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Facente SN, Grebe E, Maher AD, Fox D, Scheer S, Mahy M, Dalal S, Lowrance D, Marsh K. Use of HIV Recency Assays for HIV Incidence Estimation and Other Surveillance Use Cases: Systematic Review. JMIR Public Health Surveill 2022; 8:e34410. [PMID: 35275085 PMCID: PMC8956992 DOI: 10.2196/34410] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/16/2022] [Accepted: 02/02/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND HIV assays designed to detect recent infection, also known as "recency assays," are often used to estimate HIV incidence in a specific country, region, or subpopulation, alone or as part of recent infection testing algorithms (RITAs). Recently, many countries and organizations have become interested in using recency assays within case surveillance systems and routine HIV testing services to measure other indicators beyond incidence, generally referred to as "non-incidence surveillance use cases." OBJECTIVE This review aims to identify published evidence that can be used to validate methodological approaches to recency-based incidence estimation and non-incidence use cases. The evidence identified through this review will be used in the forthcoming technical guidance by the World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) on the use of HIV recency assays for identification of epidemic trends, whether for HIV incidence estimation or non-incidence indicators of recency. METHODS To identify the best methodological and field implementation practices for the use of recency assays to estimate HIV incidence and trends in recent infections for specific populations or geographic areas, we conducted a systematic review of the literature to (1) understand the use of recency testing for surveillance in programmatic and laboratory settings, (2) review methodologies for implementing recency testing for both incidence estimation and non-incidence use cases, and (3) assess the field performance characteristics of commercially available recency assays. RESULTS Among the 167 documents included in the final review, 91 (54.5%) focused on assay or algorithm performance or methodological descriptions, with high-quality evidence of accurate age- and sex-disaggregated HIV incidence estimation at national or regional levels in general population settings, but not at finer geographic levels for prevention prioritization. The remaining 76 (45.5%) described the field use of incidence assays including field-derived incidence (n=45), non-incidence (n=25), and both incidence and non-incidence use cases (n=6). The field use of incidence assays included integrating RITAs into routine surveillance and assisting with molecular genetic analyses, but evidence was generally weaker or only reported on what was done, without validation data or findings related to effectiveness of using non-incidence indicators calculated through the use of recency assays as a proxy for HIV incidence. CONCLUSIONS HIV recency assays have been widely validated for estimating HIV incidence in age- and sex-specific populations at national and subnational regional levels; however, there is a lack of evidence validating the accuracy and effectiveness of using recency assays to identify epidemic trends in non-incidence surveillance use cases. More research is needed to validate the use of recency assays within HIV testing services, to ensure findings can be accurately interpreted to guide prioritization of public health programming.
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Affiliation(s)
- Shelley N Facente
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, United States.,Facente Consulting, Richmond, CA, United States.,Vitalant Research Institute, San Francisco, CA, United States
| | - Eduard Grebe
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, United States.,Vitalant Research Institute, San Francisco, CA, United States.,South African Centre for Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Andrew D Maher
- South African Centre for Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Douglas Fox
- Facente Consulting, Richmond, CA, United States
| | | | - Mary Mahy
- Strategic Information Department, The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Shona Dalal
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - David Lowrance
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - Kimberly Marsh
- Strategic Information Department, The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
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Loevinsohn G, Kigozi G, Kagaayi J, Wawer MJ, Nalugoda F, Chang LW, Quinn TC, Serwadda D, Reynolds SJ, Nelson L, Mills L, Alamo S, Nakigozi G, Kabuye G, Ssekubugu R, Tobian AAR, Gray RH, Grabowski MK. Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda. Clin Infect Dis 2021; 73:e1946-e1953. [PMID: 33043978 PMCID: PMC8492113 DOI: 10.1093/cid/ciaa1533] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/06/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President's Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. METHODS A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men. RESULTS A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21-35 years) to 22 years (IQR, 18-29 years) (P for trend < .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28-.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time. CONCLUSIONS VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.
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Affiliation(s)
- Gideon Loevinsohn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Larry W Chang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas C Quinn
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- School of Public Health, Makerere University, Kampala, Uganda
| | - Steven J Reynolds
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute for Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Nelson
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Lisa Mills
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | - Stella Alamo
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Geoffrey Kabuye
- US Centers for Disease Control and Prevention Uganda, Kampala, Uganda
| | | | - Aaron A R Tobian
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - M Kathryn Grabowski
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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3
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Hines JZ, Sachathep K, Pals S, Davis SM, Toledo C, Bronson M, Parekh B, Carrasco M, Xaba S, Mandisarisa J, Kamobyi R, Chituwo O, Kirungi WL, Alamo S, Kabuye G, Awor AC, Mmbando S, Simbeye D, Aupokolo MA, Zemburuka B, Nyirenda R, Msungama W, Tarumbiswa T, Manda R, Nuwagaba-Biribonwoha H, Kiggundu V, Thomas AG, Watts H, Voetsch AC, Williams DB. HIV Incidence by Male Circumcision Status From the Population-Based HIV Impact Assessment Surveys-Eight Sub-Saharan African Countries, 2015-2017. J Acquir Immune Defic Syndr 2021; 87:S89-S96. [PMID: 33765683 PMCID: PMC11187824 DOI: 10.1097/qai.0000000000002658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Male circumcision (MC) offers men lifelong partial protection from heterosexually acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally representative samples. Data from the population-based HIV impact assessments were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. METHODS Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random-effects logistic regression model using pooled survey weights. Analyses were age stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. RESULTS Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men [0.04% (95% CI: 0.00% to 0.10%) versus 0.34% (95% CI: 0.10% to 0.57%), respectively; P value = 0.01]; whereas among men 35-59 years, there was no significant incidence difference [1.36% (95% CI: 0.32% to 2.39%) versus 0.55% (95% CI: 0.14% to 0.67%), respectively; P value = 0.14]. DISCUSSION Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa.
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Affiliation(s)
- Jonas Z. Hines
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Karampreet Sachathep
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Sherri Pals
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stephanie M. Davis
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos Toledo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Megan Bronson
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bharat Parekh
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maria Carrasco
- Office of HIV and AIDS, U.S. Agency for International Development, Washington, District of Columbia
| | | | - John Mandisarisa
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | | | - Omega Chituwo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Stella Alamo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Geoffrey Kabuye
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Anna Colletar Awor
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Susan Mmbando
- National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Daimon Simbeye
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | - Mekondjo A. Aupokolo
- National HIV/AIDS, STI and Hepatitis Control Program, Ministry of Health and Social Services, Windhoek, Namibia
| | - Brigitte Zemburuka
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | | | - Wezi Msungama
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Robert Manda
- U.S. Agency for International Development, Maseru, Lesotho
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia University, Mbabane, Eswatini
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Valerian Kiggundu
- Office of HIV and AIDS, U.S. Agency for International Development, Washington, District of Columbia
| | - Anne G. Thomas
- Defense Health Agency, U.S. Department of Defense, San Diego, California
| | - Heather Watts
- Office of Global AIDS Coordinator, Washington, District of Columbia
| | - Andrew C. Voetsch
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dan B. Williams
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysis. LANCET GLOBAL HEALTH 2021; 9:e932-e941. [PMID: 33939956 PMCID: PMC8690595 DOI: 10.1016/s2214-109x(21)00102-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/08/2021] [Accepted: 02/25/2021] [Indexed: 02/02/2023]
Abstract
Background Medical male circumcision (MMC) reduces HIV infection among heterosexual men. There are concerns MMC might prompt higher-risk sexual behaviours because of lower self-perceived risk of HIV infection. We reviewed the published literature to examine associations between MMC and both condom use and number of sex partners among heterosexual men. Methods In this systematic review and meta-analysis, we searched PubMed, Embase, and the Cochrane Library for studies published before Nov 15, 2020. Interventional and observational studies were included if they contained original quantitative data describing the association between MMC and condom use or number of sex partners among heterosexual men. We excluded data from men whose circumcisions were ritual or religious and data from men who have sex with men. We extracted odds ratios (ORs) and 95% CIs for the associations between MMC and condomless sex and MMC and multiple sex partners directly from the publications if available, selecting adjusted ORs when provided; when necessary, we calculated ORs and 95% CIs using original study data provided in the publication. We used the Mantel-Haenszel random effects model to calculate pooled ORs and 95% CIs. Findings Our search yielded 3035 results, of which 471 were duplicates and 2537 did not meet the inclusion criteria. From the remaining 27 eligible studies, we identified 99 292 men from 31 independent population samples. 24 studies were done in Africa. We found no statistically significant associations between MMC and condomless sex (OR 0·91, 95% CI 0·80–1·05; k=30; I2=88·7%) or multiple sex partners (1·02, 0·88–1·18; k=27; I2=90·1%). No associations between MMC and condomless sex or multiple sexual partners were found in any subgroup analyses by study design, income of country, age, recruitment setting, circumcision assessment, circumcision prevalence, and risk of publication bias. Interpretation The promotion of circumcision as an HIV preventive measure does not appear to increase higher-risk sexual behaviours in heterosexual men. Ongoing sexual health education should be maintained as a vital component of effective MMC programmes.
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Peebles K, Mittler JE, Goodreau SM, Murphy JT, Reid MC, Abernethy N, Gottlieb GS, Barnabas RV, Herbeck JT. Risk compensation after HIV-1 vaccination may accelerate viral adaptation and reduce cost-effectiveness: a modeling study. Sci Rep 2021; 11:6798. [PMID: 33762616 PMCID: PMC7991033 DOI: 10.1038/s41598-021-85487-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/22/2021] [Indexed: 11/09/2022] Open
Abstract
Pathogen populations can evolve in response to selective pressure from vaccine-induced immune responses. For HIV, models predict that viral adaptation, either via strain replacement or selection on de novo mutation, may rapidly reduce the effectiveness of an HIV vaccine. We hypothesized that behavioral risk compensation after vaccination may accelerate the transmission of vaccine resistant strains, increasing the rate of viral adaptation and leading to a more rapid decline in vaccine effectiveness. To test our hypothesis, we modeled: (a) the impact of risk compensation on rates of HIV adaptation via strain replacement in response to a partially effective vaccine; and (b) the combined impact of risk compensation and viral adaptation on vaccine-mediated epidemic control. We used an agent-based epidemic model that was calibrated to HIV-1 trends in South Africa, and includes demographics, sexual network structure and behavior, and within-host disease dynamics. Our model predicts that risk compensation can increase the rate of HIV viral adaptation in response to a vaccine. In combination, risk compensation and viral adaptation can, under certain scenarios, reverse initial declines in prevalence due to vaccination, and result in HIV prevalence at 15 years equal to or greater than prevalence without a vaccine.
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Affiliation(s)
- Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - John E Mittler
- Department of Microbiology, University of Washington, Seattle, WA, USA
| | - Steven M Goodreau
- Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, USA
- Department of Anthropology, University of Washington, Seattle, WA, USA
| | - James T Murphy
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Molly C Reid
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Neil Abernethy
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Geoffrey S Gottlieb
- Department of Medicine, University of Washington, Seattle, WA, USA
- Center for Emerging and Re-Emerging Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- International Clinical Research Center, University of Washington, Seattle, WA, USA
| | - Joshua T Herbeck
- Department of Global Health, University of Washington, Seattle, WA, USA.
- International Clinical Research Center, University of Washington, Seattle, WA, USA.
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Korenromp EL, Bershteyn A, Mudimu E, Weiner R, Bonecwe C, Loykissoonlal D, Manuhwa C, Pretorius C, Teng Y, Stover J, Johnson LF. The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models. Gates Open Res 2021; 5:15. [PMID: 33615145 PMCID: PMC7878969 DOI: 10.12688/gatesopenres.13220.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/24/2022] Open
Abstract
Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.
