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Asa GA, Fauk NK, Ward PR. Traditional male circumcision and the risk for HIV transmission among men: a systematic review. BMJ Open 2023; 13:e072118. [PMID: 37208134 DOI: 10.1136/bmjopen-2023-072118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVES To synthesise evidence to determine whether, in contrast to medical male circumcision, traditional male circumcision (TMC) practices may contribute to HIV transmission and what the impacts of TMC are on the initiates, their families and societies. DESIGN Systematic review. DATA SOURCE PubMed, CINHAL, SCOPUS, ProQuest, Cochrane database and Medline were searched between 15 and 30 October 2022. ELIGIBILITY CRITERIA (1) Studies involving young men, young male adults, male adults and mixed male and female participants; (2) studies on TMC involving men living with HIV (married and non-married); (3) studies on TMC, HIV transmission and impact in low-income and middle-income countries; (4) qualitative, quantitative and mixed-method studies and (5) studies aimed at exploring TMC and how it contributes to HIV transmission and the impacts of HIV on circumcised men and their families. DATA EXTRACTION Data were extracted based on study details, study design, characteristics of participants and results. RESULT A total of 18 studies were included: 11 were qualitative studies, five were quantitative studies and two were mixed-method studies. All the studies included were conducted in areas where TMC was performed (17 in Africa and one in Papua New Guinea). The review's findings were categorised into themes: TMC as a cultural practice, consequences of not being traditionally circumcised on men and their families and TMC-related risk of HIV transmission. CONCLUSION This systematic review highlights that TMC practice and HIV risk could negatively impact men and their families. Existing evidence suggests that little attention has been paid to men and their families experiencing the impacts of TMC and HIV risk factors. The findings recommend the need for health intervention programmes such as safe circumcision and safe sexual behaviours following TMC and efforts to address psychological and social challenges in communities practising TMC. PROSPERO REGISTRATION NUMBER CRD42022357788.
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Affiliation(s)
- Gregorius Abanit Asa
- Research Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia, Australia
| | - Nelsensius Klau Fauk
- Research Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia, Australia
| | - Paul Russell Ward
- Research Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia, Australia
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Jindai K, Farley T, Awori Q, Temu AS, Ndenzako F, Samuelson J. Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes. Gates Open Res 2023; 6:164. [PMID: 37089877 PMCID: PMC10115943 DOI: 10.12688/gatesopenres.13730.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.
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Affiliation(s)
- Kazuaki Jindai
- Department of Virology, Tohoku University, Sendai, Japan
- Department of Healthcare Epidemiology, Kyoto University, Kyoto, Japan
| | | | | | | | - Fabian Ndenzako
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
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3
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Jindai K, Farley T, Awori Q, Temu AS, Ndenzako F, Samuelson J. Systematic review: Safety of surgical male circumcision in context of HIV prevention public health programmes. Gates Open Res 2022; 6:164. [PMID: 37089877 PMCID: PMC10115943 DOI: 10.12688/gatesopenres.13730.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Since the recommendation of voluntary medical male circumcision (VMMC) to reduce the risk of heterosexually acquired HIV, a number of adolescent boys and men in 15 priority countries in Africa have been circumcised. Our primary goal was to identify the incidence of adverse events (AEs) associated with VMMC and to assess the safety profile among adolescent boys 10 - 14 years. Methods: We searched the databases MEDLINE and Embase, WHO, and conference abstracts from 2005 to 2019. The incidence of AEs was estimated by type of AE, size of study and age. Results: We retained 40 studies. Severe and moderate AEs overall were estimated at 0.30 per 100 VMMC clients with wide variability per study type. A higher rate was noted in small and moderate scale programmes and device method research studies compared with larger scale programmes. There was a limited number of studies reporting AEs among younger adolescent boys and they had higher infection-related AEs than those aged 20 years and older. Case studies noted rare AEs such as necrotizing fasciitis, tetanus, and glans injury. Conclusions: AE rates were comparable to those from the randomized controlled trials (RCTs) that led to recommendations and implementation of VMMC in high HIV burden countries, despite being implemented in low resource settings. Clients over time have increasingly included adolescents under the age of 15 years. Studies suggest potentially higher risks in this age group. As VMMC services are sustained, patient safety surveillance systems and promoting a patient safety culture are crucial to identify and mitigate potential harms from medical male circumcision.
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Affiliation(s)
- Kazuaki Jindai
- Department of Virology, Tohoku University, Sendai, Japan
- Department of Healthcare Epidemiology, Kyoto University, Kyoto, Japan
| | | | | | | | - Fabian Ndenzako
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
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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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Kankaka EN, Nalugoda F, Serwadda D, Makumbi F, Wawer MJ, Gray RH, Quinn TC, Reynolds SJ, Nakigozi G, Lutalo T, Kigozi G, Sewankambo NK, Kagaayi J. Makerere's contribution to the development of a high impact HIV research population-based cohort in the Rakai Region, Uganda. Afr Health Sci 2022; 22:42-50. [PMID: 36321125 PMCID: PMC9590336 DOI: 10.4314/ahs.v22i2.7s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Longitudinal population-based cohort studies can provide critical insights on temporal, spatial and sociodemographic changes in health status and health determinants that are not obtained by other study designs. However, establishing and maintaining such a cohort study can be challenging and expensive. Here, we describe the role of Makerere University in the development and conduct of such a cohort. We chronicle the first academia-led reports of HIV in East Africa; how this led to initiation of the Rakai Community Cohort Study in 1988, the first and oldest HIV cohort in sub-Saharan Africa; its impact on HIV prevention, care and treatment; how the cohort has been maintained; and opportunities, challenges, and future directions including non-communicable diseases.
