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Akugizibwe L, Benyumiza D, Nekesa C, Kumakech E, Kigongo E, Ashaba N, Kabunga A, Tumwesigye R. Knowledge, Perception, and Practice of Safe Medical Circumcision on HIV Infection Risk Reduction among Undergraduate Students of a Public University in Northern Uganda: A Cross-Sectional Study. BIOMED RESEARCH INTERNATIONAL 2024; 2024:1534139. [PMID: 38633241 PMCID: PMC11022510 DOI: 10.1155/2024/1534139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
Background About 70% (25.6 million) of the global HIV/AIDS burden is from Sub-Saharan Africa. Safe male circumcision (SMC) is one of the measures that were adopted by the Ugandan government aimed at reducing the risk of HIV infection contraction, as recommended by the WHO. Its main goal was to maximize HIV prevention impact with voluntary medical circumcision services to all adult men and adolescent boys. The objective of our study was to assess the knowledge, perception, and practice of safe medical circumcision on HIV infection risk reduction among undergraduate students of a public university in Northern Uganda. Methods We conducted a cross-sectional survey among 556 randomly selected Lira University undergraduate students from March 2023 to June 2023. With the use of a self-administered questionnaire, we collected data on the knowledge and perceptions of undergraduate students towards safe medical circumcision. Data were exported to Stata® 17 statistical software. Univariate, bivariate, and multivariate regression analyses were done at a statistical level of significance P value < 0.05. Results Our 556 study participants had an age range of 21-25 years. The majority (81.29%) of the respondents knew that safe medical circumcision reduces the risk of acquiring HIV. However, the perception is that close to 3 in 4 (74.46%) of the students were unsure if they would opt for safe medical circumcision as risk reduction measure against HIV. The practice of safe medical circumcision was 64.8% among the study participants. Conclusions More than three in four of the undergraduate students have knowledge on safe medical circumcision as risk reduction measure for HIV infection. And close to 3 in 4 (74.46%) of the student's perception were unsure if they would opt for safe medical circumcision as risk reduction measure against HIV. The practice of safe medical circumcision was 64.8% among the study participants. Therefore, in an effort to increase SMC's adoption for HIV/AIDS prevention, the Ministry of Health of Uganda and related stakeholders in health should work hand in hand with university study bodies in order to optimize SMC uptake among university students.
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Affiliation(s)
- Lucky Akugizibwe
- Department of Environmental Health and Disease Control, Faculty of Public Health, Lira University, P.O. Box 1035 Lira City, Uganda
| | - Deo Benyumiza
- Department of Midwifery, Faculty of Nursing and Midwifery, Lira University, P.O. Box 1035 Lira City, Uganda
| | - Catherine Nekesa
- Department of Midwifery, Faculty of Nursing and Midwifery, Lira University, P.O. Box 1035 Lira City, Uganda
| | - Edward Kumakech
- Department of Midwifery, Faculty of Nursing and Midwifery, Lira University, P.O. Box 1035 Lira City, Uganda
| | - Eustes Kigongo
- Department of Environmental Health and Disease Control, Faculty of Public Health, Lira University, P.O. Box 1035 Lira City, Uganda
| | - Nasser Ashaba
- Department of Environmental Health and Disease Control, Faculty of Public Health, Lira University, P.O. Box 1035 Lira City, Uganda
| | - Amir Kabunga
- Department of Psychiatry, Faculty of Medicine, Lira University, P.O. Box 1035 Lira City, Uganda
| | - Raymond Tumwesigye
- Department of Emergency Nursing and Critical Care, Faculty of Nursing and Midwifery, Lira University, P.O. Box 1035 Lira City, Uganda
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Bershteyn A, Mudimu E, Platais I, Mwalili S, Zulu JE, Mwanza WN, Kripke K. Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges. Curr HIV/AIDS Rep 2022; 19:526-536. [PMID: 36459306 PMCID: PMC9759505 DOI: 10.1007/s11904-022-00639-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE OF REVIEW Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations. RECENT FINDINGS Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Edinah Mudimu
- Department of Decision Sciences, College of Economic and Management Sciences, University of South Africa, Pretoria, Gauteng South Africa
| | - Ingrida Platais
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Samuel Mwalili
- Strathmore Institute of Mathematical Sciences, Strathmore University, Nairobi, Kenya
| | - James E. Zulu
- Zambia Field Epidemiology Training Program, Workforce Development Cluster, Zambia National Public Health Institute, Lusaka, Zambia
| | - Wiza N. Mwanza
- Directorate of Public Health and Research, Ministry of Health, Lusaka, Zambia
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3
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Nanteza BM, Makumbi FE, Gray RH, Serwadda D, Yeh PT, Kennedy CE. Enhancers and barriers to uptake of male circumcision services in Northern Uganda: a qualitative study. AIDS Care 2019; 32:1061-1068. [PMID: 31795737 DOI: 10.1080/09540121.2019.1698703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda.
