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Perkins JM, Kakuhikire B, Baguma C, Jeon S, Walker SF, Dongre R, Kyokunda V, Juliet M, Satinsky EN, Comfort AB, Siedner MJ, Ashaba S, Tsai AC. Male circumcision uptake and misperceived norms about male circumcision: Cross-sectional, population-based study in rural Uganda. J Glob Health 2023; 13:04149. [PMID: 38112224 PMCID: PMC10731132 DOI: 10.7189/jogh.13.04149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
Background Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circumcision for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention. The prevalence of male circumcision in Uganda nearly doubled from 26% in 2011 to 43% in 2016, but remains below the 2020 target level. Little is known about how common male circumcision is perceived to be, how accurate such perceptions are, and whether they are associated with men's own circumcision uptake. Methods We conducted a cross-sectional study of all adult residents of eight villages in Rwampara District, southwestern Uganda in 2020-2022. We elicited their perceptions of the adult male circumcision prevalence within their village: >50% (most men), 10% to <50% (some), <10%, (few to none), or do not know. We compared their perceived norms to the aggregated prevalence of circumcision reported in these villages. We used a modified multivariable Poisson regression model to estimate the association between perceived norms and personal circumcision uptake among men. Results We surveyed 1566 participants (91% response rate): 698 men and 868 women. Among the men, 167 (27%) reported being circumcised, including 167/444 (38%) men <50 years of age. Approximately one-fourth of the population (189 (27%) men and 177 (20%) women) believed that few to no men in their own village had been circumcised. In a multivariable regression model, men who underestimated the prevalence of male circumcision were less likely to be circumcised themselves (adjusted relative risk (aRR) = 0.51; 95% confidence interval (CI) = 0.37-0.83). Conclusions In this population-based study in rural Uganda, one-fourth of men underestimated the prevalence of male circumcision. Men who underestimated the extent of circumcision uptake were themselves less likely to be circumcised. If the observed association is causal and underestimates within the population contribute to low uptake, then interventions correcting these misperceived norms could increase uptake of voluntary medical male circumcision.
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Affiliation(s)
- Jessica M Perkins
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sehee Jeon
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, Tennessee, USA
| | - Sarah F Walker
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, Tennessee, USA
| | - Rohit Dongre
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, Tennessee, USA
| | - Viola Kyokunda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mercy Juliet
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emily N Satinsky
- Department of Psychology, University of Southern California, Los Angeles, California, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alison B Comfort
- Bixby Center for Global Reproductive Health, University of California, San Franciso, California, USA
| | - Mark J Siedner
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA
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Peck ME, Ong K, Lucas T, Thomas AG, Wandira R, Ntwaaga B, Mkhontfo M, Zegeye T, Yohannes F, Mulatu D, Gultie T, Juma AW, Odoyo-June E, Maida A, Msungama W, Canda M, Mutandi G, Zemburuka BLT, Kankindi I, Vranken P, Maphothi N, Loykissoonlal D, Bunga S, Grund JM, Kazaura KJ, Kabuye G, Chituwo O, Muyunda B, Kamboyi R, Lingenda G, Mandisarisa J, Peterson A, Malaba R, Xaba S, Moyo T, Toledo C. Preventing HIV Among Adolescent Boys and Young Men Through PEPFAR-Supported Voluntary Medical Male Circumcision in 15 Sub-Saharan African Countries, 2018-2021. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2023; 35:67-81. [PMID: 37406146 PMCID: PMC11002756 DOI: 10.1521/aeap.2023.35.suppa.67] [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] [Indexed: 07/07/2023]
Abstract
Voluntary medical male circumcision (VMMC) is an HIV prevention intervention that has predominantly targeted adolescent and young men, aged 10-24 years. In 2020, the age eligibility for VMMC shifted from 10 to 15 years of age. This report describes the VMMC client age distribution from 2018 to 2021, at the site, national, and regional levels, among 15 countries in southern and eastern Africa. Overall, in 2018 and 2019, the highest proportion of VMMCs were performed among 10-14-year-olds (45.6% and 41.2%, respectively). In 2020 and 2021, the 15-19-year age group accounted for the highest proportion (37.2% and 50.4%, respectively) of VMMCs performed across all age groups. Similarly, in 2021 at the site level, 68.1% of VMMC sites conducted the majority of circumcisions among men aged 15-24 years. This analysis highlights that adolescent boys and young men are the primary recipients of VMMC receiving an important lifetime reduction in HIV risk.
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Affiliation(s)
- Megan E Peck
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Katherine Ong
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Todd Lucas
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Anne G Thomas
- HIV/AIDS Prevention Program, U.S. Department of Defense, San Diego, California
| | - Ronald Wandira
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | - Mandzisi Mkhontfo
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Tiruneh Zegeye
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Fikirte Yohannes
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Dejene Mulatu
- Disease Prevention and Control Directorate Senior, HIV Prevention and Control Expert, Addis Ababa, Ethiopia
| | | | | | - Elijah Odoyo-June
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Alice Maida
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Wezi Msungama
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Marcos Canda
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Gram Mutandi
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Brigitte L T Zemburuka
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Ida Kankindi
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Peter Vranken
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Nandi Maphothi
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | - Sudhir Bunga
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Jonathan M Grund
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Kokuhumbya J Kazaura
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Geoffrey Kabuye
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Omega Chituwo
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Brian Muyunda
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | | | - John Mandisarisa
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Amy Peterson
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Rickie Malaba
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | - Talent Moyo
- Ministry of Health and Child Care, Harare, Zimbabwe
| | - Carlos Toledo
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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Perkins JM, Kakuhikire B, Baguma C, Jeon S, Walker SF, Dongre R, Kyokunda V, Juliet M, Satinsky EN, Comfort AB, Siedner M, Ashaba S, Tsai AC. Perceived norms about male circumcision and personal circumcision status: a cross-sectional, population-based study in rural Uganda. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.24.23288996. [PMID: 37163008 PMCID: PMC10168507 DOI: 10.1101/2023.04.24.23288996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Introduction Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men. Methods We conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women reported as the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men. Results Overall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors. Conclusions Across eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.
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Affiliation(s)
- Jessica M. Perkins
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sehee Jeon
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
| | - Sarah F. Walker
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
| | - Rohit Dongre
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN, USA
| | - Viola Kyokunda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mercy Juliet
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emily N. Satinsky
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
| | - Alison B. Comfort
- Bixby Center for Global Reproductive Health, University of California, San Franciso, USA
| | - Mark Siedner
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
- Harvard Medical School, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston MA USA
| | | | - Alexander C. Tsai
- Center for Global Health, Massachusetts General Hospital, Boston MA USA
- Harvard Medical School, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston MA USA
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Murenje V, Omollo V, Gonouya P, Hove J, Munyaradzi T, Marongwe P, Tshimanga M, Chitimbire V, Xaba S, Mandisarisa J, Balachandra S, Makunike-Chikwinya B, Holec M, Mangwiro T, Barnhart S, Feldacker C. Urethrocutaneous fistula following VMMC: a case series from March 2013 to October 2019 in ZAZIC's voluntary medical male circumcision program in Zimbabwe. BMC Urol 2022; 22:20. [PMID: 35172795 PMCID: PMC8849017 DOI: 10.1186/s12894-022-00973-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/02/2022] [Indexed: 11/30/2022] Open
Abstract
Background Urethrocutaneous fistula (subsequently, fistula) is a rare adverse event (AE) in voluntary medical male circumcision (VMMC) programs. Global fistula rates of 0.19 and 0.28 per 100,000 VMMCs were reported. Management of fistula can be complex and requires expert skills. We describe seven cases of fistula in our large-scale VMMC program in Zimbabwe. We present fistula rates; provide an overview of initial management, surgical interventions, and patient outcomes; discuss causes; and suggest future prevention efforts. Results Case details are presented on fistulas identified between March 2013 and October 2019. Among the seven fistula clients, ages ranged from 10 to 22 years; 6 cases were among boys under 15 years of age. All clients received surgical VMMC by trained providers in an outreach setting. Clients presented with fistulae 2–42 days after VMMC. Secondary infection was identified in 6 of 7 cases. Six cases were managed through surgical repair. The number of repair attempts ranged from 1 to 10. One case healed spontaneously with conservative management. Fistula rates are presented as cases/100,000 VMMCs. Conclusion Fistula is an uncommon but severe AE that requires clinical expertise for successful management and repair. High-quality AE surveillance should identify fistula promptly and include consultation with experienced urologists. Strengthening provider surgical skills and establishment of standard protocols for fistula management would aid future prevention efforts in VMMC programs.
