1
|
Awuoche HC, Joseph RH, Magut F, Khagayi S, Odongo FS, Otieno M, Appolonia A, Odoyo-June E, Kwaro DO. Prevalence and risk factors of sexually transmitted infections in the setting of a generalized HIV epidemic-a population-based study, western Kenya. Int J STD AIDS 2024; 35:418-429. [PMID: 38240604 PMCID: PMC11047016 DOI: 10.1177/09564624241226487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/09/2023] [Accepted: 12/29/2023] [Indexed: 04/28/2024]
Abstract
BACKGROUND Sexually transmitted infections (STIs) cause adverse health outcomes, including increasing HIV acquisition/transmission risk. We analyzed data from an HIV biomarker and behavioral survey to estimate STI prevalence, and explore associated factors in the setting of a generalized HIV epidemic in Siaya County, western Kenya. METHODS Data were collected in March-September 2022 through face-to-face interviews using structured questionnaires; records from 9643 sexually active participants aged 13+ years were included in the analysis. We calculated weighted self-reported STI prevalence, by sex, age, and HIV status and explored associated factors using multivariable logistic regression. RESULTS Median age was 37 years and 59.9% were female; HIV prevalence was 18.0%. Overall STI prevalence was 1.8%; 1.5-fold higher among males vs. females, and 2.6-fold higher among participants living with HIV vs. those without. HIV status and multiple sexual partners were independently associated with STI in both sexes. Mind-altering substance use and being circumcised were associated with STI among males. CONCLUSIONS This study estimates STI prevalence in the setting of high HIV prevalence. Findings underscore the importance of: effective STI screening in HIV clinics and HIV testing and counseling in STI clinics; screening and counseling on substance use, and HIV pre-exposure prophylaxis; and intensive sexual health counseling in male circumcision programmes.
Collapse
Affiliation(s)
- Hellen Carolyne Awuoche
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Rachael H Joseph
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Faith Magut
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Sammy Khagayi
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Fredrick S Odongo
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Moses Otieno
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| | - Aoko Appolonia
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Elijah Odoyo-June
- United States Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Daniel O Kwaro
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kisumu, Kenya
| |
Collapse
|
2
|
Luseno WK, Rennie S, Gilbertson A. A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa. Int J Impot Res 2023; 35:269-278. [PMID: 34702986 PMCID: PMC8545773 DOI: 10.1038/s41443-021-00484-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022]
Abstract
Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.
Collapse
Affiliation(s)
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA
- UNC Center for Bioethics, University of North Carolina, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, NC, USA
| |
Collapse
|
3
|
Laher F, Otwombe K, Mokwena O, Bekker LG, Allen M. Use of Varied Screening Risk Criteria and HIV Incidence in Phase 1 and 2 HIV Vaccine Trials in South Africa. AIDS Behav 2023; 27:1314-1320. [PMID: 36287343 PMCID: PMC10038814 DOI: 10.1007/s10461-022-03867-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 11/01/2022]
Abstract
Many early phase HIV prevention studies define HIV risk-related eligibility criteria. We conducted a retrospective review of HIV Vaccine Trials Network (HVTN) Phase 1 and 2 HIV vaccine clinical trials completed in South Africa from 2003 to 2020, evaluating HIV incidence by protocol-defined risk criteria. Comparisons between groups controlled for age, gender and year of trial initiation. Across 12 trials, 1 did not specify risk criteria, and 11 specified various low risk criteria thematically categorized under sexual behaviors, clinical characteristics, and/or drug use behavior. Of the 11 trials, 6 used low sexual risk eligibility criteria standardized by the HVTN in 2009. Of the 1249 participants, median age 23.0 years, 66% were enrolled with the HVTN 2009 standardized low risk criteria, 15% using other sets of low risk criteria, and 19% using no risk criteria. Compared with the standardized low risk criteria group [2.3], HIV incidence per 100 person-years was significantly higher in the non-standardized low risk criteria group [5.0] and in the no risk criteria group [4.8]. In South Africa, cohorts with low HIV incidence can be identified primarily through sexual behavior and clinical characteristics.
Collapse
Affiliation(s)
- Fatima Laher
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Soweto, South Africa.
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Soweto, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ofentse Mokwena
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Soweto, South Africa
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Mary Allen
- Vaccine Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
4
|
Agot K, Onyango J, Ochillo M, Odoyo-June E. VMMC Programmatic Successes and Challenges: Western Kenya Case Study. Curr HIV/AIDS Rep 2022; 19:491-500. [PMID: 36445648 DOI: 10.1007/s11904-022-00644-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW The Nyanza region of western Kenya is lauded for impressive coverage of voluntary medical male circumcision (VMMC) and remains the bedrock of the VMMC program in Kenya. We conducted literature review on programmatic successes and challenges of implementing VMMC program in the region. RECENT FINDINGS Responsive stakeholders' engagement, robust policy environment, effective technical working groups, prompt capacity building of health facilities, government support, flexible implementation strategies, and sustained donor funding contributed to the successes of the program that saw circumcision prevalence in Nyanza reach between 75.6 and 85.3% among 15-29-year-olds by 2019. However, the lack of support for early infant circumcision, inadequate domestic financing, and slow pace of service integration into government health facilities continue to undermine the progress towards sustainability. While local ownership of the VMMC program has been demonstrated through its inclusion in county annual health workplans and progressive integration into routine health care, continued dependence on declining external funding threatens its sustainability. Furthermore, Kenya is experiencing a youth bulge with a projected high demand for VMMC which calls for increased resource inputs into the program. Strategies are therefore needed to increase domestic resource inflows into VMMC.
Collapse
Affiliation(s)
- Kawango Agot
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya.
| | - Jacob Onyango
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya
| | - Marylyn Ochillo
- Impact Research and Development Organization, Mito Jura Road, Tom Mboya Estate, P.O BOX, Kisumu, 9171-40141, Kenya
| | - Elijah Odoyo-June
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global, HIV & TB, Kisumu, Kenya
| |
Collapse
|
5
|
Magadi M, Gazimbi M, Wafula C, Kaseje M. Understanding ethnic variations in HIV prevalence in Kenya: the role of cultural practices. CULTURE, HEALTH & SEXUALITY 2021; 23:822-839. [PMID: 32364024 DOI: 10.1080/13691058.2020.1734661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/21/2020] [Indexed: 06/11/2023]
Abstract
Patterns of HIV prevalence in Kenya suggest that areas where various cultural practices are prevalent bear a disproportionate burden of HIV. This paper examines (i) the contextual effects of cultural practices (polygyny, male circumcision) and related sexual behaviour factors on HIV prevalence and (ii) the extent to which specific cultural practices in a community/county might explain existing ethnic variations in HIV prevalence in Kenya. The analysis applies multilevel logistic regression to data from the 2012/13 Kenya AIDS Indicator Survey. The results reveal striking ethnic variations in HIV prevalence in Kenya. The prevalence of polygyny in a community is positively associated with HIV prevalence, while a higher level of male circumcision in a county is protective for both men and women. The effects of these factors are stronger for men than women at both individual and contextual (community/county) levels. These cultural practices and associated risk factors partly explain existing ethnic differences in HIV prevalence in Kenya, but there remain significant ethnic variations that are not explained by these cultural practices or related sexual behaviour factors. These call for stronger empirical evidence to offer stronger theoretical explanations and inform effective policy and practice to address HIV epidemic in adversely affected communities in Kenya and similar settings in sub-Saharan Africa.
Collapse
Affiliation(s)
- Monica Magadi
- School of Education and Social Sciences, University of Hull, Hull, UK
| | - Martin Gazimbi
- School of Education and Social Sciences, University of Hull, Hull, UK
| | - Charles Wafula
- Research Department, Tropical Institute of Community Health and Development (TICH), Kisumu, Kenya
| | - Margaret Kaseje
- Research Department, Tropical Institute of Community Health and Development (TICH), Kisumu, Kenya
| |
Collapse
|
6
|
Kusemererwa S, Abaasa A, Kabarambi A, Onyango M, Mugisha JO. Assessment of risk compensation following use of the dapivirine vaginal ring in southwestern Uganda. Sex Transm Infect 2021; 98:32-37. [PMID: 33542153 PMCID: PMC8785055 DOI: 10.1136/sextrans-2020-054718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/06/2022] Open
Abstract
Objectives Participation in HIV prevention trials could trigger risk compensation among participants. We evaluated potential risk compensation following use of a vaginal ring microbicide by women in a phase III trial in southwestern Uganda. Methods We used markers of sexual risk behaviour documented on standardised questionnaires, tested for STIs at baseline and quarterly for 2 years. Risk compensation was defined as a significant increase (trend p<0.05) in the proportion of women reporting risky sexual behaviour or a diagnosed STI between baseline and end of follow-up. Results Between September 2013 and December 2016, 197 women (active arm: n=132 and placebo: n=65) were enrolled at the Masaka site. There were decreases in all markers of sexual risk behaviour with statistically significant decreases in only the proportion of women reporting ≥2 sexual partners, p=0.026 and those diagnosed with Trichomonas vaginalis p<0.001 and or Neisseria gonorrhoeae p<0.001 Conclusions No evidence of risk compensation was observed in this trial. Trial registration number NCT01539226.
Collapse
Affiliation(s)
- Sylvia Kusemererwa
- Department of HIV Interventions, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Andrew Abaasa
- Department of Statistics, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Anita Kabarambi
- Department of HIV Interventions, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Martin Onyango
- Department of HIV Interventions, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Joseph Okello Mugisha
- Department of HIV Interventions, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Keetile M. An assessment of sexual risk behaviours among circumcised and uncircumcised men before and after the implementation of the safe male circumcision programme in Botswana. AIDS Care 2020; 32:1594-1601. [PMID: 32449384 DOI: 10.1080/09540121.2020.1769830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HIV/AIDS prevalence is still high in Botswana. The main aim of this study was to assess and compare sexual risk behaviours of circumcised and uncircumcised men before and after the launch of the safe male circumcision programme. Data used for analyses were derived from the 2008 and 2013 Botswana AIDS Impact Surveys. Modified Poisson regression analysis was used to obtain prevalence ratios (PR) as measures of association between circumcision status and multiple sexual partners, transactional sex, inconsistent condom use and intergenerational sex. The proportion of circumcised men increased two times between 2008 (12.5%) and 2013 (25.2%). Prevalence of multiple sexual partnerships was high among uncircumcised than circumcised (54.6% vs. 46.4%) men in 2008, but in 2013 after the introduction of the SMC programme it was slightly high among circumcised men than uncircumcised men (23.2 vs. 21.8%). In the adjusted analyses, being circumcised was significantly associated with having multiple sexual partners (2008=adjusted PR=1.31, CI=1.10-1.57; 2013= adjusted PR=1.12, CI=1.01-1.41) and transactional sex (2008=adjusted PR=1.98, CI=1.26-3.11; 2013=adjusted PR=1.60, CI=1.09-1.22) for both survey periods. These results indicate the need to continuously sensitise and encourage men to stop multiple sexual partnerships and transactional sex. Moreover, there is need to encourage all men to use condoms consistently.
