1
|
Almomani O, Nnamutete J, Shao Z, Biribawa VM, Ssemunywa H, Namuniina A, Okech B, Ulanova S, Zuanazzi D, Liu CM, Tobian AAR, Galiwango RM, Kaul R, Prodger JL. Effect of cryopreservation on CD4+ T cell subsets in foreskin tissue. PLoS One 2024; 19:e0297884. [PMID: 38427640 PMCID: PMC10906856 DOI: 10.1371/journal.pone.0297884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/03/2024] [Indexed: 03/03/2024] Open
Abstract
Voluntary medical male circumcision (VMMC) reduces HIV acquisition by at least 60%, but the determinants of HIV susceptibility in foreskin tissues are incompletely understood. Flow cytometry is a powerful tool that helps us understand tissue immune defenses in mucosal tissue like the inner foreskin, but foreskin flow cytometry has only been validated using fresh tissue samples. This restricts immune analyses to timepoints immediately after surgical acquisition and hinders research in this area. We compared fresh analysis with whole tissue cryopreservation and later thawing and digestion to analyze CD4+ T cell populations relevant to HIV susceptibility (CCR5, CD25, CD127, CCR4, CXCR3, CCR6, CCR10, HLA-DR, and CD38). Eight foreskin samples from HIV-negative males aged >18 years were collected after VMMC. For each sample, half the foreskin was immediately cryopreserved for later digestion and flow cytometry analysis, while the remaining tissues were analyzed fresh. We demonstrate no significant impact of cryopreservation on CD4+ T cell expression of CD25, CCR4, CCR6, HLA-DR, CCR10, or CD127. Although expression levels of CCR5, CD38, and CXCR3 were increased after cryopreservation, the relative ranking of participants was retained. In conclusion, cryopreserved foreskin tissues may be suitable for subsequent digestion and flow cytometry phenotyping of HIV-susceptible T cell populations.
Collapse
Affiliation(s)
- Omar Almomani
- Department of Microbiology and Immunology, Western University, London, Canada
| | | | - Zhongtian Shao
- Department of Microbiology and Immunology, Western University, London, Canada
| | | | | | | | - Brenda Okech
- UVRI-IAVI HIV Vaccine Program Limited, Entebbe, Uganda
| | - Sofya Ulanova
- Department of Microbiology and Immunology, Western University, London, Canada
| | - David Zuanazzi
- Department of Microbiology and Immunology, Western University, London, Canada
| | - Cindy M. Liu
- Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America
| | - Aaron A. R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Rupert Kaul
- Departments of Medicine and Immunology, University of Toronto, Toronto, Canada
- University Health Network, Toronto, Canada
| | - Jessica L. Prodger
- Department of Microbiology and Immunology, Western University, London, Canada
| |
Collapse
|
2
|
Kaisara T, Nyabadza F. Modelling Botswana's HIV/AIDS response and treatment policy changes: Insights from a cascade of mathematical models. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:1122-1147. [PMID: 36650805 DOI: 10.3934/mbe.2023052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The management of HIV/AIDS has evolved ever since advent of the disease in the past three decades. Many countries have had to revise their policies as new information on the virus, and its transmission dynamics emerged. In this paper, we track the changes in Botswana's HIV/AIDS response and treatment policies using a piece-wise system of differential equations. The policy changes are easily tracked in three epochs. Models for each era are formulated from a "grand model" that can be linked to all the epochs. The grand model's steady states are determined and analysed in terms of the model reproduction number, $ R_{0}. $ The model exhibits a backward bifurcation, where a stable disease-free equilibrium coexists with a stable endemic equilibrium when $ R_{0} < 1. $ The stability of the models for the other epochs can be derived from that of the grand model by setting some parameters to zero. The models are fitted to HIV/AIDS prevalence data from Botswana for the past three decades. The changes in the populations in each compartment are tracked as the response to the disease and treatment policy changed over time. Finally, projections are made to determine the possible trajectory of HIV/AIDS in Botswana. The implications of the policy changes are easily seen, and a discussion on how these changes impacted the epidemic are articulated. The results presented have crucial impact on how policy changes affected and continue to influence the trajectory of the HIV/AIDS epidemic in Botswana.
Collapse
Affiliation(s)
- Tefa Kaisara
- University of Johannesburg, Department of Mathematics and Applied Mathematics, P.O. Box 524, Auckland Park, 2006, South Africa
- Botswana International University of Science and Technology, Department of Mathematics and Statistical Sciences, Private Bag 16, Palapye, Botswana
| | - Farai Nyabadza
- University of Johannesburg, Department of Mathematics and Applied Mathematics, P.O. Box 524, Auckland Park, 2006, South Africa
| |
Collapse
|
3
|
Prevalence and Risk Factors for HIV Infection Among Heterosexual Men Recruited from Socializing Venues in Rural KwaZulu-Natal, South Africa. AIDS Behav 2021; 25:3528-3537. [PMID: 33575900 DOI: 10.1007/s10461-021-03182-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 02/07/2023]
Abstract
Young heterosexual men have low uptake of HIV prevention and treatment services and represent an important key population that may require novel strategies. We recruited 1271 heterosexual men, 12 years and older from socializing venues such as "shebeens", transport hubs, "spaza" shops, and community centers in rural KwaZulu-Natal, South Africa. Participants completed a questionnaire and were tested for HIV serostatus. Generalized estimating equations (GEE) with exchangeable covariance structure estimated factors independently associated with prevalent HIV infection. Median age was 25 years [Interquartile range (IQR) 21-29]. HIV prevalence was 15.5% [95% confidence interval (CI) 11.0-21.9] and increased significantly by age. Factors associated with higher odds of HIV infection were being 25 years and older [adjusted odds ratio (aOR) 4.82, 95% CI 3.47-6.69; p < 0.001), not completing high school (aOR 1.60, 95% CI 1.39-1.85; p < 0.001), not using condoms at first sex (aOR 1.43, 95% CI 1.20-1.70; p < 0.001), consuming alcohol (aOR 1.63, 95% CI 1.15-2.31; p = 0.006) or substances (aOR 1.37, 95% CI 1.31-1.44; p < 0.001), and absence of medical circumcision (aOR 2.05, 95% CI 1.71-2.44; p < 0.001). Risk was lower among those testing for HIV in last 12 months (aOR 0.54, 95% CI 0.36-0.80; p = 0.002). Greater effort is needed to implement innovative programs within settings that are easily accessible and where heterosexual men are likely to be.
Collapse
|
4
|
Baker Z, Javanbakht M, Moore J, Brosnan H, Squires K, Bunge K, Zimet G, Mensch B, Soto-Torres L, Kapogiannis B, Levy L, Hoesley C, Reirden D, Gaur A, Mayer K, Futterman D, Gorbach P. Qualitative Study on the Acceptability of and Adherence to a Vaginal Ring for HIV Prophylaxis Among Adolescent Girls. J Acquir Immune Defic Syndr 2021; 87:944-950. [PMID: 33675614 PMCID: PMC8192420 DOI: 10.1097/qai.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls. DESIGN Qualitative study. METHODS Ninety-six girls aged 15-17 years from 6 urban US sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial, for assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth interviews. Interviews were transcribed verbatim and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified. RESULTS Factors related to relationships rarely seemed to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, seemed to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR on first impression. Although most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation. CONCLUSION Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.
Collapse
Affiliation(s)
- Zoë Baker
- Division of Urology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Marjan Javanbakht
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Janell Moore
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Hannah Brosnan
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Kathleen Squires
- Division of Infectious Diseases, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
- Global Center of Scientific Affairs, Merck Research Labs, Rahway, NJ
| | - Katherine Bunge
- Department of Obstetrics, Gynecology & Reproductive Services, University of Pittsburgh, Pittsburgh, PA
| | - Gregory Zimet
- Department of Pediatrics, Indiana University, Bloomington, IA
| | | | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, Division of AIDS, Bethesda, MD
| | - Bill Kapogiannis
- Maternal and Pediatric Infectious Disease Branch, National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Craig Hoesley
- Division of Infectious Diseases, University of Alabama, Birmingham, AL
| | - Daniel Reirden
- Department of Adolescent Medicine, Children's Hospital Colorado, Aurora, CO
| | - Aditya Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN
| | - Kenneth Mayer
- Department of Global Health and Population, Harvard School of Public Health, The Fenway Institute, Boston, MA; and
| | - Donna Futterman
- Department of Pediatrics, Albert Einstein College of Medicine, the Bronx, NY
| | - Pamina Gorbach
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| |
Collapse
|
5
|
Nzamwita P, Biracyaza E. Factors Associated with Low Uptake of Voluntary Medical Male Circumcision as HIV-Prevention Strategy among Men Aged 18-49 Years from Nyanza District, Rwanda. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2021; 13:377-388. [PMID: 33833586 PMCID: PMC8021263 DOI: 10.2147/hiv.s301045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/15/2021] [Indexed: 01/22/2023]
Abstract
Background Voluntary medical male circumcision (VMMC) is an effective biomedical intervention against HIV in developed and developing countries. However, there is low uptake of VMMC due to various factors, which hinders achievement of health-policy goals to increase uptake. Numerous campaigns offering the procedure free of charge exist in developing countries, but such initiatives seem to bear little fruit in attracting men to these services. This study assessed risk factors associated with the low uptake of VMMC among men in Nyanza district, Southern Province, Rwanda. Methods A cross-sectional study was conducted among adult males in Nyanza. A total of 438 men participated in individual interviews. Bivariate and multivariate logistic regression models were used with 95% confidence intervals and p≤0.05 was taken as statistically significant. Results Our results indicated that a low update of VMMC was highly prevalent (35.8%). A majority (84.7%) of participants had heard about VMMC, its complications, advantages in preventiing penile cancer, sexually transmitted infections, and HIV, condom use after circumcision, abstinence for 6 weeks after circumcision, and improving penile hygiene. Religion and education were significant factors in low uptake. Catholics were less likely to undergo VMMC than Muslims (OR 7.19, 95% CI 1.742–29.659; p=0.01). Those of other faiths were less likely to undergo VMMC than Muslims (OR 6.035, 95% CI 1.731–21.039; p=0.005). Participants with secondary education were less likely to undergo VMMC than those with primary education only (OR 1.4, 95% CI 0.74–2.64; p=0.03). Having no formal education decreased the odds of being uncircumcised (OR 0.37, 95% CI 0.14–0.977; p=0.045) when compared to those with primary education. Conclusion Uptake of VMMC remains low in Nyanza, but most men had sufficient knowledge about it. Education, religion, and marital status were major factors in the low uptake. Programs targeting peer influences and parents need to be prioritized.
