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Luvuno ZPB, Wiafe E, Mpofana N, Urusla MM, Nxumalo CT. Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review. Afr J Prim Health Care Fam Med 2024; 16:e1-e12. [PMID: 38708735 PMCID: PMC11079388 DOI: 10.4102/phcfm.v16i1.4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Targeted interventions for key populations remain critical for realisation of epidemic control for human immunodeficiency virus (HIV) infection because of the causal relationship between HIV infection in the general population and among key population groups. AIM To consolidate evidence on the fast-track interventions towards achieving HIV epidemic control among key populations. METHODS A rapid scoping review was conducted using the methodological framework by Arksey and O' Malley. The Population, Intervention, Context and Outcome (PICO) framework was used to identify relevant studies using key words with Boolean operators in electronic data bases, namely CINHAL, Web of Science, Psych Info and Sabinet. Studies were extracted using a modified data extraction tool, and results were presented narratively. RESULTS A total of 19 articles were included in this review. Most articles were primary studies (n = 17), while another involved the review of existing literature and policies (n = 2) and routinely collected data (n = 1). Most studies were conducted in the United States of America (n = 6), while another were conducted in China, Kenya, Botswana, South Africa and Mozambique. All studies revealed findings on tested interventions to achieve HIV epidemic control among key populations. CONCLUSION Effective interventions for HIV epidemic control were stand-alone behavioural preventive interventions, stand-alone biomedical preventive strategies and combination prevention approaches. Furthermore, the findings suggest that effective activities to achieve HIV epidemic control among key populations should be centred around prevention.Contribution: The findings of this study have policy and practice implications for high HIV burden settings such as South Africa in terms of interventions to facilitate realisation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets, thereby contributing to HIV epidemic control.
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Affiliation(s)
- Zamasomi P B Luvuno
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Howard Campus, Durban.
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Peck ME, Ong K, Lucas T, Thomas AG, Wandira R, Ntwaaga B, Mkhontfo M, Zegeye T, Yohannes F, Mulatu D, Gultie T, Juma AW, Odoyo-June E, Maida A, Msungama W, Canda M, Mutandi G, Zemburuka BLT, Kankindi I, Vranken P, Maphothi N, Loykissoonlal D, Bunga S, Grund JM, Kazaura KJ, Kabuye G, Chituwo O, Muyunda B, Kamboyi R, Lingenda G, Mandisarisa J, Peterson A, Malaba R, Xaba S, Moyo T, Toledo C. Preventing HIV Among Adolescent Boys and Young Men Through PEPFAR-Supported Voluntary Medical Male Circumcision in 15 Sub-Saharan African Countries, 2018-2021. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2023; 35:67-81. [PMID: 37406146 PMCID: PMC11002756 DOI: 10.1521/aeap.2023.35.suppa.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Voluntary medical male circumcision (VMMC) is an HIV prevention intervention that has predominantly targeted adolescent and young men, aged 10-24 years. In 2020, the age eligibility for VMMC shifted from 10 to 15 years of age. This report describes the VMMC client age distribution from 2018 to 2021, at the site, national, and regional levels, among 15 countries in southern and eastern Africa. Overall, in 2018 and 2019, the highest proportion of VMMCs were performed among 10-14-year-olds (45.6% and 41.2%, respectively). In 2020 and 2021, the 15-19-year age group accounted for the highest proportion (37.2% and 50.4%, respectively) of VMMCs performed across all age groups. Similarly, in 2021 at the site level, 68.1% of VMMC sites conducted the majority of circumcisions among men aged 15-24 years. This analysis highlights that adolescent boys and young men are the primary recipients of VMMC receiving an important lifetime reduction in HIV risk.
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Affiliation(s)
- Megan E Peck
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Katherine Ong
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Todd Lucas
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Anne G Thomas
- HIV/AIDS Prevention Program, U.S. Department of Defense, San Diego, California
| | - Ronald Wandira
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | - Mandzisi Mkhontfo
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Tiruneh Zegeye
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Fikirte Yohannes
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Dejene Mulatu
- Disease Prevention and Control Directorate Senior, HIV Prevention and Control Expert, Addis Ababa, Ethiopia
| | | | | | - Elijah Odoyo-June
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Alice Maida
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Wezi Msungama
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Marcos Canda
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Gram Mutandi
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Brigitte L T Zemburuka
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Ida Kankindi
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Peter Vranken
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Nandi Maphothi
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | - Sudhir Bunga
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Jonathan M Grund
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Kokuhumbya J Kazaura
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Geoffrey Kabuye
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Omega Chituwo
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Brian Muyunda
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | | | - John Mandisarisa
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Amy Peterson
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | - Rickie Malaba
- The following authors are affiliated with the respective country offices of the Division of Global HIV and TB, CGH, CDC: Ronald Wandira (Gaborone, Botswana), Mandzisi Mkhontfo (Mbabane, Eswatini), Tiruneh Zegeye, and Fikirte Yohannes (Addis Ababa, Ethiopia), Elijah Odoyo-June (Nairobi, Kenya), Alice Maida, and Wezi Msungama (Lilongwe, Malawi), Marcos Canda (Maputo, Mozambique), Gram Mutandi, and Brigitte L. T. Zemburuka (Windhoek, Namibia), Ida Kankindi (Kigali, Rwanda), Peter Vranken, and Nandi Maphothi (Pretoria, South Africa), Sudhir Bunga (Juba, South Sudan), Jonathan M. Grund, and Kokuhumbya J. Kazaura (Dar es Salaam, Tanzania), Geoffrey Kabuye (Kampala, Uganda), Omega Chituwo, and Brian Muyunda (Lusaka, Zambia), and John Mandisarisa, Amy Peterson, and Rickie Malaba (Harare, Zimbabwe)
| | | | - Talent Moyo
- Ministry of Health and Child Care, Harare, Zimbabwe
| | - Carlos Toledo
- Division of Global HIV and Tuberculosis (TB), Center for Global Health (CGH), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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Bowa K, Rodriguez VJ, Malik FS, Knight J, Cristofari N, Parrish MS, Jones DL, Zulu R, Weiss SM. Dissemination of the Spear & Shield Project using a Training of Trainers Model: A reflection on challenges and successes. Transl Behav Med 2022; 12:622-629. [PMID: 35312766 PMCID: PMC9154251 DOI: 10.1093/tbm/ibac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Several large-scale clinical trials have conclusively demonstrated that voluntary medical male circumcision (VMMC) could provide a 50%-70% reduction in HIV acquisition, but willingness to undergo VMMC has been lowest in Zambia compared to other countries in eastern and southern Africa. This manuscript describes training for "task-shifting" among local healthcare workers at Community Health Centers (CHCs) applying state of the art strategies (e.g., Training of Trainers, i.e., ToT, and Training of Facilitators, ToF) to provide novel clinical services. Staff at 96 CHCs from four Provinces in Zambia were sequentially trained to provide the Spear & Shield intervention. A total of 45,630 men (n = 23,236) and women (n = 22,394) volunteered to participate in the S&S intervention service program when offered in the CHCs. Group session (total = 5313 sessions; 2,736 men's and 2,582 women's sessions) were conducted over 4.5 years. Remarkably, both men and women's groups achieved 97% retention. Of these, 256 sessions recorded from 128 group leaders were assessed and scored for intervention fidelity; fidelity was 80%-90% among the majority of clinics. S&S program sustainment exceeded expectations among 85% of clinics (82/96) in all provinces across the duration of the study. Of note, attendance in the S&S program was encouraged by CHC staff, but no financial incentives were provided to those attending S&S. This study examined the effectiveness of the ToT/ToF model in dissemination of the S&S program, which proved to be feasible even in resource-limited settings. Benefits and challenges are discussed.
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Affiliation(s)
- Kasonde Bowa
- School of Medicine and Health Sciences, University of Lusaka, Lusaka, Zambia
| | - Violeta J Rodriguez
- Department of Psychology, University of Georgia, Athens, GA,USA
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Fayeza S Malik
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Jennifer Knight
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Nicholas Cristofari
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Manasi S Parrish
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Correspondence to: DL Jones,
| | - Robert Zulu
- Ministry of Health, Provincial Health Office, Ndola, Copperbelt,Zambia
- Department of Health Promotion and Education, University of Zambia, School of Public Health, Lusaka, Zambia
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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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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Hines JZ, Sachathep K, Pals S, Davis SM, Toledo C, Bronson M, Parekh B, Carrasco M, Xaba S, Mandisarisa J, Kamobyi R, Chituwo O, Kirungi WL, Alamo S, Kabuye G, Awor AC, Mmbando S, Simbeye D, Aupokolo MA, Zemburuka B, Nyirenda R, Msungama W, Tarumbiswa T, Manda R, Nuwagaba-Biribonwoha H, Kiggundu V, Thomas AG, Watts H, Voetsch AC, Williams DB. HIV Incidence by Male Circumcision Status From the Population-Based HIV Impact Assessment Surveys-Eight Sub-Saharan African Countries, 2015-2017. J Acquir Immune Defic Syndr 2021; 87:S89-S96. [PMID: 33765683 PMCID: PMC11187824 DOI: 10.1097/qai.0000000000002658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Male circumcision (MC) offers men lifelong partial protection from heterosexually acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally representative samples. Data from the population-based HIV impact assessments were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. METHODS Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random-effects logistic regression model using pooled survey weights. Analyses were age stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. RESULTS Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men [0.04% (95% CI: 0.00% to 0.10%) versus 0.34% (95% CI: 0.10% to 0.57%), respectively; P value = 0.01]; whereas among men 35-59 years, there was no significant incidence difference [1.36% (95% CI: 0.32% to 2.39%) versus 0.55% (95% CI: 0.14% to 0.67%), respectively; P value = 0.14]. DISCUSSION Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa.