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Affiliation(s)
| | - Anna Bershteyn
- Department of Population and Health, NYU Langone Medical Center, New York, NY, 11016, USA
| | - Edina Mudimu
- Department of Decision Sciences, University of South Africa (UNISA), Pretoria, 0003, South Africa
| | - Renay Weiner
- Research and Training for Health and Development, Johannesburg, 2196, South Africa
| | | | | | - Clarence Manuhwa
- FHI 360, Pretoria, 0083, South Africa
- Independent Consultant, Pretoria, 0083, South Africa
| | - Carel Pretorius
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Yu Teng
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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7
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Cork MA, Wilson KF, Perkins S, Collison ML, Deshpande A, Eaton JW, Earl L, Haeuser E, Justman JE, Kinyoki DK, Mayala BK, Mosser JF, Murray CJL, Nkengasong JN, Piot P, Sartorius B, Schaeffer LE, Serfes AL, Sligar A, Steuben KM, Tanser FC, VanderHeide JD, Yang M, Wabiri N, Hay SI, Dwyer-Lindgren L. Mapping male circumcision for HIV prevention efforts in sub-Saharan Africa. BMC Med 2020; 18:189. [PMID: 32631314 PMCID: PMC7339571 DOI: 10.1186/s12916-020-01635-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/14/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND HIV remains the largest cause of disease burden among men and women of reproductive age in sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk of female-to-male transmission of HIV by 50-60%. The World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries for VMMC campaigns and set a coverage goal of 80% for men ages 15-49. From 2008 to 2017, over 18 million VMMCs were reported in priority countries. Nonetheless, relatively little is known about local variation in male circumcision (MC) prevalence. METHODS We analyzed geo-located MC prevalence data from 109 household surveys using a Bayesian geostatistical modeling framework to estimate adult MC prevalence and the number of circumcised and uncircumcised men aged 15-49 in 38 countries in sub-Saharan Africa at a 5 × 5-km resolution and among first administrative level (typically provinces or states) and second administrative level (typically districts or counties) units. RESULTS We found striking within-country and between-country variation in MC prevalence; most (12 of 14) priority countries had more than a twofold difference between their first administrative level units with the highest and lowest estimated prevalence in 2017. Although estimated national MC prevalence increased in all priority countries with the onset of VMMC campaigns, seven priority countries contained both subnational areas where estimated MC prevalence increased and areas where estimated MC prevalence decreased after the initiation of VMMC campaigns. In 2017, only three priority countries (Ethiopia, Kenya, and Tanzania) were likely to have reached the MC coverage target of 80% at the national level, and no priority country was likely to have reached this goal in all subnational areas. CONCLUSIONS Despite MC prevalence increases in all priority countries since the onset of VMMC campaigns in 2008, MC prevalence remains below the 80% coverage target in most subnational areas and is highly variable. These mapped results provide an actionable tool for understanding local needs and informing VMMC interventions for maximum impact in the continued effort towards ending the HIV epidemic in sub-Saharan Africa.
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Affiliation(s)
- Michael A Cork
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kate F Wilson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Samantha Perkins
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Michael L Collison
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Aniruddha Deshpande
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jeffrey W Eaton
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Lucas Earl
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Emily Haeuser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jessica E Justman
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.,Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Damaris K Kinyoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Jonathan F Mosser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - John N Nkengasong
- Africa Centres for Disease Control and Prevention, African Union, Addis Ababa, Ethiopia
| | - Peter Piot
- London School of Hygiene & Tropical Medicine, London, UK
| | - Benn Sartorius
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.,London School of Hygiene & Tropical Medicine, London, UK
| | - Lauren E Schaeffer
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Audrey L Serfes
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Amber Sligar
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Krista M Steuben
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Frank C Tanser
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,Research Department of Infection & Population Health, University College London, London, UK
| | - John D VanderHeide
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Mingyou Yang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Njeri Wabiri
- HIV/AIDS, STIs & TB Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. .,Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
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Farley TMM, Samuelson J, Grabowski MK, Ameyan W, Gray RH, Baggaley R. Impact of male circumcision on risk of HIV infection in men in a changing epidemic context - systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25490. [PMID: 32558344 PMCID: PMC7303540 DOI: 10.1002/jia2.25490] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/10/2020] [Accepted: 03/17/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION WHO/UNAIDS recommended Voluntary Medical Male Circumcision in 2007 based on systematic review of observational studies prior to 1999 and three randomized controlled trials (RCTs). To inform updated WHO guidance, we conducted a systematic review and meta-analysis of impact of circumcision on the risk of HIV infection among heterosexual men. METHODS Studies in PubMed of HIV incidence and changes in prevalence in heterosexual men by circumcision status were identified. Pooled incidence rate ratios were computed using fixed- and random-effects meta-analysis and risk of bias was assessed using the ROBINS-I tool. RESULTS AND DISCUSSION In three RCTs, the pooled incidence ratio was 0.41 (95% CI 0.30 to 0.56), with risk difference 10 (8 to 12) fewer infections per 1000 person-years (py). Pooled incidence ratios were 0.34 (0.24 to 0.49) in two post-RCT follow-up studies, 0.29 (0.19 to 0.43) in men at high HIV risk (five cohorts), 0.48 (0.33 to 0.70) in four community-based cohorts before circumcision scale-up, and 0.56 (0.49 to 0.64) (7 [6 to 8] fewer per 1000 py) in six community-based cohorts during circumcision and antiretroviral treatment scale-up. Heterogeneity between studies was low except in men at high HIV risk. We estimated 520,000 (425,000 to 605,000) fewer infections occurred in men by end of 2018 from 22.7 million circumcisions performed since 2008 and increasing by 155,000 (125,000 to 180,000) annually if epidemic conditions remain similar. After exclusion of studies with high risk of bias and those conducted outside Africa, pooled incidence ratios were similar. There was no evidence of confounding nor changes in risk behaviour following circumcision. In post-hoc exploratory analyses we observed a trend of decreasing effectiveness of circumcision in cohorts with lower HIV incidence. CONCLUSIONS Efficacy of medical male circumcision on HIV incidence from randomized controlled trials was supported by effectiveness from observational studies in populations with diverse HIV risk and changing epidemic contexts. Voluntary Medical Male Circumcision remains an important evidence-based intervention for control of generalized HIV epidemics.
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Affiliation(s)
| | - Julia Samuelson
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - M Kate Grabowski
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMDUSA
| | - Wole Ameyan
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Ronald H Gray
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Rakai Health Sciences ProgramKalisizoUganda
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
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Barone MA, Li PS, Lee RK, Ouma D, Oundo M, Barasa M, Oketch J, Otiende P, Nyangweso N, Maina M, Kiswi N, Chirchir B, Goldstein M, Awori QD. Simplifying the ShangRing technique for circumcision in boys and men: use of the no-flip technique with randomization to removal at 7 days versus spontaneous detachment. Asian J Androl 2020; 21:324-331. [PMID: 30520424 PMCID: PMC6628734 DOI: 10.4103/aja.aja_91_18] [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: 12/13/2022] Open
Abstract
To assess safety of the no-flip ShangRing male circumcision technique and to determine clinical course and safety of spontaneous detachment (i.e., allowing the device to fall off), we conducted a case series of no-flip ShangRing circumcision combined with a randomized controlled trial of removal 7 days postcircumcision versus spontaneous detachment at two health facilities in Kenya. The primary outcome was the safety of the no-flip technique based on moderate and severe adverse events (AEs) during the procedure and through 42-day follow-up. A main secondary outcome was clinical course and safety of spontaneous detachment. Two hundred and thirty males 10 years and older underwent no-flip circumcision; 114 randomized to 7-day removal and 116 to spontaneous detachment. All circumcisions were successfully completed. Overall 5.3% (6/114) of participants in the 7-day group and 1.7% (2/116) in the spontaneous group had an AE; with no differences when compared to the 3% AE rate in historical data from African studies using the original flip technique (P = 0.07 and P = 0.79, respectively). Overall 72.4% (84/116) of participants in the spontaneous group wore the ShangRing until it detached. Among the remaining (27.6%; 32/116), the ring was removed, primarily at the participants' request, due to pain or discomfort. There was no difference in AE rates (P = 0.169), visit day declared healed (P = 0.324), or satisfaction (P = 0.371) between randomization groups. The median time to detachment was 14.0 (IQR: 7–21, range: 5–35) days. The no-flip technique and spontaneous detachment are safe, effective, and acceptable to boys and men 10 years and older. Phimosis and penile adhesions do not limit successful ShangRing circumcision with the no-flip technique.
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Affiliation(s)
| | - Philip S Li
- Center for Male Reproductive Medicine and Surgery, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | - Richard K Lee
- Center for Male Reproductive Medicine and Surgery, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | | | | | | | - Jairus Oketch
- Homa Bay County Teaching and Referral Hospital, Homa Bay 40300, Kenya
| | - Patrick Otiende
- Homa Bay County Teaching and Referral Hospital, Homa Bay 40300, Kenya
| | - Nixon Nyangweso
- Homa Bay County Teaching and Referral Hospital, Homa Bay 40300, Kenya
| | - Mary Maina
- Vipingo Health Centre, Vipingo 80119, Kenya
| | | | | | - Marc Goldstein
- Center for Male Reproductive Medicine and Surgery, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male circumcision: A systematic review. J Evid Based Med 2019; 12:263-290. [PMID: 31496128 PMCID: PMC6899915 DOI: 10.1111/jebm.12361] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/03/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To systematically evaluate evidence against male circumcision (MC). METHODS We searched PubMed, Google Scholar, EMBASE and Cochrane databases. RESULTS Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. CONCLUSIONS Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.
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Affiliation(s)
- Brian J Morris
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | - John N Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattleWashington
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Morris BJ, Hankins CA, Banerjee J, Lumbers ER, Mindel A, Klausner JD, Krieger JN. Does Male Circumcision Reduce Women's Risk of Sexually Transmitted Infections, Cervical Cancer, and Associated Conditions? Front Public Health 2019; 7:4. [PMID: 30766863 PMCID: PMC6365441 DOI: 10.3389/fpubh.2019.00004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Male circumcision (MC) is proven to substantially reduce men's risk of a number of sexually transmitted infections (STIs). We conducted a detailed systematic review of the scientific literature to determine the relationship between MC and risk of STIs and associated conditions in women. Methods: Database searches by "circumcision women" and "circumcision female" identified 68 relevant articles for inclusion. Examination of bibliographies of these yielded 14 further publications. Each was rated for quality using a conventional rating system. Results: Evaluation of the data from the studies retrieved showed that MC is associated with a reduced risk in women of being infected by oncogenic human papillomavirus (HPV) genotypes and of contracting cervical cancer. Data from randomized controlled trials and other studies has confirmed that partner MC reduces women's risk not only of oncogenic HPV, but as well Trichomonas vaginalis, bacterial vaginosis and possibly genital ulcer disease. For herpes simplex virus type 2, Chlamydia trachomatis, Treponema pallidum, human immunodeficiency virus and candidiasis, the evidence is mixed. Male partner MC did not reduce risk of gonorrhea, Mycoplasma genitalium, dysuria or vaginal discharge in women. Conclusion: MC reduces risk of oncogenic HPV genotypes, cervical cancer, T. vaginalis, bacterial vaginosis and possibly genital ulcer disease in women. The reduction in risk of these STIs and cervical cancer adds to the data supporting global efforts to deploy MC as a health-promoting and life-saving public health measure and supplements other STI prevention strategies.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW, Australia
| | - Catherine A. Hankins
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- London School of Hygiene and Tropical Medicine, Bloomsbury, London, United Kingdom
| | | | - Eugenie R. Lumbers
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine and Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Adrian Mindel
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey D. Klausner
- Division of Infectious Diseases and the Program in Global Health, Fielding School of Public Health, University of California Los Angeles Care Center, Los Angeles, CA, United States
| | - John N. Krieger
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States
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Reed JB, Patel RR, Baggaley R. Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up. Int J STD AIDS 2018; 29:1432-1443. [PMID: 30114997 PMCID: PMC6287252 DOI: 10.1177/0956462418787896] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Oral pre-exposure prophylaxis (PrEP) has the ability to curb HIV incidence worldwide and bring us closer to ending the HIV epidemic. Scale up of PrEP service delivery has many similar challenges to those faced by voluntary medical male circumcision (VMMC) services roll-out. This article outlines ten important lessons learned during the scale up of VMMC services in sub-Saharan Africa and their application to current oral PrEP implementation efforts to promote faster expansion for public health impact.
