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Awuoche HC, Joseph RH, Magut F, Khagayi S, Odongo FS, Otieno M, Appolonia A, Odoyo-June E, Kwaro DO. Prevalence and risk factors of sexually transmitted infections in the setting of a generalized HIV epidemic-a population-based study, western Kenya. Int J STD AIDS 2024; 35:418-429. [PMID: 38240604 PMCID: PMC11047016 DOI: 10.1177/09564624241226487] [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: 09/27/2023] [Revised: 12/09/2023] [Accepted: 12/29/2023] [Indexed: 04/28/2024]
Abstract
BACKGROUND Sexually transmitted infections (STIs) cause adverse health outcomes, including increasing HIV acquisition/transmission risk. We analyzed data from an HIV biomarker and behavioral survey to estimate STI prevalence, and explore associated factors in the setting of a generalized HIV epidemic in Siaya County, western Kenya. METHODS Data were collected in March-September 2022 through face-to-face interviews using structured questionnaires; records from 9643 sexually active participants aged 13+ years were included in the analysis. We calculated weighted self-reported STI prevalence, by sex, age, and HIV status and explored associated factors using multivariable logistic regression. RESULTS Median age was 37 years and 59.9% were female; HIV prevalence was 18.0%. Overall STI prevalence was 1.8%; 1.5-fold higher among males vs. females, and 2.6-fold higher among participants living with HIV vs. those without. HIV status and multiple sexual partners were independently associated with STI in both sexes. Mind-altering substance use and being circumcised were associated with STI among males. CONCLUSIONS This study estimates STI prevalence in the setting of high HIV prevalence. Findings underscore the importance of: effective STI screening in HIV clinics and HIV testing and counseling in STI clinics; screening and counseling on substance use, and HIV pre-exposure prophylaxis; and intensive sexual health counseling in male circumcision programmes.
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Affiliation(s)
- Hellen Carolyne Awuoche
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Rachael H Joseph
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Faith Magut
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Sammy Khagayi
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Fredrick S Odongo
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Moses Otieno
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Aoko Appolonia
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Elijah Odoyo-June
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Daniel O Kwaro
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
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Elsayed B, Elmarasi M, Madzime RJ, Mapahla L, ElBadway MMS, Chivese T. Estimates of the prevalence of male circumcision in sub-Saharan Africa from 2010-2023-A systematic review and meta-analysis. PLoS One 2024; 19:e0298387. [PMID: 38478528 PMCID: PMC10936832 DOI: 10.1371/journal.pone.0298387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/23/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Male circumcision (MC) is a key part of the package of interventions to prevent HIV, the biggest health challenge in sub-Saharan Africa. OBJECTIVE To estimate the male circumcision prevalence and to evaluate the progress towards meeting WHO targets in sub-Saharan Africa during the period 2010-2023. METHODS We carried out a systematic review and meta-analysis of studies published during the period 2010-2023. We searched PubMed, Scopus, Cochrane CENTRAL, Google Scholar, WHO and the Demographic and Health Survey for reports on MC prevalence in sub-Saharan Africa. MC prevalence was synthesized using inverse-variance heterogeneity models, heterogeneity using I2 statistics and publication bias using funnel plots. RESULTS A total of 53 studies were included. The overall prevalence during the study period was 45.9% (95% CI 32.3-59.8), with a higher MC prevalence in Eastern (69.9%, 95%CI 49.9-86.8) compared to Southern African (33.3%, 95%CI 21.7-46.2). The overall prevalence was higher in urban (45.3%, 95%CI 27.7-63.4) compared to rural settings (42.6%, 95% 26.5-59.5). Male circumcision prevalence increased from 40.2% (95% CI 25.0-56.3) during 2010-2015 to 56.2% (95% CI 31.5-79.5) during 2016-2023. Three countries exceeded 80% MC coverage, namely, Ethiopia, Kenya and Tanzania. CONCLUSION Overall, the current MC prevalence is below 50%, with higher prevalence in Eastern African countries and substantially lower prevalence in Southern Africa. Most of the priority countries need to do more to scale up medical male circumcision programs.
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Affiliation(s)
- Basant Elsayed
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Qatar
| | - Mohamed Elmarasi
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Qatar
| | - Ruvarashe J. Madzime
- Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lovemore Mapahla
- Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Tawanda Chivese
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Qatar
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3
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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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Matoga MM, Hosseinipour MC, Jewett S, Chasela C. Uptake of voluntary medical male circumcision among men with sexually transmitted infections in Lilongwe, Malawi: a protocol for a pre-interventional and post-interventional study. BMJ Open 2022; 12:e057507. [PMID: 35042709 PMCID: PMC8768936 DOI: 10.1136/bmjopen-2021-057507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Voluntary medical male circumcision (VMMC) is one of the key interventions for HIV prevention. However, its uptake among men in Malawi is low. Implementation science strategies for demand creation of VMMC increase uptake. We designed an implementation science demand-creation intervention to increase the uptake of VMMC among men with sexually transmitted infections (STIs). METHODS AND ANALYSIS We designed a pragmatic pre-interventional and post-interventional quasi-experimental study combined with a prospective observational design to determine the uptake, acceptability, appropriateness and feasibility of a multifaceted intervention for scale up of uptake of VMMC among men with STIs at Bwaila STI clinic in Lilongwe, Malawi. The intervention includes transport reimbursement (R), intensified health education (I) and short messaging service (SMS)/telephonic tracing (Te) (RITe). The intervention will be implemented in phases: pre-implementation and implementation. Pre-implementation phase will be used for collecting baseline data, while the RITe intervention will be rolled-out in the implementation phase. The RITe intervention will be implemented in a sequential and incremental manner called implementation blocks: block 1: intensified health education; block 2: intensified health education and SMS/telephonic tracing; and block 3: intensified health education, SMS/telephonic tracing and transport reimbursement. The target sample size is 80 uncircumcised men for each intervention block, including the pre-implementation sample, making a total of 320 men (280 total, 70 per block will be surveyed). The primary outcome is uptake of VMMC during the implementation period. Mixed methods assessments will be conducted to evaluate the acceptability, appropriateness and feasibility of the RITe intervention. ETHICS AND DISSEMINATION The study protocol was approved by the Malawi's National Health Sciences Research Ethics Committee (approval number: 19/10/2412), University of North Carolina at Chapel Hill's Institutional Review Board (approval number: 19-2559) and University of the Witwatersrand's Health Research Ethics Committee (approval number: M200328). Results will be disseminated via publication in a peer-reviewed journal and presentations at relevant scientific conferences and meetings. TRIAL REGISTRATION NUMBER NCT04677374.
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Affiliation(s)
- Mitch M Matoga
- University of North Carolina Project, Lilongwe, Malawi
- Department of Epidemiology and Biostatistics, University of the Witwatersrand, Johannesburg, South Africa
| | - Mina C Hosseinipour
- University of North Carolina Project, Lilongwe, Malawi
- Department of Medicine, Institution for Global Health and Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Sara Jewett
- Health and Society Division, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Department of Epidemiology and Biostatistics, University of the Witwatersrand, Johannesburg, South Africa
- Implementation Science Unit, Right to Care, Centurion, South Africa
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5
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Nxumalo CT, Mchunu GG. Healthcare providers' perceptions and understanding of voluntary medical male circumcision in KwaZulu-Natal, South Africa: A qualitative study. S Afr Fam Pract (2004) 2021; 63:e1-e6. [PMID: 34476965 PMCID: PMC8424757 DOI: 10.4102/safp.v63i1.5318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/13/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background There is compelling evidence that voluntary medical male circumcision (VMMC) reduces the chances of heterosexual transmission of HIV infection. Healthcare workers are among the key influencers in terms of the scale-up of VMMC as they are often involved in mobilisation for uptake. There is a paucity of qualitative research on healthcare workers’ experiences, understanding and perceptions of VMMC; particularly in the South African rural primary healthcare context. This study was conducted to examine healthcare workers perceptions and understanding of VMMC in KwaZulu-Natal, South Africa. Methods The study employed a qualitative approach using a phenomenographic design. A purposive sample of 15 doctors, nurses and clinical associates working in 6 different rural clinics in KwaZulu-Natal, South Africa, were interviewed in English in-depth using a semi-structured interview schedule. The interviews were audio-recorded, and transcribed. The results were analysed thematically using phenomenographic data analysis procedures. Results Categories of description in participants’ perceptions and understanding of VMMC emerged. The findings of this study revealed that healthcare workers perceptions and understanding of VMMC were predominantly influenced by the hegemonic religious and cultural norms associated with male circumcision in KwaZulu-Natal, South Africa. Conclusion The findings of this study suggest that tailored training to address healthcare workers misperceptions and poor understanding of VMMC is necessary to ensure that they become effective custodians for VMMC implementation.
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Affiliation(s)
- Celenkosini T Nxumalo
- KwaZulu-Natal Department of Health, Ndwedwe Community Health Centre, Verulam, South Africa; and, School of Nursing and Public Health, Faculty of Health Sciences, University of KwaZulu-Natal, Durban.
