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Byabagambi JB, Hollingsworth B, Limmer M. Deficits and opportunities, pivots and shifts for scaling-up voluntary medical male circumcision in Uganda: a qualitative reflexive thematic analysis study. BMC Public Health 2024; 24:2232. [PMID: 39152417 PMCID: PMC11329999 DOI: 10.1186/s12889-024-19796-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/14/2024] [Indexed: 08/19/2024] Open
Abstract
Despite voluntary medical male circumcision (VMMC) being a cost-effective intervention for preventing HIV transmission, its scale-up has faced challenges. Several interventions to address these challenges in priority countries, including Uganda, have not yielded the desired results. This cross-sectional qualitative study aimed to explore the factors that affect the demand for VMMC and identify possible solutions. Semi-structured phone interviews were conducted with 29 males aged at least 18 and not more than 65 drawn randomly from a database representative of the general population maintained by an independent research organisation. Reflexive thematic analysis was conducted, and data analysis was done using NVivo version 12. The results were presented in narrative format with supporting quotes. The study received ethical and regulatory clearance to be conducted in Uganda. The average age of the respondents was 28 years. Almost all respondents had some education, and most lived in rural areas. Two themes were generated, namely, 1) deficits and opportunities for VMMC, which are issues that currently hinder the uptake of VMMC but, if addressed, would lead to better demand, and 2) pivots and shifts for VMMC, which are changes that need to be made to improve the uptake of VMMC. We found that several challenges, including myths, misconceptions, health system gaps, and uncertainties about the postoperative period, hindered the uptake of VMMC. Pivots and shifts for improving the uptake of VMMC include intensifying VMMC campaigns, addressing inequities, and addressing access barriers. We concluded that several challenges, including myths and misconceptions, health system-related gaps, and uncertainties in the post-circumcision period, persist and negatively impact the scale-up of VMMC in Uganda. VMMC beneficiaries have plausible proposals for addressing challenges. The Uganda Ministry of Health should address the myths, misconceptions, health system-related gaps, and uncertainties about the postoperative period and should involve VMMC beneficiaries in reviewing interventions to address gaps.
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Affiliation(s)
| | | | - Mark Limmer
- Department of Health Research, Lancaster University, Lancaster, UK
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Thomas ML, Zuma K, Loykissoonlal D, Dube ZB, Vranken P, Porter SE, Kripke K, Seatlhodi T, Meyer-Rath G, Johnson LF, Imai-Eaton JW. Substantial but spatially heterogeneous progress in male circumcision for HIV prevention in South Africa. COMMUNICATIONS MEDICINE 2024; 4:1. [PMID: 38172187 PMCID: PMC10764768 DOI: 10.1038/s43856-023-00405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 11/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) reduces the risk of male HIV acquisition by 60%. Programmes to provide VMMCs for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Traditional circumcision is also a long-standing male coming-of-age ritual, but practices vary considerably across populations. Accurate estimates of circumcision coverage by age, type, and time at subnational levels are required for planning and delivering VMMCs to meet targets and evaluating their impacts on HIV incidence. METHODS We developed a Bayesian competing risks time-to-event model to produce region-age-time-type specific probabilities and coverage of male circumcision with probabilistic uncertainty. The model jointly synthesises data from household surveys and health system data on the number of VMMCs conducted. We demonstrated the model using data from five household surveys and VMMC programme data to produce estimates of circumcision coverage for 52 districts in South Africa between 2008 and 2019. RESULTS Nationally, in 2008, 24.1% (95% CI: 23.4-24.8%) of men aged 15-49 were traditionally circumcised and 19.4% (18.9-20.0%) were medically circumcised. Between 2010 and 2019, 4.25 million VMMCs were conducted. Circumcision coverage among men aged 15-49 increased to 64.0% (63.2-64.9%) and medical circumcision coverage to 42% (41.3-43.0%). Circumcision coverage varied widely across districts, ranging from 13.4 to 86.3%. The average age of traditional circumcision ranged between 13 and 19 years, depending on local cultural practices. CONCLUSION South Africa has made substantial, but heterogeneous, progress towards increasing medical circumcision coverage. Detailed subnational information on coverage and practices can guide programmes to identify unmet need to achieve national and international targets.
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Affiliation(s)
- Matthew L Thomas
- Department of Earth and Environmental Sciences, University of Manchester, Manchester, UK.
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK.
| | - Khangelani Zuma
- Human and Social Capabilities Research Division, Human Sciences Research Council, Pretoria, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Peter Vranken
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Sarah E Porter
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Thapelo Seatlhodi
- National Department of Health, Pretoria, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Jeffrey W Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Ashipala DO, Nhokwara TB, Joel MH. Facilitators and barriers to voluntary medical male circumcision as an HIV prevention strategy in Kavango East, Namibia. S Afr Fam Pract (2004) 2023; 65:e1-e9. [PMID: 37265134 DOI: 10.4102/safp.v65i1.5684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/19/2023] [Accepted: 03/22/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) is a strategy used to try to limit new human immunodeficiency virus (HIV) infections, as it has the potential to reduce HIV and/or AIDS transmission from women to men by up to 60%. However, in spite of efforts by the Ministry of Health and Social Services, only a few men in Namibia have been circumcised. The objective of this study was to explore and describe the facilitators of, and barriers to, medical male circumcision for HIV prevention in Kavango East, Namibia. METHODS A qualitative, explorative, descriptive and contextual design was employed. The accessible population in this study comprised 18 health professionals who were selected for the study using a purposive sampling technique. RESULTS Participants reported numerous barriers to VMMC in Namibia. Barriers to VMMC included 'myths' and misconceptions attached to VMMC, age limitations, fear of pain and stigma associated with HIV, small VMMC team and long distances from health facilities. Facilitators to VMMC included family support, having experienced genital sores and genital warts or phimosis and paraphimosis. CONCLUSION The study revealed that a number of barriers must be overcome before VMMC before the desired number of men take advantage of VMMC. Multiple factors act as constraints to VMMC, including fear, myths and misconceptions, small VMMC teams and the long distance between clients' homes and VMMC services.Contribution: The study's findings can be used to develop targeted interventions and strategies that can be used by VMMC providers to address the identified barriers.
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Affiliation(s)
- Daniel O Ashipala
- Department of General Nursing Sciences, School of Nursing and Public Health, Faculty of Health Sciences and Veterinary Medicine, University of Namibia, Rundu.
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Feldacker C, Pienaar J, Wasunna B, Ndebele F, Khumalo C, Day S, Tweya H, Oni F, Sardini M, Adhikary B, Waweru E, Wafula MB, Dixon A, Jafa K, Su Y, Sherr K, Setswe G. Expanding the Evidence on the Safety and Efficiency of 2-Way Text Messaging-Based Telehealth for Voluntary Medical Male Circumcision Follow-up Compared With In-Person Reviews: Randomized Controlled Trial in Rural and Urban South Africa. J Med Internet Res 2023; 25:e42111. [PMID: 37159245 DOI: 10.2196/42111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/22/2022] [Accepted: 02/24/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND There is a dearth of high-quality evidence from digital health interventions in routine program settings in low- and middle-income countries. We previously conducted a randomized controlled trial (RCT) in Zimbabwe, demonstrating that 2-way texting (2wT) was safe and effective for follow-up after adult voluntary medical male circumcision (VMMC). OBJECTIVE To demonstrate the replicability of 2wT, we conducted a larger RCT in both urban and rural VMMC settings in South Africa to determine whether 2wT improves adverse event (AE) ascertainment and, therefore, the quality of follow-up after VMMC while reducing health care workers' workload. METHODS A prospective, unblinded, noninferiority RCT was conducted among adult participants who underwent VMMC with cell phones randomized in a 1:1 ratio between 2wT and control (routine care) in North West and Gauteng provinces. The 2wT participants responded to a daily SMS text message with in-person follow-up only if desired or an AE was suspected. The control group was requested to make in-person visits on postoperative days 2 and 7 as per national VMMC guidelines. All participants were asked to return on postoperative day 14 for study-specific review. Safety (cumulative AEs ≤day 14 visit) and workload (number of in-person follow-up visits) were compared. Differences in cumulative AEs were calculated between groups. Noninferiority was prespecified with a margin of -0.25%. The Manning score method was used to calculate 95% CIs. RESULTS The study was conducted between June 7, 2021, and February 21, 2022. In total, 1084 men were enrolled (2wT: n=547, 50.5%, control: n=537, 49.5%), with near-equal proportions of rural and urban participants. Cumulative AEs were identified in 2.3% (95% CI 1.3-4.1) of 2wT participants and 1.0% (95% CI 0.4-2.3) of control participants, demonstrating noninferiority (1-sided 95% CI -0.09 to ∞). Among the 2wT participants, 11 AEs (9 moderate and 2 severe) were identified, compared with 5 AEs (all moderate) among the control participants-a nonsignificant difference in AE rates (P=.13). The 2wT participants attended 0.22 visits, and the control participants attended 1.34 visits-a significant reduction in follow-up visit workload (P<.001). The 2wT approach reduced unnecessary postoperative visits by 84.8%. Daily response rates ranged from 86% on day 3 to 74% on day 13. Among the 2wT participants, 94% (514/547) responded to ≥1 daily SMS text messages over 13 days. CONCLUSIONS Across rural and urban contexts in South Africa, 2wT was noninferior to routine in-person visits for AE ascertainment, demonstrating 2wT safety. The 2wT approach also significantly reduced the follow-up visit workload, improving efficiency. These results strongly suggest that 2wT provides quality VMMC follow-up and should be adopted at scale. Adaptation of the 2wT telehealth approach to other acute follow-up care contexts could extend these gains beyond VMMC. TRIAL REGISTRATION ClinicalTrials.gov NCT04327271; https://www.clinicaltrials.gov/ct2/show/NCT04327271.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | | | | | | | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Geoffrey Setswe
- Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
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Jindai K, Farley T, Awori Q, Temu AS, Ndenzako F, Samuelson J. Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes. Gates Open Res 2023; 6:164. [PMID: 37089877 PMCID: PMC10115943 DOI: 10.12688/gatesopenres.13730.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.
