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Risk Compensation in Voluntary Medical Male Circumcision Programs. Curr HIV/AIDS Rep 2022; 19:516-521. [PMID: 36350470 DOI: 10.1007/s11904-022-00635-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW Evidence from clinical trials identified the effectiveness of voluntary medical male circumcision (VMMC) as an additional strategy to reduce the risk of HIV transmission from women to men. However, concerns about post-circumcision sexual risk compensation may hinder the scale-up of VMMC programs. We reviewed the evidence of changes in risky sexual behaviors after circumcision, including condomless sex, multiple sex partners, and early resumption of sex after surgery. RECENT FINDINGS Most clinical trial data indicate that condomless sex and multiple partners did not increase for men after circumcision, and early resumption of sex is rare. Only one post-trial surveillance reports that some circumcised men had more sex partners after surgery, but this did not offset the effect of VMMC. Conversely, qualitative studies report that a small number of circumcised men had increased risky sexual behaviors, and community-based research reports that more men resumed sex early after surgery. With the large-scale promotion and expansion of VMMC services, it may be challenging to maintain effective sexual health educations due to various restrictions. Misunderstandings of the effect of VMMC in preventing HIV infection are the main reason for increasing risky sexual behaviors after surgery. Systematic and practical sexual health counseling services should be in place on an ongoing basis to maximize the effect of VMMC.
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Chatsika ZJ, Kumitawa A, Samuel V, Azizi SC, Jumbe VC. Voluntary medical male circumcision and sexual practices among sexually active circumcised men in Mzuzu, Malawi: a cross-sectional study. BMC Public Health 2020; 20:211. [PMID: 32046686 PMCID: PMC7014635 DOI: 10.1186/s12889-020-8309-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/31/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Voluntary Medical Male Circumcision (VMMC) is one of the strategies being promoted to prevent sexual heterosexual transmission of HIV. It has been adopted by 14 countries with high HIV prevalence and low circumcision rates. The 60.0% protective efficacy of VMMC has come with misconceptions in some societies in Malawi, hence VMMC clients may opt for risky sexual practices owing to its perceived protective effect. The study estimated proportion of circumcised men engaging in risky sexual behaviors post-VMMC, assessed knowledge on VMMC protective effect and identified socio-demographic factors associated with risky sexual practices. METHOD A cross sectional study was conducted at two sites of Mzuzu city. Systematic random sampling was used to select 322 participants aged 18-49 who had undergone VMMC. The independent variables included age, location, occupation, religion, marital status and education. Outcome variables were non condom use, having multiple sexual partners and engaging in transactional sex. Data from questionnaires was analyzed using Pearson's chi square test and logistic regression. RESULTS Out of 322 respondents, 84.8% (273) understood the partial protection offered by VMMC in HIV prevention. Ninety-six percent of the participants self-reported continued use of condoms post VMMC. Overall 23.7-38.3% participants self-reported engaging in risky sexual practices post VMMC, 23.7% (76) had more than one sexual partner; 29.2% (94) paid for sex while 39.9% (n = 187) did not use a condom. Residing in high density areas was associated with non-condom use, (p = 0.043). Being single (p < 0.001), and residing in low density areas (p = 0.004) was associated with engaging in transactional sex. CONCLUSION Risky sexual practices are evident among participants that have undergone VMMC. Messages on safer sexual practices and limitations of VMMC need to be emphasized to clients, especially unmarried or single and those residing in low density areas.
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Affiliation(s)
- Zimveka Jones Chatsika
- College of Medicine, Public Health Department, P/Bag 360, Chichiri, Blantyre 3, Malawi. .,Malawi Defence Force, Malawi Military Health Services, Moyale Barracks, P.O Box 23, Mzuzu, Malawi.