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6
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Ntabona A, Binanga A, Bapitani MDJ, Bobo B, Mukengeshayi B, Akilimali P, Kalong G, Mujani Z, Hernandez J, Bertrand JT. The scale-up and integration of contraceptive service delivery into nursing school training in the Democratic Republic of the Congo. Health Policy Plan 2021; 36:848-860. [PMID: 34009259 PMCID: PMC8227455 DOI: 10.1093/heapol/czab014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
In Kinshasa, Democratic Republic of the Congo (DRC), modern contraceptive prevalence is low by international standards: 29.6% as of 2020. A 2015 pilot study demonstrated the feasibility and acceptability of using medical and nursing students to administer DMPA-SC (the subcutaneous injection) among other methods at the community level. The more far-reaching discovery was the potential of clinically trained students to increase access to low-cost contraception in the short-run, while improving the quality of service delivery for future generations of healthcare providers. Scale-up involved integrating the family planning curriculum into the training of nursing students, including classroom instruction in contraceptive technology and service delivery, coupled with a year-long field practicum in which students offered a range of contraceptive methods during intermittent outreach events, door-to-door distribution or sales from their homes. Starting in 2015, a multi-agency team consisting of an international non-governmental organizations (NGO), several Ministry of Health directorates and a local NGO used the ExpandNet/WHO framework to guide this scale-up. This article details the nine steps in the scale-up process. It presents results on increases in contraceptive uptake, feedback from participating nursing school personnel and the employment experience of the graduates from this programme. Between 2015 and 2019, the family planning curriculum was incorporated into 30.8% of the 477 nursing schools in 7 of the 26 provinces in the DRC. Students delivered 461 769 couple-years of protection (the key output indicator for family planning programmes). Nursing school personnel were strongly favourable to the approach, although they needed continued support to adequately implement a set of additional interventions related to the service delivery components of the new training approach. Post-graduation, only 40.1% of graduates had paid employment (reflecting the staggering unemployment in the DRC); among those, over 90% used their family planning training in their work. We describe the multiple challenges faced during the scale-up process and in planning for expansion to additional schools.
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Affiliation(s)
| | | | | | - Beatrice Bobo
- D6 Directorate in Charge of Nursing Schools, Ministry of Health
| | | | | | - Gloria Kalong
- Tulane School of Public Health and Tropical Medicine (SPHTM), 1440 Canal St, Suite 1900, New Orleans, LA 70112, USA
| | - Zenon Mujani
- Tulane International LLC, Kinshasa, DRC.,National Programme for Reproductive Health (PNSR), Maternité de Kintambo, Kinshasa, DRC
| | - Julie Hernandez
- Tulane School of Public Health and Tropical Medicine (SPHTM), 1440 Canal St, Suite 1900, New Orleans, LA 70112, USA
| | - Jane T Bertrand
- Tulane School of Public Health and Tropical Medicine (SPHTM), 1440 Canal St, Suite 1900, New Orleans, LA 70112, USA
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7
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Makono P, Mhagama P, Tsitsi C. The influence of branding on the uptake of voluntary medical male circumcision: a case study of " Ndife Otsogola" in Lilongwe, Malawi. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2021; 19:323-330. [PMID: 33530852 DOI: 10.2989/16085906.2020.1850482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: "Ndife Otsogola" [We are forward thinkers] is the voluntary male medical circumcision (VMMC) campaign in Malawi that is part of the HIV and AIDS health promotion strategy. In 2012, the government of Malawi and its VMMC stakeholders developed communication strategies to advance the uptake of VMMC using the "Ndife Otsogola" brand to increase uptake of the service among the target population. However, since the campaign was scaled up country wide, the uptake of VMCC remains at 28%, well below the target of 80%. Therefore, this study aimed to evaluate whether the "Ndife Otsogola" brand and its associated communications achieved its intended aim. Method: Data for this study were collected through face-to-face interviews with 25 men aged between18 and 35 years, all of whom were linked to the circumcision services. Data were also collected from five key informants through a self-administered questionnaire. Results: The "Ndife Otsogola" campaign had limited influence on the uptake of VMMC among men in urban Lilongwe, Malawi. Conclusion: Branding can sometimes obscure the main message that is intended to be conveyed. Target audiences can sometimes fail to link a brand name to the product being promoted, as was the case with "Ndife Otsogola". We recommend that more research be undertaken in Malawi to determine the relevance and influence of the entire VMMC communication strategy.
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Affiliation(s)
- Patrick Makono
- Department of Language and Communication, University of Malawi, Zomba, Malawi
| | - Peter Mhagama
- Department of Language and Communication, University of Malawi, Zomba, Malawi
| | - Chimwemwe Tsitsi
- Department of Language and Communication, University of Malawi, Zomba, Malawi
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8
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Mhagama P, Makono P, Tsitsi C. Communication-related factors influencing the uptake of voluntary medical male circumcision among men in Lilongwe Urban, Malawi. COGENT MEDICINE 2021. [DOI: 10.1080/2331205x.2021.1892289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Peter Mhagama
- The Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre, 3, Malawi
| | - Patrick Makono
- The Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre, 3, Malawi
| | - Chimwemwe Tsitsi
- The Polytechnic, University of Malawi, Private Bag 303, Chichiri, Blantyre, 3, Malawi
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9
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Dybul M, Attoye T, Baptiste S, Cherutich P, Dabis F, Deeks SG, Dieffenbach C, Doehle B, Goodenow MM, Jiang A, Kemps D, Lewin SR, Lumpkin MM, Mathae L, McCune JM, Ndung'u T, Nsubuga M, Peay HL, Pottage J, Warren M, Sikazwe I. The case for an HIV cure and how to get there. Lancet HIV 2021; 8:e51-e58. [PMID: 33271124 PMCID: PMC7773626 DOI: 10.1016/s2352-3018(20)30232-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022]
Abstract
In light of the increasing global burden of new HIV infections, growing financial requirements, and shifting funding landscape, the global health community must accelerate the development and delivery of an HIV cure to complement existing prevention modalities. An effective curative intervention could prevent new infections, overcome the limitations of antiretroviral treatment, combat stigma and discrimination, and provide a sustainable financial solution for pandemic control. We propose steps to plan for an HIV cure now, including defining a target product profile and establishing the HIV Cure Africa Acceleration Partnership (HCAAP), a multidisciplinary public-private partnership that will catalyse and promote HIV cure research through diverse stakeholder engagement. HCAAP will convene stakeholders, including people living with HIV, at an early stage to accelerate the design, social acceptability, and rapid adoption of HIV-cure products.
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Affiliation(s)
- Mark Dybul
- Center for Global Health Practice and Impact, Georgetown University, Washington, DC, USA.
| | - Timothy Attoye
- Global Health Division, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Solange Baptiste
- International Treatment Preparedness Coalition, Johannesburg, South Africa
| | | | - François Dabis
- Agence Nationale de Recherches sur le SIDA et les Hepatites Virales, Paris, France
| | - Steven G Deeks
- University of California, San Francisco, California, USA
| | - Carl Dieffenbach
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Rockville, MD, USA
| | - Brian Doehle
- Global Health Division, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Maureen M Goodenow
- Office of AIDS Research, National Institutes of Health, Department of Health and Human Services, Rockville, MD, USA
| | - Adam Jiang
- McKinsey & Company Secondee at The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | | | - Sharon R Lewin
- Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia; Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Murray M Lumpkin
- Global Health Division, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Lauren Mathae
- Center for Global Health Practice and Impact, Georgetown University, Washington, DC, USA
| | - Joseph M McCune
- Global Health Division, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Thumbi Ndung'u
- Africa Health Research Institute, Durban, South Africa; HIV Pathogenesis Programme, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban South Africa; Max Planck Institute for Infection Biology, Berlin, Germany; University College London, London, UK
| | - Moses Nsubuga
- Joint Adherent Brothers & Sisters Against AIDS, Kampala, Uganda
| | - Holly L Peay
- RTI International, Research Triangle Park, NC, USA
| | | | | | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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10
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Strengthening health policy development and management systems in low- and middle- income countries: South Africa's approach. HEALTH POLICY OPEN 2020. [DOI: 10.1016/j.hpopen.2020.100010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Menendez YA, Cambaco O, Mindú C, Nhantumbo H, Uamusse T, Matsinhe G, Matsinhe B, Manjate RM, Bardají A, Menendez C, Sevene E, Munguambe K. Lay knowledge of cervical cancer in Manhiça district, Mozambique: a qualitative study. Reprod Health 2020; 17:130. [PMID: 32831101 PMCID: PMC7444028 DOI: 10.1186/s12978-020-00980-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 08/10/2020] [Indexed: 11/16/2022] Open
Abstract
Background Mozambique has one of the highest cervical cancer incidence rates in the world. Health interventions are still being conceived solely from a non-communicable disease standpoint despite that it is also a sexual and reproductive health problem. The objective of this study was to assess the extent to which lay perceptions of cervical cancer align with biomedical knowledge from the standpoint of sexual and reproductive health. Methods 10 focus group discussions were carried out with 10 target groups in Manhiça. The target groups were diverse in terms of age, sex, educational level and occupation. There were a total of 116 participants. The focus groups discussions were applied to obtain verbal information and trigger debates around beliefs and attitudes about cervical cancer as well as to explore notions of transmission and aetiology of the disease. The discussions were recorded for later transcription and analysis, following a combination of content and thematic analysis. Results Participants were familiar with the biomedical term ‘cervical cancer’ but knowledge of its aetiology and transmission was limited. Cervical cancer was readily associated to sexual transmission and sexually transmitted infections, and conceived as a ‘wound that does not heal’. The term ‘cancer’ caused confusion, as it was perceived to happen only in limbs, understood as hereditary, not transmissible and as an illness of the West. Conclusions Lay perceptions of cervical cancer do, to a large extent, align with biomedical ones, thus, there is common ground to frame future health interventions from a sexual and reproductive health standpoint. Some misperceptions were identified which could be reduced through social behaviour change communication initiatives.
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Affiliation(s)
| | - Olga Cambaco
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique
| | - Carolina Mindú
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique
| | - Hoticha Nhantumbo
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique
| | - Titos Uamusse
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique
| | - Graça Matsinhe
- Extended Program on Immunization (PAV), Ministry of Health (MISAU), Maputo, Mozambique
| | - Benigna Matsinhe
- National Directorate for Public Health (DNSP), Ministry of Health (MISAU), Maputo, Mozambique
| | - Rosa Marlene Manjate
- National Directorate for Public Health (DNSP), Ministry of Health (MISAU), Maputo, Mozambique
| | - Azucena Bardají
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique
| | - Clara Menendez
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique.,Barcelona Institute for Global Health (ISGLOBAL)/Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Esperança Sevene
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique.,Faculty of Medicine, Eduardo Mondlane University (UEM), Maputo, Mozambique
| | - Khátia Munguambe
- Manhiça Health Research Centre (CISM), Rua 12 - Cambeve, Manhiça, Mozambique. .,Faculty of Medicine, Eduardo Mondlane University (UEM), Maputo, Mozambique.