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Affiliation(s)
- Barbara M Nanteza
- AIDS Control Program, Ministry of Health, Nakasero, Uganda.,College of Health Sciences, School of Public Health, Department of Epidemiology and Biostatistics, Makerere University, Nakasero, Uganda
| | - Fredrick E Makumbi
- College of Health Sciences, School of Public Health, Department of Epidemiology and Biostatistics, Makerere University, Nakasero, Uganda
| | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Serwadda
- College of Health Sciences, School of Public Health, Department of Disease Control and Environmental Health, Makerere University, Nakasero, Uganda
| | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Gilbertson A, Ongili B, Odongo FS, Hallfors DD, Rennie S, Kwaro D, Luseno WK. Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets. PLoS One 2019; 14:e0224548. [PMID: 31682626 PMCID: PMC6827911 DOI: 10.1371/journal.pone.0224548] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. Methods and results The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. Conclusion Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.
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Affiliation(s)
- Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | | | | | - Denise D. Hallfors
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
| | - Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
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Njeuhmeli E, Opuni M, Schnure M, Tchuenche M, Stegman P, Gold E, Kiggundu V, Parks N, Seifert Ahanda K, Carrasco M, Kripke K. Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries. Clin Infect Dis 2019; 66:S166-S172. [PMID: 29617778 DOI: 10.1093/cid/cix969] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background The new World Health Organization and Joint United Nations Programme on HIV/AIDS strategic framework for voluntary medical male circumcision (VMMC) aims to increase VMMC coverage among males aged 10-29 years in priority settings to 90% by 2021. We use mathematical modeling to assess the likelihood that selected countries will achieve this objective, given their historical VMMC progress and current implementation options. Methods We use the Decision Makers' Program Planning Toolkit, version 2, to examine 4 ambitious but feasible scenarios for scaling up VMMC coverage from 2017 through 2021, inclusive in Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, and Zimbabwe. Results Tanzania is the only country that would reach the goal of 90% VMMC coverage in 10- to 29-year-olds by the end of 2021 in the scenarios assessed, and this was true in 3 of the scenarios studied. Mozambique, South Africa, and Lesotho would come close to reaching the objective only in the most ambitious scenario examined. Conclusions Major changes in VMMC implementation in most countries will be required to increase the proportion of circumcised 10- to 29-year-olds to 90% by the end of 2021. Scaling up VMMC coverage in males aged 10-29 years will require significantly increasing the number of circumcisions provided to 10- to 14-year-olds and 15- to 29-year-olds.
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Affiliation(s)
- Emmanuel Njeuhmeli
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia
| | | | | | | | | | - Elizabeth Gold
- Johns Hopkins Center for Communication Programs, Baltimore, Maryland
| | - Valerian Kiggundu
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia
| | - Nida Parks
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia
| | - Kim Seifert Ahanda
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia
| | - Maria Carrasco
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia.,Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Torres-Rueda S, Wambura M, Weiss HA, Plotkin M, Kripke K, Chilongani J, Mahler H, Kuringe E, Makokha M, Hellar A, Schutte C, Kazaura KJ, Simbeye D, Mshana G, Larke N, Lija G, Changalucha J, Vassall A, Hayes R, Grund JM, Terris-Prestholt F. Cost and Cost-Effectiveness of a Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision in Tanzania: Spending More to Spend Less. J Acquir Immune Defic Syndr 2019; 78:291-299. [PMID: 29557854 PMCID: PMC6012046 DOI: 10.1097/qai.0000000000001682] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20–34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20–34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness. Setting: Tanzania (Njombe and Tabora regions). Methods: Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios. Results: Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and $130 in Njombe, and in the control arms $70 and $191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed. Conclusions: Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving.
