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Adetokunboh OO, Are EB. Spatial distribution and determinants of HIV high burden in the Southern African sub-region. PLoS One 2024; 19:e0301850. [PMID: 38669230 PMCID: PMC11051620 DOI: 10.1371/journal.pone.0301850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Spatial analysis at different levels can help understand spatial variation of human immunodeficiency virus (HIV) infection, disease drivers, and targeted interventions. Combining spatial analysis and the evaluation of the determinants of the HIV burden in Southern African countries is essential for a better understanding of the disease dynamics in high-burden settings. METHODS The study countries were selected based on the availability of demographic and health surveys (DHS) and corresponding geographic coordinates. We used multivariable regression to evaluate the determinants of HIV burden and assessed the presence and nature of HIV spatial autocorrelation in six Southern African countries. RESULTS The overall prevalence of HIV for each country varied between 11.3% in Zambia and 22.4% in South Africa. The HIV prevalence rate was higher among female respondents in all six countries. There were reductions in prevalence estimates in most countries yearly from 2011 to 2020. The hotspot cluster findings show that the major cities in each country are the key sites of high HIV burden. Compared with female respondents, the odds of being HIV positive were lesser among the male respondents. The probability of HIV infection was higher among those who had sexually transmitted infections (STI) in the last 12 months, divorced and widowed individuals, and women aged 25 years and older. CONCLUSIONS Our research findings show that analysis of survey data could provide reasonable estimates of the wide-ranging spatial structure of the HIV epidemic in Southern African countries. Key determinants such as individuals who are divorced, middle-aged women, and people who recently treated STIs, should be the focus of HIV prevention and control interventions. The spatial distribution of high-burden areas for HIV in the selected countries was more pronounced in the major cities. Interventions should also be focused on locations identified as hotspot clusters.
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Affiliation(s)
- Olatunji O. Adetokunboh
- DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Global Health, Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town, South Africa
| | - Elisha B. Are
- DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Mathematics, Simon Fraser University, Burnaby, BC, Canada
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Mphepo KY, Muula AS, Sadalaki JR, Phuka F, Mfutso-Bengo J. "Our [Yao people's] circumcision is of the 'brain' not of the 'penis'": factors behind the resistance to voluntary medical male circumcision among Yao people of Mangochi in Southern Malawi. Malawi Med J 2022; 34:281-286. [PMID: 38125772 PMCID: PMC10645834 DOI: 10.4314/mmj.v34i4.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Aim Malawi officially launched Voluntary Male Medical Circumcision (VMMC) in 2012 after the 2007 joint WHO /UNAIDS recommendation that VMMC be a key HIV prevention strategy for Sub-Sahara African region. Malawi data, however, contradicted the findings of three randomized studies conducted in Uganda, Kenya and South Africa between 2005 and 2007. While randomized trials demonstrated that male circumcision could contribute to a 60% relative reduction of HIV acquisition by men through heterosexual intercourse, HIV prevalence in Malawi was highest in the Southern Region where 47% of males were traditionally circumcised yet Central Region had 15.4% and Northern Region, 6.3%. By December 2018, Malawi had only achieved 756, 780 surgeries constituting 31% against the target of 60% of eligible men. The low achievement was due to resistance to services even in traditionally circumcising Yao communities. This study sought views of Yao respondents in Mangochi district, in Southern Malawi, on VMMC. Methods 156 participants were interviewed (103 males and 53 females): 15 FGDs (involving 86 males and 50 females); 17 IDIs (involving 14 males, 3 females); 3 Key KIIs (involving 3 males, 0 females). For this paper, the authors only analyzed FGDs, IDIs and KIIs. Quotes from FGDs were not significant. Results The study identified that VMMC: a) did not contribute to societal moral values; b) involved female circumcisers; c) threatened chiefs' political authority and economic gains; d) threatened continuity of jando; e) was impotent against witchcraft; f) provided by inefficient providers; g) resembled Yao circumcision; h) wrongly translated as 'm'dulidwe wa abambo.' Conclusions The key barrier to VMMC services in Yao communities of Mangochi was the mistrust between government and implementers on one hand and Yao communities on the other due to inadequate engagement prior to the rollout of services.