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12
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Moodley J, Naidoo S, Kelly C, Reddy T, Ramjee G. The Impact of Male Partner Circumcision on Women's Health Outcomes. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2020; 32:356-366. [PMID: 32897129 PMCID: PMC7585933 DOI: 10.1521/aeap.2020.32.4.356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Medical male circumcision is a proven method of HIV risk reduction in men with no known direct benefit to women. We investigated the benefit of partner circumcision on women's health. We conducted a secondary analysis of 5,029 women enrolled in the Vaginal and Oral Interventions to Control the Epidemic trial across 15 African sites, to look at the impact of partner circumcision status on sexually transmitted infections, pregnancy, frequency of sex, and condom use in women. Of 4,982 participants with a baseline response, 31% had circumcised partners. Women with circumcised partners had a significantly reduced risk of syphilis acquisition, hazard ratio 0.51 (0.26, 1.00), p value = .05. Participants with uncircumcised partners were significantly less likely to have used a condom at the last sex act than the other two groups, adj. relative risk 0.86 (0.80, 0.92), adj. p value < .0001. We found no evidence of sexual risk compensation in women with circumcised partners.
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Affiliation(s)
- Jayajothi Moodley
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
- Aurum Institute, Johannesburg, South Africa
| | - Sarita Naidoo
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
- Aurum Institute, Johannesburg, South Africa
| | - Cliff Kelly
- SCHARP (Statistical Center for HIV/AIDS Research and Prevention), Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Tarylee Reddy
- Biostatistics Unit, South African Medical Research Council
| | - Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa
- Aurum Institute, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine and the School of Medicine, University of Washington, Seattle, Washington
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Nxumalo CT, Mchunu GG. Healthcare workers' perceptions and experiences of implementing voluntary medical male circumcision in KwaZulu-Natal, South Africa. Afr J Prim Health Care Fam Med 2020; 12:e1-e10. [PMID: 32242429 PMCID: PMC7160602 DOI: 10.4102/phcfm.v12i1.2253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/10/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Abstract
Background Voluntary Medical Male Circumcision (VMMC) is an effective HIV prevention strategy prioritized by the World Health Organisation (WHO) for regions of high HIV prevalence, South Africa (SA) and in particular KwaZulu-Natal (KZN) is one of such regions. Since the roll out of VMMC in 2010 there has been little research conducted on the implementation of this service. Existing studies on the uptake of VMMC have mainly focused on service users resulting in a paucity of data on health care workers perspectives on the intervention. Aim To analyse health care workers’ perceptions and experiences of implementing voluntary medical male circumcision in KZN, SA. Setting The study took place at six different health districts and their six respective rural clinics in the KZN province of SA. Methods A qualitative approach using a phenomenographic design was employed. Data were collected from a sample of 18 participants comprising of health care providers (n = 12) and health policy makers (n = 6). Individual, face-to-face interviews were conducted using a semi-structured interview guide. An audiotape was used to record the data, which were transcribed verbatim and then analysed using a step-wise phenomenographic data analysis procedure. Results Participants reported that VMMC was implemented by the department of health with support from non-governmental organisations and private general practitioners. Negative perceptions and negative experiences regarding VMMC and implementation were reported. Conclusion The implementation of VMMC is compromised due to poor preparation and training of healthcare workers for implementing the service. Addressing health care workers’ needs for training and preparation is crucial for successful implementation of VMMC.
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Nxumalo CT, Mchunu GG. Zulu Men's Conceptions, Understanding, and Experiences of Voluntary Medical Male Circumcision in KwaZulu-Natal, South Africa. Am J Mens Health 2020; 14:1557988319892437. [PMID: 32131678 PMCID: PMC7059234 DOI: 10.1177/1557988319892437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Voluntary Medical Male Circumcision (VMMC) is proven to reduce transmission of
HIV/AIDS. Despite concerted efforts to scale up VMMC in men aged 18–49, the
number of medically circumcised men in this age group remains suboptimal.
Research has shown that several individual factors hinder and promote uptake of
VMMC. The nature of these factors is not clearly understood within the
dimensions of religion, culture and tradition, particularly in a low-income
rural setting. This study aimed to analyze Zulu men’s conceptions, understanding
and experiences regarding VMMC in KwaZulu-Natal (KZN), South Africa. A
qualitative phenomenographic study approach was used to collect data from 20
uncircumcised males at six different clinics that provide VMMC services. Ethical
approval to collect data was obtained from the Biomedical Research Ethics
Committee of the University of KZN (BREC – BE627/18). Individual in-depth face
to face interviews were conducted using a semistructured interview guide.
Audiotapes were used to record interviews which were transcribed verbatim and
then analyzed manually. The conceptions regarding medical circumcision appeared
to be related to religious and cultural beliefs surrounding circumcision and the
historical traditional practice thereof. The understanding of males regarding
VMMC was mainly attributed to HIV prevention; however, knowledge on the degree
of partial protection appeared to be limited. An array of negative accounted in
the form of complications such as poor wound healing and postoperative pain
undergone by peers and other close influencers’ accounted for participants’
experiences of VMMC. Poor knowledge and negative experiences relating to VMMC
could account for reasons why men choose not to undergo VMMC.
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Affiliation(s)
- Celenkosini Thembelenkosini Nxumalo
- KZN Department of Health, Ndwedwe Community Health Centre, Verulam, KwaZulu-Natal, South Africa.,Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Gugu Gladness Mchunu
- Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Scholman C, Westra JM, Zwakenberg MA, Dikkers FG, Halmos GB, Wedman J, Wachters JE, van der Laan BFAM, Plaat BEC. Differences in the diagnostic value between fiberoptic and high definition laryngoscopy for the characterisation of pharyngeal and laryngeal lesions: A multi-observer paired analysis of videos. Clin Otolaryngol 2019; 45:119-125. [PMID: 31747481 PMCID: PMC6972529 DOI: 10.1111/coa.13476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/06/2019] [Accepted: 11/17/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES High definition laryngoscopy (HDL) could lead to better interpretation of the pharyngeal and laryngeal mucosa than regularly used fiberoptic laryngoscopy (FOL). The primary aim of this study is to quantify the diagnostic advantage of HDL over FOL in detecting mucosal anomalies in general, in differentiating malignant from benign lesions and in predicting specific histological entities. The secondary aim is to analyse image quality of both laryngoscopes. DESIGN Retrospective paired analysis with multiple observers evaluating endoscopic videos simulating daily clinical practice. SETTING A tertiary referral hospital. PARTICIPANTS In 36 patients, both FOL and HDL videos were obtained. Six observers were provided with additional clinical information, and 36 FOL and HDL videos were evaluated in a randomised order. MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive value and diagnostic accuracy of observers using both flexible laryngoscopes were calculated for detection of mucosal lesions in general and uncovering malignant lesions. Sensitivities were calculated for prediction of specific histological entities. Image quality (scale 1-10) was assessed for both flexible laryngoscopes. RESULTS HDL reached higher sensitivity compared to FOL for detection of mucosal abnormalities in general (96.0% vs 90.4%; P = .03), differentiating malignant from benign lesions (91.7% vs 79.8%; P = .03) and prediction of specific histological entities (59.7% vs 47.2%; P < .01). Image quality was judged better with HDL in comparison with FOL (mean: 8.4 vs 5.4, P < .01). CONCLUSIONS HDL is superior to FOL in detecting mucosal anomalies in general, malignancies and specific histological entities. Image quality is considered as superior using HDL compared to FOL.
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Affiliation(s)
- Constanze Scholman
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jeroen M Westra
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Manon A Zwakenberg
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik G Dikkers
- Department of Otorhinolaryngology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gyorgy B Halmos
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Wedman
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan E Wachters
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bernard F A M van der Laan
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn E C Plaat
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Salas-Ortiz A, La Hera-Fuentes G, Nance N, Sosa-Rubí SG, Bautista-Arredondo S. The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries. PLoS One 2019; 14:e0222180. [PMID: 31581192 PMCID: PMC6776351 DOI: 10.1371/journal.pone.0222180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/23/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission—the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. Methods We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. Results Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. Conclusions No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.
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Affiliation(s)
- Andrea Salas-Ortiz
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- University of York, York, United Kingdom
| | - Gina La Hera-Fuentes
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- University of Newcastle, Newcastle, Australia
| | - Nerissa Nance
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Sandra G. Sosa-Rubí
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- School of Public Health, University of California, Berkeley, California, United States of America
- * E-mail:
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Schenker I. Cutting-Edge Success in Preventing Heterosexual HIV Transmission in Africa: Voluntary Medical Male Circumcision Has Reached 15 Million Men. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2018; 30:232-242. [PMID: 29969309 DOI: 10.1521/aeap.2018.30.3.232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Male circumcision is a minor surgery performed for religious and medical reasons. Three randomized clinical trials demonstrated it could reduce heterosexual HIV transmission from infected females to males by over 60%, paving the way in 2006 for multinational efforts to circumcise 27 million men in sub-Saharan Africa by 2021. It is estimated that by 2030 male circumcision will avert at least 500,000 HIV infections in Africa, saving lives and budgets. Voluntary medical male circumcision (VMMC) of adults and adolescents has challenged policy makers, implementers, funders, and civil society in bringing surgery to the frontline of HIV prevention. Five key challenges are discussed: policy, clinical, demand, supply, and scaling up. A unique Israel-Senegal-South Africa collaboration, which enhanced high-volume (100 VMMCs per day) and high-quality (less than 2% minor adverse events) procedures, is described, highlighting VMMC as one of the most impressive public health collaborative interventions in HIV/AIDS prevention globally.