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Affiliation(s)
- Jonas Z. Hines
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Karampreet Sachathep
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York
| | - Sherri Pals
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stephanie M. Davis
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos Toledo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Megan Bronson
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bharat Parekh
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maria Carrasco
- Office of HIV and AIDS, U.S. Agency for International Development, Washington, District of Columbia
| | | | - John Mandisarisa
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | | | - Omega Chituwo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - Stella Alamo
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Geoffrey Kabuye
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Anna Colletar Awor
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda
| | - Susan Mmbando
- National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Daimon Simbeye
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | - Mekondjo A. Aupokolo
- National HIV/AIDS, STI and Hepatitis Control Program, Ministry of Health and Social Services, Windhoek, Namibia
| | - Brigitte Zemburuka
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Windhoek, Namibia
| | | | - Wezi Msungama
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Robert Manda
- U.S. Agency for International Development, Maseru, Lesotho
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia University, Mbabane, Eswatini
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Valerian Kiggundu
- Office of HIV and AIDS, U.S. Agency for International Development, Washington, District of Columbia
| | - Anne G. Thomas
- Defense Health Agency, U.S. Department of Defense, San Diego, California
| | - Heather Watts
- Office of Global AIDS Coordinator, Washington, District of Columbia
| | - Andrew C. Voetsch
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dan B. Williams
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Odoyo-June E, Davis S, Owuor N, Laube C, Wambua J, Musingila P, Young PW, Aoko A, Agot K, Joseph R, Mwandi Z, Ojiambo V, Lucas T, Toledo C, Wanyonyi A. Prevalence of male circumcision in four culturally non-circumcising counties in western Kenya after 10 years of program implementation from 2008 to 2019. PLoS One 2021; 16:e0254140. [PMID: 34264971 PMCID: PMC8281999 DOI: 10.1371/journal.pone.0254140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 06/20/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Kenya started implementing voluntary medical male circumcision (VMMC) for HIV prevention in 2008 and adopted the use of decision makers program planning tool version 2 (DMPPT2) in 2016, to model the impact of circumcisions performed annually on the population prevalence of male circumcision (MC) in the subsequent years. Results of initial DMPPT2 modeling included implausible MC prevalence estimates, of up to 100%, for age bands whose sustained high uptake of VMMC pointed to unmet needs. Therefore, we conducted a cross-sectional survey among adolescents and men aged 10-29 years to determine the population level MC prevalence, guide target setting for achieving the goal of 80% MC prevalence and for validating DMPPT2 modelled estimates. METHODS Beginning July to September 2019, a total of 3,569 adolescents and men aged 10-29 years from households in Siaya, Kisumu, Homa Bay and Migori Counties were interviewed and examined to establish the proportion already circumcised medically or non-medically. We measured agreement between self-reported and physically verified circumcision status and computed circumcision prevalence by age band and County. All statistical were test done at 5% level of significance. RESULTS The observed MC prevalence for 15-29-year-old men was above 75% in all four counties; Homa Bay 75.6% (95% CI [69.0-81.2]), Kisumu 77.9% (95% CI [73.1-82.1]), Siaya 80.3% (95% CI [73.7-85.5]), and Migori 85.3% (95% CI [75.3-91.7]) but were 0.9-12.4% lower than DMPPT2-modelled estimates. For young adolescents 10-14 years, the observed prevalence ranged from 55.3% (95% CI [40.2-69.5]) in Migori to 74.9% (95% CI [68.8-80.2]) in Siaya and were 25.1-32.9% lower than DMMPT 2 estimates. Nearly all respondents (95.5%) consented to physical verification of their circumcision status with an agreement rate of 99.2% between self-reported and physically verified MC status (kappa agreement p-value<0.0001). CONCLUSION This survey revealed overestimation of MC prevalence from DMPPT2-model compared to the observed population MC prevalence and provided new reference data for setting realistic program targets and re-calibrating inputs into DMPPT2. Periodic population-based MC prevalence surveys, especially for established programs, can help reconcile inconsistencies between VMMC program uptake data and modeled MC prevalence estimates which are based on the number of procedures reported in the program annually.
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Affiliation(s)
- Elijah Odoyo-June
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | - Stephanie Davis
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB Atlanta, GA, United States of America
| | | | - Catey Laube
- Jhpiego, Baltimore, Maryland, United States of America
| | | | - Paul Musingila
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | - Peter W. Young
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | - Appolonia Aoko
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | - Kawango Agot
- Impact Research and Development Organization (IRDO), Kisumu, Kenya
| | - Rachael Joseph
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | | | | | - Todd Lucas
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB Atlanta, GA, United States of America
| | - Carlos Toledo
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB Atlanta, GA, United States of America
| | - Ambrose Wanyonyi
- National AIDS and STI Control Program (NASCOP), Ministry of Health, Nairobi, Kenya
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Korenromp EL, Bershteyn A, Mudimu E, Weiner R, Bonecwe C, Loykissoonlal D, Manuhwa C, Pretorius C, Teng Y, Stover J, Johnson LF. The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models. Gates Open Res 2021; 5:15. [PMID: 33615145 PMCID: PMC7878969 DOI: 10.12688/gatesopenres.13220.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/24/2022] Open
Abstract
Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.
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Affiliation(s)
| | - Anna Bershteyn
- Department of Population and Health, NYU Langone Medical Center, New York, NY, 11016, USA
| | - Edina Mudimu
- Department of Decision Sciences, University of South Africa (UNISA), Pretoria, 0003, South Africa
| | - Renay Weiner
- Research and Training for Health and Development, Johannesburg, 2196, South Africa
| | | | | | - Clarence Manuhwa
- FHI 360, Pretoria, 0083, South Africa
- Independent Consultant, Pretoria, 0083, South Africa
| | - Carel Pretorius
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Yu Teng
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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Integrating Economic Evaluation and Implementation Science to Advance the Global HIV Response. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S314-S321. [PMID: 31764269 DOI: 10.1097/qai.0000000000002219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous cost-effectiveness analyses have indicated good value for money from a wide array of interventions for treatment and prevention of HIV/AIDS. There is limited evidence, however, regarding how cost-effectiveness information contributes to better decision-making around investment and action in the global HIV response. METHODS We review challenges for economic evaluation relevant to the global HIV response and consider how the practice of cost-effectiveness analysis could integrate approaches and insights from implementation science to enhance the impact and efficiency of HIV investments. RESULTS In light of signals that cost-effectiveness analyses may be vulnerable to systematic bias toward overly optimistic conclusions, we emphasize two priorities for advancing the field of economic evaluation in HIV/AIDS and more broadly in global health: (1) systematic reevaluation of the cost-effectiveness literature with reference to ex-post empirical evidence on costs and effects in real-world programs and (2) development and adoption of good-practice guidelines for incorporating implementation and delivery aspects into economic evaluations. Toward the latter aim, we propose an integrative approach that focuses on comparative evaluation of strategies, which specify both technologies/interventions as well as the delivery platforms, complementary interventions, and actions needed to increase coverage, quality, and uptake of those technologies/interventions. Specific recommendations draw on several existing implementation science models that provide systematic frameworks for understanding implementation barriers and enablers, designing and choosing specific implementation and policy actions, and evaluating outcomes. DISCUSSION These preliminary steps aimed at bridging the divide between economic evaluation and implementation science can help to advance the practice of economic evaluation toward a science of comparative strategy evaluation.
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Nxumalo CT, Mchunu GG. Healthcare workers' perceptions and experiences of implementing voluntary medical male circumcision in KwaZulu-Natal, South Africa. Afr J Prim Health Care Fam Med 2020; 12:e1-e10. [PMID: 32242429 PMCID: PMC7160602 DOI: 10.4102/phcfm.v12i1.2253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/10/2019] [Accepted: 01/16/2020] [Indexed: 12/03/2022] Open
Abstract
Background Voluntary Medical Male Circumcision (VMMC) is an effective HIV prevention strategy prioritized by the World Health Organisation (WHO) for regions of high HIV prevalence, South Africa (SA) and in particular KwaZulu-Natal (KZN) is one of such regions. Since the roll out of VMMC in 2010 there has been little research conducted on the implementation of this service. Existing studies on the uptake of VMMC have mainly focused on service users resulting in a paucity of data on health care workers perspectives on the intervention. Aim To analyse health care workers’ perceptions and experiences of implementing voluntary medical male circumcision in KZN, SA. Setting The study took place at six different health districts and their six respective rural clinics in the KZN province of SA. Methods A qualitative approach using a phenomenographic design was employed. Data were collected from a sample of 18 participants comprising of health care providers (n = 12) and health policy makers (n = 6). Individual, face-to-face interviews were conducted using a semi-structured interview guide. An audiotape was used to record the data, which were transcribed verbatim and then analysed using a step-wise phenomenographic data analysis procedure. Results Participants reported that VMMC was implemented by the department of health with support from non-governmental organisations and private general practitioners. Negative perceptions and negative experiences regarding VMMC and implementation were reported. Conclusion The implementation of VMMC is compromised due to poor preparation and training of healthcare workers for implementing the service. Addressing health care workers’ needs for training and preparation is crucial for successful implementation of VMMC.