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Affiliation(s)
- Kent Yg Mphepo
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Adamson S Muula
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - John R Sadalaki
- National Council for Higher Education (NCHE) Private Bag B-371, Lilongwe 3, Malawi
| | - Felix Phuka
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
| | - Joseph Mfutso-Bengo
- Department of Public Health, Kamuzu University of Health Sciences (KUHeS), Blantyre, Malawi
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3
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Simmons SS. A longitudinal multilevel analysis of the evermigrated population subjective HIV infection expectation in Malawi. Psychol Health 2021; 37:890-902. [PMID: 33879011 DOI: 10.1080/08870446.2021.1910697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The primary purpose of this study is to assess the variance in the effects of factors influencing ever migrated Malawian population's subjective HIV infection expectation. DESIGN Using data from the Malawi Longitudinal Study of Families and Health (MLSFH) survey (1998-2010), 7805 ever migrated Malawian adults were selected for the study. Summary statistics, logistic regression and longitudinal multi-level models were fitted for the study. A binary logistic regression was used to estimate the direction and magnitude of the associations between the variables selected for the study Five multilevel models with random intercepts and coefficients nominal response were fitted. RESULTS The study revealed that sexual behaviours had the most significant effect on ever migrated Malawian's subjective HIV infection expectation. All metrics showed that the conditional growth model had the most signficant outcome. The addition of time and other variables as predictors had a significant effect on the conditional growth model. CONCLUSION Interventions designed to decrease the spread of HIV should target sexual behaviours and widespread testing among the ever migrated population to reduce subjective HIV infection thoughts.
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Affiliation(s)
- Sally Sonia Simmons
- Department of Social Policy, London School of Economics and Political Science, London, UK.,Institute of Demography, National Research University-Higher School of Economics, Moscow, Russia
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4
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Thiabaud A, Triulzi I, Orel E, Tal K, Keiser O. Social, Behavioral, and Cultural factors of HIV in Malawi: Semi-Automated Systematic Review. J Med Internet Res 2020; 22:e18747. [PMID: 32795992 PMCID: PMC7455873 DOI: 10.2196/18747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/20/2020] [Accepted: 06/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Demographic and sociobehavioral factors are strong drivers of HIV infection rates in sub-Saharan Africa. These factors are often studied in qualitative research but ignored in quantitative analyses. However, they provide in-depth insight into the local behavior and may help to improve HIV prevention. OBJECTIVE To obtain a comprehensive overview of the sociobehavioral factors influencing HIV prevalence and incidence in Malawi, we systematically reviewed the literature using a newly programmed tool for automatizing part of the systematic review process. METHODS Due to the choice of broad search terms ("HIV AND Malawi"), our preliminary search revealed many thousands of articles. We, therefore, developed a Python tool to automatically extract, process, and categorize open-access articles published from January 1, 1987 to October 1, 2019 in the PubMed, PubMed Central, JSTOR, Paperity, and arXiV databases. We then used a topic modelling algorithm to classify and identify publications of interest. RESULTS Our tool extracted 22,709 unique articles; 16,942 could be further processed. After topic modelling, 519 of these were clustered into relevant topics, of which 20 were kept after manual screening. We retrieved 7 more publications after examining the references so that 27 publications were finally included in the review. Reducing the 16,942 articles to 519 potentially relevant articles using the software took 5 days. Several factors contributing to the risk of HIV infection were identified, including religion, gender and relationship dynamics, beliefs, and sociobehavioral attitudes. CONCLUSIONS Our software does not replace traditional systematic reviews, but it returns useful results to broad queries of open-access literature in under a week, without a priori knowledge. This produces a "seed dataset" of relevance that could be further developed. It identified known factors and factors that may be specific to Malawi. In the future, we aim to expand the tool by adding more social science databases and applying it to other sub-Saharan African countries.