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The cost of demand creation activities and voluntary medical male circumcision targeting school-going adolescents in KwaZulu-Natal, South Africa. PLoS One 2017. [PMID: 28632768 PMCID: PMC5478150 DOI: 10.1371/journal.pone.0179854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Voluntary medical male circumcision is an integral part of the South African government’s response to the HIV and AIDS epidemic. However, there remains a limited body of economic analysis on the cost of VMMC programming, and the demand creation activities used to mobilize males, especially among adolescent boys in school. This study addresses this gap by presenting the costs of a VMMC program which adopted two demand creation strategies targeting school-going males in South Africa. Methods Cost data was collected from a VMMC program in the KwaZulu-Natal province of South Africa. A retrospective, micro-costing ingredient approach was applied to identify, measure and value resources of two demand creation strategies targeting young males. Results The program circumcised 4987 young males between May 2011 and February 2013, at a cost of $127.68 per circumcision. Demand creation activities accounted for 32% of the total cost, HCT contributing 10% with the medical circumcision procedure accounting for 58% of the total cost. Using the first demand creation strategy, 2168 circumcisions were performed at a cost of $149.57 per circumcision. Following this first strategy, a second demand creation strategy was adopted which saw the cost fall to $110.85 per circumcision. More young males were recruited following the second strategy with clinic services more efficiently utilized. Whilst the cost per circumcision of demand activities rose slightly between the first ($39.94) and second ($41.65) strategy, there was a substantial reduction in the cost of the circumcision procedure; $90.01 under the first strategy falling to $60.60 following the adoption of the second demand creation strategy. Conclusion Ensuring the optimal use of clinic facilities was the primary driver in reducing the cost per circumcision. This VMMC program has illustrated the value of evaluating progress and instituting changes to attain better cost efficiencies. This adjustment resulted in a substantial reduction in the cost per circumcision.
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Use of Economic Compensation to Increase Demand for Voluntary Medical Male Circumcision in Kenya: Qualitative Interviews With Male Participants in a Randomized Controlled Trial and Their Partners. J Acquir Immune Defic Syndr 2017; 72 Suppl 4:S306-10. [PMID: 27404013 PMCID: PMC5054958 DOI: 10.1097/qai.0000000000001047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Interventions to increase demand for medical male circumcision are urgently needed in eastern and southern Africa. Following promising evidence that providing economic compensation can increase male circumcision uptake in Kenya, there is a need to understand the role of this intervention in individuals' decision-making regarding circumcision and explore perceptions of the intervention and concerns such as coercion. METHODS As part of a randomized controlled trial in Kenya that found compensation in the form of food vouchers worth US $8.75-US $15.00 to be effective in increasing male circumcision uptake, we conducted qualitative in-depth interviews with 45 circumcised and uncircumcised male participants and 19 female partners to explore how compensation provision influenced the decision to get circumcised. Interview transcripts were coded and an inductive thematic analysis was conducted to identify patterns in decision-making. RESULTS Interviews revealed that compensation promoted circumcision uptake by addressing a major barrier to male circumcision uptake: lost wages during and after the circumcision procedure. Participants who did not get circumcised perceived the compensation amounts to be insufficient for offsetting their costs associated with getting circumcised or reported having nonfinancial barriers that were not addressed by the intervention, such as fear of pain. Participants also reported that they did not feel compelled to get circumcised for financial gain. Female partners of circumcised participants felt that the intervention helped to motivate their partners to get circumcised. CONCLUSIONS The results suggest that the provision of economic compensation is an acceptable intervention that can address an important barrier to male circumcision uptake. Providing compensation to circumcision clients in the form of food vouchers warrants further consideration in voluntary medical male circumcision demand creation efforts.
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Wilson N, Janicki M. A cut above the rest? Private anthropometrics in marriage markets. ECONOMICS AND HUMAN BIOLOGY 2016; 23:164-179. [PMID: 27690137 DOI: 10.1016/j.ehb.2016.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 08/16/2016] [Accepted: 08/23/2016] [Indexed: 06/06/2023]
Abstract
A large body of economic research suggests that publicly observable anthropometric characteristics affect labor and marriage market outcomes. Private anthropometrics may not affect these outcomes. We examine male circumcision in marriage markets in Zambia. Our analysis reveals substantial variation across local marriage markets in circumcision prevalence relative to preference for circumcised partners, as well as excess aggregate demand for circumcised males. Regression estimates suggest a marriage market premium of approximately one-half to one year of additional schooling for matching with a partner of preferred anthropometric type in a local marriage market with excess demand for that anthropometric characteristic.
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Fitzgerald L, Benzerga W, Mirira M, Adamu T, Shissler T, Bitchong R, Malaza M, Mamba M, Mangara P, Curran K, Khumalo T, Mlambo P, Njeuhmeli E, Maziya V. Scaling Up Early Infant Male Circumcision: Lessons From the Kingdom of Swaziland. GLOBAL HEALTH, SCIENCE AND PRACTICE 2016; 4 Suppl 1:S76-86. [PMID: 27413086 PMCID: PMC4944582 DOI: 10.9745/ghsp-d-15-00186] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 03/17/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The government of the Kingdom of Swaziland recognizes that it must urgently scale up HIV prevention interventions, such as voluntary medical male circumcision (VMMC). Swaziland has adopted a 2-phase approach to male circumcision scale-up. The catch-up phase prioritizes VMMC services for adolescents and adults, while the sustainability phase involves the establishment of early infant male circumcision (EIMC). Swaziland does not have a modern-day tradition of circumcision, and the VMMC program has met with client demand challenges. However, since the launch of the EIMC program in 2010, Swaziland now leads the Eastern and Southern Africa region in the scale-up of EIMC. Here we review Swaziland's program and its successes and challenges. METHODS From February to May 2014, we collected data while preparing Swaziland's "Male Circumcision Strategic and Operational Plan for HIV Prevention 2014-2018." We conducted structured stakeholder focus group discussions and in-depth interviews, and we collected EIMC service delivery data from an implementing partner responsible for VMMC and EIMC service delivery. Data were summarized in consolidated narratives. RESULTS Between 2010 and 2014, trained providers performed more than 5,000 EIMCs in 11 health care facilities in Swaziland, and they reported no moderate or severe adverse events. According to a broad group of EIMC program stakeholders, an EIMC program needs robust support from facility, regional, and national leadership, both within and outside of HIV prevention coordination bodies, to promote institutionalization and ownership. Providers and health care managers in 3 of Swaziland's 4 regional hospitals suggest that when EIMC is introduced into reproductive, maternal, newborn, and child health platforms, dedicated staff attention can help ensure that EIMC is performed amid competing priorities. Creating informed demand from communities also supports EIMC as a service delivery priority. Formative research shows that EIMC programs should address the fears and anxieties of parents so that they, especially fathers, understand the health benefits of EIMC before the birth of their babies. CONCLUSION The vast majority of public-sector facilities in Swaziland are led by nurses, and nurses and midwives have borne the brunt of caring for patients with HIV/AIDS in Swaziland. Like prevention of mother-to-child transmission, EIMC provides an opportunity for nurses and midwives to stand at the forefront of HIV prevention efforts. Rapid scale-up of VMMC and EIMC in Swaziland has the potential to avert more than 56,000 HIV infections and save US$370 million in the next 20 years.
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Affiliation(s)
| | - Wendy Benzerga
- U.S. Agency for International Development (USAID), Mbabane, Swaziland
| | - Munamato Mirira
- U.S. Agency for International Development (USAID), Mbabane, Swaziland
| | | | | | | | - Mandla Malaza
- Population Services International, Mbabane, Swaziland
| | | | - Paul Mangara
- Family Life Association of Swaziland, Manzini, Swaziland
| | | | | | | | | | - Vusi Maziya
- Swaziland National AIDS Program, Mbabane, Swaziland
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22
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Johnson LF, Chiu C, Myer L, Davies MA, Dorrington RE, Bekker LG, Boulle A, Meyer-Rath G. Prospects for HIV control in South Africa: a model-based analysis. Glob Health Action 2016; 9:30314. [PMID: 27282146 PMCID: PMC4901512 DOI: 10.3402/gha.v9.30314] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 05/07/2016] [Accepted: 05/18/2016] [Indexed: 01/17/2023] Open
Abstract
Background The goal of virtual elimination of horizontal and mother-to-child HIV transmission in South Africa (SA) has been proposed, but there have been few systematic investigations of which interventions are likely to be most critical to reducing HIV incidence. Objective This study aims to evaluate SA's potential to achieve virtual elimination targets and to identify which interventions will be most critical to achieving HIV incidence reductions. Design A mathematical model was developed to simulate the population-level impact of different HIV interventions in SA. Probability distributions were specified to represent uncertainty around 32 epidemiological parameters that could be influenced by interventions, and correlation coefficients (r) were calculated to assess the sensitivity of the adult HIV incidence rates and mother-to-child transmission rates (2015–2035) to each epidemiological parameter. Results HIV incidence in SA adults (ages 15–49) is expected to decline from 1.4% in 2011–2012 to 0.29% by 2035 (95% CI: 0.10–0.62%). The parameters most strongly correlated with future adult HIV incidence are the rate of viral suppression after initiating antiretroviral treatment (ART) (r=−0.56), the level of condom use in non-marital relationships (r=−0.40), the phase-in of intensified risk-reduction counselling for HIV-positive adults (r=0.29), the uptake of medical male circumcision (r=−0.24) and the phase-in of universal ART eligibility (r=0.22). The paediatric HIV parameters most strongly associated with mother-to-child transmission rates are the relative risk of transmission through breastfeeding when the mother is receiving ART (r=0.70) and the rate of ART initiation during pregnancy (r=−0.16). Conclusions The virtual elimination target of a 0.1% incidence rate in adults will be difficult to achieve. Interventions that address the infectiousness of patients after ART initiation will be particularly critical to achieving long-term HIV incidence declines in South Africa.