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Affiliation(s)
- Vernon Murenje
- Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe.
| | - Victor Omollo
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Paidemoyo Gonouya
- Zimbabwe Association of Church-Related Hospitals (ZACH), Harare, Zimbabwe
| | - Joseph Hove
- Zimbabwe Association of Church-Related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Phiona Marongwe
- Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Vuyelwa Chitimbire
- Zimbabwe Association of Church-Related Hospitals (ZACH), Harare, Zimbabwe
| | | | - John Mandisarisa
- The Centers for Disease Control and Prevention (CDC), Harare, Zimbabwe
| | | | | | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
| | - Tonderayi Mangwiro
- Department of Surgery, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, USA.,International Training and Education Center for Health (I-TECH), Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, USA.,International Training and Education Center for Health (I-TECH), Seattle, WA, USA
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Nyengerai T, Phohole M, Iqaba N, Kinge CW, Gori E, Moyo K, Chasela C. Quality of service and continuous quality improvement in voluntary medical male circumcision programme across four provinces in South Africa: Longitudinal and cross-sectional programme data. PLoS One 2021; 16:e0254850. [PMID: 34351933 PMCID: PMC8341521 DOI: 10.1371/journal.pone.0254850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/03/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Recent studies in the Sub-Saharan countries in Africa have indicated gaps and challenges for voluntary medical male circumcision (VMMC) quality of service. Less has focused on the changes in quality of service after implementation of continuous quality improvement (CQI) action plans. This study aimed to evaluate the impact of coaching, provision of standard operating procedures (SOPS) and guidelines, mentoring and on-site in-service training in improving quality of VMMC services across four Right to Care (RTC) supported provinces in South Africa. METHOD This was a pre- and post-interventional study on RTC supported VMMC sites from July 2018 to October 2019. All RTC-supported sites that were assessed at baseline and post-intervention were included in the study. Data for baseline CQI assessment and re-assessments was collected using a standardized National Department of Health (NDoH) CQI assessment tool for VMMC services from routine RTC facility level VMMC programme data. Quality improvement support was provided through a combination of coaching, provision of standard operating procedures and guidelines, mentoring and on-site in-service training on quality improvement planning and implementation. The main outcome measure was quality of service. A paired sample t-test was used to compare the difference in mean quality of service scores before and after CQI implementation by quality standard. RESULTS A total of 40 health facilities were assessed at both baseline and after CQI support visits. Results showed significant increases for the overall changes in quality of service after CQI support intervention of 12% for infection prevention (95%CI: 7-17; p<0.001) and 8% for male circumcision surgical procedure, (95%CI: 3-13; p<0.01). Similarly, individual counselling, and HIV testing increased by 14%, (95%CI: 7-20; p<0.001), group counselling, registration and communication by 8%, (95%CI: 3-14; p<0.001), and 35% for monitoring and evaluation, (95%CI: 28-42; p<0.001). In addition, there were significant increases for management systems of 29%, (95%CI: 22-35; p<0.001), leadership and planning 23%, (95%CI: 13-34; p<0.001%) and supplies, equipment, environment and emergency 5%, (95%CI: 1-9; p<0.01). The overall quality of service performance across provinces increased by 18% (95%CI: 14-21; p<0.001). CONCLUSION The overall quality of service performance across provinces was significantly improved after implementation of CQI support intervention program. Regular visits and intensive CQI support are required for sites that will be performing below quality standards.
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Affiliation(s)
- Tawanda Nyengerai
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Motshana Phohole
- Voluntary Medical Male Circumcision (VMMC) Programme, Right to Care, Johannesburg, Gauteng, South Africa
| | - Nelson Iqaba
- Voluntary Medical Male Circumcision (VMMC) Programme, Right to Care, Johannesburg, Gauteng, South Africa
| | - Constance Wose Kinge
- Department of Implementation Science, Right to Care, Johannesburg, Gauteng, South Africa
| | - Elizabeth Gori
- Department of Pre-Clinical Veterinary Science, University of Zimbabwe, Harare, Zimbabwe
| | - Khumbulani Moyo
- Voluntary Medical Male Circumcision (VMMC) Programme, Right to Care, Johannesburg, Gauteng, South Africa
| | - Charles Chasela
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Department of Implementation Science, Right to Care, Johannesburg, Gauteng, South Africa
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6
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Tusa BS, Weldesenbet AB, Tefera TK, Kebede SA. Spatial distribution of traditional male circumcision and associated factors in Ethiopia; using multilevel generalized linear mixed effects model. BMC Public Health 2021; 21:1423. [PMID: 34281503 PMCID: PMC8287814 DOI: 10.1186/s12889-021-11482-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 07/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background Traditional male circumcision (TMC) is primarily associated with a religious or cultural purpose and may lead to complications. To reduce risks of complication and long-term disabilities that may happen from circumcisions that are undertaken in non-clinical settings, information concerning TMC is very important. Therefore, this study is aimed at identifying spatial distribution of TMC and the factors associated with TMC in Ethiopia. Methods A secondary data analysis was conducted among 11,209 circumcised males using data from 2016 Ethiopian Demographic and Health Survey (EDHS). Global Moran’s I statistic was observed to check whether there was a significant clustering of TMC. Primary and secondary clusters of TMC were identified by fitting Bernoulli model in Kulldorff’s SaTScan software. Multilevel Generalized Linear Mixed effects Model (GLMM) was fitted to identify factors associated with TMC. Result The spatial distribution of TMC was nonrandom across the country with Global Moran’s I = 0.27 (p-value < 0.0001). The primary clusters of TMC were identified in the southern part of Oromia and Tigray, northern part of SNNPR, Amhara, Gambella and Benishangul regions. Current age, age at circumcision, ethnicity, religion, place of residence, wealth index, media exposure, sex of household head and age of household head were factors associated with TMC in Ethiopia. Conclusions The spatial distribution of TMC was varied across the country. This variation might be due to the diversity of culture, ethnicity and religion across the regions. Thus, there is a need to rearrange the regulations on standards of TMC practice, conduct training to familiarize operation technique and general hygiene procedures, and launch cross-referral systems between traditional circumcisers and health workers. While undertaking these public health interventions, due attention should be given to the identified clusters and significant factors.