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Affiliation(s)
| | | | - David Serwadda
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Public Health
| | - Fredrick Makumbi
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Public Health
| | - Maria J Wawer
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
- Johns Hopkins University School of Medicine
| | - Ronald H Gray
- Rakai Health Sciences Program
- Johns Hopkins Bloomberg School of Public Health
| | - Thomas C Quinn
- Johns Hopkins University School of Medicine
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH
| | - Steven J Reynolds
- Johns Hopkins University School of Medicine
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH
| | | | - Tom Lutalo
- Rakai Health Sciences Program
- Uganda Virus Research Institute
| | | | - Nelson K Sewankambo
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Medicine
| | - Joseph Kagaayi
- Rakai Health Sciences Program
- Makerere University College of Health Sciences, School of Public Health
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Transitioning a digital health innovation from research to routine practice: Two-way texting for male circumcision follow-up in Zimbabwe. PLOS DIGITAL HEALTH 2022; 1:e0000066. [PMID: 36812548 PMCID: PMC9931231 DOI: 10.1371/journal.pdig.0000066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022]
Abstract
Adult medical male circumcision (MC) is safe: global notifiable adverse event (AE) rates average below 2.0%. With Zimbabwe's shortage of health care workers (HCWs) compounded by COVID-19 constraints, two-way text-based (2wT) MC follow-up may be advantageous over routinely scheduled in-person reviews. A 2019 randomized control trial (RCT) found 2wT to be safe and efficient for MC follow-up. As few digital health interventions successfully transition from RCT to scale, we detail the 2wT scale-up approach from RCT to routine MC practice comparing MC safety and efficiency outcomes. After the RCT, 2wT transitioned from a site-based (centralized) system to hub-and-spoke model for scale-up where one nurse triaged all 2wT patients, referring patients in need to their local clinic. No post-operative visits were required with 2wT. Routine patients were expected to attend at least one post-operative review. We compare 1) AEs and in-person visits between 2wT men from RCT and routine MC service delivery; and 2) 2wT-based and routine follow-up among adults during the 2wT scale-up period, January to October 2021. During scale-up period, 5084 of 17417 adult MC patients (29%) opted into 2wT. Of the 5084, 0.08% (95% CI: 0.03, 2.0) had an AE and 71.0% (95% CI: 69.7, 72.2) responded to ≥1 daily SMS, a significant decrease from the 1.9% AE rate (95% CI: 0.7, 3.6; p<0.001) and 92.5% response rate (95% CI: 89.0, 94.6; p<0.001) from 2wT RCT men. During scale-up, AE rates did not differ between routine (0.03%; 95% CI: 0.02, 0.08) and 2wT (p = 0.248) groups. Of 5084 2wT men, 630 (12.4%) received telehealth reassurance, wound care reminders, and hygiene advice via 2wT; 64 (19.7%) were referred for care of which 50% had visits. Similar to RCT outcomes, routine 2wT was safe and provided clear efficiency advantages over in-person follow-up. 2wT reduced unnecessary patient-provider contact for COVID-19 infection prevention. Rural network coverage, provider hesitancy, and the slow pace of MC guideline changes slowed 2wT expansion. However, immediate 2wT benefits for MC programs and potential benefits of 2wT-based telehealth for other health contexts outweigh limitations.
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Reducing Provider Workload While Preserving Patient Safety: A Randomized Control Trial Using 2-Way Texting for Postoperative Follow-up in Zimbabwe's Voluntary Medical Male Circumcision Program. J Acquir Immune Defic Syndr 2020; 83:16-23. [PMID: 31809358 PMCID: PMC6903365 DOI: 10.1097/qai.0000000000002198] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is Available in the Text. Voluntary medical male circumcisions (MCs) are safe: the majority of men heal without complication. However, guidelines require multiple follow-up visits. In Zimbabwe, where there is high mobile phone ownership, severe health care worker shortages, and rapid MC scale up intersect, we tested a 2-way texting (2wT) intervention to reduce provider workload while safeguarding patient safety.