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Affiliation(s)
- Sergio Torres-Rueda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mwita Wambura
- National Institute for Medical Research (NIMR), Mwanza, Tanzania
| | - Helen A Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Marya Plotkin
- Jhpiego Tanzania, Dar es Salaam, Tanzania.,Currently, Jhpiego, Baltimore, MD
| | | | - Joseph Chilongani
- National Institute for Medical Research (NIMR), Mwanza, Tanzania.,Currently, District Commissioner's Office, Meatu, Simiyu, Tanzania
| | - Hally Mahler
- Jhpiego Tanzania, Dar es Salaam, Tanzania.,Current, FHI360, Washington, DC
| | - Evodius Kuringe
- National Institute for Medical Research (NIMR), Mwanza, Tanzania
| | | | | | - Carl Schutte
- Strategic Development Consultants, Durban, South Africa
| | - Kokuhumbya J Kazaura
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Dar es Salaam, Tanzania
| | - Daimon Simbeye
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Dar es Salaam, Tanzania
| | - Gerry Mshana
- National Institute for Medical Research (NIMR), Mwanza, Tanzania
| | - Natasha Larke
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gissenge Lija
- Ministry of Health and Social Welfare, National AIDS Control Program, Dar es Salaam, Tanzania
| | - John Changalucha
- National Institute for Medical Research (NIMR), Mwanza, Tanzania
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Richard Hayes
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jonathan M Grund
- Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Atlanta, GA.,Currently, Centers for Disease Control and Prevention, Center for Global Health, Division of Global HIV & TB, Pretoria, South Africa
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Dent J, Gaspar N, Njeuhmeli E, Kripke K. Age targeting and scale-up of voluntary medical male circumcision in Mozambique. PLoS One 2019; 14:e0211958. [PMID: 30794561 PMCID: PMC6386365 DOI: 10.1371/journal.pone.0211958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/24/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The voluntary medical male circumcision (VMMC) program in Mozambique aimed to increase male circumcision (MC) coverage to 80 percent among males ages 10 to 49 by 2018. Given the difficulty in attracting adult men over age 20 for circumcision, Mozambique became interested in assessing its age-targeting strategy and progress at the provincial level to inform program planning. METHODS We examined the impact and cost-effectiveness of circumcising different age groups of men using the Decision Makers' Program Planning Toolkit, Version 2.1 (DMPPT 2). We also applied the model to assess the scale-up efforts through the end of September 2017 and project their impact on HIV incidence through 2030. The DMPPT 2 is a compartmental Excel-based model that analyzes the effects of age at circumcision on program impact and cost-effectiveness. The model tracks changes in age-specific MC coverage due to VMMC program circumcisions. Baseline MC prevalence was based on data from the 2011 Demographic and Health Survey. The DMPPT 2 was populated with HIV incidence projections from Spectrum/Goals under an assumption that Mozambique would reach its national targets for HIV treatment and prevention by 2022. RESULTS We estimate the VMMC program increased MC coverage among males ages 10 to 49 from 27 percent in 2009 to 48 percent by end of September 2017. Coverage increased primarily in males ages 10 to 29. VMMCs conducted in the national program through the end of September 2017 are projected to avert 67,076 HIV infections from 2010 to 2030. Scaling up circumcisions in males ages 20 to 29 will have the most immediate impact on HIV incidence, while the greatest impact over a 15-year period is obtained by circumcising males ages 15 to 24 in the majority of priority provinces. Circumcising 80 percent of males ages 10 to 29 can achieve 77 percent of the impact through 2030 compared with circumcising 80 percent of males ages 10 to 49. CONCLUSION The VMMC program in Mozambique has made great strides in increasing MC coverage, particularly for males ages 10 to 29. Scaling up and maintaining MC coverage in this age group offers an attainable and cost-effective target for VMMC in Mozambique.
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Affiliation(s)
- Juan Dent
- The Palladium Group, Washington DC, United States of America
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Data triangulation to estimate age-specific coverage of voluntary medical male circumcision for HIV prevention in four Kenyan counties. PLoS One 2018; 13:e0209385. [PMID: 30562394 PMCID: PMC6298728 DOI: 10.1371/journal.pone.0209385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/04/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Kenya is 1 of 14 priority countries in Africa scaling up voluntary medical male circumcision (VMMC) for HIV prevention following the recommendations of the World Health Organization and the Joint United Nations Programme on HIV/AIDS. To inform VMMC target setting, we modeled the impact of circumcising specific client age groups across several Kenyan geographic areas. METHODS The Decision Makers' Program Planning Tool, Version 2 (DMPPT 2) was applied in Kisumu, Siaya, Homa Bay, and Migori counties. Initial modeling done in mid-2016 showed coverage estimates above 100% in age groups and geographic areas where demand for VMMC continued to be high. On the basis of information obtained from country policy makers and VMMC program implementers, we adjusted circumcision coverage for duplicate reporting, county-level population estimates, migration across county boundaries for VMMC services, and replacement of traditional circumcision with circumcisions in the VMMC program. To address residual inflated coverage following these adjustments we applied county-specific correction factors computed by triangulating model results with coverage estimates from population surveys. RESULTS A program record review identified duplicate reporting in Homa Bay, Kisumu, and Siaya. Using county population estimates from the Kenya National Bureau of Statistics, we found that adjusting for migration and correcting for replacement of traditional circumcision with VMMC led to lower estimates of 2016 male circumcision coverage especially for Kisumu, Migori, and Siaya. Even after addressing these issues, overestimation of 2016 male circumcision coverage persisted, especially in Homa Bay. We estimated male circumcision coverage in 2016 by applying correction factors. Modeled estimates for 2016 circumcision coverage for the 10- to 14-year age group ranged from 50% in Homa Bay to approximately 90% in Kisumu. Results for the 15- to 19-year age group suggest almost complete coverage in Kisumu, Migori, and Siaya. Coverage for the 20- to 24-year age group ranged from about 80% in Siaya to about 90% in Homa Bay, coverage for those aged 25-29 years ranged from about 60% in Siaya to 80% in Migori, and coverage in those aged 30-34 years ranged from about 50% in Siaya to about 70% in Migori. CONCLUSIONS Our analysis points to solutions for some of the data issues encountered in Kenya. Kenya is the first country in which these data issues have been encountered because baseline circumcision rates were high. We anticipate that some of the modeling methods we developed for Kenya will be applicable in other countries.