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Affiliation(s)
- Amaury Thiabaud
- Institut de Santé Globale, Université de Genève, Genève, Switzerland
| | - Isotta Triulzi
- Institut de Santé Globale, Université de Genève, Genève, Switzerland
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Erol Orel
- Institut de Santé Globale, Université de Genève, Genève, Switzerland
| | - Kali Tal
- Institut de Santé Globale, Université de Genève, Genève, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Olivia Keiser
- Institut de Santé Globale, Université de Genève, Genève, Switzerland
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Nutor JJ, Duah HO, Agbadi P, Duodu PA, Gondwe KW. Spatial analysis of factors associated with HIV infection in Malawi: indicators for effective prevention. BMC Public Health 2020; 20:1167. [PMID: 32711500 PMCID: PMC7382788 DOI: 10.1186/s12889-020-09278-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/19/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The objective of this study was to model the predictors of HIV prevalence in Malawi through a complex sample logistic regression and spatial mapping approach using the national Demographic and Health Survey datasets. METHODS We conducted a secondary data analysis using the 2015-2016 Malawi Demographic and Health Survey and AIDS Indicator Survey. The analysis was performed in three stages while incorporating population survey sampling weights to: i) interpolate HIV data, ii) identify the spatial clusters with the high prevalence of HIV infection, and iii) perform a multivariate complex sample logistic regression. RESULTS In all, 14,779 participants were included in the analysis with an overall HIV prevalence of 9% (7.0% in males and 10.8% in females). The highest prevalence was found in the southern region of Malawi (13.2%), and the spatial interpolation revealed that the HIV epidemic is worse at the south-eastern part of Malawi. The districts in the high HIV prevalent zone of Malawi are Thyolo, Zomba, Mulanje, Phalombe and Blantyre. In central and northern region, the district HIV prevalence map identified Lilongwe in the central region and Karonga in the northern region as districts that equally deserve attention. People residing in urban areas had a 2.2 times greater risk of being HIV-positive compared to their counterparts in the rural areas (AOR = 2.16; 95%CI = 1.57-2.97). Other independent predictors of HIV prevalence were gender, age, marital status, number of lifetime sexual partners, extramarital partners, the region of residence, condom use, history of STI in the last 12 months, and household wealth index. Disaggregated analysis showed in-depth sociodemographic regional variations in HIV prevalence. CONCLUSION These findings identify high-risk populations and regions to be targeted for Pre-Exposure Prophylaxis (PrEP) campaigns, HIV testing, treatment and education to decrease incidence, morbidity, and mortality related to HIV infection in Malawi.
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Affiliation(s)
- Jerry John Nutor
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, USA.
| | | | - Pascal Agbadi
- Department of Nursing, Faculty of Allied Health Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Kaboni W Gondwe
- College of Nursing, University of Wisconsin-Milwaukee, Milwaukee, WI, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
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Mensch BS, Grant MJ, Soler-Hampejsek E, Kelly CA, Chalasani S, Hewett PC. Does schooling protect sexual health? The association between three measures of education and STIs among adolescents in Malawi. POPULATION STUDIES 2019; 74:241-261. [PMID: 31619138 PMCID: PMC7162723 DOI: 10.1080/00324728.2019.1656282] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
While multiple studies have documented shifting educational gradients in HIV prevalence, less attention has been given to the effect of school participation and academic skills on infection during adolescence. Using the Malawi Schooling and Adolescent Study, a longitudinal survey that followed 2,649 young people aged 14-17 at baseline from 2007 to 2013, we estimate the effect of three education variables: school enrolment, grade attainment, and academic skills-numeracy and Chichewa literacy-on herpes simplex virus type 2 (HSV-2) and HIV incidence using interval-censored survival analysis. We find that grade attainment is significantly associated with lower rates of both HSV-2 and HIV among girls, and is negatively associated with HSV-2 but not HIV among boys. School enrolment and academic skills are not significantly associated with sexually transmitted infections (STIs) for boys or girls in our final models. Efforts to encourage school progression in high-prevalence settings in sub-Saharan Africa could well reduce, or at least postpone, acquisition of STIs.