Collapse
Affiliation(s)
- Mpho Keetile
- Department of Population Studies, University of Botswana, Gaborone, Botswana
| |
Collapse
|
9
|
Mukudu H, Dietrich J, Otwombe K, Manentsa M, Hlongwane K, Haas-Kogan M, Sartorius B, Martinson N. Voluntary medical male circumcision (VMMC) for prevention of heterosexual transmission of HIV and risk compensation in adult males in Soweto: Findings from a programmatic setting. PLoS One 2019; 14:e0213571. [PMID: 30845185 PMCID: PMC6405100 DOI: 10.1371/journal.pone.0213571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/25/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical trials have clearly shown a reduction in HIV acquisition through voluntary medical male circumcision (VMMC). However, data assessing risk compensation under programmatic conditions is limited. METHODS This was a prospective cohort of HIV seronegative males aged 18-40 years receiving VMMC between November 2012 and July 2014. HIV serostatus was determined pre and post VMMC. Risk compensation was defined as a decrease in condom use at last sex act and/or an increase in concurrent sexual relationships, both measured twelve months post-circumcision. RESULTS A total of 233 males were enrolled and underwent voluntary medical male circumcision (VMMC) for prevention against HIV. There was no evidence of risk compensation post-circumcision as defined in this study. Significant increases in proportion of participants in the 18-24 years age group who knew the HIV status of their sexual partner (39% to 56%, p = 0.0019), self-reported condom use at last sex act (21% to 34%, p = 0.0106) and those reporting vaginal sexual intercourse in the past 12 months (67% to 79%, p-value = <0.0001) were found. In both 18-24 and 25-40 years age groups, there was a significant increase in perception of being at risk of contracting HIV (70% to 84%, p-value = <0.0001). CONCLUSION No significant risk compensation was observed in this study on comparing pre-and post-circumcision behaviour. An increase in proportion of participants in the 18-24 years age group who had vaginal intercourse in the first 12 months post-circumcision as a possibility of risk compensation was minimal and negated by an increase in proportion of those reporting using a condom at the last sex act, increase in knowledge of partner's HIV status and lack of increase in alcohol post-circumcision.
Collapse
Affiliation(s)
- Hillary Mukudu
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mmatsie Manentsa
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Khuthadzo Hlongwane
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maetal Haas-Kogan
- Harvard Global Health Institute and Harvard University Center for AIDS Research, Harvard University, Cambridge, United States of America
| | - Benn Sartorius
- Department of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
10
|
Ortblad KF, Harling G, Chimbindi N, Tanser F, Salomon JA, Bärnighausen T. Does Incident Circumcision Lead to Risk Compensation? Evidence From a Population Cohort in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr 2019; 80:269-275. [PMID: 30531298 PMCID: PMC6375765 DOI: 10.1097/qai.0000000000001912] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Voluntary medical male circumcision reduces men's risk of HIV acquisition and may thus increase HIV risk-related sexual behaviors through risk compensation. We analyze longitudinal data from one of Africa's largest population cohorts using fixed-effects panel estimation to measure the effect of incident circumcision on sexual behaviors. SETTING KwaZulu-Natal, South Africa. METHODS An open population cohort of men was followed from 2009 to 2015. Men self-reported their circumcision status and sexual behavior annually. We used linear regression models with individual-level fixed effects to measure the effect of incident circumcision on recent sex (past 12 months) and sexual behaviors that increase HIV risk (not using a condom at last sex, never using condoms with the most recent sexual partner, concurrent sexual partners at present, and multiple sexual partners in the past 12 months). We controlled for potential time-varying confounders: calendar year, age, education, and sexual debut. RESULTS The 5127 men in the cohort had a median age of 18 years (interquartile range 16-24) at cohort entry. Over the study period, almost 1 in 5 of these men (19.4%) became newly circumcised. Incident circumcision affected neither recent sex [percentage point (PP) change 0.0, 95% confidence interval: -1.2 to 1.3] nor sexual behaviors that increase HIV risk (PP -1.6, 95% confidence interval: -4.5 to 1.4). CONCLUSIONS The data from this study strongly reject the hypothesis that circumcision affects sexual risk-taking. Risk compensation should not serve as an argument against increased and accelerated scale-up of circumcision in this and similar communities in South Africa.
Collapse
Affiliation(s)
| | - Guy Harling
- Institute for Global Health, University College London, London, UK
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Natsayi Chimbindi
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Joshua A. Salomon
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
- Insititue of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany
| |
Collapse
|
11
|
Risk Compensation Following Medical Male Circumcision: Results from a 1-Year Prospective Cohort Study of Young School-Going Men in KwaZulu-Natal, South Africa. Int J Behav Med 2018; 25:123-130. [PMID: 28688094 DOI: 10.1007/s12529-017-9673-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE This study sought to assess risk compensation following voluntary medical male circumcision of young school-going men. Risk compensation is defined as an inadvertent increase in sexual risk behaviors and a corresponding decrease in self-perceived risk for contracting HIV following the application of a risk reduction technology. METHODS This study documented the sexual practices of circumcised (n = 485) and uncircumcised (n = 496) young men in 42 secondary schools at three time points (baseline and 6 and 12 months) in a sub-district of KwaZulu-Natal, South Africa. Study participants were aged from 16 to 24 years old. RESULTS At the end of the study period, there was no significant difference between the two cohorts concerning learners' perceptions of being at risk of contracting HIV (interaction effect: b = -0.12, p = 0.40). There was also no significant difference in the number of sexual partners in the previous month (interaction effect: b = -0.23, p = 0.15). The proportion of learners who have never used a condom decreased significantly over time (time effect: b = -0.27, p = 0.01), and there was no difference between the circumcised and uncircumcised learners (interaction effect: b = -0.09, p = 0.91). CONCLUSIONS Risk compensation, as evidenced in this study over a 1-year period, was not associated with undergoing voluntary medical male circumcision (VMMC) in our sample of young school-going men. However, it is of concern that at the end of this study, less than half of the sexually active sample in a high-HIV-prevalence community used condoms consistently in the previous month (39% for both study cohorts). The latter underscores the need to view VMMC as a potential entry point for planned HIV and sexuality education interventions targeting young men in this community.
Collapse
|
12
|
Rosenberg MS, Gómez-Olivé FX, Rohr JK, Kahn K, Bärnighausen TW. Are circumcised men safer sex partners? Findings from the HAALSI cohort in rural South Africa. PLoS One 2018; 13:e0201445. [PMID: 30067842 PMCID: PMC6070310 DOI: 10.1371/journal.pone.0201445] [Citation(s) in RCA: 8] [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: 07/07/2017] [Accepted: 07/16/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The real-world association between male circumcision and HIV status has important implications for policy and intervention practice. For instance, women may assume that circumcised men are safer sex partners than non-circumcised men and adjust sexual partnering and behavior according to these beliefs. Voluntary medical male circumcision (VMMC) is highly efficacious in preventing HIV acquisition in men and this biological efficacy should lead to a negative association between circumcision and HIV. However, behavioral factors such as differential selection into circumcision based on current HIV status or factors associated with future HIV status could reverse the association. Here, we examine how HIV prevalence differs by circumcision status in older adult men in a rural South African community, a non-experimental setting in a time of expanding VMMC access. METHODS We analyzed data collected from a population-based sample of 2345 men aged 40 years and older in a rural community served by the Agincourt Health and socio-Demographic Surveillance System site in Mpumalanga province, South Africa. We describe circumcision prevalence and estimate the association between circumcision and laboratory-confirmed HIV status with log-binomial regression models. RESULTS One quarter of older men reported circumcision, with slightly more initiation-based circumcisions (56%) than hospital-based circumcisions (44%). Overall, the evidence did not suggest differences in HIV prevalence between circumcised and uncircumcised men; however, those who reported hospital-based circumcision were more likely to test HIV-positive [PR (95% CI): 1.28 (1.03, 1.59)] while those who reported initiation-based circumcision were less likely to test HIV-positive [PR (95% CI): 0.68 (0.51, 0.90)]. Effects were attenuated, but not reversed after adjustment for key covariates. CONCLUSIONS Medically circumcised older men in a rural South African community had higher HIV prevalence than uncircumcised men, suggesting that the effect of selection into circumcision may be stronger than the biological efficacy of circumcision in preventing HIV acquisition. The impression given from circumcision policy and dissemination of prior trial findings that those who are circumcised are safer sex partners may be incorrect in this age group and needs to be countered by interventions, such as educational campaigns.
Collapse
Affiliation(s)
- Molly S. Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, Indiana, United States of America
| | - Francesc X. Gómez-Olivé
- Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Julia K. Rohr
- Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Till W. Bärnighausen
- Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
- Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
13
|
Nelson Kankaka E, Ssekasanvu J, Prodger J, Nabukalu D, Nakawooya H, Ndyanabo A, Kigozi G, Gray R. Sexual risk behaviors following circumcision among HIV-positive men in Rakai, Uganda. AIDS Care 2018; 30:990-996. [PMID: 29433386 PMCID: PMC6284241 DOI: 10.1080/09540121.2018.1437253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine whether circumcision of HIV-positive men is associated with increased subsequent sexual risk behaviors which may place their female partners at risk. METHODS Newly circumcised and uncircumcised HIV-positive men in the Rakai Community Cohort Study were followed from baseline (July 2013-January 2015) to determine trend in sexual risk behaviors and association of circumcision with subsequent sexual risk behaviors at follow up (February 2015-September 2016). Risk behaviors included sexual activity, alcohol before sex, transactional sex, multiple sex partners, casual sex partners, and inconsistent condom use with casual partners. The association was evaluated using modified Poisson regression, and sensitivity analyses were performed after multiple imputation with chained equations for missing data. RESULTS We identified 538 eligible men, of whom 113(21.0%) were circumcised at baseline and 425(79.0%) were uncircumcised. Men in fishing communities were more likely to be circumcised (p = 0.032) as well as those exposed to targeted HIV messaging (p < 0.001). Overall, 188(34.9%) men were lost to follow up and most were uncircumcised (p = 0.020). Among those followed up, behaviors remained largely unchanged with no differences by circumcision status. Transactional sex appeared to be associated with circumcision in unadjusted analyses (PR = 1.58, 95%CI = 1.01,2.48; p = 0.045, p = 0.05) and adjusted analyses (adj.PR = 1.54, 95%CI = 1.06,2.23; p = 0.022). However, the association was no longer significant in sensitivity analyses after accounting for loss to follow up (adj.PR = 1.43, 95%CI = 0.98,2.08; p = 0.066). No association with circumcision was observed for other sexual risk behaviors. CONCLUSION We found no association between circumcision of HIV-positive men and subsequent sexual risk behavior.