Collapse
Affiliation(s)
- Pascal Nzamwita
- Department of Community Health, School of Public Health, University of Rwanda, Kigali, Rwanda.,Department of Prevention, ADIS Healthcare Foundation (AHF) Rwanda, Kigali, Rwanda
| | - Emmanuel Biracyaza
- Department of Community Health, School of Public Health, University of Rwanda, Kigali, Rwanda.,District Manager of Sociotherapy Programme, Prison Fellowship Rwanda (PFR), Kigali, Rwanda
| |
Collapse
|
6
|
Spees LP, Wirth KE, Mawandia S, Bazghina-Werq S, Ledikwe JH. Sexual risk compensation following voluntary medical male circumcision: Results from a prospective cohort study amongst human immunodeficiency virus-negative adult men in Botswana. South Afr J HIV Med 2021; 21:1157. [PMID: 33391832 PMCID: PMC7756904 DOI: 10.4102/sajhivmed.v21i1.1157] [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: 08/19/2020] [Accepted: 10/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background Circumcised men may increase sexual risk-taking following voluntary medical male circumcision (VMMC) because of decreased perceptions of risk, which may negate the beneficial impact of VMMC in preventing new human immunodeficiency virus (HIV) infections. Objectives We evaluated changes in sexual behaviour following VMMC. Method We conducted a prospective cohort study amongst sexually active, HIV-negative adult men undergoing VMMC in Gaborone, Botswana, during 2013–2015. Risky sexual behaviour, defined as the number of sexual partners in the previous month and ≥ 1 concurrent sexual partnerships during the previous 3 months, was assessed at baseline (prior to VMMC) and 3 months post-VMMC. Change over time was assessed by using inverse probability weighted linear and conditional logistic regression models. Results We enrolled 523 men; 509 (97%) provided sexual behaviour information at baseline. At 3 months post-VMMC, 368 (72%) completed the follow-up questionnaire. At baseline, the mean (95% confidence interval) number of sexual partners was 1.60 (1.48, 1.65), and 111 (31% of 353 with data) men reported engaging in concurrent partnerships. At 3 months post-VMMC, 70 (23% of 311 with data) reported fewer partners and 19% had more partners. Amongst 111 men with a concurrent partnership at baseline, 52% reported none post-VMMC. Amongst the 242 (69%) without a concurrent partnership at baseline, 19% reported initiating one post-VMMC. After adjustment for loss to follow-up, risky sexual behaviour post-VMMC (measured as mean changes in a number of partners and proportion engaging in concurrency) was similar to baseline levels. Conclusion We found no evidence of sexual risk compensation in the 3 months following VMMC.
Collapse
Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States of America
| | - Kathleen E Wirth
- Department of Biostatistics, Faculty of Health Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Shreshth Mawandia
- Department of Health Policy and Management, Faculty of Medicine, Botswana International Training and Education Center for Health, Gaborone, Botswana.,Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Semo Bazghina-Werq
- Department of Global Health, University of Washington, Seattle, WA, United States of America.,Independent Global Health Consultant, Washington, DC, United States of America
| | - Jenny H Ledikwe
- Department of Health Policy and Management, Faculty of Medicine, Botswana International Training and Education Center for Health, Gaborone, Botswana.,Department of Global Health, University of Washington, Seattle, WA, United States of America
| |
Collapse
|
7
|
Straubinger T, Kay K, Bies R. Modeling HIV Pre-Exposure Prophylaxis. Front Pharmacol 2020; 10:1514. [PMID: 32082142 PMCID: PMC7005100 DOI: 10.3389/fphar.2019.01514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 11/21/2019] [Indexed: 11/26/2022] Open
Abstract
Pre-exposure prophylaxis (PrEP) has emerged as a promising strategy for preventing the transmission of HIV. Although only one formulation is currently approved for PrEP, research into both new compounds and new delivery systems for PrEP regimens offer intriguing challenges from the perspective of pharmacokinetic and pharmacodynamic modeling. This review aims to provide an overview the current modeling landscape for HIV PrEP, focused on PK/PD and QSP models relating to antiretroviral agents. Both current PrEP treatments and new compounds that show promise as PrEP agents are highlighted, as well as models of uncommon administration routes, predictions based on models of mechanism of action and viral dynamics, and issues related to adherence to therapy. The spread of human immunodeficiency virus (HIV) remains one of the foremost global health concerns. In the absence of a vaccine, other prophylactic strategies have been developed to prevent HIV transmission. One approach, known as pre-exposure prophylaxis (PrEP), allows HIV-negative individuals who are at high risk of exposure to the virus, be it through an HIV-positive sexual partner or through the shared use of drug injection equipment, to substantially reduce the risk of developing an HIV infection. PrEP is a relatively recent approach to combating the HIV epidemic, with the only currently approved treatment being Truvada, a daily oral antiretroviral (ARV) therapy initially indicated in the treatment of active HIV-1 infections, but approved for HIV PrEP in 2012. Although PrEP therapy has consistently demonstrated high efficacy in preventing HIV infection, this efficacy is dependent on patient adherence to the prescribed treatment regimen. This can present a significant problem in low- and middle-income countries, which may lack the infrastructure to provide sufficient access to PrEP medication to maintain daily dosing regimens. Furthermore, while the conventional approach has generally been to advocate for continuous administration akin to regimens used for viral suppression in infected patients, there has been some discussion of whether a better treatment paradigm might be to push for PrEP therapy primarily during those known periods of heightened exposure risk, while relying on post-exposure prophylaxis regimens to prevent infection after unanticipated exposures during low-risk periods. These considerations have led to a push for the development of long-duration and on-demand PrEP formulations, including subdermal and subcutaneous implants, slow-release intramuscular depot injections, vaginal and rectal antimicrobial gels, and intravaginal rings and dissolving films. PrEP therapy is a quickly evolving field, with a variety of antiretroviral compounds and formulations under investigation. This review aims to report on notable drugs and formulations from a pharmacokinetic/pharmacodynamic (PK/PD) modeling perspective. Given the nature of PrEP as a preventive therapy designed for long-term use, clinical trials for PrEP therapies can last for months or even years, particularly in the case of long-duration formulations. Furthermore, in contrast to antiretroviral trials in infected patients, pharmacodynamic endpoints in PrEP therapies are difficult to quantify, as the primary endpoint for efficacy is generally the rate of seroconversion. Computational modeling approaches offer flexible and powerful tools to provide insight into drug behavior in clinical settings, and can ultimately reduce the time, expense, and patient burden incurred in the development of PrEP therapies.
Collapse
Affiliation(s)
- Thomas Straubinger
- Department of Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
| | - Katherine Kay
- Metrum Research Group, Tariffville, CT, United States
| | - Robert Bies
- Department of Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, United States
| |
Collapse
|
8
|
Lau B, Duggal P, Ehrhardt S. Epidemiology at a time for unity. Int J Epidemiol 2019; 47:1366-1371. [PMID: 30165517 DOI: 10.1093/ije/dyy179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephan Ehrhardt
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
9
|
Spees LP, Ledikwe JH, Kleinman NJ, Ntsuape C, Semo BW, Barnhart S, Wirth KE. Immediate Motivators to Seeking Voluntary Medical Male Circumcision Among HIV-Negative Adult Men in an Urban Setting in Botswana. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:136-151. [PMID: 30917017 DOI: 10.1521/aeap.2019.31.2.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces HIV acquisition risk in men. We sought to identify subpopulations of Botswanan men with high levels of VMMC uptake by comparing an observational cohort of men presenting for circumcision services at two high-volume clinics in Botswana's capital city, Gabo-rone, with a matched, population-based random sample of uncircumcised men. Among these high uptake VMMC subpopulations, we then examined the immediate factors that play a role in men's decision to seek VMMC services. As compared to their population-based controls, men choosing to undergo circumcision were more likely to be ages 24-34, more highly educated, to have a religious affiliation, and in a serious relationship. Our results suggest that married men and highly educated men were more likely to pursue circumcision for personal hygiene reasons. These findings have direct implications for targeted demand creation and mobilization activities to increase VMMC uptake in Botswana.
Collapse
Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Jenny H Ledikwe
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Global Health, University of Washington, Seattle, Washington
| | - Nora J Kleinman
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Global Health, University of Washington, Seattle, Washington
- NJK Consulting, Seattle
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health, Gaborone, Botswana
| | - Bazghina-Werq Semo
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Global Health, University of Washington, Seattle, Washington
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kathleen E Wirth
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Epidemiology and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
10
|
Morris BJ, Hankins CA, Banerjee J, Lumbers ER, Mindel A, Klausner JD, Krieger JN. Does Male Circumcision Reduce Women's Risk of Sexually Transmitted Infections, Cervical Cancer, and Associated Conditions? Front Public Health 2019; 7:4. [PMID: 30766863 PMCID: PMC6365441 DOI: 10.3389/fpubh.2019.00004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Male circumcision (MC) is proven to substantially reduce men's risk of a number of sexually transmitted infections (STIs). We conducted a detailed systematic review of the scientific literature to determine the relationship between MC and risk of STIs and associated conditions in women. Methods: Database searches by "circumcision women" and "circumcision female" identified 68 relevant articles for inclusion. Examination of bibliographies of these yielded 14 further publications. Each was rated for quality using a conventional rating system. Results: Evaluation of the data from the studies retrieved showed that MC is associated with a reduced risk in women of being infected by oncogenic human papillomavirus (HPV) genotypes and of contracting cervical cancer. Data from randomized controlled trials and other studies has confirmed that partner MC reduces women's risk not only of oncogenic HPV, but as well Trichomonas vaginalis, bacterial vaginosis and possibly genital ulcer disease. For herpes simplex virus type 2, Chlamydia trachomatis, Treponema pallidum, human immunodeficiency virus and candidiasis, the evidence is mixed. Male partner MC did not reduce risk of gonorrhea, Mycoplasma genitalium, dysuria or vaginal discharge in women. Conclusion: MC reduces risk of oncogenic HPV genotypes, cervical cancer, T. vaginalis, bacterial vaginosis and possibly genital ulcer disease in women. The reduction in risk of these STIs and cervical cancer adds to the data supporting global efforts to deploy MC as a health-promoting and life-saving public health measure and supplements other STI prevention strategies.
Collapse
Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW, Australia
| | - Catherine A. Hankins
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- London School of Hygiene and Tropical Medicine, Bloomsbury, London, United Kingdom
| | | | - Eugenie R. Lumbers
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine and Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Adrian Mindel
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey D. Klausner
- Division of Infectious Diseases and the Program in Global Health, Fielding School of Public Health, University of California Los Angeles Care Center, Los Angeles, CA, United States
| | - John N. Krieger
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States
| |
Collapse
|
11
|
Chetty-Makkan CM, Grund JM, Munyai R, Gadla V, Chihota V, Maraisane M, Charalambous S. "To speak or not to speak": A qualitative analysis on the attitude and willingness of women to start conversations about voluntary medical male circumcision with their partners in a peri-urban area, South Africa. PLoS One 2019; 14:e0210480. [PMID: 30682057 PMCID: PMC6347244 DOI: 10.1371/journal.pone.0210480] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/25/2018] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men and has long-term indirect protection for women, yet VMMC uptake in South Africa remains low (49.8%) in men (25-49 years). We explored the attitude and willingness of women to start conversations on VMMC with their sexual partners in a South African peri-urban setting to increase VMMC uptake. METHODS Thirty women with median age of 30 years (inter-quartile range 26-33 years) were interviewed in a language of their choice. Key questions included: types of approach to use, gender roles, benefits and barriers to introducing the topic of VMMC, and perceptions of VMMC. Interviews were digitally-recorded, transcribed, and translated. Through a standard iterative process, a codebook was developed (QSR NVIVO 10 software) and inductive thematic analysis applied. RESULTS Most women were willing talk to their sexual partners about circumcision, but indicated that the decision to circumcise remained that of their sexual partner. Women felt that they should encourage their partners, show more interest in circumcision, be patient, speak in a caring and respectful tone, choose a correct time when their partner was relaxed and talk in a private space about VMMC. Using magazine/newspaper articles, pamphlets or advertisements were identified as tools that could aid their discussion. Substantial barriers to initiating conversations on VMMC included accusations by partner on infidelity, fear of gender-based violence, cultural restrictions and hesitation to speak to a mature partner about circumcision. CONCLUSIONS Women need to ensure that before talking to their partner about circumcision, the environment and approach that they use are conducive. Female social network forums could be used to educate women on conversation techniques, skills to use when talking to their partners and how to address communication challenges about circumcision. Involvement of women in VMMC awareness campaigns could encourage circumcision uptake among men.