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Morris BJ, Hankins CA, Banerjee J, Lumbers ER, Mindel A, Klausner JD, Krieger JN. Does Male Circumcision Reduce Women's Risk of Sexually Transmitted Infections, Cervical Cancer, and Associated Conditions? Front Public Health 2019; 7:4. [PMID: 30766863 PMCID: PMC6365441 DOI: 10.3389/fpubh.2019.00004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Male circumcision (MC) is proven to substantially reduce men's risk of a number of sexually transmitted infections (STIs). We conducted a detailed systematic review of the scientific literature to determine the relationship between MC and risk of STIs and associated conditions in women. Methods: Database searches by "circumcision women" and "circumcision female" identified 68 relevant articles for inclusion. Examination of bibliographies of these yielded 14 further publications. Each was rated for quality using a conventional rating system. Results: Evaluation of the data from the studies retrieved showed that MC is associated with a reduced risk in women of being infected by oncogenic human papillomavirus (HPV) genotypes and of contracting cervical cancer. Data from randomized controlled trials and other studies has confirmed that partner MC reduces women's risk not only of oncogenic HPV, but as well Trichomonas vaginalis, bacterial vaginosis and possibly genital ulcer disease. For herpes simplex virus type 2, Chlamydia trachomatis, Treponema pallidum, human immunodeficiency virus and candidiasis, the evidence is mixed. Male partner MC did not reduce risk of gonorrhea, Mycoplasma genitalium, dysuria or vaginal discharge in women. Conclusion: MC reduces risk of oncogenic HPV genotypes, cervical cancer, T. vaginalis, bacterial vaginosis and possibly genital ulcer disease in women. The reduction in risk of these STIs and cervical cancer adds to the data supporting global efforts to deploy MC as a health-promoting and life-saving public health measure and supplements other STI prevention strategies.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW, Australia
| | - Catherine A. Hankins
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- London School of Hygiene and Tropical Medicine, Bloomsbury, London, United Kingdom
| | | | - Eugenie R. Lumbers
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine and Priority Research Centre for Reproductive Science, University of Newcastle, Callaghan, NSW, Australia
- Mothers and Babies Research Centre, Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Adrian Mindel
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jeffrey D. Klausner
- Division of Infectious Diseases and the Program in Global Health, Fielding School of Public Health, University of California Los Angeles Care Center, Los Angeles, CA, United States
| | - John N. Krieger
- Department of Urology, University of Washington School of Medicine, Seattle, WA, United States
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8
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Poku RA, Owusu AY, Mullen PD, Markham C, McCurdy SA. HIV antiretroviral medication stock-outs in Ghana: contributors and consequences. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2018; 16:231-239. [PMID: 28978293 DOI: 10.2989/16085906.2017.1364275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Drug stock-outs are an unfortunate yet common reality for patients living in low and middle income countries, particularly in sub-Saharan Africa where trouble with consistent stock of antiretroviral medications (ARVs) continues. Our study takes a snapshot of this problem in Ghana. Although the country launched its antiretroviral therapy (ART) programme in 2003, progress toward realising the full benefit of ART for treated individuals has been limited, in part, because of stock-outs. In Ghana's Greater Accra region, we conducted semi-structured interviews with 40 women living with HIV (WLHIV) and 15 individuals with a history of HIV-related work in government or non-governmental organisations, or healthcare facilities. We used repeated review with coding and mapping techniques to analyse the transcripts and identify common themes. Stock-outs of ARVs result in inconsistent administration of therapy, increased indirect medical costs for WLHIV, and negative labelling of patients. Inefficiencies in drug supply, poor coordination with port authorities, inadequate government funding and dependence on international aid contribute to the stock-outs experienced in Ghana. Although using ARVs produced in-country could reduce supply problems, the domestically-manufactured product currently does not meet World Health Organization (WHO) standards. We recommend focused efforts to produce WHO standard ARVs in Ghana, and a review of current supply chain management to identify and mend pitfalls in the system.