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Pintye J, Wirth KE, Ntsuape C, Kleinman NJ, Spees LP, Semo BW, Mawandia S, Ledikwe JH. Early resumption of sex after voluntary medical male circumcision for HIV prevention within a programmatic delivery setting in Botswana. Int J STD AIDS 2019; 30:1275-1283. [PMID: 31631778 DOI: 10.1177/0956462419866051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To maximize the public health benefits of voluntary medical male circumcision (VMMC) in real-world settings, sexual abstinence is recommended for six weeks following VMMC to ensure complete wound healing. We determined the frequency and predictors of early resumption of sex among a cohort of HIV-negative, sexually active men 18–49 years who underwent VMMC within a public-sector clinic in Botswana. Multivariate robust Poisson regression methods were used to identify predictors of having any sexual intercourse in the last six weeks since undergoing VMMC. In total, 433/519 (83%) men had data available on sexual activity at six weeks post-VMMC. Median age was 27 years, 57% had a higher than secondary education, 72% were employed, and 9% were married. Overall, 122/433 (28%) men had sexual intercourse within the six weeks since VMMC, of whom 36% reported inconsistent condom use. Compared to men ≥34 years, men aged <30 years (adjusted risk ratio [aRR] = 1.71, 95% CI 0.95–3.08) and men 30–34 years had a two-fold higher likelihood of resuming sexual activity early in multivariate analyses (aRR = 2.31, 95% CI 1.26–4.25, Wald p = 0.018). Employed men were more likely to resume sexual activity early than unemployed men (aRR = 1.58, 95% CI 1.02–2.44, p = 0.039). Additional interventions are needed to encourage abstinence until complete wound healing.
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Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kathleen E Wirth
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health, Gaborone, Botswana
| | - Nora J Kleinman
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,NJK Consulting, Seattle, WA, USA
| | - Lisa P Spees
- Department of Health Policy and Management, University of North Carolina Chapel Hil, Chapel Hill, NC, USA
| | - Bazghina-Werq Semo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Shreshth Mawandia
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Jenny H Ledikwe
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
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Lubogo M, Anguzu R, Wanzira H, Shour AR, Mukose AD, Nyabigambo A, Tumwesigye NM. Utilization of safe male circumcision among adult men in a fishing community in rural Uganda. Afr Health Sci 2019; 19:2645-2653. [PMID: 32127837 PMCID: PMC7040272 DOI: 10.4314/ahs.v19i3.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background In Uganda, most-at-riskpopulations(MARPs) such as fishing communities remain vulnerable to preventable HIV acquisition. Safe Male Circumcision (SMC) has been incorporated into Uganda's HIV prevention strategies. This study aimed at determining SMC utilization and associated factors among adult men in a rural fishing community in Uganda. Methods A cross-sectional study was conducted in a rural fishing village in central Uganda. Stratified random sampling of 369 fishermen aged 18–54 yearswas used according to their occupational category; fish monger, boat crew and general merchandise. The dependent variable wasutilization of SMC.A forward fitting multivariable logistic regression model was fitted with variables significant at p≤0.05 controlling for confounding and effect modification. Results Respondents'mean(SD) age was 30.0(9.3) years. Only8.4%hadSMC and among non-circumcised men, 84.9% had adequate knowledge of SMC benefits while 79.3% did not know were SMC services were offered. Peer support(AOR0.17;95%-CI0.05–0.60) and perceived procedural safety (AOR6.8;95%CI2.16–21.17) were independently associated with SMC utilization. Conclusion In this rural fishing community, SMC utilization was low. These findings underscore the need to inform HIV preventionstrategies inthecontextof peer support and perceptionsheld by rural dwelling men.
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Affiliation(s)
- Mutaawe Lubogo
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Uganda
| | - Ronald Anguzu
- Institute of Health and Equity, Medical College of Wisconsin, US
| | | | - Abdul R Shour
- Institute of Health and Equity, Medical College of Wisconsin, US
| | - Aggrey D Mukose
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Uganda
| | - Agnes Nyabigambo
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University, Uganda
| | - Nazarius M Tumwesigye
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Uganda
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Srithanaviboonchai K, Srirak N, Pruenglampoo B, Thaikla K, Suwanteerangkul J, Khorana J, Danthamrongkul V, Paileeklee S, Pattanasattayavong U, Grimes DE, Grimes RM. Physicians' and nurses' thoughts and concerns about introducing neonatal male circumcision in Thailand: a qualitative study. BMC Health Serv Res 2018; 18:275. [PMID: 29642890 PMCID: PMC5896126 DOI: 10.1186/s12913-018-3093-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 04/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure. METHODS In-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes. RESULTS Six themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented. CONCLUSIONS Thai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.