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Atkins K, Yeh PT, Kennedy CE, Fonner VA, Sweat MD, O’Reilly KR, Baggaley R, Rutherford GW, Samuelson J. Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review. PLoS One 2020; 15:e0227755. [PMID: 31929587 PMCID: PMC6957297 DOI: 10.1371/journal.pone.0227755] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 12/27/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (VMMC) remains an essential component of combination HIV prevention services, particularly in priority countries in sub-Saharan Africa. As VMMC programs seek to maximize impact and efficiency, and to support World Health Organization guidance, specific uptake-enhancing strategies are critical to identify. METHODS We systematically reviewed the literature to evaluate the impact of service delivery interventions (e.g., facility layout, service co-location, mobile outreach) on VMMC uptake among adolescent and adult men. For the main effectiveness review, we searched for publications or conference abstracts that measured VMMC uptake or uptake of HIV testing or risk reduction counselling within VMMC services. We synthesized data by coding categories and outcomes. We also reviewed studies assessing acceptability, values/preferences, costs, and feasibility. RESULTS Four randomized controlled trials and five observational studies were included in the effectiveness review. Studies took place in South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. They assessed a range of service delivery innovations, including community-, school-, and facility-based interventions. Overall, interventions increased VMMC uptake; some successfully improved uptake among age-specific subpopulations, but urban-rural stratification showed no clear trends. Interventions that increased adult men's uptake included mobile services (compared to static facilities), home-based testing with active referral follow-up, and facility-based HIV testing with enhanced comprehensive sexual education. Six acceptability studies suggested interventions were generally perceived to help men choose to get circumcised. Eleven cost studies suggested interventions create economies-of-scale and efficiencies. Three studies suggested such interventions were feasible, improving facility preparedness, service quality and quantity, and efficiencies. CONCLUSIONS Innovative changes in male-centered VMMC services can improve adult men's and adolescent boys' VMMC uptake. Limited evidence on interventions that enhance access and acceptability show promising results, but evidence gaps persist due to inconsistent intervention definition and delivery, due in part to contextual relevance and limited age disaggregation.
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Affiliation(s)
- Kaitlyn Atkins
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ping Teresa Yeh
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Caitlin E. Kennedy
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Virginia A. Fonner
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Michael D. Sweat
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Kevin R. O’Reilly
- Division of Global and Community Health, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Rachel Baggaley
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - George W. Rutherford
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Julia Samuelson
- Department of HIV, World Health Organization, Geneva, Switzerland
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Luseno WK, Field SH, Iritani BJ, Rennie S, Gilbertson A, Odongo FS, Kwaro D, Ongili B, Hallfors DD. Consent Challenges and Psychosocial Distress in the Scale-up of Voluntary Medical Male Circumcision Among Adolescents in Western Kenya. AIDS Behav 2019; 23:3460-3470. [PMID: 31375957 PMCID: PMC6854308 DOI: 10.1007/s10461-019-02620-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In priority sub-Saharan African countries, on the ground observations suggest that the success of voluntary medical male circumcision (VMMC) programs should not be based solely on numbers of males circumcised. We identify gaps in the consent process and poor psychosocial outcomes among a key target group: male adolescents. We assessed compliance with consent and assent requirements for VMMC in western Kenya among males aged 15-19 (N = 1939). We also examined differences in quality of life, depression, and anticipated HIV stigma between uncircumcised and circumcised adolescents. A substantial proportion reported receiving VMMC services as minors without parent/guardian consent. In addition, uncircumcised males were significantly more likely than their circumcised peers to have poor quality of life and symptoms of depression. Careful monitoring of male adolescents' well-being is needed in large-scale VMMC programs. There is also urgent need for research to identify effective strategies to address gaps in the delivery of VMMC services.
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Affiliation(s)
- Winnie K Luseno
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA.
| | - Samuel H Field
- Independent Statistical Consultant, Chapel Hill, NC, USA
| | - Bonita J Iritani
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA
| | - Fredrick S Odongo
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Barrack Ongili
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Denise D Hallfors
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Suite 200, Chapel Hill, NC, USA
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Olapade-Olaopa EO, Salami MA, Lawal TA. Male circumcision and global HIV/AIDS epidemic challenges. AFRICAN JOURNAL OF UROLOGY 2019. [DOI: 10.1186/s12301-019-0005-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background
Given the devastating mortality and morbidity associated with HIV/AIDS, many potential prevention measures against HIV infection continue to be explored. Most prevention methods are in the realm of sexual behavior change. However, of all aspects of human behavior, it is sexual behavior that is least amenable to change. Newer and simpler interventions are therefore required. Male circumcision, the surgical removal of some or all of the foreskin (or prepuce) from the penis, is one of the ways being promoted as a preventive measure. This paper reviews the scientific basis and evidence for the efficacy of male circumcision within the context of the global challenges involved.
Main body
We reviewed articles with emphasis on male circumcision and HIV/AIDS transmission. Published abstracts of presentations at international scientific meetings were also reviewed.
Conclusions
Current epidemiological evidence supports the promotion of male circumcision for HIV prevention, especially in populations with high HIV prevalence and low circumcision rates. Three notable randomized control trials strengthen the case for applied research studies to demonstrate that safe male circumcision is protective at the population level, particularly as ideal and well-resourced conditions of a randomized trial are often not replicated in other service delivery settings. Ethically and culturally responsive strategies in promoting circumcision in a culturally heterogenous world need to be developed, too. Male circumcision should also be viewed as a complementary measure along with other proven approaches to turn the HIV/AIDS epidemic around.
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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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14
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Abstract
The study analysed the HIV/AIDS situation in Zambia six years after the onset of mass campaigns of Voluntary Medical Male Circumcision (VMMC). The analysis was based on data from Demographic and Health Surveys (DHS) conducted in 2001, 2007 and 2013. Results show that HIV prevalence among men aged 15-29 (the target group for VMMC) did not decrease over the period, despite a decline in HIV prevalence among women of the same age group (most of their partners). Correlations between male circumcision and HIV prevalence were positive for a variety of socioeconomic groups (urban residence, province of residence, level of education, ethnicity). In a multivariate analysis, based on the 2013 DHS survey, circumcised men were found to have the same level of infection as uncircumcised men, after controlling for age, sexual behaviour and socioeconomic status. Lastly, circumcised men tended to have somewhat riskier sexual behaviour than uncircumcised men. This study, based on large representative samples of the Zambian population, questions the current strategy of mass circumcision campaigns in southern and eastern Africa.
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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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16
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Zhang C, Penson DF, Qian HZ, Webb GF, Lou J, Shepherd BE, Liu Y, Vermund SH. Modeling economic and epidemiological impact of voluntary medical male circumcision among men who have sex with men in Beijing, China. Int J STD AIDS 2019; 30:630-638. [PMID: 30890118 PMCID: PMC6666307 DOI: 10.1177/0956462419831859] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Voluntary medical male circumcision (VMMC) among men who have sex with men (MSM) may protect against HIV acquisition. We conducted a series of analyses to assess if expanded VMMC might reduce HIV incidence among MSM effectively and economically. We used a deterministic compartmental model to project new HIV cases (2016-2026) under annual VMMC coverage rates (λ) ranging from 0.0001 to 0.15. The 'number needed to avert' (NNA) is defined as the cumulative number of VMMCs conducted up to that year divided by the cumulative number of HIV cases averted in that specific year. Compared with the baseline circumcision coverage rate, we projected that new HIV cases would be reduced with increasing coverage. By 2026 (last year simulated), the model generated the lowest ratio (11.10) when the annual circumcision rate was the most optimistic (λ = 0.15). The breakeven point was observed at the year of 2019 with the annual VMMC coverage rate of 0.001. The total cost saved by averting HIV cases would range from 2.5 to 811 million US dollars by the end of 2026 with different hypothetical coverage rates. Our model suggests that acceleration in VMMC implementation among MSM could help stem the HIV/AIDS epidemic.