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Affiliation(s)
- Jason B Reed
- HIV-Malaria-Infectious Diseases, Jhpiego, Baltimore, MD, USA
| | - Rupa R Patel
- Division of Infectious Diseases, Washington University in St. Louis, St Louis, MO, USA
| | - Rachel Baggaley
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
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Nakyanjo N, Piccinini D, Kisakye A, Yeh PT, Ddaaki W, Kigozi G, Gray RH, Kennedy CE. Women's role in male circumcision promotion in Rakai, Uganda. AIDS Care 2018; 31:443-450. [PMID: 30010413 DOI: 10.1080/09540121.2018.1500009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Medical male circumcision (MMC) has expanded in sub-Saharan Africa, yet uptake remains sub-optimal. We sought to understand women's perceptions of and influence on MMC in Rakai, Uganda. We conducted in-depth interviews with 27 women in fishing and trading communities, including women married to circumcised and uncircumcised men, single women, and sex workers. Data analysis followed a team-based framework approach. All female participants preferred circumcised men because of perceived reduced HIV and sexually transmitted infection (STI) risk, improved penile hygiene, and increased sexual pleasure. Perceived negative aspects included abstinence during wound healing, potentially increased male sexual risk behaviors, fear of being blamed for HIV acquisition, and economic insecurity due to time off work. Participants felt women could persuade their partners to be circumcised, accompany them to the clinic, refuse sex with uncircumcised men, and participate in community MMC activities. Findings support women's important role in MMC acceptance.
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Affiliation(s)
- Neema Nakyanjo
- a Social and Behavioral Sciences Department , Rakai Health Sciences Program, Research Directorate , Kalisizo , Uganda
| | - Danielle Piccinini
- b Center for Communications Programs , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Alice Kisakye
- c Rakai Health Sciences Program, Programs Directorate , Kalisizo , Uganda
| | - Ping Teresa Yeh
- d Department of International Health, Social and Behavioral Interventions Program , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - William Ddaaki
- a Social and Behavioral Sciences Department , Rakai Health Sciences Program, Research Directorate , Kalisizo , Uganda
| | - Godfrey Kigozi
- e Rakai Health Sciences Program, Research Directorate , Kalisizo , Uganda
| | - Ronald H Gray
- f Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Caitlin E Kennedy
- d Department of International Health, Social and Behavioral Interventions Program , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Field evaluation of the safety, acceptability, and feasibility of early infant male circumcision using the AccuCirc device. PLoS One 2018; 13:e0191501. [PMID: 29444116 PMCID: PMC5812570 DOI: 10.1371/journal.pone.0191501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 01/05/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As countries scale up adult voluntary medical male circumcision (VMMC) for HIV prevention, they are looking ahead to long term sustainable strategies, including introduction of early infant male circumcision (EIMC). Although a number of devices for EIMC are prequalified by the World Health Organization, evaluation of additional devices can provide policy-makers and clinicians the information required to make informed decisions. We undertook a field evaluation of the safety and acceptability of the AccuCirc device in Kisumu County, Kenya. METHODS Procedures were performed by four trained clinicians in two public facilities. Participants were recruited from surrounding public health facilities through informational talks at antenatal clinics, maternity wards, and maternal neonatal child health clinics. Healthy infants ages 0-60 days, with no penile abnormality, without a family history of bleeding disorder, with current weight-for-age within -2 Z-scores of WHO growth standards, and whose mother was at least 16 years of age were eligible for EIMC. The procedure was performed after administration of a penile dorsal nerve block using 2% lidocaine and administration of Vitamin K. The mother was given post-operative instructions on wound care and asked to remain in the clinic with the baby for an observational period of one hour, during which a face-to-face questionnaire was administered. RESULTS Of 1259 babies screened, 704 were enrolled and circumcised. Median age of the infants was 16 days (IQR: 7-32.5) and of the mothers was 26 years (IQR: 22-30). Median time for the procedure was 19 minutes (IQR: 15-23). There were no serious adverse events (AE), and 20 (2.8%) moderate AEs, all of which were due to bleeding that required application of one to three sutures. There were 22 (3.8%) procedures in which the device did not fully incise the entire circumference of the foreskin and had to be completed using sterile scissors. 89.9% of mothers had knowledge of EIMC, but few (8.1%) had any knowledge of devices used for EIMC. Protection against HIV/AIDS was the most cited reason to circumcise a baby (65.3%), while the baby being ill (38.1%) and pain (34.4%) were the most cited barriers to uptake. 99% of mothers were "very satisfied" or "completely satisfied" with the procedure. CONCLUSIONS This evaluation of the AccuCirc device is the largest to date and indicates that the device is safe and acceptable, achieving high levels of parental satisfaction. The AccuCirc device should be considered for WHO prequalification to increase options for safe and sustainable provision of EIMC.
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Sharma SC, Raison N, Khan S, Shabbir M, Dasgupta P, Ahmed K. Male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition: a meta-analysis. BJU Int 2018; 121:515-526. [DOI: 10.1111/bju.14102] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Nicholas Raison
- Division of Transplantation Immunology and Mucosal Biology; Faculty of Life Sciences and Medicine; King's College London; London UK
| | - Shamim Khan
- Division of Transplantation Immunology and Mucosal Biology; Faculty of Life Sciences and Medicine; King's College London; London UK
| | - Majid Shabbir
- Department of Urology; Guy's and St Thomas' NHS Trust; London UK
| | - Prokar Dasgupta
- Division of Transplantation Immunology and Mucosal Biology; Faculty of Life Sciences and Medicine; King's College London; London UK
| | - Kamran Ahmed
- Division of Transplantation Immunology and Mucosal Biology; Faculty of Life Sciences and Medicine; King's College London; London UK
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Ganczak M, Korzeń M, Olszewski M. Attitudes, Beliefs and Predictors of Male Circumcision Promotion among Medical University Students in a Traditionally Non-Circumcising Region. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E1097. [PMID: 28934174 PMCID: PMC5664598 DOI: 10.3390/ijerph14101097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/12/2017] [Accepted: 09/18/2017] [Indexed: 12/24/2022]
Abstract
Objective: To evaluate the beliefs of medical university students regarding male circumcision (MC), as well as attitudes and the predictors of its promotion in the case of adults at risk of HIV. Methods: A cross-sectional survey was conducted between 2013-2016 at the Medical University in Szczecin, Poland, among final year Polish/foreign students from Northern Europe, using a standardized questionnaire. Results: There were 539 participants, median age 25 years, 40.8% males, and 66.8% were Polish nationals. The MC rate was 16.7%. Regarding HIV/AIDS knowledge, 66.6% of the students scored more than 75%; and, 34.2% knew that MC reduces the risk of HIV infection. One in eleven respondents (9.1%) believed that circumcised men felt more intense sexual pleasure. More than half of the respondents (54.8%) declared that they would recommend MC to adult patients at risk for HIV. The belief that circumcised men felt more intense sexual pleasure, and knowledge on MC regarding HIV risk reduction was associated with greater odds of recommending adult MC (OR = 3.35 and OR = 2.13, respectively). Conclusions: Poor knowledge of its benefits and a low willingness to promote the procedure-strongly dependent on personal beliefs-suggest that medical students may need additional training to help them to discuss MC more openly with adult men at risk for HIV infection. Knowledge may be an effective tool when making decisions regarding MC promotion.
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Affiliation(s)
- Maria Ganczak
- Department of Epidemiology and Management, Faculty of Medical Sciences, Pomeranian Medical University, 71-210 Szczecin, Poland.
| | - Marcin Korzeń
- Department of Methods of Artificial Intelligence and Applied Mathematics, Faculty of Computer Science and Information Technology, West Pomeranian University of Technology, 71-210 Szczecin, Poland.
| | - Maciej Olszewski
- Students' Scientific Association, Pomeranian Medical University, 70-204 Szczecin, Poland.
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Johnson LF, Dorrington RE, Moolla H. HIV epidemic drivers in South Africa: A model-based evaluation of factors accounting for inter-provincial differences in HIV prevalence and incidence trends. South Afr J HIV Med 2017; 18:695. [PMID: 29568631 PMCID: PMC5843035 DOI: 10.4102/sajhivmed.v18i1.695] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 06/01/2017] [Indexed: 01/24/2023] Open
Abstract
Background HIV prevalence differs substantially between South Africa’s provinces, but the factors accounting for this difference are poorly understood. Objectives To estimate HIV prevalence and incidence trends by province, and to identify the epidemiological factors that account for most of the variation between provinces. Methods A mathematical model of the South African HIV epidemic was applied to each of the nine provinces, allowing for provincial differences in demography, sexual behaviour, male circumcision, interventions and epidemic timing. The model was calibrated to HIV prevalence data from antenatal and household surveys using a Bayesian approach. Parameters estimated for each province were substituted into the national model to assess sensitivity to provincial variations. Results HIV incidence in 15–49-year-olds peaked between 1997 and 2003 and has since declined steadily. By mid-2013, HIV prevalence in 15–49-year-olds varied between 9.4% (95% CI: 8.5%–10.2%) in Western Cape and 26.8% (95% CI: 25.8%–27.6%) in KwaZulu-Natal. When standardising parameters across provinces, this prevalence was sensitive to provincial differences in the prevalence of male circumcision (range 12.3%–21.4%) and the level of non-marital sexual activity (range 9.5%–24.1%), but not to provincial differences in condom use (range 17.7%–21.2%), sexual mixing (range 15.9%–19.2%), marriage (range 18.2%–19.4%) or assumed HIV prevalence in 1985 (range 17.0%–19.1%). Conclusion The provinces of South Africa differ in the timing and magnitude of their HIV epidemics. Most of the heterogeneity in HIV prevalence between South Africa’s provinces is attributable to differences in the prevalence of male circumcision and the frequency of non-marital sexual activity.
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Affiliation(s)
- Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - Rob E Dorrington
- Centre for Actuarial Research, University of Cape Town, South Africa
| | - Haroon Moolla
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population, 2008-2013. J Acquir Immune Defic Syndr 2017; 74:e30-e37. [PMID: 27632232 DOI: 10.1097/qai.0000000000001180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors. METHODS Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference. RESULTS The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception. CONCLUSIONS The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.
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Factors Associated With Delayed Healing in a Study of the PrePex Device for Adult Male Circumcision in Kenya. J Acquir Immune Defic Syndr 2017; 72 Suppl 1:S24-9. [PMID: 27331586 PMCID: PMC4936424 DOI: 10.1097/qai.0000000000000736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To explore factors associated with healing requiring more than 6 weeks after placement of the PrePex device for adult medical male circumcision. METHODS We enrolled 427 men ages 18-49 years in an observational study of PrePex at 1 urban and 2 peripheral clinics in western Kenya. Participants were scheduled for device removal at day 7 and a follow-up visit at day 42 (allowable range, 40-44) at which the provider recorded wound status, with complete healing defined as a dry wound without any scab, later confirmed by site investigator review of digital penile photographs. We performed univariate and multivariate logistic regression to explore associations between selected demographic, surgical, and follow-up factors and delayed healing (not healed by day 42 visit). RESULTS Of the 427 men, 341 completing a day 42 visit with physical examination and recorded healing status were included. Fifty-four percent of included men were healed by day 42 visit. Factors associated with delayed healing in univariate analysis and remaining significant in the multivariate analysis were as follows: age 25 years or older [odds ratio (OR): 1.8; 95% confidence interval (CI): 1.4 to 2.4], an adverse event by day 44 (OR: 1.4; 95% CI: 1.03 to 2.0), and severe pain during device removal (protective association: OR: 0.7; 95% CI: 0.5 to 0.99). CONCLUSIONS Older age (25+ years), occurrence of an adverse event, and lesser self-reported pain at device removal were associated with delayed wound healing. If confirmed by larger surveillance studies, these results should be incorporated into the counseling given to male circumcision clients.