Collapse
Affiliation(s)
| | - Jonathan M. Grund
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | | | | | | | - Salome Charalambous
- The Aurum Institute, Parktown, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
12
|
Srithanaviboonchai K, Srirak N, Pruenglampoo B, Thaikla K, Suwanteerangkul J, Khorana J, Danthamrongkul V, Paileeklee S, Pattanasattayavong U, Grimes DE, Grimes RM. Physicians' and nurses' thoughts and concerns about introducing neonatal male circumcision in Thailand: a qualitative study. BMC Health Serv Res 2018; 18:275. [PMID: 29642890 PMCID: PMC5896126 DOI: 10.1186/s12913-018-3093-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 04/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure. METHODS In-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes. RESULTS Six themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented. CONCLUSIONS Thai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.
Collapse
Affiliation(s)
- Kriengkrai Srithanaviboonchai
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Namtip Srirak
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Kanittha Thaikla
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Jiraporn Khorana
- Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Vipa Danthamrongkul
- College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | | | - Deanna E. Grimes
- School of Nursing, University of Texas Health Science Center, Houston, Texas USA
- Baylor-UT Houston Center for AIDS Research, Houston, Texas USA
| | - Richard M. Grimes
- Baylor-UT Houston Center for AIDS Research, Houston, Texas USA
- Division of General Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas USA
| |
Collapse
|
13
|
Hudson FP, Miller WC, Rao S, Agot K, Thirumurthy H. Prevalence and Predictors of Uncircumcised, Kenyan Men's Desire for Circumcision for Their Infant Sons. AIDS Behav 2018; 22:471-478. [PMID: 28101789 DOI: 10.1007/s10461-017-1681-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Men are key decision makers for their son's circumcision, so understanding their beliefs is important for the uptake of early infant male circumcision in countries in sub-Saharan Africa that have high HIV prevalence. We analyzed men's preferences for circumcising their sons using data from a population-representative survey of 1501 uncircumcised men aged 25-49 years in western Kenya. Most men (59%) reported they would "definitely" want their son circumcised if a son was born to them within the next year. However, only 25% intended to become circumcised themselves. In multivariable Poisson regression models to estimate prevalence ratios, key predictors of the desire to circumcise their sons included knowledge that circumcision reduces HIV acquisition, having a supportive partner, discussing circumcision with the partner, altruism, and intention to be circumcised himself. Focusing on partner dynamics may have the greatest capacity to increase demand since 55% had not talked to their partner about circumcision.
Collapse
Affiliation(s)
- F Parker Hudson
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, 1912 Speedway, SZB 546.05, Austin, TX, 78712, USA.
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - William C Miller
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samwel Rao
- Impact Research and Development Organization, Kisumu, Kenya
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Harsha Thirumurthy
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
14
|
Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population, 2008-2013. J Acquir Immune Defic Syndr 2017; 74:e30-e37. [PMID: 27632232 DOI: 10.1097/qai.0000000000001180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors. METHODS Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference. RESULTS The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception. CONCLUSIONS The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.
Collapse
|
15
|
Awad SF, Sgaier SK, Lau FK, Mohamoud YA, Tambatamba BC, Kripke KE, Thomas AG, Bock N, Reed JB, Njeuhmeli E, Abu-Raddad LJ. Could Circumcision of HIV-Positive Males Benefit Voluntary Medical Male Circumcision Programs in Africa? Mathematical Modeling Analysis. PLoS One 2017; 12:e0170641. [PMID: 28118387 PMCID: PMC5261810 DOI: 10.1371/journal.pone.0170641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 01/09/2017] [Indexed: 01/24/2023] Open
Abstract
Background The epidemiological and programmatic implications of inclusivity of HIV-positive males in voluntary medical male circumcision (VMMC) programs are uncertain. We modeled these implications using Zambia as an illustrative example. Methods and Findings We used the Age-Structured Mathematical (ASM) model to evaluate, over an intermediate horizon (2010–2025), the effectiveness (number of VMMCs needed to avert one HIV infection) of VMMC scale-up scenarios with varying proportions of HIV-positive males. The model was calibrated by fitting to HIV prevalence time trend data from 1990 to 2014. We assumed that inclusivity of HIV positive males may benefit VMMC programs by increasing VMMC uptake among higher risk males, or by circumcision reducing HIV male-to-female transmission risk. All analyses were generated assuming no further antiretroviral therapy (ART) scale-up. The number of VMMCs needed to avert one HIV infection was projected to increase from 12.2 VMMCs per HIV infection averted, in a program that circumcises only HIV-negative males, to 14.0, in a program that includes HIV-positive males. The proportion of HIV-positive males was based on their representation in the population (e.g. 12.6% of those circumcised in 2010 would be HIV-positive based on HIV prevalence among males of 12.6% in 2010). However, if a program that only reaches out to HIV-negative males is associated with 20% lower uptake among higher-risk males, the effectiveness would be 13.2 VMMCs per infection averted. If improved inclusivity of HIV-positive males is associated with 20% higher uptake among higher-risk males, the effectiveness would be 12.4. As the assumed VMMC efficacy against male-to-female HIV transmission was increased from 0% to 20% and 46%, the effectiveness of circumcising regardless of HIV status improved from 14.0 to 11.5 and 9.1, respectively. The reduction in the HIV incidence rate among females increased accordingly, from 24.7% to 34.8% and 50.4%, respectively. Conclusion Improving inclusivity of males in VMMC programs regardless of HIV status increases VMMC effectiveness, if there is moderate increase in VMMC uptake among higher-risk males and/or if there is moderate efficacy for VMMC against male-to-female transmission. In these circumstances, VMMC programs can reduce the HIV incidence rate in males by nearly as much as expected by some ART programs, and additionally, females can benefit from the intervention nearly as much as males.
Collapse
Affiliation(s)
- Susanne F Awad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar
| | - Sema K Sgaier
- Surgo Foundation, Washington, District of Columbia, United States of America.,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America.,Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Fiona K Lau
- Surgo Foundation, Washington, District of Columbia, United States of America
| | - Yousra A Mohamoud
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar
| | | | - Katharine E Kripke
- Health Policy Initiative, Avenir Health, Washington, District of Columbia, United States of America
| | - Anne G Thomas
- Naval Health Research Center, U.S. Department of Defense, San Diego, California, United States of America
| | - Naomi Bock
- Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Jason B Reed
- Jhpiego, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, District of Columbia, United States of America
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.,Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, United States of America.,College of Public Health, Hamad bin Khalifa University, Qatar Foundation, Education City, Doha, Qatar
| |
Collapse
|
16
|
Masese RJ, Chimango JL, Mbirimtengerenji ND. Overcoming Barriers to Uptake of Voluntary Medical Male Circumcision in a Traditionally Circumcising Community in Machinga District, Malawi. ACTA ACUST UNITED AC 2017. [DOI: 10.4236/wja.2017.71005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
17
|
Thornton R, Godlonton S. Medical male circumcision: How does price affect the risk-profile of take-up? Prev Med 2016; 92:68-73. [PMID: 27283093 DOI: 10.1016/j.ypmed.2016.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 04/19/2016] [Accepted: 06/05/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The benefit of male circumcision is greatest among men who are most at risk of HIV infection. Encouraging this population of men to get circumcised maximizes the benefit that can be achieved through the scale-up of circumcision programs. This paper examines how the price of circumcision affects the risk profile of men who receive a voluntary medical circumcision. METHODS In 2010, 1649 uncircumcised adult men in urban Malawi were interviewed and provided a voucher for a subsidized voluntary medical male circumcision, at randomly assigned prices. Clinical data were collected indicating whether the men in the study received a circumcision. RESULTS Men who took-up circumcision with a zero-priced voucher were 25 percentage points less likely than those who took-up with a positive-price voucher, to be from a tribe that traditionally circumcises (p=0.101). Zero-priced vouchers also brought in men with more sexual partners in the past year (p=0.075) and past month (p=0.003). None of the men who were most at risk of HIV at baseline (those with multiple partners and who did not use a condom the last time they had sex) received a circumcision if they were offered a positive-priced voucher. Lowering the price to zero increased circumcision take-up to 25% for men of this risk group. The effect of price on take-up was largest among those at highest risk (p=0.096). CONCLUSIONS Reducing the price of circumcision surgery to zero can increase take-up among those who are most at risk of HIV infection.
Collapse
|
18
|
Haacker M, Fraser-Hurt N, Gorgens M. Effectiveness of and Financial Returns to Voluntary Medical Male Circumcision for HIV Prevention in South Africa: An Incremental Cost-Effectiveness Analysis. PLoS Med 2016; 13:e1002012. [PMID: 27138961 PMCID: PMC4854479 DOI: 10.1371/journal.pmed.1002012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 03/21/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Empirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach-analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC's cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period. METHODS/FINDINGS The model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold-the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government. CONCLUSIONS VMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age.
Collapse
Affiliation(s)
- Markus Haacker
- World Bank, Washington, District of Columbia, United States of America
- Harvard School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- * E-mail:
| | | | - Marelize Gorgens
- World Bank, Washington, District of Columbia, United States of America
| |
Collapse
|
19
|
Barone MA, Li PS, Awori QD, Lee R, Goldstein M. Clinical trials using the Shang Ring device for male circumcision in Africa: a review. Transl Androl Urol 2016; 3:113-24. [PMID: 26816759 PMCID: PMC4708291 DOI: 10.3978/j.issn.2223-4683.2014.01.09] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Male circumcision (MC) reduces the risk of HIV and other sexually transmitted infections (STIs), including human papillomavirus (HPV) and herpes simplex virus type 2 (HSV-2), and is recommended as an important component of a comprehensive package of HIV prevention interventions. While computer modeling has demonstrated that substantial reductions in HIV could be achieved with rapid scale-up of MC services in sub-Saharan Africa, scale-up has lagged due to scarcity of trained providers coupled with relative technical difficulty of recommended surgical MC techniques. Simplified techniques, such as devices, have the potential to allow for a more rapid roll-out of MC. One such device is the Shang Ring, a novel disposable MC device that eliminates the need for suturing and has been on the Chinese market since 2005. Results from Chinese studies have demonstrated that the Shang Ring is both safe and easy to use. Since 2008, a series of studies using the Shang Ring for adult MC have been carried out in Kenya, Uganda and Zambia, according to guidelines established by World Health Organization (WHO) for clinical evaluation of new devices for adult MC. These include a proof of concept study, a study of delayed removal of the Shang Ring, two studies comparing Shang Ring circumcision to conventional surgical approaches, and a large field trial to evaluate safety of Shang Ring circumcision during routine service delivery. Results from these studies demonstrate that the Shang Ring has an excellent safety profile and that Shang Ring circumcision is relatively easy to teach and learn, making Shang Ring MC an appealing technique for use in sub-Saharan Africa where doctors are in short supply and non-physician providers such as nurses and clinical officers are playing a major role in providing MC through task shifting. Shang Ring MC and device removals were uneventfully performed by trained nurses and clinical officers, who preferred the Shang Ring to conventional surgical techniques. Adverse event rates were similar to those observed with conventional surgical circumcision and were managed with, at most, minor interventions, resolving with no long-term sequale. Perhaps one of the biggest advantages of the Shang Ring is the relatively short 3-6 minutes procedure time. Importantly, men also preferred the Shang Ring compared to conventional circumcision and satisfaction with cosmetic appearance of their circumcised penis was very high. The vast majority of participants in studies in Africa as well as China have reported few problems and little disruption to daily life while wearing the device. The Shang Ring holds great promise as an innovative technology that has the potential to facilitate the safe and effective scale-up of circumcision services in settings where MC is not widely used and where the burden of HIV-disease is high.