Collapse
Affiliation(s)
- Edward Nelson Kankaka
- Rakai Health Sciences Program, Rakai, Uganda
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
| | - Joseph Ssekasanvu
- Rakai Health Sciences Program, Rakai, Uganda
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jessica Prodger
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | - Ronald Gray
- Rakai Health Sciences Program, Rakai, Uganda
- Department of Epidemiology, Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
14
|
Dave S, Afshar K, Braga LH, Anderson P. Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version). Can Urol Assoc J 2018; 12:E76-E99. [PMID: 29381458 PMCID: PMC5937400 DOI: 10.5489/cuaj.5033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sumit Dave
- Department of Surgery (Urology), Western University, London, ON; Canada
| | - Kourosh Afshar
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC; Canada
| | - Luis H. Braga
- Department of Surgery (Urology), McMaster University, Hamilton, ON; Canada
| | - Peter Anderson
- Department of Urology, Dalhousie University, Halifax, NS; Canada
| |
Collapse
|
15
|
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
| |
Collapse
|
16
|
Kalichman S, Mathews C, Kalichman M, Eaton LA, Nkoko K. Male circumcision for HIV prevention: Awareness, risk compensation, and risk perceptions among South African women. Glob Public Health 2018; 13:1682-1690. [PMID: 29368579 DOI: 10.1080/17441692.2018.1427277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Medical male circumcision (MMC) is a proven method of HIV risk reduction for men in southern Africa. MMC promotion campaigns and scale-up programmes are widely implemented throughout the Republic of South Africa. However, the impact of promoting MMC on women's awareness, beliefs, and behaviours has been understudied. We conducted a self-administered anonymous survey of 279 women receiving health services in an impoverished township located in Cape Town, South Africa. Results showed that two in three women were unaware that male circumcision partially protects men from contracting HIV. Women who were aware of MMC for HIV prevention also endorsed beliefs that male circumcision reduces the need for men to worry about HIV and reduces the need for men to use condoms. Male circumcision awareness was also related to reduced perceptions of HIV risk among women. Multivariable models showed that women's MMC awareness, circumcision risk compensation beliefs, and risk perceptions were associated with decreased condom use and higher HIV risk index scores defined as number of condomless vaginal intercourse X number of sex partners. These results suggest a need for MMC education efforts tailored for women living in communities with high-HIV prevalence where men are targeted for MMC.
Collapse
Affiliation(s)
- Seth Kalichman
- a Institute for Collaboration on Health, Intervention, and Policy , University of Connecticut , Storrs , CT , USA
| | - Catherine Mathews
- b Health Systems Research Unit , South African Medical Research Council , Cape Town , South Africa
| | - Moira Kalichman
- a Institute for Collaboration on Health, Intervention, and Policy , University of Connecticut , Storrs , CT , USA
| | - Lisa A Eaton
- a Institute for Collaboration on Health, Intervention, and Policy , University of Connecticut , Storrs , CT , USA
| | - Koena Nkoko
- c City Health Directorate , Cape Town , South Africa
| |
Collapse
|
17
|
Kabwama SN, Ssewanyana D, Berg-Beckhoff G. The Association Between Male Circumcision and Condom Use Behavior - a Meta-Analysis. Mater Sociomed 2018; 30:62-66. [PMID: 29670480 PMCID: PMC5857052 DOI: 10.5455/msm.2018.30.62-66] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction The protective benefit of male circumcision against spreading HIV is well established. Aim The objective of this Meta-analysis was to investigate behavioral risk compensation measured as the change in condom use behavior in light of knowledge of the benefits of circumcision. Material and Methods A systematic search was conducted from 6 bibliographic databases for studies that quantitatively assessed a link between male circumcision and condom use behavior. Pooled odd ratios (OR) of condom use during any sexual activity were generated from three cohort studies and two Randomized Control Trails (RCT) that were included in the review. Results The pooled effects from cohort and RCTs were not statistically significant at 6 months follow-up (OR=0.91, 95% CI: 0.57-1.45), at 12 months (OR=1.08, 95% CI=0.87-1.34) and 24 or more months (OR=1.11, 95% CI: 0.85, 1.45). Conclusion Male circumcision does not influence condom use behavior in the medium and short term.
Collapse
|
18
|
Evaluation of Sexual Risk Behavior Among Study Participants in the TDF2 PrEP Study Among Heterosexual Adults in Botswana. J Acquir Immune Defic Syndr 2017; 73:556-563. [PMID: 27509251 DOI: 10.1097/qai.0000000000001143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Among participants of a clinical trial to test the efficacy of tenofovir/emtricitabine in protecting heterosexual men and women living in Botswana from HIV infection, the aim was to determine (1) if sexual risk behavior, specifically condomless sex acts and number of sex partners, changed over time, (2) factors associated with condomless sex acts and number of sex partners, and (3) the effect of participant treatment arm perception on risk behavior to address the possibility of risk compensation. METHODS A longitudinal modeling of rates of risk behaviors was used to determine if the rate of condomless sex acts (#acts/person) and rate of sex partners (#partners/person) changed over time and which factors were associated with behavior change. RESULTS One thousand two hundred participants were analyzed over 1 year. There was a 25% decrease in the rate of sex partners among participants sexually active in the last 30 days. The rate of reported condomless sex acts was greater for males [rate ratio (RR) = 1.34; confidence interval (CI): 1.07 to 1.67] and participants whose sexual debut in years was ≤15 years of age (RR = 1.65; CI: 1.14 to 2.38) and 16-17 (RR = 1.68; CI: 1.22 to 2.31) compared with those ≥20 years. Rate of reported sex partners was greater for males (RR = 3.67; CI: 2.86 to 4.71) and participants whose age at sexual debut in years was ≤15 (RR = 2.92; CI: 2.01 to 4.22) and 16-17 (RR = 2.34; CI: 1.69 to 3.24) compared with those ≥20. There was no effect of participant treatment arm perception on risk behavior. CONCLUSIONS Our study of preexposure prophylaxis to prevent HIV infection found no evidence of risk compensation which may have been due to participants' motivations to reduce their risk behaviors and risk-reduction counseling.
Collapse
|
19
|
Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population, 2008-2013. J Acquir Immune Defic Syndr 2017; 74:e30-e37. [PMID: 27632232 DOI: 10.1097/qai.0000000000001180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors. METHODS Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference. RESULTS The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception. CONCLUSIONS The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.
Collapse
|
20
|
Maffioli EM. Is traditional male circumcision effective as an HIV prevention strategy? Evidence from Lesotho. PLoS One 2017; 12:e0177076. [PMID: 28498835 PMCID: PMC5428932 DOI: 10.1371/journal.pone.0177076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 04/22/2017] [Indexed: 11/29/2022] Open
Abstract
In many developing countries, male circumcision has been promoted as an effective HIV prevention strategy, and medical randomized controlled trials have indeed shown a causal link. However, there is limited empirical evidence to support this conclusion in countries where individuals can voluntary opt for different types of circumcision. The present study considers male circumcision in Lesotho, where HIV prevalence is among the highest in the world (23%). Here, men can opt for one of two types of circumcision: traditional male circumcision in initiation schools, or the medical option in health clinics. This paper investigates whether the former has medical effects on individual HIV status that are as beneficial as those shown for the latter. Controlling for the potential individual behavioral response after the operation, it was found that circumcision performed in initiation schools wholly offset the medical benefits of the surgical procedure. This supports anecdotal evidence that the operation performed by traditional circumcisers does not have the same protective effect against HIV transmission as the medical operation. No evidence of “disinhibition” behavior among circumcised men was found, nor differential risky sexual behavior among men circumcised, traditionally or medically. Considering that, in Lesotho, traditional male circumcision is undertaken by more than 90% of circumcised men, the findings highlight the need for further research into how the operation in initiation schools is performed and its medical benefits.
Collapse
Affiliation(s)
- Elisa M. Maffioli
- Department of Economics, Duke University Durham, NC, United States of America
- Duke Global Health Institute, Duke University Durham, NC, United States of America
- * E-mail:
| |
Collapse
|
21
|
Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized Sub-Saharan countries. PLoS One 2017; 12:e0175928. [PMID: 28441458 PMCID: PMC5404849 DOI: 10.1371/journal.pone.0175928] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/03/2017] [Indexed: 11/19/2022] Open
Abstract
Background WHO and UNAIDS prioritized 14 eastern and southern African countries with high HIV and low male circumcision prevalence for a voluntary medical male circumcision (VMMC) scale-up in 2007. Because circumcision provides only partial protection against HIV infection to men, the issue of possible risk compensation in response to VMMC campaigns is of particular concern. In this study, we looked at population-level survey data from the countries prioritized by WHO for a VMMC scale-up. We compared the difference in sexual risk behaviours (SRB) between circumcised and uncircumcised men before and after the WHO’s official VMMC promotion. Materials and methods Ten countries (Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe) participating in the WHO’s VMMC scale-up had available data from the Demographic and Health Surveys (DHS). We used cumulative-link mixed models to investigate interactions between survey period and circumcision status in predicting SRB, in order to evaluate whether the difference between the behavior of the two groups changed before and after the scale-up, while controlling for socio-demographic and knowledge-related covariates. The main responses were condom use at last sex and number of non-cohabiting sexual partners, both in the last 12 months. Results There was little change in condom use by circumcised men relative to uncircumcised men from before the VMMC scale up to after the scale up. The relative odds ratio is 1.06 (95% CI, 0.95–1.18; interaction P = 0.310). Similarly, there was little change in the number of non-cohabiting partners in circumcised men (relative to uncircumcised men): the relative odds ratio of increasing the number of partners is 0.95 (95% CI, 0.86–1.05; interaction P = 0.319). Age, religion, education, job, marital status, media use and HIV knowledge also showed statistically significant association with the studied risk behaviours. We also found significant differences among countries, while controlling for covariates. Conclusions Overall, we find no evidence of sexual risk compensation in response to VMMC campaigns in countries prioritized by WHO. Changes in relative partner behaviour and the relative odds of condom use were small (and of uncertain sign). In fact, our estimates, though not significant, both suggest slightly less risky behavior. We conclude that sexual risk compensation in response to VMMC campaigns has not been a serious problem to date, but urge continued attention to local context, and to promulgating accurate messages about circumcision within and beyond the VMMC context.