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Nanteza BM, Serwadda D, Kankaka EN, Mongo GB, Gray R, Makumbi FE. Knowledge on voluntary medical male circumcision in a low uptake setting in northern Uganda. BMC Public Health 2018; 18:1278. [PMID: 30453966 PMCID: PMC6245765 DOI: 10.1186/s12889-018-6158-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/26/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Free VMMC services have been available in Uganda since 2010. However, uptake in Northern Uganda remains disproportionately low. We aimed to determine if this is due to men's insufficient knowledge on VMMC, and if women's knowledge on VMMC has any association with VMMC status of their male sexual partners. METHODS In this cross sectional study, participants were asked their circumcision status (or that of their male sexual partner for female respondents) and presented with 14 questions on VMMC benefits, procedure, risk, and misconceptions. Chi square tests or fisher exact tests were used to compare circumcision prevalence among those who gave correct responses versus those who failed to and if p < 0.05, the comparison groups were balanced with propensity score weights in modified poisson models to estimate prevalence ratios, PR. RESULTS A total of 396 men and 50 women were included in the analyses. Circumcision was 42% less prevalent among males who failed to reject the misconception that VMMC reduces sexual performance (PR = 0.58, 95% CI 0.38-0.89, p = 0.012), and less prevalent among male sexual partners of females who failed to reject the same misconception (PR = 0.22, 95% CI = 0.07-0.76, p = 0.016). Circumcision was also 35% less prevalent among male respondents who failed to reject the misconception that VMMC increases a man's desire for more sexual partners i.e. promiscuity (PR = 0.65, 95% CI = 0.46-0.92, p = 0.014). CONCLUSION Misconceptions regarding change in sexual drive or performance were associated with circumcision status in this population, while knowledge of VMMC benefits, risks and procedure was not.
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Affiliation(s)
- Barbara Marjorie Nanteza
- Department of epidemiology and biostatistics, Makerere University School of Public Health, Kampala, Uganda
- Uganda Ministry of Health, AIDS Control Program- National Male Circumcision office, Kampala, Uganda
| | - David Serwadda
- Department of epidemiology and biostatistics, Makerere University School of Public Health, Kampala, Uganda
- Rakai Health Sciences Program, Department of Grants, Training & Science, Rakai, Uganda
| | - Edward Nelson Kankaka
- Rakai Health Sciences Program, Department of Grants, Training & Science, Rakai, Uganda
| | - Grace Bua Mongo
- Rakai Health Sciences Program, Department of Grants, Training & Science, Rakai, Uganda
| | - Ronald Gray
- Johns Hopkins Bloomberg School of Public health, Department of Epidemiology, Baltimore, MD USA
| | - Frederick Edward Makumbi
- Department of epidemiology and biostatistics, Makerere University School of Public Health, Kampala, Uganda
- Rakai Health Sciences Program, Department of Grants, Training & Science, Rakai, Uganda
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Davis SM, Hines JZ, Habel M, Grund JM, Ridzon R, Baack B, Davitte J, Thomas A, Kiggundu V, Bock N, Pordell P, Cooney C, Zaidi I, Toledo C. Progress in voluntary medical male circumcision for HIV prevention supported by the US President's Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data. BMJ Open 2018; 8:e021835. [PMID: 30173159 PMCID: PMC6120649 DOI: 10.1136/bmjopen-2018-021835] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This article provides an overview and interpretation of the performance of the US President's Emergency Plan for AIDS Relief's (PEPFAR's) male circumcision programme which has supported the majority of voluntary medical male circumcisions (VMMCs) performed for HIV prevention, from its 2007 inception to 2017, and client characteristics in 2017. DESIGN Longitudinal collection of routine programme data and disaggregations. SETTING 14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes. PARTICIPANTS Clients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above. MAIN OUTCOME MEASURES Numbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance. RESULTS PEPFAR supported a total of 15 269 720 circumcisions in 14 countries in Southern and Eastern Africa. In 2017, 45% of clients were under 15 years of age, 8% had unknown HIV status, 1% of those tested were HIV+ and 84% returned for a follow-up visit within 14 days of circumcision. CONCLUSIONS Over 15 million VMMCs have been supported by PEPFAR since 2007. VMMC continues to attract primarily young clients. The non-trivial proportion of clients not testing for HIV is expected, and may be reassuring that testing is not being presented as mandatory for access to circumcision, or in some cases reflect test kit stockouts or recent testing elsewhere. While VMMC is extremely safe, achieving the highest possible follow-up rates for early diagnosis and intervention on complications is crucial, and programmes continue to work to raise follow-up rates. The VMMC programme has achieved rapid scale-up but continues to face challenges, and new approaches may be needed to achieve the new Joint United Nations Programme on HIV/AIDS goal of 27 million additional circumcisions through 2020.