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Participant Experiences and Views of Odor and PrePex Device Removal Pain in a VMMC Pilot Study in Botswana. J Acquir Immune Defic Syndr 2017; 72 Suppl 1:S73-7. [PMID: 27331595 PMCID: PMC4936428 DOI: 10.1097/qai.0000000000000765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess participant experiences and perceptions of removal pain and odor associated with the PrePex device procedure. METHODS We analyzed data from a PrePex device pilot implementation study of 802 male participants aged 18-49 years at 2 clinics in Botswana, 2013. Study staff administered survey questions on device-related odor and assessed pain using visual analog scale scores categorized as no pain (0), mild (1-4), moderate (5-7), or severe pain (8-10). RESULTS Mean participant age was 27.7 (range = 18-48) years. Of the 802 participants, 751 (94%) reported to have noticed an unusual or unpleasant odor while wearing the device. Of these, 193 (26%) participants tried something to combat the odor. A total of 84 (10%) participants reported no pain, 655 (82%) mild pain, 48 (6%) moderate pain, and 15 (2%) severe pain at 2 minutes after device removal. Pain reports at 15 minutes after removal were 553 (69%) no pain, 247 (31%) mild pain, and 2 (0.25%) moderate pain, with no report of severe pain at this time point. Of 740 participants interviewed on day 42 after device placement, 678 (92%) were satisfied with the procedure and 681 (92%) would recommend it to another man considering circumcision, including 488 (66%) who would recommend it strongly. CONCLUSIONS An unusual or unpleasant odor while wearing the PrePex device and mild self-limiting pain at device removal were common, but overall, these did neither seem to impair satisfaction nor deter participants from recommending PrePex to others, which could suggest good prospects for uptake of the device in this setting.
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Men's Understanding of and Experiences During the Postcircumcision Abstinence Period: Results From a Field Study of ShangRing Circumcision During Routine Clinical Services in Kenya and Zambia. J Acquir Immune Defic Syndr 2017; 72 Suppl 1:S18-23. [PMID: 27331585 PMCID: PMC4936421 DOI: 10.1097/qai.0000000000000704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Men's understanding of counseling messages after voluntary medical male circumcision (VMMC) plays an important role in whether they follow them. Data on triggers for early resumption of sex may be useful as scale-up of VMMC for HIV prevention continues in sub-Saharan Africa. Methods: Data on understanding of post-VMMC abstinence recommendations, resumption of sex, condom use, and triggers for resuming sex were collected from participants during a follow-up interview 35–42 days after ShangRing circumcision in Kenya and Zambia. Results: Of 1149 men who had ShangRing circumcision, 1096 (95.4%) completed follow-up. Nearly all (99.2%) reported being counseled to abstain from sex post-VMMC; among those, most (92.2%) recalled the recommended abstinence period was 6 weeks. Most men (94.1%) reported that the counselor gave reasons for post-VMMC abstinence and recalled appropriate reasons. Few (13.4%) men reported resuming sex at 35–42 days' follow-up. Among those, 54.8% reported never using a condom post-VMMC. Younger participants (odds ratio 0.3, 95% confidence interval: 0.2 to 0.5, P < 0.0001) and those reporting at least some condom use at baseline (odds ratio 0.5, 95% confidence interval: 0.3 to 0.7, P = 0.0003) were less likely to report resuming sex. Among men who reported some condom use, most (71.5%) said condoms were much easier or easier to use after circumcision. Men reported various reasons for early resumption of sex, primarily strong sexual desire (76.4%). Conclusions: Most men reported awareness of and adherence to the counseling recommendations for post-VMMC abstinence. A minority reported early resumption of sex, and, among those, condom use was low. Results could be used to improve post-VMMC counseling.
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Randomized Controlled Trial of the ShangRing for Adult Medical Male Circumcision: Safety, Effectiveness, and Acceptability of Using 7 Versus 14 Device Sizes. J Acquir Immune Defic Syndr 2017; 72 Suppl 1:S30-5. [PMID: 27331587 PMCID: PMC4936423 DOI: 10.1097/qai.0000000000001015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives: To assess the safety, effectiveness, and acceptability of providing a reduced number of ShangRing sizes for adult voluntary medical male circumcision (VMMC) within routine service delivery in Lusaka, Zambia. Methods: We conducted a randomized controlled trial and enrolled 500 HIV-negative men aged 18–49 years at 3 clinics. Participants were randomized to 1 of 2 study arms (Standard Sizing arm vs Modified Sizing arm) in a 1:1 ratio. All 14 adult ShangRing sizes (40–26 mm inner diameter, each varying by 1 mm) were available in the Standard Sizing arm; the Modified Sizing arm used every other size (40, 38, 36, 34, 32, 30, 28 mm inner diameter). Each participant was scheduled for 2 follow-up visits: the removal visit (day 7 after placement) and the healing check visit (day 42 after placement), when they were evaluated for adverse events (AEs), pain, and healing. Results: Four hundred and ninety-six men comprised the analysis population, with 255 in the Standard Sizing arm and 241 in the Modified Sizing arm. Three men experienced a moderate or severe AEs (0.6%), including 2 in the Standard Sizing arm (0.8%) and 1 in the Modified Sizing arm (0.4%). 73.2% of participants were completely healed at the scheduled day 42 healing check visit, with similar percentages across study arms. Virtually all (99.6%) men, regardless of study arm, stated that they were very satisfied or satisfied with the appearance of their circumcised penis, and 98.6% stated that they would recommend ShangRing circumcision to family/friends. Conclusions: The moderate/severe AE rate was low and similar in the 2 study arms, suggesting that provision of one-half the number of adult device sizes is sufficient for safe service delivery. Effectiveness, time to healing, and acceptability were similar in the study arms. The simplicity of the ShangRing technique, and its relative speed, could facilitate VMMC program goals. In addition, sufficiency of fewer device sizes would simplify logistics and inventory.
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Abstract
BACKGROUND Devices can potentially accelerate scale-up of voluntary medical male circumcision in sub-Saharan Africa. Studies have demonstrated advantages of the ShangRing device over conventional circumcision. With the need to train providers rapidly for scale-up, concerns arise about the transferability of techniques and the expertise of new trainees. METHODS We compared outcomes of ShangRing circumcisions conducted in Kenya by experienced providers (experience with more than 100 ShangRing circumcisions) and newly trained providers (trained in Kenya by the experienced providers before the study began). During training, trainees performed at least 7 ShangRing circumcisions and 3 removals. Newly trained providers received intermittent clinical mentoring initially during the study but otherwise conducted circumcisions on their own. RESULTS Four hundred six and 115 ShangRing procedures were performed by the new trainees and the experienced providers, respectively. The mean duration of circumcisions was 6.2 minutes for both trained and experienced provider groups (P = 0.45), whereas the mean pain score (on an 11-point scale) was 2.5 and 3.2, respectively (P = 0.65). There was no difference in the proportion of participants healed by the day 42 visit (P = 0.13) nor in the incidence of moderate and severe adverse events observed (P = 0.16). Participants in both groups were equally satisfied with final wound cosmesis. DISCUSSION Results demonstrate that the ShangRing circumcision technique is easy to learn and master. Newly trained providers can safely conduct ShangRing circumcisions in routine service settings. The ShangRing can facilitate rapid rollout of voluntary medical male circumcision for HIV prevention in sub-Saharan Africa.
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Williams BG, Gupta S, Wollmers M, Granich R. Progress and prospects for the control of HIV and tuberculosis in South Africa: a dynamical modelling study. LANCET PUBLIC HEALTH 2017; 2:e223-e230. [PMID: 29253488 DOI: 10.1016/s2468-2667(17)30066-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/21/2017] [Accepted: 02/23/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND In September, 2016, South Africa adopted a policy of providing antiretroviral treatment to everyone infected with HIV irrespective of their CD4 cell count. Studies of universal treatment and expanded prevention of HIV differ widely in their projections of effects and the associated costs, so we did this analysis to attempt to find a consensus. METHODS We used data on HIV from the Joint UN Programme on HIV and AIDS (UNAIDS) from 1988 to 2013 and from data from WHO on tuberculosis from 1980 to to 2013 to fit a dynamical model to time trends in HIV prevalence, antiretroviral therapy (ART) coverage, and tuberculosis notification rates in South Africa. We then used the model to estimate current trends and project future patterns in HIV prevalence and incidence, AIDS-related mortality, and tuberculosis notification rates, and we used data from the South African National AIDS Council to assess current and future costs under different combinations of treatment and prevention approaches. We considered two treatment strategies: the Constant Effort strategy, in which people infected with HIV continue to start treatment at the rate in 2016, and the Expanded Treatment and Prevention (ETP) strategy, in which testing rates are increased, treatment is started immediately after HIV is detected, and prevention programmes are expanded. FINDINGS Our estimates show that HIV incidence among adults aged 15 years or older fell from 2·3% per year in 1996 to 0·65% per year in 2016, AIDS-related mortality decreased from 1·4% per year in 2006 to 0·37% per year in 2016, and both continue to fall at a relative rate of 17% per year. Our model shows that maintenance of Constant Effort will have a substantial effect on HIV but will not end AIDS, whereas ETP could end AIDS by 2030, with incidence of HIV and AIDs-related mortality rates both at less than one event per 1000 adults per year. Under ETP the annual cost of health care and prevention will increase from US$2·3 billion in 2016 to $2·9 billion in 2018, then decrease to $1·7 billion in 2030 and $0·9 billion in 2050. Over the next 35 years, the expansion of treatment will avert an additional 3·8 million new infections, save 1·1 million lives, and save $3·2 billion compared with continuing Constant Effort up to 2050. Expansion of prevention, including provision of pre-exposure prophylaxis, condom distribution, and male circumcision, could avert a further 150 000 new infections, save 5000 lives, and cost an additional $5·7 billion compared with Constant Effort. INTERPRETATION Our results suggest that South Africa is on track to reduce HIV incidence and AIDS-related mortality substantially by 2030, saving both lives and money. Success will depend on high rates of HIV testing, ART delivery and adherence, good patient monitoring and support, and data to monitor progress. FUNDING None.
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Affiliation(s)
- Brian G Williams
- South African Centre for Epidemiological Modelling and Analysis, University of Stellenbosch, Stellenbosch, South Africa.
| | - Somya Gupta
- International Association of Providers of AIDS Care, Washington, DC, USA
| | | | - Reuben Granich
- International Association of Providers of AIDS Care, Washington, DC, USA
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Women's knowledge and perception of male circumcision before and after its roll-out in the South African township of Orange Farm from community-based cross-sectional surveys. PLoS One 2017; 12:e0173595. [PMID: 28339497 PMCID: PMC5365100 DOI: 10.1371/journal.pone.0173595] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 02/23/2017] [Indexed: 12/19/2022] Open
Abstract
The roll-out of medical male circumcision (MC) is progressing in Southern and Eastern Africa. Little is known about the effect of this roll-out on women. The objective of this study was to assess the knowledge and perceptions of women regarding MC in a setting before and after the roll-out. This study was conducted in the South African township of Orange Farm where MC prevalence among men increased from 17% to 53% in the period 2008–2010. Data from three community-based cross sectional surveys conducted in 2007, 2010 and 2012 among 1258, 1197 and 2583 adult women, respectively were studied. In 2012, among 2583 women, 73.7% reported a preference for circumcised partners, and 87.9% knew that circumcised men could become infected with HIV. A total of 95.8% preferred to have their male children circumcised. These three proportions increased significantly during the roll-out. In 2007, the corresponding values were 64.4%, 82.9% and 80.4%, respectively. Among 2581 women having had sexual intercourse with circumcised and uncircumcised men, a majority (55.8%, 1440/2581) agreed that it was easier for a circumcised man to use a condom, 20.5% (530/2581) disagreed; and 23.07 (611/2581) did not know. However, some women incorrectly stated that they were fully (32/2579; 1.2%; 95%CI: 0.9% to 1.7%) or partially (233/2579; 9.0%; 95%CI: 8.0% to 10.2%) protected when having unprotected sex with a circumcised HIV-positive partner. This study shows that the favorable perception of women and relatively correct knowledge regarding VMMC had increased during the roll-out of VMMC. When possible, women should participate in the promotion of VMMC although further effort should be made to improve their knowledge.
