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Thomas ML, Zuma K, Loykissoonlal D, Dube ZB, Vranken P, Porter SE, Kripke K, Seatlhodi T, Meyer-Rath G, Johnson LF, Imai-Eaton JW. Substantial but spatially heterogeneous progress in male circumcision for HIV prevention in South Africa. COMMUNICATIONS MEDICINE 2024; 4:1. [PMID: 38172187 PMCID: PMC10764768 DOI: 10.1038/s43856-023-00405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 11/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) reduces the risk of male HIV acquisition by 60%. Programmes to provide VMMCs for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Traditional circumcision is also a long-standing male coming-of-age ritual, but practices vary considerably across populations. Accurate estimates of circumcision coverage by age, type, and time at subnational levels are required for planning and delivering VMMCs to meet targets and evaluating their impacts on HIV incidence. METHODS We developed a Bayesian competing risks time-to-event model to produce region-age-time-type specific probabilities and coverage of male circumcision with probabilistic uncertainty. The model jointly synthesises data from household surveys and health system data on the number of VMMCs conducted. We demonstrated the model using data from five household surveys and VMMC programme data to produce estimates of circumcision coverage for 52 districts in South Africa between 2008 and 2019. RESULTS Nationally, in 2008, 24.1% (95% CI: 23.4-24.8%) of men aged 15-49 were traditionally circumcised and 19.4% (18.9-20.0%) were medically circumcised. Between 2010 and 2019, 4.25 million VMMCs were conducted. Circumcision coverage among men aged 15-49 increased to 64.0% (63.2-64.9%) and medical circumcision coverage to 42% (41.3-43.0%). Circumcision coverage varied widely across districts, ranging from 13.4 to 86.3%. The average age of traditional circumcision ranged between 13 and 19 years, depending on local cultural practices. CONCLUSION South Africa has made substantial, but heterogeneous, progress towards increasing medical circumcision coverage. Detailed subnational information on coverage and practices can guide programmes to identify unmet need to achieve national and international targets.
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Affiliation(s)
- Matthew L Thomas
- Department of Earth and Environmental Sciences, University of Manchester, Manchester, UK.
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK.
| | - Khangelani Zuma
- Human and Social Capabilities Research Division, Human Sciences Research Council, Pretoria, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Peter Vranken
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Sarah E Porter
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Thapelo Seatlhodi
- National Department of Health, Pretoria, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Jeffrey W Imai-Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Ntshiqa T, Musekiwa A, Manesen R, Mdose H, Ngoma N, Kuonza L, Dlamini T, Reddy C, Williams S. Knowledge, Attitudes, Practices, and Acceptability of Medical Male Circumcision among Males in Traditionally Circumcising Rural Communities of Alfred Nzo District, Eastern Cape, South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7091. [PMID: 38063521 PMCID: PMC10706319 DOI: 10.3390/ijerph20237091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023]
Abstract
Male circumcision (MC) reduces HIV transmission risk by up to 60% in heterosexual men. However, uptake of medical male circumcision (MMC) is low in traditionally circumcising communities of South Africa. We assessed knowledge, attitudes, and practices to identify factors predicting acceptability of MMC among males in the Alfred Nzo District. A cross-sectional study was conducted among males aged 15-49 years in this district. Logistic regression was used to identify factors predicting acceptability of MMC. We interviewed 343 males who had a median age of 19 years (interquartile range (IQR): 16-25 years). Of these, 77% (95% confidence interval (CI): 72-82) were circumcised: 77% (95% CI: 71-82) were circumcised in a traditional setting and 21% (95% CI: 16-26) in a medical setting. The median score of knowledge about the benefits of MMC was 62.5% (IQR: 37.5-75.0), with 59% (95% CI: 53-64) demonstrating a positive attitude towards MMC and 68% (95% CI: 63-73) accepting involvement of health workers in MC. Excellent knowledge (adjusted odds ratio (aOR): 3.07, 95% CI: 0.99-9.58, p = 0.053), awareness (aOR: 3.26, 95% CI: 1.08-9.86, p = 0.037), and positive attitude towards MMC (aOR: 2.35, 95% CI: 1.30-4.25, p = 0.005) were associated with acceptability of MMC. Participants demonstrated good knowledge and acceptance of the MMC programme. Knowledge, attitude, and awareness were significant predictors of MMC acceptability.
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Affiliation(s)
- Thobani Ntshiqa
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- South African National Aids Council, Pretoria 0002, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
- The Aurum Institute, Johannesburg 2193, South Africa;
| | - Alfred Musekiwa
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Riyadh Manesen
- The Aurum Institute, Johannesburg 2193, South Africa;
- GERMS-SA, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa
- Epidemiology Unit, Eastern Cape Department of Health, Bisho 5605, South Africa;
| | - Hetani Mdose
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Nqobile Ngoma
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Lazarus Kuonza
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
| | - Thomas Dlamini
- Epidemiology Unit, Eastern Cape Department of Health, Bisho 5605, South Africa;
| | - Carl Reddy
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- School of Health Systems and Public Health, University of Pretoria, Pretoria 0002, South Africa
- TEPHINET Secretariat, The Task Force for Global Health, Decatur, GA 30030, USA
| | - Seymour Williams
- South African Field Epidemiology Training Programme, National Institute for Communicable Disease, Sandringham, Johannesburg 2131, South Africa; (A.M.); (H.M.); (N.N.); (L.K.); (C.R.); (S.W.)