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Affiliation(s)
- Stephanie M Davis
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonas Z Hines
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa Habel
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonathan M Grund
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Renee Ridzon
- President's Emergency Plan for AIDS Relief, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Brittney Baack
- Division of Global HIV and TB, Monitoring, Evaluation, and Data Analytics Branch, Clinical Monitoring and Evaluation Team, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jonathan Davitte
- US Department of Defense HIV/AIDS Prevention Program (DHAPP), Naval Health Research Center, San Diego, California, USA
| | - Anne Thomas
- US Department of Defense HIV/AIDS Prevention Program (DHAPP), Naval Health Research Center, San Diego, California, USA
| | - Valerian Kiggundu
- United States Agency for International Development, Global Health Bureau, Office of HIV/AIDS, Prevention, Care and Treatment Division, Washington, District of Columbia, USA
| | - Naomi Bock
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Paran Pordell
- Division of Global HIV and TB, Monitoring, Evaluation, and Data Analytics Branch, Clinical Monitoring and Evaluation Team, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Caroline Cooney
- President's Emergency Plan for AIDS Relief, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Irum Zaidi
- President's Emergency Plan for AIDS Relief, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, District of Columbia, USA
| | - Carlos Toledo
- Division of Global HIV and TB, HIV Prevention Branch, Voluntary Medical Male Circumcision Team, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Miiro G, DeCelles J, Rutakumwa R, Nakiyingi-Miiro J, Muzira P, Ssembajjwe W, Musoke S, Gibson LJ, Hershow RB, Francis S, Torondel B, Ross DA, Weiss HA. Soccer-based promotion of voluntary medical male circumcision: A mixed-methods feasibility study with secondary students in Uganda. PLoS One 2017; 12:e0185929. [PMID: 29016651 PMCID: PMC5633183 DOI: 10.1371/journal.pone.0185929] [Citation(s) in RCA: 9] [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: 03/13/2017] [Accepted: 09/21/2017] [Indexed: 11/18/2022] Open
Abstract
The Ugandan government is committed to scaling-up proven HIV prevention strategies including safe male circumcision, and innovative strategies are needed to increase circumcision uptake. The aim of this study was to assess the acceptability and feasibility of implementing a soccer-based intervention (“Make The Cut”) among schoolboys in a peri-urban district of Uganda. The intervention was led by trained, recently circumcised “coaches” who facilitated a 60-minute session delivered in schools, including an interactive penalty shoot-out game using metaphors for HIV prevention, sharing of the coaches’ circumcision story, group discussion and ongoing engagement from the coach to facilitate linkage to male circumcision. The study took place in four secondary schools in Entebbe sub-district, Uganda. Acceptability of safe male circumcision was assessed through a cross-sectional quantitative survey. The feasibility of implementing the intervention was assessed by piloting the intervention in one school, modifying it, and implementing the modified version in a second school. Perceptions of the intervention were assessed with in-depth interviews with participants. Of the 210 boys in the cross-sectional survey, 59% reported being circumcised. Findings showed high levels of knowledge and generally favourable perceptions of circumcision. The initial implementation of Make The Cut resulted in 6/58 uncircumcised boys (10.3%) becoming circumcised. Changes made included increasing engagement with parents and improved liaison with schools regarding the timing of the intervention. Following this, uptake improved to 18/69 (26.1%) in the second school. In-depth interviews highlighted the important role of family and peer support and the coach in facilitating the decision to circumcise. This study showed that the modified Make The Cut intervention may be effective to increase uptake of safe male circumcision in this population. However, the intervention is time-intensive, and further work is needed to assess the cost-effectiveness of the intervention conducted at scale.