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Affiliation(s)
- Rebecca A Poku
- a The University of Texas Health Science Center at Houston School of Public Health , Houston , Texas , USA
| | - Adobea Yaa Owusu
- b Institute of Statistical, Social, and Economic Research, University of Ghana , Legon , Ghana
| | - Patricia Dolan Mullen
- a The University of Texas Health Science Center at Houston School of Public Health , Houston , Texas , USA
| | - Christine Markham
- a The University of Texas Health Science Center at Houston School of Public Health , Houston , Texas , USA
| | - Sheryl A McCurdy
- a The University of Texas Health Science Center at Houston School of Public Health , Houston , Texas , USA
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An D, Eggum-Wilkens ND, Chae S, Hayford SR, Yabiku ST, Glick JE, Zhang L. Adults' Conceptualisations of Children's Social Competence in Nepal and Malawi. PSYCHOLOGY AND DEVELOPING SOCIETIES 2018; 30:81-104. [PMID: 30078957 PMCID: PMC6071425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Adults in Nepal (N = 14) and Malawi (N = 12) were interviewed about their views regarding social competence of 5- to 17-year-old children in their societies. Both Nepali and Malawian adults discussed themes consistent with those expected in collectivistic societies with economic challenges (e.g., respect and obedience, family responsibilities, social relationships). There were also unique themes emphasized in each country, which may correspond with country-specific religious beliefs or social problems (e.g., rules and self-control, sexual restraint). Nepali adults described a wider variety of socialization strategies compared with Malawian adults. Results provide novel information regarding adults' perceptions of children's social competence in Nepal and Malawi and may help guide the development of measures of social competence.
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An D, Eggum-Wilkens ND, Chae S, Hayford SR, Yabiku ST, Glick JE, Zhang L. Adults’ Conceptualisations of Children’s Social Competence in Nepal and Malawi. PSYCHOLOGY AND DEVELOPING SOCIETIES 2018. [DOI: 10.1177/0971333617747345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adults in Nepal ( N = 14) and Malawi ( N = 12) were interviewed about their views regarding social competence of 5- to 17-year-old children in their societies. Both Nepali and Malawian adults discussed themes consistent with those expected in collectivistic societies with economic challenges (e.g., respect and obedience, family responsibilities, and social relationships). There were also unique themes emphasised in each country, which may correspond with country-specific religious beliefs or social problems (e.g., rules and self-control, and sexual restraint). Results provide novel information regarding adults’ perceptions of children’s social competence in Nepal and Malawi, and may help guide the development of measures of social competence.
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Affiliation(s)
- Danming An
- T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Tempe, AZ, USA
| | | | - Sophia Chae
- T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Tempe, AZ, USA
| | - Sarah R. Hayford
- T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Tempe, AZ, USA
| | - Scott T. Yabiku
- T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Tempe, AZ, USA
| | - Jennifer E. Glick
- T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Tempe, AZ, USA
| | - Linlin Zhang
- T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Tempe, AZ, USA
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Grund JM, Bryant TS, Jackson I, Curran K, Bock N, Toledo C, Taliano J, Zhou S, Del Campo JM, Yang L, Kivumbi A, Li P, Pals S, Davis SM. Association between male circumcision and women's biomedical health outcomes: a systematic review. Lancet Glob Health 2017; 5:e1113-e1122. [PMID: 29025633 PMCID: PMC5728090 DOI: 10.1016/s2214-109x(17)30369-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 07/21/2017] [Accepted: 08/25/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Male circumcision reduces men's risk of acquiring HIV and some sexually transmitted infections from heterosexual exposure, and is essential for HIV prevention in sub-Saharan Africa. Studies have also investigated associations