- Centers for Disease Control and Prevention, Atlanta, GA 30328, USA
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Zulu JM, Mwamba T, Rosen A, Matenga TFL, Mulanda J, Kaimba M, Chilembo M, Silondwa M, Kamboyi RL, Simwanza SC, Sichone G, Chavula MP. Community engagement for the Voluntary Medical Male Circumcision (VMMC) program: an analysis of key stakeholder roles to promote a sustainable program in Zambia. Gates Open Res 2023; 6:50. [PMID: 37069966 PMCID: PMC10105033 DOI: 10.12688/gatesopenres.13587.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 05/31/2023] Open
Abstract
Background: Within the Voluntary Medical Male Circumcision (VMMC) programme, community engagement has been central in facilitating the acceptance of VMMC, especially in non-circumcising communities. We used the case of the development of community engagement plans for sustainability of VMMC in Zambia to illustrate diversity of stakeholders, their power, roles, and strategies in community engagement. Methods: Data were collected using document review, in-depth interviews (n=35) and focus group discussions (n=35) with community stakeholders, health workers, health centre committees, counsellors, teachers, community volunteers and parents/caregivers. Data were analysed using thematic analysis. The analysis was guided by the power and interest model. Results: Differences were noted between the rural and urban sites in terms of power/influence and interest rating of community stakeholders who could be involved in the sustainability phase of the VMMC response in Zambia. For example, in the urban setting, neighbourhood health committees (NHCs), health workers, leaders of clubs, community health workers (CHWs), radio, television and social media platforms were ranked highest. From this list, social media and television platforms were not highly ranked in rural areas. Some stakeholders had more sources of power than others. Forms or sources of power included technical expertise, local authority, financial resources, collective action (action through schools, churches, media platforms, other community spaces), and relational power. Key roles and strategies included strengthening and broadening local coordination systems, enhancing community involvement, promoting community-led monitoring and evaluation, through the use of locally recognised communication spaces and channels, facilitating ownership of VMMC, and improving local accountability processes in VMMC activities. Conclusions: By consulting with the most relevant stakeholders, and considering community needs in programme development, the VMMC programme may be able to leverage the community structures and systems to reduce long term demand generation costs for VMMC and increase the acceptability and frequency of male circumcision.
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Affiliation(s)
- Joseph M. Zulu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Trevor Mwamba
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Alyssa Rosen
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Tulani Francis L. Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Joseph Mulanda
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Mutale Kaimba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Masitano Chilembo
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Madaliso Silondwa
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Royd L. Kamboyi
- Ministry of Health, Ministry of Health, Lusaka, Lusaka, 10101, Zambia
| | | | - George Sichone
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Malizgani Paul Chavula
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
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Luseno WK, Rennie S, Gilbertson A. A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa. Int J Impot Res 2023; 35:269-278. [PMID: 34702986 PMCID: PMC8545773 DOI: 10.1038/s41443-021-00484-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022]
Abstract
Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.
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Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, NC, USA
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Zewdie K, Pickles M, Floyd S, Fidler S, Ayles H, Bock P, Hoddinott G, Mandla N, Shanaube K, Simwinga M, Fraser C, Seeley J, Piwowar-Manning E, Hayes R, Donnell D. Uptake of medical male circumcision with household-based testing, and the association of traditional male circumcision and HIV infection. AIDS 2023; 37:795-802. [PMID: 36727597 PMCID: PMC10023451 DOI: 10.1097/qad.0000000000003463] [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] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Voluntary medical male circumcision (VMMC) is an important component of combination HIV prevention. Inclusion of traditionally circumcised HIV negative men in VMMC uptake campaigns may be important if traditional male circumcision is less protective against HIV acquisition than VMMC. METHODS We used data from the HIV Prevention Trials Network (HPTN) 071 (PopART) study. This cluster-randomized trial assessed the impact of a combination prevention package on population-level HIV incidence in 21 study communities in Zambia and South Africa. We evaluated uptake of VMMC, using a two-stage analysis approach and used discrete-time survival analysis to evaluate the association between the types of male circumcision and HIV incidence. RESULTS A total of 10 803 HIV-negative men with self-reported circumcision status were included in this study. At baseline, 56% reported being uncircumcised, 26% traditionally circumcised and 18% were medically circumcised. During the PopART intervention, 11% of uncircumcised men reported uptake of medical male circumcision. We found no significant difference in the uptake of VMMC in communities receiving the PopART intervention package and standard of care {adj. rate ratio=1·10 [95% confidence interval (CI) 0.82, 1.50, P = 0.48]}. The rate of HIV acquisition for medically circumcised men was 70% lower than for those who were uncircumcised adjusted hazard ratio (adjHR) = 0.30 (95% CI 0.16-0.55; P < 0.0001). There was no difference in rate of HIV acquisition for traditionally circumcised men compared to those uncircumcised adjHR = 0.84 (95% CI 0.54, 1.31; P = 0.45). CONCLUSIONS Household-based delivery of HIV testing followed by referral for medical male circumcision did not result in substantial VMMC uptake. Traditional circumcision is not associated with lower risk of HIV acquisition.