Collapse
Affiliation(s)
- Mark A Barone
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Philip S Li
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Quentin D Awori
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Richard Lee
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| | - Marc Goldstein
- 1 EngenderHealth, New York, NY, USA ; 2 Center for Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell Medical College, New York, NY, USA ; 3 EngenderHealth, Nairobi, Kenya
| |
Collapse
|
20
|
Awad SF, Sgaier SK, Tambatamba BC, Mohamoud YA, Lau FK, Reed JB, Njeuhmeli E, Abu-Raddad LJ. Investigating Voluntary Medical Male Circumcision Program Efficiency Gains through Subpopulation Prioritization: Insights from Application to Zambia. PLoS One 2015; 10:e0145729. [PMID: 26716442 PMCID: PMC4696770 DOI: 10.1371/journal.pone.0145729] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 12/07/2015] [Indexed: 12/01/2022] Open
Abstract
Background Countries in sub-Saharan Africa are scaling-up voluntary male medical circumcision (VMMC) as an HIV intervention. Emerging challenges in these programs call for increased focus on program efficiency (optimizing program impact while minimizing cost). A novel analytic approach was developed to determine how subpopulation prioritization can increase program efficiency using an illustrative application for Zambia. Methods and Findings A population-level mathematical model was constructed describing the heterosexual HIV epidemic and impact of VMMC programs (age-structured mathematical (ASM) model). The model stratified the population according to sex, circumcision status, age group, sexual-risk behavior, HIV status, and stage of infection. A three-level conceptual framework was also developed to determine maximum epidemic impact and program efficiency through subpopulation prioritization, based on age, geography, and risk profile. In the baseline scenario, achieving 80% VMMC coverage by 2017 among males 15–49 year old, 12 VMMCs were needed per HIV infection averted (effectiveness). The cost per infection averted (cost-effectiveness) was USD $1,089 and 306,000 infections were averted. Through age-group prioritization, effectiveness ranged from 11 (20–24 age-group) to 36 (45–49 age-group); cost-effectiveness ranged from $888 (20–24 age-group) to $3,300 (45–49 age-group). Circumcising 10–14, 15–19, or 20–24 year old achieved the largest incidence rate reduction; prioritizing 15–24, 15–29, or 15–34 year old achieved the greatest program efficiency. Through geographic prioritization, effectiveness ranged from 9–12. Prioritizing Lusaka achieved the highest effectiveness. Through risk-group prioritization, prioritizing the highest risk group achieved the highest effectiveness, with only one VMMC needed per infection averted; the lowest risk group required 80 times more VMMCs. Conclusion Epidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.
Collapse
Affiliation(s)
- Susanne F. Awad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar
| | - Sema K. Sgaier
- Integrated Delivery, Global Development Program, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Yousra A. Mohamoud
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar
| | - Fiona K. Lau
- Integrated Delivery, Global Development Program, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Jason B. Reed
- Office of the U.S. Global AIDS Coordinator, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, District of Columbia, United States of America
| | - Laith J. Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar
- Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
- College of Public Health, Hamad bin Khalifa University, Qatar Foundation, Education City, Doha, Qatar
- * E-mail:
| |
Collapse
|
21
|
Mukama T, Ndejjo R, Musinguzi G, Musoke D. Perceptions about medical male circumcision and sexual behaviours of adults in rural Uganda: a cross sectional study. Pan Afr Med J 2015; 22:354. [PMID: 26985272 PMCID: PMC4779633 DOI: 10.11604/pamj.2015.22.354.7125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/10/2015] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Medical male circumcision is currently recognized as an additional important HIV preventive intervention to reduce the risk of heterosexually acquired HIV infection in men. However, sexual behaviours after medical circumcision can potentially reduce the expected benefits of the practice. This study explored the perceptions about medical male circumcision and sexual behaviours of adults in Kayunga district, Uganda. METHODS A cross-sectional study was carried out among 393 respondents using a semi structured questionnaire. In addition, four focus group discussions were conducted. Quantitative data was analysed using STATA 12. Univariate, bivariate and multivariate analyses were carried out. Qualitative data was analysed thematically. RESULTS The study established various perceptions about medical male circumcision and sexual behaviours. Majority 247 (64.5%) did not perceive circumcision as a practice that can lead men to have multiple sexual partners. Males were 3 times more likely to think that circumcision would lead to having multiple sexual partners than females (AOR=2.99, CI: 1.93-4.61). Only 89 (23.2%) believed that circumcision would lead to complacency and compromise the use of condoms to prevent against infection with HIV. Respondents who had education above primary were less likely to think that circumcision would compromise the use of condoms (AOR=0.49, CI: 0.31- 0.79). The perception that circumcised youths were less likely to abstain from sexual intercourse was less held among those with education above primary (AOR=0.58, CI: 0.37-0.91) and those older than 30 years (AOR=0.59, CI: 0.38-0.92). CONCLUSION There were gaps in knowledge and negative perceptions about MMC in the study community. Measures are needed to avert the negative perceptions by equipping communities with sufficient, accurate and consistent information about medical male circumcision and sexual behaviour.
Collapse
Affiliation(s)
- Trasias Mukama
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
| | - Geofrey Musinguzi
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
| |
Collapse
|
22
|
Chinkoyo E, Pather M. Erectile function in circumcised and uncircumcised men in Lusaka, Zambia: A cross-sectional study. Afr J Prim Health Care Fam Med 2015; 7:766. [PMID: 26245613 PMCID: PMC4564873 DOI: 10.4102/phcfm.v7i1.766] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/22/2014] [Indexed: 11/11/2022] Open
Abstract
Background Evidence from three randomised control trials in South Africa, Uganda and Kenya showing that male circumcision can reduce heterosexual transmission of human immunodeficiency virus (HIV) infection from infected females to their male partners by up to 60% has led to an increase in circumcisions in most African countries. This has created anxieties around possible deleterious effects of circumcision on erectile function (EF). Aim To compare EF in circumcised and uncircumcised men aged 18 years and older. Setting Four primary healthcare facilities in Lusaka, Zambia. Methods Using a cross-sectional survey 478 participants (242 circumcised and 236 uncircumcised) from four primary healthcare facilities in Lusaka, Zambia were asked to complete the IIEF-5 questionnaire. EF scores were calculated for the two groups, where normal EF constituted an IIEF-5 score ≥ 22 (out of 25). Results Circumcised men had higher average EF scores compared to their uncircumcised counterparts, (p < 0.001). The prevalence of erectile dysfunction was lower in circumcised men (56%) compared to uncircumcised men (68%) (p < 0.05). EF scores were similar in those circumcised in childhood and those who had the procedure in adulthood, (p = 0.59). The groups did not differ significantly in terms of age, relationship status, smoking, alcohol and medication use. A statistically significant difference was observed in education levels, with the circumcision group having higher levels of education (p < 0.005). Conclusion The higher EF scores in circumcised men show that circumcision does not confer adverse EF effects in men. These results suggest that circumcision can be considered safe in terms of EF. A definitive prospective study is needed to confirm these findings.
Collapse
Affiliation(s)
- Evans Chinkoyo
- Faculty of Medicine and Health Sciences, Department of Interdisciplinary Health Sciences, Division of Family Medicine and Primary Care, University of Stellenbosch, South Africa and Chipata Level 1 Hospital, Lusaka.
| | | |
Collapse
|
23
|
Blaizot S, Riche B, Maman D, Mukui I, Kirubi B, Etard JF, Ecochard R. Estimation and Short-Term Prediction of the Course of the HIV Epidemic Using Demographic and Health Survey Methodology-Like Data. PLoS One 2015; 10:e0130387. [PMID: 26091253 PMCID: PMC4474856 DOI: 10.1371/journal.pone.0130387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 05/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Mathematical models have played important roles in the understanding of epidemics and in the study of the impacts of various behavioral or medical measures. However, modeling accurately the future spread of an epidemic requires context-specific parameters that are difficult to estimate because of lack of data. Our objective is to propose a methodology to estimate context-specific parameters using Demographic and Health Survey (DHS)-like data that can be used in mathematical modeling of short-term HIV spreading. METHODS AND FINDINGS The model splits the population according to sex, age, HIV status, and antiretroviral treatment status. To estimate context-specific parameters, we used individuals' histories included in DHS-like data and a statistical analysis that used decomposition of the Poisson likelihood. To predict the course of the HIV epidemic, sex- and age-specific differential equations were used. This approach was applied to recent data from Kenya. The approach allowed the estimation of several key epidemiological parameters. Women had a higher infection rate than men and the highest infection rate in the youngest age groups (15-24 and 25-34 years) whereas men had the highest infection rate in age group 25-34 years. The immunosuppression rates were similar between age groups. The treatment rate was the highest in age group 35-59 years in both sexes. The results showed that, within the 15-24 year age group, increasing male circumcision coverage and antiretroviral therapy coverage at CD4 ≤ 350/mm3 over the current 70% could have short-term impacts. CONCLUSIONS The study succeeded in estimating the model parameters using DHS-like data rather than literature data. The analysis provides a framework for using the same data for estimation and prediction, which can improve the validity of context-specific predictions and help designing HIV prevention campaigns.
Collapse
Affiliation(s)
- Stéphanie Blaizot
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France
- Université de Lyon, F-69000, Lyon, France
- Université Lyon 1, F-69100, Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
| | - Benjamin Riche
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France
- Université de Lyon, F-69000, Lyon, France
- Université Lyon 1, F-69100, Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
| | | | - Irene Mukui
- National AIDS and STDs Control Program, Nairobi, Kenya
| | | | - Jean-François Etard
- Epicentre, F-75011, Paris, France
- UMI 233 TransVIHMI, Institut de Recherche pour le Développement, INSERM U1175, Université Montpellier 1, F-34000, Montpellier, France
| | - René Ecochard
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France
- Université de Lyon, F-69000, Lyon, France
- Université Lyon 1, F-69100, Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
| |
Collapse
|
24
|
Bulled N, Green EC. Making voluntary medical male circumcision a viable HIV prevention strategy in high prevalence countries by engaging the traditional sector. CRITICAL PUBLIC HEALTH 2015; 26:258-268. [PMID: 27110065 DOI: 10.1080/09581596.2015.1055319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Voluntary medical male circumcision (VMMC) has been rapidly accepted by global HIV policy and donor institutions as a highly valuable HIV prevention strategy given its cost-effectiveness, limited interactions with a health facility, and projected long-lasting benefits. Many southern African countries have incorporated VMMC into their national HIV prevention strategies. However, intensive VMMC promotion programs have met with limited success to date and many HIV researchers have voiced concerns. This commentary discusses reasons behind the less-than-desired public demand and suggests how inclusion of the traditional sector - traditional leaders, healers, and circumcisers - with their local knowledge, cultural expertise and social capital, particularly in the realm of social meanings ascribed to male circumcision, may improve the uptake of this HIV prevention strategy. We offer Lesotho and Swaziland as case studies of the integration of universal VMMC policies; these are countries with a shared HIV burden, yet contrasting contemporary socio-cultural practices of male circumcision. The similar hesitant responses expressed by these two countries towards VMMC remind us that the incorporation of any new or revised and revitalized public health strategy must be considered within unique historical, political, economic, and socio-cultural contexts.