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Affiliation(s)
- Kazuaki Jindai
- Department of Virology, Tohoku University, Sendai, Japan
- Department of Healthcare Epidemiology, Kyoto University, Kyoto, Japan
| | | | | | | | - Fabian Ndenzako
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
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Luseno WK, Rennie S, Gilbertson A. A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa. Int J Impot Res 2023; 35:269-278. [PMID: 34702986 PMCID: PMC8545773 DOI: 10.1038/s41443-021-00484-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022]
Abstract
Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.
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Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, NC, USA
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Mphepo KYG, Muula AS, Suzi J, Phuka F, Mfutso-Bengo J. Exploring culturally-preferred communication approaches for increased uptake of voluntary medical male circumcision (VMMC) services in rural Malawi. BMC Public Health 2023; 23:590. [PMID: 36991391 PMCID: PMC10061708 DOI: 10.1186/s12889-023-15363-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 03/02/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND In 2007 WHO and UNAIDS recommended communication interventions as a key strategy for creating demand for Voluntary Medical Male Circumcision (VMMC) in Southern Africa. In Malawi, VMMC communication interventions, implemented by health communication agencies, have effectively raised awareness of services. However, high awareness of VMMC has not resulted in increased uptake. Consequently, Malawi has achieved the lowest number of circumcisions in Southern Africa. METHODS These researchers carried out a study among the traditionally circumcising Yaos of Mangochi in Southern Region and the non-circumcising Chewas in Central Region. Data were collected using FGDs, KIIs, IDIs, Life Histories and Participatory Rural Appraisal methods. Data were analyzed thematically. RESULTS This study demonstrates two lessons. First, Laswell's Theory, which has traditionally been used in politics, is relevant to the health sector where the message delivery continuum also needs to be clear on source, message, audience, channel and intended effects. Secondly, according to informants, allowing communities to give feedback to the VMMC messages delivered by health promoters is fundamental. Therefore, failure by Laswell Theory to emphasize on feedback compromises its efficacy. It weakens its ability to foster a common vision between the source and the audience which is prerequisite for behavioral change. CONCLUSION The study concluded that community engagement and interpersonal communication which provide room for real-time feedback in any communicative event are the most preferred communication interventions for VMMC services among Yaos and Chewas.
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Affiliation(s)
- Kent Yelemia G Mphepo
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi.
| | - Adamson Sinjani Muula
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Joel Suzi
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Felix Phuka
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Joseph Mfutso-Bengo
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
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Peck ME, Ong KS, Lucas T, Harvey P, Lekone P, Letebele M, Thomas VT, Maziya V, Mkhontfo M, Gultie T, Mulatu D, Shimelis M, Zegeye T, Juma AW, Odoyo-June E, Musingila PK, Njenga J, Auld A, Kapito M, Maida A, Msungama W, Canda M, Come J, Malimane I, Aupokolo M, Zemburuka B, Kankindi I, Malamba S, Remera E, Tubane E, Machava R, Maphothi N, Vranken P, Amuri M, Kazaura KJ, Simbeye D, Alamo S, Kabuye G, Chituwo O, Kamboyi R, Masiye J, Mandisarisa J, Xaba S, Toledo C. Voluntary Medical Male Circumcisions for HIV Prevention - 13 Countries in Eastern and Southern Africa, 2017-2021. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2023; 72:256-260. [PMID: 36893046 PMCID: PMC10010757 DOI: 10.15585/mmwr.mm7210a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
In 2007, voluntary medical male circumcision (VMMC) was endorsed by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS after it was found to be associated with approximately a 60% reduction in the risk for female-to-male transmission of HIV (1). As a result of this endorsement, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), through partnerships with U.S. government agencies, including CDC, the U.S. Department of Defense, and the U.S. Agency for International Development, started supporting VMMCs performed in prioritized countries in southern and eastern Africa. During 2010-2016, CDC supported 5,880,372 VMMCs in 12 countries (2,3). During 2017-2021, CDC supported 8,497,297 VMMCs performed in 13 countries. In 2020, the number of VMMCs performed declined 31.8% compared with the number in 2019, primarily because of COVID-19-related disruptions to VMMC service delivery. PEPFAR 2017-2021 Monitoring, Evaluation, and Reporting data were used to provide an update and describe CDC's contribution to the scale-up of the VMMC program, which is important to meeting the 2025 Joint United Nations Programme on HIV/AIDS (UNAIDS) target of 90% of males aged 15-59 years having access to VMMC services in prioritized countries to help end the AIDS epidemic by 2030 (4).
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Kiyai RN, Ejalu DL, Kimuli D. Missed opportunity: low uptake of VMMC among men attending the OPD of a public health facility offering free VMMC services in Uganda. BMC Public Health 2023; 23:129. [PMID: 36653836 PMCID: PMC9847073 DOI: 10.1186/s12889-023-15056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Studies in various countries including Uganda and Kenya have shown a much lower incidence of the human immunodeficiency virus (HIV) among men that underwent voluntary medical male circumcision (VMMC) compared to uncircumcised men. Wakiso district, the district with the highest prevalence of HIV in Uganda (7%), has a very low estimated proportion of men who have undergone VMMC (30.5%). Within the district, various public health facilities provide free VMMC services. This study examined the prevalence and factors associated with the uptake of VMMC among men attending the outpatient department (OPD) of a public facility offering VMMC services. METHODS We conducted a cross-sectional study between July to August 2021 using a sample of men attending the OPD at Kira Health Centre IV. We defined VMMC uptake as the removal of all or part of the foreskin of the penis by a trained healthcare professional. We determined factors independently associated with VMMC uptake using a modified Poisson regression analysis with robust standard errors at a 5% statistical significance level. Adjusted prevalence risk ratios (APRR) were reported as the measure of outcome. RESULTS Overall, 389 participants were enrolled in the study. The mean age of the participants was 27.2 (standard deviation ± 9.02) years. The prevalence of VMMC uptake was 31.4% (95% Confidence Interval [CI] 26.8-36.2). In the adjusted analysis, the uptake of VMMC among men attending the OPD of Kira HC IV was less likely among married participants compared to unmarried participants (APRR 0.64, 95% CI 0.48-0.88), among participants from Western tribes (APRR 0.50, 95% CI 0.41-0.86) or Eastern tribes (APPR 0.31, 95% CI 0.13-0.72) compared to participants from the Central tribes and among participants who didn't disclose their sexual partner number compared to those that had one or no sexual partner (APRR 0.62, 95% CI 0.40-0.97). On the other hand, the prevalence of uptake of VMMC was 7 times among participants who were aware of VMMC compared to those who were not aware of VMMC (APRR 7.85 95% CI 1.07-9.80) and 2.7 times among participants who knew their HIV status compared to those that didn't know (APRR 2.75, 95% CI 1.85-4.0). Also, the uptake of VMMC was 85% more among participants who knew that Kira HC IV provided free VMMC services compared to those that didn't (APRR 1.85, 95% CI 1.85-4.08). CONCLUSION VMMC among men attending the OPD at the largest public healthcare facility proving free VMMC services in Kira Municipality was low. The OPD may provide a quick win for improving VMMC uptake. Collaborative efforts among the administration of Kira HC IV, the Ministry of Health and VMMC implementation partners could work towards developing health-facility-based strategies that can improve VMMC awareness and uptake with emphasis on the OPD.