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Affiliation(s)
- Kidist Zewdie
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, UK
| | - Helen Ayles
- ZAMBART, University of Zambia, School of Medicine, Ridgeway Campus, Lusaka, Zambia; Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Nomtha Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Kwame Shanaube
- ZAMBART, University of Zambia, School of Medicine, Ridgeway Campus, Lusaka, Zambia
| | - Musonda Simwinga
- ZAMBART, University of Zambia, School of Medicine, Ridgeway Campus, Lusaka, Zambia
| | - Christophe Fraser
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford
| | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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6
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Voluntary Medical Male Circumcision for HIV Prevention: a Global Overview. Curr HIV/AIDS Rep 2022; 19:474-483. [PMID: 36348186 DOI: 10.1007/s11904-022-00632-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW With the promise of HIV prevention, there has been a scale-up of voluntary medical male circumcision (VMMC) in high HIV incidence/low circumcision prevalence nations worldwide. Nonetheless, debates over the implementation and the effectiveness and safety of the VMMC in real-world settings persist. We revisit the role of VMMC in HIV prevention to inform health professionals, policymakers, and advocates or opponents in this new era. RECENT FINDINGS There has been substantial progress on VMMC scale-up to date, but this has varied considerably by region. The evidence of solid and direct protection of VMMC is available for heterosexual men and older adolescent boys in sub-Saharan Africa. The protective effect in men who have sex with men is suggested by systematic reviews but is not confirmed by clinical trials. Sexual partners, including women, likely benefit indirectly from the increased VMMC coverage through a decreased risk of exposure to infected male partners. Fortunately, the preponderance of studies does not suggest higher sexual risk behaviors among circumcised men, so-called risk compensation. VMMC requires health systems strengthening and continued promulgation of other evidence-based HIV prevention strategies to be successful. Health authorities in high HIV incidence areas that have low circumcision coverage should implement VMMC within a context of complementary biomedical and behavioral prevention strategies.
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Tusabe J, Muyinda H, Nangendo J, Kwesiga D, Nabikande S, Muhoozi M, Agwang W, Okello T, Rutebemberwa E. Factors Influencing the Uptake of Voluntary Medical Male Circumcision Among Boda-Boda Riders Aged 18–49 Years in Hoima, Western Uganda. HIV AIDS (Auckl) 2022; 14:437-449. [PMID: 36188163 PMCID: PMC9516793 DOI: 10.2147/hiv.s382219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
- Joan Tusabe
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
- Correspondence: Joan Tusabe, Email
| | - Herbert Muyinda
- Child Health and Development Center, School of Medicine Makerere University, Kampala, Uganda
| | - Joanita Nangendo
- Clinical epidemiology Unit, School of Medicine, Makerere University, Kampala, Uganda
| | - Doris Kwesiga
- Department of Health Policy, Planning and Management, School of public health, Makerere University, Kampala, Uganda
| | - Sherifah Nabikande
- Department of Health Policy, Planning and Management, School of public health, Makerere University, Kampala, Uganda
| | - Michael Muhoozi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Winnie Agwang
- Department of Health Policy, Planning and Management, School of public health, Makerere University, Kampala, Uganda
| | - Tom Okello
- Clinical epidemiology Unit, School of Medicine, Makerere University, Kampala, Uganda
| | - Elizeus Rutebemberwa
- Department of Health Policy, Planning and Management, School of public health, Makerere University, Kampala, Uganda
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Johnson LF, Meyer-Rath G, Dorrington RE, Puren A, Seathlodi T, Zuma K, Feizzadeh A. The Effect of HIV Programs in South Africa on National HIV Incidence Trends, 2000-2019. J Acquir Immune Defic Syndr 2022; 90:115-123. [PMID: 35125471 DOI: 10.1097/qai.0000000000002927] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent studies have shown HIV incidence declines at a population level in several African countries. However, these studies have not directly quantified the extent to which incidence declines are attributable to different HIV programs. METHODS We calibrated a mathematical model of the South African HIV epidemic to age- and sex-specific data from antenatal surveys, household surveys, and death registration, using a Bayesian approach. The model was also parameterized using data on self-reported condom use, voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral treatment (ART). Model estimates of HIV incidence were compared against the incidence rates that would have been expected had each program not been implemented. RESULTS The model estimated incidence in 15-49 year olds of 0.84% (95% CI: 0.75% to 0.96%) at the start of 2019. This represents a 62% reduction (95% CI: 55% to 66%) relative to 2000, a 47% reduction (95% CI: 42% to 51%) relative to 2010, and a 73% reduction (95% CI: 68% to 77%) relative to the incidence that would have been expected in 2019 in the absence of any interventions. The reduction in incidence in 2019 because of interventions was greatest for ART and condom promotion, with VMMC and behavior change after HIV testing having relatively modest impacts. HIV program impacts differed significantly by age and sex, with condoms and VMMC having greatest impact in youth, and overall incidence reductions being greater in men than in women. CONCLUSIONS HIV incidence in South Africa has declined substantially since 2000, with ART and condom promotion contributing most significantly to this decline.