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Affiliation(s)
- Kriengkrai Srithanaviboonchai
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Namtip Srirak
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Kanittha Thaikla
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Jiraporn Khorana
- Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Vipa Danthamrongkul
- College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | | | - Deanna E. Grimes
- School of Nursing, University of Texas Health Science Center, Houston, Texas USA
- Baylor-UT Houston Center for AIDS Research, Houston, Texas USA
| | - Richard M. Grimes
- Baylor-UT Houston Center for AIDS Research, Houston, Texas USA
- Division of General Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas USA
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Tshimanga M, Makunike-Chikwinya B, Mangwiro T, Tapiwa Gundidza P, Chatikobo P, Murenje V, Herman-Roloff A, Kilmarx PH, Holec M, Gwinji G, Mugurungi O, Murwira M, Xaba S, Barnhart S, Feldacker C. Safety and efficacy of the PrePex device in HIV-positive men: A single-arm study in Zimbabwe. PLoS One 2017; 12:e0189146. [PMID: 29220392 PMCID: PMC5722373 DOI: 10.1371/journal.pone.0189146] [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: 07/26/2017] [Accepted: 11/17/2017] [Indexed: 11/21/2022] Open
Abstract
Male circumcision (MC) for sexually active, HIV-negative men reduces HIV transmission and averts HIV infections. Excluding HIV-positive men from MC decreases access to additional health and hygiene benefits. In settings where HIV-testing is, or is perceived to be, required for MC, testing may reduce MC uptake. Reducing promotion of HIV testing within MC settings and promoting device-based MC may speed MC scale-up. To assess safety and efficacy of PrePex MC device among HIV-positive men, we conducted a one-arm, open-label, prospective study in otherwise healthy HIV-positive men in Zimbabwe.
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Affiliation(s)
- Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | | | | | | | - Pesanai Chatikobo
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | - Peter H. Kilmarx
- U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
| | | | | | | | | | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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Ledikwe JH, Ramabu NM, Spees LP, Barnhart S, Ntsuape C, Semo BW, Wirth KE. Early resumption of sexual activity following voluntary medical male circumcision in Botswana: A qualitative study. PLoS One 2017; 12:e0186831. [PMID: 29136009 PMCID: PMC5685600 DOI: 10.1371/journal.pone.0186831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/09/2017] [Indexed: 11/30/2022] Open
Abstract
Unprotected sexual intercourse after undergoing voluntary medical male circumcision but prior to complete wound healing can lead to major adverse events including HIV acquisition. To better understand perceptions related to early resumption of sex prior to wound healing, 27 focus group discussions were conducted among 238 adult men, women, and community leaders in Botswana. Median age among all participants was 31 years of whom 60% were male and 51% were either employed and receiving salary or self-employed. Only 12% reported being currently married. Pain, not risk of HIV acquisition, was perceived as the main adverse consequence of early resumption of sex. In fact, no participant mentioned that early resumption of sex could lead to an increase in HIV risk. Demonstrating masculinity and virility, fear of losing female partners, and misperception about post-operative wound healing also played key roles in the decision to resume sex prior to complete wound healing. Findings from this study highlight a potentially widespread lack of awareness of the increased risk of HIV acquisition during the wound healing period. Strengthening post-operative counseling and identifying strategies to discourage the early resumption of sex will be increasingly important as older men and HIV-positive men seek voluntary medical male circumcision services.
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Affiliation(s)
- Jenny H. Ledikwe
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Nankie M. Ramabu
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Lisa P. Spees
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health, Gaborone, Botswana
| | - Bazghina-werq Semo
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Kathleen E. Wirth
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Men's Understanding of and Experiences During the Postcircumcision Abstinence Period: Results From a Field Study of ShangRing Circumcision During Routine Clinical Services in Kenya and Zambia. J Acquir Immune Defic Syndr 2017; 72 Suppl 1:S18-23. [PMID: 27331585 PMCID: PMC4936421 DOI: 10.1097/qai.0000000000000704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Men's understanding of counseling messages after voluntary medical male circumcision (VMMC) plays an important role in whether they follow them. Data on triggers for early resumption of sex may be useful as scale-up of VMMC for HIV prevention continues in sub-Saharan Africa. Methods: Data on understanding of post-VMMC abstinence recommendations, resumption of sex, condom use, and triggers for resuming sex were collected from participants during a follow-up interview 35–42 days after ShangRing circumcision in Kenya and Zambia. Results: Of 1149 men who had ShangRing circumcision, 1096 (95.4%) completed follow-up. Nearly all (99.2%) reported being counseled to abstain from sex post-VMMC; among those, most (92.2%) recalled the recommended abstinence period was 6 weeks. Most men (94.1%) reported that the counselor gave reasons for post-VMMC abstinence and recalled appropriate reasons. Few (13.4%) men reported resuming sex at 35–42 days' follow-up. Among those, 54.8% reported never using a condom post-VMMC. Younger participants (odds ratio 0.3, 95% confidence interval: 0.2 to 0.5, P < 0.0001) and those reporting at least some condom use at baseline (odds ratio 0.5, 95% confidence interval: 0.3 to 0.7, P = 0.0003) were less likely to report resuming sex. Among men who reported some condom use, most (71.5%) said condoms were much easier or easier to use after circumcision. Men reported various reasons for early resumption of sex, primarily strong sexual desire (76.4%). Conclusions: Most men reported awareness of and adherence to the counseling recommendations for post-VMMC abstinence. A minority reported early resumption of sex, and, among those, condom use was low. Results could be used to improve post-VMMC counseling.