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Affiliation(s)
- Ruth Nyaiti Kiyai
- grid.442648.80000 0001 2173 196XFaculty of Health Sciences, Uganda Martyrs University, P.O. Box 5498, Kampala, Uganda
| | - David Livingstone Ejalu
- grid.442648.80000 0001 2173 196XFaculty of Health Sciences, Uganda Martyrs University, P.O. Box 5498, Kampala, Uganda
| | - Derrick Kimuli
- Galen Holdings Group, P.O.Box, 7714, Kampala, Uganda. .,Faculty of Science and Technology, Department of Health Sciences, Cavendish University Uganda, P.O Box 33145, Kampala, Uganda.
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Gillespie SL, Chinen J, Paul ME. Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Jaradeh K, Van Fleet Kingery T, Cheruiyot J, Odhiambo F, Bukusi EA, Cohen CR, Shade SB. Cost comparison of a rapid results initiative against standard clinic-based model to scale-up voluntary medical male circumcision in Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000817. [PMID: 36989245 PMCID: PMC10057778 DOI: 10.1371/journal.pgph.0000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Voluntary male medical circumcision (VMMC) reduces HIV acquisition by up to 60%. Kenya has successfully scaled up VMMC to an estimated 91% of eligible men and boys in certain regions in combination due to VMMC and cultural circumcisions. VMMC as a program is implemented regionally in traditionally non-circumcising counties where the prevalence is still below 91%, ranging from 56.4% to 66.7%. Given that funding toward VMMC is expected to decline in the coming years, it is important to identify what models of service delivery are most appropriate and efficient to sustainably meet the VMMC needs of new cohorts' eligible men. To this end, we compared the costs of facility-based VMMC and one within a rapid results initiative (RRI), a public health service scheduled during school holidays to perform many procedures over a short period. We employed activity-based micro-costing to estimate the costs, from the implementer perspective, of facility-based VMMC and RRI-based VMMC conducted between October 2017 and September 2018 at 41 sites in Kisumu County, Kenya supported by the Family AIDS care & Education Services (FACES). We conducted site visits and reviewed financial ledger and programmatic data to identify and quantify resources consumed and the number of VMMC procedures performed during routine care and RRIs. Ledger data were used to estimate fixed costs, recurring costs, and cost per circumcision (CPC) in United States dollar (USD). A sensitivity analysis was done to estimate CPC where we allocated 6 months of the ledger to facility-based and 6 months to RRI. Overall, FACES spent $3,092,891 toward VMMC services and performed 42,139 procedures during the funding year. This included $2,644,910 in stable programmatic costs, $139,786 procedure costs, and $308,195 for RRI-specific activities. Over the year, 49% (n = 20,625) of procedures were performed as part of routine care and 51% (n = 21,514) were performed during the RRIs. Procedures conducted during facility-based cost $99.35 per circumcision, those conducted during the RRIs cost $48.51 per circumcision, and according to our sensitivity analysis, CPC for facility-based ranges from $99.35 to $287.24 and for RRI costs ranged from $29.81 to $48.51. The cost of VMMC during the RRI was substantially lower than unit costs reported in previous costing studies. We conclude that circumcision campaigns, such as the RRI, offer an efficient and sustainable approach to VMMC.
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Affiliation(s)
- Katrin Jaradeh
- School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Tyler Van Fleet Kingery
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Jackline Cheruiyot
- Centre for Microbiology Research, Kenya Medical Research Institute, Nyakach, Kenya
| | - Francesca Odhiambo
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nyakach, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Starley B Shade
- School of Medicine, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
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12
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Jindai K, Farley T, Awori Q, Temu AS, Ndenzako F, Samuelson J. Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes. Gates Open Res 2022; 6:164. [PMID: 37089877 PMCID: PMC10115943 DOI: 10.12688/gatesopenres.13730.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.
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Affiliation(s)
- Kazuaki Jindai
- Department of Virology, Tohoku University, Sendai, Japan
- Department of Healthcare Epidemiology, Kyoto University, Kyoto, Japan
| | | | | | | | - Fabian Ndenzako
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
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Voluntary Medical Male Circumcision for HIV Prevention: a Global Overview. Curr HIV/AIDS Rep 2022; 19:474-483. [PMID: 36348186 DOI: 10.1007/s11904-022-00632-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW With the promise of HIV prevention, there has been a scale-up of voluntary medical male circumcision (VMMC) in high HIV incidence/low circumcision prevalence nations worldwide. Nonetheless, debates over the implementation and the effectiveness and safety of the VMMC in real-world settings persist. We revisit the role of VMMC in HIV prevention to inform health professionals, policymakers, and advocates or opponents in this new era. RECENT FINDINGS There has been substantial progress on VMMC scale-up to date, but this has varied considerably by region. The evidence of solid and direct protection of VMMC is available for heterosexual men and older adolescent boys in sub-Saharan Africa. The protective effect in men who have sex with men is suggested by systematic reviews but is not confirmed by clinical trials. Sexual partners, including women, likely benefit indirectly from the increased VMMC coverage through a decreased risk of exposure to infected male partners. Fortunately, the preponderance of studies does not suggest higher sexual risk behaviors among circumcised men, so-called risk compensation. VMMC requires health systems strengthening and continued promulgation of other evidence-based HIV prevention strategies to be successful. Health authorities in high HIV incidence areas that have low circumcision coverage should implement VMMC within a context of complementary biomedical and behavioral prevention strategies.
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Peck ME, Ong KS, Lucas T, Prainito A, Thomas AG, Brun A, Kiggundu V, Yansaneh A, Busang L, Kgongwana K, Kelaphile D, Seipone K, Letebele MH, Makadzange PF, Marwiro A, Sesinyi M, Lapidos T, Lukhele N, Maziya V, Mkhontfo M, Gultie T, Mulatu D, Shimelis M, Zegeye T, Teka T, Bulterys M, Njenga JN, Odoyo-June E, Juma AW, Soo L, Talam N, Brown M, Chakare T, Nonyana N, Khoabane MA, Auld AF, Maida A, Msungama W, Kapito M, Nyirenda R, Matchere F, Odek J, Canda M, Malimane I, Come J, Gaspar N, Langa A, Aupokolo MA, Vejorerako KC, Kahindi L, Mali D, Zegeye A, Mangoya D, Zemburuka BL, Bamwesigye J, Kankindi I, Kayirangwa E, Malamba SS, Roels T, Kayonde L, Zimulinda E, Ndengo E, Nsanzimana S, Remera E, Rwibasira GN, Sangwayire B, Semakula M, Rugira E, Rugwizangoga E, Tubane E, Yoboka E, Lawrence J, Loykissoonlal D, Maphothi N, Achut V, Bunga S, Moi M, Amuri M, Kazaura K, Simbeye D, Fida N, Kayange AA, Seleman M, Akao J, Alamo ST, Kabuye G, Kyobutungi S, Makumbi FE, Mudiope P, Nantez B, Chituwo O, Godfrey L, Muyunda B, Kamboyi R, Masiye J, Lifuka E, Mandisarisa J, Mhangara M, Xaba S, Toledo C. Effects of COVID-19 Pandemic on Voluntary Medical Male Circumcision Services for HIV Prevention, Sub-Saharan Africa, 2020. Emerg Infect Dis 2022; 28:S262-S269. [PMID: 36502454 DOI: 10.3201/eid2813.212455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Beginning in March 2020, to reduce COVID-19 transmission, the US President's Emergency Plan for AIDS Relief supporting voluntary medical male circumcision (VMMC) services was delayed in 15 sub-Saharan African countries. We reviewed performance indicators to compare the number of VMMCs performed in 2020 with those performed in previous years. In all countries, the annual number of VMMCs performed decreased 32.5% (from 3,898,960 in 2019 to 2,631,951 in 2020). That reduction is largely attributed to national and local COVID-19 mitigation measures instituted by ministries of health. Overall, 66.7% of the VMMC global annual target was met in 2020, compared with 102.0% in 2019. Countries were not uniformly affected; South Africa achieved only 30.7% of its annual target in 2020, but Rwanda achieved 123.0%. Continued disruption to the VMMC program may lead to reduced circumcision coverage and potentially increased HIV-susceptible populations. Strategies for modifying VMMC services provide lessons for adapting healthcare systems during a global pandemic.