Collapse
|
22
|
Brito MO, Khosla S, Pananookooln S, Fleming PJ, Lerebours L, Donastorg Y, Bailey RC. Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic. J Sex Med 2017; 14:526-534. [PMID: 28258953 DOI: 10.1016/j.jsxm.2017.01.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 01/16/2017] [Accepted: 01/27/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) is effective in decreasing the risk of HIV acquisition. As men resume sexual activity after circumcision, it will be important to study their satisfaction with the procedure, sexual pleasure and function, coital trauma, and risk compensation (RC), which can hamper or facilitate the long-term success of VMMC programs. AIM To assess men's satisfaction with VMMC, sexual pleasure and function, coital trauma, and RC after VMMC. METHODS This is a cohort study of circumcised men who presented for follow-up 6 to 24 months after VMMC. Logarithmic binomial regression was performed to explore factors associated with any increase in the number of sex partners after VMMC as a measurement of RC. MAIN OUTCOME MEASURES (i) Men's satisfaction with their VMMC; (ii) sexual pleasure and function after VMMC; (iii) coital trauma; and (iv) RC. RESULTS Of 454 circumcised men, 362 (80%) returned for a follow-up visit 6 to 24 months after VMMC. Almost all (98%) were satisfied with the outcome of their VMMC; most (95%) reported that their female partners were satisfied with their circumcision. Two thirds (67%) reported enjoying sex more after VMMC and most were very satisfied or somewhat satisfied (94%) with sexual intercourse after VMMC. Sexual function improved and reported sex-induced coital injuries decreased significantly in most men after VMMC. There was an increase in the proportion of men who reported at least two sexual partners after VMMC compared with baseline. In multivariate analysis, having sex with a woman they met the same day (adjusted relative risk = 1.7, 95% CI = 1.2-2.4) and having at least two sexual partners at baseline (adjusted relative risk = 0.5, 95% CI = 0.3-0.8) were associated with the outcome of any increase in the number of partners after VMMC. CLINICAL IMPLICATIONS VMMC can be offered to Dominican men for HIV prevention without adversely affecting sexual pleasure or function. The procedure substantially reduces coital trauma. STRENGTHS & LIMITATIONS This is the first report of long-term overall satisfaction, sexual pleasure/function and sex behaviors in the context of VMMC outside of Africa. Limitations of the study included the reliance on self-reported sex behaviors, the lack of physiologic measurement of penile sensitivity and the lack of follow up data beyond 24 months, which precludes the assessment of longer term RC. CONCLUSION The study confirmed men's long-term satisfaction with the outcome of their VMMC. VMMC improved sexual pleasure and function for most men and significantly decreased coital injuries. There was mixed evidence of RC. Brito MO, Khosla S, Pananookooln S, et al. Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic. J Sex Med 2017;14:526-534.
Collapse
Affiliation(s)
- Maximo O Brito
- School of Public Health and Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA.
| | - Shaveta Khosla
- School of Public Health and Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
| | - Sheewin Pananookooln
- School of Public Health and Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
| | - Paul J Fleming
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | | | - Yeycy Donastorg
- HIV Vaccine Trials Unit, Instituto Dermatológico y Cirugía De Piel, Santo Domingo, Dominican Republic
| | - Robert C Bailey
- School of Public Health and Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
23
|
George G, Govender K, Beckett S, Montague C, Frohlich J. Early Resumption of Sex following Voluntary Medical Male Circumcision amongst School-Going Males. PLoS One 2016; 11:e0168091. [PMID: 27930720 PMCID: PMC5145213 DOI: 10.1371/journal.pone.0168091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/25/2016] [Indexed: 11/20/2022] Open
Abstract
Voluntary medical male circumcision is an integral part of the South African government’s response to the HIV and AIDS epidemic. Following circumcision, it is recommended that patients abstain from sexual activity for six weeks, as sex may increase the risk of female-to-male HIV transmission and prolong the healing period. This paper investigates the resumption of sexual activity during the healing period among a cohort of school-going males in the KwaZulu-Natal province of South Africa. The analysis for this paper compares two groups of sexually active school-going males: the first group reported having sex during the healing period (n = 40) and the second group (n = 98) reported no sex during the healing period (mean age: 17.7, SD: 1.7).The results show that 29% (n = 40) of young males (mean age: 17.9, SD: 1.8) who were previously sexually active, resumed sexual activity during the healing period, had on average two partners and used condoms inconsistently. In addition, those males that engage in sexual activity during the healing period were less inclined to practice safe sex in the future (AOR = 0.055, p = 0.002) than the group of males who reported no sex during the healing period. These findings suggest that a significant proportion of young males may currently and in the future, subject themselves to high levels of risk for contracting HIV post circumcision. Education, as part of a VMMC campaign, must emphasize the high risk of HIV transmission for both the males their partners during the healing period.
Collapse
Affiliation(s)
- Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
- * E-mail:
| | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa
| | - Carl Montague
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Janet Frohlich
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| |
Collapse
|
24
|
Moodley N, Gray G, Bertram M. The Price of Prevention: Cost Effectiveness of Biomedical HIV Prevention Strategies in South Africa. CLINICAL RESEARCH IN HIV/AIDS 2016; 3:1031. [PMID: 28824960 PMCID: PMC5562157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND South Africa has the highest global burden of human immunodefciency virus [HIV]. The study compared the cost-effectiveness of individual and combination HIV preventive strategies against the current rollout of ART and possible ART scale-up. METHODS Adolescents attending South African schools in 2012 were included in the semi-Markov running annual cycles. The ART and HIV counseling and testing program [comparator] was weighed against the interventions [viz. HIV vaccine, a dual vaccine strategy [HIV and HPV vaccines], oral pre-exposure prophylaxis [PrEP] and voluntary medical male circumcision [VMMC]; and various combinations thereof. Quality-adjusted life years [QALY] determined changes in HIV associated mortality and infections averted. One-way and probabilistic sensitivity analysis determined parameter uncertainty. Discount rates of 3% with a lifetime horizon [70 years] were applied. RESULTS Dual vaccination was highly cost-effective strategy [US$ 7 per QALY gained] and averted 29% of new HIV infections. VMMC [US$ 30 per QALY gained] proved more cost-effective than HIV vaccination alone [US$ 93 per QALY gained], though VMMC averted 6% more new infections than the HIV vaccine when considered among male participants. PrEP interventions were the least cost-effective with pharmaceutical and human resource spending driving the costs. Combined dual vaccination and VMMC strategies were a dominant intervention. Strategies involving PrEP were the least cost-effective. CONCLUSION VMMC, HIV vaccination and dual vaccination strategies were more cost-effective than any PrEP strategies. A multi-intervention biomedical approach could avert considerable new HIV infections and present a cost-effective use of resources; particularly where large scale multi-interventional randomized controlled trials are absent.
Collapse
Affiliation(s)
- Nishila Moodley
- Department of Health Sciences, University of the Witwatersrand, South Africa
- South African HVTN AIDS Vaccine Early Stage Investigator Program [SHAPe]
- Department of Science and Technology, University of Stellenbosch, South Africa
| | - Glenda Gray
- Department of Health Sciences, University of the Witwatersrand, South Africa
- South African HVTN AIDS Vaccine Early Stage Investigator Program [SHAPe]
- Department Medical Research Council, Fred Hutchinson Cancer Research Centre, South Africa
| | - Melanie Bertram
- Department of Health Systems Governance and Finance, World Health Organization, Geneva
| |
Collapse
|
25
|
Circumcision Status and Time to Sexual Debut Among Youth in Sub-Saharan Africa: Evidence from Six Demographic and Health Surveys. AIDS Behav 2016; 20:2514-2528. [PMID: 26350790 DOI: 10.1007/s10461-015-1141-8] [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: 10/23/2022]
Abstract
This paper examines the relationship between circumcision status and timing of sexual debut among unmarried youth in Sub-Saharan Africa using Demographic and Health Surveys. Results from survival analysis indicate that the association between circumcision and timing of first sex is place and context specific. Compared to uncircumcised, circumcised men in Rwanda, Uganda and Namibia hasten sexual initiation, whilst circumcised youth in Ethiopia and Mali delayed sex initiation. In Togo however, we found parity in timing to sexual debut. Our multivariate results reveal that, knowledge of HIV/AIDS risk and educational level also feed into the association between circumcision and timing of sex initiation- implying that efforts to prevent new HIV infection through circumcision could benefit from a proper understanding of how diverse set of factors interact in specific contexts to shape youth's decisions to initiate early sex.
Collapse
|
26
|
Self-selection of male circumcision clients and behaviors following circumcision in a service program in Uganda. AIDS 2016; 30:2125-9. [PMID: 27203716 DOI: 10.1097/qad.0000000000001169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Sub-Saharan African countries have substantially scaled-up safe male circumcision (SMC) services. However, it is unclear whether services are reaching men most at risk of HIV and whether there is behavioral disinhibition after SMC. We compared characteristics of SMC acceptors and nonacceptors in Rakai, Uganda. DESIGN Cohort design. METHODS Through the Rakai Community Cohort Study, baseline characteristics of 587 non-Muslim men who subsequently accepted SMC were compared with those of 4907 uncircumcised non-Muslim men. Behaviors after SMC were compared with those of men who remained uncircumcised. Poisson multivariable regression was used to estimate adjusted prevalence rate ratios of behaviors in circumcised versus uncircumcised men. RESULTS At baseline (pre-SMC), men subsequently circumcised were younger (mean = 26.1 years), as compared with the uncircumcised (mean = 28.5 years, P < 0.001), more likely to live in urban areas (21.1 versus 12.4%, P < 0.001), less likely to have been currently or previously married (36.5 versus 45.8%, P < 0.001) and more likely to report multiple sexual partners (48.3 versus 41.6%, P = 0.05) and genital discharge (7.4 versus 4.4%, P = 0.03). At follow-up (post-SMC), behaviors and genital discharge did not differ between the groups. Genital ulcers were less reported among circumcised (6.8%) compared with uncircumcised men (10.5%; adjusted prevalence rate ratios = 0.60, 95% confidence interval = 0.42-0.87, P = 0.007). CONCLUSION In Rakai district, Uganda, the circumcision service program is attracting sexually active men at higher risk of HIV and we find no evidence of behavioral disinhibition following circumcision. The SMC program in this setting has the potential to reduce the HIV epidemic among men.