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What device would be best for early infant male circumcision in east and southern Africa? Provider experiences and opinions with three different devices in Kenya. PLoS One 2017; 12:e0171445. [PMID: 28196085 PMCID: PMC5308609 DOI: 10.1371/journal.pone.0171445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/20/2017] [Indexed: 11/30/2022] Open
Abstract
Voluntary medical male circumcision (VMMC) reduces risk of HIV acquisition in heterosexual men by approximately 60%. As some countries approach targets for proportions of adolescents and adults circumcised, some are considering early infant male circumcision (EIMC) as a means to achieve sustainability of VMMC for long term reduction of HIV incidence. Evaluations of specialized devices for EIMC are important to provide programs with information required to make informed decisions about how to design safe, effective EIMC programs. We provide assessments by 11 providers with experience in Kenya employing all three of the devices most likely to be considered by various EIMC programs in east and Southern Africa. There was no one device that was seen to be clearly superior to the others. Each had its own advantages and disadvantages. Provider preferences were situation-specific. Most preferred the Mogen Clamp if they themselves were performing the procedure. However, most were concerned that not everyone will have the skills necessary for optimal safety. If someone else were circumcising their son, most would opt for the AccuCirc because of the risk of severing the glans when using the Mogen. A minority preferred the PrePex, but only if the baby received local anesthesia, not EMLA cream (a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%), as presently prescribed by the manufacturer. In the context of a national EIMC program, all participants agreed that AccuCirc would be the device they would recommend due to protection of the glans from laceration and to the provision of a pre-assembled sterile kit that overcomes the need for additional supplies or autoclaving. All agreed that scaling up EIMC, integrating it with existing maternal child health services, will face significant challenges, not least of which is persuading already over-burdened providers to take on additional workload. These results will be useful to programmers considering introduction of EIMC services in sub-Saharan African settings.
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Gyan T, McAuley K, Strobel NA, Shannon C, Newton S, Tawiah-Agyemang C, Amenga-Etego S, Owusu-Agyei S, Kirkwood B, Edmond KM. Determinants of morbidity associated with infant male circumcision: community-level population-based study in rural Ghana. Trop Med Int Health 2017; 22:312-322. [PMID: 27990718 DOI: 10.1111/tmi.12829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Male circumcision services have expanded throughout Africa as part of a long-term HIV prevention strategy. We assessed the effect of type of service provider (formal and informal) and hygiene practices on circumcision-related morbidities in rural Ghana. METHODS Population-based, cross-sectional study conducted between May and December 2012 involving 2850 circumcised infant males aged under 12 weeks. Multivariable logistic regression models were adjusted for maternal age, maternal education, income, birthweight and site of circumcision. RESULTS A total of 2850 (90.7%) infant males were circumcised. Overall, the risk of experiencing a morbidity (defined as complications occurring during or after the circumcision procedure as reported by the primary caregiver) was 8.1% (230). Risk was not significantly increased if the circumcision was performed by informal providers (121, 7.2%) vs. formal health service providers (109, 9.8%) [adjusted odds ratio (aOR) 1.11, 95% CI 0.80-1.47, P = 0.456]. Poor hygiene practices were associated with significantly increased risk of morbidity: no handwashing [148 (11.7%)] (aOR 1.78, 95% CI 1.27-2.52, P = 0.001); not cleaning circumcision instruments [174 (10.6%)] (aOR 1.80, 95% CI 1.27-2.54, P = 0.001); and uncleaned penile area [190 (10.0%)] (aOR 1.84, 95% CI 1.25-2.70, P = 0.002). CONCLUSION The risk of morbidity after infant male circumcision in rural Ghana is high, chiefly due to poor hygiene practices. Governmental and non-governmental organisations need to improve training of circumcision providers in hygiene practices in sub-Saharan Africa.
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Affiliation(s)
- Thomas Gyan
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia.,Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Kimberley McAuley
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Natalie A Strobel
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | | | - Sam Newton
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Betty Kirkwood
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Karen M Edmond
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
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Baxter C, Abdool Karim S. Combination HIV prevention options for young women in Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017; 15:109-21. [PMID: 27399041 DOI: 10.2989/16085906.2016.1196224] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although the number of new HIV infections has declined by over 30% in the past decade, the number of people who acquire HIV each year remains unacceptably high. In 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that there were about 2 million new HIV infections. The virus continues to spread, particularly in key populations, such as men who have sex with men (MSM), transgender individuals, sex workers and people who inject drugs. In Africa, young women have the highest HIV incidence rates. Scaling up known efficacious HIV prevention strategies for these groups at high risk is therefore a high priority. HIV prevention has generally been targeted at HIV-negative individuals or in some instances, entire communities. Prevention efforts are, however, shifting from a narrow focus on HIV-uninfected persons to a continuum of prevention that includes both HIV-negative and HIV-positive individuals. Given that a single HIV prevention intervention is unlikely to be able to alter the epidemic trajectory as HIV epidemics in communities are complex and comprise a mosaic of different risk factors and different routes of transmission, there is need to provide combination prevention. Hence, a mix of behavioural, biomedical and structural HIV prevention options is likely to be needed to alter the course of the HIV epidemic. The combination of HIV prevention interventions needed will vary depending on cultural context, the population targeted and the stage of the epidemic. This paper reviews the available HIV prevention strategies for young women and discusses new HIV prevention approaches in development.
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Affiliation(s)
- Cheryl Baxter
- a Centre for the AIDS Programme of Research in South Africa (CAPRISA) , University of KwaZulu-Natal , South Africa
| | - Salim Abdool Karim
- a Centre for the AIDS Programme of Research in South Africa (CAPRISA) , University of KwaZulu-Natal , South Africa.,b Department of Epidemiology , Columbia University , New York , USA
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Fleming PJ, Barrington C, Pearce LD, Lerebours L, Donastorg Y, Brito MO. "I Feel Like More of a Man": A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention. JOURNAL OF SEX RESEARCH 2017; 54:42-54. [PMID: 26942550 PMCID: PMC5011023 DOI: 10.1080/00224499.2015.1137539] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Ethnographic studies from numerous societies have documented the central role of male circumcision in conferring masculinity and preparing boys for adult male sexuality. Despite this link between masculinity, sexuality, and circumcision, there has been little research on these dynamics among men who have been circumcised for HIV prevention. We employed a mixed methods approach with data collected from recently circumcised men in the Dominican Republic (DR) to explore this link. We analyzed survey data collected six to 12 months post-circumcision (N = 293) as well as in-depth interviews conducted with a subsample of those men (n = 30). We found that 42% of men felt more masculine post-circumcision. In multivariate analysis, feeling more masculine was associated with greater concern about being perceived as masculine (OR = 1.70, 95% CI: 1.25-2.32), feeling more potent erections post-circumcision (OR = 2.25, 95% CI: 1.26-4.03), and reporting increased ability to satisfy their partners post-circumcision (OR = 2.30, 95% CI: 1.11-4.77). In qualitative interviews, these factors were all related to masculine norms of sexually satisfying one's partner, and men's experiences of circumcision were shaped by social norms of masculinity. This study highlights that circumcision is not simply a biomedical intervention and that circumcision programs need to incorporate considerations of masculine norms and male sexuality into their programming.
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Affiliation(s)
- Paul J. Fleming
- Division of Global Public Health, University of California, San Diego, La Jolla, CA, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Lisa D. Pearce
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Sociology, University of North Carolina, Chapel Hill, NC, USA
| | | | - Yeycy Donastorg
- HIV Vaccine Trials Unit, Instituto Dermatológico y Cirugía de Piel, Santo Domingo, Dominican Republic
| | - Maximo O. Brito
- Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL
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Marshall E, Rain-Taljaard R, Tsepe M, Monkwe C, Taljaard D, Hlatswayo F, Xaba D, Molomo T, Lissouba P, Puren A, Auvert B. Obtaining a male circumcision prevalence rate of 80% among adults in a short time: An observational prospective intervention study in the Orange Farm township of South Africa. Medicine (Baltimore) 2017; 96:e5328. [PMID: 28121914 PMCID: PMC5287938 DOI: 10.1097/md.0000000000005328] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
World Health Organization recommends a target for the male circumcision prevalence rate of 80%. This rate will have a substantial impact on the human immunodeficiency virus-acquired immunodeficiency syndrome epidemic in Eastern and Southern Africa. The objective of the study was to assess whether an innovative intervention can lead to an increased voluntary male medical circumcision (VMMC) uptake among adults in a short time. This prospective observational study of a demand generation intervention was conducted in the township of Orange Farm (South Africa) in August to November 2015. In this community male circumcision prevalence rate among adults was stable between 2010 and 2015 at 55% and 57%, despite regular VMMC campaigns at community level and the presence of a VMMC clinic that offered free VMMC. The intervention took place in a random sample of 981 households where 522 men aged 18 to 49 years accepted to participate in the study. Among the 226 uncircumcised men, 212 accepted to be enrolled in the intervention study. A personal male circumcision adviser trained in interpersonal communication skills was assigned to each uncircumcised participant. The male circumcision advisers were trained to explain the risks and benefits of VMMC, and to discuss 24 possible reasons given by men for not being circumcised. Participants were then followed for 9 weeks. Each participant had a maximum of 3 motivational interviews at home. Participants who decided to be circumcised received financial compensation for their time equivalent to 2.5 days of work at the minimum South African salary rate. Among the 212 uncircumcised men enrolled in the intervention, 69.8% (148/212; 95% confidence interval [CI]; 63.4%-75.7%) agreed to be circumcised, which defines the uptake of the intervention. The male circumcision prevalence rate of the sample increased from 56.7% (296/522) to 81.4% (425/522; 77.9%-84.6%), P < 0.001, corresponding to a relative increase of 43.6% (95% CI: 35.4%-53.7%). The reported reasons for accepting circumcision were motivational interviews with the male circumcision adviser (83.1%), and time compensation (39.4%).Increased uptake of VMMC uptake can be obtained in a short time among adult males but requires an intense intervention centered on uncircumcised men at an individual level and time compensation.
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Affiliation(s)
- Esaie Marshall
- INSERM U1018, Centre for Research in Epidemiology and Population Health, Paris
- EA 4184, Faculty of Medicine, University of Burgundy, Dijon, France
| | | | | | | | | | | | | | | | | | - Adrian Puren
- National Institute for Communicable Diseases, National Health Laboratory Service
- Division of Virology, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Bertran Auvert
- INSERM U1018, Centre for Research in Epidemiology and Population Health, Paris
- Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Paris
- Faculty of Medicine, University of Versailles-Saint Quentin, Versailles, France
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Sousa JD, Temudo MP, Hewlett BS, Camacho RJ, Müller V, Vandamme AM. Male Circumcision and the Epidemic Emergence of HIV-2 in West Africa. PLoS One 2016; 11:e0166805. [PMID: 27926927 PMCID: PMC5142780 DOI: 10.1371/journal.pone.0166805] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/03/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Epidemic HIV-2 (groups A and B) emerged in humans circa 1930-40. Its closest ancestors are SIVsmm infecting sooty mangabeys from southwestern Côte d'Ivoire. The earliest large-scale serological surveys of HIV-2 in West Africa (1985-91) show a patchy spread. Côte d'Ivoire and Guinea-Bissau had the highest prevalence rates by then, and phylogeographical analysis suggests they were the earliest epicenters. Wars and parenteral transmission have been hypothesized to have promoted HIV-2 spread. Male circumcision (MC) is known to correlate negatively with HIV-1 prevalence in Africa, but studies examining this issue for HIV-2 are lacking. METHODS We reviewed published HIV-2 serosurveys for 30 cities of all West African countries and obtained credible estimates of real prevalence through Bayesian estimation. We estimated past MC rates of 218 West African ethnic groups, based on ethnographic literature and fieldwork. We collected demographic tables specifying the ethnic partition in cities. Uncertainty was incorporated by defining plausible ranges of parameters (e.g. timing of introduction, proportion circumcised). We generated 1,000 sets of past MC rates per city using Latin Hypercube Sampling with different parameter combinations, and explored the correlation between HIV-2 prevalence and estimated MC rate (both logit-transformed) in the 1,000 replicates. RESULTS AND CONCLUSIONS Our survey reveals that, in the early 20th century, MC was far less common and geographically more variable than nowadays. HIV-2 prevalence in 1985-91 and MC rates in 1950 were negatively correlated (Spearman rho = -0.546, IQR: -0.553--0.546, p≤0.0021). Guinea-Bissau and Côte d'Ivoire cities had markedly lower MC rates. In addition, MC was uncommon in rural southwestern Côte d'Ivoire in 1930.The differential HIV-2 spread in West Africa correlates with different historical MC rates. We suggest HIV-2 only formed early substantial foci in cities with substantial uncircumcised populations. Lack of MC in rural areas exposed to bushmeat may have had a role in successful HIV-2 emergence.