between male circumcision and risk of acquisition of HIV and sexually transmitted infections in women. We aimed to review all evidence on associations between male circumcision and women's health outcomes to benefit women's health programmes. METHODS In this systematic review we searched for peer-reviewed and grey literature publications reporting associations between male circumcision and women's health outcomes up to April 11, 2016. All biomedical (not psychological or social) outcomes in all study types were included. Searches were not restricted by year of publication, or to sub-Saharan Africa. Publications without primary data and not in English were excluded. We extracted data and assessed evidence on each outcome as high, medium, or low consistency on the basis of agreement between publications; outcomes found in fewer than three publications were indeterminate consistency. FINDINGS 60 publications were included in our assessment. High-consistency evidence was found for five outcomes, with male circumcision protecting against cervical cancer, cervical dysplasia, herpes simplex virus type 2, chlamydia, and syphilis. Medium-consistency evidence was found for male circumcision protecting against human papillomavirus and low-risk human papillomavirus. Although the evidence shows a protective association with HIV, it was categorised as low consistency, because one trial showed an increased risk to female partners of HIV-infected men resuming sex early after male circumcision. Seven outcomes including HIV had low-consistency evidence and six were indeterminate. INTERPRETATION Scale-up of male circumcision in sub-Saharan Africa has public health implications for several outcomes in women. Evidence that female partners are at decreased risk of several diseases is highly consistent. Synergies between male circumcision and women's health programmes should be explored. FUNDING US Centers for Disease Control and Prevention and Jhpiego.
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Affiliation(s)
- Jonathan M Grund
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA
| | - Tyler S Bryant
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Inimfon Jackson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Naomi Bock
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA
| | - Carlos Toledo
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA
| | - Joanna Taliano
- LAC Group, Contractor to US Centers for Disease Control and Prevention, Library Science Branch, Division of Public Health Information Dissemination, Center for Surveillance, Epidemiology, and Laboratory Services, Atlanta, GA, USA
| | - Sheng Zhou
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Ling Yang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Apollo Kivumbi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peizi Li
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sherri Pals
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA
| | - Stephanie M Davis
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Atlanta, GA, USA.
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"They are looking just the same": Antiretroviral treatment as social danger in rural Malawi. Soc Sci Med 2016; 167:71-8. [PMID: 27608050 DOI: 10.1016/j.socscimed.2016.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 07/27/2016] [Accepted: 08/16/2016] [Indexed: 11/21/2022]
Abstract
Research on the social impact of ART pivots on questions of individual adherence and community acceptability of treatment programmes. In this paper we examine unexpected and unintended consequences of the scale-up of treatment in rural Malawi, using a unique dataset of more than 150 observational journals from three sites, spanning 2010 to 2013, focusing on men's everyday conversations. Through thematic content analysis, we explore the emerging perception that the widespread availability of ART constitutes a form of social danger, as treatment makes it difficult to tell who does or does not have AIDS. This ambiguity introduced through ART is interpreted as putting individuals at risk, because it is no longer possible to tell who might be infected - indeed, the sick now look healthier and "plumper" than the well. This ambivalence over the social impact of ART co-exists with individual demand for and appreciation of the benefits of treatment.