Collapse
|
27
|
Lower HIV Risk Among Circumcised Men Who Have Sex With Men in China: Interaction With Anal Sex Role in a Cross-Sectional Study. J Acquir Immune Defic Syndr 2016; 71:444-51. [PMID: 26413852 DOI: 10.1097/qai.0000000000000856] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain. METHODS Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed. RESULTS Among 1155 participants (242 were seropositive and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by examination) was associated with 47% lower odds of being HIV seropositive [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.27 to 1.02] after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR: 0.38; 95% CI: 0.09 to 1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR: 0.54; 95% CI: 0.25 to 1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR: 0.15; 95% CI: 0.04 to 0.65). Circumcision was not associated clearly with lower syphilis risk (aOR: 0.91; 95% CI: 0.51 to 1.61). CONCLUSIONS Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed.
Collapse
|
28
|
Wang Z, Feng T, Lau JTF. Prevalence and associated factors of behavioral intention for risk compensation following voluntary medical male circumcision among male sexually transmitted diseases patients in China. AIDS Care 2016; 28:1332-7. [PMID: 27120407 DOI: 10.1080/09540121.2016.1178696] [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: 10/21/2022]
Abstract
Risk compensation was an important concern of voluntary medical male circumcision (VMMC) promotion campaigns. No study investigated risk compensation following VMMC among male sexually transmitted diseases patients (MSTDP). A cross-sectional survey interviewed 308 uncircumcised MSTDP in Shenzhen, China. 26.9% of them intended to perform at least one of the five types of risk compensation behaviors following VMMC. In the summary stepwise model, provision of incorrect response to HIV/sexually transmitted diseases knowledge items (multivariate odds ratios (ORm) = 2.30), genital herpes infection (ORm = 3.19), Risk Reduction Score for Unprotected Sex, and Negative Condom Attitudes Scale (ORm = 1.13) were significantly associated with behavioral intention to perform at least one type of risk compensation behavior following VMMC. The results provided a framework for developing related interventions. Prevention of risk compensation should be an essential component of VMMC promotion for all MSTDP, irrespective of their intention for VMMC.
Collapse
Affiliation(s)
- Zixin Wang
- a Centre for Health Behaviours Research, JC School of Public Health and Primary Care , The Chinese University of Hong Kong , Hong Kong SAR , People's Republic of China.,b Shenzhen Research Institute (SZRI), The Chinese University of Hong Kong , Shenzhen , People's Republic of China
| | - Tiejian Feng
- c Shenzhen Center for Chronic Disease Control , Shenzhen , People's Republic of China
| | - Joseph T F Lau
- a Centre for Health Behaviours Research, JC School of Public Health and Primary Care , The Chinese University of Hong Kong , Hong Kong SAR , People's Republic of China.,b Shenzhen Research Institute (SZRI), The Chinese University of Hong Kong , Shenzhen , People's Republic of China
| |
Collapse
|
29
|
Zungu NP, Simbayi LC, Mabaso M, Evans M, Zuma K, Ncitakalo N, Sifunda S. HIV risk perception and behavior among medically and traditionally circumcised males in South Africa. BMC Public Health 2016; 16:357. [PMID: 27112917 PMCID: PMC4845373 DOI: 10.1186/s12889-016-3024-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 04/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In South Africa, voluntary medical male circumcision (VMMC) has recently been implemented as a strategy for reducing the risk of heterosexual HIV acquisition among men. However, there is some concern that VMMC may lead to low risk perception and more risky sexual behavior. This study investigated HIV risk perception and risk behaviors among men who have undergone either VMMC or traditional male circumcision (TMC) compared to those that had not been circumcised. METHODS Data collected from the 2012 South African national population-based household survey for males aged 15 years and older were analyzed using bivariate and multivariate multinomial logistic regression, and relative risk ratios (RRRs) with 95 % confidence interval (CI) were used to assess factors associated with each type of circumcision relative no circumcision. RESULTS Of the 11,086 males that indicated that they were circumcised or not, 19.5 % (95 % CI: 17.9-21.4) were medically circumcised, 27.2 % (95 % CI: 24.7-29.8) were traditionally circumcised and 53.3 % (95 % CI: 50.9-55.6) were not circumcised. In the final multivariate models, relative to uncircumcised males, males who reported VMMC were significantly more likely to have had more than two sexual partners (RRR = 1.67, p = 0.009), and males who reported TMC were significantly less likely to be low risk alcohol users (RRR = 0.72, p < 0.001). CONCLUSION There is a need to strengthen and improve the quality of the counselling component of VMMC with the focus on education about the real and present risk for HIV infection associated with multiple sexual partners and alcohol abuse following circumcision.
Collapse
Affiliation(s)
- N P Zungu
- Human Sciences Research Council, Office of the CEO, Private Bag X41, Pretoria, 0001, South Africa.
| | - L C Simbayi
- Human Sciences Research Council, Office of the CEO, Private Bag X41, Pretoria, 0001, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Mabaso
- Human Sciences Research Council, Office of the CEO, Private Bag X41, Pretoria, 0001, South Africa
| | - M Evans
- Human Sciences Research Council, Office of the CEO, Private Bag X41, Pretoria, 0001, South Africa
| | - K Zuma
- Human Sciences Research Council, Office of the CEO, Private Bag X41, Pretoria, 0001, South Africa
| | | | - S Sifunda
- Human Sciences Research Council, Office of the CEO, Private Bag X41, Pretoria, 0001, South Africa
| |
Collapse
|
30
|
Haberland NA, Kelly CA, Mulenga DM, Mensch BS, Hewett PC. Women's Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia. PLoS One 2016; 11:e0149517. [PMID: 26937971 PMCID: PMC4777382 DOI: 10.1371/journal.pone.0149517] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/02/2016] [Indexed: 12/04/2022] Open
Abstract
Women's perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women's health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men's risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman's HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women's misperception regarding MC. Programs should address women's informational needs and continue to emphasize that condoms remain critical, regardless of male partner's circumcision status.
Collapse
Affiliation(s)
| | | | | | | | - Paul C. Hewett
- Population Council, Washington DC, United States of America
| |
Collapse
|
31
|
Milford C, Rambally L, Mantell JE, Kelvin EA, Mosery NF, Smit JA. Healthcare providers' knowledge, attitudes and practices towards medical male circumcision and their understandings of its partial efficacy in HIV prevention: Qualitative research in KwaZulu-Natal, South Africa. Int J Nurs Stud 2015; 53:182-9. [PMID: 26302657 DOI: 10.1016/j.ijnurstu.2015.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 07/25/2015] [Accepted: 07/26/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Medical male circumcision has been shown to reduce HIV transmission to an uninfected male partner. In South Africa, medical male circumcision programs were rolled-out in 2010. OBJECTIVES Prior to roll-out, we explored healthcare providers' knowledge, attitudes and practices about medical male circumcision and their understandings of partial efficacy for HIV prevention. DESIGN We conducted qualitative research, using in-depth interviews. SETTING Participants were from three rural and three urban primary healthcare clinics, randomly selected in eThekwini District, KwaZulu-Natal. PARTICIPANTS 25 healthcare providers (including nurse managers, nurses and counselors) were purposively selected from the clinics. METHODS In-depth interviews were recorded, transcribed and translated. Independent researchers reviewed the transcripts and developed a codebook based on emergent themes, using thematic analysis. NVivo 8 was used to facilitate data management, coding and analysis. RESULTS Although most providers had heard that medical male circumcision can reduce risk of HIV acquisition in men, most did not have accurate scientific understandings of this. Some providers had misperceptions about the limited/partial protection medical male circumcision offers. Many had concerns that their communities would misunderstand it, causing increased risky sexual behavior. CONCLUSIONS These data provide a baseline of providers' understandings of medical male circumcision prior to roll-out, and can be used to compare current data and ensure accurate messaging to clients. Healthcare provider messaging should build client understandings of the meaning of partially efficacious technologies.
Collapse
Affiliation(s)
- Cecilia Milford
- MatCH Research (Maternal, Adolescent and Child Health Research), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa.
| | - Letitia Rambally
- MatCH Research (Maternal, Adolescent and Child Health Research), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Joanne E Mantell
- HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality and Health, NY State Psychiatric Institute and Columbia University, USA
| | - Elizabeth A Kelvin
- HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality and Health, NY State Psychiatric Institute and Columbia University, USA; CUNY School of Public Health, Hunter College, City University of New York, USA
| | - Nzwakie F Mosery
- MatCH Research (Maternal, Adolescent and Child Health Research), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Jennifer A Smit
- MatCH Research (Maternal, Adolescent and Child Health Research), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| |
Collapse
|
32
|
Chikutsa A, Maharaj P. Social representations of male circumcision as prophylaxis against HIV/AIDS in Zimbabwe. BMC Public Health 2015; 15:603. [PMID: 26133368 PMCID: PMC4489047 DOI: 10.1186/s12889-015-1967-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 06/25/2015] [Indexed: 11/14/2022] Open
Abstract
Background The World Health Organisation recommended the scale-up of voluntary medical male circumcision (VMMC) as an additional HIV prevention method in 2007 and several countries with high HIV prevalence rates including Zimbabwe have since adopted the procedure. Since then researchers have been preoccupied with establishing the level of knowledge and acceptability of circumcision in communities that did not traditionally circumcise. Despite evidence to suggest that knowledge and acceptability of voluntary medical male circumcision is high, there is also emerging evidence that suggest that uptake of circumcision among men has been below expectations. The purpose of this study was thus to investigate people’s representations of male circumcision that may influence its uptake. Methods Data for this study was collected through focus group discussions with men and women aged between 18 and 49 years. This age group was selected because they are still very sexually active and are within the target population of the upscale of voluntary medical male circumcision programme. Women were included in the study because they would be directly involved in a decision to have their son(s) get circumcised for HIV prevention. The study was carried out in Harare, Zimbabwe. Obtained qualitative data was analysed using thematic content analysis. Results Results suggest that circumcision is perceived as an alien culture or something for “younger” men or “boys” who are not yet married. The findings also suggest that there are beliefs that circumcision maybe associated with satanic rituals. The issue of condom use after circumcision was also discussed and it was found that some men do not see the need for using condoms after getting circumcised. Conclusions There is an urgent need for the development of communications that directly address the misconceptions about voluntary medical male circumcision. There is need for communication that encourages circumcised men to continue using condoms.