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Affiliation(s)
- Biruk Shalmeno Tusa
- Department of Epidemiology and Biostatistics, College of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia.
| | - Adisu Birhanu Weldesenbet
- Department of Epidemiology and Biostatistics, College of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia
| | | | - Sewnet Adem Kebede
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
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7
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Mangenah C, Mavhu W, Garcia DC, Gavi C, Mleya P, Chiwawa P, Chidawanyika S, Ncube G, Xaba S, Mugurungi O, Taruberekera N, Madidi N, Fielding KL, Johnson C, Hatzold K, Terris-Prestholt F, Cowan FM, Bautista-Arredondo S. Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe. BMJ Glob Health 2021; 6:bmjgh-2021-004983. [PMID: 34275870 PMCID: PMC8287601 DOI: 10.1136/bmjgh-2021-004983] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Supply and demand-side factors continue to undermine voluntary medical male circumcision (VMMC) uptake. We assessed relative economic costs of four VMMC demand creation/service-delivery modalities as part of a randomised controlled trial in Zimbabwe. METHODS Interpersonal communication agents were trained and incentivised to generate VMMC demand across five districts using four demand creation modalities (standard demand creation (SDC), demand creation plus offer of HIV self-testing (HIVST), human-centred design (HCD)-informed approach, HCD-informed demand creation approach plus offer of HIVST). Annual provider financial expenditure analysis and activity-based-costing including time-and-motion analysis across 15 purposively selected sites accounted for financial expenditures and donated inputs from other programmes and funders. Sites represented three models of VMMC service-delivery: static (fixed) model offering VMMC continuously to walk-in clients at district hospitals and serving as a district hub for integrated mobile and outreach services, (2) integrated (mobile) modelwhere staff move from the district static (fixed) site with their commodities to supplement existing services or to recently capacitated health facilities, intermittently and (3) mobile/outreach model offering VMMC through mobile clinic services in more remote sites. RESULTS Total programme cost was $752 585 including VMMC service-delivery costs and average cost per client reached and cost per circumcision were $58 and $174, respectively. Highest costs per client reached were in the HCD arm-$68 and lowest costs in standard demand creation ($52) and HIVST ($55) arms, respectively. Highest cost per client circumcised was observed in the arm where HIVST and HCD were combined ($226) and the lowest in the HCD alone arm ($160). Across the three VMMC service-delivery models, unit cost was lowest in static (fixed) model ($54) and highest in integrated mobile model ($63). Overall, economies of scale were evident with unit costs lower in sites with higher numbers of clients reached and circumcised. CONCLUSIONS There was high variability in unit costs across arms and sites suggesting opportunities for cost reductions. Highest costs were observed in the HCD+HIVST arm when combined with an integrated service-delivery setting. Mobilisation programmes that intensively target higher conversion rates as exhibited in the SDC and HCD arms provide greater scope for efficiency by spreading costs. TRIAL REGISTRATION NUMBER PACTR201804003064160.
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Affiliation(s)
- Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe .,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Diego Cerecero Garcia
- Division of Health Economics and Health Systems Innovations, Instituto Nacional de Salud Publica, Cuernavaca, Mexico
| | - Chiedza Gavi
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Polite Mleya
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Progress Chiwawa
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | | | | | | | | | | | - Katherine L Fielding
- Faculty of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Karin Hatzold
- Population Services International, Washington, District of Columbia, USA
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, Instituto Nacional de Salud Publica, Cuernavaca, Mexico
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8
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Rennie S, Gilbertson A, Hallfors D, Luseno WK. Ethics of pursuing targets in public health: the case of voluntary medical male circumcision for HIV-prevention programs in Kenya. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106293. [PMID: 33148776 PMCID: PMC8144939 DOI: 10.1136/medethics-2020-106293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 05/03/2023]
Abstract
The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets in global public health using our fieldwork on and experiences with voluntary medical male circumcision (VMMC) initiatives in Kenya. Among the many countries involved in VMMC for HIV prevention, Kenya is considered a success story, its programmes having medically circumcised nearly 2 million men since 2007. We describe ethically problematic practices in Kenyan VMMC programmes revealed by our fieldwork, how the problems are related to the pursuit of targets and discuss possible approaches to their management. Although the establishment and pursuit of targets in public health can have many benefits, assessments of target-driven programmes tend to focus on quantifiable outcomes rather than the processes by which the outcomes are obtained. However, in order to speak more robustly about programmatic 'success', and to maintain community trust, it is vital to ethically evaluate how a public health initiative is actually implemented in the pursuit of its targets.
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Affiliation(s)
- Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
| | - Denise Hallfors
- Retired, Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
| | - Winnie K Luseno
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
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9
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Cork MA, Wilson KF, Perkins S, Collison ML, Deshpande A, Eaton JW, Earl L, Haeuser E, Justman JE, Kinyoki DK, Mayala BK, Mosser JF, Murray CJL, Nkengasong JN, Piot P, Sartorius B, Schaeffer LE, Serfes AL, Sligar A, Steuben KM, Tanser FC, VanderHeide JD, Yang M, Wabiri N, Hay SI, Dwyer-Lindgren L. Mapping male circumcision for HIV prevention efforts in sub-Saharan Africa. BMC Med 2020; 18:189. [PMID: 32631314 PMCID: PMC7339571 DOI: 10.1186/s12916-020-01635-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/14/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND HIV remains the largest cause of disease burden among men and women of reproductive age in sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk of female-to-male transmission of HIV by 50-60%. The World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries for VMMC campaigns and set a coverage goal of 80% for men ages 15-49. From 2008 to 2017, over 18 million VMMCs were reported in priority countries. Nonetheless, relatively little is known about local variation in male circumcision (MC) prevalence. METHODS We analyzed geo-located MC prevalence data from 109 household surveys using a Bayesian geostatistical modeling framework to estimate adult MC prevalence and the number of circumcised and uncircumcised men aged 15-49 in 38 countries in sub-Saharan Africa at a 5 × 5-km resolution and among first administrative level (typically provinces or states) and second administrative level (typically districts or counties) units. RESULTS We found striking within-country and between-country variation in MC prevalence; most (12 of 14) priority countries had more than a twofold difference between their first administrative level units with the highest and lowest estimated prevalence in 2017. Although estimated national MC prevalence increased in all priority countries with the onset of VMMC campaigns, seven priority countries contained both subnational areas where estimated MC prevalence increased and areas where estimated MC prevalence decreased after the initiation of VMMC campaigns. In 2017, only three priority countries (Ethiopia, Kenya, and Tanzania) were likely to have reached the MC coverage target of 80% at the national level, and no priority country was likely to have reached this goal in all subnational areas. CONCLUSIONS Despite MC prevalence increases in all priority countries since the onset of VMMC campaigns in 2008, MC prevalence remains below the 80% coverage target in most subnational areas and is highly variable. These mapped results provide an actionable tool for understanding local needs and informing VMMC interventions for maximum impact in the continued effort towards ending the HIV epidemic in sub-Saharan Africa.