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15
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Agot K, Onyango J, Ochillo M, Odoyo-June E. VMMC Programmatic Successes and Challenges: Western Kenya Case Study. Curr HIV/AIDS Rep 2022; 19:491-500. [PMID: 36445648 DOI: 10.1007/s11904-022-00644-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW The Nyanza region of western Kenya is lauded for impressive coverage of voluntary medical male circumcision (VMMC) and remains the bedrock of the VMMC program in Kenya. We conducted literature review on programmatic successes and challenges of implementing VMMC program in the region. RECENT FINDINGS Responsive stakeholders' engagement, robust policy environment, effective technical working groups, prompt capacity building of health facilities, government support, flexible implementation strategies, and sustained donor funding contributed to the successes of the program that saw circumcision prevalence in Nyanza reach between 75.6 and 85.3% among 15-29-year-olds by 2019. However, the lack of support for early infant circumcision, inadequate domestic financing, and slow pace of service integration into government health facilities continue to undermine the progress towards sustainability. While local ownership of the VMMC program has been demonstrated through its inclusion in county annual health workplans and progressive integration into routine health care, continued dependence on declining external funding threatens its sustainability. Furthermore, Kenya is experiencing a youth bulge with a projected high demand for VMMC which calls for increased resource inputs into the program. Strategies are therefore needed to increase domestic resource inflows into VMMC.
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Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya.
| | - Jacob Onyango
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya
| | - Marylyn Ochillo
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya
| | - Elijah Odoyo-June
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global, HIV & TB, Kisumu, Kenya
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Transitioning a digital health innovation from research to routine practice: Two-way texting for male circumcision follow-up in Zimbabwe. PLOS DIGITAL HEALTH 2022; 1:e0000066. [PMID: 36812548 PMCID: PMC9931231 DOI: 10.1371/journal.pdig.0000066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022]
Abstract
Adult medical male circumcision (MC) is safe: global notifiable adverse event (AE) rates average below 2.0%. With Zimbabwe's shortage of health care workers (HCWs) compounded by COVID-19 constraints, two-way text-based (2wT) MC follow-up may be advantageous over routinely scheduled in-person reviews. A 2019 randomized control trial (RCT) found 2wT to be safe and efficient for MC follow-up. As few digital health interventions successfully transition from RCT to scale, we detail the 2wT scale-up approach from RCT to routine MC practice comparing MC safety and efficiency outcomes. After the RCT, 2wT transitioned from a site-based (centralized) system to hub-and-spoke model for scale-up where one nurse triaged all 2wT patients, referring patients in need to their local clinic. No post-operative visits were required with 2wT. Routine patients were expected to attend at least one post-operative review. We compare 1) AEs and in-person visits between 2wT men from RCT and routine MC service delivery; and 2) 2wT-based and routine follow-up among adults during the 2wT scale-up period, January to October 2021. During scale-up period, 5084 of 17417 adult MC patients (29%) opted into 2wT. Of the 5084, 0.08% (95% CI: 0.03, 2.0) had an AE and 71.0% (95% CI: 69.7, 72.2) responded to ≥1 daily SMS, a significant decrease from the 1.9% AE rate (95% CI: 0.7, 3.6; p<0.001) and 92.5% response rate (95% CI: 89.0, 94.6; p<0.001) from 2wT RCT men. During scale-up, AE rates did not differ between routine (0.03%; 95% CI: 0.02, 0.08) and 2wT (p = 0.248) groups. Of 5084 2wT men, 630 (12.4%) received telehealth reassurance, wound care reminders, and hygiene advice via 2wT; 64 (19.7%) were referred for care of which 50% had visits. Similar to RCT outcomes, routine 2wT was safe and provided clear efficiency advantages over in-person follow-up. 2wT reduced unnecessary patient-provider contact for COVID-19 infection prevention. Rural network coverage, provider hesitancy, and the slow pace of MC guideline changes slowed 2wT expansion. However, immediate 2wT benefits for MC programs and potential benefits of 2wT-based telehealth for other health contexts outweigh limitations.
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Marukutira T, Ussery F, Kadima E, Mills LA, Moore J, Block L, Bachanas P, Davis S, Schissler T, Mosha R, Komotere O, Diswai T, Ntsuape C, Lebelonyane R, Bock N. Male circumcision uptake during the Botswana Combination Prevention Project. PLoS One 2022; 17:e0269178. [PMID: 35704556 PMCID: PMC9200323 DOI: 10.1371/journal.pone.0269178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Voluntary medical male circumcision (VMMC) uptake has been slow in some countries, including Botswana. To inform demand creation efforts, we examined sociodemographic characteristics and referral procedures associated with VMMC uptake in the Botswana Combination Prevention Project (BCPP) and examined the effectiveness of referral of men to MC services from HIV testing venues. DESIGN BCPP was a community-randomized trial evaluating the impact of a combination HIV prevention package which included VMMC on community HIV incidence. We conducted a sub-analysis of VMMC uptake in intervention communities. METHODS During the initial VMMC campaign in 15 intervention communities, baseline male circumcision (MC) status was assessed among men eligible for HIV testing. Uncircumcised male community residents aged 16-49 years with negative/unknown HIV status were mobilized and linked to study VMMC services. Outcomes included MC baseline status and uptake through study services. Univariate and multivariate logistic regressions were performed to identify factors associated with MC uptake. RESULTS Of 12,864 men eligible for testing, 50% (n = 6,448) were already circumcised. Among the uncircumcised men (n = 6,416), 10% (n = 635) underwent MC. Of the 5,071 men identified as eligible for MC through HIV testing services, 78% declined referral and less than 1% of those were circumcised. Of those accepting referral (n = 1,107), 16% were circumcised. Younger (16-24 years) (aOR: 1.51; 95%CI:1.22,1.85), unemployed men (aOR:1.34; 95%CI: 1.06,1.69), and those undergoing HIV testing at mobile venues (aOR: 1.88; 95%CI: 1.53,2.31) were more likely to get circumcised. Fear of pain was the most prevalent (27%) reason given for not being circumcised. CONCLUSION Younger, unemployed men seeking HIV testing at mobile sites in Botswana were more likely to get VMMC. Addressing unique barriers for employed and older men may be necessary. Given the simplicity of VMMC as an intervention, the HIV testing programs offer a platform for identifying uncircumcised men and offering information and encouragement to access services.
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Affiliation(s)
| | - Faith Ussery
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Etienne Kadima
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Lisa A. Mills
- Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Jan Moore
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Lisa Block
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Northrop Grumman Corporation, Atlanta, Georgia, United States of America
| | - Pam Bachanas
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Stephanie Davis
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | | | | | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Ministry of Health, Gaborone, Botswana
| | | | - Naomi Bock
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Defining the Global Research and Programmatic Agenda and Priority Actions for Voluntary Medical Male Circumcision for HIV Prevention. Curr HIV/AIDS Rep 2022; 19:537-547. [PMID: 36367637 PMCID: PMC9651117 DOI: 10.1007/s11904-022-00640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE OF REVIEW Since 2007, voluntary medical male circumcision (VMMC) programs have been associated with substantially reduced HIV incidence across 15 prioritized countries in Eastern and Southern Africa. Drawing on the programmatic experience of global VMMC leaders, this report reviews progress made in the first 15 years of the program, describes programmatic and research gaps, and presents considerations to maximize the impact of VMMC. RECENT FINDINGS Overall, key programmatic and research gaps include a lack of robust male circumcision coverage estimates due to limitations to the data and a lack of standardized approaches across programs; challenges enhancing VMMC uptake include difficulties reaching populations at higher risk for HIV infection and men 30 years and older; limitations to program and procedural quality and safety including variations in approaches used by programs; and lastly, sustainability with limited evidence-based practices. Considerations to address these gaps include the need for global guidance on estimating coverage, conducting additional research on specific sub-populations to improve VMMC uptake, implementation of responsive and comprehensive approaches to adverse event surveillance, and diversifying financing streams to progress towards sustainability. This report's findings may help establish a global VMMC research and programmatic agenda to inform policy, research, and capacity-building activities at the national and global levels.
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19
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Njeuhmeli E, Tchuenche M, Opuni M, Stegman P, Hamilton M, Forsythe S, Nhaduco F, Zita F, Gaspar N, Come J. The voluntary medical male circumcision Site Capacity and Productivity Assessment Tool (SCPT): An innovative visual management tool to optimize site service delivery. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000126. [PMID: 36962141 PMCID: PMC10022027 DOI: 10.1371/journal.pgph.0000126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/31/2021] [Indexed: 11/17/2022]
Abstract
Given constrained funding for HIV, achieving global goals on VMMC scale-up requires that providers improve service delivery operations and use labor and capital inputs as efficiently as possible to produce as many quality VMMCs as feasible. The Voluntary Medical Male Circumcision Site Capacity and Productivity Assessment Tool (SCPT) is an electronic visual management tool developed to help VMMC service providers to understand and improve their site's performance. The SCPT allows VMMC providers to: 1) track the most important human resources and capital inputs to VMMC service delivery, 2) strategically plan site capacity and targets, and 3) monitor key site-level VMMC service delivery performance indicators. To illustrate a real-world application of the SCPT, we present selected data from two provinces in Mozambique-Manica and Tete, where the SCPT was piloted We looked at the data prior to the introduction of SCPT (October 2014 to August 2016), and during the period when the tool began to be utilized (September 2016 to September 2017). The tool was implemented as part of a broader VMMC site optimization strategy that VMMC implementers in Mozambique put in place to maximize programmatic impact. Routine program data for Manica and Tete from October 2014 to September 2017 showcase the turnaround of the VMMC program that accompanied the implementation of the SCPT together with the other components of the VMMC site optimizatio strategy. From October 2016, there was a dramatic increase in the number of VMMCs performed. The number of fixed service delivery sites providing VMMC services was expanded, and each fixed site extended service delivery by performing VMMCs in outreach sites. Alignment between site targets and the number of VMMCs performed improved from October 2016. Utilization rates stabilized between October 2016 and September 2017, with VMMCs performed closely tracking VMMC site capacity in most sites. The SCPT is designed to address the need for site level data for programmatic decision-making during site planning, implementation, monitoring and evaluation. Deployment of the SCPT can help VMMC providers monitor the performance of VMMC service delivery sites and improve their performance. We recommend use of the customized version of this tool and model to the need of other programs.