Collapse
Affiliation(s)
- Nicola Bulled
- The Center for Global Health, University of Virginia, Charlottesville, VA, USA
| | | |
Collapse
|
25
|
Omondi Aduda DS, Ouma C, Onyango R, Onyango M, Bertrand J. Voluntary medical male circumcision scale-up in Nyanza, Kenya: evaluating technical efficiency and productivity of service delivery. PLoS One 2015; 10:e0118152. [PMID: 25706119 PMCID: PMC4338032 DOI: 10.1371/journal.pone.0118152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 01/08/2015] [Indexed: 12/02/2022] Open
Abstract
Background Voluntary medical male circumcision (VMMC) service delivery is complex and resource-intensive. In Kenya’s context there is still paucity of information on resource use vis-à-vis outputs as programs scale up. Knowledge of technical efficiency, productivity and potential sources of constraints is desirable to improve decision-making. Objective To evaluate technical efficiency and productivity of VMMC service delivery in Nyanza in 2011/2012 using data envelopment analysis. Design Comparative process evaluation of facilities providing VMMC in Nyanza in 2011/2012 using output orientated data envelopment analysis. Results Twenty one facilities were evaluated. Only 1 of 7 variables considered (total elapsed operation time) significantly improved from 32.8 minutes (SD 8.8) in 2011 to 30 minutes (SD 6.6) in 2012 (95%CI = 0.0350–5.2488; p = 0.047). Mean scale technical efficiency significantly improved from 91% (SD 19.8) in 2011 to 99% (SD 4.0) in 2012 particularly among outreach compared to fixed service delivery facilities (CI -31.47959–4.698508; p = 0.005). Increase in mean VRS technical efficiency from 84% (SD 25.3) in 2011 and 89% (SD 25.1) in 2012 was not statistically significant. Benchmark facilities were #119 and #125 in 2011 and #103 in 2012. Malmquist Productivity Index (MPI) at fixed facilities declined by 2.5% but gained by 4.9% at outreach ones by 2012. Total factor productivity improved by 83% (p = 0.032) in 2012, largely due to progress in technological efficiency by 79% (p = 0.008). Conclusions Significant improvement in scale technical efficiency among outreach facilities in 2012 was attributable to accelerated activities. However, ongoing pure technical inefficiency requires concerted attention. Technological progress was the key driver of service productivity growth in Nyanza. Incorporating service-quality dimensions and using stepwise-multiple criteria in performance evaluation enhances comprehensiveness and validity. These findings highlight site-level resource use and sources of variations in VMMC service productivity, which are important for program planning.
Collapse
Affiliation(s)
| | - Collins Ouma
- Department of Biomedical Sciences and Technology, Maseno University, Maseno, Kenya
| | - Rosebella Onyango
- Department of Public Health and Community Development, Maseno University, Maseno, Kenya
| | - Mathews Onyango
- Male Circumcision Consortium, FHI360, Kisumu Office, Kisumu, Kenya
| | - Jane Bertrand
- Department of Global Health Systems and Development, Tulane University. New Orleans, LA, 70112, United States of America
| |
Collapse
|
26
|
Giami A, Perrey C, Mendonça ALDO, de Camargo KR. Hybrid forum or network? The social and political construction of an international 'technical consultation': male circumcision and HIV prevention. Glob Public Health 2015; 10:589-606. [PMID: 25646671 DOI: 10.1080/17441692.2014.998697] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The technical consultation in Montreux, organised by World Health Organization and UNAIDS in 2007, recommended male circumcision as a method for preventing HIV transmission. This consultation came out of a long process of releasing reports and holding international and regional conferences, a process steered by an informal network. This network's relations with other parties is analysed along with its way of working and the exchanges during the technical consultation that led up to the formal adoption of a recommendation. Conducted in relation to the concepts of a 'hybrid forum' and 'network', this article shows that the decision was based on the formation and consolidation of a network of persons. They were active in all phases of this process, ranging from studies of the recommendation's efficacy, feasibility and acceptability to its adoption and implementation. In this sense, this consultation cannot be described as the constitution of a 'hybrid forum', which is characterised by its openness to a debate as well as a plurality of issues formulated by the actors and of resources used by them. On the contrary, little room was allowed for contradictory discussions, as if the decision had already been made before the Montreux consultation.
Collapse
Affiliation(s)
- Alain Giami
- a Team Gender, Sexual and Reproductive Health, F-94276 , Inserm, CESP Centre for Research in Epidemiology and Population Health, U1018 , Le Kremlin Bicetre , France
| | | | | | | |
Collapse
|
27
|
Wamai RG, Morris BJ, Bailey RC, Klausner JD, Boedicker MN. Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress. Glob Public Health 2015; 10:639-66. [PMID: 25613581 PMCID: PMC6352987 DOI: 10.1080/17441692.2014.989532] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.
Collapse
Affiliation(s)
- Richard G. Wamai
- Department of African-American Studies, Northeastern University, Boston, Massachusetts, USA
| | - Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Robert C. Bailey
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeffrey D. Klausner
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, USA
| | | |
Collapse
|
28
|
Bulled NL. Hesitance towards voluntary medical male circumcision in Lesotho: reconfiguring global health governance. Glob Public Health 2014; 10:757-72. [PMID: 25300786 DOI: 10.1080/17441692.2014.962559] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention - voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the country's high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of 'partnerships' has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesotho's domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesotho's resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture.
Collapse
Affiliation(s)
- Nicola L Bulled
- a Department of Anthropology , University of Connecticut , Storrs , CT , USA
| |
Collapse
|
29
|
Westercamp N, Agot K, Jaoko W, Bailey RC. Risk compensation following male circumcision: results from a two-year prospective cohort study of recently circumcised and uncircumcised men in Nyanza Province, Kenya. AIDS Behav 2014; 18:1764-75. [PMID: 25047688 DOI: 10.1007/s10461-014-0846-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30-14 vs. 24-21 % in controls) and increased sexual activity among the youngest participants (18-24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.
Collapse
Affiliation(s)
- Nelli Westercamp
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St. MC 923, Chicago, IL, 60612, USA,
| | | | | | | |
Collapse
|
30
|
Marrazzo JM, del Rio C, Holtgrave DR, Cohen MS, Kalichman SC, Mayer KH, Montaner JSG, Wheeler DP, Grant RM, Grinsztejn B, Kumarasamy N, Shoptaw S, Walensky RP, Dabis F, Sugarman J, Benson CA. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA 2014; 312:390-409. [PMID: 25038358 PMCID: PMC6309682 DOI: 10.1001/jama.2014.7999] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Emerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings. OBJECTIVE To provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings. DATA SOURCES, STUDY SELECTION, AND DATA SYNTHESIS Data published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society-USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus. RESULTS Testing for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible. CONCLUSIONS AND RELEVANCE Data support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.
Collapse
Affiliation(s)
| | | | - David R Holtgrave
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | | | | | | | | | - Beatriz Grinsztejn
- Evandro Chagas Clinical Research Institute (IPEC)-FIOCRUZ, Rio de Janeiro, Brazil
| | - N Kumarasamy
- YR Gaitonde Centre for AIDS Research and Education, Chennai, India
| | | | | | | | | | | |
Collapse
|
31
|
Riess TH, Achieng' MM, Bailey RC. Women's beliefs about male circumcision, HIV prevention, and sexual behaviors in Kisumu, Kenya. PLoS One 2014; 9:e97748. [PMID: 24844845 PMCID: PMC4028254 DOI: 10.1371/journal.pone.0097748] [Citation(s) in RCA: 22] [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: 01/05/2014] [Accepted: 04/24/2014] [Indexed: 11/19/2022] Open
Abstract
It is important to understand how women's sexual practices may be influenced by male circumcision (MC) as an HIV prevention effort. Women's beliefs about MC and sexual behaviour will likely influence the scale-up and uptake of medical MC. We conducted qualitative interviews with 30 sexually active women in Kisumu, Kenya. Women discussed MC related to perceived health benefits, condom use, sexual behaviour, knowledge of susceptibility to HIV and sexually transmitted infections (STIs), circumcision preference, and influence on circumcision uptake. Respondents had a good understanding of the partial protection of MC for acquisition of HIV for men. Women perceived circumcised men as cleaner, carrying fewer diseases, and taking more time to reach ejaculation. Male's circumcision status is a salient factor for women's sexual decision making, including partner choice, and condom use. It will be important that educational information affirms that MC provides only partial protection against female to male transmission of HIV and some STIs; that other HIV and STI prevention methods such as condoms need to be used in conjunction with MC; that MC does not preclude a man from having HIV; and that couples should develop plans for not having sex while the man is healing.
Collapse
Affiliation(s)
- Thomas H. Riess
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Maryline M. Achieng'
- Liverpool VCT, Care and Treatment, Research and Policy Department, Nairobi, Kenya
| | - Robert C. Bailey
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, United States of America
| |
Collapse
|
32
|
Montaño DE, Kasprzyk D, Hamilton DT, Tshimanga M, Gorn G. Evidence-based identification of key beliefs explaining adult male circumcision motivation in Zimbabwe: targets for behavior change messaging. AIDS Behav 2014; 18:885-904. [PMID: 24443147 PMCID: PMC3984408 DOI: 10.1007/s10461-013-0686-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Male circumcision (MC) reduces HIV acquisition among men, leading WHO/UNAIDS to recommend a goal to circumcise 80 % of men in high HIV prevalence countries. Significant investment to increase MC capacity in priority countries was made, yet only 5 % of the goal has been achieved in Zimbabwe. The integrated behavioral model (IBM) was used as a framework to investigate the factors affecting MC motivation among men in Zimbabwe. A survey instrument was designed based on elicitation study results, and administered to a representative household-based sample of 1,201 men aged 18-30 from two urban and two rural areas in Zimbabwe. Multiple regression analysis found all five IBM constructs significantly explained MC Intention. Nearly all beliefs underlying the IBM constructs were significantly correlated with MC Intention. Stepwise regression analysis of beliefs underlying each construct respectively found that 13 behavioral beliefs, 5 normative beliefs, 4 descriptive norm beliefs, 6 efficacy beliefs, and 10 control beliefs were significant in explaining MC Intention. A final stepwise regression of the five sets of significant IBM construct beliefs identified 14 key beliefs that best explain Intention. Similar analyses were carried out with subgroups of men by urban-rural and age. Different sets of behavioral, normative, efficacy, and control beliefs were significant for each sub-group, suggesting communication messages need to be targeted to be most effective for sub-groups. Implications for the design of effective MC demand creation messages are discussed. This study demonstrates the application of theory-driven research to identify evidence-based targets for intervention messages to increase men's motivation to get circumcised and thereby improve demand for male circumcision.