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Affiliation(s)
- Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA
| | - Rob E Dorrington
- Centre for Actuarial Research, School of Management Studies, University of Cape Town, Cape Town, South Africa
| | - Adrian Puren
- Division of Virology, School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Thapelo Seathlodi
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine University of Cape Town, Cape Town, South Africa
| | - Khangelani Zuma
- Human Sciences Research Council, Pretoria, South Africa ; and
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9
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Bowa K, Rodriguez VJ, Malik FS, Knight J, Cristofari N, Parrish MS, Jones DL, Zulu R, Weiss SM. Dissemination of the Spear & Shield Project using a Training of Trainers Model: A reflection on challenges and successes. Transl Behav Med 2022; 12:622-629. [PMID: 35312766 PMCID: PMC9154251 DOI: 10.1093/tbm/ibac013] [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] [Indexed: 11/13/2022] Open
Abstract
Several large-scale clinical trials have conclusively demonstrated that voluntary medical male circumcision (VMMC) could provide a 50%-70% reduction in HIV acquisition, but willingness to undergo VMMC has been lowest in Zambia compared to other countries in eastern and southern Africa. This manuscript describes training for "task-shifting" among local healthcare workers at Community Health Centers (CHCs) applying state of the art strategies (e.g., Training of Trainers, i.e., ToT, and Training of Facilitators, ToF) to provide novel clinical services. Staff at 96 CHCs from four Provinces in Zambia were sequentially trained to provide the Spear & Shield intervention. A total of 45,630 men (n = 23,236) and women (n = 22,394) volunteered to participate in the S&S intervention service program when offered in the CHCs. Group session (total = 5313 sessions; 2,736 men's and 2,582 women's sessions) were conducted over 4.5 years. Remarkably, both men and women's groups achieved 97% retention. Of these, 256 sessions recorded from 128 group leaders were assessed and scored for intervention fidelity; fidelity was 80%-90% among the majority of clinics. S&S program sustainment exceeded expectations among 85% of clinics (82/96) in all provinces across the duration of the study. Of note, attendance in the S&S program was encouraged by CHC staff, but no financial incentives were provided to those attending S&S. This study examined the effectiveness of the ToT/ToF model in dissemination of the S&S program, which proved to be feasible even in resource-limited settings. Benefits and challenges are discussed.
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Affiliation(s)
- Kasonde Bowa
- School of Medicine and Health Sciences, University of Lusaka, Lusaka, Zambia
| | - Violeta J Rodriguez
- Department of Psychology, University of Georgia, Athens, GA,USA
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Fayeza S Malik
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Jennifer Knight
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Nicholas Cristofari
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Manasi S Parrish
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Correspondence to: DL Jones,
| | - Robert Zulu
- Ministry of Health, Provincial Health Office, Ndola, Copperbelt,Zambia
- Department of Health Promotion and Education, University of Zambia, School of Public Health, Lusaka, Zambia
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Zulu JM, Mwamba T, Rosen A, Matenga TFL, Mulanda J, Kaimba M, Chilembo M, Silondwa M, Kamboyi RL, Simwanza SC, Sichone G, Chavula MP. Community engagement for the Voluntary Medical Male Circumcision (VMMC) program: an analysis of key stakeholder roles to promote a sustainable program in Zambia. Gates Open Res 2022; 6:50. [PMID: 37069966 PMCID: PMC10105033 DOI: 10.12688/gatesopenres.13587.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Within the Voluntary Medical Male Circumcision (VMMC) programme, community engagement has been central in facilitating the acceptance of VMMC, especially in non-circumcising communities. We used the case of the development of community engagement plans for sustainability of VMMC in Zambia to illustrate diversity of stakeholders, their power, roles, and strategies in community engagement. Methods: Data were collected using document review, in-depth interviews (n=35) and focus group discussions (n=35) with community stakeholders, health workers, health centre committees, counsellors, teachers, community volunteers and parents/caregivers. Data were analysed using thematic analysis. The analysis was guided by the power and interest model. Results: Differences were noted between the rural and urban sites in terms of power/influence and interest rating of community stakeholders who could be involved in the sustainability phase of the VMMC response in Zambia. For example, in the urban setting, neighbourhood health committees (NHCs), health workers, leaders of clubs, community health workers (CHWs), radio, television and social media platforms were ranked highest. From this list, social media and television platforms were not highly ranked in rural areas. Some stakeholders had more sources of power than others. Forms or sources of power included technical expertise, local authority, financial resources, collective action (action through schools, churches, media platforms, other community spaces), and relational power. Key roles and strategies included strengthening and broadening local coordination systems, enhancing community involvement, promoting community-led monitoring and evaluation, through the use of locally recognised communication spaces and channels, facilitating ownership of VMMC, and improving local accountability processes in VMMC activities. Conclusions: By consulting with the most relevant stakeholders, and considering community needs in programme development, the VMMC programme may be able to leverage the community structures and systems to reduce long term demand generation costs for VMMC and increase the acceptability and frequency of male circumcision.