| | - Andrew Kumitawa
- College of Medicine, Public Health Department, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Vincent Samuel
- College of Medicine, Research Support Centre, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Steven Chifundo Azizi
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Post Box 50110, Lusaka, Zambia.,Malawi Defence Force, Malawi Military Health Services, Kamuzu Barracks, Private Bag 43, Lilongwe, Malawi
| | - Vincent C Jumbe
- College of Medicine, Department of Public health, Health Systems and Policy, P/Bag 360, Chichiri, Blantyre 3, Malawi
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Engl E, Sgaier SK. CUBES: A practical toolkit to measure enablers and barriers to behavior for effective intervention design. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.12923.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A pressing goal in global development and other sectors is often to understand what drives people’s behaviors, and how to influence them. Yet designing behavior change interventions is often an unsystematic process, hobbled by insufficient understanding of contextual and perceptual behavioral drivers and a narrow focus on limited research methods to assess them. We propose a toolkit (CUBES) of two solutions to help programs arrive at more effective interventions. First, we introduce a novel framework of behavior, which is a practical tool for programs to structure potential drivers and match corresponding interventions. This evidence-based framework was developed through extensive cross-sectoral literature research and refined through application in large-scale global development programs. Second, we propose a set of descriptive, experimental, and simulation approaches that can enhance and expand the methods commonly used in global development. Since not all methods are equally suited to capture the different types of drivers of behavior, we present a decision aid for method selection. We recommend that existing commonly used methods, such as observations and surveys, use CUBES as a scaffold and incorporate validated measures of specific types of drivers in order to comprehensively test all the potential components of a target behavior. We also recommend under-used methods from sectors such as market research, experimental psychology, and decision science, which programs can use to extend their toolkit and test the importance and impact of key enablers and barriers. The CUBES toolkit enables programs across sectors to streamline the process of conceptualizing, designing, and optimizing interventions, and ultimately to change behaviors and achieve targeted outcomes.
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Engl E, Sgaier SK. CUBES: A practical toolkit to measure enablers and barriers to behavior for effective intervention design. Gates Open Res 2019; 3:886. [PMID: 31294419 PMCID: PMC6601426 DOI: 10.12688/gatesopenres.12923.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 02/04/2023] Open
Abstract
A pressing goal in global development and other sectors is often to understand what drives people’s behaviors, and how to influence them. Yet designing behavior change interventions is often an unsystematic process, hobbled by insufficient understanding of contextual and perceptual behavioral drivers and a narrow focus on limited research methods to assess them. We propose a toolkit (CUBES) of two solutions to help programs arrive at more effective interventions. First, we introduce a novel framework of behavior, which is a practical tool for programs to structure potential drivers and match corresponding interventions. This evidence-based framework was developed through extensive cross-sectoral literature research and refined through application in large-scale global development programs. Second, we propose a set of descriptive, experimental, and simulation approaches that can enhance and expand the methods commonly used in global development. Since not all methods are equally suited to capture the different types of drivers of behavior, we present a decision aid for method selection. We recommend that existing commonly used methods, such as observations and surveys, use CUBES as a scaffold and incorporate validated measures of specific types of drivers in order to comprehensively test all the potential components of a target behavior. We also recommend under-used methods from sectors such as market research, experimental psychology, and decision science, which programs can use to extend their toolkit and test the importance and impact of key enablers and barriers. The CUBES toolkit enables programs across sectors to streamline the process of conceptualizing, designing, and optimizing interventions, and ultimately to change behaviors and achieve targeted outcomes.
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Affiliation(s)
- Elisabeth Engl
- Surgo Foundation, Washington, District of Columbia, 20001, USA
| | - Sema K Sgaier
- Surgo Foundation, Washington, District of Columbia, 20001, USA.,Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Global Health, University of Washington, Seattle, Washington, USA
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Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized Sub-Saharan countries. PLoS One 2017; 12:e0175928. [PMID: 28441458 PMCID: PMC5404849 DOI: 10.1371/journal.pone.0175928] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/03/2017] [Indexed: 11/19/2022] Open
Abstract
Background WHO and UNAIDS prioritized 14 eastern and southern African countries with high HIV and low male circumcision prevalence for a voluntary medical male circumcision (VMMC) scale-up in 2007. Because circumcision provides only partial protection against HIV infection to men, the issue of possible risk compensation in response to VMMC campaigns is of particular concern. In this study, we looked at population-level survey data from the countries prioritized by WHO for a VMMC scale-up. We compared the difference in sexual risk behaviours (SRB) between circumcised and uncircumcised men before and after the WHO’s official VMMC promotion. Materials and methods Ten countries (Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe) participating in the WHO’s VMMC scale-up had available data from the Demographic and Health Surveys (DHS). We used cumulative-link mixed models to investigate interactions between survey period and circumcision status in predicting SRB, in order to evaluate whether the difference between the behavior of the two groups changed before and after the scale-up, while controlling for socio-demographic and knowledge-related covariates. The main responses were condom use at last sex and number of non-cohabiting sexual partners, both in the last 12 months. Results There was little change in condom use by circumcised men relative to uncircumcised men from before the VMMC scale up to after the scale up. The relative odds ratio is 1.06 (95% CI, 0.95–1.18; interaction P = 0.310). Similarly, there was little change in the number of non-cohabiting partners in circumcised men (relative to uncircumcised men): the relative odds ratio of increasing the number of partners is 0.95 (95% CI, 0.86–1.05; interaction P = 0.319). Age, religion, education, job, marital status, media use and HIV knowledge also showed statistically significant association with the studied risk behaviours. We also found significant differences among countries, while controlling for covariates. Conclusions Overall, we find no evidence of sexual risk compensation in response to VMMC campaigns in countries prioritized by WHO. Changes in relative partner behaviour and the relative odds of condom use were small (and of uncertain sign). In fact, our estimates, though not significant, both suggest slightly less risky behavior. We conclude that sexual risk compensation in response to VMMC campaigns has not been a serious problem to date, but urge continued attention to local context, and to promulgating accurate messages about circumcision within and beyond the VMMC context.