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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;
| | - Calvin Chiu
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Landon Myer
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob E Dorrington
- Centre for Actuarial Research, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- 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, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Center for Global Health and Development, Boston University, Boston, MA, USA
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Wirth KE, Semo BW, Ntsuape C, Ramabu NM, Otlhomile B, Plank RM, Barnhart S, Ledikwe JH. Triggering the decision to undergo medical male circumcision: a qualitative study of adult men in Botswana. AIDS Care 2016; 28:1007-12. [PMID: 26754167 DOI: 10.1080/09540121.2015.1133797] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In 2007, the World Health Organization endorsed voluntary medical male circumcision (VMMC) as part of comprehensive HIV-prevention strategies. A major challenge facing VMMC programs in sub-Saharan Africa remains demand creation; there is urgent need for data on key elements needed to trigger the decision among eligible men to seek VMMC. Using qualitative methods, we sought to better understand the circumcision decision-making process in Botswana related to VMMC. From July to November 2013, we conducted 27 focus group discussions in four purposively selected communities in Botswana with men (stratified by circumcision status and age), women (stratified by age) and community leaders. All discussions were facilitated by a trained same-sex interviewer, audio recorded, transcribed and translated to English, and analyzed for key themes using an inductive content analytic approach. Improved hygiene was frequently cited as a major benefit of circumcision and many participants believed that cleanliness was directly responsible for the protective effect of VMMC on HIV infection. While protection against HIV was frequently noted as a benefit of VMMC, the data indicate that increased sexual pleasure and perceived attractiveness, not fear of HIV infection, was an underlying reason why men sought VMMC. Data from this qualitative study suggest that more immediate benefits of VMMC, such as improved hygiene and sexual pleasure, play a larger role in the circumcision decision compared with protection from potential HIV infection. These findings have immediate implications for targeted demand creation and mobilization activities for increasing uptake of VMMC among adult men in Botswana.
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Affiliation(s)
- Kathleen E Wirth
- a Botswana International Training and Education Center for Health (I-TECH) , Gaborone , Botswana.,b Department of Epidemiology , Harvard T. H. Chan School of Public Health , Boston , Massachusetts , USA.,c Department of Immunology and Infectious Diseases , Harvard T. H. Chan School of Public Health , Boston , Massachusetts , USA
| | - Bazghina-Werq Semo
- a Botswana International Training and Education Center for Health (I-TECH) , Gaborone , Botswana.,d Department of Global Health , University of Washington , Seattle , Washington , USA
| | - Conrad Ntsuape
- e Department of HIV/AIDS Prevention and Care , Botswana Ministry of Health , Gaborone , Botswana
| | - Nankie M Ramabu
- a Botswana International Training and Education Center for Health (I-TECH) , Gaborone , Botswana
| | - Boyce Otlhomile
- a Botswana International Training and Education Center for Health (I-TECH) , Gaborone , Botswana
| | - Rebeca M Plank
- c Department of Immunology and Infectious Diseases , Harvard T. H. Chan School of Public Health , Boston , Massachusetts , USA.,f Division of Infectious Diseases , Brigham and Women's Hospital , Boston , Massachusetts , USA.,g Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education , Gaborone , Botswana
| | - Scott Barnhart
- d Department of Global Health , University of Washington , Seattle , Washington , USA
| | - Jenny H Ledikwe
- a Botswana International Training and Education Center for Health (I-TECH) , Gaborone , Botswana.,d Department of Global Health , University of Washington , Seattle , Washington , USA
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Tobian AAR, Adamu T, Reed JB, Kiggundu V, Yazdi Y, Njeuhmeli E. Voluntary medical male circumcision in resource-constrained settings. Nat Rev Urol 2015; 12:661-70. [PMID: 26526758 DOI: 10.1038/nrurol.2015.253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Throughout East and Southern Africa, the WHO recommends voluntary medical male circumcision (VMMC) to reduce heterosexual HIV acquisition. Evidence has informed policy and the implementation of VMMC programmes in these countries. VMMC has been incorporated into the HIV prevention portfolio and more than 9 million VMMCs have been performed. Conventional surgical procedures consist of forceps-guided, dorsal slit or sleeve resection techniques. Devices are also becoming available that might help to accelerate the scale-up of adult VMMC. The ideal device should make VMMC easier, safer, faster, sutureless, inexpensive, less painful, require less infrastructure, be more acceptable to patients and should not require follow-up visits. Elastic collar compression devices cause vascular obstruction and necrosis of foreskin tissue and do not require sutures or injectable anaesthesia. Collar clamp devices compress the proximal part of the foreskin to reach haemostasis; the distal foreskin is removed, but the device remains and therefore no sutures are required. Newer techniques and designs, such as tissue adhesives and a circular cutter with stapled anastomosis, are improvements, but none of these methods have achieved all desirable characteristics. Further research, design and development are needed to address this gap to enable the expansion of the already successful VMMC programmes for HIV prevention.
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Affiliation(s)
- Aaron A R Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Carnegie 437, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Tigistu Adamu
- JHPIEGO, 1615 Thames Street, Baltimore, MD 21231, USA
| | - Jason B Reed
- Office of the U.S. Global AIDS Coordinator, 1776 Massachusetts Avenue NW, Suite 300, Washington, DC 20036, USA
| | - Valerian Kiggundu
- Office of HIV/AIDS at the US Agency for International Development, 2100 Crystal Drive, 9th Floor, Arlington, VA 22202, USA
| | - Youseph Yazdi
- Johns Hopkins Center for Bioengineering Innovation &Design (CBID), Clark Hall Suite 208, 3400 North Charles Street, Baltimore, MD 21218, USA
| | - Emmanuel Njeuhmeli
- Office of HIV/AIDS at the US Agency for International Development, 2100 Crystal Drive, 9th Floor, Arlington, VA 22202, USA
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Zamawe COF, Kusamula F. What are the social and individual factors that are associated with undergoing male circumcision as an HIV prevention strategy? A mixed methods study in Malawi. Int Health 2015; 8:170-8. [PMID: 26503362 DOI: 10.1093/inthealth/ihv061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/31/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is compelling evidence that medical male circumcision (MMC) decreases transmission of HIV. Nevertheless, the uptake of MMC is generally very low. Understanding the characteristics of individuals who choose MMC could inform future strategies for scaling-up MMC. The main objective of this study was to explore the social and individual characteristics of men that are associated with the uptake of circumcision as an HIV prevention strategy. METHODS A mixed-methods study, comprising a cross-sectional survey and an exploratory qualitative study, was conducted in Malawi. A total number of 1644 men, of at least 18 years old, participated in this study. A multistage sampling approach was used in the survey while convenience sampling was adopted in the qualitative study. Descriptive statistics, bivariate analyses and multivariable logistic regression were performed to analyze the cross-sectional data and thematic content approach to analyze the qualitative data. RESULTS Individuals who chose MMC were more likely to be unemployed (AOR=1.65; 95% CI: 1.30-2.11), to be married (AOR=3.16; 95% CI: 2.21-4.52) and to have had exposure to MMC promotions (AOR=1.81; 95% CI: 1.41-2.33). They were also more likely to reside in rural areas (AOR=1.85; 95% CI: 1.44-2.38), to perceive themselves as more vulnerable to HIV (AOR=1.60; 95% CI: 1.19-2.15) and to be more knowledgeable about the benefits of MMC (AOR=1.51; 95% CI: 1.16-1.97). CONCLUSIONS The findings suggest that men who had certain social and individual characteristics (for example better knowledge of the benefits of MMC, greater perceived vulnerability to HIV, married and unemployed) were more likely to choose circumcision as a prevention strategy for HIV than those who lacked those characteristics. Strategies for increasing MMC take-up should recognize the current social/individual landscape of MMC uptake and ensure that deliberate efforts targeting marginalized categories of men are available.
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Affiliation(s)
- Collins O F Zamawe
- Blantyre International University, Community Health Department, Private Bag 98, Blantyre, Malawi Parent and Child Health Initiative (PACHI), Research Centre, P.O. Box 31686, Lilongwe, Malawi
| | - Fatsani Kusamula
- Parent and Child Health Initiative (PACHI), Research Centre, P.O. Box 31686, Lilongwe, Malawi
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Hankins C, Macklin R, Warren M. Translating PrEP effectiveness into public health impact: key considerations for decision-makers on cost-effectiveness, price, regulatory issues, distributive justice and advocacy for access. J Int AIDS Soc 2015; 18:19973. [PMID: 26198343 PMCID: PMC4509900 DOI: 10.7448/ias.18.4.19973] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 04/06/2015] [Accepted: 04/15/2015] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The extraordinary feat of proving the effectiveness of oral pre-exposure prophylaxis (PrEP) in clinical trials in different populations in a variety of settings may prove to have been easier than ensuring it is used well. Decision-makers must make difficult choices to realize the promise of antiretroviral prophylaxis for their countries. This paper outlines key economic, regulatory and distributive justice issues that must be addressed for effective and acceptable PrEP implementation. DISCUSSION In considering the role that PrEP can play in combination prevention programmes, decision-makers must determine who can benefit most from PrEP, how PrEP can be provided safely and efficiently, and what kind of health system support will ensure successful implementation. To do this, they need contextualized information on disease burden by population, analyses of how PrEP services might best be delivered, and projections of the human resource and infrastructure requirements for each potential delivery model. There are cost considerations, varying cost-effectiveness results and regulatory challenges. The principles of ethics can inform thorny discussions about who should be prioritized for oral PrEP and how best to introduce it fairly. We describe the cost-effectiveness of PrEP in different populations at higher risk of HIV exposure, its price in low- and middle-income countries, and the current regulatory situation. We explore the principles of ethics that can inform resource allocation decision-making about PrEP anchored in distributive justice, at a time when universal access to antiretroviral treatment remains to be assured. We then highlight the role of advocacy in moving the PrEP agenda forward. CONCLUSIONS The time is ripe now for decisions about whether, how and for whom PrEP should be introduced into a country's HIV response. It has the potential to contribute significantly to high impact HIV prevention if it is tailored to those who can most benefit from it and if current regulatory and pricing barriers can be overcome. Advocacy at all levels can help inform decision-making and push the access agenda to avert HIV infections among those at highest risk of HIV exposure. The benefits will accrue beyond the individual level to slow HIV transmission at the population level.