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Affiliation(s)
- George Miiro
- Uganda Virus Research Institute, Entebbe, Uganda
| | - Jeff DeCelles
- Grassroot Soccer, Cape Town, South Africa
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - Rwamahe Rutakumwa
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Jessica Nakiyingi-Miiro
- Medical Research Council/Uganda Virus Research Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | | | | | - Lorna J. Gibson
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rebecca B. Hershow
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - Suzanna Francis
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Belen Torondel
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David A. Ross
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Swizterland
| | - Helen A. Weiss
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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12
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Correction: Modeling the Impact of Uganda's Safe Male Circumcision Program: Implications for Age and Regional Targeting. PLoS One 2017; 12:e0169699. [PMID: 28046081 PMCID: PMC5207635 DOI: 10.1371/journal.pone.0169699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
Voluntary Medical Male Circumcision (VMMC) for human immunodeficiency virus (HIV) prevention has scaled up rapidly among young men in western Kenya since 2008. Whether the program has successfully reached uncircumcised men evenly across the region is largely unknown. Using data from two cluster randomized surveys from the 2008 and 2014 Kenyan Demographic Health Survey (KDHS), we mapped the continuous spatial distribution of circumcised men by age group across former Nyanza Province to identify geographic areas where local circumcision prevalence is lower than the overall, regional prevalence. The prevalence of self-reported circumcision among men 15 to 49 across six counties in former Nyanza Province increased from 45.6% (95% CI = 33.2-58.0%) in 2008 to 71.4% (95% CI = 67.4-75.0%) in 2014, with the greatest increase in men 15 to 24 years of age, from 40.4% (95% CI = 27.7-55.0%) in 2008 to 81.6% (95% CI = 77.2-85.0%) in 2014. Despite the dramatic scale-up of VMMC in western Kenya, circumcision coverage in parts of Kisumu, Siaya, and Homa Bay counties was lower than expected (P < 0.05), with up to 50% of men aged 15 to 24 still uncircumcised by 2014 in some areas. The VMMC program has proven successful in reaching a large population of uncircumcised men in western Kenya, but as of 2014, pockets of low circumcision coverage still existed. Closing regional gaps in VMMC prevalence to reach 80% coverage may require targeting specific areas where VMMC prevalence is lower than expected.
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Affiliation(s)
| | - Mathews Onyango
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | | | - Jacob Odhiambo
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
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Kripke K, Hatzold K, Mugurungi O, Ncube G, Xaba S, Gold E, Ahanda KS, Kruse-Levy N, Njeuhmeli E. Modeling Impact and Cost-Effectiveness of Increased Efforts to Attract Voluntary Medical Male Circumcision Clients Ages 20-29 in Zimbabwe. PLoS One 2016; 11:e0164144. [PMID: 27783637 PMCID: PMC5082672 DOI: 10.1371/journal.pone.0164144] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Zimbabwe aims to increase circumcision coverage to 80% among 13- to 29-year-olds. However, implementation data suggest that high coverage among men ages 20 and older may not be achievable without efforts specifically targeted to these men, incurring additional costs per circumcision. Scale-up scenarios were created based on trends in implementation data in Zimbabwe, and the cost-effectiveness of increasing efforts to recruit clients ages 20-29 was examined. METHODS Zimbabwe voluntary medical male circumcision (VMMC) program data were used to project trends in male circumcision coverage by age into the future. The projection informed a base scenario in which, by 2018, the country achieves 80% circumcision coverage among males ages 10-19 and lower levels of coverage among men above age 20. The Zimbabwe DMPPT 2.0 model was used to project costs and impacts, assuming a US$109 VMMC unit cost in the base scenario and a 3% discount rate. Two other scenarios assumed that the program could increase coverage among clients ages 20-29 with a corresponding increase in unit cost for these age groups. RESULTS When circumcision coverage among men ages 20-29 is increased compared with a base scenario reflecting current implementation trends, fewer VMMCs are required to avert one infection. If more than 50% additional effort (reflected as multiplying the unit cost by >1.5) is required to double the increase in coverage among this age group compared with the base scenario, the cost per HIV infection averted is higher than in the base scenario. CONCLUSIONS Although increased investment in recruiting VMMC clients ages 20-29 may lead to greater overall impact if recruitment efforts are successful, it may also lead to lower cost-effectiveness, depending on the cost of increasing recruitment. Programs should measure the relationship between increased effort and increased ability to attract this age group.
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Affiliation(s)
- Katharine Kripke
- Health Policy Project, Avenir Health, Washington, District of Columbia, United States of America
| | | | - Owen Mugurungi
- Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Gertrude Ncube
- Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Elizabeth Gold
- Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kim Seifert Ahanda
- The United States Agency for International Development (USAID), Washington, District of Columbia, United States of America
| | | | - Emmanuel Njeuhmeli
- The United States Agency for International Development (USAID), Washington, District of Columbia, United States of America
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15
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Hankins C, Warren M, Njeuhmeli E. Voluntary Medical Male Circumcision for HIV Prevention: New Mathematical Models for Strategic Demand Creation Prioritizing Subpopulations by Age and Geography. PLoS One 2016; 11:e0160699. [PMID: 27783613 PMCID: PMC5082625 DOI: 10.1371/journal.pone.0160699] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Over 11 million voluntary medical male circumcisions (VMMC) have been performed of the projected 20.3 million needed to reach 80% adult male circumcision prevalence in priority sub-Saharan African countries. Striking numbers of adolescent males, outside the 15-49-year-old age target, have been accessing VMMC services. What are the implications of overall progress in scale-up to date? Can mathematical modeling provide further insights on how to efficiently reach the male circumcision coverage levels needed to create and sustain further reductions in HIV incidence to make AIDS no longer a public health threat by 2030? Considering ease of implementation and cultural acceptability, decision makers may also value the estimates that mathematical models can generate of immediacy of impact, cost-effectiveness, and magnitude of impact resulting from different policy choices. This supplement presents the results of mathematical modeling using the Decision Makers' Program Planning Tool Version 2.0 (DMPPT 2.0), the Actuarial Society of South Africa (ASSA2008) model, and the age structured mathematical (ASM) model. These models are helping countries examine the potential effects on program impact and cost-effectiveness of prioritizing specific subpopulations for VMMC services, for example, by client age, HIV-positive status, risk group, and geographical location. The modeling also examines long-term sustainability strategies, such as adolescent and/or early infant male circumcision, to preserve VMMC coverage gains achieved during rapid scale-up. The 2016-2021 UNAIDS strategy target for VMMC is an additional 27 million VMMC in high HIV-prevalence settings by 2020, as part of access to integrated sexual and reproductive health services for men. To achieve further scale-up, a combination of evidence, analysis, and impact estimates can usefully guide strategic planning and funding of VMMC services and related demand-creation strategies in priority countries. Mid-course corrections now can improve cost-effectiveness and scale to achieve the impact needed to help turn the HIV pandemic on its head within 15 years.