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Affiliation(s)
- Emmanuel Njeuhmeli
- Rollins School of Public Health, Emory University School of Public Health, Atlanta, GA United States of America
| | | | | | - Peter Stegman
- Avenir Health, Glastonbury, CT, United States of America
| | - Matt Hamilton
- Avenir Health, Glastonbury, CT, United States of America
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Rosen JG, Carrasco MA, Traub AM, Kumoji E‘K. Barriers, benefits, and behaviour: Voluntary medical male circumcision ideation in a population-based sample of Zambian men. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2021; 20:314-323. [PMID: 34905454 PMCID: PMC8994851 DOI: 10.2989/16085906.2021.2006727] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Reaching ambitious voluntary medical male circumcision (VMMC) coverage targets requires a deeper understanding of the multifaceted processes shaping men's willingness to access VMMC. Guided by the Ideation Model for Health Communication, this population-based study identifies correlates of Zambian men's future VMMC intentions. Multistage cluster sampling was used to identify households with adult men in 14 districts. Multivariable Poisson regression with robust standard errors modelled associations of future VMMC intent with ideational factors (e.g. perceived benefits and barriers) and sexual behaviours respectively. Forty per cent (40%) of uncircumcised men (N = 1 204) expressed future VMMC intentions. In multivariable analysis, VMMC intent was associated with secondary education or higher (Adjusted Prevalence Ratio [APR] 1.30, 95% Confidence Interval [95% CI]: 1.02-1.66), perceiving VMMC to increase sexual satisfaction (APR 1.45, 95% CI: 1.11-1.89), reporting distance to services as a barrier to VMMC uptake (APR = 0.54, 95% CI: 1.27-1.87), unprotected last sex (APR 1.54, 95% CI: 1.11-2.14), and ≥ 2 sexual partners in the past 12 months (APR 1.45, 95% CI: 1.05-1.99). Being aged ≥ 45 years (vs 18-24 years: APR 0.23, 95% CI: 0.13-0.40) and perceiving that circumcision: (1) is unimportant (APR 0.71, 95% CI: 0.51-0.98); (2) is incompatible with local customs (APR 0.41, 95% CI: 0.18-0.94); or (3) reduces sexual satisfaction (APR 0.10, 95% CI: 0.02-0.62) were inversely associated with future VMMC intent. Demand-creation efforts must confront salient cognitive and social barriers to VMMC uptake, including concerns around incompatibility with local customs. Simultaneously, promotional efforts should emphasise relevant VMMC benefits beyond HIV prevention that resonate with men (e.g. penile hygiene) without reinforcing harmful gender norms.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Maria A Carrasco
- Office of Family Planning and Reproductive Health, United States Agency for International Development, Washington DC, USA
| | - Ariana M Traub
- Office of HIV/AIDS, United States Agency for International Development, Washington DC, USA
| | - E ‘Kuor Kumoji
- Research and Evaluation Division, Johns Hopkins Center for Communication Programs, Baltimore, USA
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Loevinsohn G, Kigozi G, Kagaayi J, Wawer MJ, Nalugoda F, Chang LW, Quinn TC, Serwadda D, Reynolds SJ, Nelson L, Mills L, Alamo S, Nakigozi G, Kabuye G, Ssekubugu R, Tobian AAR, Gray RH, Grabowski MK. Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda. Clin Infect Dis 2021; 73:e1946-e1953. [PMID: 33043978 PMCID: PMC8492113 DOI: 10.1093/cid/ciaa1533] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/06/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President's Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. METHODS A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men. RESULTS A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21-35 years) to 22 years (IQR, 18-29 years) (P for trend < .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28-.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time. CONCLUSIONS VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.
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Affiliation(s)
- Gideon Loevinsohn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Larry W Chang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- School of Public Health, Makerere University, Kampala, Uganda
| | - Steven J Reynolds
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Nelson
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Lisa Mills
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Stella Alamo
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Geoffrey Kabuye
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Aaron A R Tobian
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - M Kathryn Grabowski
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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22
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Glidden DV. Statistical approaches to accelerate the development of long-acting antiretrovirals for HIV pre-exposure prophylaxis. Curr Opin HIV AIDS 2021; 15:56-60. [PMID: 31567437 DOI: 10.1097/coh.0000000000000589] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review considers statistical issues in the design and analysis of the studies used to develop long-acting formulations of antiretrovirals for pre-exposure prophylaxis (PrEP). RECENT FINDING An abundant pipeline of products is maturing. Accelerating their evaluation as clinical products requires abandonment of noninferiority standards. Randomized trials should be based on the comparison of principled but innovative estimates of background HIV risk and enrich enrollment for those who do not desire current PrEP products. At every stage of testing, innovative analyses can be applied to help inform and accelerate later studies. SUMMARY The development of new long-acting PrEP regimens can be accelerated by innovations in design, ingenuity in synthesizing data sources, and application of causal inference methods.
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Bautista-Arredondo S, Pineda-Antunez C, Cerecero-Garcia D, Cameron DB, Alexander L, Chiwevu C, Forsythe S, Tchuenche M, Dow WH, Kahn J, Gomez GB, Vassall A, Bollinger LA, Levin C. Moving away from the "unit cost". Predicting country-specific average cost curves of VMMC services accounting for variations in service delivery platforms in sub-Saharan Africa. PLoS One 2021; 16:e0249076. [PMID: 33886576 PMCID: PMC8062035 DOI: 10.1371/journal.pone.0249076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/10/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND One critical element to optimize funding decisions involves the cost and efficiency implications of implementing alternative program components and configurations. Program planners, policy makers and funders alike are in need of relevant, strategic data and analyses to help them plan and implement effective and efficient programs. Contrary to widely accepted conceptions in both policy and academic arenas, average costs per service (so-called "unit costs") vary considerably across implementation settings and facilities. The objective of this work is twofold: 1) to estimate the variation of VMMC unit costs across service delivery platforms (SDP) in Sub-Saharan countries, and 2) to develop and validate a strategy to extrapolate unit costs to settings for which no data exists. METHODS We identified high-quality VMMC cost studies through a literature review. Authors were contacted to request the facility-level datasets (primary data) underlying their results. We standardized the disparate datasets into an aggregated database which included 228 facilities in eight countries. We estimated multivariate models to assess the correlation between VMMC unit costs and scale, while simultaneously accounting for the influence of the SDP (which we defined as all possible combinations of type of facility, ownership, urbanicity, and country), on the unit cost variation. We defined SDP as any combination of such four characteristics. Finally, we extrapolated VMMC unit costs for all SDPs in 13 countries, including those not contained in our dataset. RESULTS The average unit cost was 73 USD (IQR: 28.3, 100.7). South Africa showed the highest within-country cost variation, as well as the highest mean unit cost (135 USD). Uganda and Namibia had minimal within-country cost variation, and Uganda had the lowest mean VMMC unit cost (22 USD). Our results showed evidence consistent with economies of scale. Private ownership and Hospitals were significant determinants of higher unit costs. By identifying key cost drivers, including country- and facility-level characteristics, as well as the effects of scale we developed econometric models to estimate unit cost curves for VMMC services in a variety of clinical and geographical settings. CONCLUSION While our study did not produce new empirical data, our results did increase by a tenfold the availability of unit costs estimates for 128 SDPs in 14 priority countries for VMMC. It is to our knowledge, the most comprehensive analysis of VMMC unit costs to date. Furthermore, we provide a proof of concept of the ability to generate predictive cost estimates for settings where empirical data does not exist.