Collapse
Affiliation(s)
- Antony Chikutsa
- School of Built Environment and Development Studies, University of KwaZulu Natal, Durban, South Africa. .,Department of Development Studies, Zimbabwe Open University, Harare, Zimbabwe.
| | - Pranitha Maharaj
- School of Built Environment and Development Studies, University of KwaZulu Natal, Durban, South Africa
| |
Collapse
|
33
|
Chikutsa A, Ncube AC, Mutsau S. Association between wanting circumcision and risky sexual behaviour in Zimbabwe: evidence from the 2010-11 Zimbabwe demographic and health survey. Reprod Health 2015; 12:15. [PMID: 25889318 PMCID: PMC4364469 DOI: 10.1186/s12978-015-0001-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 01/28/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Zimbabwe adopted voluntary medical male circumcision (VMMC) as an additional HIV prevention strategy in 2009. A number of studies have been conducted to understand the determinants of VMMC uptake but few studies have examined the characteristics of men who are willing to get circumcised or the link between wanting circumcision and risky sexual behaviour. This study investigated the relationship between wanting male circumcision and engaging in risky sex behaviours. This was based on the assumption that those who are willing to undergo circumcision are already engaging in risky sexual behaviours. DATA AND METHODS Data from men age 15-45 years who were interviewed during the 2010-11 Zimbabwe Demographic and Health Survey of 2010-11 was used. A total of 7480 men were included in the sample for this study. Logistic regression was used to assess the association between wanting circumcision and risky sexual behaviours. FINDINGS Men in the highest wealth tercile were significantly more likely to want circumcision compared to men in lower wealth terciles (OR=1.36, p<0.01). Wanting circumcision was also significantly associated with age. Men in the 25-34 age category reported wanting circumcision more (OR=1.21, p < 0.05) while older men were significantly less likely to want circumcision (OR=0.63, p<0.01). Christian men and those residing in rural areas were also less likely to want circumcision (OR=0.74, p<0.05 and OR = 0.75, p < 0.001 respectively). The findings of this study indicate a strong association between wanting circumcision and having had risky sex (OR=1.36, p<0.01), having multiple partners (OR=1.35, p<0.01) and having paid for sex (OR=1.42, p < 0.001) However, wanting circumcision was negatively associated with having used a condom at the last risky sex (OR=0.76, p<0.001). CONCLUSIONS The association between demand for VMMC and risky sexual behaviour need continuous monitoring. We emphasise that the promotion of VMMC for HIV prevention should not overshadow the promotion of existing methods of HIV prevention such as condoms and reduction of sexual partners.
Collapse
|
34
|
Wamai RG, Morris BJ, Bailey RC, Klausner JD, Boedicker MN. Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress. Glob Public Health 2015; 10:639-66. [PMID: 25613581 PMCID: PMC6352987 DOI: 10.1080/17441692.2014.989532] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.
Collapse
Affiliation(s)
- Richard G. Wamai
- Department of African-American Studies, Northeastern University, Boston, Massachusetts, USA
| | - Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Robert C. Bailey
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeffrey D. Klausner
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, USA
| | | |
Collapse
|
35
|
Ediau M, Matovu JKB, Byaruhanga R, Tumwesigye NM, Wanyenze RK. Risk factors for HIV infection among circumcised men in Uganda: a case-control study. J Int AIDS Soc 2015; 18:19312. [PMID: 25556374 PMCID: PMC4283027 DOI: 10.7448/ias.18.1.19312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 11/16/2014] [Accepted: 11/21/2014] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Male circumcision (MC) reduces the risk of HIV infection. However, the risk reduction effect of MC can be modified by type of circumcision (medical, traditional and religious) and sexual risk behaviours post-circumcision. Understanding the risk behaviours associated with HIV infection among circumcised men (regardless of form of circumcision) is critical to the design of comprehensive risk reduction interventions. This study assessed risk factors for HIV infection among men circumcised through various circumcision approaches. METHODS This was a case-control study which enrolled 155 cases (HIV-infected) and 155 controls (HIV-uninfected), all of whom were men aged 18-35 years presenting at the AIDS Information Center for HIV testing and care. The outcome variable was HIV sero-status. Using SPSS version 17, multivariable logistic regression was performed to identify factors independently associated with HIV infection. RESULTS Overall, 83.9% among cases and 56.8% among controls were traditionally circumcised; 7.7% of cases and 21.3% of controls were religiously circumcised while 8.4% of cases and 21.9% of controls were medically circumcised. A higher proportion of cases than controls reported resuming sexual intercourse before complete wound healing (36.9% vs. 14.1%; p<0.01). Risk factors for HIV infection prior to circumcision were:being in a polygamous marriage (AOR: 6.6, CI: 2.3-18.8) and belonging to the Bagisu ethnic group (AOR: 6.1, CI: 2.6-14.0). After circumcision, HIV infection was associated with: being circumcised at >18 years (AOR: 5.0, CI: 2.4-10.2); resuming sexual intercourse before wound healing (AOR: 3.4, CI: 1.6-7.3); inconsistent use of condoms (AOR: 2.7, CI: 1.5-5.1); and having sexual intercourse under the influence of peers (AOR: 2.9, CI: 1.5-5.5). Men who had religious circumcision were less likely to have HIV infection (AOR: 0.4, 95% CI: 0.2-0.9) than the traditionally circumcised but there was no statistically significant difference between those who were traditionally circumcised and those who were medically circumcised (AOR: 0.40, 95% CI: 0.1-1.1). CONCLUSIONS Being circumcised at adulthood, resumption of sexual intercourse before wound healing, inconsistent condom use and having sex under the influence of peers were significant risk factors for HIV infection. Risk reduction messages should address these risk factors, especially among traditionally circumcised men.
Collapse
Affiliation(s)
- Michael Ediau
- Makerere University School of Public Health-CDC Fellowship Program, Kampala, Uganda;
| | - Joseph K B Matovu
- Makerere University School of Public Health-CDC Fellowship Program, Kampala, Uganda; Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | | | - Nazarius M Tumwesigye
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Rhoda K Wanyenze
- Makerere University School of Public Health-CDC Fellowship Program, Kampala, Uganda; Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| |
Collapse
|
36
|
Westercamp N, Agot K, Jaoko W, Bailey RC. Risk compensation following male circumcision: results from a two-year prospective cohort study of recently circumcised and uncircumcised men in Nyanza Province, Kenya. AIDS Behav 2014; 18:1764-75. [PMID: 25047688 DOI: 10.1007/s10461-014-0846-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30-14 vs. 24-21 % in controls) and increased sexual activity among the youngest participants (18-24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.
Collapse
Affiliation(s)
- Nelli Westercamp
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor St. MC 923, Chicago, IL, 60612, USA,
| | | | | | | |
Collapse
|
37
|
Jones A, Cremin I, Abdullah F, Idoko J, Cherutich P, Kilonzo N, Rees H, Hallett T, O'Reilly K, Koechlin F, Schwartlander B, de Zalduondo B, Kim S, Jay J, Huh J, Piot P, Dybul M. Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention. Lancet 2014; 384:272-9. [PMID: 24740087 DOI: 10.1016/s0140-6736(13)62230-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Large declines in HIV incidence have been reported since 2001, and scientific advances in HIV prevention provide strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public health approach to combination prevention that understands that risk is not evenly distributed and that effective interventions can vary by risk profile. Different countries have different microepidemics, with very different levels of transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies, people at highest risk for HIV, and the package of interventions that are most likely to have the largest effect in each different microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision, as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.
Collapse
Affiliation(s)
- Alexandra Jones
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Ide Cremin
- School of Public Health, Imperial College London, London, UK
| | - Fareed Abdullah
- South Africa National AIDS Council (SANAC), Pretoria, South Africa
| | - John Idoko
- National Agency for the Control of AIDS, Abuja, Nigeria
| | - Peter Cherutich
- National AIDS/STD Control Programme (NASCOP), Nairobi, Kenya
| | - Nduku Kilonzo
- Liverpool Voluntary Counselling and Testing, Care and Treatment, Nairobi, Kenya
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Witwatersrand, South Africa
| | - Timothy Hallett
- School of Public Health, Imperial College London, London, UK
| | - Kevin O'Reilly
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Florence Koechlin
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Barbara de Zalduondo
- Office of the Deputy Executive Director for Programme, UNAIDS, Geneva, Switzerland
| | - Susan Kim
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Jonathan Jay
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Jacqueline Huh
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Peter Piot
- Director's Office, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Dybul
- O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA; The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.
| |
Collapse
|
38
|
Kikaya V, Skolnik L, García MC, Nkonyana J, Curran K, Ashengo TA. Voluntary medical male circumcision programs can address low HIV testing and counseling usage and ART enrollment among young men: lessons from Lesotho. PLoS One 2014; 9:e83614. [PMID: 24801714 PMCID: PMC4011866 DOI: 10.1371/journal.pone.0083614] [Citation(s) in RCA: 5] [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: 08/13/2013] [Accepted: 11/05/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Early diagnosis of HIV and treatment initiation at higher CD4 counts improves outcomes and reduces transmission. However, Lesotho is not realizing the full benefits of ART because of the low proportion of men tested (40%). Public sector VMMC services, which were launched in district hospitals in February 2012 by the Lesotho MOH supported by USAID/MCHIP, include HIV testing with referral to care and treatment. The objective of this study was to better understand the contribution of VMMC services to HIV diagnosis and treatment. METHODS VMMC clients diagnosed with HIV were traced after 6 months to ascertain whether they: (1) presented to the referral HIV center, (2) had a CD4 count done and (3) were enrolled on ART. Linkages between VMMC and HIV services were assessed by comparing the proportion of HIV-infected males referred from VMMC services with those from other hospital departments. RESULTS Between March and September 2012, 72 men presenting for VMMC services tested positive for HIV, representing 65% of the total male tests at the hospital; 45 of these men (62.5%) received an immediate CD4 count and went to the HIV referral site; 40 (89%) were eligible for treatment and initiated ART. 27 clients did not have a CD4 count due to stock-out of reagents. Individuals who did not receive a CD4 count on the same day did not return to the HIV center. CONCLUSION All VMMC clients testing positive for HIV and receiving a CD4 count on the testing day began ART. Providing VMMC services in a district hospital offering the continuum of care could increase diagnoses and treatment uptake among men, but requires an investment in communication between VMMC and ART clinics. In high HIV prevalence settings, investing in PIMA CD4 devices at integrated VMMC clinics is likely to increase male ART enrolment.