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What Messages are Adolescent Voluntary Medical Male Circumcision (VMMC) Clients Getting and How? Findings From an Observational Study in Tanzania. AIDS Behav 2017; 21:1383-1393. [PMID: 27557986 PMCID: PMC5378739 DOI: 10.1007/s10461-016-1515-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Uncircumcised adolescent males in sub-Saharan Africa are an important group to reach with voluntary medical male circumcision (VMMC) services due to high HIV burden occurring among this age group. Appropriateness of the content and delivery of sexual health and HIV prevention messages to adolescent VMMC clients has not been extensively described. A study was conducted in Tanzania to examine quality, delivery and content of messages provided to adolescent (aged 15-19) and adult (aged 20+) VMMC clients (n = 320). Results show that counseling of mixed age groups during group education lacked selected key messages, compared to more age-homogeneous groups. Additionally, adolescents received more comprehensive information in individual counseling compared to group education. We recommend that health care providers are provided with skills and job aides to assist them to segment VMMC clients by age; provide age-appropriate messages; and increase use of individual counseling as a means to communicate with adolescent clients.
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Lunsford SS, Byabagambi J, Falconer-Stout Z, Karamagi E. Improving voluntary medical male circumcision standards adherence and post-procedure follow-up in Uganda: A mixed methods study. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017; 16:39-46. [PMID: 28367749 DOI: 10.2989/16085906.2017.1293701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Voluntary medical male circumcision (VMMC) has been demonstrated to reduce the transmission of HIV by 60%. Scaling up VMMC services requires that they be of high quality, socially accepted, and effective. We evaluated an intervention aimed at improving VMMC standards adherence and patient follow-up rates in nine facilities in Uganda. We also qualitatively explored why some men return for follow-up care and others do not. The completeness and quality of clinical documentation was poor at baseline, but significantly improved at endline. We observed significant improvements in management systems; supplies, equipment, and environment; and monitoring and evaluation. Due to the volume of missing data, results were less clear for registration, group education, and information, education and communication; individual counselling and HIV testing; and infection prevention. Significant improvements were also observed in follow-up rates at 48 hours and 7 days, and 6 weeks. Interviews revealed the importance of peers, including female partners, in deciding to get circumcised and in seeking follow-up care. Among the men who did not return for follow-up services, most reported they had no problems and did not see it as necessary. For those who did have mild or moderate adverse events, follow-up care was often sought at a facility closer to the patients' home rather than the circumcising facility. However, information systems were unable to capture this. Applying improvement approaches to VMMC services can promote improved standards adherence and follow-up rates and should be integrated into scale-up plans.
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Lilleston PS, Marcell AV, Nakyanjo N, Leonard L, Wawer MJ. Multilevel influences on acceptance of medical male circumcision in Rakai District, Uganda. AIDS Care 2017; 29:1049-1055. [PMID: 28278564 DOI: 10.1080/09540121.2016.1274014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Despite access to safe medical male circumcision (MMC) and proven effectiveness of the procedure in reducing acquisition of HIV and other sexually transmitted infections, uptake remains suboptimal in many settings in sub-Saharan Africa, including Rakai District, Uganda. This study explored multilevel barriers and facilitators to MMC in focus group discussions (FGDs) (n = 35 groups) in Rakai. Focus groups were conducted from May through July 2012 with adolescent and adult males, with a range of HIV risk and reproductive health service use profiles, and with adolescent and adult females. Data were analyzed using Atlas.ti and an inductive approach. Participants' discussions produced several key themes representing multilevel influences that may facilitate or create barriers to uptake of MMC. These include availability of MMC services, economic costs, masculine ideals, religion, and social influence. Understanding how males and females view MMC is a crucial step towards increasing uptake of the procedure and reducing disease transmission.