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Affiliation(s)
- João Dinis Sousa
- KU Leuven—University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, B-3000, Leuven, Belgium
- Center for Global Health and Tropical Medicine, Unidade de Microbiologia Médica, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Marina Padrão Temudo
- Department of Natural Resources, Environment, and Land, CEF, School of Agriculture, University of Lisbon, Lisbon, Portugal
| | - Barry Stephen Hewlett
- Department of Anthropology, Washington State University Vancouver, Vancouver, Washington, United States of America
| | - Ricardo Jorge Camacho
- KU Leuven—University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, B-3000, Leuven, Belgium
| | - Viktor Müller
- Institute of Biology, Eötvös Loránd University, Budapest, Hungary
- Parmenides Center for the Conceptual Foundations of Science, Pullach/Munich, Germany
| | - Anne-Mieke Vandamme
- KU Leuven—University of Leuven, Department of Microbiology and Immunology, Rega Institute for Medical Research, Clinical and Epidemiological Virology, B-3000, Leuven, Belgium
- Center for Global Health and Tropical Medicine, Unidade de Microbiologia Médica, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
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Young MR, Adera F, Mehta SD, Jaoko W, Adipo T, Badia J, Nordstrom SK, Irwin TE, Ongong’a D, Bailey RC. Factors Associated with Preference for Early Infant Male Circumcision Among a Representative Sample of Parents in Homa Bay County, Western Kenya. AIDS Behav 2016; 20:2545-2554. [PMID: 26781868 DOI: 10.1007/s10461-016-1288-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Several countries scaling-up adult medical male circumcision (MMC) for HIV prevention intend to introduce early infant male circumcision (EIMC). To assess preference for EIMC in a community with a mature adult MMC program, we conducted a cross-sectional survey of a representative sample of mothers (n = 613) and fathers (n = 430) of baby boys ("index son") at 16 health facilities in western Kenya. Most (59 %) were for EIMC, generally. Just 29 % were for circumcising the index son. Pain and protection from HIV were the most frequently cited barrier and facilitator to EIMC, respectively. In multivariable logistic regression, ever talking with the partner about EIMC and positive serostatus were associated with preference for EIMC for the index son. Attitudes towards EIMC are favorable. Willingness to circumcise an infant son is modest. To facilitate EIMC uptake, education about EIMC pain management and encouraging discussion between parents about EIMC during pregnancy should be integrated into programs.
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Tchuenche M, Palmer E, Haté V, Thambinayagam A, Loykissoonlal D, Njeuhmeli E, Forsythe S. The Cost of Voluntary Medical Male Circumcision in South Africa. PLoS One 2016; 11:e0160207. [PMID: 27783612 PMCID: PMC5082632 DOI: 10.1371/journal.pone.0160207] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 07/17/2016] [Indexed: 11/23/2022] Open
Abstract
Given compelling evidence associating voluntary medical male circumcision (VMMC) with men's reduced HIV acquisition through heterosexual intercourse, South Africa in 2010 began scaling up VMMC. To project the resources needed to complete 4.3 million circumcisions between 2010 and 2016, we (1) estimated the unit cost to provide VMMC; (2) assessed cost drivers and cost variances across eight provinces and VMMC service delivery modes; and (3) evaluated the costs associated with mobilize and motivate men and boys to access VMMC services. Cost data were systematically collected and analyzed using a provider's perspective from 33 Government and PEPFAR-supported (U.S. President's Emergency Plan for AIDS Relief) urban, rural, and peri-urban VMMC facilities. The cost per circumcision performed in 2014 was US$132 (R1,431): higher in public hospitals (US$158 [R1,710]) than in health centers and clinics (US$121 [R1,309]). There was no substantial difference between the cost at fixed circumcision sites and fixed sites that also offer outreach services. Direct labor costs could be reduced by 17% with task shifting from doctors to professional nurses; this could have saved as much as $15 million (R163.20 million) in 2015, when the goal was 1.6 million circumcisions. About $14.2 million (R154 million) was spent on medical male circumcision demand creation in South Africa in 2014-primarily on personnel, including community mobilizers (36%), and on small and mass media promotions (35%). Calculating the unit cost of VMMC demand creation was daunting, because data on the denominator (number of people reached with demand creation messages or number of people seeking VMMC as a result of demand creation) were not available. Because there are no "dose-response" data on demand creation ($X in demand creation will result in an additional Z% increase in VMMC clients), research is needed to determine the appropriate amount and allocation of demand creation resources.
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Affiliation(s)
- Michel Tchuenche
- Health Policy Project, Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Eurica Palmer
- Health Policy Project, Palladium Consultant, Johannesburg, South Africa
| | - Vibhuti Haté
- George Washington University, Washington, District of Columbia, United States of America
| | | | | | | | - Steven Forsythe
- Health Policy Project, Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
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Level of viral suppression and the cascade of HIV care in a South African semi-urban setting in 2012. AIDS 2016; 30:2107-16. [PMID: 27163707 DOI: 10.1097/qad.0000000000001155] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE In 2012, 7 years after the introduction of antiretroviral treatment (ART) in the South African township of Orange Farm, we measured the proportion of HIV-positive people who were virally suppressed, especially among high-risk groups (women 18-29 years and men 25-34 years). DESIGN A community-based cross-sectional representative survey was conducted among 3293 men and 3473 women. METHODS Study procedures included a face-to-face interview and collection of blood samples that were tested for HIV, 11 antiretroviral drugs and HIV-viral load. RESULTS HIV prevalence was 17.0% [95% confidence interval: 15.7-18.3%] among men and 30.1% [28.5-31.6%] among women. Overall, 59.1% [57.4-60.8%] of men and 79.5% [78.2-80.9%] of women had previously been tested for HIV. When controlling for age, circumcised men were more likely to have been tested compared with uncircumcised men (66.1 vs 53.6%; P < 0.001). Among HIV+, 21.0% [17.7-24.6%] of men and 30.5% [27.7-33.3%] of women tested positive for one or more antiretroviral drugs. Using basic calculations, we estimated that, between 2005 and 2012, ART programs prevented between 46 and 63% of AIDS-related deaths in the community. Among antiretroviral-positive, 91.9% [88.7-94.3%] had viral suppression (viral load <400 copies/ml). The proportion of viral suppression among HIV+ was 27.0% [24.3-29.9%] among women and 17.5% [14.4-20.9%] among men. These proportions were lower among the high-risk groups: 15.6% [12.1-19.7%] among women and 8.4% [5.0-13.1%] among men. CONCLUSION In Orange Farm, between 2005 and 2012, ART programs were suboptimal and, among those living with HIV, the proportion with viral suppression was still low, especially among the young age groups. However, our study showed that, in reality, antiretroviral drugs are highly effective in viral suppression at an individual level.
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Marshall E, Rain-Taljaard R, Tsepe M, Monkwe C, Hlatswayo F, Tshabalala S, Khela S, Xulu L, Xaba D, Molomo T, Malinga T, Puren A, Auvert B. Sequential Cross-Sectional Surveys in Orange Farm, a Township of South Africa, Revealed a Constant Low Voluntary Medical Male Circumcision Uptake among Adults despite Demand Creation Campaigns and High Acceptability. PLoS One 2016; 11:e0158675. [PMID: 27427957 PMCID: PMC4948820 DOI: 10.1371/journal.pone.0158675] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/20/2016] [Indexed: 11/19/2022] Open
Abstract
Background WHO recommends a male circumcision (MC) prevalence rate higher than 80% to have a substantial impact on the HIV-AIDS epidemic in Eastern and Southern Africa. Orange Farm, a township in South Africa, has a free-for-service voluntary medical male circumcision (VMMC) clinic in operation since 2008. Following an intense campaign from 2008 to 2010, MC prevalence rate increased to 55.4% (ANRS-12126). Ongoing and past VMMC campaigns focused on youths, through school talks, and adults at a community level. The main objective of the study was to assess the change in MC prevalence rate among adults aged 18–19 and 18–49 years in the past 5 years. Methods A cross-sectional survey (ANRS-12285) was conducted among a random sample of 522 adult men in 2015. MC status and characteristics of participants were collected through a genital examination and a face-to-face questionnaire. Results MC prevalence rate among young adult men aged 18–19 years increased markedly from 61.2% (95%CI: 57.4% to 65.0%) in 2010 to 87.5% (76.0% to 94.6%) in 2015 (p<0.001). In the same period, among men aged 18–49 years, MC prevalence rate varied slightly from 55.4% (53.6% to 57.1%) to 56.7% (52.4% to 60.9%). In 2015, 84.9% (79.2% to 89.5%) of uncircumcised adult men reported that they were willing to be circumcised. However, we estimated that only 4.6% (11/237; 2.5% to 7.9%) of the uncircumcised men underwent circumcision in 2015, despite 117/185 (63.2%; 95%CI: 56.1% to 69.9%) who reported that they were definitely willing to become circumcised. Conclusions In Orange Farm, VMMC campaigns were successful among the youth and led to a sufficiently high MC prevalence rate to have a substantial impact in the future on the HIV-AIDS epidemic. However, despite high acceptability and a free VMMC service, VMMC campaigns since 2010 have failed to increase MC prevalence rate among adults to above 80%. These campaigns should be revisited.