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Affiliation(s)
- Joseph M. Zulu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Trevor Mwamba
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Alyssa Rosen
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Tulani Francis L. Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Joseph Mulanda
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Mutale Kaimba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Masitano Chilembo
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Madaliso Silondwa
- Clinton Health Access Initiative, Clinton Health Access Initiative, Lusaka, 10101, Zambia
| | - Royd L. Kamboyi
- Ministry of Health, Ministry of Health, Lusaka, Lusaka, 10101, Zambia
| | | | - George Sichone
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
| | - Malizgani Paul Chavula
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia, University of Zambia, Lusaka, 10101, Zambia
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Khumalo GE, Ntuli S, Lutge E, Mashamba-Thompson TP. Geo-analysis: the distribution of community health workers in relation to the HIV prevalence in KwaZulu-Natal province, South Africa. BMC Health Serv Res 2022; 22:326. [PMID: 35277152 PMCID: PMC8915516 DOI: 10.1186/s12913-022-07707-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022] Open
Abstract
Background The South African Ward Based Primary Health Care Outreach Team (WBPHCOT) policy framework states that the distribution of community health workers (CHWs) should be proportional to levels of poverty and disease within the population. We aimed to describe the spatial distribution of CHWs in relation to the prevalence of the Human Immunodeficiency Virus (HIV) which has itself been associated with poverty in previous studies. Methods This was a descriptive, cross-sectional study in which secondary data was used for geospatial analysis. Based on the extrapolation from the norm of one WBPHCOT per 6000 individuals, we utilized geographic information system (GIS) methods to visualize the distribution of CHWs in relation to the prevalence of HIV in KwaZulu-Natal (KZN). Dot density mapping was used to visualize the random distribution of CHWs in relation to HIV prevalence and population in the districts. The districts’ HIV prevalence, number of PLWH, ratio of CHW: people living with HIV (PLWH), ratio of CHW: population and poverty scores were mapped using choropleth mapping. MapInfo Pro 17.0 was used to map geospatial presentation of the data. Results Overall, KZN province showed under allocation of CHWs with a CHW: people ratio of 1: 1156 compared to the estimated norm of 1: 600–1000. At district level, only two of 11 districts met the suggested norm of CHW: PLWH (1: 109–181). This indicates shortages and misallocation of CHWs in the nine remaining districts. Furthermore, our findings showed extensive geospatial heterogeneity with no clear pattern in the distribution of CHWs. There was no relationship between CHW distribution and HIV prevalence or poverty scores in the districts. Conclusion This study shows inequality in the distribution of CHWs which may be associated with inequalities in the provision of HIV related services. It is critical to strengthen the response to the HIV epidemic through the appropriate distribution of CHWs especially in those districts with high levels of HIV prevalence and poverty.
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Parmley LE, Chingombe I, Wu Y, Mapingure M, Mugurungi O, Samba C, Rogers JH, Hakim AJ, Gozhora P, Miller SS, Musuka G, Harris TG. High Burden of Active Syphilis and Human Immunodeficiency Virus/Syphilis Coinfection Among Men Who Have Sex With Men, Transwomen, and Genderqueer Individuals in Zimbabwe. Sex Transm Dis 2022; 49:111-116. [PMID: 34508022 PMCID: PMC8746901 DOI: 10.1097/olq.0000000000001553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Syphilis increases human immunodeficiency virus (HIV) acquisition risk and impacts the immunologic and virologic response among people living with HIV (PLHIV). We assessed the prevalence of active or current syphilis and HIV/syphilis and their correlates among men who have sex with men (MSM), transwomen, and genderqueer (TGW/GQ) individuals in Zimbabwe. METHODS Among a respondent-driven sample of MSM and TGW/GQ who were tested for HIV and syphilis in Harare and Bulawayo, Zimbabwe in 2019 (n = 1511), multiple logistic regression was used to assess correlates of active syphilis. Unadjusted logistic regression was used among PLHIV (n = 340) due to small sample size. All analyses were unweighted as data did not reach convergence for HIV. RESULTS Prevalence of active syphilis overall and among PLHIV was 5.5% and 10.1%, respectively, in Harare, and 5.6% and 11.0%, respectively, in Bulawayo. Participants were more likely to have active syphilis if they were PLHIV (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.4-3.6), aged 25-34 years (aOR, 2.2 years; 95% CI, 1.3-3.8 years; reference, 18-24 years), or self-report sexually transmitted infection symptoms (aOR, 1.8; 95% CI, 1.1-3.0). Compared with Bulawayo TGW/GQ, MSM in Harare (aOR, 0.2; 95% CI, 0.1-0.5) and Bulawayo (aOR, 0.2; 95% CI, 0.1-0.4), and TGW/GQ in Harare (aOR, 0.2; 95% CI, 0.1-0.6) were less likely to have active syphilis. Among PLHIV, coinfection was 13.0% among TGW/GQ and 9.7% among MSM. Odds of coinfection were higher for those aged 25 to 34 years (OR, 3.7 years; 95% CI, 1.2-11.1 years) and lower among Harare MSM (OR, 0.2; 95% CI, 0.1-0.7), Bulawayo MSM (OR, 0.1; 95% CI, 0.0-0.4), and Harare TGW/GQ (OR, 0.1; 95% CI, 0.0-0.4) compared with Bulawayo TGW/GQ. CONCLUSIONS Findings highlight a high burden of syphilis among MSM and TGW/GQ and underscore the importance of HIV/syphilis detection and improved service delivery for these groups.