Collapse
Affiliation(s)
- Daniel E Montaño
- Health and Analytics, Battelle, 1100 Dexter Avenue North, Suite 400, Seattle, WA, 98109-3598, USA,
| | | | | | | | | |
Collapse
|
33
|
Abstract
BACKGROUND In three randomized trials, medical male circumcision (MMC) reduced HIV acquisition in heterosexual men in sub-Saharan Africa by approximately 60%, after 21-24 months of follow-up. We estimated the 72-month efficacy of MMC against HIV among men retained in the Kisumu randomized trial, in which HIV acquisition was reduced by 60% after 24 months. METHODS From 2002 to 2005, 2784 men aged 18-24 were enrolled and randomized 1 : 1 to immediate circumcision or control. At trial end in December 2006, control men were offered free circumcision. Follow-up continued to September 2010. Cox proportional hazards regression incorporating stabilized inverse probability of treatment and censoring weights generated through marginal structural modeling, was used to account for potential time-varying confounding and censoring to estimate the efficacy of MMC on HIV risk. RESULTS The cumulative 72-month HIV incidence was 7.21% [95% confidence interval (CI): 5.98-8.68%]: 4.81% among circumcised men, 11.0% among uncircumcised men. The crude hazard ratio of HIV seroconversion for circumcised vs. uncircumcised men was 0.38 [95% CI: 0.26-0.55]. In weight-adjusted Cox regression, the hazard ratio was 0.42 [95% CI: 0.26-0.66]. CONCLUSION The efficacy of MMC was sustained at 58% at 72 months, similar to overall findings of the three trials under conditions of randomization. These findings provide an estimate of the long-term efficacy of circumcision against HIV acquisition. Our results support programmatic scale-up recommendations that are based on assumptions of sustained efficacy.
Collapse
|
34
|
MacLaren D, Tommbe R, Mafile’o T, Manineng C, Fregonese F, Redman-MacLaren M, Wood M, Browne K, Muller R, Kaldor J, McBride WJ. Foreskin cutting beliefs and practices and the acceptability of male circumcision for HIV prevention in Papua New Guinea. BMC Public Health 2013; 13:818. [PMID: 24015786 PMCID: PMC3846639 DOI: 10.1186/1471-2458-13-818] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 09/05/2013] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Male circumcision (MC) reduces HIV acquisition and is a key public health intervention in settings with high HIV prevalence, heterosexual transmission and low MC rates. In Papua New Guinea (PNG), where HIV prevalence is 0.8%, there is no medical MC program for HIV prevention. There are however many different foreskin cutting practices across the country's 800 language groups. The major form exposes the glans but does not remove the foreskin. This study aimed to describe and quantify foreskin cutting styles, practices and beliefs. It also aimed to assess the acceptability of MC for HIV prevention in PNG. METHODS Cross-sectional multicentre study, at two university campuses (Madang Province and National Capital District) and at two 'rural development' sites (mining site Enga Province; palm-oil plantation in Oro Province). Structured questionnaires were completed by participants originating from all regions of PNG who were resident at each site for study or work. RESULTS Questionnaires were completed by 861 men and 519 women. Of men, 47% reported a longitudinal foreskin cut (cut through the dorsal surface to expose the glans but foreskin not removed); 43% reported no foreskin cut; and 10% a circumferential foreskin cut (complete removal). Frequency and type of cut varied significantly by region of origin (p < .001). Most men (72-82%) were cut between the ages of 10-20 years. Longitudinal cuts were most often done in a village by a friend, with circumferential cuts most often done in a clinic by a health professional. Most uncut men (71%) and longitudinal cut men (84%) stated they would remove their foreskin if it reduced the risk of HIV infection. More than 95% of uncut men and 97% of longitudinal cut men would prefer the procedure in a clinic or hospital. Most men (90%) and women (74%) stated they would remove the foreskin of their son if it reduced the risk of HIV infection. CONCLUSION Although 57% of men reported some form of foreskin cut only 10% reported the complete removal of the foreskin, the procedure on which international HIV prevention strategies are based. The acceptability of MC (complete foreskin removal) is high among men (for themselves and their sons) and women (for their sons). Potential MC services need to be responsive to the diversity of beliefs and practices and consider health system constraints. A concerted research effort to investigate the potential protective effects of longitudinal cuts for HIV acquisition is essential given the scale of longitudinal cuts in PNG.
Collapse
Affiliation(s)
- David MacLaren
- School of Medicine and Dentistry, James Cook University, McGregor Road, Smithfield, Cairns 4878, Queensland, Australia
| | - Rachael Tommbe
- School of Health Science, Pacific Adventist University, Port Moresby, National Capital District, Papua New Guinea
| | - Tracie Mafile’o
- Deputy Vice Chancellor, Pacific Adventist University, Port Moresby, National Capital District, Papua New Guinea
| | - Clement Manineng
- Faculty of Health Science, Divine Word University, Madang, Madang Province, Papua New Guinea
| | - Federica Fregonese
- Global Health Unit, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Michelle Redman-MacLaren
- School of Medicine and Dentistry, James Cook University, McGregor Road, Smithfield, Cairns 4878, Queensland, Australia
| | - Michael Wood
- School of Arts and Social Science, James Cook University, Cairns, Queensland, Australia
| | - Kelwyn Browne
- Rural Primary Health Services Delivery Project, National Department of Health, Port Moresby, Papua New Guinea
| | - Reinhold Muller
- School of Public Health, Tropical Medicine and Rehabilitation Science, James Cook University, Cairns, Queensland, Australia
- Tropical Health Solutions, Townsville, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - William John McBride
- School of Medicine and Dentistry, James Cook University, McGregor Road, Smithfield, Cairns 4878, Queensland, Australia
| |
Collapse
|
35
|
Abstract
Neonatal male circumcision (NMC) is an uncommon procedure in Southern Africa, but is being scaled up in Zambia for long-term HIV prevention. We conducted a cross-sectional survey on NMC with a convenience sample of mothers of newborn boys at two public clinics in Lusaka. Following the survey, mothers received information on availability of NMC, and uptake of the service was tracked. Predictors of uptake were assessed using bivariate and multivariate logistic regression. Of the 1,249 eligible mothers approached, 1000 (80%) agreed to participate. Although 97% of surveyed mothers said they definitely or probably planned to have their newborn son circumcised, only 11% of participants brought their newborn sons for NMC. Significant predictors of uptake in adjusted models included: Older maternal age (AOR 3.77, 95% CI 1.48-9.63 for age 36 and above compared to mothers age 25 and below), having attended antenatal care at an NMC site (AOR 2.13, 95% CI 1.32-3.44), older paternal age (AOR 4.36, 95% CI 1.28-14.91 for age 26-35 compared to fathers age 25 and below), and the infant's father being circumcised (AOR 2.21, 95% CI 1.35-3.62). While acceptability studies in Southern Africa have suggested strong support for MC among parents for having their sons circumcised, this may not translate to high uptake of newly-introduced NMC services.
Collapse
|
36
|
A controlled trial of three methods for neonatal circumcision in Lusaka, Zambia. J Acquir Immune Defic Syndr 2013; 62:e1-6. [PMID: 23075913 DOI: 10.1097/qai.0b013e318275741b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Neonatal male circumcision (NMC) is not routinely practiced in Zambia, but it is a promising long-term HIV prevention strategy. We studied the feasibility and safety of three different NMC methods. METHODS We enrolled healthy newborns in a controlled trial of the Mogen, Gomco, and Plastibell devices. Doctors, nurses, and clinical officers were trained to perform Mogen, Gomco, and Plastibell techniques. Each provider performed at least 10 circumcisions using each device. Neonates were reviewed at 1 and 6 weeks after circumcision for adverse events. RESULTS Between October 2009 and March 2011, 17 providers (5 physicians, 9 nurse midwives, and 3 clinical officers) without previous NMC experience were trained, and 640 circumcisions were performed. The median infant birth weight was 3.2 kg (interquartile range: 2.9-3.5 kg), and median age at the time of procedure was 11 days (interquartile range: 7-18 days); 149 babies (23.3%) were exposed to HIV. The overall adverse event rate was 4.9% (n = 31/630), and the moderate-severe adverse event rate was 4.1% (n = 26/630). Rates did not significantly differ by method. Most providers (65%) preferred Mogen clamp over Gomco and Plastibell. CONCLUSIONS Doctors, nurses, and clinical officers can be trained to safely provide NMC in a programmatic setting. The 3 studied techniques had comparable safety profiles. Mogen clamp was the preferred device for most providers.
Collapse
|
37
|
Mishra S, Thompson LH, Sonia A, Khalid N, Emmanuel F, Blanchard JF. Sexual behaviour, structural vulnerabilities and HIV prevalence among female sex workers in Pakistan. Sex Transm Infect 2013; 89 Suppl 2:ii34-42. [PMID: 23413402 PMCID: PMC3756444 DOI: 10.1136/sextrans-2012-050776] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background We sought to describe differences in individual and structural vulnerabilities faced by female sex workers (FSWs) in Pakistan between 2006 and 2011, and to characterise risk factors for inconsistent condom use and HIV prevalence in this population. Methods To describe differences in vulnerabilities, we analysed behavioural data from serial cross-sectional surveys conducted across nine cities in 2006 and 2011. Using data from 12 cities in 2011, we used logistic regression to characterise risk factors for (a) inconsistent condom use in the past month (N=6987), and (b) HIV (N=4301). Results Compared to FSWs in 2006, FSWs in 2011 were significantly more likely to solicit clients via cell phones, and to report a larger client volume and anal sex with clients, but also consistent condom use with clients (30.0% vs 23.6% in 2006). In 2011, independent risk factors for inconsistent condom use with clients included: recent sexual violence, recent sex with a person who injects drugs, and absence of programme exposure. HIV prevalence was 0.63% (95% CI 0.43% to 0.92%) in 2011, and was associated with a recent history of injection drug use and absence of programme exposure. Conclusions While condom use with clients was higher in 2011, protective behaviours remained low and vulnerabilities related to sex work may have risen. HIV is emerging in this population and an adaptive HIV prevention programme that addresses different vulnerabilities and the intersection of sexual networks with injection drug use is needed.
Collapse
Affiliation(s)
- Sharmistha Mishra
- Department of Infectious Disease Epidemiology, Imperial College London, , London, UK
| | | | | | | | | | | |
Collapse
|
38
|
Obiero W, Young MR, Bailey RC. The PrePex device is unlikely to achieve cost-savings compared to the forceps-guided method in male circumcision programs in sub-Saharan Africa. PLoS One 2013; 8:e53380. [PMID: 23349708 PMCID: PMC3549910 DOI: 10.1371/journal.pone.0053380] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 11/30/2012] [Indexed: 11/18/2022] Open
Abstract
Background Male circumcision (MC) reduces the risk of heterosexual HIV acquisition in men by approximately 60%. MC programs for HIV prevention are currently being scaled-up in fourteen countries in sub-Saharan Africa. The current standard surgical technique for MC in many sub-Saharan African countries is the forceps-guided male circumcision (FGMC) method. The PrePex male circumcision (PMC) method could replace FGMC and potentially reduce MC programming costs. We compared the potential costs of introducing the PrePex device into MC programming to the cost of the forceps-guided method. Methods Data were obtained from the Nyanza Reproductive Health Society (NRHS), an MC service delivery organization in Kenya, and from the Kenya Ministry of Health. Analyses are based on 48,265 MC procedures performed in four Districts in western Kenya from 2009 through 2011. Data were entered into the WHO/UNAIDS Decision Makers Program Planning Tool. The tool assesses direct and indirect costs of MC programming. Various sensitivity analyses were performed. Costs were discounted at an annual rate of 6% and are presented in United States Dollars. Results Not including the costs of the PrePex device or referral costs for men with phimosis/tight foreskin, the costs of one MC surgery were $44.54–$49.02 and $54.52–$55.29 for PMC and FGMC, respectively. Conclusion The PrePex device is unlikely to result in significant cost-savings in comparison to the forceps-guided method. MC programmers should target other aspects of the male circumcision minimum package for improved cost efficiency.