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Affiliation(s)
- Esaie Marshall
- Institut National de la Santé et de la Recherche Médicale, Unit 1018, Centre for Research in Epidemiology and Population Health, Villejuif, France
- Faculty of medicine, Research Unit 4184, Faculty of Medicine, University of Burgundy, Dijon, France
| | | | | | | | | | | | - Simphiwe Khela
- Progressus Research and Development, Johannesburg, South Africa
| | - Lindo Xulu
- Progressus Research and Development, Johannesburg, South Africa
| | - Dumazile Xaba
- Progressus Research and Development, Johannesburg, South Africa
| | - Tebogo Molomo
- Progressus Research and Development, Johannesburg, South Africa
| | - Thobile Malinga
- Progressus Research and Development, Johannesburg, South Africa
| | - Adrian Puren
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bertran Auvert
- Institut National de la Santé et de la Recherche Médicale, Unit 1018, Centre for Research in Epidemiology and Population Health, Villejuif, France
- Assistance Publique—Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France
- Faculty of Medicine, University of Versailles-Saint Quentin, Versailles, France
- * E-mail:
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Kong X, Kigozi G, Ssekasanvu J, Nalugoda F, Nakigozi G, Ndyanabo A, Lutalo T, Reynolds SJ, Ssekubugu R, Kagaayi J, Bugos E, Chang LW, Nanlesta P, Mary G, Berman A, Quinn TC, Serwadda D, Wawer MJ, Gray RH. Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai, Uganda. JAMA 2016; 316:182-90. [PMID: 27404186 PMCID: PMC5027874 DOI: 10.1001/jama.2016.7292] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Medical male circumcision (MMC) and antiretroviral therapy (ART) are proven HIV prevention interventions, but there are limited data on the population-level effect of scale-up of these interventions in sub-Saharan Africa. Such evaluation is important for planning and resource allocation. OBJECTIVE To examine whether increasing community MMC and ART coverage was associated with reduced community HIV incidence in Rakai District, Uganda. DESIGN, SETTING, AND PARTICIPANTS Using person-level data from population-based surveys conducted from 1999 through 2013 in 45 rural Rakai communities, community-level ART and MMC coverage, sociodemographics, sexual behaviors, and HIV prevalence and incidence were estimated in 3 periods: prior to the availability of ART and MMC (1999-2004), during early availability of ART and MMC (2004-2007), and during mature program scale-up (2007-2013). EXPOSURES Community MMC coverage in males and ART coverage in HIV-positive persons of the opposite sex based on self-reported MMC status and ART use. MAIN OUTCOMES AND MEASURES Adjusted incidence rate ratios (IRRs) for sex-specific community HIV incidence estimated using multivariable Poisson regression with generalized estimating equations. RESULTS From 1999 through 2013, 44,688 persons participated in 1 or more surveys (mean age at the first survey, 24.6 years [range, 15-49]; female, 56.5%; mean survey participation rate, 92.6% [95% CI, 92.4%-92.7%]). Median community MMC coverage increased from 19% to 39%, and median community ART coverage rose from 0% to 21% in males and from 0% to 26% in females. Median community HIV incidence declined from 1.25 to 0.84 per 100 person-years in males, and from 1.25 to 0.99 per 100 person-years in females. Among males, each 10% increase in community MMC coverage was associated with an adjusted IRR of 0.87 (95% CI, 0.82-0.93). Comparing communities with MMC coverage more than 40% (mean male community incidence, 1.03 per 100 person-years) with communities with coverage of 10% or less (mean male incidence, 1.69 per 100 person-years), the adjusted IRR was 0.61 (95% CI, 0.43-0.88). For each 10% increase in female self-reported ART coverage, there was no significant reduction in male HIV incidence (adjusted IRR, 0.95 [95% CI, 0.81-1.13]). Comparing communities with female ART coverage more than 20% (mean male incidence, 0.87 per 100 person-years) to communities with female ART coverage of 20% or less (mean male incidence, 1.17 per 100 person-years), the adjusted IRR was 0.77 (95% CI, 0.61-0.98). Neither MMC nor male ART coverage was associated with lower female community HIV incidence. CONCLUSIONS AND RELEVANCE In Rakai, Uganda, increasing community MMC and female ART coverage was associated with lower community HIV incidence in males. If similar associations are found elsewhere, this would support further scale-up of MMC and ART for HIV prevention in sub-Saharan Africa.
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Affiliation(s)
- Xiangrong Kong
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Department of Biostatistics, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | | | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Eva Bugos
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Larry W. Chang
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Grabowski Mary
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Amanda Berman
- Center for Communications Programs, Johns Hopkins University, Baltimore, MD
| | - Thomas C. Quinn
- Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- School of Public Health, Makerere University, Kampala, Uganda
| | - Maria J. Wawer
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Ronald H. Gray
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
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37
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Howard-Payne L, Bowman B. Citizenship in a time of HIV: Understanding medical adult male circumcision in South Africa. J Health Psychol 2016; 23:871-881. [PMID: 27297633 DOI: 10.1177/1359105316651709] [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] [Indexed: 11/15/2022] Open
Abstract
Medical adult male circumcision has been shown to offer men significant protection against HIV infection during peno-vaginal sex. This has resulted in calls for a national roll-out of medical adult male circumcision in South Africa, a rights-based constitutional democracy. This article explores the ways that the potential tensions between this call to circumcise as a practice of good health citizenship and the guaranteed right to bodily integrity are negotiated in interviews with 30 urban-based men in Johannesburg. The results suggest that despite its demonstrable biological efficacy, these tensions may paralyse decision- and policy-makers in grappling with the potential scaling up of medical adult male circumcision for HIV prevention in South Africa.
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Affiliation(s)
| | - Brett Bowman
- University of the Witwatersrand, Johannesburg, South Africa
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38
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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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Blaizot S, Maman D, Riche B, Mukui I, Kirubi B, Ecochard R, Etard JF. Potential impact of multiple interventions on HIV incidence in a hyperendemic region in Western Kenya: a modelling study. BMC Infect Dis 2016; 16:189. [PMID: 27129591 PMCID: PMC4851795 DOI: 10.1186/s12879-016-1520-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 04/18/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Multiple prevention interventions, including early antiretroviral therapy initiation, may reduce HIV incidence in hyperendemic settings. Our aim was to predict the short-term impact of various single and combined interventions on HIV spreading in the adult population of Ndhiwa subcounty (Nyanza Province, Kenya). METHODS A mathematical model was used with data on adults (15-59 years) from the Ndhiwa HIV Impact in Population Survey to compare the impacts on HIV prevalence, HIV incidence rate, and population viral load suppression of various interventions. These interventions included: improving the cascade of care (use of three guidelines), increasing voluntary medical male circumcision (VMMC), and implementing pre-exposure prophylaxis (PrEP) use among HIV-uninfected women. RESULTS After four years, improving separately the cascade of care under the WHO 2013 guidelines and under the treat-all strategy would reduce the overall HIV incidence rate by 46 and 58 %, respectively, vs. the baseline rate, and by 35 and 49 %, respectively, vs. the implementation of the current Kenyan guidelines. With conservative and optimistic scenarios, VMMC and PrEP would reduce the HIV incidence rate by 15-25 % and 22-28 % vs. the baseline, respectively. Combining the WHO 2013 guidelines with VMMC would reduce the HIV incidence rate by 35-56 % and combining the treat-all strategy with VMMC would reduce it by 49-65 %. Combining the WHO 2013 guidelines, VMMC, and PrEP would reduce the HIV incidence rate by 46-67 %. CONCLUSIONS The impacts of the WHO 2013 guidelines and the treat-all strategy were relatively close; their implementation is desirable to reduce HIV spread. Combining several strategies is promising in adult populations of hyperendemic areas but requires regular, reliable, and costly monitoring.
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Affiliation(s)
- Stéphanie Blaizot
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France. .,Université de Lyon, F-69000, Lyon, France. .,Université Lyon 1, F-69100, Villeurbanne, France. .,CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France.
| | | | - Benjamin Riche
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France.,Université de Lyon, F-69000, Lyon, France.,Université Lyon 1, F-69100, Villeurbanne, France.,CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
| | - Irene Mukui
- National AIDS and STDs Control Program, Nairobi, Kenya
| | | | - René Ecochard
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France.,Université de Lyon, F-69000, Lyon, France.,Université Lyon 1, F-69100, Villeurbanne, France.,CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
| | - Jean-François Etard
- Epicentre, F-75011, Paris, France.,UMI 233 TransVIHMI, Institut de Recherche pour le Développement, Université Montpellier 1, F-34000, Montpellier, France
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40
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Morris BJ, Barboza G, Wamai RG, Krieger JN. Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe. Glob Public Health 2016; 13:1889-1899. [PMID: 27043484 DOI: 10.1080/17441692.2016.1164737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A meta-analysis by Van Howe of 109 populations confirms the well-known association of male circumcision (MC) with reduced HIV prevalence. He then performed meta-regression adjusting for location, risk and MC prevalence. When one or two of these adjustments in combination were applied MC appeared protective, but when all three were introduced the association remained significant in high-risk populations, but not in general populations within Africa with a hypothetical MC prevalence of <25% or elsewhere with hypothetical MC prevalence of <75%. However, many MC prevalence values given differed from those reported in references cited (including all US studies). This and other problems invalidate his adjustments for MC prevalence, undermining most of his meta-regression results. Meta-regression is a highly sophisticated statistical tool and is prone to error if not applied correctly. The study contained a high risk of bias arising from confounding. We also question his use of crude, rather than adjusted, odds ratios and his inclusion of unpublished data, so precluding replication by others. Flawed statistics, opaque presentation of results and inclusion of previously repudiated arguments downplaying a role for MC in HIV prevention programmes should lead readers to be sceptical of the findings and conclusions of Van Howe's study.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute , University of Sydney , Sydney , Australia
| | - Gia Barboza
- b Department of African-American Studies , Northeastern University , Boston , MA , USA.,c School of Criminology and Criminal Justice , Northeastern University , Boston , MA , USA
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- d University of Washington School of Medicine and VA Puget Sound Health Care System, Section of Urology , Seattle , WA , USA
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41
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Kasprzyk D, Montaño DE, Hamilton DT, Down KL, Marrett KD, Tshimanga M, Xaba S, Mugurungi O. Psychosocial Results from a Phase I Trial of a Nonsurgical Circumcision Device for Adult Men in Zimbabwe. AIDS Patient Care STDS 2016; 30:25-33. [PMID: 26745142 DOI: 10.1089/apc.2015.0111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Male circumcision (MC), an effective HIV prevention tool, has been added to Zimbabwe's Ministry of Health and Child Care HIV/AIDS Prevention Program. A Phase I safety trial of a nonsurgical male circumcision device was conducted and extensive psychosocial variables were assessed. Fifty-three men (18 and older) were recruited for the device procedure; 13 follow-up clinical visits were completed. Interviews conducted three times (before the procedure, at 2 weeks and 90 days post-procedure) assessed: Satisfaction; expectations; actual experience; activities of daily living; sexual behavior; and HIV risk perception. Using the Integrated Behavioral Model, attitudes towards MC, sex, and condoms, and sources of social influence and support were also assessed. Men (mean age 32.5, range 18-50; mean years of education = 13.6; 55% employed) were satisfied with device circumcision results. Men understand that MC is only partially protective against HIV acquisition. Most (94.7%) agreed that they will continue to use condoms to protect themselves from HIV. Pain ratings were surprisingly negative for a procedure billed as painless. Men talked to many social networks members about their MC experience; post-procedure (mean of 14 individuals). Minimal impact on activities of daily living and absenteeism indicate possible cost savings of device circumcisions. Spontaneous erections occurred frequently post-procedure. The results had important implications for changes in the pre-procedure clinical counseling protocol. Clear-cut counseling to manage pain and erection expectations should result in improved psychosocial outcomes in future roll-out of device circumcisions. Men's expectations must be managed through evidence-based counseling, as they share their experiences broadly among their social networks.
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Affiliation(s)
- Danuta Kasprzyk
- Department of Family and Child Nursing, School of Nursing, Seattle, Washington
- Center for Studies in Demography and Ecology, University of Washington, Seattle, Washington
| | - Daniel E. Montaño
- Department of Family and Child Nursing, School of Nursing, Seattle, Washington
- Center for Studies in Demography and Ecology, University of Washington, Seattle, Washington
| | - Deven T. Hamilton
- Center for Studies in Demography and Ecology, University of Washington, Seattle, Washington
| | - Kayla L. Down
- Department of Health Services, University of Washington, Seattle, Washington
| | - Karl D. Marrett
- Department of Neurobiology, University of Washington, Seattle, Washington
| | - Mufuta Tshimanga
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- AIDS, TB, and STI Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Sinokuthemba Xaba
- AIDS, TB, and STI Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Owen Mugurungi
- AIDS, TB, and STI Unit, Ministry of Health and Child Care, Harare, Zimbabwe
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Odoyo-June E, Feldblum PJ, Fischer S, Bailey RC, Obiero W, Hart C, Veena V, Combes S, Cherutich P. Unexpected Complications Following Adult Medical Male Circumcision Using the PrePex Device. Urol Int 2015; 96:188-93. [PMID: 26684654 DOI: 10.1159/000442753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/24/2015] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In this study, we describe and depict unexpected sequelae of adult medical male circumcision (MMC) using the PrePex device. MATERIALS AND METHODS The PrePex system is an elastic compression device for adult MMC. The device is well studied, has been pre-qualified by the World Health Organization (WHO), and its use is being scaled-up in African countries targeted by WHO. We conducted a PrePex implementation study in routine service delivery among 427 men in the age range of 18-49 in western Kenya. We captured penile photographs to create a record of adverse events (AEs) and to monitor healing. Several unexpected AEs ensued, including some that have not been reported in other PrePex studies. We describe and depict those unexpected complications and resulting treatments to alert circumcision providers in the relevant areas. RESULTS We observed 5 device displacements (1.2%); 3 cases of early sloughing of foreskin tissue (0.7%) among men with long foreskins; 2 cases of a long foreskin obstructing urine flow, as it became dry and necrotic (0.5%); and 2 cases of insufficient foreskin removal caused by invagination for which surgical completion was necessary (0.5%). All of the participants healed completely by day 42 post-circumcision or shortly thereafter. CONCLUSION The potential for these complications should be incorporated into PrePex training programs. Integration of devices into MMC programs in medically underserved areas requires the availability of prompt surgical intervention for some sequelae, particularly displacement events.