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Affiliation(s)
- Chen Zhang
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - David F. Penson
- Departments of Urologic Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Han-zhu Qian
- School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Glenn F. Webb
- Department of Mathematics, Vanderbilt University School of Arts and Sciences, Nashville, Tennessee, USA
| | - Jie Lou
- Department of Mathematics, Shanghai University, Shanghai, China
| | - Brian E. Shepherd
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Yu Liu
- Department of Public Health Science, University of Rochester Medical Center, Rochester, New York, USA
| | - Sten H. Vermund
- School of Public Health, Yale University, New Haven, Connecticut, USA
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17
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Peebles K, Baeten JM. Cost-effectiveness of HIV Prevention Interventions: Estimates from Real-world Implementation Needed. EClinicalMedicine 2019; 10:8-9. [PMID: 31193844 PMCID: PMC6543194 DOI: 10.1016/j.eclinm.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Kathryn Peebles
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Jared M. Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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18
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Sarkar S, Corso P, Ebrahim-Zadeh S, Kim P, Charania S, Wall K. Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review. EClinicalMedicine 2019; 10:10-31. [PMID: 31193863 PMCID: PMC6543190 DOI: 10.1016/j.eclinm.2019.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources. METHODS We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist. FINDINGS 60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk. INTERPRETATION The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.
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Affiliation(s)
- Supriya Sarkar
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Phaedra Corso
- Department of Health Policy and Management, Kennesaw State University, Kennesaw, GA, USA
| | | | - Patricia Kim
- Department of Economics, Emory University, Atlanta, GA, USA
| | - Sana Charania
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin Wall
- Department of Epidemiology, Emory University, Atlanta, GA, USA
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19
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Spees LP, Ledikwe JH, Kleinman NJ, Ntsuape C, Semo BW, Barnhart S, Wirth KE. Immediate Motivators to Seeking Voluntary Medical Male Circumcision Among HIV-Negative Adult Men in an Urban Setting in Botswana. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:136-151. [PMID: 30917017 DOI: 10.1521/aeap.2019.31.2.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces HIV acquisition risk in men. We sought to identify subpopulations of Botswanan men with high levels of VMMC uptake by comparing an observational cohort of men presenting for circumcision services at two high-volume clinics in Botswana's capital city, Gabo-rone, with a matched, population-based random sample of uncircumcised men. Among these high uptake VMMC subpopulations, we then examined the immediate factors that play a role in men's decision to seek VMMC services. As compared to their population-based controls, men choosing to undergo circumcision were more likely to be ages 24-34, more highly educated, to have a religious affiliation, and in a serious relationship. Our results suggest that married men and highly educated men were more likely to pursue circumcision for personal hygiene reasons. These findings have direct implications for targeted demand creation and mobilization activities to increase VMMC uptake in Botswana.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Jenny H Ledikwe
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Global Health, University of Washington, Seattle, Washington
| | - Nora J Kleinman
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Global Health, University of Washington, Seattle, Washington
- NJK Consulting, Seattle
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health, Gaborone, Botswana
| | - Bazghina-Werq Semo
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Global Health, University of Washington, Seattle, Washington
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, Washington
| | - Kathleen E Wirth
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Epidemiology and the Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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20
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Jones DL, Rodriguez VJ, Butts SA, Arheart K, Zulu R, Chitalu N, Weiss SM. Increasing acceptability and uptake of voluntary male medical circumcision in Zambia: implementing and disseminating an evidence-based intervention. Transl Behav Med 2019; 8:907-916. [PMID: 30010980 DOI: 10.1093/tbm/iby078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Voluntary medical male circumcision (VMMC) uptake in Africa could prevent 3.4 million HIV infections across a 10 year span. In Zambia, however, ~80 per cent of uncircumcised men report no interest in undergoing VMMC. The Spear & Shield (S&S) intervention has been shown to be more effective than control or observation of only conditions at increasing the number of VMMCs. This study identified predictors of S&S implementation success or failure to create an "early warning" system to enable remedial action during implementation. Participants were n = 48 staff members from 12 community health facilities conducting the S&S program in Lusaka Province, Zambia. Quantitative assessments included demographics, provider attitudes, barriers to research uptake, staff burnout, and organizational readiness. Qualitative interviews were also conducted and quantified for analysis using the Consolidated Framework for Implementation Research (CFIR). Two-thirds (66%) of staff were women with a mean age of 37.67 years (SD = 7.51). Quantitatively, staff performance (p = .033) and decreased levels of staff burnout (p = .025) were associated with S&S implementation success. Qualitatively, constructs such as improved planning, executing, and self-reflection and evaluation were associated with S&S implementation success (p = .005). Identifying these factors facilitated remedial action across health facilities. This study illustrates the utility of the CFIR to guide program decision making in VMMC implementation in the Zambian context. Early identification of challenges to implementation may enable remedial action to enhance the likelihood of program sustainability. Effective monitoring strategies for HIV prevention interventions may thus enhance dissemination, implementation, and sustainability goals to bridge research and practice.
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Affiliation(s)
- Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Psychology, University of Georgia, Athens, GA, USA
| | - Stefani A Butts
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kris Arheart
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Robert Zulu
- Department of Surgery, University of Zambia School of Medicine, Lusaka, Zambia.,Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Ndashi Chitalu
- Department of Surgery, University of Zambia School of Medicine, Lusaka, Zambia.,Department of Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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21
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Kwena ZA, Njuguna SW, Ssetala A, Seeley J, Nielsen L, De Bont J, Bukusi EA. HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. PLoS One 2019; 14:e0214360. [PMID: 30908555 PMCID: PMC6433243 DOI: 10.1371/journal.pone.0214360] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/12/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Global efforts to end HIV by 2030 focus on reducing and eventually eliminating new infections in priority populations. Identifying these populations and characterizing their vulnerability factors helps in guiding investment of scarce HIV prevention resources to achieve maximum impact. We sought to establish HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. METHODS We conducted a cross-sectional survey of 2637 people from all the 308 fish-landing beaches on the Kenyan shore of Lake Victoria. The number of participants enrolled at each beach were weighted based on the size of the beach, determined by the number of functional registered boats. We used simple random sampling to select those to be approached for study participation. Consenting participants were privately interviewed about their socio-economic and demographic characteristics and sexual behavior, and were invited for HIV test using the Kenya rapid HIV testing protocol. We used descriptive statistics and multivariate logistic and linear regression for analysis. RESULTS We found high HIV prevalence of 32% with significant differences between men (29%) and women (38%). Among men, having an HIV negative sexual partner, being circumcised, increasing number of condom protected sex acts in the preceding month, being younger and being a resident of Homa Bay, Kisumu, Siaya and Busia counties compared to Migori County reduced the risk of HIV infection. For women, being married, having more children with the current spouse, having an HIV negative sexual partner and being a resident of Busia compared to Migori County reduced the risk of HIV infection. We also found that longer distance from the beaches to the nearest public health facilities was associated with increasing cumulative HIV prevalence at the beaches. CONCLUSION Fishing communities have high HIV prevalence and may greatly benefit from interventions such as wider ART coverage, couple HIV risk reduction counseling, PrEP use for HIV negative partner at substantial continuous risk, alongside other HIV prevention services that the Kenyan government is currently rolling out. This will additionally require adequate plans to synchronize the provision of these services with the population's routine schedules for all these options to be reasonably accessible to them.
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Affiliation(s)
| | | | - Ali Ssetala
- UVRI-IAVI HIV Vaccine Program, Entebbe, Uganda
| | | | - Leslie Nielsen
- International AIDS Vaccine Initiative, New York, United States of America
| | - Jan De Bont
- International AIDS Vaccine Initiative, New York, United States of America
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Njeuhmeli E, Schnure M, Vazzano A, Gold E, Stegman P, Kripke K, Tchuenche M, Bollinger L, Forsythe S, Hankins C. Using mathematical modeling to inform health policy: A case study from voluntary medical male circumcision scale-up in eastern and southern Africa and proposed framework for success. PLoS One 2019; 14:e0213605. [PMID: 30883583 PMCID: PMC6422273 DOI: 10.1371/journal.pone.0213605] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Modeling contributes to health program planning by allowing users to estimate future outcomes that are otherwise difficult to evaluate. However, modeling results are often not easily translated into practical policies. This paper examines the barriers and enabling factors that can allow models to better inform health decision-making. Description The Decision Makers’ Program Planning Tool (DMPPT) and its successor, DMPPT 2, are illustrative examples of modeling tools that have been used to inform health policy. Their use underpinned Voluntary Medical Male Circumcision (VMMC) scale-up for HIV prevention in southern and eastern Africa. Both examine the impact and cost-effectiveness of VMMC scale-up, with DMPPT used initially in global advocacy and DMPPT 2 then providing VMMC coverage estimates by client age and subnational region for use in country-specific program planning. Their application involved three essential steps: identifying and engaging a wide array of stakeholders from the outset, reaching consensus on key assumptions and analysis plans, and convening data validation meetings with critical stakeholders. The subsequent DMPPT 2 Online is a user-friendly tool for in-country modeling analyses and continuous program planning and monitoring. Lessons learned Through three iterations of the DMPPT applied to VMMC, a comprehensive framework with six steps was identified: (1) identify a champion, (2) engage stakeholders early and often, (3) encourage consensus, (4) customize analyses, (5), build capacity, and (6) establish a plan for sustainability. This framework could be successfully adapted to other HIV prevention programs to translate modeling results to policy and programming. Conclusions Models can be used to mobilize support, strategically plan, and monitor key programmatic elements, but they can also help inform policy environments in which programs are conceptualized and implemented to achieve results. The ways in which modeling has informed VMMC programs and policy may be applicable to an array of other health interventions.