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Affiliation(s)
| | - Carlos Pineda-Antunez
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Diego Cerecero-Garcia
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Drew B. Cameron
- University of California Berkeley, Berkeley, CA, United States of America
| | - Lily Alexander
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Chris Chiwevu
- Independent Consultant, Fairfax, VA, United States of America
| | | | | | - William H. Dow
- University of California Berkeley, Berkeley, CA, United States of America
| | - James Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, United States of America
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Carol Levin
- University of California Berkeley, Berkeley, CA, United States of America
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Masango BZ, Ferrandiz-Mont D, Chiao C. Associations Between Early Circumcision, Sexual and Protective Practices, and HIV Among a National Sample of Male Adults in Eswatini. AIDS Behav 2021; 25:973-982. [PMID: 33025391 DOI: 10.1007/s10461-020-03056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Abstract
To reduce HIV incidence in countries such as Eswatini (Swaziland), UNAIDS has recommended male circumcision as one possible effective strategy. We analyzed the 2016s Swaziland HIV Incidence Measurement Survey to explore the association between early circumcision and HIV history among 2964 sexually active adult males aged 15 to 64 years old. Early circumcision was defined as circumcision practiced at an age of 15 years old or younger. Results from logistic regression and OLS regression found that male adults with early circumcision are more likely to have multiple sexual partners and to use condoms. Multiple partners and condom use at last sex encounter remained associated with a higher odds of being HIV positive after controlling for all factors. Nevertheless, early circumcision is significantly associated with a lower odds of being HIV positive (AOR 0.53, p < 0.01). These findings suggest that HIV prevention may benefit when early male circumcision is carried out.
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25
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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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26
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Toms K, Potter H, Balaba M, Parkes-Ratanshi R. Efficacy of HIV interventions in African fishing communities: A systematic review and qualitative synthesis. Int J Infect Dis 2020; 101:326-333. [PMID: 33017696 DOI: 10.1016/j.ijid.2020.09.1476] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/26/2020] [Accepted: 09/27/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES This systematic review aims to qualitatively synthesize existing evidence on the efficacy of HIV interventions in African fishing communities. METHODS Five databases (NCBI PubMed, EMBASE, Web of Science Core Collection, The Cochrane Library, and CABI Global Health Database) were searched in March 2019 for eligible studies. All peer-reviewed papers with a defined HIV intervention explicitly mentioning African fishing communities were included. Outcomes included any measure of the efficacy of HIV interventions. RESULTS Of 22,289 search results, data was extracted from 25 eligible studies that passed critical appraisal; seven involved HIV prevention, six HIV testing and counseling, three treatment, and nine combinations of more than one intervention. Findings include a high coverage of safe male circumcision (SMC) but low condom use among fisher folk, and a preference for PrEP over other HIV prevention services. Uptake of HIV testing and ART coverage are below levels required to reach UNAIDS 90-90-90 targets, and there is a high demand for ART and HIV self-testing kits. CONCLUSIONS Greater provision of services to combat HIV, specifically amongst fishing communities, is required; there is limited information on retaining fisher folk in care and achieving an undetectable viral load. Interventions tailored to individual fishing populations, offered in parallel to education or counseling services are likely to be most effective. Use of innovations, including mobile health and medical drones, could assist these hard-to-reach populations. Our findings will inform future HIV service provision in fishing communities.
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Affiliation(s)
- Kieran Toms
- University of Cambridge School of Clinical Medicine, Box 111 Cambridge Biomedical Campus, Cambridge, CB2 0SP, UK.
| | - Harriet Potter
- University of Cambridge School of Clinical Medicine, Box 111 Cambridge Biomedical Campus, Cambridge, CB2 0SP, UK.
| | - Martin Balaba
- Infectious Disease Institute, Makerere University, P.O. Box 22418, Kampala, Uganda.
| | - Rosalind Parkes-Ratanshi
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Cambridge, CB2 0SR, UK.
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27
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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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28
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Carrasco MA, Rosen JG, Maile L, Manda R, Amzel A, Kiggundu V. Medically, Traditionally, and Dually Circumcised Men in Lesotho: Population-Based Measurements of HIV/STI Infections, Sexual Risk Behaviors, and Service Use Patterns. AIDS Behav 2020; 24:2112-2118. [PMID: 31927757 DOI: 10.1007/s10461-019-02776-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Voluntary medical male circumcision (VMMC) is an HIV prevention priority in Lesotho, but uptake remains suboptimal. We analyzed the 2014 Lesotho Demographic and Health Survey to assess population-level social, behavioral, and serological correlates of circumcision status, specifically traditional and/or medical circumcision. Among 2931 men, approximately half were traditionally circumcised, and fewer than 25% were medically circumcised. Only 4% were dually (traditionally and medically) circumcised. In multivariate analysis, only medical circumcision emerged as significantly (p < 0.05) protective against HIV infection, whereas dual circumcision was significantly associated with past-year STI symptomology. Younger (ages 15-24), lower educated, rural-dwelling, and traditionally circumcised men, including those who never tested for HIV, had significantly lower odds of medical circumcision. Our findings indicate other unmeasured behavioral factors may mitigate VMMC's protective effect against HIV and STI infections in dually circumcised men. Further research can help identify counseling and demand creation strategies for traditionally circumcised men presenting for VMMC.
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Affiliation(s)
- Maria A Carrasco
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA.
- , Arlington, USA.
| | - Joseph G Rosen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Limpho Maile
- Ministry of Health, Kingdom of Lesotho, Maseru, Lesotho
| | - Robert Manda
- United States Agency for International Development, Maseru, Lesotho
| | - Anouk Amzel
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Valerian Kiggundu
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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29
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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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30
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Wirth KE, Gaolathe T, Pretorius Holme M, Mmalane M, Kadima E, Chakalisa U, Manyake K, Matildah Mbikiwa A, Simon SV, Letlhogile R, Mukokomani K, van Widenfelt E, Moyo S, Bennett K, Leidner J, Powis KM, Lebelonyane R, Alwano MG, Jarvis J, Dryden-Peterson SL, Kgathi C, Moore J, Bachanas P, Raizes E, Abrams W, Block L, Sento B, Novitsky V, El-Halabi S, Marukutira T, Mills LA, Sexton C, Pals S, Shapiro RL, Wang R, Lei Q, DeGruttola V, Makhema J, Essex M, Lockman S, Tchetgen Tchetgen EJ. Population uptake of HIV testing, treatment, viral suppression, and male circumcision following a community-based intervention in Botswana (Ya Tsie/BCPP): a cluster-randomised trial. Lancet HIV 2020; 7:e422-e433. [PMID: 32504575 PMCID: PMC7864245 DOI: 10.1016/s2352-3018(20)30103-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 03/20/2020] [Accepted: 03/20/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND In settings with high HIV prevalence and treatment coverage, such as Botswana, it is unknown whether uptake of HIV prevention and treatment interventions can be increased further. We sought to determine whether a community-based intervention to identify and rapidly treat people living with HIV, and support male circumcision could increase population levels of HIV diagnosis, treatment, viral suppression, and male circumcision in Botswana. METHODS The Ya Tsie Botswana Combination Prevention Project study was a pair-matched cluster-randomised trial done in 30 communities across Botswana done from Oct 30, 2013, to June 30, 2018. 15 communities were randomly assigned to receive HIV prevention and treatment interventions, including enhanced HIV testing, earlier antiretroviral therapy (ART), and strengthened male circumcision services, and 15 received standard of care. The first primary endpoint of HIV incidence has already been reported. In this Article, we report findings for the second primary endpoint of population uptake of HIV prevention services, as measured by proportion of people known to be HIV-positive or tested HIV-negative in the preceding 12 months; proportion of people living with HIV diagnosed and on ART; proportion of people living with HIV on ART with viral suppression; and proportion of HIV-negative men circumcised. A longitudinal cohort of residents aged 16-64 years from a random, approximately 20% sample of households across the 15 communities was enrolled to assess baseline uptake of study outcomes; we also administered an end-of-study survey to all residents not previously enrolled in the longitudinal cohort to provide study end coverage estimates. Differences in intervention uptake over time by randomisation group were tested via paired Student's t test. The study has been completed and is registered with ClinicalTrials.gov (NCT01965470). FINDINGS In the six communities participating in the end-of-study survey, 2625 residents (n=1304 from standard-of-care communities, n=1321 from intervention communities) were enrolled into the 20% longitudinal cohort at baseline from Oct 30, 2013, to Nov 24, 2015. In the same communities, 10 791 (86%) of 12 489 eligible enumerated residents not previously enrolled in the longitudinal cohort participated in the end-of-study survey from March 30, 2017, to Feb 25, 2018 (5896 in intervention and 4895 in standard-of-care communities). At study end, in intervention communities, 1228 people living with HIV (91% of 1353) were on ART; 1166 people living with HIV (88% of 1321 with available viral load) were virally suppressed, and 673 HIV-negative men (40% of 1673) were circumcised in intervention communities. After accounting for baseline differences, at study end the proportion of people living with HIV who were diagnosed was significantly higher in intervention communities (absolute increase of 9% to 93%) compared with standard-of-care communities (absolute increase of 2% to 88%; prevalence ratio [PR] 1·08 [95% CI 1·02-1·14], p=0·032). Population levels of ART, viral suppression, and male circumcision increased from baseline in both groups, with greater increases in intervention communities (ART PR 1·12 [95% CI 1·07-1·17], p=0·018; viral suppression 1·13 [1·09-1·17], p=0·017; male circumcision 1·26 [1·17-1·35], p=0·029). INTERPRETATION It is possible to achieve very high population levels of HIV testing and treatment in a high-prevalence setting. Maintaining these coverage levels over the next decade could substantially reduce HIV transmission and potentially eliminate the epidemic in these areas. FUNDING US President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.