Collapse
|
39
|
Auvert B, Taljaard D, Rech D, Lissouba P, Singh B, Bouscaillou J, Peytavin G, Mahiane SG, Sitta R, Puren A, Lewis D. Association of the ANRS-12126 male circumcision project with HIV levels among men in a South African township: evaluation of effectiveness using cross-sectional surveys. PLoS Med 2013; 10:e1001509. [PMID: 24019763 PMCID: PMC3760784 DOI: 10.1371/journal.pmed.1001509] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 07/26/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Randomized controlled trials have shown that voluntary medical male circumcision (VMMC) reduces HIV infection by 50% to 60% in sub-Saharan African populations; however, little is known about the population-level effect of adult male circumcision (MC) as an HIV prevention method. We assessed the effectiveness of VMMC roll-out on the levels of HIV in the South African township of Orange Farm where the first randomized controlled trial (RCT) to test the effect of VMMC on HIV acquisition was conducted in 2002-2005. METHODS AND FINDINGS The Bophelo Pele project is a community-based campaign against HIV, which includes the roll-out of free VMMC. A baseline cross-sectional biomedical survey was conducted in 2007-2008 among a random sample of 1,998 men aged 15 to 49 (survey response rate 80.7%). In 2010-2011, we conducted a follow-up random survey among 3,338 men aged 15 to 49 (survey response rate 79.6%) to evaluate the project. Participants were interviewed, blood samples were collected and tested for HIV and recent HIV infection (using the BED HIV incidence assay), and MC status was assessed through a clinical examination. Data were analyzed using multivariate and propensity statistical methods. Owing to the VMMCs performed in the context of the RCT and the Bophelo Pele project, the prevalence rate of adult MC increased from 0.12 (95% CI 0.10-0.14) to 0.53 (95% CI 0.51-0.55). Without these VMMCs, the HIV prevalence rate in 2010-2011 would have been 19% (95% CI 12%-26%) higher (0.147 instead of 0.123). When comparing circumcised and uncircumcised men, no association of MC status with sexual behavior was detected. Among circumcised and uncircumcised men, the proportion consistently using condoms with non-spousal partners in the past 12 months was 44.0% (95% CI 41.7%-46.5%) versus 45.4% (95% CI 42.2%-48.6%) with weighted prevalence rate ratio (wPRR) = 0.94 (95% CI 0.85-1.03). The proportion having two or more non-spousal partners was 50.4% (95% CI 47.9%-52.9%) versus 44.2% (95% CI 41.3%-46.9%) with wPRR = 1.03 (95% CI 0.95-1.10). We found a reduction of BED-estimated HIV incidence rate ranging from 57% (95% CI 29%-76%) to 61% (95% CI 14%-83%) among circumcised men in comparison with uncircumcised men. CONCLUSIONS Findings suggest that the roll-out of VMMC in Orange Farm is associated with a significant reduction of HIV levels in the community. The main limitation of the study is that it was not randomized and cannot prove a causal association. The roll-out of VMMC among adults in sub-Saharan Africa should be an international priority and needs to be accelerated to effectively combat the spread of HIV. Please see later in the article for the Editors' Summary.
Collapse
Affiliation(s)
- Bertran Auvert
- UMRS-1018, CESP, INSERM Villejuif, France
- AP-HP, Hôpital Ambroise Paré, Boulogne, France
- University of Versailles-Saint Quentin, Versailles, France
- * E-mail:
| | | | - Dino Rech
- Progressus, Johannesburg, South Africa
| | | | - Beverley Singh
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | | | | | - Séverin Guy Mahiane
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Rémi Sitta
- UMRS-1018, CESP, INSERM Villejuif, France
| | - Adrian Puren
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David Lewis
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
40
|
Kelly A, Kupul M, Nake Trumb R, Aeno H, Neo J, Fitzgerald L, Hill PS, Kaldor JM, Siba P, Vallely A. More than just a cut: a qualitative study of penile practices and their relationship to masculinity, sexuality and contagion and their implications for HIV prevention in Papua New Guinea. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2012; 12:10. [PMID: 22818494 PMCID: PMC3520875 DOI: 10.1186/1472-698x-12-10] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 06/27/2012] [Indexed: 11/10/2022]
Abstract
Background Male circumcision (MC) has been shown to reduce vaginal transmission of HIV to men. While community acceptability is important in a countries preparedness to introduce MC, it is equally important to map contemporary MC and other penile cutting practices, and the socio-cultural dimensions underpinning these practices. Methods A total of 482 men and women (n = 276 and n = 210, respectively) participated in 82 semi-structured and 45 focus group discussions from four different provinces of Papua New Guinea (PNG), each representing one of the four socially and geographically diverse regions of the country. Results Of the men interviewed 131 self-reported that they had undergone a penile alteration with some reporting multiple types. Practices were diverse and could be grouped into five broad categories: traditional (customary) penile cutting; contemporary penile cutting; medical circumcision; penile inserts; and penile bloodletting practices in which sharp objects are used to incise the glans and or inserted and withdrawn from the male urethra or in order to induce bleeding. Socio-cultural traditions, enhanced sexual pleasure and improved genital hygiene were key motivators for all forms of penile practices. Conclusions The findings from this study highlight the complex and diverse nature of penile practices in PNG and their association with notions of masculinity, sexuality and contagion. Contemporary penile practices are critical to a community’s acceptance of MC and of a country’s ability to successfully implement MC in the context of a rich and dynamic culture of penile practices. If a MC program were to be successfully rolled out in PNG to prevent HIV it would need to work within and build upon these diverse cultural meanings and motivators for penile practices already commonly performed in PNG by men.
Collapse
Affiliation(s)
- Angela Kelly
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Bhunu C, Mushayabasa S. Assessing the impact of using antiretroviral drugs as pre-exposure vaccines. HIV & AIDS REVIEW 2012. [DOI: 10.1016/j.hivar.2012.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
42
|
Kelly A, Kupul M, Fitzgerald L, Aeno H, Neo J, Naketrumb R, Siba P, Kaldor JM, Vallely A. "Now we are in a different time; various bad diseases have come." Understanding men's acceptability of male circumcision for HIV prevention in a moderate prevalence setting. BMC Public Health 2012; 12:67. [PMID: 22264256 PMCID: PMC3298502 DOI: 10.1186/1471-2458-12-67] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 01/22/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Adult male surgical circumcision (MC) has been shown to reduce HIV acquisition in men and is recommended by the WHO for inclusion in comprehensive national HIV prevention programs in high prevalence settings. Only limited research to date has been conducted in countries experiencing moderate burden epidemics, where the acceptability, operational feasibility and potential epidemiological impact of MC remain unclear. METHODS A multi-method qualitative research study was conducted at four sites in Papua New Guinea (PNG), with 24 focus group discussions and 65 in-depth interviews carried out among 276 men. RESULTS The majority of men were in favour of MC being introduced for HIV prevention in PNG and considered improved genital hygiene, enhanced sexual pleasure and culturally appropriateness key factors in the acceptability of a future intervention. A minority of men were against the introduction of MC, primarily due to concerns regarding sexual risk compensation and that the intervention went against prevailing cultural and religious beliefs. CONCLUSION This is one of the first community-based MC acceptability studies conducted in a moderate prevalence setting outside of Africa. Research findings from this study suggest that a future MC program for HIV prevention would be widely accepted by men in PNG.
Collapse
Affiliation(s)
- Angela Kelly
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka EHP 441, Papua New Guinea
- International HIV Research Group, School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Martha Kupul
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka EHP 441, Papua New Guinea
| | - Lisa Fitzgerald
- School of Population Health, University of Queensland, Brisbane, Australia
| | - Herick Aeno
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka EHP 441, Papua New Guinea
| | - James Neo
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka EHP 441, Papua New Guinea
| | - Richard Naketrumb
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka EHP 441, Papua New Guinea
| | - Peter Siba
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka EHP 441, Papua New Guinea
| | - John M Kaldor
- Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical Research), University of New South Wales, Sydney, Australia
| | - Andrew Vallely
- Sexual and Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka EHP 441, Papua New Guinea
- Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical Research), University of New South Wales, Sydney, Australia
| |
Collapse
|
43
|
Johnson LF, Hallett TB, Rehle TM, Dorrington RE. The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: a model-based analysis. J R Soc Interface 2012; 9:1544-54. [PMID: 22258551 DOI: 10.1098/rsif.2011.0826] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study aims to assess trends in human immunodeficiency virus (HIV) incidence in South Africa, and to assess the extent to which prevention and treatment programmes have reduced HIV incidence. Two models of the South African HIV epidemic, the STI (sexually transmitted infection)-HIV Interaction model and the ASSA2003 AIDS and Demographic model, were adapted. Both models were fitted to age-specific HIV prevalence data from antenatal clinic surveys and household surveys, using a Bayesian approach. Both models suggest that HIV incidence in 15-49 year olds declined significantly between the start of 2000 and the start of 2008: by 27 per cent (95% CI: 21-32%) in the STI-HIV model and by 31 per cent (95% CI: 23-39%) in the ASSA2003 model, when expressed as a percentage of incidence rates in 2000. By 2008, the percentage reduction in incidence owing to increased condom use was 37 per cent (95% CI: 34-41%) in the STI-HIV model and 23 per cent (95% CI: 14-34%) in the ASSA2003 model. Both models also estimated a small reduction in incidence owing to antiretroviral treatment by 2008. Increased condom use therefore appears to be the most significant factor explaining the recent South African HIV incidence decline.
Collapse
Affiliation(s)
- Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa.
| | | | | | | |
Collapse
|
44
|
Modeling the population-level effects of male circumcision as an HIV-preventive measure: a gendered perspective. PLoS One 2011; 6:e28608. [PMID: 22205956 PMCID: PMC3243682 DOI: 10.1371/journal.pone.0028608] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 11/11/2011] [Indexed: 11/29/2022] Open
Abstract
Background Evidence from biological, epidemiological, and controlled intervention studies has demonstrated that male circumcision (MC) protects males from HIV infection, and MC is now advocated as a public-health intervention against HIV. MC provides direct protection only to men, but is expected to provide indirect protection to women at risk of acquiring HIV from heterosexual transmission. How such indirect protection interacts with the possibility that MC campaigns will lead to behavior changes, however, is not yet well understood. Our objective here is to investigate the link between individual-level effects of MC campaigns and long-term population-level outcomes resulting from disease dynamics, looking at both genders separately, over a broad range of parameters. Methods and Findings We use simple mathematical models of heterosexual transmission to investigate the potential effects of a circumcision scale-up, combined with possible associated behavioral disinhibition. We examine patterns in expected long-term prevalence using a simple equilibrium model based on transmission factors, and validate our results with ODE-based simulations, focusing on the link between effects on females and those on males.We find that the long-term population-level effects on females and males are not strongly linked: there are many possible ways in which an intervention which reduces prevalence in males might nonetheless increase prevalence in females. Conclusions Since an intervention that reduces long-term male prevalence could nonetheless increase long-term female prevalence, MC campaigns should explicitly consider both the short-term and long-term effects of MC interventions on females. Our findings strongly underline the importance of pairing MC programs with education, support programs and HIV testing and counseling, together with other prevention measures.