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Affiliation(s)
- Pamela S Lilleston
- a Department of Health, Behavior, and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Arik V Marcell
- b Department of Population, Family, and Reproductive Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | | | - Lori Leonard
- a Department of Health, Behavior, and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Maria J Wawer
- d Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Awad SF, Sgaier SK, Lau FK, Mohamoud YA, Tambatamba BC, Kripke KE, Thomas AG, Bock N, Reed JB, Njeuhmeli E, Abu-Raddad LJ. Could Circumcision of HIV-Positive Males Benefit Voluntary Medical Male Circumcision Programs in Africa? Mathematical Modeling Analysis. PLoS One 2017; 12:e0170641. [PMID: 28118387 PMCID: PMC5261810 DOI: 10.1371/journal.pone.0170641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 01/09/2017] [Indexed: 01/24/2023] Open
Abstract
Background The epidemiological and programmatic implications of inclusivity of HIV-positive males in voluntary medical male circumcision (VMMC) programs are uncertain. We modeled these implications using Zambia as an illustrative example. Methods and Findings We used the Age-Structured Mathematical (ASM) model to evaluate, over an intermediate horizon (2010–2025), the effectiveness (number of VMMCs needed to avert one HIV infection) of VMMC scale-up scenarios with varying proportions of HIV-positive males. The model was calibrated by fitting to HIV prevalence time trend data from 1990 to 2014. We assumed that inclusivity of HIV positive males may benefit VMMC programs by increasing VMMC uptake among higher risk males, or by circumcision reducing HIV male-to-female transmission risk. All analyses were generated assuming no further antiretroviral therapy (ART) scale-up. The number of VMMCs needed to avert one HIV infection was projected to increase from 12.2 VMMCs per HIV infection averted, in a program that circumcises only HIV-negative males, to 14.0, in a program that includes HIV-positive males. The proportion of HIV-positive males was based on their representation in the population (e.g. 12.6% of those circumcised in 2010 would be HIV-positive based on HIV prevalence among males of 12.6% in 2010). However, if a program that only reaches out to HIV-negative males is associated with 20% lower uptake among higher-risk males, the effectiveness would be 13.2 VMMCs per infection averted. If improved inclusivity of HIV-positive males is associated with 20% higher uptake among higher-risk males, the effectiveness would be 12.4. As the assumed VMMC efficacy against male-to-female HIV transmission was increased from 0% to 20% and 46%, the effectiveness of circumcising regardless of HIV status improved from 14.0 to 11.5 and 9.1, respectively. The reduction in the HIV incidence rate among females increased accordingly, from 24.7% to 34.8% and 50.4%, respectively. Conclusion Improving inclusivity of males in VMMC programs regardless of HIV status increases VMMC effectiveness, if there is moderate increase in VMMC uptake among higher-risk males and/or if there is moderate efficacy for VMMC against male-to-female transmission. In these circumstances, VMMC programs can reduce the HIV incidence rate in males by nearly as much as expected by some ART programs, and additionally, females can benefit from the intervention nearly as much as males.
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Affiliation(s)
- Susanne F Awad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar
| | - Sema K Sgaier
- Surgo Foundation, Washington, District of Columbia, United States of America.,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America.,Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Fiona K Lau
- Surgo Foundation, Washington, District of Columbia, United States of America
| | - Yousra A Mohamoud
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar
| | | | - Katharine E Kripke
- Health Policy Initiative, Avenir Health, Washington, District of Columbia, United States of America
| | - Anne G Thomas
- Naval Health Research Center, U.S. Department of Defense, San Diego, California, United States of America
| | - Naomi Bock
- Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Jason B Reed
- Jhpiego, Washington, District of Columbia, United States of America
| | - Emmanuel Njeuhmeli
- United States Agency for International Development, Washington, District of Columbia, United States of America
| | - Laith J Abu-Raddad
- Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.,Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, United States of America.,College of Public Health, Hamad bin Khalifa University, Qatar Foundation, Education City, Doha, Qatar
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18
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Brook I. Infectious Complications of Circumcision and Their Prevention. Eur Urol Focus 2016; 2:453-459. [DOI: 10.1016/j.euf.2016.01.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/14/2016] [Accepted: 01/25/2016] [Indexed: 12/15/2022]
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Lama JR, Karuna ST, Grant SP, Swann EM, Ganoza C, Segura P, Montano SM, Lacherre M, De Rosa SC, Buchbinder S, Sanchez J, McElrath MJ, Lemos MP. Transient Peripheral Immune Activation follows Elective Sigmoidoscopy or Circumcision in a Cohort Study of MSM at Risk of HIV Infection. PLoS One 2016; 11:e0160487. [PMID: 27536938 PMCID: PMC4990246 DOI: 10.1371/journal.pone.0160487] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/20/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Rectal and genital sampling in HIV prevention trials permits assessments at the site of HIV entry. Yet the safety and acceptability of circumcision and sigmoidoscopy (and associated abstinence recommendations) are unknown in uncircumcised men who have sex with men (MSM) at high risk of HIV infection. METHODS Twenty-nine HIV-seronegative high-risk Peruvian MSM agreed to elective sigmoidoscopy biopsy collections (weeks 2 and 27) and circumcision (week 4) in a 28-week cohort study designed to mimic an HIV vaccine study mucosal collection protocol. We monitored adherence to abstinence recommendations, procedure-related complications, HIV infections, peripheral immune activation, and retention. RESULTS Twenty-three (79.3%) underwent a first sigmoidoscopy, 21 (72.4%) were circumcised, and 16 (55.2%) completed a second sigmoidoscopy during the study period. All who underwent procedures completed the associated follow-up safety visits. Those completing the procedures reported they were well tolerated, and complication rates were similar to those reported in the literature. Immune activation was detected during the healing period (1 week post-sigmoidoscopy, 6 weeks post-circumcision), including increases in CCR5+CD4+T cells and α4β7+CD4+T cells. Most participants adhered to post-circumcision abstinence recommendations whereas reduced adherence occurred post-sigmoidoscopy. CONCLUSION Rectosigmoid mucosal and genital tissue collections were safe in high-risk MSM. Although the clinical implications of the post-procedure increase in peripheral immune activation markers are unknown, they reinforce the need to provide ongoing risk reduction counseling and support for post-procedure abstinence recommendations. Future HIV vaccine studies should also consider the effects of mucosal and tissue collections on peripheral blood endpoints in trial design and analysis. TRIAL REGISTRATION ClinicalTrials.gov NCT02630082.