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Affiliation(s)
- Lauren E. Parmley
- From the Strategic Information Unit, ICAP at Columbia University, New York, NY
| | | | - Yingfeng Wu
- From the Strategic Information Unit, ICAP at Columbia University, New York, NY
| | | | - Owen Mugurungi
- AIDS and TB Programme, Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - John H. Rogers
- Division of Global HIV & TB, U.S. Centres for Disease Control and Prevention, Harare, Zimbabwe
| | - Avi J. Hakim
- Division of Global HIV & TB, U.S. Centres for Disease Control and Prevention, Atlanta, GA
| | | | - Sophia S. Miller
- From the Strategic Information Unit, ICAP at Columbia University, New York, NY
| | | | - Tiffany G. Harris
- From the Strategic Information Unit, ICAP at Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Defining the Global Research and Programmatic Agenda and Priority Actions for Voluntary Medical Male Circumcision for HIV Prevention. Curr HIV/AIDS Rep 2022; 19:537-547. [PMID: 36367637 PMCID: PMC9651117 DOI: 10.1007/s11904-022-00640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE OF REVIEW Since 2007, voluntary medical male circumcision (VMMC) programs have been associated with substantially reduced HIV incidence across 15 prioritized countries in Eastern and Southern Africa. Drawing on the programmatic experience of global VMMC leaders, this report reviews progress made in the first 15 years of the program, describes programmatic and research gaps, and presents considerations to maximize the impact of VMMC. RECENT FINDINGS Overall, key programmatic and research gaps include a lack of robust male circumcision coverage estimates due to limitations to the data and a lack of standardized approaches across programs; challenges enhancing VMMC uptake include difficulties reaching populations at higher risk for HIV infection and men 30 years and older; limitations to program and procedural quality and safety including variations in approaches used by programs; and lastly, sustainability with limited evidence-based practices. Considerations to address these gaps include the need for global guidance on estimating coverage, conducting additional research on specific sub-populations to improve VMMC uptake, implementation of responsive and comprehensive approaches to adverse event surveillance, and diversifying financing streams to progress towards sustainability. This report's findings may help establish a global VMMC research and programmatic agenda to inform policy, research, and capacity-building activities at the national and global levels.
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Bershteyn A, Mudimu E, Platais I, Mwalili S, Zulu JE, Mwanza WN, Kripke K. Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges. Curr HIV/AIDS Rep 2022; 19:526-536. [PMID: 36459306 PMCID: PMC9759505 DOI: 10.1007/s11904-022-00639-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE OF REVIEW Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations. RECENT FINDINGS Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Edinah Mudimu
- Department of Decision Sciences, College of Economic and Management Sciences, University of South Africa, Pretoria, Gauteng South Africa
| | - Ingrida Platais
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Samuel Mwalili
- Strathmore Institute of Mathematical Sciences, Strathmore University, Nairobi, Kenya
| | - James E. Zulu
- Zambia Field Epidemiology Training Program, Workforce Development Cluster, Zambia National Public Health Institute, Lusaka, Zambia
| | - Wiza N. Mwanza
- Directorate of Public Health and Research, Ministry of Health, Lusaka, Zambia
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Key challenges to voluntary medical male circumcision uptake in traditionally circumcising settings of Machinga district in Malawi. BMC Public Health 2021; 21:1957. [PMID: 34711179 PMCID: PMC8555288 DOI: 10.1186/s12889-021-11979-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) is becoming more popular as an important HIV prevention strategy. Malawi, with a high HIV and AIDS prevalence rate of 8.8% and a low male circumcision prevalence rate of 28% in 2016, is one of the priority countries recommended for VMMC scale-up. This paper investigates the attitudes and key challenges to VMMC adoption in a traditionally circumcising community in Malawi where male circumcision is culturally significant. METHODS A mixed design study using quantitative and qualitative data collection methods was carried out to determine the attitudes of 262 randomly selected males towards VMMC in a culturally circumcising community in Malawi. Statistical Package for the Social Sciences (SPSS) version 20 was used to analyse the quantitative data. To identify predictors of VMMC uptake, we used logistic regression analysis. To identify the themes, qualitative data were analysed using content analysis. RESULTS The findings indicate that, while more males in this community prefer medical circumcision, traditional circumcision is still practised. Panic (63%) perceived surgical complications (31%), and cost (27%) in accessing VMMC services were some of the barriers to VMMC uptake. Age and culture were found to be statistically significant predictors of voluntary medical male circumcision in the logistic analysis. According to qualitative data analysis, the key challenges to VMMC uptake were the involvement of female health workers in the circumcision team and the incentives provided to traditional circumcisers. CONCLUSION According to the findings of this study, VMMC services should be provided in a culturally competent manner that respects and considers existing cultural beliefs and practices in the community. Coordination between local leaders and health workers should be encouraged so that VMMC services are provided in traditional settings, allowing for safe outcomes, and increasing VMMC uptake.