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Affiliation(s)
- Catherine Hankins
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | | | - Emmanuel Njeuhmeli
- USAID, Washington, District of Columbia, United States of America
- * E-mail:
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Kripke K, Njeuhmeli E, Samuelson J, Schnure M, Dalal S, Farley T, Hankins C, Thomas AG, Reed J, Stegman P, Bock N. Assessing Progress, Impact, and Next Steps in Rolling Out Voluntary Medical Male Circumcision for HIV Prevention in 14 Priority Countries in Eastern and Southern Africa through 2014. PLoS One 2016; 11:e0158767. [PMID: 27441648 PMCID: PMC4955652 DOI: 10.1371/journal.pone.0158767] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 06/17/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries across eastern and southern Africa for scaling up voluntary medical male circumcision (VMMC) services. Several years into this effort, we reflect on progress. METHODS Using the Decision Makers' Program Planning Tool (DMPPT) 2.1, we assessed age-specific impact, cost-effectiveness, and coverage attributable to circumcisions performed through 2014. We also compared impact of actual progress to that of achieving 80% coverage among men ages 15-49 in 12 VMMC priority countries and Nyanza Province, Kenya. We populated the models with age-disaggregated VMMC service statistics and with population, mortality, and HIV incidence and prevalence projections exported from country-specific Spectrum/Goals files. We assumed each country achieved UNAIDS' 90-90-90 treatment targets. RESULTS More than 9 million VMMCs were conducted through 2014: 43% of the estimated 20.9 million VMMCs required to reach 80% coverage by the end of 2015. The model assumed each country reaches the UNAIDS targets, and projected that VMMCs conducted through 2014 will avert 240,000 infections by the end of 2025, compared to 1.1 million if each country had reached 80% coverage by the end of 2015. The median estimated cost per HIV infection averted was $4,400. Nyanza Province in Kenya, the 11 priority regions in Tanzania, and Uganda have reached or are approaching MC coverage targets among males ages 15-24, while coverage in other age groups is lower. Across all countries modeled, more than half of the projected HIV infections averted were attributable to circumcising 10- to 19-year-olds. CONCLUSIONS The priority countries have made considerable progress in VMMC scale-up, and VMMC remains a cost-effective strategy for epidemic impact, even assuming near-universal HIV diagnosis, treatment coverage, and viral suppression. Examining circumcision coverage by five-year age groups will inform countries' decisions about next steps.
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Affiliation(s)
- Katharine Kripke
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- U.S. Agency for International Development, Washington, District of Columbia, United States of America
| | | | - Melissa Schnure
- Project SOAR, Palladium Group, Washington, District of Columbia, United States of America
| | - Shona Dalal
- World Health Organization, Geneva, Switzerland
| | | | - Catherine Hankins
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Anne G. Thomas
- Naval Health Research Center, US Department of Defense, San Diego, California, United States of America
| | - Jason Reed
- Jhpiego, Washington, District of Columbia, United States of America
| | - Peter Stegman
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Naomi Bock
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Kripke K, Opuni M, Schnure M, Sgaier S, Castor D, Reed J, Njeuhmeli E, Stover J. Age Targeting of Voluntary Medical Male Circumcision Programs Using the Decision Makers' Program Planning Toolkit (DMPPT) 2.0. PLoS One 2016; 11:e0156909. [PMID: 27410966 PMCID: PMC4943717 DOI: 10.1371/journal.pone.0156909] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 05/20/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Despite considerable efforts to scale up voluntary medical male circumcision (VMMC) for HIV prevention in priority countries over the last five years, implementation has faced important challenges. Seeking to enhance the effect of VMMC programs for greatest and most immediate impact, the U. S. President's Plan for AIDS Relief (PEPFAR) supported the development and application of a model to inform national planning in five countries from 2013-2014. METHODS AND FINDINGS The Decision Makers' Program Planning Toolkit (DMPPT) 2.0 is a simple compartmental model designed to analyze the effects of client age and geography on program impact and cost. The DMPPT 2.0 model was applied in Malawi, South Africa, Swaziland, Tanzania, and Uganda to assess the impact and cost of scaling up age-targeted VMMC coverage. The lowest number of VMMCs per HIV infection averted would be produced by circumcising males ages 20-34 in Malawi, South Africa, Tanzania, and Uganda and males ages 15-34 in Swaziland. The most immediate impact on HIV incidence would be generated by circumcising males ages 20-34 in Malawi, South Africa, Tanzania, and Uganda and males ages 20-29 in Swaziland. The greatest reductions in HIV incidence over a 15-year period would be achieved by strategies focused on males ages 10-19 in Uganda, 15-24 in Malawi and South Africa, 10-24 in Tanzania, and 15-29 in Swaziland. In all countries, the lowest cost per HIV infection averted would be achieved by circumcising males ages 15-34, although in Uganda this cost is the same as that attained by circumcising 15- to 49-year-olds. CONCLUSIONS The efficiency, immediacy of impact, magnitude of impact, and cost-effectiveness of VMMC scale-up are not uniform; there is important variation by age group of the males circumcised and countries should plan accordingly.