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Affiliation(s)
| | - Shelly T. Karuna
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Shannon P. Grant
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Edith M. Swann
- Vaccine Clinical Research Branch, Division of AIDS, National Institutes of Allergy and Infectious Diseases, US National Institutes of Health, Bethesda, Maryland, United States of America
| | | | | | | | | | - Stephen C. De Rosa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Susan Buchbinder
- San Francisco Department of Health, San Francisco, California, United States of America
| | - Jorge Sanchez
- Asociacion Civil Impacta Salud y Educacion, Lima, Peru
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - M. Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Maria P. Lemos
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
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Thomsen SC, Skinner D, Toefy Y, Esterhuizen T, McCaul M, Petzold M, Diwan V. Voice-Message-Based mHealth Intervention to Reduce Postoperative Penetrative Sex in Recipients of Voluntary Medical Male Circumcision in the Western Cape, South Africa: Protocol of a Randomized Controlled Trial. JMIR Res Protoc 2016; 5:e155. [PMID: 27460771 PMCID: PMC4978861 DOI: 10.2196/resprot.5958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/02/2016] [Accepted: 07/04/2016] [Indexed: 12/01/2022] Open
Abstract
Background There is an increased risk of transmission of sexually transmitted infections (STIs), including HIV, in the postoperative period after receiving voluntary medical male circumcision (VMMC). In South Africa, over 4 million men are being targeted with VMMC services but the health system is not able to offer quality counseling. More innovative strategies for communicating with and altering behavior in men and their partners in the postoperative period after VMMC are needed. Objective This paper presents a study protocol to test the effectiveness of an mHealth intervention designed to task-shift behavior change communication from health care personnel to an automated phone message system, encouraging self-care. Methods A single-blind, randomized controlled trial will be used. A total of 1188 participants will be recruited by nurses or clinicians at clinics in the study districts that have a high turnover of VMMC clients. The population will consist of men aged 18 years and older who indicate at the precounseling session that they possess a mobile phone and consent to participating in the study. Consenting participants will be randomized into either the control or intervention arm before undergoing VMMC. The control arm will receive the standard of care (pre- and postcounseling). The intervention arm will received standard of care and will be sent 38 messages over the 6-week recovery period. Patients will be followed up after 42 days. The primary outcome is self-reported sexual intercourse during the recovery period. Secondary outcomes include nonpenetrative sexual activity, STI symptoms, and perceived risk of acquiring HIV. Analysis will be by intention-to-treat. Results Enrollment is completed. Follow-up is ongoing. Loss to follow-up is under 10%. No interim analyses have been conducted. Conclusions The intervention has the potential of reducing risky sexual behavior after VMMC. The platform itself can be used for many other areas of health that require task shifting to patients for better efficiency and access. Trial Registration Pan-African Clinical Trial Registry: PACTR201506001182385
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Affiliation(s)
- Sarah C Thomsen
- Global Health, Department of Public Health Sciences, Karolinska Institutet, Solna, Sweden.
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21
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Abstract
Highly active antiretroviral therapy has dramatically reduced morbidity and mortality among patients who are HIV-positive. A retrospective review of the authors' data separated subjects into cohorts based on HIV status and matched them for age and gender. The authors' data reveal a higher fraction of venous ulcers compared with a lower fraction of pressure ulcers in the seropositive population.
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Nanteza B, Galukande M, Aceng J, Musinguzi J, Opio A, Mbonye AK, Mukooyo E, Behumize P, Makumbi F. The burden of tetanus in Uganda. SPRINGERPLUS 2016; 5:705. [PMID: 27350934 PMCID: PMC4902800 DOI: 10.1186/s40064-016-2309-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 05/09/2016] [Indexed: 01/22/2023]
Abstract
Background The successful scale-up of safe male circumcision (SMC) in Uganda has been hinged on client’s safety and quality of services. However, after the recent three tetanus deaths after circumcision a review of all tetanus cases in one of the hospitals where the cases occurred was initiated. This was to ascertain the potential for an association between tetanus infection and circumcision. Routinely collected national data were also reviewed to determine the burden of tetanus in Uganda and contextualize these incidents. Methods A review of medical charts of tetanus cases identified from the inpatients registry at Masafu hospital, Busia district for the period 2009/2010–2013/2014. Data were abstracted from the inpatients registries, charts and HMIS annual reports, and a key informant interview conducted with the in-charge of the ward that treats tetanus patients. All quantitative data were captured in an electronic database. Routine facility data from the National District health Information Software-2 (DHIS-2) for all the 112 districts were also used. Descriptive analysis and Poisson regression models were used for statistical analysis using STATA version 13.0. Results Data from the routine DHIS-2 showed a high and increasing burden of tetanus from the emergency/out-patient department records over the 4 year period, highest among females aged 5+ years in all the regions. At the Masafa hospital, the chart review revealed a total of 25 tetanus cases and all were males. Nearly a third (32 %) was aged 7–15 years, with no evidence of circumcision apart from only one case. The rate of tetanus infection among male inpatients over the review period was 2–6 per 1000. The case fatality rate was nearly a half (47.4 %) with deaths occurring within 2 days after admission, and rates of patients’ self-discharge against medical advice were high, 36.8 %. The most common tetanus entry wounds were due to road traffic accidents, followed by diabetic foot. Anti-tetanus serum was only not readily available. Conclusion The burden of tetanus is increasing, especially among females aged 5+ years. Tetanus entry wounds among the inpatients in Masafa hospital were mostly due to road traffic accidents, and young males. The tetanus case fatality was very high (47.4 %) and so was patient requested discharge. There is a need to do more to protect the population against tetanus infection, especially among females, and males who need either initial or booster tetanus immunization as SMC is scaled up.