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13
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Zamawe COF, Kusamula F. What are the social and individual factors that are associated with undergoing male circumcision as an HIV prevention strategy? A mixed methods study in Malawi. Int Health 2015; 8:170-8. [PMID: 26503362 DOI: 10.1093/inthealth/ihv061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/31/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is compelling evidence that medical male circumcision (MMC) decreases transmission of HIV. Nevertheless, the uptake of MMC is generally very low. Understanding the characteristics of individuals who choose MMC could inform future strategies for scaling-up MMC. The main objective of this study was to explore the social and individual characteristics of men that are associated with the uptake of circumcision as an HIV prevention strategy. METHODS A mixed-methods study, comprising a cross-sectional survey and an exploratory qualitative study, was conducted in Malawi. A total number of 1644 men, of at least 18 years old, participated in this study. A multistage sampling approach was used in the survey while convenience sampling was adopted in the qualitative study. Descriptive statistics, bivariate analyses and multivariable logistic regression were performed to analyze the cross-sectional data and thematic content approach to analyze the qualitative data. RESULTS Individuals who chose MMC were more likely to be unemployed (AOR=1.65; 95% CI: 1.30-2.11), to be married (AOR=3.16; 95% CI: 2.21-4.52) and to have had exposure to MMC promotions (AOR=1.81; 95% CI: 1.41-2.33). They were also more likely to reside in rural areas (AOR=1.85; 95% CI: 1.44-2.38), to perceive themselves as more vulnerable to HIV (AOR=1.60; 95% CI: 1.19-2.15) and to be more knowledgeable about the benefits of MMC (AOR=1.51; 95% CI: 1.16-1.97). CONCLUSIONS The findings suggest that men who had certain social and individual characteristics (for example better knowledge of the benefits of MMC, greater perceived vulnerability to HIV, married and unemployed) were more likely to choose circumcision as a prevention strategy for HIV than those who lacked those characteristics. Strategies for increasing MMC take-up should recognize the current social/individual landscape of MMC uptake and ensure that deliberate efforts targeting marginalized categories of men are available.
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Affiliation(s)
- Collins O F Zamawe
- Blantyre International University, Community Health Department, Private Bag 98, Blantyre, Malawi Parent and Child Health Initiative (PACHI), Research Centre, P.O. Box 31686, Lilongwe, Malawi
| | - Fatsani Kusamula
- Parent and Child Health Initiative (PACHI), Research Centre, P.O. Box 31686, Lilongwe, Malawi
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Parkhurst JO, Chilongozi D, Hutchinson E. Doubt, defiance, and identity: Understanding resistance to male circumcision for HIV prevention in Malawi. Soc Sci Med 2015; 135:15-22. [PMID: 25939072 DOI: 10.1016/j.socscimed.2015.04.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Global policy recommendations to scale up of male circumcision (MC) for HIV prevention tend to frame the procedure as a simple and efficacious public health intervention. However, there has been variable uptake of MC in countries with significant HIV epidemics. Kenya, for example, has embraced MC and has been dubbed a 'leader' by the global health community, while Malawi has been branded a 'laggard' in its slow adoption of a national programme, with a strong political discourse of resistance forming around MC. Regardless of any epidemiological or technical evidence, the uptake of international recommendations will be shaped by how a policy, and the specific artefacts that constitute that policy, intersect with local concerns. MC holds particular significance within many ethnic and religious groups, serving as an important rite of passage, but also designating otherness or enabling the identification of the social and political self. Understanding how the artefact of MC intersects with local social, economic, and political contexts, is therefore essential to understand the acceptance or resistance of global policy recommendations. In this paper we present an in-depth analysis of Malawi's political resistance to MC, finding that ethnic and religious divisions dominating recent political movements aligned well with differing circumcision practices. Political resistance was further found to manifest through two key narratives: a 'narrative of defiance' around the need to resist donor manipulation, and a 'narrative of doubt' which seized on a piece of epidemiological evidence to refute global claims of efficacy. Further, we found that discussions over MC served as an additional arena through which ethnic identities and claims to power could themselves be negotiated, and therefore used to support claims of political legitimacy.