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Affiliation(s)
- Catherine Hankins
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, England; ;
| | - Ruth Macklin
- Epidemiology & Population Health, Albert Einstein College of Medicine New York, NY, USA
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Cáceres CF, Mayer KH, Baggaley R, O'Reilly KR. PrEP Implementation Science: State-of-the-Art and Research Agenda. J Int AIDS Soc 2015; 18:20527. [PMID: 26198351 PMCID: PMC4581083 DOI: 10.7448/ias.18.4.20527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Blower S, Palk L. Combination HIV prevention and the battle of the sexes. THE LANCET. INFECTIOUS DISEASES 2015; 15:261-3. [PMID: 25749218 DOI: 10.1016/s1473-3099(15)70037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Sally Blower
- Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA.
| | - Laurence Palk
- Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, CA 90024, USA
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Parkhurst JO, Chilongozi D, Hutchinson E. Doubt, defiance, and identity: Understanding resistance to male circumcision for HIV prevention in Malawi. Soc Sci Med 2015; 135:15-22. [PMID: 25939072 DOI: 10.1016/j.socscimed.2015.04.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Global policy recommendations to scale up of male circumcision (MC) for HIV prevention tend to frame the procedure as a simple and efficacious public health intervention. However, there has been variable uptake of MC in countries with significant HIV epidemics. Kenya, for example, has embraced MC and has been dubbed a 'leader' by the global health community, while Malawi has been branded a 'laggard' in its slow adoption of a national programme, with a strong political discourse of resistance forming around MC. Regardless of any epidemiological or technical evidence, the uptake of international recommendations will be shaped by how a policy, and the specific artefacts that constitute that policy, intersect with local concerns. MC holds particular significance within many ethnic and religious groups, serving as an important rite of passage, but also designating otherness or enabling the identification of the social and political self. Understanding how the artefact of MC intersects with local social, economic, and political contexts, is therefore essential to understand the acceptance or resistance of global policy recommendations. In this paper we present an in-depth analysis of Malawi's political resistance to MC, finding that ethnic and religious divisions dominating recent political movements aligned well with differing circumcision practices. Political resistance was further found to manifest through two key narratives: a 'narrative of defiance' around the need to resist donor manipulation, and a 'narrative of doubt' which seized on a piece of epidemiological evidence to refute global claims of efficacy. Further, we found that discussions over MC served as an additional arena through which ethnic identities and claims to power could themselves be negotiated, and therefore used to support claims of political legitimacy.
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Affiliation(s)
| | - David Chilongozi
- I-TECH (International Training & Education Centre for Health), Malawi
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Van Howe RS. Circumcision as a primary HIV preventive: extrapolating from the available data. Glob Public Health 2015; 10:607-25. [PMID: 25760456 DOI: 10.1080/17441692.2015.1016446] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Billions of dollars to circumcise millions of African males as an HIV infection prevention have been sought, yet the effectiveness of circumcision has not been demonstrated. Data from 109 populations comparing HIV prevalence and incidence in men based on circumcision status were evaluated using meta-regression. The impact on the association between circumcision and HIV incidence/prevalence of the HIV risk profile of the population, the circumcision rates within the population and whether the population was in Africa were assessed. No significant difference in the risk of HIV infection based on the circumcision status was seen in general populations. Studies of high-risk populations and populations with a higher prevalence of male circumcision reported significantly greater odds ratios (odds of intact man having HIV) (p < .0001). When adjusted for the impact of a high-risk population and the circumcision rate of the population, the baseline odds ratio was 0.78 (95% CI = 0.56-1.09). No consistent association between presence of HIV infection and circumcision status of adult males in general populations was found. When adjusted for other factors, having a foreskin was not a significant risk factor. This undermines the justification for using circumcision as a primary preventive for HIV infection.
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Affiliation(s)
- Robert S Van Howe
- a College of Medicine, Central Michigan University , Saginaw , MI , USA
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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.
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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
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Ledikwe JH, Nyanga RO, Hagon J, Grignon JS, Mpofu M, Semo BW. Scaling-up voluntary medical male circumcision - what have we learned? HIV AIDS-RESEARCH AND PALLIATIVE CARE 2014; 6:139-46. [PMID: 25336991 PMCID: PMC4199973 DOI: 10.2147/hiv.s65354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15–49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008–2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.
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Affiliation(s)
- Jenny H Ledikwe
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Robert O Nyanga
- International Training and Education Center for Health, Botswana, Gaborone, Botswana
| | - Jaclyn Hagon
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jessica S Grignon
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Mulamuli Mpofu
- International Training and Education Center for Health, Botswana, Gaborone, Botswana
| | - Bazghina-Werq Semo
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
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Mutabazi V, Forrest JI, Ford N, Mills EJ. How do you circumcise a nation? The Rwandan case study. BMC Med 2014; 12:184. [PMID: 25604003 PMCID: PMC4186219 DOI: 10.1186/s12916-014-0184-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/11/2014] [Indexed: 01/10/2023] Open
Abstract
Voluntary medical male circumcision has been conclusively demonstrated to reduce the lifetime risk of male acquisition of HIV. The strategy has been adopted as a component of a comprehensive strategy towards achieving an AIDS-free generation. A number of countries in which prevalence of HIV is high and circumcision is low have been identified as a priority, where innovative approaches to scale-up are currently being explored. Rwanda, as one of the priority countries, has faced a number of challenges to successful scale-up. We discuss here how simplifications in the procedure, addressing a lack of healthcare infrastructure and mobilizing resources, and engaging communities of both men and women have permitted Rwanda to move forward with more optimism in its scale-up tactics. Examples from Rwanda are used to highlight how these barriers can and should be addressed.
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Affiliation(s)
- Vincent Mutabazi
- Ministry of Health, Republic of Rwanda, Rwanda Biomedical Centre-Medical Research Centre, PO Box 2717, Kigali, Rwanda.
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.
| | - Edward J Mills
- Global Evaluative Sciences, Calgary, Canada. .,Stanford Prevention Research Center, Stanford University, Stanford, USA.
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Jones A, Cremin I, Abdullah F, Idoko J, Cherutich P, Kilonzo N, Rees H, Hallett T, O'Reilly K, Koechlin F, Schwartlander B, de Zalduondo B, Kim S, Jay J, Huh J, Piot P, Dybul M. Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention. Lancet 2014; 384:272-9. [PMID: 24740087 DOI: 10.1016/s0140-6736(13)62230-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Large declines in HIV incidence have been reported since 2001, and scientific advances in HIV prevention provide strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public health approach to combination prevention that understands that risk is not evenly distributed and that effective interventions can vary by risk profile. Different countries have different microepidemics, with very different levels of transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies, people at highest risk for HIV, and the package of interventions that are most likely to have the largest effect in each different microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision, as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.
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Affiliation(s)
- Alexandra Jones
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Ide Cremin
- School of Public Health, Imperial College London, London, UK
| | - Fareed Abdullah
- South Africa National AIDS Council (SANAC), Pretoria, South Africa
| | - John Idoko
- National Agency for the Control of AIDS, Abuja, Nigeria
| | - Peter Cherutich
- National AIDS/STD Control Programme (NASCOP), Nairobi, Kenya
| | - Nduku Kilonzo
- Liverpool Voluntary Counselling and Testing, Care and Treatment, Nairobi, Kenya
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Witwatersrand, South Africa
| | - Timothy Hallett
- School of Public Health, Imperial College London, London, UK
| | - Kevin O'Reilly
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Florence Koechlin
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Barbara de Zalduondo
- Office of the Deputy Executive Director for Programme, UNAIDS, Geneva, Switzerland
| | - Susan Kim
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Jonathan Jay
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Jacqueline Huh
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Peter Piot
- Director's Office, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Dybul
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA; The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.
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Surgical efficiencies and quality in the performance of voluntary medical male circumcision (VMMC) procedures in Kenya, South Africa, Tanzania, and Zimbabwe. PLoS One 2014; 9:e84271. [PMID: 24802412 PMCID: PMC4011873 DOI: 10.1371/journal.pone.0084271] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 11/13/2013] [Indexed: 12/02/2022] Open
Abstract
Introduction This analysis explores the association between elements of surgical efficiency in voluntary medical male circumcision (VMMC), quality of surgical technique, and the amount of time required to conduct VMMC procedures in actual field settings. Efficiency outcomes are defined in terms of the primary provider’s time with the client (PPTC) and total elapsed operating time (TEOT). Methods Two serial cross-sectional surveys of VMMC sites were conducted in Kenya, Republic of South Africa, Tanzania and Zimbabwe in 2011 and 2012. Trained clinicians observed quality of surgical technique and timed 9 steps in the VMMC procedure. Four elements of efficiency (task-shifting, task-sharing [of suturing], rotation among multiple surgical beds, and use of electrocautery) and quality of surgical technique were assessed as explanatory variables. Mann Whitney and Kruskal Wallis tests were used in the bivariate analysis and linear regression models for the multivariate analyses to test the relationship between these five explanatory variables and two outcomes: PPTC and TEOT. The VMMC procedure TEOT and PPTC averaged 23–25 minutes and 6–15 minutes, respectively, across the four countries and two years. The data showed time savings from task-sharing in suturing and use of electrocautery in South Africa and Zimbabwe (where task-shifting is not authorized). After adjusting for confounders, results demonstrated that having a secondary provider complete suturing and use of electrocautery reduced PPTC. Factors related to TEOT varied by country and year, but task-sharing of suturing and/or electrocautery were significant in two countries. Quality of surgical technique was not significantly related to PPTC or TEOT, except for South Africa in 2012 where higher quality was associated with lower TEOT. Conclusions SYMMACS data confirm the efficiency benefits of task-sharing of suturing and use of electrocautery for decreasing TEOT. Reduced TEOT and PPTC in high volume setting did not result in decreased quality of surgical care.