Collapse
Affiliation(s)
| | | | - Macarena C. García
- Lesotho PEPFAR Program, U.S. Agency for International Development, Maseru, Lesotho
| | | | - Kelly Curran
- Jhpiego, Baltimore, Maryland, United States of America
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Tigistu Adamu Ashengo
- Jhpiego, Baltimore, Maryland, United States of America
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| |
Collapse
|
39
|
L’Engle K, Lanham M, Loolpapit M, Oguma I. Understanding partial protection and HIV risk and behavior following voluntary medical male circumcision rollout in Kenya. HEALTH EDUCATION RESEARCH 2014; 29:122-130. [PMID: 24293524 PMCID: PMC3894669 DOI: 10.1093/her/cyt103] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 10/27/2013] [Indexed: 06/02/2023]
Abstract
In the midst of scaling up voluntary medical male circumcision (VMMC) in Kenya, there is concern that men do not adequately understand that circumcision provides only partial protection against HIV. The study goal was to determine men's understanding of partial protection, perceptions of HIV risk before and after VMMC and use of protective measures following VMMC. In-depth interviews with 44 men aged 18-39 years recently circumcised or planning to undergo VMMC were conducted in two urban and rural districts in Nyanza Province, Kenya. Participants described partial protection as the need to continue using other HIV protective measures such as condoms, with numbers such as a '60 percent protection' or 'not 100 percent protection', and described how circumcision reduces HIV transmission such as reduced penile bruising or bleeding. Most said their HIV risk before VMMC was high and that VMMC would reduce their risk moderately. Participants demonstrated good understanding of partial protection and there was little suggestion of risk compensation following VMMC.
Collapse
Affiliation(s)
- K. L’Engle
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
| | - M. Lanham
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
| | - M. Loolpapit
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
| | - I. Oguma
- Social and Behavioral Health Sciences, FHI 360, PO Box 13950, Research Triangle Park, NC 27709, USA and Male Circumcision Consortium Project, FHI 360, PO Box 38835-0062, Nairobi, Kenya
| |
Collapse
|
40
|
Cori A, Ayles H, Beyers N, Schaap A, Floyd S, Sabapathy K, Eaton JW, Hauck K, Smith P, Griffith S, Moore A, Donnell D, Vermund SH, Fidler S, Hayes R, Fraser C. HPTN 071 (PopART): a cluster-randomized trial of the population impact of an HIV combination prevention intervention including universal testing and treatment: mathematical model. PLoS One 2014; 9:e84511. [PMID: 24454728 PMCID: PMC3893126 DOI: 10.1371/journal.pone.0084511] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 11/20/2013] [Indexed: 02/08/2023] Open
Abstract
Background The HPTN 052 trial confirmed that antiretroviral therapy (ART) can nearly eliminate HIV transmission from successfully treated HIV-infected individuals within couples. Here, we present the mathematical modeling used to inform the design and monitoring of a new trial aiming to test whether widespread provision of ART is feasible and can substantially reduce population-level HIV incidence. Methods and Findings The HPTN 071 (PopART) trial is a three-arm cluster-randomized trial of 21 large population clusters in Zambia and South Africa, starting in 2013. A combination prevention package including home-based voluntary testing and counseling, and ART for HIV positive individuals, will be delivered in arms A and B, with ART offered universally in arm A and according to national guidelines in arm B. Arm C will be the control arm. The primary endpoint is the cumulative three-year HIV incidence. We developed a mathematical model of heterosexual HIV transmission, informed by recent data on HIV-1 natural history. We focused on realistically modeling the intervention package. Parameters were calibrated to data previously collected in these communities and national surveillance data. We predict that, if targets are reached, HIV incidence over three years will drop by >60% in arm A and >25% in arm B, relative to arm C. The considerable uncertainty in the predicted reduction in incidence justifies the need for a trial. The main drivers of this uncertainty are possible community-level behavioral changes associated with the intervention, uptake of testing and treatment, as well as ART retention and adherence. Conclusions The HPTN 071 (PopART) trial intervention could reduce HIV population-level incidence by >60% over three years. This intervention could serve as a paradigm for national or supra-national implementation. Our analysis highlights the role mathematical modeling can play in trial development and monitoring, and more widely in evaluating the impact of treatment as prevention.
Collapse
Affiliation(s)
- Anne Cori
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Helen Ayles
- ZAMBART, University of Zambia, School of Medicine, Ridgeway Campus, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Ab Schaap
- ZAMBART, University of Zambia, School of Medicine, Ridgeway Campus, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kalpana Sabapathy
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeffrey W. Eaton
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Katharina Hauck
- Business School, Imperial College London, South Kensington, London, United Kingdom
| | - Peter Smith
- Business School, Imperial College London, South Kensington, London, United Kingdom
| | - Sam Griffith
- FHI 360, Research Triangle Park, North Carolina, United States of America
| | - Ayana Moore
- FHI 360, Research Triangle Park, North Carolina, United States of America
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Sten H. Vermund
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christophe Fraser
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
- * E-mail:
| | | |
Collapse
|
41
|
Layer EH, Beckham SW, Momburi RB, Peter M, Laizer E, Kennedy CE. 'He is proud of my courage to ask him to be circumcised': experiences of female partners of male circumcision clients in Iringa region, Tanzania. CULTURE, HEALTH & SEXUALITY 2014; 16:258-272. [PMID: 24400819 DOI: 10.1080/13691058.2013.873481] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Male circumcision programmes in Tanzania seek to increase demand among older, married clients who are more likely to have steady female sexual partners. Understanding women's roles throughout their partners' circumcision and any resultant changes in relationship dynamics are important considerations as efforts are made to scale up male circumcision. We conducted interviews with 32 wives of male circumcision clients from November 2011 to February 2012 in Iringa, Tanzania. Transcripts were digitally recorded, transcribed and translated into English and codes were developed based on emerging themes. Women were instrumental in convincing their husbands to be circumcised, but early resumption of sexual activity was common and a minority of women reported their husbands' emotional abuse or risk compensation following circumcision. These findings suggest that married women play a key role in their husbands' decisions to be circumcised, but women's needs for information and education are not being met and gender inequalities further decrease women's abilities to reduce their risk of HIV in this context. Strategies to more meaningfully engage women in male circumcision programmes are needed.
Collapse
Affiliation(s)
- Erica H Layer
- a Department of International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , USA
| | | | | | | | | | | |
Collapse
|
42
|
Wilson NL, Xiong W, Mattson CL. Is Sex Like Driving? HIV Prevention and Risk Compensation. JOURNAL OF DEVELOPMENT ECONOMICS 2014; 106:78-91. [PMID: 26997745 PMCID: PMC4794434 DOI: 10.1016/j.jdeveco.2013.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Risk compensation has been called the "Achilles' heel" of HIV prevention policies (Cassell et al 2006). This paper examines the behavioral response to male circumcision, a major HIV prevention policy currently being implemented throughout much of Sub-Saharan Africa. Contrary to the presumption of risk compensation, we find that the response due to the perceived reduction in HIV transmission appears to have been a reduction in risky sexual behavior. We suggest a mechanism for this finding: circumcision may reduce fatalism about acquiring HIV/AIDS and increase the salience of the tradeoff between engaging in additional risky behavior and avoiding acquiring HIV. We also find what appears to be a competing effect that does not operate through the circumcision recipient's belief about the reduction in the risk of acquiring HIV.
Collapse
|
43
|
Marcus JL, Glidden DV, Mayer KH, Liu AY, Buchbinder SP, Amico KR, McMahan V, Kallas EG, Montoya-Herrera O, Pilotto J, Grant RM. No evidence of sexual risk compensation in the iPrEx trial of daily oral HIV preexposure prophylaxis. PLoS One 2013; 8:e81997. [PMID: 24367497 PMCID: PMC3867330 DOI: 10.1371/journal.pone.0081997] [Citation(s) in RCA: 179] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 10/17/2013] [Indexed: 11/19/2022] Open
Abstract
Objective Preexposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) reduced HIV acquisition in the iPrEx trial among men who have sex with men and transgender women. Self-reported sexual risk behavior decreased overall, but may be affected by reporting bias. We evaluated potential risk compensation using biomarkers of sexual risk behavior. Design and methods Sexual practices were assessed at baseline and quarterly thereafter; perceived treatment assignment and PrEP efficacy beliefs were assessed at 12 weeks. Among participants with ≥1 follow-up behavioral assessment, sexual behavior, syphilis, and HIV infection were compared by perceived treatment assignment, actual treatment assignment, and perceived PrEP efficacy. Results Overall, acute HIV infection and syphilis decreased during follow-up. Compared with participants believing they were receiving placebo, participants believing they were receiving FTC/TDF reported more receptive anal intercourse partners prior to initiating drug (12.8 vs. 7.7, P = 0.04). Belief in receiving FTC/TDF was not associated with an increase in receptive anal intercourse with no condom (ncRAI) from baseline through follow-up (risk ratio [RR] 0.9, 95% confidence interval [CI]: 0.6–1.4; P = 0.75), nor with a decrease after stopping study drug (RR 0.8, 95% CI: 0.5–1.3; P = 0.46). In the placebo arm, there were trends toward lower HIV incidence among participants believing they were receiving FTC/TDF (incidence rate ratio [IRR] 0.8, 95% CI: 0.4–1.8; P = 0.26) and also believing it was highly effective (IRR 0.5, 95% CI: 0.1–1.7; P = 0.12). Conclusions There was no evidence of sexual risk compensation in iPrEx. Participants believing they were receiving FTC/TDF had more partners prior to initiating drug, suggesting that risk behavior was not a consequence of PrEP use.
