumcision. As with vaccination, circumcision of newborn boys should be part of public health policies. Campaigns should prioritize population subgroups with lower circumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, NSW, Australia.
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Denis P. New patterns of disclosure: how HIV-positive support group members from KwaZulu-Natal speak of their status in oral narratives. MEDICAL HISTORY 2014; 58:278-97. [PMID: 24775433 PMCID: PMC4006135 DOI: 10.1017/mdh.2014.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This paper examines the representations and emotions associated with disclosure and stigma in Pietermaritzburg, KwaZulu-Natal, seven years after the start of the South African government's ARV roll-out programme on the basis of in-depth oral history interviews of HIV-positive support group members. It argues that the wider availability of ARV treatment, the ensuing reduced fatality rate and the increased number of people, including men, who receive counselling and testing, may mean that HIV/AIDS is less stigmatised and that disclosure has become easier. This does not mean that stigma has disappeared and that the confusion created by competing world-views and belief systems has dissipated. Yet the situation of extreme denial and ideological confusion observed, for example, by Deborah Posel and her colleagues in 2003 and 2004 in the Mpumalanga province seems to have lessened. The interviews hint at the possibility that people living with HIV may have, more than a decade before, a language to express the emotions and feelings associated with HIV/AIDS. They were also found to be more assertive in matters of gender relations. These new attitudes would make disclosure easier and stigma more likely to recede.
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Sources of HIV incidence among stable couples in sub-Saharan Africa. J Int AIDS Soc 2014; 17:18765. [PMID: 24560339 PMCID: PMC3935448 DOI: 10.7448/ias.17.1.18765] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 12/20/2013] [Accepted: 01/20/2014] [Indexed: 02/07/2023] Open
Abstract
Introduction The recent availability of efficacious prevention interventions among stable couples offers new opportunities for reducing HIV incidence in sub-Saharan Africa. Understanding the dynamics of HIV incidence among stable couples is critical to inform HIV prevention strategy across sub-Saharan Africa. Methods We quantified the sources of HIV incidence arising among stable couples in sub-Saharan Africa using a cohort-type mathematical model parameterized by nationally representative data. Uncertainty and sensitivity analyses were incorporated. Results HIV incidence arising among stable concordant HIV-negative couples contribute each year, on average, 29.4% of total HIV incidence; of those, 22.5% (range: 11.1%–39.8%) are infections acquired by one of the partners from sources external to the couple, less than 1% are infections acquired by both partners from external sources within a year and 6.8% (range: 3.6%–11.6%) are transmissions to the uninfected partner in the couple in less than a year after the other partner acquired the infection from an external source. The mean contribution of stable HIV sero-discordant couples to total HIV incidence is 30.4%, with most of those, 29.7% (range: 9.1%–47.9%), being due to HIV transmissions from the infected to the uninfected partner within the couple. The remaining incidence, 40.2% (range: 23.7%–64.6%), occurs among persons not in stable couples. Conclusions Close to two-thirds of total HIV incidence in sub-Saharan Africa occur among stable couples; however, only half of this incidence is attributed to HIV transmissions from the infected to the uninfected partner in the couple. The remaining incidence is acquired through extra-partner sex. Substantial reductions in HIV incidence can be achieved only through a prevention approach that targets all modes of HIV exposure among stable couples and among individuals not in stable couples.
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Dionne KY, Poulin M. Ethnic identity, region and attitudes towards male circumcision in a high HIV-prevalence country. Glob Public Health 2014; 8:607-18. [PMID: 23731239 DOI: 10.1080/17441692.2013.790988] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We study how considerations of male circumcision (MC) as both a favourable practice and as protective against HIV are linked with ethnicity in sub-Saharan Africa, where many ethnic groups do not traditionally circumcise. We focus on Malawi, a country with a high HIV prevalence but low MC prevalence. Survey data from a population-based random sample in rural Malawi (N =3400) were analysed for ethnoregional patterns in attitudes towards MC. We used logit regression models to measure how reported circumcision status, region of residence and ethnic identity relate to attitudes towards circumcision. Overall, Malawians reported more negative than positive opinions about MC, but attitudes towards circumcision varied by ethnicity and region. The implications for agencies and governments aggressively scaling up the provision of MC are clear; acceptance of circumcision as a tool for HIV prevention could be low in societies divided by ethnoregional identities that also shape the practice of circumcision.