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Affiliation(s)
- Michael A Cork
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kate F Wilson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Samantha Perkins
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Michael L Collison
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Aniruddha Deshpande
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jeffrey W Eaton
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Emily Haeuser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jessica E Justman
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Damaris K Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Jonathan F Mosser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - John N Nkengasong
- Africa Centres for Disease Control and Prevention, African Union, Addis Ababa, Ethiopia
| | - Peter Piot
- London School of Hygiene & Tropical Medicine, London, UK
| | - Benn Sartorius
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.,London School of Hygiene & Tropical Medicine, London, UK
| | - Lauren E Schaeffer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Audrey L Serfes
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Amber Sligar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Krista M Steuben
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Frank C Tanser
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,Research Department of Infection & Population Health, University College London, London, UK
| | - John D VanderHeide
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Mingyou Yang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Njeri Wabiri
- HIV/AIDS, STIs & TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. .,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
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10
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Feldacker C, Holeman I, Murenje V, Xaba S, Korir M, Wambua B, Makunike-Chikwinya B, Holec M, Barnhart S, Tshimanga M. Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe. PLoS One 2020; 15:e0233234. [PMID: 32544161 PMCID: PMC7297350 DOI: 10.1371/journal.pone.0233234] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/30/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (MC) is safe and effective. Nevertheless, MC programs require multiple post-operative visits. In Zimbabwe, a randomized control trial (RCT) found that post-operative two-way texting (2wT) between clients and MC providers instead of in-person reviews reduced provider workload and safeguarded patient safety. A critical component of the RCT assessed usability and acceptability of 2wT among providers and clients. These findings inform scale-up of the 2wT approach to post-operative follow-up. METHODS The RCT assigned 362 adult MC clients with cell phones into 2wT; these men responded to 13 automated daily texts supported by interactive texting or in-person follow-up, when needed. A subset of 100 texting clients filled a self-administered usability survey on day 14. 2wT acceptability was ascertained via 2wT response rates. Among 2wT providers, eight key informant interviews focused on 2wT acceptability and usability. Influences of wage and age on response rates and client-reported potential AEs were explored using linear and logistic regression models, respectively. RESULTS Clients felt confident, comfortable, satisfied, and well-supported with 2wT-based follow-up; few noted texting challenges or concerns about healing. Clients felt 2wT saved them time and money. Response rates (92%) suggested 2wT acceptability. Both clients and providers felt 2wT was highly usable. Providers noted 2wT saved them time, empowered clients to engage in their healing, and closed gaps in MC service quality. For scale, providers reinforced good post-operative counseling on AEs and texting instructions. Wage and age did not influence text response rates or potential AE texts. CONCLUSION Results strongly suggest that 2wT is highly usable and acceptable for providers and patients. Men with concerns solicited provider guidance and reassurance offered via text. Providers noted that men engaged proactively in their healing. 2wT between providers and patients should be expanded for MC and considered for other short-term care contexts. The trial is registered on ClinicalTrials.gov, trial NCT03119337, and was activated on April 18, 2017. https://clinicaltrials.gov/ct2/show/NCT03119337.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Isaac Holeman
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Medic Mobile, Nairobi, Kenya
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | | | | | | | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
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Nxumalo CT, Mchunu GG. Circumcised men's perceptions, understanding and experiences of voluntary medical male circumcision in KwaZulu-Natal, South Africa. S Afr Fam Pract (2004) 2020; 62:e1-e8. [PMID: 32501036 PMCID: PMC8378007 DOI: 10.4102/safp.v62i1.5083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/06/2020] [Accepted: 02/07/2020] [Indexed: 12/22/2022] Open
Abstract
Background KwaZulu-Natal, South Africa, has rolled out voluntary medical male circumcision (VMMC) in response to recommendations that regions with a high human immunodeficiency virus (HIV) prevalence adopt VMMC as an additional HIV prevention strategy. There is a paucity of South African data on the motivators, barriers and experiences of adult male candidates regarding VMMC. This study was conducted to analyse circumcised men’s perceptions, understanding and experiences of VMMC in KwaZulu-Natal, South Africa. Methods A qualitative phenomenographic design was used. Ethical clearance was obtained from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BE 627/18). Data were collected from 12 circumcised male candidates. Individual interviews were conducted and recorded by using an audiotape. Data were transcribed verbatim and analysed manually. Results Participants’ perceptions regarding VMMC are health related and appear to be the motivators for the uptake of medical circumcision. Circumcised men in this study appeared to misunderstand VMMC in terms of healing and performance time and the nature of the procedure. Negative experiences in terms of quality of care received were reported. Conclusion The study findings imply that practice interventions to promote demand generation for VMMC in KwaZulu-Natal, South Africa, should incorporate the perceptions and experiences of male candidates regarding the procedure. Tailored messaging to address misunderstanding related to the nature of VMMC should also be provided. Regular in-service training on standardised VMMC implementation practices should be provided to ensure the delivery of optimum quality VMMC services.
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Affiliation(s)
- Celenkosini T Nxumalo
- Department of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban.
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12
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Nxumalo CT, Mchunu GG. Healthcare workers' perceptions and experiences of implementing voluntary medical male circumcision in KwaZulu-Natal, South Africa. Afr J Prim Health Care Fam Med 2020; 12:e1-e10. [PMID: 32242429 PMCID: PMC7160602 DOI: 10.4102/phcfm.v12i1.2253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/10/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Abstract
Background Voluntary Medical Male Circumcision (VMMC) is an effective HIV prevention strategy prioritized by the World Health Organisation (WHO) for regions of high HIV prevalence, South Africa (SA) and in particular KwaZulu-Natal (KZN) is one of such regions. Since the roll out of VMMC in 2010 there has been little research conducted on the implementation of this service. Existing studies on the uptake of VMMC have mainly focused on service users resulting in a paucity of data on health care workers perspectives on the intervention. Aim To analyse health care workers’ perceptions and experiences of implementing voluntary medical male circumcision in KZN, SA. Setting The study took place at six different health districts and their six respective rural clinics in the KZN province of SA. Methods A qualitative approach using a phenomenographic design was employed. Data were collected from a sample of 18 participants comprising of health care providers (n = 12) and health policy makers (n = 6). Individual, face-to-face interviews were conducted using a semi-structured interview guide. An audiotape was used to record the data, which were transcribed verbatim and then analysed using a step-wise phenomenographic data analysis procedure. Results Participants reported that VMMC was implemented by the department of health with support from non-governmental organisations and private general practitioners. Negative perceptions and negative experiences regarding VMMC and implementation were reported. Conclusion The implementation of VMMC is compromised due to poor preparation and training of healthcare workers for implementing the service. Addressing health care workers’ needs for training and preparation is crucial for successful implementation of VMMC.
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Gilbertson A, Ongili B, Odongo FS, Hallfors DD, Rennie S, Kwaro D, Luseno WK. Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets. PLoS One 2019; 14:e0224548. [PMID: 31682626 PMCID: PMC6827911 DOI: 10.1371/journal.pone.0224548] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. Methods and results The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. Conclusion Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.
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Affiliation(s)
- Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | | | | | - Denise D. Hallfors
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
| | - Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
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Kim Y. The effectiveness of PEPFAR's funding for women and children with HIV/AIDS. Int J Health Plann Manage 2018; 34:e896-e916. [PMID: 30451315 DOI: 10.1002/hpm.2706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 11/05/2022] Open
Abstract
Has President's Emergency Plan for AIDS Relief's (PEPFAR) funding been effective in reducing the rate of HIV new infections and AIDS-related deaths among women and children? While previous studies have found HIV/AIDS aid to be ineffective and PEPFAR funding to produce negative externalities, there is lack of empirical examination of the impact of PEPFAR on women and children despite the emphasis on prevention of mother-to-child transmission of HIV during the Bush and Obama administrations. Using descriptive analysis and difference-in-differences (DID) regression, this study finds that PEPFAR's funding has reduced the HIV new infections and AIDS-related death rates of women and children for both focus countries and recipient countries, which are those that were added in a second phase. These findings show that PEPFAR's strategy for women and children has been effective and that it should be continued. However, while PEPFAR has contributed to the fight against HIV/AIDS, the effects of its work have been underestimated.