Collapse
Affiliation(s)
- Julia L. Marcus
- Gladstone Institute of Virology and Immunology, San Francisco, California, United States of America
- University of California, Berkeley, California, United States of America
| | - David V. Glidden
- University of California San Francisco, San Francisco, California, United States of America
| | - Kenneth H. Mayer
- Fenway Institute, Fenway Health, Boston, Massachusetts, United States of America
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Albert Y. Liu
- University of California San Francisco, San Francisco, California, United States of America
- Bridge HIV, San Francisco Department of Public Health, San Francisco, California, United States of America
| | - Susan P. Buchbinder
- University of California San Francisco, San Francisco, California, United States of America
- Bridge HIV, San Francisco Department of Public Health, San Francisco, California, United States of America
| | - K. Rivet Amico
- Center for Health, Intervention and Prevention, University of Connecticut, Storrs, Connecticut, United States of America
| | - Vanessa McMahan
- Gladstone Institute of Virology and Immunology, San Francisco, California, United States of America
| | - Esper Georges Kallas
- Division of Clinical Immunology and Allergy, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Jose Pilotto
- Laboratorio de AIDS e Imunologia Molecular, Hospital Geral de Nova Iguacu, Rio de Janeiro, Brazil
| | - Robert M. Grant
- Gladstone Institute of Virology and Immunology, San Francisco, California, United States of America
- University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| |
Collapse
|
44
|
Ott MA, Alexander AB, Lally M, Steever JB, Zimet GD. Preventive misconception and adolescents' knowledge about HIV vaccine trials. JOURNAL OF MEDICAL ETHICS 2013; 39:765-771. [PMID: 23355050 PMCID: PMC3677956 DOI: 10.1136/medethics-2012-100821] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Adolescents have had very limited access to research on biomedical prevention interventions despite high rates of HIV acquisition. One concern is that adolescents are a vulnerable population, and trials carry a possibility of harm, requiring investigators to take additional precautions. Of particular concern is preventive misconception, or the overestimation of personal protection that is afforded by enrolment in a prevention intervention trial. METHODS As part of a larger study of preventive misconception in adolescent HIV vaccine trials, we interviewed 33 male and female 16-19-year-olds who have sex with men. Participants underwent a simulated HIV vaccine trial consent process, and then completed a semistructured interview about their understanding and opinions related to enrolment in a HIV vaccine trial. A grounded theory analysis looked for shared concepts, and focused on the content and process of adolescent participants' understanding of HIV vaccination and the components of preventive misconception, including experiment, placebo and randomisation. RESULTS Across interviews, adolescents demonstrated active processing of information, in which they questioned the interviewer, verbally worked out their answers based upon information provided, and corrected themselves. We observed a wide variety of understanding of research concepts. While most understood experiment and placebo, fewer understood randomisation. All understood the need for safer sex even if they did not understand the more basic concepts. CONCLUSIONS Education about basic concepts related to clinical trials, time to absorb materials and assessment of understanding may be necessary in future biomedical prevention trials.
Collapse
Affiliation(s)
- Mary A. Ott
- Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis IN, USA
| | - Andreia B. Alexander
- Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis IN, USA
| | - Michelle Lally
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - John B. Steever
- Department of Pediatrics, Mount Sinai School of Medicine, New York, NY, USA
| | - Gregory D. Zimet
- Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis IN, USA
| | | |
Collapse
|
45
|
Westercamp N, Mattson CL, Bailey RC. Measuring prevalence and correlates of concurrent sexual partnerships among young sexually active men in Kisumu, Kenya. AIDS Behav 2013; 17:3124-32. [PMID: 23532398 DOI: 10.1007/s10461-013-0457-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Our objectives were to: (1) compare multiple measures of partnership concurrency, including the UNAIDS-recommended definition and (2) describe the prevalence and correlates of concurrent sexual partnerships among young Kenyan men. We analyzed 10,907 lifetime partnerships of 1,368 men ages 18-24 years enrolled in a randomized trial of male circumcision to reduce HIV-1 incidence in Kisumu. Partnership concurrency was determined by overlapping dates and examined over varying recall periods and assumptions. The lifetime prevalence of concurrency was 77 %. Sixty-one percent of all partnerships were concurrent and factors associated with concurrency differed by partner type. Point prevalence of concurrency at the time of the interview was consistently the highest and UNAIDS-recommended definition was the most conservative (25 vs. 18 % at baseline, respectively). Estimates of concurrency were influenced by methods for definition and measurement. Regardless of definition, concurrent partnerships are frequent in this population of young, sexually active men in high HIV prevalence Kisumu, Kenya.
Collapse
|
46
|
Limburgh CM, van Schalkwyk GI, Lee KH, Buys C, De Kock M, Horn M, Bhyat A, van Schalkwyk SC. Cutting to the chase: Participation factors, behavioral effects, and cultural perspectives of participants in an adult circumcision campaign. AIDS Care 2013; 25:1278-83. [DOI: 10.1080/09540121.2013.764392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
47
|
Layer EH, Beckham SW, Mgeni L, Shembilu C, Momburi RB, Kennedy CE. "After my husband's circumcision, I know that I am safe from diseases": women's attitudes and risk perceptions towards male circumcision in Iringa, Tanzania. PLoS One 2013; 8:e74391. [PMID: 24009771 PMCID: PMC3756960 DOI: 10.1371/journal.pone.0074391] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/31/2013] [Indexed: 11/19/2022] Open
Abstract
While male circumcision reduces the risk of female-to-male HIV transmission and certain sexually transmitted infections (STIs), there is little evidence that circumcision provides women with direct protection against HIV. This study used qualitative methods to assess women's perceptions of male circumcision in Iringa, Tanzania. Women in this study had strong preferences for circumcised men because of the low risk perception of HIV with circumcised men, social norms favoring circumcised men, and perceived increased sexual desirability of circumcised men. The health benefits of male circumcision were generally overstated; many respondents falsely believed that women are also directly protected against HIV and that the risk of all STIs is greatly reduced or eliminated in circumcised men. Efforts to engage women about the risks and limitations of male circumcision, in addition to the benefits, should be expanded so that women can accurately assess their risk of HIV or STIs during sexual intercourse with circumcised men.
Collapse
Affiliation(s)
- Erica H Layer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Tran BR, Thomas AG, Ditsela M, Vaida F, Phetogo R, Kelapile D, Chambers C, Haubrich R, Shaffer R. Condom use behaviours and correlates of use in the Botswana Defence Force. Int J STD AIDS 2013; 24:883-92. [PMID: 23970609 DOI: 10.1177/0956462413486889] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preventing HIV infection is a priority for militaries. HIV prevention research is needed to monitor existing programme, identify areas for modification, and develop new interventions. Correct and consistent condom use is highly effective against HIV. However, use among soldiers is lower than ideal. This study describes condom use behaviours and examines correlates of use in the Botswana Defence Force (BDF). Analyses were based on 211 male BDF personnel, aged 18-30, who completed a cross-sectional survey that collected baseline data for an intervention study. Results showed that 51% of participants reported always using condoms, 35% used condoms most times, and 14% used condoms occasionally/never. Condom use varied by partner type and was typically higher with casual partners in comparison to regular partners. After adjustment for age and marital status, factors associated with lower condom use included excessive alcohol use, perception that using condoms reduce sexual pleasure, and having a trusted partner. However, higher levels of HIV knowledge and reports of being circumcised were protective against lower condom use. HIV interventions aimed at increasing condom use in the BDF should address condom perceptions, alcohol abuse, and issues of trust. Innovative ways to increase condom use in this population should also be explored.
Collapse
Affiliation(s)
- Bonnie Robin Tran
- Naval Health Research Center, Department of Defense HIV/AIDS Prevention Program, San Diego, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Mkandawire P, Luginaah I, Dixon J, Armah F, Arku G. Circumcision status and time to first sex among never-married young men in Malawi: evidence from the demographic and health survey. AIDS Behav 2013; 17:2123-35. [PMID: 23474595 DOI: 10.1007/s10461-013-0444-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This study examines the association between circumcision status and the timing of first sexual intercourse among adolescents in Malawi. Results of survival models applied to nationally representative sample of never-married young men aged between 15 and 24 obtained from the Demographic and Health Survey data show that being circumcised is associated with earlier initiation of sexual activity in Malawi. Young men who reported being circumcised experienced their first sexual intercourse earlier in life than their uncircumcised counterparts. Although the introduction of theoretically relevant knowledge, socio-cultural, demographic, and socioeconomic variables in the multivariate models attenuated the association between circumcision and earlier sexual initiation, the relationship nonetheless remained robust. The study concludes by discussing the implications of these findings and suggests relevant policy recommendations.
Collapse
Affiliation(s)
- Paul Mkandawire
- Institute of Interdisciplinary Studies, Carleton University, 1125 Colonel By Drive, Ottawa, ON K1S 5B6, Canada.
| | | | | | | | | |
Collapse
|
50
|
Friedland BA, Apicella L, Schenk KD, Sheehy M, Hewett PC. How informed are clients who consent? A mixed-method evaluation of comprehension among clients of male circumcision services in Zambia and Swaziland. AIDS Behav 2013; 17:2269-82. [PMID: 23392912 DOI: 10.1007/s10461-013-0424-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Comprehension is fundamental for informed consent--an individual's right to choose a medical procedure, such as male circumcision (MC). Because optimal benefits depend on post-surgical behaviors, comprehension is particularly critical for MC programs. We evaluated clients' comprehension of MC's risks and benefits, wound care instructions, and risk reduction post-MC using a true/false test (n = 1181) and 92 semi-structured interviews (SSIs) in Zambia and Swaziland. Most participants (89% Zambia, 93% Swaziland) passed the true/false test, although adolescents scored lower (significantly so in Swaziland) than adults and one-third (including nearly half of adolescents in Zambia) said MC has no risks. SSIs indicated confusion between "risk" of adverse surgical outcomes and reduced "risk" of HIV; most respondents acknowledged the 6 week abstinence period post-MC, yet few said resuming sex early increases HIV risk. Providers should distinguish between surgical "risks" and reduced HIV "risk," and emphasize that HIV risk increases with sex before complete healing.
Collapse
|