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Affiliation(s)
- Katharine Kripke
- Health Policy Project, Avenir Health, Washington, DC, United States of America
| | - Marjorie Opuni
- United Nations Joint Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Melissa Schnure
- Health Policy Project, Futures Group, Washington, DC, United States of America
| | - Sema Sgaier
- Bill & Melinda Gates Foundation, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Delivette Castor
- Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, United States of America
| | - Jason Reed
- Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, United States of America
| | | | - John Stover
- Health Policy Project, Avenir Health, Glastonbury, CT, United States of America
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Kripke K, Okello V, Maziya V, Benzerga W, Mirira M, Gold E, Schnure M, Sgaier S, Castor D, Reed J, Njeuhmeli E. Voluntary Medical Male Circumcision for HIV Prevention in Swaziland: Modeling the Impact of Age Targeting. PLoS One 2016; 11:e0156776. [PMID: 27410687 PMCID: PMC4943626 DOI: 10.1371/journal.pone.0156776] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 05/19/2016] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) for HIV prevention has been a priority for Swaziland since 2009. Initially focusing on men ages 15-49, the Ministry of Health reduced the minimum age for VMMC from 15 to 10 years in 2012, given the existing demand among 10- to 15-year-olds. To understand the implications of focusing VMMC service delivery on specific age groups, the MOH undertook a modeling exercise to inform policy and implementation in 2013-2014. METHODS AND FINDINGS The impact and cost of circumcising specific age groups were assessed using the Decision Makers' Program Planning Tool, Version 2.0 (DMPPT 2.0), a simple compartmental model. We used age-specific HIV incidence from the Swaziland HIV Incidence Measurement Survey (SHIMS). Population, mortality, births, and HIV prevalence were imported from a national Spectrum/Goals model recently updated in consultation with country stakeholders. Baseline male circumcision prevalence was derived from the most recent Swaziland Demographic and Health Survey. The lowest numbers of VMMCs per HIV infection averted are achieved when males ages 15-19, 20-24, 25-29, and 30-34 are circumcised, although the uncertainty bounds for the estimates overlap. Circumcising males ages 25-29 and 20-24 provides the most immediate reduction in HIV incidence. Circumcising males ages 15-19, 20-24, and 25-29 provides the greatest magnitude incidence reduction within 15 years. The lowest cost per HIV infection averted is achieved by circumcising males ages 15-34: $870 U.S. dollars (USD). CONCLUSIONS The potential impact, cost, and cost-effectiveness of VMMC scale-up in Swaziland are not uniform. They vary by the age group of males circumcised. Based on the results of this modeling exercise, the Ministry of Health's Swaziland Male Circumcision Strategic and Operational Plan 2014-2018 adopted an implementation strategy that calls for circumcision to be scaled up to 50% coverage for neonates, 80% among males ages 10-29, and 55% among males ages 30-34.
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Affiliation(s)
- Katharine Kripke
- Health Policy Project, Avenir Health, Washington, DC, United States of America
| | | | | | - Wendy Benzerga
- U. S. Agency for International Development (USAID), Mbabane, Swaziland
| | - Munamato Mirira
- U. S. Agency for International Development (USAID), Mbabane, Swaziland
| | - Elizabeth Gold
- Johns Hopkins Center for Communication Programs, Baltimore, MD, United States of America
| | - Melissa Schnure
- Health Policy Project, the Palladium Group, Washington, DC, United States of America
| | - Sema Sgaier
- Bill & Melinda Gates Foundation, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | | | - Jason Reed
- Jhpiego, Baltimore, MD, United States of America
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