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Affiliation(s)
- Yiyeon Kim
- Department of Political Science & International Studies, Yonsei University, Seoul, South Korea
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Feldacker C, Makunike-Chikwinya B, Holec M, Bochner AF, Stepaniak A, Nyanga R, Xaba S, Kilmarx PH, Herman-Roloff A, Tafuma T, Tshimanga M, Sidile-Chitimbire VT, Barnhart S. Implementing voluntary medical male circumcision using an innovative, integrated, health systems approach: experiences from 21 districts in Zimbabwe. Glob Health Action 2018; 11:1414997. [PMID: 29322867 PMCID: PMC5769777 DOI: 10.1080/16549716.2017.1414997] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite increased support for voluntary medical male circumcision (VMMC) to reduce HIV incidence, current VMMC progress falls short. Slow progress in VMMC expansion may be partially attributed to emphasis on vertical (stand-alone) over more integrated implementation models that are more responsive to local needs. In 2013, the ZAZIC consortium began implementation of a 5-year, integrated VMMC program jointly with Ministry of Health and Child Care (MoHCC) in Zimbabwe. OBJECTIVE To explore ZAZIC's approach emphasizing existing healthcare workers and infrastructure, increasing program sustainability and resilience. METHODS A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses. METHODS A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses. RESULTS In start-up and year 1 (March 2013-September, 2014), ZAZIC expanded from two to 36 static VMMC sites and conducted 46,011 VMMCs; 39,840 completed from October 2013 to September 2014. From October 2014 to September 2015, 44,868 VMMCs demonstrated 13% increased productivity. In October, 2015, ZAZIC was required by its donor to consolidate service provision from 21 to 10 districts over a 3-month period. Despite this shock, 57,282 VMMCs were completed from October 2015 to September 2016 followed by 44,414 VMMCs in only 6 months, from October 2016 to March 2017. Overall, ZAZIC performed 192,575 VMMCs from March 2013 to March, 2017. The vast majority of VMMCs were completed safely by MoHCC staff with a reported moderate and severe adverse event rate of 0.3%. CONCLUSION The safety, flexibility, and pace of scale-up associated with the integrated VMMC model appears similar to vertical delivery with potential benefits of capacity building, sustainability and health system strengthening. These models also appear more adaptable to local contexts. Although more complicated than traditional approaches to program implementation, attention should be given to this country-led approach for its potential to spur positive health system changes, including building local ownership, capacity, and infrastructure for future public health programming.
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Affiliation(s)
- Caryl Feldacker
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA.,b Department of Global Health , University of Washington , Seattle , WA , USA
| | | | - Marrianne Holec
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | - Aaron F Bochner
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | - Abby Stepaniak
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | - Robert Nyanga
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA
| | | | - Peter H Kilmarx
- e U.S. Centers for Disease Control and Prevention , Harare , Zimbabwe
| | - Amy Herman-Roloff
- e U.S. Centers for Disease Control and Prevention , Harare , Zimbabwe
| | - Taurayi Tafuma
- e U.S. Centers for Disease Control and Prevention , Harare , Zimbabwe
| | - Mufuta Tshimanga
- f Zimbabwe Community Health Intervention Project (ZiCHIRe) , Harare , Zimbabwe
| | | | - Scott Barnhart
- a International Training and Education Center for Health (I-TECH) , Seattle , WA , USA.,b Department of Global Health , University of Washington , Seattle , WA , USA.,h Department of Medicine , University of Washington , Seattle , WA , USA
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Davis SM, Hines JZ, Habel M, Grund JM, Ridzon R, Baack B, Davitte J, Thomas A, Kiggundu V, Bock N, Pordell P, Cooney C, Zaidi I, Toledo C. Progress in voluntary medical male circumcision for HIV prevention supported by the US President's Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data. BMJ Open 2018; 8:e021835. [PMID: 30173159 PMCID: PMC6120649 DOI: 10.1136/bmjopen-2018-021835] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This article provides an overview and interpretation of the performance of the US President's Emergency Plan for AIDS Relief's (PEPFAR's) male circumcision programme which has supported the majority of voluntary medical male circumcisions (VMMCs) performed for HIV prevention, from its 2007 inception to 2017, and client characteristics in 2017. DESIGN Longitudinal collection of routine programme data and disaggregations. SETTING 14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes. PARTICIPANTS Clients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above. MAIN OUTCOME MEASURES Numbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance. RESULTS PEPFAR supported a total of 15 269 720 circumcisions in 14 countries in Southern and Eastern Africa. In 2017, 45% of clients were under 15 years of age, 8% had unknown HIV status, 1% of those tested were HIV+ and 84% returned for a follow-up visit within 14 days of circumcision. CONCLUSIONS Over 15 million VMMCs have been supported by PEPFAR since 2007. VMMC continues to attract primarily young clients. The non-trivial proportion of clients not testing for HIV is expected, and may be reassuring that testing is not being presented as mandatory for access to circumcision, or in some cases reflect test kit stockouts or recent testing elsewhere. While VMMC is extremely safe, achieving the highest possible follow-up rates for early diagnosis and intervention on complications is crucial, and programmes continue to work to raise follow-up rates. The VMMC programme has achieved rapid scale-up but continues to face challenges, and new approaches may be needed to achieve the new Joint United Nations Programme on HIV/AIDS goal of 27 million additional circumcisions through 2020.
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Affiliation(s)
- Stephanie M Davis
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonas Z Hines
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa Habel
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonathan M Grund
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Renee Ridzon
- President's Emergency Plan for AIDS Relief, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Brittney Baack
- Division of Global HIV and TB, Monitoring, Evaluation, and Data Analytics Branch, Clinical Monitoring and Evaluation Team, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jonathan Davitte
- US Department of Defense HIV/AIDS Prevention Program (DHAPP), Naval Health Research Center, San Diego, California, USA
| | - Anne Thomas
- US Department of Defense HIV/AIDS Prevention Program (DHAPP), Naval Health Research Center, San Diego, California, USA
| | - Valerian Kiggundu
- United States Agency for International Development, Global Health Bureau, Office of HIV/AIDS, Prevention, Care and Treatment Division, Washington, District of Columbia, USA
| | - Naomi Bock
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Paran Pordell
- Division of Global HIV and TB, Monitoring, Evaluation, and Data Analytics Branch, Clinical Monitoring and Evaluation Team, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Caroline Cooney
- President's Emergency Plan for AIDS Relief, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Irum Zaidi
- President's Emergency Plan for AIDS Relief, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Carlos Toledo
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Odoyo-June E, Agot K, Mboya E, Grund J, Musingila P, Emusu D, Soo L, Otieno-Nyunya B. Agreement between self-reported and physically verified male circumcision status in Nyanza region, Kenya: Evidence from the TASCO study. PLoS One 2018; 13:e0192823. [PMID: 29432444 PMCID: PMC5809057 DOI: 10.1371/journal.pone.0192823] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 01/31/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Self-reported male circumcision (MC) status is widely used to estimate community prevalence of circumcision, although its accuracy varies in different settings depending on the extent of misreporting. Despite this challenge, self-reported MC status remains essential because it is the most feasible method of collecting MC status data in community surveys. Therefore, its accuracy is an important determinant of the reliability of MC prevalence estimates based on such surveys. We measured the concurrence between self-reported and physically verified MC status among men aged 25-39 years during a baseline household survey for a study to test strategies for enhancing MC uptake by older men in Nyanza region of Kenya. The objective was to determine the accuracy of self-reported MC status in communities where MC for HIV prevention is being rolled out. METHODS Agreement between self-reported and physically verified MC status was measured among 4,232 men. A structured questionnaire was used to collect data on MC status followed by physical examination to verify the actual MC status whose outcome was recorded as fully circumcised (no foreskin), partially circumcised (foreskin is past corona sulcus but covers less than half of the glans) or uncircumcised (foreskin covers half or more of the glans). The sensitivity and specificity of self-reported MC status were calculated using physically verified MC status as the gold standard. RESULTS Out of 4,232 men, 2,197 (51.9%) reported being circumcised, of whom 99.0% were confirmed to be fully circumcised on physical examination. Among 2,035 men who reported being uncircumcised, 93.7% (1,907/2,035) were confirmed uncircumcised on physical examination. Agreement between self-reported and physically verified MC status was almost perfect, kappa (k) = 98.6% (95% CI, 98.1%-99.1%. The sensitivity of self-reporting being circumcised was 99.6% (95% CI, 99.2-99.8) while specificity of self-reporting uncircumcised was 99.0% (95% CI, 98.4-99.4) and did not differ significantly by age group based on chi-square test. Rate of consenting to physical verification of MC status differed by client characteristics; unemployed men were more likely to consent to physical verification (odds ratio [OR] = 1.48, (95% CI, 1.30-1.69) compared to employed men and those with post-secondary education were less likely to consent to physical verification than those with primary education or less (odds ratio [OR] = 0.61, (95% CI, 0.51-0.74). CONCLUSIONS In this Kenyan context, both sensitivity and specificity of self-reported MC status was high; therefore, MC prevalence estimates based on self-reported MC status should be deemed accurate and applicable for planning. However MC programs should assess accuracy of self-reported MC status periodically for any secular changes that may undermine its usefulness for estimating community MC prevalence in their unique settings.