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Affiliation(s)
- Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, District of Columbia, United States of America
- * E-mail:
| | - Melissa Schnure
- Project SOAR (Supporting Operational AIDS Research), Palladium, Washington, District of Columbia, United States of America
| | - Andrea Vazzano
- Project SOAR (Supporting Operational AIDS Research), Palladium, Washington, District of Columbia, United States of America
| | - Elizabeth Gold
- AIDSFree, JSI Research and Training Institute, Arlington, Virginia, United States of America
| | - Peter Stegman
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Katharine Kripke
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Michel Tchuenche
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Lori Bollinger
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Steven Forsythe
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, District of Columbia, United States of America
| | - Catherine Hankins
- Department of Global Health and Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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23
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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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Tchuenche M, Njeuhmeli E, Schütte C, Ngubeni L, Choge I, Martin E, Loykissoonlal D, Kiggundu V, Yansaneh A, Forsythe S. Voluntary medical male circumcision service delivery in South Africa: The economic costs and potential opportunity for private sector involvement. PLoS One 2018; 13:e0208698. [PMID: 30557330 PMCID: PMC6296535 DOI: 10.1371/journal.pone.0208698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 11/22/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2010, the South African Government initiated a voluntary medical male circumcision (VMMC) program as a part of the country's HIV prevention strategy based on compelling evidence that VMMC reduces men's risk of becoming HIV infected by approximately 60%. A previous VMMC costing study at Government and PEPFAR-supported facilities noted that the lack of sufficient data from the private sector represented a gap in knowledge concerning the overall cost of scaling up VMMC services. This study, conducted in mid-2016, focused on surgical circumcision and aims to address this limitation. METHODS VMMC service delivery cost data were collected at 13 private facilities in three provinces in South Africa: Gauteng, KwaZulu-Natal, and Mpumalanga. Unit costs were calculated using a bottom-up approach by cost components, and then disaggregated by facility type and urbanization level. VMMC demand creation, and higher-level management and program support costs were not collected. The unit cost of VMMC service delivery at private facilities in South Africa was calculated as a weighted average of the unit costs at the 13 facilities. KEY FINDINGS At the average annual exchange rate of R10.83 = $1, the unit cost including training and cost of continuous quality improvement (CQI) to provide VMMC at private facilities was $137. The largest cost components were consumables (40%) and direct labor (35%). Eleven out of the 13 surveyed private sector facilities were fixed sites (with a unit cost of $142), while one was a fixed site with outreach services (with a unit cost of $156), and the last one provided services at a combination of fixed, outreach and mobile sites (with a unit cost per circumcision performed of $123). The unit cost was not substantially different based on the level of urbanization: $141, $129, and $143 at urban, peri-urban, and rural facilities, respectively. CONCLUSIONS The private sector VMMC unit cost ($137) did not differ substantially from that at government and PEPFAR-supported facilities ($132 based on results from a similar study conducted in 2014 in South Africa at 33 sites across eight of the countries nine provinces). The two largest cost drivers, consumables and direct labor, were comparable across the two studies (75% in private facilities and 67% in public/PEPFAR-supported facilities). Results from this study provide VMMC unit cost data that had been missing and makes an important contribution to a better understanding of the costs of VMMC service delivery, enabling VMMC programs to make informed decisions regarding funding levels and scale-up strategies for VMMC in South Africa.
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Affiliation(s)
- Michel Tchuenche
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, DC, United States of America
| | | | - Carl Schütte
- Strategic Development Consultants, KwaZulu Natal, South Africa
| | - Lahla Ngubeni
- Avenir Health Consultant, Johannesburg, South Africa
| | | | | | | | | | - Aisha Yansaneh
- USAID, Washington, Washington, DC, United States of America
| | - Steven Forsythe
- Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, DC, United States of America
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Strauss M, George G, Mantell JE, Romo ML, Mwai E, Nyaga EN, Odhiambo JO, Govender K, Kelvin EA. Stated and revealed preferences for HIV testing: can oral self-testing help to increase uptake amongst truck drivers in Kenya? BMC Public Health 2018; 18:1231. [PMID: 30400898 PMCID: PMC6219162 DOI: 10.1186/s12889-018-6122-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 10/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-distance truck drivers in Africa are particularly at risk of HIV acquisition and offering self-testing could help increase testing coverage in this hard-to-reach population. The aims of this study are twofold: (1) to examine the preference structures of truck drivers in Kenya regarding HIV testing service delivery models and what they mean for the roll-out of HIV self-testing, and (2) to compare the preference data collected from a hypothetical discrete choice experiment with the actual choices made by participants in the intervention arm of a randomised controlled trial (RCT) who were offered HIV testing choices. METHODS Using data from 150 truck drivers, this paper examines whether the stated preferences regarding HIV testing in a discrete choice experiment predict the actual test selected when offered HIV testing choices. Conditional logit models were used for main effects analysis and stratified models were run by HIV testing choices made in the trial to assess if the attributes preferred differed by test chosen. RESULTS The strongest driver of stated preference among all participants was cost. However, two preferences diverged between those who actually chose self-testing in the RCT and those who chose a provider administered test: the type of test (p < 0.001) and the type of counselling (p = 0.003). Self-testers preferred oral-testing to finger-prick testing (OR 1.26 p = 0.005), while non-self-testers preferred finger-prick testing (OR 0.56 p < 0.001). Non-self-testers preferred in-person counselling to telephonic counselling (OR 0.64 p < 0.001), while self-testers were indifferent to type of counselling. Preferences in both groups regarding who administered the test were not significant. CONCLUSIONS We found stated preference structures helped explain the actual choices participants made regarding the type of HIV testing they accepted. Offering oral testing may be an effective strategy for increasing willingness to test among certain groups of truck drivers. However, the importance of in-person counselling and support, and concern that an oral test cannot detect HIV infection may mean that continuing to offer finger-prick testing at roadside wellness centres will best align with the preferences of those already attending these facilities. More research is needed to explore whether who administers the HIV test (provider versus self) makes any difference. TRIAL REGISTRATION This trial is registered with the Registry for International Development Impact Evaluations ( RIDE ID#55847d64a454f ).
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Affiliation(s)
- Michael Strauss
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, 4th Floor J-Block, University of KwaZulu-Natal Westville Campus, University Drive, Durban, 4041 South Africa
| | - Gavin George
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, 4th Floor J-Block, University of KwaZulu-Natal Westville Campus, University Drive, Durban, 4041 South Africa
| | - Joanne E. Mantell
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute & Columbia University, 1051 Riverside Drive, New York, NY 10032 USA
| | - Matthew L. Romo
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy and Institute for Implementation Science in Population Health, City University of New York, 55 West 125th Street, New York, NY 10027 USA
| | - Eva Mwai
- North Star Alliance, PO Box 165, Nairobi, 00202 Kenya
| | | | | | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, 4th Floor J-Block, University of KwaZulu-Natal Westville Campus, University Drive, Durban, 4041 South Africa
| | - Elizabeth A. Kelvin
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health and Health Policy and Institute for Implementation Science in Population Health, City University of New York, 55 West 125th Street, New York, NY 10027 USA
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McGillen JB, Stover J, Klein DJ, Xaba S, Ncube G, Mhangara M, Chipendo GN, Taramusi I, Beacroft L, Hallett TB, Odawo P, Manzou R, Korenromp EL. The emerging health impact of voluntary medical male circumcision in Zimbabwe: An evaluation using three epidemiological models. PLoS One 2018; 13:e0199453. [PMID: 30020940 PMCID: PMC6051576 DOI: 10.1371/journal.pone.0199453] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/07/2018] [Indexed: 12/26/2022] Open
Abstract
Background Zimbabwe adopted voluntary medical male circumcision (VMMC) as a priority HIV prevention strategy in 2007 and began implementation in 2009. We evaluated the costs and impact of this VMMC program to date and in future. Methods Three mathematical models describing Zimbabwe’s HIV epidemic and program evolution were calibrated to household survey data on prevalence and risk behaviors, with circumcision coverage calibrated to program-reported VMMCs. We compared trends in new infections and costs to a counterfactual without VMMC. Input assumptions were agreed in workshops with national stakeholders in 2015 and 2017. Results The VMMC program averted 2,600–12,200 infections (among men and women combined) by the end of 2016. This impact will grow as circumcised men are protected lifelong, and onward dynamic transmission effects, which protect women via reduced incidence and prevalence in their male partners, increase over time. If other prevention interventions remain at 2016 coverages, the VMMCs already performed will avert 24,400–69,800 infections (2.3–5% of all new infections) through 2030. If coverage targets are achieved by 2021 and maintained, the program will avert 108,000–171,000 infections (10–13% of all new infections) by 2030, costing $2,100–3,250 per infection averted relative to no VMMC. Annual savings from averted treatment needs will outweigh VMMC maintenance costs once coverage targets are reached. If Zimbabwe also achieves ambitious UNAIDS targets for scaling up treatment and prevention efforts, VMMC will reduce the HIV incidence remaining at 2030 by one-third, critically contributing to the UNAIDS goal of 90% incidence reduction. Conclusions VMMC can substantially impact Zimbabwe’s HIV epidemic in the coming years; this investment will save costs in the longer term.