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Affiliation(s)
- Kathleen E Wirth
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | | | - Molly Pretorius Holme
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Mompati Mmalane
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Etienne Kadima
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Unoda Chakalisa
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kutlo Manyake
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Rona Letlhogile
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Sikhulile Moyo
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kara Bennett
- Bennett Statistical Consulting, Ballston Lake, NY, USA
| | - Jean Leidner
- Goodtables Data Consulting, Norman, Oklahoma, USA
| | - Kathleen M Powis
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | - Mary Grace Alwano
- Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Joseph Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Scott L Dryden-Peterson
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Coulson Kgathi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Janet Moore
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Pam Bachanas
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elliot Raizes
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William Abrams
- Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Lisa Block
- Centers for Disease Control and Prevention, Atlanta, GA, USA; Intellectual Concepts, Atlanta, GA, USA
| | - Baraedi Sento
- Tebelopele Voluntary Counseling and Testing Center, Gaborone, Botswana
| | - Vlad Novitsky
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | - Lisa A Mills
- Centers for Disease Control and Prevention-Botswana, Gaborone, Botswana
| | - Connie Sexton
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sherri Pals
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Roger L Shapiro
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rui Wang
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA; Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Quanhong Lei
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Victor DeGruttola
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Joseph Makhema
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Myron Essex
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Shahin Lockman
- Department of Immunology and Infectious Diseases, Harvard T H Chan School of Public Health, Boston, MA, USA; Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eric J Tchetgen Tchetgen
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Statistics, The Wharton School at the University of Pennsylvania, Philadelphia, PA, USA
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Pintye JC, Wirth KE, Ntsuape C, Kleinman NJ, Spees L, Semo BW, Mawandia S, Ledikwe J. Sexual function after voluntary medical male circumcision for human immunodeficiency virus prevention: Results from a programmatic delivery setting in Botswana. South Afr J HIV Med 2020; 21:1042. [PMID: 32391176 PMCID: PMC7203194 DOI: 10.4102/sajhivmed.v21i1.1042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/28/2019] [Indexed: 11/04/2022] Open
Abstract
Background Uptake of voluntary medical male circumcision (VMMC) remains modest in Botswana in spite of the government’s commitment and service provision availability. Data on sexual function post-VMMC in programmatic settings could help guide messaging tailored to Botswana. Objectives At 3-month post-VMMC, we evaluated changes in sexual function and satisfaction with the VMMC procedure amongst a cohort of HIV-negative, sexually active men aged 18–49 years who underwent VMMC in a public-sector clinic in Botswana. Methods We assessed whether each of the following domains of sexual function had improved, stayed the same or worsened since VMMC: sexual desire, ability to use condoms, ease of vaginal penetration, ease of ejaculation, ability to achieve and maintain an erection and hygiene or cleanliness. Results Data on sexual function were available for 378 men at 3-month post-VMMC. Median age was 27 years – 54% had a higher than secondary education, 72% were employed and 27% were married. Nearly all (96%) the men reported improvement in at least one domain of sexual function, while 19% reported improvement in all six domains. One-fourth (91/378, 24%) of the men reported that at least one domain of sexual function worsened post-VMMC. The most frequently reported domain that worsened was sexual desire (11%); in all other domains, < 10% of the men reported worsening. Men who reported any worsening sexual function were 2.3-fold as likely to be less than ‘very satisfied’ with the VMMC procedure (risk ratio 2.36, 95% confidence interval [CI] 1.66–3.34, p < 0.001). Conclusion Emphasising improved sexual function experienced after VMMC in demand-creation efforts could potentially increase VMMC uptake in Botswana.
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Affiliation(s)
- Jillian C Pintye
- Department of Global Health, University of Washington, Seattle, United States
| | - Kathleen E Wirth
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health and Wellness, Gaborone, Botswana
| | - Nora J Kleinman
- Department of Global Health, University of Washington, Seattle, United States.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,NJK Consulting, Seattle, Washington, United States.,Amgen Asia Holdings Ltd, Hong Kong, Japan
| | - Lisa Spees
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, United States.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, United States
| | - Bazghina-Werq Semo
- Department of Global Health, University of Washington, Seattle, United States.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,FHI 360, Washington, Washington, United States
| | - Shreshth Mawandia
- Department of Global Health, University of Washington, Seattle, United States.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Jenny Ledikwe
- Department of Global Health, University of Washington, Seattle, United States.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
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32
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Medical Male Circumcision and Associations Among Sexually Transmitted Infections Service Attendees. AIDS Behav 2020; 24:1422-1431. [PMID: 31720907 DOI: 10.1007/s10461-019-02729-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Medical male circumcision (MMC) is a proven intervention for preventing HIV acquisition among males. We describe the circumcision status, eligibility for MMC referral and associations with HIV positivity among symptomatic males attending sexually transmitted infections (STI) services. This study was a secondary analysis of cross-sectional data collected during sentinel surveillance for STI aetiologies. In the sentinel surveillance conducted at primary care facilities located in six South African provinces, an anonymous questionnaire was administered followed by collection of appropriate genital and blood specimens for laboratory testing including HIV, rapid plasma reagin (RPR) and HSV-2 serological testing. During analysis, multivariable logistic regression was used to determine association between prevalent HIV infection and male circumcision among males who were HSV-2 AND/OR RPR serology positive and among those who were negative. A total of 847 males were included the analysis, among whom the median age was 28 years (IQR 24-32 years) with 26.3% aged < 25 years. Of these, 166 (19.6%) were medically circumcised, 350 (41.4%) traditionally circumcised while 324 (39%) were not circumcised. The yield of assessment for MMC referral was 27.7%. Overall HIV positivity was 23.1%. Compared to no circumcision, MMC had a statistically insignificant 62% lower odds of being HIV positive -among males who were HSV-2 and RPR negative- adjusted odds ratio [aOR] 0.38 [95% confidence interval (CI) 0.12-1.18], p = 0.094. Among those HSV-2 AND/OR RPR positive, MMC had a statistically insignificant 26% lower odds of being HIV positive- aOR 0.74 (95% CI 0.41-1.36), p = 0.334. In both groups HIV positivity increased with age but was positively associated with condom use at last sexual encounter [aOR 3.41 (95% CI 1.43-8.15)] and previous treatment for an STI syndrome [aOR 3.81 (95% CI 1.60-9.05)] among those HSV-2 and RPR negative. High HIV positivity and high yield of eligibility for VMMC referral among males attending STI services points to the need for better integration of HIV prevention and treatment with STI care.
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Social representations of the prevention of heterosexual transmission of HIV among young Africans from five countries, 1997-2014. PLoS One 2020; 15:e0227878. [PMID: 32142515 PMCID: PMC7059925 DOI: 10.1371/journal.pone.0227878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/31/2019] [Indexed: 01/29/2023] Open
Abstract
HIV prevention has evolved dramatically since the 1990s. The ABC trilogy (abstinence, be faithful, use a condom) has expanded to incorporate a range of biomedical prevention strategies, including voluntary medical male circumcision, pre- and post-exposure prophylaxis, and treatment-as-prevention, and to accommodate structural and combination prevention approaches. This study examines how young Africans from five epidemiologically and socio-culturally diverse countries (Swaziland, Kenya, Nigeria, Burkina Faso and Senegal) made sense of the evolving prevention of sexual transmission of HIV between 1997 and 2014. It uses a distinctive data source: 1,343 creative narratives submitted to HIV-themed scriptwriting competitions by young people aged 10–24. The study triangulates between analysis of quantifiable characteristics of the narratives, thematic qualitative analysis, and narrative-based approaches. Over time, HIV prevention themes become less prominent. Condoms are represented less often from 2008, though representations become more favourable. Biomedical prevention is all but absent through 2014. While prevention strategies may be described as effective in narratorial commentary, they are rarely depicted as preventing HIV, but are evoked instead in moralistic cautionary tales or represented as ineffective. Over time, an increasing proportion of protagonists are female. One in five narratives acknowledge structural drivers of HIV, but these are generally either disempowering or condemn characters for failing to prevent HIV in the face of often overwhelming structural challenges. In the context of combination prevention, there is a need to disseminate an empowering cultural narrative that models successful use of HIV prevention strategies despite structural constraints and avoids blaming and stigma.