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Affiliation(s)
- Elijah Odoyo-June
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
- * E-mail:
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Edward Mboya
- Impact Research and Development Organization, Kisumu, Kenya
| | - Jonathan Grund
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
| | - Donath Emusu
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
| | - Leonard Soo
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
| | - Boaz Otieno-Nyunya
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
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Women's knowledge and perception of male circumcision before and after its roll-out in the South African township of Orange Farm from community-based cross-sectional surveys. PLoS One 2017; 12:e0173595. [PMID: 28339497 PMCID: PMC5365100 DOI: 10.1371/journal.pone.0173595] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 02/23/2017] [Indexed: 12/19/2022] Open
Abstract
The roll-out of medical male circumcision (MC) is progressing in Southern and Eastern Africa. Little is known about the effect of this roll-out on women. The objective of this study was to assess the knowledge and perceptions of women regarding MC in a setting before and after the roll-out. This study was conducted in the South African township of Orange Farm where MC prevalence among men increased from 17% to 53% in the period 2008–2010. Data from three community-based cross sectional surveys conducted in 2007, 2010 and 2012 among 1258, 1197 and 2583 adult women, respectively were studied. In 2012, among 2583 women, 73.7% reported a preference for circumcised partners, and 87.9% knew that circumcised men could become infected with HIV. A total of 95.8% preferred to have their male children circumcised. These three proportions increased significantly during the roll-out. In 2007, the corresponding values were 64.4%, 82.9% and 80.4%, respectively. Among 2581 women having had sexual intercourse with circumcised and uncircumcised men, a majority (55.8%, 1440/2581) agreed that it was easier for a circumcised man to use a condom, 20.5% (530/2581) disagreed; and 23.07 (611/2581) did not know. However, some women incorrectly stated that they were fully (32/2579; 1.2%; 95%CI: 0.9% to 1.7%) or partially (233/2579; 9.0%; 95%CI: 8.0% to 10.2%) protected when having unprotected sex with a circumcised HIV-positive partner. This study shows that the favorable perception of women and relatively correct knowledge regarding VMMC had increased during the roll-out of VMMC. When possible, women should participate in the promotion of VMMC although further effort should be made to improve their knowledge.
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Needs Assessment and Theory-Based Promotion of Voluntary Medical Male Circumcision (VMMC) Among Male Sexually Transmitted Diseases Patients (MSTDP) in China. AIDS Behav 2016; 20:2489-2502. [PMID: 25801474 DOI: 10.1007/s10461-015-1040-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Voluntary medical male circumcision (VMMC) is an evidence-based biomedical HIV prevention method. It is under-utilized in countries outside Africa, including China. The present single-arm, non-blinded test-of-concept trial was designed to promote VMMC among 179 male sexually transmitted diseases patients (MSTDP) in Shenzhen, China. It was based on behavioral health theories and results of a formative survey. At month 4, 45.5 % of the MSTDP responded positively to the intervention (19.9 % had taken up VMMC and 25.6 % intended to do so in the next 6 months). Adjusted analysis showed that cognitive variables measured at baseline (perceived self-efficacy, subjective norm and behavioral intention) significantly predicted adoption of VMMC during the 4-month follow-up period. Process evaluation involving clinicians of the STD clinics was positive. At month 6, 36.0 % of the circumcised participants used condom less frequently with their regular sex partner. We recommend scaling up the intervention, taking prevention of risk compensation into account.
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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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Miller KS, Winskell K, Berrier FL. Responding to Changes in HIV Policy: Updating and Enhancing the Families Matter! Curriculum. HEALTH EDUCATION JOURNAL 2016; 75:409-420. [PMID: 26949267 PMCID: PMC4770810 DOI: 10.1177/0017896915595530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVES The past decade has seen changes in US HIV policy in sub-Saharan Africa in response to a new Administration and far-reaching technical, scientific and programmatic developments. These include: dramatically increased access to life-saving ART and related services; the roll-out of voluntary medical male circumcision; and growing sensitivity to gender-based violence, including child sexual abuse, and to its role in increasing vulnerability to HIV. The Families Matter! Program (FMP) is an intervention for parents and caregivers of 9-12 year-olds that promotes effective parent-child communication about sexuality and sexual risk reduction. FMP was adapted from a US evidence-based intervention in 2003-4 and is now implemented in eight African countries. In 2012-13, the FMP curriculum was updated and enhanced to respond to new US Government priorities. METHODS Enhancements to the curriculum drew on the results of Violence Against Children surveys, on a review of existing literature, on feedback from the field on the existing curriculum, and on stories written by young people across Africa for scriptwriting competitions. RESULTS We updated FMP with scientific content and stronger linkages to services. We also intensified our focus on structural determinants of risk. This contextualisation of sexual risk-taking within structural constraints led us to place greater emphasis on gendered vulnerability and the diverse pressures children face, and to intensify our situation-based pedagogical approach, drawing on the authentic youth-authored narratives. CONCLUSION We describe these changes as an illustration of and source of insight into much-needed programmatic adaptation in response to evolving HIV policy.
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Affiliation(s)
- Kim S. Miller
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kate Winskell
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Faith L. Berrier
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Schenker I, Westreich M. Voluntary medical male circumcision: A necessary surgical intervention in curbing HIV/AIDS. ACTA ACUST UNITED AC 2015. [DOI: 10.1308/rcsbull.2015.378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An Israeli surgeon and a Global Health Specialist working in Africa address some of the persistent myths surrounding this practice.
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Bulled NL. Social models of HIV risk among young adults in Lesotho. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 14:239-54. [PMID: 26284999 DOI: 10.2989/16085906.2015.1054295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Extensive research over the past 30 years has revealed that individual and social determinants impact HIV risk. Even so, prevention efforts focus primarily on individual behaviour change, with little recognition of the dynamic interplay of individual and social environment factors that further exacerbate risk engagement. Drawing on long-term research with young adults in Lesotho, I examine how social environment factors contribute to HIV risk. During preliminary ethnographic analysis, I developed novel scales to measure social control, adoption of modernity, and HIV knowledge. In survey research, I examined the effects of individual characteristics (i.e., socioeconomic status, HIV knowledge, adoption of modernity) and social environment (i.e., social control) on HIV risk behaviours. In addition, I measured the impact of altered environments by taking advantage of an existing situation whereby young adults attending a national college are assigned to either a main campus in a metropolitan setting or a satellite campus in a remote setting, irrespective of the environment in which they were socialised as youth. This arbitrary assignment process generates four distinct groups of young adults with altered or constant environments. Regression models show that lower levels of perceived social control and greater adoption of modernity are associated with HIV risk, controlling for other factors. The impact of social control and modernity varies with environment dynamics.