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Affiliation(s)
- Jessica B. McGillen
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - John Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Daniel J. Klein
- Institute for Disease Modeling, Seattle, Washington, United States of America
| | | | - Getrude Ncube
- Ministry of Health and Child Welfare, Harare, Zimbabwe
| | | | | | | | - Leo Beacroft
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | | | - Rumbidzai Manzou
- Zimbabwe Country Office, Clinton Health Access Initiative, Harare, Zimbabwe
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George G, Govender K, Beckett S, Montague C, Frohlich J. Factors associated with the take-up of voluntary medical male circumcision amongst learners in rural KwaZulu-Natal. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2018; 16:251-256. [PMID: 28978292 DOI: 10.2989/16085906.2017.1369441] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Voluntary medical male circumcision (VMMC) is an integral part of South Africa's HIV prevention programme. School-going males, in particular, are considered a cost-effective target population. However, ambitious policy targets have not been achieved due to the plateau in demand for VMMC. This study documents the factors influencing demand for VMMC amongst school-going males. Data were collected from 750 learners (251 circumcised and 499 uncircumcised) from 42 secondary schools in KwaZulu-Natal, South Africa. There was a positive association between the perceived benefit of VMMC and the likelihood of undergoing circumcision (AOR: 1.41, p = 0.01). There was a negative association between self-efficacy to use condoms and likelihood of undergoing VMMC (AOR: 0.75, p < 0.01). Learners who perceived VMMC as having a number of health benefits, including reducting of the chances of contracting HIV and sexually transmitted infections (STIs), increasing penile hygiene and the belief that VMMC allows them to use condoms less frequently, were more likely to undergo VMMC. Of concern, learners who were confident in their ability to access condoms and t use a condom with their partner were less likely to undergo VMMC.
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Affiliation(s)
- Gavin George
- a Health Economics and HIV/AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - Kaymarlin Govender
- a Health Economics and HIV/AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa.,b School of Psychology , University of KwaZulu-Natal , Durban , South Africa
| | - Sean Beckett
- a Health Economics and HIV/AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - Carl Montague
- c Centre for the AIDS Programme of Research in South Africa (CAPRISA) , KwaZulu-Natal , Durban , South Africa
| | - Janet Frohlich
- c Centre for the AIDS Programme of Research in South Africa (CAPRISA) , KwaZulu-Natal , Durban , South Africa
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Dubé K, Luter S, Lesnar B, Newton L, Galea J, Brown B, Gianella S. Use of 'eradication' in HIV cure-related research: a public health debate. BMC Public Health 2018; 18:245. [PMID: 29439706 PMCID: PMC5812044 DOI: 10.1186/s12889-018-5141-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The landscape of Human Immunodeficiency Virus (HIV) research has changed drastically over the past three decades. With the remarkable success of antiretroviral treatment (ART) in decreasing AIDS-related mortality, some researchers have shifted their HIV research focus from treatment to cure research. The HIV cure research community often uses the term eradication to describe the science, and talks about eradicating the virus from the body. In public discourse, the term eradication could be conflated with disease eradication at the population level. In this paper, we call for a reframing of HIV cure research as control, as it is a more accurate descriptor and achievable goal in the foreseeable future. DISCUSSION The properties of HIV are discordant with eradicability standards at both the individual level (as a clinical concept), and at the population level (as a public health concept). At the individual level, true eradication would necessitate absolute elimination of all latent HIV reservoirs from the body. Current HIV cure-related research strategies have proven unsuccessful at accurately quantifying, let alone eliminating these reservoirs. At the population level, eradication implies the permanent global reduction of HIV to zero new cases and to zero risk for future cases. Given the absence of an efficacious HIV vaccine and the impracticality and unethicality of eliminating animal reservoirs, global eradication of HIV is highly implausible. From a public health perspective, HIV eradication remains an elusive goal. CONCLUSION The term 'eradication' is a misleading description of current HIV cure-related research. Instead, we call for the use of more realistic expressions such as 'sustained virologic HIV suppression (or control)' or 'management of HIV persistence' to describe HIV cure-related research. Using these terms reorients what HIV cure science can potentially achieve in the near future and avoids creating unrealistic expectations, particularly among the millions of people globally who live with HIV.
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Affiliation(s)
- Karine Dubé
- UNC Gillings School of Global Public Health, 4108 McGavran-Greenberg Hall, Chapel Hill, NC 27516 USA
| | - Stuart Luter
- UNC Gillings School of Global Public Health, 4108 McGavran-Greenberg Hall, Chapel Hill, NC 27516 USA
| | - Breanne Lesnar
- UNC Gillings School of Global Public Health, 4108 McGavran-Greenberg Hall, Chapel Hill, NC 27516 USA
| | - Luke Newton
- UNC Gillings School of Global Public Health, 4108 McGavran-Greenberg Hall, Chapel Hill, NC 27516 USA
| | - Jerome Galea
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115 USA
| | - Brandon Brown
- Center for Healthy Communities, Department of Social Medicine and Population Health, University of California Riverside School of Medicine, 3333 14th Street, Riverside, CA 92501 USA
| | - Sara Gianella
- University of San Diego School of Medicine, 9500 Gilman Drive #0679, La Jolla, CA 92093 USA
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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. Correction: 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 2017; 12:e0169698. [PMID: 28046112 PMCID: PMC5207647 DOI: 10.1371/journal.pone.0169698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tchuenche M, Haté V, McPherson D, Palmer E, Thambinayagam A, Loykissoonlal D, Njeuhmeli E, Forsythe S. Estimating Client Out-of-Pocket Costs for Accessing Voluntary Medical Male Circumcision in South Africa. PLoS One 2016; 11:e0164147. [PMID: 27783635 PMCID: PMC5082609 DOI: 10.1371/journal.pone.0164147] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022] Open
Abstract
In 2010, South Africa launched a countrywide effort to scale up its voluntary medical male circumcision (VMMC) program on the basis of compelling evidence that circumcision reduces men's risk of acquiring HIV through heterosexual intercourse. Even though VMMC is free there, clients can incur indirect out-of-pocket costs (for example transportation cost or foregone income). Because these costs can be barriers to increasing the uptake of VMMC services, we assessed them from a client perspective, to inform VMMC demand creation policies. Costs (calculated using a bottom-up approach) and demographic data were systematically collected through 190 interviews conducted in 2015 with VMMC clients or (for minors) their caregivers at 25 VMMC facilities supported by the government and the President's Emergency Plan for AIDS Relief in eight of South Africa's nine provinces. The average age of VMMC clients was 22 years and nearly 92% were under 35 years of age. The largest reported out-of-pocket expenditure was transportation, at an average of US$9.20 (R 100). Only eight clients (4%) reported lost days of work. Indirect expenditures were childcare costs (one client) and miscellaneous items such as food or medicine (20 clients). Given competing household expense priorities, spending US$9.20 (R100) per person on transportation to access VMMC services could be a significant burden on clients and households, and a barrier to South Africa's efforts to create demand for VMMC. Thus, we recommend a more focused analysis of clients' transportation costs to access VMMC services.