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Stegman PM, Yee R, Davis J, Tchuenche M, Linder R, Zembe L, Frescura L, Kripke KE. Estimating male circumcision coverage in 15 priority countries in sub-Saharan Africa. J Int AIDS Soc 2021; 24 Suppl 5:e25789. [PMID: 34546643 PMCID: PMC8454680 DOI: 10.1002/jia2.25789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/19/2021] [Indexed: 01/05/2023] Open
Abstract
Introduction Given the importance of voluntary medical male circumcision (VMMC) in reducing HIV incidence, access to and use of quality data for programme planning and management are essential. Unfortunately, such data are currently not standardized for reliable and consistent programme use in priority countries. To redress this, the UNAIDS Reference Group (RG) on Estimates, Modelling, and Projection worked with partner Avenir Health to use the Decision Makers Program Planning Toolkit (DMPPT) 2 Online to provide estimates of VMMC coverage and to support countries to set age‐ and geographic‐specific targets. This article describes the methods and tools used for assembling, reviewing and validating VMMC programme data as part of the 2021 Estimates process. Discussion The approach outlined for integrating VMMC data using the DMPPT2 Online required significant country engagement as well as upgrades to the DMPPT2 Online. The process brought together local‐level VMMC stakeholders, for example Ministries of Health, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the US President's Emergency Plan for AIDS Relief, the World Health Organization (WHO), VMMC implementers and so on, to review, amend and agree on historical and more recent VMMC data. The DMPPT2 Online was upgraded to align with the Spectrum and Naomi models used in the Annual HIV Estimates process. In addition, new and revised inputs were incorporated to enhance accuracy of modelled outputs. The process was successful in mobilizing stakeholders behind efforts to integrate VMMC into the annual HIV Estimates process and generating comprehensive, country‐owned and validated VMMC data that will enhance programme monitoring and planning. Conclusions VMMC programme data from most of the priority countries were successfully reviewed, updated, validated and incorporated into the annual HIV Estimates process in 2020. It is important to ensure that these data continue to be used for programme planning and management. Current and future data issues will need to be addressed, and countries will need ongoing support to do so. The integration of the DMPPT2 Online into the annual HIV Estimates process is a positive step forward in terms of streamlining country‐owned planning and analytical practices for the HIV response.
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Affiliation(s)
| | - Randy Yee
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Joshua Davis
- US Agency for International Development, Washington, DC, USA
| | | | | | - Lycias Zembe
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Luisa Frescura
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
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Bjertrup PJ, Mmema N, Dlamini V, Ciglenecki I, Mpala Q, Matse S, Kerschberger B, Wringe A. PrEP reminds me that I am the one to take responsibility of my life: a qualitative study exploring experiences of and attitudes towards pre-exposure prophylaxis use by women in Eswatini. BMC Public Health 2021; 21:727. [PMID: 33853575 PMCID: PMC8048211 DOI: 10.1186/s12889-021-10766-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pre-exposure-prophylaxis (PrEP) has been heralded for its potential to put women in control of preventing HIV infection, but uptake and continuation rates have been disappointing in high-incidence settings in sub-Saharan Africa. We explored structural and social factors that influenced PrEP use among young women and pregnant or breastfeeding women in rural Eswatini. METHODS We conducted two in-depth interviews with ten women on PrEP, and one-time in-depth interviews with fourteen women who declined or discontinued PrEP. Interviews covered decision-making processes around PrEP initiation and experiences with pill-taking. In-depth interviews were conducted with nine health workers, covering experiences in delivering PrEP services, and two focus group discussions were held with men to elicit their perceptions of PrEP. Interviews and discussions were audio-recorded, translated, transcribed and analysed thematically, using an inductive approach. RESULTS PrEP initiation and use were experienced by many women as empowering them to take control of their health and well-being, and stay HIV free, facilitating them to realise their aspirations relating to motherhood and educational attainment. However, the social norms that defined relationship dynamics with partners or family members either undermined or promoted this empowerment potential. In particular, young women were rarely supported by family members to take PrEP unless it was perceived to be for protecting an unborn child. Stigmatisation of pill-taking through its associations with HIV and the burden of daily pill-taking also contributed to PrEP discontinuation. CONCLUSIONS Unlike many prevention tools, PrEP enabled women to achieve a sense of control over their lives. Nevertheless, women's agency to continue and adhere to PrEP was influenced by social and structural factors including gender norms, family expectations of young women, relationship dynamics and stigma related to HIV. Future interventions should address these barriers to promote PrEP use among sexually-active women.