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Jennings L, Bertrand J, Rech D, Harvey SA, Hatzold K, Samkange CA, Omondi Aduda DS, Fimbo B, Cherutich P, Perry L, Castor D, Njeuhmeli E. Quality of voluntary medical male circumcision services during scale-up: a comparative process evaluation in Kenya, South Africa, Tanzania and Zimbabwe. PLoS One 2014; 9:e79524. [PMID: 24801073 PMCID: PMC4011679 DOI: 10.1371/journal.pone.0079524] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 10/02/2013] [Indexed: 11/30/2022] Open
Abstract
Background The rapid expansion of voluntary medical male circumcision (VMMC) has raised concerns whether health systems can deliver and sustain VMMC according to minimum quality criteria. Methods and Findings A comparative process evaluation was used to examine data from SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-Up, among health facilities providing VMMC across two years of program scale-up. Site-level assessments examined the availability of guidelines, supplies and equipment, infection control, and continuity of care services. Direct observation of VMMC surgeries were used to assess care quality. Two sample tests of proportions and t-tests were used to examine differences in the percent of facilities meeting requisite preparedness standards and the mean number of directly-observed surgical tasks performed correctly. Results showed that safe, high quality VMMC can be implemented and sustained at-scale, although substantial variability was observed over time. In some settings, facility preparedness and VMMC service quality improved as the number of VMMC facilities increased. Yet, lapses in high performance and expansion of considerably deficient services were also observed. Surgical tasks had the highest quality scores, with lower performance levels in infection control, pre-operative examinations, and post-operative patient monitoring and counseling. The range of scale-up models used across countries additionally underscored the complexity of delivering high quality VMMC. Conclusions Greater efforts are needed to integrate VMMC scale-up and quality improvement processes in sub-Saharan African settings. Monitoring of service quality, not just adverse events reporting, will be essential in realizing the full health impact of VMMC for HIV prevention.
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Affiliation(s)
- Larissa Jennings
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Jane Bertrand
- Tulane University School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America
| | - Dino Rech
- The Centre for HIV and AIDS Prevention Studies, Johannesburg, South Africa
| | - Steven A. Harvey
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America
| | | | - Christopher A. Samkange
- Institute of Continuing Health Education, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | | | - Bennett Fimbo
- Ministry of Health and Social Welfare, National AIDS Control Programme, Dar es Salaam, Tanzania
| | - Peter Cherutich
- National AIDS and Sexually Transmitted Infections Control Program, Nairobi, Kenya
| | - Linnea Perry
- Tulane University School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, Louisiana, United States of America
| | - Delivette Castor
- United States Agency for International Development, Washington, D.C., United States of America
| | - Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, D.C., United States of America
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Prabhughate A, Sarna A, Brady M. Tenofovir gel for HIV prevention for women: Perspectives of Key Opinion Leaders from India. HEALTH POLICY AND TECHNOLOGY 2014. [DOI: 10.1016/j.hlpt.2013.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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.
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Alpern R, Canavan ME, Thompson JT, McNatt Z, Tatek D, Lindfield T, Bradley EH. Development of a brief instrument for assessing healthcare employee satisfaction in a low-income setting. PLoS One 2013; 8:e79053. [PMID: 24223878 PMCID: PMC3818514 DOI: 10.1371/journal.pone.0079053] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 09/18/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ethiopia is one of 57 countries identified by the World Health Report 2006 as having a severely limited number of health care professionals. In recognition of this shortage, the Ethiopian Federal Ministry of Health, through the Ethiopian Hospital Management Initiative, prioritized the need to improve retention of health care workers. Accordingly, we sought to develop the Satisfaction of Employees in Health Care (SEHC) survey for use in hospitals and health centers throughout Ethiopia. METHODS Literature reviews and cognitive interviews were used to generate a staff satisfaction survey for use in the Ethiopian healthcare setting. We pretested the survey in each of the six hospitals and four health centers across Ethiopia (98% response rate). We assessed content validity and convergent validity using factor analysis and examined reliability using the Cronbach alpha coefficients to assess internal consistency. The final survey was comprised of 18 questions about specific aspects of an individual's work and two overall staff satisfaction questions. RESULTS We found support for content validity, as data from the 18 responses factored into three factors, which we characterized as 1) relationship with management and supervisors, 2) job content, and 3) relationships with coworkers. Summary scores for two factors (relationship with management and supervisors and job content) were significantly associated (P-value, <0.001) with the two overall satisfaction items. Cronbach's alpha coefficients showed good to excellent internal consistency (Cronbach alpha coefficients >0.70) for the items in the three summary scores. CONCLUSIONS The introduction of consistent and reliable measures of staff satisfaction is crucial to understand and improve employee retention rates, which threaten the successful achievement of the Millennium Development Goals in low-income countries. The use of the SEHC survey in Ethiopian healthcare facilities has ample leadership support, which is essential for addressing problems that reduce staff satisfaction and exacerbate excessive workforce shortages.
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Affiliation(s)
- Rachelle Alpern
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Maureen E. Canavan
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Jennifer T. Thompson
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Zahirah McNatt
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Dawit Tatek
- Yale School of Public Health, New Haven, Connecticut, United States of America
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McPherson DB, Balisanga HN, Mbabazi JK. Bridging the accountability divide: male circumcision planning in Rwanda as a case study in how to merge divergent operational planning approaches. Health Policy Plan 2013; 29:883-92. [PMID: 24056898 PMCID: PMC4186211 DOI: 10.1093/heapol/czt069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
When voluntary medical male circumcision (MC) was confirmed as an effective tool for HIV prevention in sub-Saharan Africa in 2007, many public health policy makers and practitioners were eager to implement the intervention. How to roll out the tool as part of comprehensive strategy however was less clear. At the time, very little was known about the capacity of health systems to scale delivery of the new intervention. Today, nearly all countries prioritized for the intervention are far behind their targets. To contribute to the discourse on why this is, we develop a historical analysis of medical MC planning in sub-Saharan Africa using our own experience of this process in Rwanda. We compare our previously unpublished feasibility analysis from 2008 with international research published in 2009, which suggested how Rwanda could reduce HIV incidence through a rapid MC intervention, and Rwanda’s eventual 2010 official operational plan. We trace how, in the face of uncertainty, operational plans avoided discussing the details of feasibility and focused instead on defining optimal circumcision capacity needed to achieve country level target reductions in HIV incidence. We show a distinct gap between the targets set in the official operational plan and what we determined was feasible in 2008. With actual data from the ground now available, we show our old feasibility models more closely approximate circumcision delivery rates to date. With an eye toward the future of long-term policy planning, we discuss the mechanics of how accountability gaps like this occur in global health policy making and how practitioners can better create achievable operational targets.
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Affiliation(s)
- Dacia B McPherson
- Columbia University Mailman School of Public Health, New York, NY, USA, Rwanda Biomedical Center/Institute of HIV/AIDS, Disease Prevention and Control, Kigali, Rwanda and U.S. Agency for International Development (USAID) Rwanda, Kigali, Rwanda
| | - Helene N Balisanga
- Columbia University Mailman School of Public Health, New York, NY, USA, Rwanda Biomedical Center/Institute of HIV/AIDS, Disease Prevention and Control, Kigali, Rwanda and U.S. Agency for International Development (USAID) Rwanda, Kigali, Rwanda
| | - Jennifer K Mbabazi
- Columbia University Mailman School of Public Health, New York, NY, USA, Rwanda Biomedical Center/Institute of HIV/AIDS, Disease Prevention and Control, Kigali, Rwanda and U.S. Agency for International Development (USAID) Rwanda, Kigali, Rwanda
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Tobian AAR, Kacker S, Quinn TC. Male circumcision: a globally relevant but under-utilized method for the prevention of HIV and other sexually transmitted infections. Annu Rev Med 2013; 65:293-306. [PMID: 24111891 DOI: 10.1146/annurev-med-092412-090539] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Randomized trials have demonstrated that male circumcision (MC) reduces heterosexual acquisition of HIV, herpes simplex virus type 2, human papillomavirus (HPV), and genital ulcer disease among men, and it reduces HPV, genital ulcer disease, bacterial vaginosis, and trichomoniasis among female partners. The pathophysiology behind these effects is multifactorial, relying on anatomic and cellular changes. MC is cost effective and potentially cost saving in both the United States and Africa. The World Health Organization and Joint United Nations Program on HIV/AIDS proposed reaching 80% MC coverage in HIV endemic countries, but current rates fall far behind targets. Barriers to scale-up include supply-side and demand-side challenges. In the United States, neonatal MC rates are decreasing, but the American Academy of Pediatrics now recognizes the medical benefits of MC and supports insurance coverage. Although MC is a globally valuable tool to prevent HIV and other sexually transmitted infections, it is underutilized. Further research is needed to address barriers to MC uptake.
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Affiliation(s)
- Aaron A R Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland 21287;
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Gray RH, Wawer MJ, Kigozi G. Programme science research on medical male circumcision scale-up in sub-Saharan Africa. Sex Transm Infect 2013; 89:345-9. [DOI: 10.1136/sextrans-2012-050595] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Tynan A, Vallely A, Kelly A, Kupul M, Neo J, Naketrumb R, Aeno H, Law G, Milan J, Siba P, Kaldor J, Hill PS. Sociocultural and individual determinants for motivation of sexual and reproductive health workers in Papua New Guinea and their implications for male circumcision as an HIV prevention strategy. HUMAN RESOURCES FOR HEALTH 2013; 11:7. [PMID: 23418879 PMCID: PMC3602021 DOI: 10.1186/1478-4491-11-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 01/28/2013] [Indexed: 06/01/2023]
Abstract
BACKGROUND The motivation of health workers (HWs) to deliver services in developing countries has been described as a critical factor in the success of health systems in implementing programmes. How the sociocultural context of Papua New Guinea (PNG) affects the values, motivation and actions of HWs involved in sexual and reproductive health services is important for policy development and programme planning. With interest in male circumcision (MC) as an HIV prevention option in PNG, this study explored the perceptions and motivations of HWs involved in sexual and reproductive health services in PNG, examining their implications for the possible future roll out of a national MC programme. METHODS A multi-method qualitative study was conducted with HWs across a range of health care professions working in sexual health facilities. A total of 29 in-depth interviews and one focus group discussion were completed. Qualitative thematic analysis of the transcripts and field notes was undertaken using a social constructivist approach and complemented by documentary organizational, programme and policy analysis. RESULTS AND DISCUSSIONS Introduction of new health programmes, such as a MC programme for HIV prevention, are likely to impact upon one or more of the many motivational determinants. Social-cultural and individual factors influencing HW motivation to be involved in sexual and reproductive health services in PNG included community expectation and concern, sense of accomplishment and religious conviction. Strong links to community responsibility outweighed organizational ties. Faced with an often dysfunctional work environment, HWs perceived themselves as responsible to compensate for the failed health system. The impact of community influence and expectation needs to be considered when introducing a MC programme, particularly to communities in PNG where penile foreskin cutting is a common and accepted practice. CONCLUSIONS The potential contribution to the success of a MC programme that HWs may have means that taking into account the differing needs of communities as well as the motivational influences on HWs that exist within the sociocultural environment is important. These findings will assist not only in programme planning for MC, but also in the expansion of other existing sexual and reproductive health services.