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Affiliation(s)
- Kim Y Dionne
- Political Science, Texas A&M University, College Station, TX, USA.
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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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Galukande M, Duffy K, Bitega JP, Rackara S, Bbaale DS, Nakaggwa F, Nagaddya T, Wooding N, Dea M, Coutinho A. Adverse events profile of PrePex a non-surgical device for adult male circumcision in a Ugandan urban setting. PLoS One 2014; 9:e86631. [PMID: 24489754 PMCID: PMC3904949 DOI: 10.1371/journal.pone.0086631] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 12/17/2013] [Indexed: 11/22/2022] Open
Abstract
Background Safe Male Circumcision is a proven approach for partial HIV prevention. Several sub Saharan African countries have plans to reach a prevalence of 80% of their adult males circumcised by 2015. These targets require out of ordinary organization, demand creation, timely execution and perhaps the use of SMC devices. Objective To profile Adverse Events rate and acceptance of PrePex, a non surgical device for adult male circumcision. Methods A prospective study, conducted at International Hospital Kampala, Uganda, between August and October 2012. Ethical approval was obtained from Uganda National Council of Science and Technology. Results Of 1,040 men received to undergo SMC, 678 opted for PrePex, 36 were excluded at an initial physical examination screening. 642 were enrolled and consented, and another 17 were excluded before device placement. 625 underwent the procedure. Average age was 24 years (±7). Twelve moderate AEs occurred among 10 participants 12/625, (1.9%). These were all reversible. Five had device displacement, one had an everted foreskin; five had bleeding after the device was removed and one had voiding difficulties. The majority (279 out of 300) of men interviewed complained of some pain within the week of placement. Mean pain score at device placement (using visual analogue scale) was 0.5, at device removal 4.5 and within 2 min of removal the pain score was 1.4. Over 70% of the devices were placed and removed by non-physician clinicians. Presented with a choice, 60% of men chose PrePex over surgical SMC. Close to 90% would recommend the device to their friends. Odour from the necrotic skin was a concern. Removals done 1–2 days earlier than day 7 were beneficial and conferred no extra risk. Conclusion AEs of a moderate or severe nature associated with PrePex were low and reversible. PrePex is feasible for mass safe male circumcision scaling up.
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Affiliation(s)
- Moses Galukande
- International Hospital Kampala, Kampala, Uganda
- Surgery Department, Mulago Hospital, Kampala, Uganda
- * E-mail:
| | - Kevin Duffy
- International Medical Group, Kampala, Uganda
| | | | - Sam Rackara
- International Hospital Kampala, Kampala, Uganda
| | | | | | - Teddy Nagaddya
- International Health Sciences University, Kampala, Uganda
| | - Nick Wooding
- International Health Sciences University, Kampala, Uganda
| | - Monica Dea
- Centre of Disease Control, Kampala, Uganda
| | - Alex Coutinho
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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DiClemente RJ, Jackson JM. Towards an integrated framework for accelerating the end for the global HIV epidemic among young people. SEX EDUCATION 2014; 14:609-621. [PMID: 25197260 PMCID: PMC4153437 DOI: 10.1080/14681811.2014.901214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
For decades the HIV epidemic has exacted an enormous toll worldwide. However, trend analyses have discerned significant declines in the overall prevalence of HIV over the last two decades. More recently, advances in biomedical, behavioural, and structural interventions offer considerable promise in the battle against generalised epidemics. Despite advances in the prevention of transmission and new infections, morbidity and mortality of HIV among young people remains a considerable concern for individuals, couples, families, communities, practitioners, and policy makers around the globe. To accelerate the end of the global HIV epidemic among young people, we must merge existing efficacious interventions with more novel, cost-effective implementation strategies to develop integrated, multilevel combination interventions. The benefits of conceptualising the HIV epidemic more broadly and adopting ecological frameworks for the development of HIV prevention programmes are critical.