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Affiliation(s)
- Pia Juul Bjertrup
- Médecins Sans Frontières, Mbabane, Eswatini
- Department of Anthropology, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen, Denmark
| | | | | | | | | | - Sindy Matse
- Eswatini National AIDS Programme, Ministry of Health, Mbabane, Eswatini
| | | | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Iyemosolo BM, Chivese T, Esterhuizen TM. A comparison of the prevalence of sexually transmitted infections among circumcised and uncircumcised adult males in Rustenburg, South Africa: a cross-sectional study. BMC Public Health 2021; 21:656. [PMID: 33823828 PMCID: PMC8022379 DOI: 10.1186/s12889-021-10509-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 02/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa has a persistent burden of sexually transmitted infections (STIs). Male circumcision has been shown to be effective in preventing HIV and STIs, but data are scarce on the protective effect of circumcision in high-risk populations such as migrant miners. The objective of this study was to assess the effect of medical and traditional circumcision on the prevalence of STIs after adjusting for other risk factors in Rustenburg, a mining town in North West Province, South Africa. METHODS This cross-sectional study used baseline data collected from a cohort study. Adult males in a mining town were assessed for STIs (gonorrhea, chlamydia, and trichomoniasis) using syndromic assessment. Data on circumcision status and other risk factors for STI syndromes were collected using an interviewer-administered questionnaire. The following symptoms were assessed; penile discharge, painful urination, dyspareunia or penile sores. These symptoms indicate sexually transmitted infection in general since laboratory tests were not performed. Multivariable log binomial regression was used to assess the independent effect of circumcision on STI presence after adjusting for confounders. RESULTS A total of 339 participants with a median age of 25 years (IQR 22-29) were included in the study, of whom 116 (34.2%) were circumcised. The overall STIs prevalence was 27.4% (95% CI 22.8 to 32.6%) and was lower in the circumcised participants compared with those who were uncircumcised (15.5% vs 33.6%, respectively, p < 0.001). Both medical (OR 0.57, 95% CI 0.34-0.95, p = 0.030) and traditional circumcision (OR 0.34, 95% CI 0.13-0.86, p = 0.022) were strongly associated with a lower risk of STIs after adjustment for employment and condom use. CONCLUSION In this high-risk population in a mining town in South Africa, with a relatively high prevalence of STIs, and where one third of males are circumcised, both medical and traditional circumcision appear to be protective against STIs.
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Affiliation(s)
- Blanchard Mbay Iyemosolo
- Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Tawanda Chivese
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Tonya M. Esterhuizen
- Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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Msungama W, Menego G, Shaba F, Flowers N, Habel M, Bonongwe A, Banda M, Shire S, Maida A, Auld A, Phiri SJP, Dumbani K, Buono N, Luhanga M, Kapito M, Gibson H, Laube C, Toledo C, Kim E, Davis SM. Sexually transmitted infections (STI) and antenatal care (ANC) clinics in Malawi: effective platforms for improving engagement of men at high HIV risk with voluntary medical male circumcision services. Sex Transm Infect 2021; 97:345-350. [PMID: 33397801 PMCID: PMC8311083 DOI: 10.1136/sextrans-2020-054776] [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: 09/05/2020] [Revised: 11/11/2020] [Accepted: 11/15/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction Voluntary medical male circumcision (VMMC), an effective HIV prevention programme for men, is implemented in East and Southern Africa. Approximately 50% of VMMC clients are aged below 15 years. More targeted interventions to reach older men and others at higher short-term HIV risk are needed. Methods We implemented a quality improvement project testing the effectiveness of an active referral-based VMMC recruitment approach, targeting men attending STI clinics and those escorting partners to antenatal care (ANC) clinics, at Bwaila Hospital in Lilongwe, Malawi. We compared the proportions aged older than 15 years among men who received VMMC following referral from STI and ANC clinics with those among men referred from standard community mobilisation. We also analysed referral cascades to VMMC. Results In total, 330 clients were circumcised after referral from STI (242) and ANC (88) clinics, as compared with 3839 other clients attributed to standard community mobilisation. All clients from ANC and STI clinics were aged over 15 years, as compared with 69% from standard community mobilisation. STI clinics had a higher conversion rate from counselling to VMMC than ANC (12% vs 9%) and a higher contribution to total circumcisions performed at the VMMC clinic (6% vs 2%). Conclusions Integrating VMMC recruitment and follow-up in STI and ANC clinics co-located with VMMC services can augment demand creation and targeting of men at risk of HIV, based on age and STI history. This approach can be replicated at least in similar health facilities with ANC and STI services in close proximity to VMMC service delivery.
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Affiliation(s)
- Wezi Msungama
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Frackson Shaba
- HIV and Infectious Disease Unit, Jhpiego, Lilongwe, Malawi
| | - Nicole Flowers
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa Habel
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Masford Banda
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Steven Shire
- HIV and Infectious Disease Unit, Jhpiego, Lilongwe, Malawi
| | - Alice Maida
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Andrew Auld
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Kayira Dumbani
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Nicole Buono
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Mishek Luhanga
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Martin Kapito
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Hannah Gibson
- HIV and Infectious Disease Unit, Jhpiego, Lilongwe, Malawi
| | - Catey Laube
- HIV and Infectious Disease Unit, Jhpiego, Nairobi, Kenya
| | - Carlos Toledo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Evelyn Kim
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Stephanie Marie Davis
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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