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Affiliation(s)
- Nicola L Bulled
- a Center for Global Health , University of Virginia , Charlottesville , Virginia , USA
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Bulled N, Green EC. Making voluntary medical male circumcision a viable HIV prevention strategy in high prevalence countries by engaging the traditional sector. CRITICAL PUBLIC HEALTH 2015; 26:258-268. [PMID: 27110065 DOI: 10.1080/09581596.2015.1055319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Voluntary medical male circumcision (VMMC) has been rapidly accepted by global HIV policy and donor institutions as a highly valuable HIV prevention strategy given its cost-effectiveness, limited interactions with a health facility, and projected long-lasting benefits. Many southern African countries have incorporated VMMC into their national HIV prevention strategies. However, intensive VMMC promotion programs have met with limited success to date and many HIV researchers have voiced concerns. This commentary discusses reasons behind the less-than-desired public demand and suggests how inclusion of the traditional sector - traditional leaders, healers, and circumcisers - with their local knowledge, cultural expertise and social capital, particularly in the realm of social meanings ascribed to male circumcision, may improve the uptake of this HIV prevention strategy. We offer Lesotho and Swaziland as case studies of the integration of universal VMMC policies; these are countries with a shared HIV burden, yet contrasting contemporary socio-cultural practices of male circumcision. The similar hesitant responses expressed by these two countries towards VMMC remind us that the incorporation of any new or revised and revitalized public health strategy must be considered within unique historical, political, economic, and socio-cultural contexts.
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Affiliation(s)
- Nicola Bulled
- The Center for Global Health, University of Virginia, Charlottesville, VA, USA
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Heaton LM, Bouey PD, Fu J, Stover J, Fowler TB, Lyerla R, Mahy M. Estimating the impact of the US President's Emergency Plan for AIDS Relief on HIV treatment and prevention programmes in Africa. Sex Transm Infect 2015; 91:615-20. [PMID: 26056389 DOI: 10.1136/sextrans-2014-051991] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 05/16/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Since 2004, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported the tremendous scale-up of HIV prevention, care and treatment services, primarily in sub-Saharan Africa. We evaluate the impact of antiretroviral treatment (ART), prevention of mother-to-child transmission (PMTCT) and voluntary medical male circumcision (VMMC) programmes on survival, mortality, new infections and the number of orphans from 2004 to 2013 in 16 PEPFAR countries in Africa. METHODS PEPFAR indicators tracking the number of persons receiving ART for their own health, ART regimens for PMTCT and biomedical prevention of HIV through VMMC were collected across 16 PEPFAR countries. To estimate the impact of PEPFAR programmes for ART, PMTCT and VMMC, we compared the current scenario of PEPFAR-supported interventions to a counterfactual scenario without PEPFAR, and assessed the number of life years gained (LYG), number of orphans averted and HIV infections averted. Mathematical modelling was conducted using the SPECTRUM modelling suite V.5.03. RESULTS From 2004 to 2013, PEPFAR programmes provided support for a cumulative number of 24 565 127 adults and children on ART, 4 154 878 medical male circumcisions, and ART for PMTCT among 4 154 478 pregnant women in 16 PEPFAR countries. Based on findings from the model, these efforts have helped avert 2.9 million HIV infections in the same period. During 2004-2013, PEPFAR ART programmes alone helped avert almost 9 million orphans in 16 PEPFAR countries and resulted in 11.6 million LYG. CONCLUSIONS Modelling results suggest that the rapid scale-up of PEPFAR-funded ART, PMTCT and VMMC programmes in Africa during 2004-2013 led to substantially fewer new HIV infections and orphaned children during that time and longer lives among people living with HIV. Our estimates do not account for the impact of the PEPFAR-funded non-biomedical interventions such as behavioural and structural interventions included in the comprehensive HIV prevention, care and treatment strategy used by PEPFAR countries. Therefore, the number of HIV infections and orphans averted and LYG may be underestimated by these models.
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Affiliation(s)
- Laura M Heaton
- Population Division, U.S. Census Bureau, Washington DC, USA
| | - Paul D Bouey
- Department of State, Country Impact, Office of the U.S. Global AIDS Coordinator, Washington DC, USA
| | - Joe Fu
- Health Policy, Children's Action Alliance, Phoenix, Arizona, USA
| | - John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, Connecticut, USA
| | | | - Rob Lyerla
- Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, Rockville, Maryland, USA
| | - Mary Mahy
- Strategic Information and Evaluation Department, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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Ledikwe JH, Nyanga RO, Hagon J, Grignon JS, Mpofu M, Semo BW. Scaling-up voluntary medical male circumcision - what have we learned? HIV AIDS-RESEARCH AND PALLIATIVE CARE 2014; 6:139-46. [PMID: 25336991 PMCID: PMC4199973 DOI: 10.2147/hiv.s65354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15–49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008–2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.
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Affiliation(s)
- Jenny H Ledikwe
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Robert O Nyanga
- International Training and Education Center for Health, Botswana, Gaborone, Botswana
| | - Jaclyn Hagon
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jessica S Grignon
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Mulamuli Mpofu
- International Training and Education Center for Health, Botswana, Gaborone, Botswana
| | - Bazghina-Werq Semo
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
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Impact of male circumcision on the HIV epidemic in Papua New Guinea: a country with extensive foreskin cutting practices. PLoS One 2014; 9:e104531. [PMID: 25111058 PMCID: PMC4128698 DOI: 10.1371/journal.pone.0104531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 07/14/2014] [Indexed: 11/19/2022] Open
Abstract
The degree to which adult medical male circumcision (MC) programs can reduce new HIV infections in a moderate HIV prevalence country like Papua New Guinea (PNG) are uncertain especially given the widespread prevalence of longitudinal foreskin cuts among adult males. We estimated the likely impact of a medical MC intervention in PNG using a mathematical model of HIV transmission. The model was age-structured and incorporated separate components for sex, rural/urban, men who have sex with men and female sex workers. Country-specific data of the prevalence of foreskin cuts, sexually transmitted infections, condom usage, and the acceptability of MC were obtained by our group through related studies. If longitudinal foreskin cutting has a protective efficacy of 20% compared to 60% for MC, then providing MC to 20% of uncut males from 2012 would require 376,000 procedures, avert 7,900 HIV infections by 2032, and require 143 MC per averted infection. Targeting uncut urban youths would achieve the most cost effective returns of 54 MC per HIV infection averted. These numbers of MC required to avert an HIV infection change little even with coverage up to 80% of men. The greater the protective efficacy of longitudinal foreskin cuts against HIV acquisition, the less impact MC interventions will have. Dependent on this efficacy, increasing condom use could have a much greater impact with a 10 percentage point increase averting 18,400 infections over this same period. MC programs could be effective in reducing HIV infections in PNG, particularly in high prevalence populations. However the overall impact is highly dependent on the protective efficacy of existing longitudinal foreskin cutting in preventing HIV.
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Affiliation(s)
- Anne Schuchat
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Correspondence to: Dr Anne Schuchat, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Mailstop A-27, 1600 Clifton Rd, NE, Atlanta, GA 30333, USA
| | - Jordan Tappero
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Blandford
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Macintyre K, Andrinopoulos K, Moses N, Bornstein M, Ochieng A, Peacock E, Bertrand J. Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods. PLoS One 2014; 9:e83998. [PMID: 24802112 PMCID: PMC4011674 DOI: 10.1371/journal.pone.0083998] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 11/11/2013] [Indexed: 11/18/2022] Open
Abstract
Background In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high. Methods and Findings Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their “protection by marriage,” cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men. Conclusions Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy.