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Mukama T, Ndejjo R, Musinguzi G, Musoke D. Perceptions about medical male circumcision and sexual behaviours of adults in rural Uganda: a cross sectional study. Pan Afr Med J 2015; 22:354. [PMID: 26985272 PMCID: PMC4779633 DOI: 10.11604/pamj.2015.22.354.7125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/10/2015] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Medical male circumcision is currently recognized as an additional important HIV preventive intervention to reduce the risk of heterosexually acquired HIV infection in men. However, sexual behaviours after medical circumcision can potentially reduce the expected benefits of the practice. This study explored the perceptions about medical male circumcision and sexual behaviours of adults in Kayunga district, Uganda. METHODS A cross-sectional study was carried out among 393 respondents using a semi structured questionnaire. In addition, four focus group discussions were conducted. Quantitative data was analysed using STATA 12. Univariate, bivariate and multivariate analyses were carried out. Qualitative data was analysed thematically. RESULTS The study established various perceptions about medical male circumcision and sexual behaviours. Majority 247 (64.5%) did not perceive circumcision as a practice that can lead men to have multiple sexual partners. Males were 3 times more likely to think that circumcision would lead to having multiple sexual partners than females (AOR=2.99, CI: 1.93-4.61). Only 89 (23.2%) believed that circumcision would lead to complacency and compromise the use of condoms to prevent against infection with HIV. Respondents who had education above primary were less likely to think that circumcision would compromise the use of condoms (AOR=0.49, CI: 0.31- 0.79). The perception that circumcised youths were less likely to abstain from sexual intercourse was less held among those with education above primary (AOR=0.58, CI: 0.37-0.91) and those older than 30 years (AOR=0.59, CI: 0.38-0.92). CONCLUSION There were gaps in knowledge and negative perceptions about MMC in the study community. Measures are needed to avert the negative perceptions by equipping communities with sufficient, accurate and consistent information about medical male circumcision and sexual behaviour.
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Affiliation(s)
- Trasias Mukama
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
| | - Geofrey Musinguzi
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences,Kampala, Uganda
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Wojczewski S, Willcox M, Mubangizi V, Hoffmann K, Peersman W, Niederkrotenthaler T, Natukunda S, Maling S, Maier M, Mant D, Kutalek R. Portrayal of the human resource crisis and accountability in healthcare: a qualitative analysis of ugandan newspapers. PLoS One 2015; 10:e0121766. [PMID: 25837490 PMCID: PMC4383446 DOI: 10.1371/journal.pone.0121766] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 02/11/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Uganda is one of the 57 countries with a critical shortage of health workers. The aim of this study was to determine how the human resources and health service crisis was covered in Ugandan newspapers and, in particular, how the newspapers attributed accountability for problems in the health services. METHODS We collected all articles related to health workers and health services for the calendar year 2012 in the two largest national newspapers in Uganda (collection on daily basis) and in one local newspaper (collection on weekly basis). These articles were analysed qualitatively regarding the main themes covered and attribution of accountability. RESULTS The two more urban national newspapers published 229 articles on human resources and health services in Uganda (on average over two articles per week), whereas the local more rural newspaper published only a single article on this issue in the 12 month period. The majority of articles described problems in the health service without discussing accountability. The question of accountability is raised in only 46% of articles (106 articles). The responsibility of the government was discussed in 50 articles (21%), and negligence, corruption and misbehaviour by individual health workers was reported in 56 articles (25%). In the articles about corruption (n=35), 60% (21 articles) mention corruption by health workers and 40% (14 articles) mention corruption by government officials. Six articles defended the situation of health workers in Uganda. CONCLUSIONS The coverage of accountability in the Ugandan newspapers surveyed is insufficient to generate informed debate on what political actions need to be taken to improve the crisis in health care and services. There exists not only an "inverse care law" but also an "inverse information law": those sections of society with the greatest health needs and problems in accessing quality health care receive the least information about health services.