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Luseno WK, Field SH, Iritani BJ, Rennie S, Gilbertson A, Odongo FS, Kwaro D, Ongili B, Hallfors DD. Consent Challenges and Psychosocial Distress in the Scale-up of Voluntary Medical Male Circumcision Among Adolescents in Western Kenya. AIDS Behav 2019; 23:3460-3470. [PMID: 31375957 PMCID: PMC6854308 DOI: 10.1007/s10461-019-02620-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In priority sub-Saharan African countries, on the ground observations suggest that the success of voluntary medical male circumcision (VMMC) programs should not be based solely on numbers of males circumcised. We identify gaps in the consent process and poor psychosocial outcomes among a key target group: male adolescents. We assessed compliance with consent and assent requirements for VMMC in western Kenya among males aged 15-19 (N = 1939). We also examined differences in quality of life, depression, and anticipated HIV stigma between uncircumcised and circumcised adolescents. A substantial proportion reported receiving VMMC services as minors without parent/guardian consent. In addition, uncircumcised males were significantly more likely than their circumcised peers to have poor quality of life and symptoms of depression. Careful monitoring of male adolescents' well-being is needed in large-scale VMMC programs. There is also urgent need for research to identify effective strategies to address gaps in the delivery of VMMC services.
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Affiliation(s)
- Winnie K Luseno
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA.
| | - Samuel H Field
- Independent Statistical Consultant, Chapel Hill, NC, USA
| | - Bonita J Iritani
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA
| | - Fredrick S Odongo
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Barrack Ongili
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Denise D Hallfors
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA
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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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36
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Pintye J, Wirth KE, Ntsuape C, Kleinman NJ, Spees LP, Semo BW, Mawandia S, Ledikwe JH. Early resumption of sex after voluntary medical male circumcision for HIV prevention within a programmatic delivery setting in Botswana. Int J STD AIDS 2019; 30:1275-1283. [PMID: 31631778 DOI: 10.1177/0956462419866051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To maximize the public health benefits of voluntary medical male circumcision (VMMC) in real-world settings, sexual abstinence is recommended for six weeks following VMMC to ensure complete wound healing. We determined the frequency and predictors of early resumption of sex among a cohort of HIV-negative, sexually active men 18–49 years who underwent VMMC within a public-sector clinic in Botswana. Multivariate robust Poisson regression methods were used to identify predictors of having any sexual intercourse in the last six weeks since undergoing VMMC. In total, 433/519 (83%) men had data available on sexual activity at six weeks post-VMMC. Median age was 27 years, 57% had a higher than secondary education, 72% were employed, and 9% were married. Overall, 122/433 (28%) men had sexual intercourse within the six weeks since VMMC, of whom 36% reported inconsistent condom use. Compared to men ≥34 years, men aged <30 years (adjusted risk ratio [aRR] = 1.71, 95% CI 0.95–3.08) and men 30–34 years had a two-fold higher likelihood of resuming sexual activity early in multivariate analyses (aRR = 2.31, 95% CI 1.26–4.25, Wald p = 0.018). Employed men were more likely to resume sexual activity early than unemployed men (aRR = 1.58, 95% CI 1.02–2.44, p = 0.039). Additional interventions are needed to encourage abstinence until complete wound healing.
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Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kathleen E Wirth
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health, Gaborone, Botswana
| | - Nora J Kleinman
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,NJK Consulting, Seattle, WA, USA
| | - Lisa P Spees
- Department of Health Policy and Management, University of North Carolina Chapel Hil, Chapel Hill, NC, USA
| | - Bazghina-Werq Semo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Shreshth Mawandia
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Jenny H Ledikwe
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
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37
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Grund JM, Bryant TS, Toledo C, Jackson I, Curran K, Zhou S, Del Campo JM, Yang L, Kivumbi A, Li P, Bock N, Taliano J, Davis SM. Association of Male Circumcision with Women's Knowledge of its Biomedical Effects and With Their Sexual Satisfaction and Function: A Systematic Review. AIDS Behav 2019; 23:1104-1114. [PMID: 30357642 PMCID: PMC6557870 DOI: 10.1007/s10461-018-2313-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Male circumcision (MC) is a key HIV prevention intervention for men in countries with high HIV prevalence. Women's understanding of MC is important but poorly understood. We conducted a systematic review including women's knowledge of MC's biomedical impacts and its association with female sexual satisfaction and function through October 2017. Thirty-eight articles were identified: thirty-two with knowledge outcomes, seven with sexual satisfaction, and four with sexual function (N = 38). Respondent proportions aware MC protects men from HIV were 9.84-91.8% (median 60.0%). Proportions aware MC protects men from STIs were 14.3-100% (72.6%). Proportions aware MC partially protects men from HIV were 37.5-82% (50.7%). Proportions aware MC is not proven to protect women from infection by an HIV-positive partner were 90.0-96.8% (93.0%). No increases over time were noted. Women's MC knowledge is variable. Education could help women support MC and make better-informed sexual decisions.
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Affiliation(s)
- Jonathan M Grund
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Tyler S Bryant
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carlos Toledo
- Division of Global HIV and TB, HIV Prevention Branch, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E04, Atlanta, GA, 30329, USA
| | - Inimfon Jackson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Sheng Zhou
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Ling Yang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Apollo Kivumbi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peizi Li
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Naomi Bock
- Division of Global HIV and TB, HIV Prevention Branch, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E04, Atlanta, GA, 30329, USA
| | - Joanna Taliano
- Division of Public Health Information Dissemination (DPHID), Library Science Branch, Center for Surveillance, Epidemiology, and Laboratory Services (CSELS), Atlanta, GA, USA
| | - Stephanie M Davis
- Division of Global HIV and TB, HIV Prevention Branch, US Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E04, Atlanta, GA, 30329, USA.
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Mavhu W, Hatzold K, Madidi N, Maponga B, Dhlamini R, Munjoma M, Xaba S, Ncube G, Mugurungi O, Cowan FM. Is the PrePex device an alternative for surgical male circumcision in adolescents ages 13-17 years? Findings from routine service delivery during active surveillance in Zimbabwe. PLoS One 2019; 14:e0213399. [PMID: 30856228 PMCID: PMC6411138 DOI: 10.1371/journal.pone.0213399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/19/2019] [Indexed: 12/16/2022] Open
Abstract
Background Male circumcision devices have the potential to accelerate adolescent voluntary medical male circumcision roll-out. Here, we present findings on safety, acceptability and satisfaction from active surveillance of PrePex implementation among 618 adolescent males (13–17 years) circumcised in Zimbabwe. Methods The first 618 adolescents consecutively circumcised from October 2015 to October 2016 using PrePex during routine service delivery were actively followed up. Outcome measures included PrePex uptake, attendance for post-circumcision visits and adverse events (AEs). A survey was conducted amongst 500 consecutive active surveillance clients to assess acceptability and satisfaction with PrePex. Results A total of 1,811 adolescent males were circumcised across the three PrePex active surveillance sites. Of these, 870 (48%) opted for PrePex but only 618/870 (71%) were eligible. Among the 618, two (0.3%) self-removals requiring surgery (severe AEs), were observed. Four (0.6%) removals by providers (moderate AEs) did not require surgery. Another 6 (1%) mild AEs were due to: bleeding (n = 2), swelling (n = 2), and infection (n = 2). All AEs resolved without sequelae. Adherence to follow-up appointments was high (97.7% attended 7 day visit). A high proportion (71.6%) of survey respondents said they heard about PrePex from a mobilizer; 49.8% said they chose PrePex because they wanted to avoid the pain associated with the surgical procedure/surgery on their penis. Acceptability and satisfaction with PrePex was high; 95.4% indicated willingness to recommend PrePex to peers. A majority (92%) reported experiencing pain when PrePex was being removed. Conclusions Active surveillance of the first 618 adolescent males circumcised using PrePex suggests that the device is both safe and acceptable when used in routine service delivery among 13–17 year-olds. There is need to intensify specific demand generation activities for PrePex male circumcision among this group of males.
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Affiliation(s)
- Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Karin Hatzold
- Population Services International (PSI), Harare, Zimbabwe
| | | | - Brian Maponga
- Population Services International (PSI), Harare, Zimbabwe
| | - Roy Dhlamini
- Population Services International (PSI), Harare, Zimbabwe
| | | | | | | | | | - Frances M. Cowan
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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