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Affiliation(s)
- Michel Tchuenche
- Health Policy Project, Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, DC, United States of America
| | - Vibhuti Haté
- Project SOAR (Supporting Operational AIDS Research), George Washington University, Washington, DC, United States of America
| | - Dacia McPherson
- Health Policy Project, Palladium Consultant, Johannesburg, South Africa
| | - Eurica Palmer
- Health Policy Project, Palladium Consultant, Johannesburg, South Africa
| | | | | | - Emmanuel Njeuhmeli
- USAID (United States Agency for International Development), Washington, DC, United States of America
| | - Steven Forsythe
- Health Policy Project, Project SOAR (Supporting Operational AIDS Research), Avenir Health, Washington, DC, United States of America
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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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Impact and Cost of Scaling Up Voluntary Medical Male Circumcision for HIV Prevention in the Context of the New 90-90-90 HIV Treatment Targets. PLoS One 2016; 11:e0155734. [PMID: 27783681 PMCID: PMC5082670 DOI: 10.1371/journal.pone.0155734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 05/03/2016] [Indexed: 01/07/2023] Open
Abstract
Background The report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for World AIDS Day 2014 highlighted a Fast-Track Strategy that sets ambitious treatment and prevention targets to reduce global HIV incidence to manageable levels by 2020 and end the AIDS epidemic by 2030. The 90-90-90 treatment targets for 2020 call for 90% of people living with HIV to know their HIV status, 90% of people who know their status to receive treatment, and 90% of people on HIV treatment to be virally suppressed. This paper examines how scale-up of voluntary medical male circumcision (VMMC) services in four priority countries in sub-Saharan Africa could contribute to ending the AIDS epidemic by 2030 in the context of concerted efforts to close the treatment gap, and what the impact of VMMC scale-up would be if the 90-90-90 treatment targets were not completely met. Methods Using the Goals module of the Spectrum suite of models, this analysis modified ART (antiretroviral treatment) scale-up coverage from base scenarios to reflect the 90-90-90 treatment targets in four countries (Lesotho, Malawi, South Africa, and Uganda). In addition, a second scenario was created to reflect viral suppression levels of 75% instead of 90%, and a third scenario was created in which the 90-90-90 treatment targets are reached in women, with men reaching more moderate coverage levels. Regarding male circumcision (MC) coverage, the analysis examined both a scenario in which VMMCs were assumed to stop after 2015, and one in which MC coverage was scaled up to 90% by 2020 and maintained at 90% thereafter. Results Across all four countries, scaling up VMMC is projected to provide further HIV incidence reductions in addition to those achieved by reaching the 90-90-90 treatment targets. If viral suppression levels only reach 75%, scaling up VMMC leads to HIV incidence reduction to nearly the same levels as those achieved with 90-90-90 without VMMC scale-up. If only women reach the 90-90-90 targets, scaling up VMMC brings HIV incidence down to near the levels projected with 90-90-90 without VMMC scale-up. Regarding cost, scaling up VMMC increases the annual costs during the scale-up phase, but leads to lower annual costs after the MC coverage target is achieved. Conclusions The scenarios modeled in this paper show that the highly durable and effective male circumcision intervention increases epidemic impact levels over those of treatment-only strategies, including the case if universal levels of viral suppression in men and women are not achieved by 2020. In the context of 90-90-90, prioritizing continued successful scale-up of VMMC increases the possibility that future generations will be free not only of AIDS but also of HIV.
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Kripke K, Njeuhmeli E, Samuelson J, Schnure M, Ncube B, Dalal S, Farley T, Hankins C, Thomas AG, Reed J, Stegman P, Bock N. Correction: 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:e0163757. [PMID: 27656897 PMCID: PMC5033447 DOI: 10.1371/journal.pone.0163757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Amuri M, Msemo G, Plotkin M, Christensen A, Boyee D, Mahler H, Phafoli S, Njozi M, Hellar A, Mlanga E, Yansaneh A, Njeuhmeli E, Lija J. Bringing Early Infant Male Circumcision Information Home to the Family: Demographic Characteristics and Perspectives of Clients in a Pilot Project in Tanzania. GLOBAL HEALTH: SCIENCE AND PRACTICE 2016; 4 Suppl 1:S29-41. [PMID: 27413081 PMCID: PMC4944577 DOI: 10.9745/ghsp-d-15-00210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
During a pilot project in Tanzania’s Iringa region, more than 2,000 male infants were circumcised in less than 2 years in 8 facilities, representing 16.4% of all male births in those facilities. The age of the infant at circumcision and the time of return for follow-up visits varied significantly between urban and rural dwellers. Early infant male circumcision (EIMC) outreach activities and use of health outposts for follow-up visits should be explored to overcome these geographic barriers. EIMC programs will also require targeted investments in demand creation, especially among fathers, to expand and thrive in traditionally non-circumcising settings such as Iringa. Iringa region of Tanzania has had great success reaching targets for voluntary medical male circumcision (VMMC). Looking to sustain high coverage of male circumcision, the government introduced a pilot project to offer early infant male circumcision (EIMC) in Iringa in 2013. From April 2013 to December 2014, a total of 2,084 male infants were circumcised in 8 health facilities in the region, representing 16.4% of all male infants born in those facilities. Most circumcisions took place 7 days or more after birth. The procedure proved safe, with only 3 mild and 3 moderate adverse events (0.4% overall adverse event rate). Overall, 93% of infants were brought back for a second-day visit and 71% for a seventh-day visit. These percentages varied significantly by urban and rural residence (97.4% urban versus 84.6% rural for day 2 visit; 82.2% urban versus 49.9% rural for day 7 visit). Mothers were more likely than fathers to have received information about EIMC. However, fathers tended to be key decision makers regarding circumcision of their sons. This suggests the importance of addressing fathers with behavioral change communication about EIMC. Successes in scaling up VMMC services in Iringa did not translate into immediate acceptability of EIMC. EIMC programs will require targeted investments in demand creation to expand and thrive in traditionally non-circumcising settings such as Iringa.
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Affiliation(s)
| | - Georgina Msemo
- Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | | | | | | | | | | | | | | | - Erick Mlanga
- U.S. Agency for International Development (USAID), Dar es Salaam, Tanzania
| | | | | | - Jackson Lija
- Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
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Kripke K, Perales N, Lija J, Fimbo B, Mlanga E, Mahler H, Juma JM, Baingana E, Plotkin M, Kakiziba D, Semini I, Castor D, Njeuhmeli E. The Economic and Epidemiological Impact of Focusing Voluntary Medical Male Circumcision for HIV Prevention on Specific Age Groups and Regions in Tanzania. PLoS One 2016; 11:e0153363. [PMID: 27410384 PMCID: PMC4943708 DOI: 10.1371/journal.pone.0153363] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/29/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Since its launch in 2010, the Tanzania National Voluntary Medical Male Circumcision (VMMC) Program has focused efforts on males ages 10-34 in 11 priority regions. Implementers have noted that over 70% of VMMC clients are between the ages of 10 and 19, raising questions about whether additional efforts would be required to recruit men age 20 and above. This analysis uses mathematical modeling to examine the economic and epidemiological consequences of scaling up VMMC among specific age groups and priority regions in Tanzania. METHODS AND FINDINGS Analyses were conducted using the Decision Makers' Program Planning Tool Version 2.0 (DMPPT 2.0), a compartmental model implemented in Microsoft Excel 2010. The model was populated with population, mortality, and HIV incidence and prevalence projections from external sources, including outputs from Spectrum/AIDS Impact Module (AIM). A separate DMPPT 2.0 model was created for each of the 11 priority regions. Tanzania can achieve the most immediate impact on HIV incidence by circumcising males ages 20-34. This strategy would also require the fewest VMMCs for each HIV infection averted. Circumcising men ages 10-24 will have the greatest impact on HIV incidence over a 15-year period. The most cost-effective approach (lowest cost per HIV infection averted) targets men ages 15-34. The model shows the VMMC program is cost saving in all 11 priority regions. VMMC program cost-effectiveness varies across regions due to differences in projected HIV incidence, with the most cost-effective programs in Njombe and Iringa. CONCLUSIONS The DMPPT 2.0 results reinforce Tanzania's current VMMC strategy, providing newfound confidence in investing in circumcising adolescents. Tanzanian policy makers and program implementers will continue to focus scale-up of VMMC on men ages 10-34 years, seeking to maximize program impact and cost-effectiveness while acknowledging trends in demand among the younger and older age groups.
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Affiliation(s)
- Katharine Kripke
- Health Policy Project, Avenir Health, Glastonbury, Connecticut, United States of America
| | - Nicole Perales
- Health Policy Project, Futures Group, Washington, District of Columbia, United States of America
| | - Jackson Lija
- Tanzania National AIDS Control Program, Dar es Salaam, Tanzania
| | | | - Eric Mlanga
- U. S. Agency for International Development, Dar es Salaam, Tanzania
| | | | | | | | - Marya Plotkin
- U. S. Agency for International Development, Dar es Salaam, Tanzania
| | | | - Iris Semini
- Joint United Nations Programme on HIV/AIDS, Dar es Salaam, Tanzania
| | - Delivette Castor
- Office of the U.S. Global AIDS Coordinator, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- U. S. Agency for International Development, Washington, District of Columbia, United States of America
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Kripke K, Chen PA, Vazzano A, Thambinayagam A, Pillay Y, Loykissoonlal D, Bonnecwe C, Barron P, Kiwango E, Castor D, Njeuhmeli E. Cost and Impact of Voluntary Medical Male Circumcision in South Africa: Focusing the Program on Specific Age Groups and Provinces. PLoS One 2016; 11:e0157071. [PMID: 27409079 PMCID: PMC4943592 DOI: 10.1371/journal.pone.0157071] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/24/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In 2012, South Africa set a goal of circumcising 4.3 million men ages 15-49 by 2016. By the end of March 2014, 1.9 million men had received voluntary medical male circumcision (VMMC). In an effort to accelerate progress, South Africa undertook a modeling exercise to determine whether circumcising specific client age groups or geographic locations would be particularly impactful or cost-effective. Results will inform South Africa's efforts to develop a national strategy and operational plan for VMMC. METHODS AND FINDINGS The study team populated the Decision Makers' Program Planning Tool, Version 2.0 (DMPPT 2.0) with HIV incidence projections from the Spectrum/AIDS Impact Module (AIM), as well as national and provincial population and HIV prevalence estimates. We derived baseline circumcision rates from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey. The model showed that circumcising men ages 20-34 offers the most immediate impact on HIV incidence and requires the fewest circumcisions per HIV infection averted. The greatest impact over a 15-year period is achieved by circumcising men ages 15-24. When the model assumes a unit cost increase with client age, men ages 15-29 emerge as the most cost-effective group. When we assume a constant cost for all ages, the most cost-effective age range is 15-34 years. Geographically, the program is cost saving in all provinces; differences in the VMMC program's cost-effectiveness across provinces were obscured by uncertainty in HIV incidence projections. CONCLUSION The VMMC program's impact and cost-effectiveness vary by age-targeting strategy. A strategy focusing on men ages 15-34 will maximize program benefits. However, because clients older than 25 access VMMC services at low rates, South Africa could consider promoting demand among men ages 25-34, without denying services to those in other age groups. Uncertainty in the provincial estimates makes them insufficient to support geographic targeting.