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Morris BJ, Wamai RG, Krieger JN, Banerjee J, Klausner JD. Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby. Glob Public Health 2015; 12:1315-1333. [PMID: 26564989 DOI: 10.1080/17441692.2015.1104371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute, University of Sydney , Sydney , NSW , Australia
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- c Section of Urology, University of Washington School of Medicine and VA Puget Sound Health Care System , Seattle , WA , USA
| | - Joya Banerjee
- d Jhpiego, an affiliate of Johns Hopkins University , Washington , DC , USA
| | - Jeffrey D Klausner
- e Division of Infectious Diseases, Department of Medicine , David Geffen School of Medicine, University of California Los Angeles , CA , USA
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Schenker I, Westreich M. Voluntary medical male circumcision: A necessary surgical intervention in curbing HIV/AIDS. ACTA ACUST UNITED AC 2015. [DOI: 10.1308/rcsbull.2015.378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An Israeli surgeon and a Global Health Specialist working in Africa address some of the persistent myths surrounding this practice.
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Longer-Term Follow-Up of Kenyan Men Circumcised Using the ShangRing Device. PLoS One 2015; 10:e0137510. [PMID: 26367141 PMCID: PMC4569077 DOI: 10.1371/journal.pone.0137510] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/15/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To ascertain clinical sequelae, client satisfaction and sexual behavior 2+ years after male circumcision using the ShangRing device. METHODS We enrolled 199 men from the Kenya sites (Homa Bay district) participating in a 2012 study of the ShangRing device used in routine male circumcision services (N = 552). We enrolled men who had had the ShangRing placed successfully, and over-sampled men who had had an adverse event and/or were HIV-positive during the field study. In the present study, each participant was examined and interviewed by a study clinician, and penile photographs were taken to document longer-term cosmetic results and any abnormal findings. RESULTS 194 men were included in the analysis. The mean and median times between circumcision and the longer-term follow-up visit in this study were 31.8 and 32 months, respectively. Four men (2.1%) had signs/symptoms of a sexually transmitted infection (STI). Virtually all (99.5%) of the men were very satisfied with the appearance of their circumcised penis, and all would recommend a ShangRing circumcision to friends or family members. The most prevalent reported advantage of the circumcision was the ease of bathing and enhanced cleanliness of the penis (75.8%). 94.3% of the men did not cite a single negative feature of their circumcision. 87.5% of men reported more sexual pleasure post-MC, the most common reason being more prolonged intercourse. The majority of men (52.6%) reported one sexual partner post-MC, but more than a quarter of the men (28.1%) reported an increased number of partners post-MC. Less than half of the men (44.3%) reported using condoms half of the time or more, but the great majority of condom users stated that condom use was much easier post-MC, and 76.9% of users said they used condoms more after circumcision than before. CONCLUSIONS This study supports the safety and acceptability of ShangRing male circumcision during 2-3 years of follow-up. It should allay worries that the ShangRing procedure could lead to delayed complications later than the observation period of most clinical studies. TRIAL REGISTRATION ClinicalTrials.gov NCT01567436.
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Morris BJ, Klausner JD. In developed countries male circumcision prevalence is inversely related to HIV prevalence. Isr J Health Policy Res 2015; 4:40. [PMID: 26269739 PMCID: PMC4533798 DOI: 10.1186/s13584-015-0034-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 07/14/2015] [Indexed: 01/10/2023] Open
Abstract
A study by Chemtob and co-workers found significantly lower prevalence of HIV amongst heterosexual men and women in Israel compared with the Netherlands and France. Risk factors for heterosexual HIV infection in these countries were similar, apart from one, namely, a strikingly higher prevalence of male circumcision (MC) in Israel compared with the Netherlands and France. It is now well established that MC protects heterosexual men against becoming infected with HIV during sexual intercourse with an infected woman. In epidemic settings, such as countries in sub-Saharan Africa, in which heterosexual contact is the primary driver for HIV infection, MC is being implemented to reduce HIV prevalence. The results of the new study by Chemtob and co-workers support the evidence and recent polices in the United States advocating MC to reduce the spread of HIV. While prevalence in developed countries is generally low, it is rising. In the long term, neonatal MC is the most desirable option, since not only is it simpler, safer, cheaper and more convenient than MC later, it provides immediate protection from infections, penile inflammation, genital cancers and physical problems. It is also cost-effective. European countries have not supported MC for its public health benefits. The new findings add to calls for European and other countries with low MC prevalence to consider developing evidence-based policies favoring MC in order to reduce HIV and other infections and diseases and at the same time reduce suffering, mortality and the cost of treating these.
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Affiliation(s)
- Brian J. Morris
- />School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, New South Wales Australia
| | - 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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Howard-Payne L. Glaser or Strauss? Considerations for selecting a grounded theory study. SOUTH AFRICAN JOURNAL OF PSYCHOLOGY 2015. [DOI: 10.1177/0081246315593071] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Originally developed by Glaser and Strauss, grounded theory is a useful research method for researchers aiming to generate novel theory as it emerges from data gathered and analysed. However, this method is not utilised extensively, and when it is applied, it often leaves researchers confused as to its utility. This article addresses the origins of grounded theory while also informing readers of some of the difficulties regarding this research method. These difficulties arise as a result of the fundamental contentions presented by Glaser and Strauss in their theoretical and methodological divorce from each other and their original grounded theory approach. Illustrative examples of the issues related to the selection of a grounded theory method are presented in relation to a study that relied on the Straussian grounded theory approach to account for the meanings of HIV prophylactic Voluntary Medical Adult Male Circumcision in South Africa.
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Blaizot S, Riche B, Maman D, Mukui I, Kirubi B, Etard JF, Ecochard R. Estimation and Short-Term Prediction of the Course of the HIV Epidemic Using Demographic and Health Survey Methodology-Like Data. PLoS One 2015; 10:e0130387. [PMID: 26091253 PMCID: PMC4474856 DOI: 10.1371/journal.pone.0130387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 05/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Mathematical models have played important roles in the understanding of epidemics and in the study of the impacts of various behavioral or medical measures. However, modeling accurately the future spread of an epidemic requires context-specific parameters that are difficult to estimate because of lack of data. Our objective is to propose a methodology to estimate context-specific parameters using Demographic and Health Survey (DHS)-like data that can be used in mathematical modeling of short-term HIV spreading. METHODS AND FINDINGS The model splits the population according to sex, age, HIV status, and antiretroviral treatment status. To estimate context-specific parameters, we used individuals' histories included in DHS-like data and a statistical analysis that used decomposition of the Poisson likelihood. To predict the course of the HIV epidemic, sex- and age-specific differential equations were used. This approach was applied to recent data from Kenya. The approach allowed the estimation of several key epidemiological parameters. Women had a higher infection rate than men and the highest infection rate in the youngest age groups (15-24 and 25-34 years) whereas men had the highest infection rate in age group 25-34 years. The immunosuppression rates were similar between age groups. The treatment rate was the highest in age group 35-59 years in both sexes. The results showed that, within the 15-24 year age group, increasing male circumcision coverage and antiretroviral therapy coverage at CD4 ≤ 350/mm3 over the current 70% could have short-term impacts. CONCLUSIONS The study succeeded in estimating the model parameters using DHS-like data rather than literature data. The analysis provides a framework for using the same data for estimation and prediction, which can improve the validity of context-specific predictions and help designing HIV prevention campaigns.
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Affiliation(s)
- Stéphanie Blaizot
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France
- Université de Lyon, F-69000, Lyon, France
- Université Lyon 1, F-69100, Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
| | - Benjamin Riche
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France
- Université de Lyon, F-69000, Lyon, France
- Université Lyon 1, F-69100, Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
| | | | - Irene Mukui
- National AIDS and STDs Control Program, Nairobi, Kenya
| | | | - Jean-François Etard
- Epicentre, F-75011, Paris, France
- UMI 233 TransVIHMI, Institut de Recherche pour le Développement, INSERM U1175, Université Montpellier 1, F-34000, Montpellier, France
| | - René Ecochard
- Service de Biostatistique, Hospices Civils de Lyon, F-69003, Lyon, France
- Université de Lyon, F-69000, Lyon, France
- Université Lyon 1, F-69100, Villeurbanne, France
- CNRS UMR 5558, Equipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Evolutive, F-69100, Villeurbanne, France
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Bulled N, Green EC. Making voluntary medical male circumcision a viable HIV prevention strategy in high prevalence countries by engaging the traditional sector. CRITICAL PUBLIC HEALTH 2015; 26:258-268. [PMID: 27110065 DOI: 10.1080/09581596.2015.1055319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Voluntary medical male circumcision (VMMC) has been rapidly accepted by global HIV policy and donor institutions as a highly valuable HIV prevention strategy given its cost-effectiveness, limited interactions with a health facility, and projected long-lasting benefits. Many southern African countries have incorporated VMMC into their national HIV prevention strategies. However, intensive VMMC promotion programs have met with limited success to date and many HIV researchers have voiced concerns. This commentary discusses reasons behind the less-than-desired public demand and suggests how inclusion of the traditional sector - traditional leaders, healers, and circumcisers - with their local knowledge, cultural expertise and social capital, particularly in the realm of social meanings ascribed to male circumcision, may improve the uptake of this HIV prevention strategy. We offer Lesotho and Swaziland as case studies of the integration of universal VMMC policies; these are countries with a shared HIV burden, yet contrasting contemporary socio-cultural practices of male circumcision. The similar hesitant responses expressed by these two countries towards VMMC remind us that the incorporation of any new or revised and revitalized public health strategy must be considered within unique historical, political, economic, and socio-cultural contexts.
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Affiliation(s)
- Nicola Bulled
- The Center for Global Health, University of Virginia, Charlottesville, VA, USA
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Pharmacodynamic Activity of Dapivirine and Maraviroc Single Entity and Combination Topical Gels for HIV-1 Prevention. Pharm Res 2015; 32:3768-81. [PMID: 26078001 DOI: 10.1007/s11095-015-1738-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/08/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE Dapivirine (DPV), a non-nucleoside reverse transcriptase inhibitor, and maraviroc (MVC), a CCR5 antagonist, were formulated into aqueous gels designed to prevent mucosal HIV transmission. METHODS 0.05% DPV, 0.1% MVC, 0.05% DPV/0.1% MVC and placebo gels were evaluated for pH, viscosity, osmolality, and in vitro release. In vitro assays and mucosal tissues were used to evaluate anti-HIV activity. Viability (Lactobacilli only) and epithelial integrity in cell lines and mucosal tissues defined safety. RESULTS The gels were acidic and viscous. DPV gel had an osmolality of 893 mOsm/kg while the other gels had an osmolality of <100 mOsm/kg. MVC release was similar from the single and combination gels (~5 μg/cm(2)/min(1/2)), while DPV release was 10-fold less from the single as compared to the combination gel (0.4331 μg/cm(2)/min(1/2)). Titrations of the gels showed 10-fold more drug was needed to protect ectocervical than colonic tissue. The combination gel showed ~10- and 100-fold improved activity as compared to DPV and MVC gel, respectively. All gels were safe. CONCLUSIONS The DPV/MVC gel showed a benefit blocking HIV infection of mucosal tissue compared to the single entity gels. Combination products with drugs affecting unique steps in the viral replication cycle would be advantageous for HIV prevention.
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