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Affiliation(s)
| | - David Chilongozi
- I-TECH (International Training & Education Centre for Health), Malawi
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15
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Angotti N, Frye M, Kaler A, Poulin M, Watkins SC, Yeatman S. Popular Moralities and Institutional Rationalities in Malawi's Struggle Against AIDS. POPULATION AND DEVELOPMENT REVIEW 2014; 40:447-473. [PMID: 26877567 PMCID: PMC4751039 DOI: 10.1111/j.1728-4457.2014.00693.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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16
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Dionne KY, Poulin M. Ethnic identity, region and attitudes towards male circumcision in a high HIV-prevalence country. Glob Public Health 2014; 8:607-18. [PMID: 23731239 DOI: 10.1080/17441692.2013.790988] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We study how considerations of male circumcision (MC) as both a favourable practice and as protective against HIV are linked with ethnicity in sub-Saharan Africa, where many ethnic groups do not traditionally circumcise. We focus on Malawi, a country with a high HIV prevalence but low MC prevalence. Survey data from a population-based random sample in rural Malawi (N =3400) were analysed for ethnoregional patterns in attitudes towards MC. We used logit regression models to measure how reported circumcision status, region of residence and ethnic identity relate to attitudes towards circumcision. Overall, Malawians reported more negative than positive opinions about MC, but attitudes towards circumcision varied by ethnicity and region. The implications for agencies and governments aggressively scaling up the provision of MC are clear; acceptance of circumcision as a tool for HIV prevention could be low in societies divided by ethnoregional identities that also shape the practice of circumcision.
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Affiliation(s)
- Kim Y Dionne
- Political Science, Texas A&M University, College Station, TX, USA.
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17
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Kohler IV, Soldo BJ, Anglewicz P, Chilima B, Kohler HP. Association of blood lipids, creatinine, albumin, and CRP with socioeconomic status in Malawi. Popul Health Metr 2013; 11:4. [PMID: 23448548 PMCID: PMC3701600 DOI: 10.1186/1478-7954-11-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 01/09/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The objective of these analyses is to document the relationship between biomarker-based indicators of health and socioeconomic status (SES) in a low-income African population where the cumulative effects of exposure to multiple stressors on physiological functions and health in general are expected to be highly detrimental for the well-being of individuals. METHODS Biomarkers were collected subsequent to the 2008 round of the Malawi Longitudinal Study of Families and Health (MLSFH), a population-based study in rural Malawi, including blood lipids (total cholesterol, LDL, HDL, ratio of total cholesterol to HDL), biomarkers of renal and liver organ function (albumin and creatinine) and wide-range C-reactive protein (CRP) as a non-specific biomarker for inflammation. These biomarkers represent widely used indicators of health that are individually or cumulatively recognized as risk factors for age-related diseases among prime-aged and elderly individuals. Quantile regressions are used to estimate the age-gradient and the within-day variation of each biomarker distribution. Differences in biomarker levels by socioeconomic status are investigated using descriptive and multivariate statistics. RESULTS Overall, the number of significant associations between the biomarkers and socioeconomic measures is very modest. None of the biomarkers significantly varies with schooling. Except for CRP where being married is weakly associated with lower risk of having an elevated CRP level, marriage is not associated with the biomarkers measured in the MLSFH. Similarly, being Muslim is associated with a lower risk of having elevated CRP but otherwise religion does not predict being in the high-risk quartiles of any of the MLSFH biomarkers. Wealth does not predict being in the high-risk quartile of any of the MLSFH biomarkers, with the exception of a weak effect on creatinine. Being overweight or obese is associated with increased likelihood of being in the high-risk quartile for cholesterol, Chol/HDL ratio, and LDL. CONCLUSIONS The results provide only weak evidence for variation of the biomarkers by socioeconomic indicators in a poor Malawian context. Our findings underscore the need for further research to understand the determinants of health outcomes in a poor low-income context such as rural Malawi.
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Affiliation(s)
- Iliana V Kohler
- Population Studies Center, University of Pennsylvania, 3718 Locust Walk, Philadelphia, PA 19104, USA
| | - Beth J Soldo
- Population Studies Center, University of Pennsylvania, 3718 Locust Walk, Philadelphia, PA 19104, USA
| | - Philip Anglewicz
- Department of International Health and Development, Tulane University, 1440 Canal St., New Orleans, LA 70112, USA
| | - Ben Chilima
- Community Health Sciences Unit, Ministry of Health and Population, Private Bag 65, Lilongwe, Malawi
| | - Hans-Peter Kohler
- Population Studies Center, University of Pennsylvania, 3718 Locust Walk, Philadelphia, PA 19104, USA
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