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Affiliation(s)
- Katharine Kripke
- Health Policy Project, Avenir Health, Washington, District of Columbia, United States of America
| | - Ping-An Chen
- Health Policy Project, Futures Group, Washington, District of Columbia, United States of America
| | - Andrea Vazzano
- Health Policy Project, Futures Group, Washington, District of Columbia, United States of America
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | | | | | - Peter Barron
- School of Public health, University of the Witwatersrand, Johannesburg, South Africa
| | - Eva Kiwango
- Joint United Nations Programme on HIV/AIDS, Pretoria, South Africa
| | - Delivette Castor
- U.S. Office of the Global AIDS Coordinator, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- U.S. Agency for International Development, Washington, District of Columbia, United States of America
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Kripke K, Vazzano A, Kirungi W, Musinguzi J, Opio A, Ssempebwa R, Nakawunde S, Kyobutungi S, Akao JN, Magala F, Mwidu G, Castor D, Njeuhmeli E. Modeling the Impact of Uganda's Safe Male Circumcision Program: Implications for Age and Regional Targeting. PLoS One 2016; 11:e0158693. [PMID: 27410234 PMCID: PMC4943628 DOI: 10.1371/journal.pone.0158693] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 06/20/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Uganda aims to provide safe male circumcision (SMC) to 80% of men ages 15-49 by 2016. To date, only 2 million men have received SMC of the 4.2 million men required. In response to age and regional trends in SMC uptake, the country sought to re-examine its targets with respect to age and subnational region, to assess the program's progress, and to refine the implementation approach. METHODS AND FINDINGS The Decision Makers' Program Planning Tool, Version 2.0 (DMPPT 2.0), was used in conjunction with incidence projections from the Spectrum/AIDS Impact Module (AIM) to conduct this analysis. Population, births, deaths, and HIV incidence and prevalence were used to populate the model. Baseline male circumcision prevalence was derived from the 2011 AIDS Indicator Survey. Uganda can achieve the most immediate impact on HIV incidence by circumcising men ages 20-34. This group will also require the fewest circumcisions for each HIV infection averted. Focusing on men ages 10-19 will offer the greatest impact over a 15-year period, while focusing on men ages 15-34 offers the most cost-effective strategy over the same period. A regional analysis showed little variation in cost-effectiveness of scaling up SMC across eight regions. Scale-up is cost-saving in all regions. There is geographic variability in program progress, highlighting two regions with low baseline rates of circumcision where additional efforts will be needed. CONCLUSION Focusing SMC efforts on specific age groups and regions may help to accelerate Uganda's SMC program progress. Policy makers in Uganda have already used model outputs in planning efforts, proposing males ages 10-34 as a priority group for SMC in the 2014 application to the Global Fund's new funding model. As scale-up continues, the country should also consider a greater effort to expand SMC in regions with low MC prevalence.
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Affiliation(s)
- Katharine Kripke
- Health Policy Project, Avenir Health, Washington, D.C., United States of America
| | - Andrea Vazzano
- Health Policy Project, Futures Group, Washington, D.C., United States of America
| | | | | | | | | | - Susan Nakawunde
- U.S. Agency for International Development (USAID), Kampala, Uganda
| | | | | | - Fred Magala
- Makerere University Walter Reed Project, Kampala, Uganda
| | - George Mwidu
- Makerere University Walter Reed Project, Kampala, Uganda
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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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Njeuhmeli E, Gorgens M, Gold E, Sanders R, Lija J, Christensen A, Benson FN, Mziray E, Ahanda KS, Kaliel D, Sint TT, Luo C. Scaling Up and Sustaining Voluntary Medical Male Circumcision: Maintaining HIV Prevention Benefits. GLOBAL HEALTH: SCIENCE AND PRACTICE 2016; 4 Suppl 1:S9-S17. [PMID: 27413088 PMCID: PMC4944584 DOI: 10.9745/ghsp-d-16-00159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 11/15/2022]
Abstract
To maintain high circumcision prevalence, voluntary medical male circumcision programs in East and Southern Africa need to plan for sustainability and conduct transition assessments early on, rather than waiting until the saturation of priority targets at the end of the program.
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Affiliation(s)
| | | | - Elizabeth Gold
- Johns Hopkins Center for Communication Programs, Baltimore, MD, USA
| | | | - Jackson Lija
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | | | | | | | | | - Deborah Kaliel
- United States Agency for International Development, Washington, DC, USA
| | | | - Chewe Luo
- United Nations Children's Fund (UNICEF), New York, NY, USA
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Kong X, Kigozi G, Ssekasanvu J, Nalugoda F, Nakigozi G, Ndyanabo A, Lutalo T, Reynolds SJ, Ssekubugu R, Kagaayi J, Bugos E, Chang LW, Nanlesta P, Mary G, Berman A, Quinn TC, Serwadda D, Wawer MJ, Gray RH. Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai, Uganda. JAMA 2016; 316:182-90. [PMID: 27404186 PMCID: PMC5027874 DOI: 10.1001/jama.2016.7292] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Medical male circumcision (MMC) and antiretroviral therapy (ART) are proven HIV prevention interventions, but there are limited data on the population-level effect of scale-up of these interventions in sub-Saharan Africa. Such evaluation is important for planning and resource allocation. OBJECTIVE To examine whether increasing community MMC and ART coverage was associated with reduced community HIV incidence in Rakai District, Uganda. DESIGN, SETTING, AND PARTICIPANTS Using person-level data from population-based surveys conducted from 1999 through 2013 in 45 rural Rakai communities, community-level ART and MMC coverage, sociodemographics, sexual behaviors, and HIV prevalence and incidence were estimated in 3 periods: prior to the availability of ART and MMC (1999-2004), during early availability of ART and MMC (2004-2007), and during mature program scale-up (2007-2013). EXPOSURES Community MMC coverage in males and ART coverage in HIV-positive persons of the opposite sex based on self-reported MMC status and ART use. MAIN OUTCOMES AND MEASURES Adjusted incidence rate ratios (IRRs) for sex-specific community HIV incidence estimated using multivariable Poisson regression with generalized estimating equations. RESULTS From 1999 through 2013, 44,688 persons participated in 1 or more surveys (mean age at the first survey, 24.6 years [range, 15-49]; female, 56.5%; mean survey participation rate, 92.6% [95% CI, 92.4%-92.7%]). Median community MMC coverage increased from 19% to 39%, and median community ART coverage rose from 0% to 21% in males and from 0% to 26% in females. Median community HIV incidence declined from 1.25 to 0.84 per 100 person-years in males, and from 1.25 to 0.99 per 100 person-years in females. Among males, each 10% increase in community MMC coverage was associated with an adjusted IRR of 0.87 (95% CI, 0.82-0.93). Comparing communities with MMC coverage more than 40% (mean male community incidence, 1.03 per 100 person-years) with communities with coverage of 10% or less (mean male incidence, 1.69 per 100 person-years), the adjusted IRR was 0.61 (95% CI, 0.43-0.88). For each 10% increase in female self-reported ART coverage, there was no significant reduction in male HIV incidence (adjusted IRR, 0.95 [95% CI, 0.81-1.13]). Comparing communities with female ART coverage more than 20% (mean male incidence, 0.87 per 100 person-years) to communities with female ART coverage of 20% or less (mean male incidence, 1.17 per 100 person-years), the adjusted IRR was 0.77 (95% CI, 0.61-0.98). Neither MMC nor male ART coverage was associated with lower female community HIV incidence. CONCLUSIONS AND RELEVANCE In Rakai, Uganda, increasing community MMC and female ART coverage was associated with lower community HIV incidence in males. If similar associations are found elsewhere, this would support further scale-up of MMC and ART for HIV prevention in sub-Saharan Africa.
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Affiliation(s)
- Xiangrong Kong
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Department of Biostatistics, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | | | - Joseph Ssekasanvu
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Eva Bugos
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Larry W. Chang
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Grabowski Mary
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Amanda Berman
- Center for Communications Programs, Johns Hopkins University, Baltimore, MD
| | - Thomas C. Quinn
- Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- School of Public Health, Makerere University, Kampala, Uganda
| | - Maria J. Wawer
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Ronald H. Gray
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
- Rakai Health Sciences Program, Entebbe, Uganda
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