Collapse
|
45
|
Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, Heard N, Castor D, Stover J, Farley T, Menon V, Hankins C. Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Med 2011; 8:e1001132. [PMID: 22140367 PMCID: PMC3226464 DOI: 10.1371/journal.pmed.1001132] [Citation(s) in RCA: 234] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 10/19/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data. METHODS AND FINDINGS We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion. CONCLUSIONS This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs.
Collapse
Affiliation(s)
- Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, District of Columbia, United States of America
- * E-mail:
| | - Steven Forsythe
- Futures Institute, Glastonbury, Connecticut, United States of America
| | - Jason Reed
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Lori Bollinger
- Futures Institute, Glastonbury, Connecticut, United States of America
| | - Nathan Heard
- Office of the U.S. Global AIDS Coordinator, United States Department of State, Washington, District of Columbia, United States of America
| | - Delivette Castor
- United States Agency for International Development, Washington, District of Columbia, United States of America
| | - John Stover
- Futures Institute, Glastonbury, Connecticut, United States of America
| | | | - Veena Menon
- Futures Group, Washington, District of Columbia, United States of America
| | | |
Collapse
|
46
|
Wamai RG, Morris BJ, Bailis SA, Sokal D, Klausner JD, Appleton R, Sewankambo N, Cooper DA, Bongaarts J, de Bruyn G, Wodak AD, Banerjee J. Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa. J Int AIDS Soc 2011; 14:49. [PMID: 22014096 PMCID: PMC3207867 DOI: 10.1186/1758-2652-14-49] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 10/20/2011] [Indexed: 11/23/2022] Open
Abstract
Heterosexual exposure accounts for most HIV transmission in sub-Saharan Africa, and this mode, as a proportion of new infections, is escalating globally. The scientific evidence accumulated over more than 20 years shows that among the strategies advocated during this period for HIV prevention, male circumcision is one of, if not, the most efficacious epidemiologically, as well as cost-wise. Despite this, and recommendation of the procedure by global policy makers, national implementation has been slow. Additionally, some are not convinced of the protective effect of male circumcision and there are also reports, unsupported by evidence, that non-sex-related drivers play a major role in HIV transmission in sub-Saharan Africa. Here, we provide a critical evaluation of the state of the current evidence for male circumcision in reducing HIV infection in light of established transmission drivers, provide an update on programmes now in place in this region, and explain why policies based on established scientific evidence should be prioritized. We conclude that the evidence supports the need to accelerate the implementation of medical male circumcision programmes for HIV prevention in generalized heterosexual epidemics, as well as in countering the growing heterosexual transmission in countries where HIV prevalence is presently low.
Collapse
Affiliation(s)
- Richard G Wamai
- Department of African-American Studies, Northeastern University, Boston, MA, USA
| | - Brian J Morris
- School of Medical Sciences, University of Sydney, Australia
| | - Stefan A Bailis
- Research & Education Association on Circumcision Health Effects, Bloomington, MN, USA
| | - David Sokal
- Behavioral and Biomedical Research, Family Health International, Research Triangle Park, NC, USA
| | - Jeffrey D Klausner
- Department of Medicine, University of California, San Francisco Department of Public Health, USA
| | - Ross Appleton
- College of Professional Studies, Northeastern University, Boston, MA, USA
| | | | - David A Cooper
- Kirby Institute, St Vincents Hospital and University of New South Wales Sydney, Australia
| | - John Bongaarts
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
| | - Guy de Bruyn
- Perinatal HIV Research Unit, New Nurses Home, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Alex D Wodak
- Alcohol & Drug Unit, St Vincent's Hospital, Sydney, Australia
| | - Joya Banerjee
- Global Youth Coalition on HIV/AIDS, Pretoria, South Africa
| |
Collapse
|
47
|
Lissouba P, Taljaard D, Rech D, Dermaux-Msimang V, Legeai C, Lewis D, Singh B, Puren A, Auvert B. Adult male circumcision as an intervention against HIV: an operational study of uptake in a South African community (ANRS 12126). BMC Infect Dis 2011; 11:253. [PMID: 21943076 PMCID: PMC3192707 DOI: 10.1186/1471-2334-11-253] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 09/26/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the knowledge, attitudes and beliefs about adult male circumcision (AMC), assess the association of AMC with HIV incidence and prevalence, and estimate AMC uptake in a Southern African community. METHODS A cross-sectional biomedical survey (ANRS-12126) conducted in 2007-2008 among a random sample of 1198 men aged 15 to 49 from Orange Farm (South Africa). Face-to-face interviews were conducted by structured questionnaire. Recent HIV infections were evaluated using the BED incidence assay. Circumcision status was self-reported and clinically assessed. Adjusted HIV incidence rate ratios (aIRR) and prevalence ratios (aPR) were calculated using Poisson regression. RESULTS The response rate was 73.9%. Most respondents agreed that circumcised men could become HIV infected and needed to use condoms, although 19.3% (95%CI: 17.1% to 21.6%) asserted that AMC protected fully against HIV. Among self-reported circumcised men, 44.9% (95%CI: 39.6% to 50.3%) had intact foreskins. Men without foreskins had lower HIV incidence and prevalence than men with foreskins (aIRR = 0.35; 95%CI: 0.14 to 0.88; aPR = 0.45, 95%CI: 0.26 to 0.79). No significant difference was found between self-reported circumcised men with foreskins and other uncircumcised men. Intention to undergo AMC was associated with ethnic group and partner and family support of AMC. Uptake of AMC was 58.8% (95%CI: 55.4% to 62.0%). CONCLUSIONS AMC uptake in this community is high but communication and counseling should emphasize what clinical AMC is and its effect on HIV acquisition. These findings suggest that AMC roll-out is promising but requires careful implementation strategies to be successful against the African HIV epidemic.
Collapse
Affiliation(s)
| | | | - Dino Rech
- Progressus, Johannesburg, South Africa
| | - Veerle Dermaux-Msimang
- National Institute for Communicable Diseases (NICD) of the National Health Laboratory Services (NHLS), Johannesburg, South Africa
| | | | - David Lewis
- National Institute for Communicable Diseases (NICD) of the National Health Laboratory Services (NHLS), Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Beverley Singh
- National Institute for Communicable Diseases (NICD) of the National Health Laboratory Services (NHLS), Johannesburg, South Africa
| | - Adrian Puren
- National Institute for Communicable Diseases (NICD) of the National Health Laboratory Services (NHLS), Johannesburg, South Africa
- University of the Witwatersrand, Johannesburg, South Africa
| | - Bertran Auvert
- CESP INSERM-UVSQ UMRS 1018, Villejuif, France
- Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France
- Université Versailles Saint-Quentin-en-Yvelines, Versailles, France
| |
Collapse
|
48
|
Andersson N, Cockcroft A. Male circumcision, attitudes to HIV prevention and HIV status: a cross-sectional study in Botswana, Namibia and Swaziland. AIDS Care 2011; 24:301-9. [PMID: 21933035 PMCID: PMC3379742 DOI: 10.1080/09540121.2011.608793] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In efficacy trials male circumcision (MC) protected men against HIV infection. Planners need information relevant to MC programmes in practice. In 2008, we interviewed 2915 men and 4549 women aged 15–29 years in representative cluster samples in Botswana, Namibia and Swaziland, asking about socio-economic characteristics, knowledge and attitudes about HIV and MC and MC history. We tested finger prick blood samples for HIV. We calculated weighted frequencies of MC knowledge and attitudes, and MC history and HIV status. Multivariate analysis examined associations between MC and other variables and HIV status. In Botswana, 11% of young men reported MC, 28% in Namibia and 8% in Swaziland; mostly (75% in Botswana, 94% – mostly Herero – in Namibia and 68% in Swaziland) as infants or children. Overall, 6.5% were HIV positive (8.3% Botswana, 2.6% Namibia and 9.1% Swaziland). Taking other variables into account, circumcised men were as likely as uncircumcised men to be HIV positive. Nearly half of the uncircumcised young men planned to be circumcised; two-thirds of young men and women planned to have their sons circumcised. Some respondents had inaccurate beliefs and unhelpful views about MC and HIV, with variation between countries. Between 9 and 15% believed a circumcised man is fully protected against HIV; 20–26% believed men need not be tested for HIV before MC; 14–26% believed HIV-positive men who are circumcised cannot transmit the virus; and 8–34% thought it was “okay for a circumcised man to expect sex without a condom”. Inaccurate perceptions about protection from MC could lead to risk compensation and reduce women's ability to negotiate safer sex. More efforts are needed to raise awareness about the limitations of MC protection, especially for women, and to study the interactions between MC roll out programmes and primary HIV prevention programmes.
Collapse
Affiliation(s)
- Neil Andersson
- Centro de Investigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero, Acapulco, Mexico.
| | | |
Collapse
|
49
|
Kigozi G, Musoke R, Anyokorit M, Nkale J, Kighoma N, Ssebanenya W, Mwinike J, Watya S, Nalugoda F, Kagaayi J, Nalwoga G, Nakigozi G, Kiwanuka N, Makumbi F, Lutalo T, Serwadda D, Wawer M, Gray R. Use of a mixture of lignocaine and bupivacaine vs lignocaine alone for male circumcision under local anaesthesia in Rakai, Uganda. BJU Int 2011; 109:1068-71. [DOI: 10.1111/j.1464-410x.2011.10505.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
50
|
Andersson KM, Owens DK, Paltiel AD. Scaling up circumcision programs in Southern Africa: the potential impact of gender disparities and changes in condom use behaviors on heterosexual HIV transmission. AIDS Behav 2011; 15:938-48. [PMID: 20924783 PMCID: PMC3112296 DOI: 10.1007/s10461-010-9784-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Circumcision significantly reduces female-to-male transmission of HIV infection, but changes in behavior may influence the overall impact on transmission. We sought to explore these effects, particularly for societies where women have less power to negotiate safe sex. We developed a compartmental epidemic model to simulate the population-level impact of various circumcision programs on heterosexual HIV transmission in Soweto. We incorporated gender-specific negotiation of condom use in sexual partnerships and explored post-circumcision changes in condom use. A 5-year prevention program in which only an additional 10% of uncircumcised males undergo circumcision each year, for example, would prevent 13% of the expected new HIV infections over 20 years. Outcomes were sensitive to potential changes in behavior and differed by gender. For Southern Africa, even modest programs offering circumcision would result in significant benefits. Because decreases in male condom use could diminish these benefits, particularly for women, circumcision programs should emphasize risk-reduction counseling.
Collapse
Affiliation(s)
- Kyeen M Andersson
- Division of Health Policy & Administration, Department of Epidemiology & Public Health, Yale University School of Medicine, 60 College Street, New Haven, CT 06510, USA.
| | | | | |
Collapse
|