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Affiliation(s)
- Anna Tynan
- Australian Centre for International & Tropical Health, School of Population Health, University of Queensland, Herston Road, Herston, Queensland, 4006, Australia
| | - Andrew Vallely
- Public Health Interventions Research Group, Kirby Institute, University of New South Wales, Cliffbrook Campus, 45 Beach Street, Coogee, New South Wales, 2034, Australia
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea
| | - Angela Kelly
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea
- International HIV Research Group, School of Public Health and Community Medicine, University of New South Wales, High Street, Kensington, 2052, Australia
| | - Martha Kupul
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea
| | - James Neo
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea
| | - Richard Naketrumb
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea
| | - Herick Aeno
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea
| | - Greg Law
- Sexual Health and Disease Control Branch, National Department of Health, P.O. Box 807, Waigani, National Capital District, 131, Papua New Guinea
| | - John Milan
- Sexual Health and Disease Control Branch, National Department of Health, P.O. Box 807, Waigani, National Capital District, 131, Papua New Guinea
| | - Peter Siba
- Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, Eastern Highlands Province, 441, Papua New Guinea
| | - John Kaldor
- Public Health Interventions Research Group, Kirby Institute, University of New South Wales, Cliffbrook Campus, 45 Beach Street, Coogee, New South Wales, 2034, Australia
| | - Peter S Hill
- Australian Centre for International & Tropical Health, School of Population Health, University of Queensland, Herston Road, Herston, Queensland, 4006, Australia
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Siegler AJ, Mbwambo JK, DiClemente RJ. Applying the Dynamic Social Systems Model to HIV prevention in a rural African context: the Maasai and the esoto dance. HEALTH EDUCATION & BEHAVIOR 2013; 40:683-93. [PMID: 23372030 DOI: 10.1177/1090198112474004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study applied the Dynamic Social Systems Model (DSSM) to the issue of HIV risk among the Maasai tribe of Tanzania, using data from a cross-sectional, cluster survey among 370 randomly selected participants from Ngorongoro and Siha Districts. A culturally appropriate survey instrument was developed to explore traditions reportedly coadunate with sexual partnership, including "wife sharing", fertility rituals, and various traditional dances. One dance, esoto, accounted for more than two thirds of participants' lifetime sexual partners (n = 10.5). The DSSM, combining structural and systems theories, was applied to systematize complex multilevel factors regarding esoto practice. Participants reported multifaceted beliefs regarding esoto; a majority viewed the dance as exciting and essential, yet most men feared social stigma and three quarters of women had experienced physical punishment for nonattendance. In multivariate logistic regression, esoto attendance was predicted by female gender (adjusted odds ratio [AOR] = 4.67, 95% confidence interval [CI] = 1.6-13.2), higher positive beliefs regarding esoto (AOR = 2.84, 95% CI = 1.9-4.2), and Maasai life cycle events (AOR = 0.06, 95% CI = 0.01-0.47). The DSSM proved useful for characterizing esoto and for revealing feedback loops that maintain esoto, thus indicating avenues for future interventions.
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Affiliation(s)
- Aaron J Siegler
- 1Emory University Rollins School of Public Health, Atlanta, GA, USA
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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.
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Lanham M, L'engle KL, Loolpapit M, Oguma IO. Women's roles in voluntary medical male circumcision in Nyanza Province, Kenya. PLoS One 2012; 7:e44825. [PMID: 23028634 PMCID: PMC3446991 DOI: 10.1371/journal.pone.0044825] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 08/07/2012] [Indexed: 11/19/2022] Open
Abstract
Women are an important audience for voluntary medical male circumcision (VMMC) communication messages so that they know that VMMC provides only partial protection against HIV. They may also be able to influence their male partners to get circumcised and practice other HIV protective measures after VMMC. This study was conducted in two phases of qualitative data collection. Phase 1 used in-depth interviews to explore women’s understanding of partial protection and their role in VMMC. Phase 2 built on the findings from the Phase 1, using focus groups to test VMMC communication messages currently used in Nyanza Province and to further explore women’s roles in VMMC. Sixty-four sexually active women between the ages of 18 and 35 participated. In Phase 1, all women said they had heard of partial protection, though some were not able to elaborate on what the concept means. When women in Phase 2 were exposed to messages about partial protection, however, participants understood the messages well and were able to identify the main points. In Phases 1 and 2, many participants said that they had discussed VMMC with their partner, and for several, it was a joint decision for the man to go for VMMC. These findings suggest that current VMMC messaging is reaching women, though communications could more effectively target women to increase their ability to communicate about partial HIV protection from VMMC. Also, women seem to be playing an important role in encouraging men to get circumcised, so reaching out to women could be a valuable intervention strategy for increasing VMMC uptake and promoting use of other HIV protective measures after VMMC.
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Affiliation(s)
- Michele Lanham
- Social and Behavioral Health Sciences, FHI 360, Research Triangle Park, North Carolina, United States of America.
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Tynan A, Vallely A, Kelly A, Law G, Millan J, Siba P, Kaldor J, Hill PS. Vasectomy as a proxy: extrapolating health system lessons to male circumcision as an HIV prevention strategy in Papua New Guinea. BMC Health Serv Res 2012; 12:299. [PMID: 22943659 PMCID: PMC3457912 DOI: 10.1186/1472-6963-12-299] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 08/30/2012] [Indexed: 11/19/2022] Open
Abstract
Background Male circumcision (MC) has been shown to reduce the risk of HIV acquisition among heterosexual men, with WHO recommending MC as an essential component of comprehensive HIV prevention programs in high prevalence settings since 2007. While Papua New Guinea (PNG) has a current prevalence of only 1%, the high rates of sexually transmissible diseases and the extensive, but unregulated, practice of penile cutting in PNG have led the National Department of Health (NDoH) to consider introducing a MC program. Given public interest in circumcision even without active promotion by the NDoH, examining the potential health systems implications for MC without raising unrealistic expectations presents a number of methodological issues. In this study we examined health systems lessons learned from a national no-scalpel vasectomy (NSV) program, and their implications for a future MC program in PNG. Methods Fourteen in-depth interviews were conducted with frontline health workers and key government officials involved in NSV programs in PNG over a 3-week period in February and March 2011. Documentary, organizational and policy analysis of HIV and vasectomy services was conducted and triangulated with the interviews. All interviews were digitally recorded and later transcribed. Application of the WHO six building blocks of a health system was applied and further thematic analysis was conducted on the data with assistance from the analysis software MAXQDA. Results Obstacles in funding pathways, inconsistent support by government departments, difficulties with staff retention and erratic delivery of training programs have resulted in mixed success of the national NSV program. Conclusions In an already vulnerable health system significant investment in training, resources and negotiation of clinical space will be required for an effective MC program. Focused leadership and open communication between provincial and national government, NGOs and community is necessary to assist in service sustainability. Ensuring clear policy and guidance across the entire sexual and reproductive health sector will provide opportunities to strengthen key areas of the health system.
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Affiliation(s)
- Anna Tynan
- Australian Centre for International & Tropical Health, School of Population Health, University of Queensland, Brisbane, Australia.
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Prevention of sexual transmission of HIV: real results, science progressing, societies remaining behind. AIDS 2012; 26:1223-9. [PMID: 22706008 DOI: 10.1097/qad.0b013e32835462b8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HIV spread has reached a turning point following decades of increasing and sustained incidence. An effective vaccine has not been developed, but critical breakthroughs with prevention based on antiretroviral treatment are promising. The new prevention technologies will have to be combined with condoms and incorporated into the mixes of combination prevention approaches that are tailored to the local epidemic and context. To address the implementation gap, more political will and leadership will be needed to overcome the socio-cultural, legal or religious barriers to prevention. We have learned that the generation of demand for HIV prevention is not easy, as for health promotion in general. Despite optimism about treatment as prevention, many western countries are facing an increase in new HIV cases, and HIV is no longer a collective concern. If we manage to find common ground on combination prevention, customize approaches to people's needs and exercise technical and political leadership, our decade may see the beginning of the end of the epidemic.
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Hankins C, Forsythe S, Njeuhmeli E. Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up. PLoS Med 2011; 8:e1001127. [PMID: 22140362 PMCID: PMC3226452 DOI: 10.1371/journal.pmed.1001127] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Scaling up voluntary medical male circumcision (VMMC) for HIV prevention is cost saving and creates fiscal space in the future that otherwise would have been encumbered by antiretroviral treatment costs. An investment of US$1,500,000,000 between 2011 and 2015 to achieve 80% coverage in 13 priority countries in southern and eastern Africa will result in net savings of US$16,500,000,000. Strong political leadership, country ownership, and stakeholder engagement, along with effective demand creation, community mobilisation, and human resource deployment, are essential. This collection of articles on determining the cost and impact of VMMC for HIV prevention signposts the way forward to scaling up VMMC service delivery safely and efficiently to reap individual- and population-level benefits.
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