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Affiliation(s)
- Ralph J. DiClemente
- Department of Behavioral Sciences & Health Education, Center for AIDS Research, Prevention Sciences & Epidemiology Core, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Ladenhauf HN, Ardelean MA, Schimke C, Yankovic F, Schimpl G. Reduced bacterial colonisation of the glans penis after male circumcision in children--a prospective study. J Pediatr Urol 2013; 9:1137-44. [PMID: 23685114 DOI: 10.1016/j.jpurol.2013.04.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 04/09/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this prospective study was to evaluate the effect of male circumcision on the bacterial colonisation of the glans penis in children. PATIENTS AND METHODS 244 males were included in this study. The study group consisted of 143 boys admitted for circumcision between August 2009 and July 2010. Periurethral swabs were taken preoperatively and one week postoperatively. The control group included 101 boys without phimosis, in which only one swab was taken. Patients were subgrouped according to age below and above five years. Bacterial cultures were analysed, results were categorized by non-uropathogenic and uropathogenic bacteria, and compared within and between groups. RESULTS Patients in both control group and study group before circumcision showed significant bacterial colonisation (>98%), involving known uropathogenic bacteria in over 86%. After circumcision, bacterial colonisation dropped from 100% to 86.3% (p < 0.005) in boys younger than five years and from 98.57% to 77.14% (p < 0.001) in those aged five or above, respectively. Moreover, the fraction of uropathogenic bacteria decreased significantly. CONCLUSION Male circumcision significantly reduces the bacterial colonisation of the glans penis with regard to both non-uropathogenic and uropathogenic bacteria.
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Affiliation(s)
- Hannah Noemi Ladenhauf
- Department of Paediatric and Adolescent Surgery, Salzburg University Hospital, Muellner Hauptstrasse 48, 5020 Salzburg, Austria.
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Castro-Vázquez G. Sexuality, gender or hygiene: urologists and plastic surgeons discussing male circumcision in Japan. CRITICAL PUBLIC HEALTH 2013. [DOI: 10.1080/09581596.2012.753409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Chemaitelly H, Awad SF, Abu-Raddad LJ. The risk of HIV transmission within HIV-1 sero-discordant couples appears to vary across sub-Saharan Africa. Epidemics 2013; 6:1-9. [PMID: 24593916 DOI: 10.1016/j.epidem.2013.11.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 09/22/2013] [Accepted: 11/11/2013] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Representative and precise estimates for the annual risk of HIV transmission (ϕ) from the infected to the uninfected partner in a stable HIV-1 sero-discordant couple (SDC) are not available. Nevertheless, quantifying HIV infectiousness is critical to understanding HIV epidemiology and implementing prevention programs. MATERIALS AND METHODS We estimated ϕ and examined its variation across 23 countries in sub-Saharan Africa (SSA) by constructing and analyzing a mathematical model that describes HIV dynamics among SDCs. The model was parameterized using empirical measures such as those of the nationally representative Demographic and Health Surveys. Uncertainty and sensitivity analyses were conducted to assess the robustness of the findings. RESULTS We estimated a median ϕ of 11.1 per 100 person-years across SSA. A clustering based on HIV population prevalence was observed with a median ϕ of 7.5 per 100 person-years in low HIV prevalence countries (<5%) compared to 19.5 per 100 person-years in high prevalence countries (>5%). The association with HIV prevalence explained 67% of the variation in ϕ, and suggested an increase of 0.95 per 100 person-years in ϕ for every 1% increase in HIV prevalence. CONCLUSIONS Empirical measures from cohort studies appear to underestimate HIV infectiousness in SSA. The risk of HIV transmission among SDCs appears also to vary across SSA, and this may have contributed to the contrasting HIV epidemic trajectories in this continent.
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Affiliation(s)
- Hiam Chemaitelly
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - Susanne F Awad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; Department of Public Health, Weill Cornell Medical College, Cornell University, New York, NY, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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