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Affiliation(s)
- Silvia Wojczewski
- Department of General Practice and Family Medicine, Centre of Public Health, Medical University of Vienna, Vienna, Austria
| | - Merlin Willcox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | | | - Kathryn Hoffmann
- Department of General Practice and Family Medicine, Centre of Public Health, Medical University of Vienna, Vienna, Austria
| | - Wim Peersman
- Department of Family Medicine and Primary Healthcare, Ghent University, University Hospital, Ghent, Belgium
| | - Thomas Niederkrotenthaler
- Department of Social Medicine, Centre of Public Health, Medical University of Vienna, Vienna, Austria
| | | | - Samuel Maling
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Manfred Maier
- Department of General Practice and Family Medicine, Centre of Public Health, Medical University of Vienna, Vienna, Austria
| | - David Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, United Kingdom
| | - Ruth Kutalek
- Department of General Practice and Family Medicine, Centre of Public Health, Medical University of Vienna, Vienna, Austria
- * E-mail:
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Martínez Pérez G, Triviño Durán L, Gasch A, Desmond N. Towards a gender perspective in qualitative research on voluntary medical male circumcision in east and southern Africa. Glob Public Health 2015; 10:626-38. [PMID: 25727455 DOI: 10.1080/17441692.2015.1014826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The World Health Organization endorsed voluntary medical male circumcision (VMMC) in 2007 as an effective method to provide partial protection against heterosexual female-to-male transmission of HIV in regions with high rates of such transmission, and where uptake of VMMC is low. Qualitative research conducted in east and southern Africa has focused on assessing acceptability, barriers to uptake of VMMC and the likelihood of VMMC increasing men's adoption of risky sexual behaviours. Less researched, however, have been the perceptions of women and sexual minorities towards VMMC, even though they are more vulnerable to HIV/AIDS transmission than are heterosexual men. The purpose of this paper is to identify core areas in which a gendered perspective in qualitative research might improve the understanding and framing of VMMC in east and southern Africa. Issues explored in this analysis are risk compensation, the post-circumcision appearance of the penis, inclusion of men who have sex with men as study respondents and the antagonistic relation between VMMC and female genital cutting. If biomedical and social science researchers explore these issues in future qualitative inquiry utilising a gendered perspective, a more thorough understanding of VMMC can be achieved, which could ultimately inform policy and implementation.
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Lagone E, Mathur S, Nakyanjo N, Nalugoda F, Santelli J. Public discourse on HIV/AIDS: an archival analysis of national newspaper reporting in Uganda, 1996-2011. SEX EDUCATION 2014; 14:556-567. [PMID: 25132802 PMCID: PMC4131432 DOI: 10.1080/14681811.2014.923304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Uganda is recognised as an early success story in the HIV epidemic at least in part due to an open and vigorous national dialogue about HIV prevention. This study examined the national discourse about HIV, AIDS, and young people in New Vision, Uganda's leading national newspaper between 1996 and 2011, building from a previous archival analysis of New Vision reporting by Kirby (1986-1995). We examined the continuing evolution in the public discourse in Uganda, focusing on reporting about young people. An increase in reporting on HIV and AIDS occurred after 2003, as antiretroviral treatment was becoming available. While the emphasis in newspaper reporting about adults and the population at large evolved to reflect the development of new HIV treatment and prevention methods, the majority of the articles focused on young people did not change. Articles about young people continued to emphasise HIV acquisition due to early and premarital sexual activity and the need for social support services for children affected by HIV and AIDS. Articles often did not report on the complex social conditions that shape HIV-related risk among young people, or address young people who are sexually active, married, and/or HIV infected. With HIV prevalence now increasing among young people and adults in Uganda, greater attention to HIV prevention is needed.
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Affiliation(s)
- Elizabeth Lagone
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sanyukta Mathur
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Neema Nakyanjo
- Rakai Health Sciences Program/Uganda Virus Research Institute, Entebbe, Uganda
| | - Fred Nalugoda
- Rakai Health Sciences Program/Uganda Virus Research Institute, Entebbe, Uganda
| | - John Santelli
- Mailman School of Public Health, Columbia University, New York, NY, USA
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