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Affiliation(s)
- Kate Macintyre
- Aidspan, Nairobi, Kenya
- Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- * E-mail:
| | - Katherine Andrinopoulos
- Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
| | | | - Marta Bornstein
- Learning for Action, San Francisco, California, United States of America
| | - Athanasius Ochieng
- National AIDS and STD Control Programme, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Erin Peacock
- Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
| | - Jane Bertrand
- Department of Global Health Systems and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
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Njeuhmeli E, Kripke K, Hatzold K, Reed J, Edgil D, Jaramillo J, Castor D, Forsythe S, Xaba S, Mugurungi O. Cost analysis of integrating the PrePex medical device into a voluntary medical male circumcision program in Zimbabwe. PLoS One 2014; 9:e82533. [PMID: 24801515 PMCID: PMC4011574 DOI: 10.1371/journal.pone.0082533] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 10/23/2013] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Fourteen African countries are scaling up voluntary medical male circumcision (VMMC) for HIV prevention. Several devices that might offer alternatives to the three WHO-approved surgical VMMC procedures have been evaluated for use in adults. One such device is PrePex, which was prequalified by the WHO in May 2013. We utilized data from one of the PrePex field studies undertaken in Zimbabwe to identify cost considerations for introducing PrePex into the existing surgical circumcision program. METHODS AND FINDINGS We evaluated the cost drivers and overall unit cost of VMMC at a site providing surgical VMMC as a routine service ("routine surgery site") and at a site that had added PrePex VMMC procedures to routine surgical VMMC as part of a research study ("mixed study site"). We examined the main cost drivers and modeled hypothetical scenarios with varying ratios of surgical to PrePex circumcisions, different levels of site utilization, and a range of device prices. The unit costs per VMMC for the routine surgery and mixed study sites were $56 and $61, respectively. The two greatest contributors to unit price at both sites were consumables and staff. In the hypothetical scenarios, the unit cost increased as site utilization decreased, as the ratio of PrePex to surgical VMMC increased, and as device price increased. CONCLUSIONS VMMC unit costs for routine surgery and mixed study sites were similar. Low service utilization was projected to result in the greatest increases in unit price. Countries that wish to incorporate PrePex into their circumcision programs should plan to maximize staff utilization and ensure that sites function at maximum capacity to achieve the lowest unit cost. Further costing studies will be necessary once routine implementation of PrePex-based circumcision is established.
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Affiliation(s)
- Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, DC, United States of America
| | - Katharine Kripke
- Health Policy Initiative, Futures Institute, Washington, DC, United States of America
- * E-mail:
| | | | - Jason Reed
- Office of the U.S. Global AIDS Coordinator, Washington, DC, United States of America
| | - Dianna Edgil
- United States Agency for International Development, Washington, DC, United States of America
| | - Juan Jaramillo
- The Partnership for Supply Chain Management System, Arlington, Virginia, United States of America
| | - Delivette Castor
- United States Agency for International Development, Washington, DC, United States of America
| | - Steven Forsythe
- Health Policy Initiative, Futures Institute, Washington, DC, United States of America
| | | | - Owen Mugurungi
- Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
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Gwandure C, Mayekiso T. Psychological Contract in HIV Prevention Clinical Trials in Resource Poor Communities in Africa. JOURNAL OF PSYCHOLOGY IN AFRICA 2014. [DOI: 10.1080/14330237.2013.10820612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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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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Abstract
Voluntary medical male circumcision (VMMC) is a cost-effective HIV-prevention intervention that reduces the risk of HIV acquisition in men by 60%. Although some countries are successfully scaling up VMMC, not all are doing this. When VMMC scale-up experiences are viewed in the context of models for the diffusion of innovation, some important themes emerge. Successful VMMC programs have in common locally led campaigns, a cultural tolerance of VMMC, strong political leadership and coordination, and adequate human and material resources. Challenges with VMMC scale-up have been marked by less flexible implementation models that seek a full integration of VMMC services at public medical facilities and by struggles to achieve geographic parity in access to care. Innovation diffusion models, especially the endogenous technology model, and multiple levels of influence on diffusion--individual males and their sex partners, communities, and health systems--remind us that the adoption of a prevention intervention, such as VMMC, is expected to start out slowly and, as information spreads, gradually speed up. In addition, the diffusion models suggest that customizing approaches to different populations is likely to accelerate VMMC scale-up and help achieve a long-term, sustainable impact on the HIV epidemic.
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Chrouser K, Bazant E, Jin L, Kileo B, Plotkin M, Adamu T, Curran K, Koshuma S. Penile Measurements in Tanzanian Males: Guiding Circumcision Device Design and Supply Forecasting. J Urol 2013; 190:544-50. [DOI: 10.1016/j.juro.2013.02.3200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2013] [Indexed: 10/27/2022]
Affiliation(s)
- Kristin Chrouser
- Department of Urology, University of Minnesota, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- Jhpiego Baltimore, Baltimore, Maryland
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Linda Jin
- Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | | | | | - Tigistu Adamu
- Jhpiego Baltimore, Baltimore, Maryland
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kelly Curran
- Jhpiego Baltimore, Baltimore, Maryland
- International Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Duffy K, Galukande M, Wooding N, Dea M, Coutinho A. Reach and cost-effectiveness of the PrePex device for safe male circumcision in Uganda. PLoS One 2013; 8:e63134. [PMID: 23717402 PMCID: PMC3661578 DOI: 10.1371/journal.pone.0063134] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/25/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Modelling, supported by the USAID Health Policy Initiative and UNAIDS, performed in 2011, indicated that Uganda would need to perform 4.2 million medical male circumcisions (MMCs) to reach 80% prevalence. Since 2010 Uganda has completed 380,000 circumcisions, and has set a national target of 1 million for 2013. OBJECTIVE To evaluate the relative reach and cost-effectiveness of PrePex compared to the current surgical SMC method and to determine the effect that this might have in helping to achieve the Uganda national SMC targets. METHODS A cross-sectional descriptive cost-analysis study conducted at International Hospital Kampala over ten weeks from August to October 2012. Data collected during the performance of 625 circumcisions using PrePex was compared to data previously collected from 10,000 circumcisions using a surgical circumcision method at the same site. Ethical approval was obtained. RESULTS The moderate adverse events (AE) ratio when using the PrePex device was 2% and no severe adverse events were encountered, which is comparable to the surgical method, thus the AE rate has no effect on the reach or cost-effectiveness of PrePex. The unit cost to perform one circumcision using PrePex is $30.55, 35% ($7.90) higher than the current surgical method, but the PrePex method improves operator efficiency by 60%, meaning that a team can perform 24 completed circumcisions compared to 15 by the surgical method. The cost-effectiveness of PrePex, comparing the cost of performing circumcisions to the future cost savings of potentially averted HIV infections, is just 2% less than the current surgical method, at a device cost price of $20. CONCLUSION PrePex is a viable SMC tool for scale-up with unrivalled potential for superior reach, however national targets can only be met with effective demand creation and availability of trained human resource.
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Affiliation(s)
- Kevin Duffy
- International Medical Group, Kampala, Uganda
| | - Moses Galukande
- International Hospital Kampala and Surgery Department, Mulago Hospital, Kampala, Uganda
- * E-mail:
| | - Nick Wooding
- International Health Sciences University, Kampala, Uganda
| | - Monica Dea
- Centers for Disease Control, Kampala, Uganda
| | - Alex Coutinho
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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