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Affiliation(s)
- Barbara Nanteza
- Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda
| | - Moses Galukande
- International Hospital Kampala, Lourdel Road, P.O. Box 8177, Namuwongo, Kampala, Uganda ; School of Medicine, College of Health Sciences, Makerere University, Mulago Hill Road, P.O. Box 7072, Kampala, Uganda
| | - Jane Aceng
- Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda
| | - Joshua Musinguzi
- Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda
| | - Alex Opio
- Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda
| | - Anthony K Mbonye
- Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda
| | - Eddie Mukooyo
- Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda
| | - Prosper Behumize
- Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda
| | - Fredrick Makumbi
- School of Public Health, College of Health Sciences, Makerere University, Mulago Hill Road, P.O. Box 7072, Kampala, Uganda
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Tobian AAR, Adamu T, Reed JB, Kiggundu V, Yazdi Y, Njeuhmeli E. Voluntary medical male circumcision in resource-constrained settings. Nat Rev Urol 2015; 12:661-70. [PMID: 26526758 DOI: 10.1038/nrurol.2015.253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Throughout East and Southern Africa, the WHO recommends voluntary medical male circumcision (VMMC) to reduce heterosexual HIV acquisition. Evidence has informed policy and the implementation of VMMC programmes in these countries. VMMC has been incorporated into the HIV prevention portfolio and more than 9 million VMMCs have been performed. Conventional surgical procedures consist of forceps-guided, dorsal slit or sleeve resection techniques. Devices are also becoming available that might help to accelerate the scale-up of adult VMMC. The ideal device should make VMMC easier, safer, faster, sutureless, inexpensive, less painful, require less infrastructure, be more acceptable to patients and should not require follow-up visits. Elastic collar compression devices cause vascular obstruction and necrosis of foreskin tissue and do not require sutures or injectable anaesthesia. Collar clamp devices compress the proximal part of the foreskin to reach haemostasis; the distal foreskin is removed, but the device remains and therefore no sutures are required. Newer techniques and designs, such as tissue adhesives and a circular cutter with stapled anastomosis, are improvements, but none of these methods have achieved all desirable characteristics. Further research, design and development are needed to address this gap to enable the expansion of the already successful VMMC programmes for HIV prevention.
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Affiliation(s)
- Aaron A R Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Carnegie 437, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Tigistu Adamu
- JHPIEGO, 1615 Thames Street, Baltimore, MD 21231, USA
| | - Jason B Reed
- Office of the U.S. Global AIDS Coordinator, 1776 Massachusetts Avenue NW, Suite 300, Washington, DC 20036, USA
| | - Valerian Kiggundu
- Office of HIV/AIDS at the US Agency for International Development, 2100 Crystal Drive, 9th Floor, Arlington, VA 22202, USA
| | - Youseph Yazdi
- Johns Hopkins Center for Bioengineering Innovation &Design (CBID), Clark Hall Suite 208, 3400 North Charles Street, Baltimore, MD 21218, USA
| | - Emmanuel Njeuhmeli
- Office of HIV/AIDS at the US Agency for International Development, 2100 Crystal Drive, 9th Floor, Arlington, VA 22202, USA
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Reed JB, Grund J, Liu Y, Mwandi Z, Howard AA, McNairy ML, Chesang K, Cherutich P, Bock N. Implementation and Operational Research: Evaluation of Loss-to-Follow-up and Postoperative Adverse Events in a Voluntary Medical Male Circumcision Program in Nyanza Province, Kenya. J Acquir Immune Defic Syndr 2015; 69:e13-23. [PMID: 25942466 DOI: 10.1097/qai.0000000000000535] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND More than 4.7 million voluntary medical male circumcisions (VMMCs) had been provided by HIV prevention programs in sub-Saharan Africa through 2013. All VMMC clients are recommended to return to the clinic for postoperative follow-up, although adherence is variable. The clinical status of clients who do not return is largely unknown. METHODS VMMC clients from Nyanza Province, Kenya, aged older than or equal to 13 years, were recruited immediately after surgery from April to October 2012 from high-volume sites. Medical record reviews at 13-14 days after surgery indicated which clients had been adherent with recommended follow-up (ADFU) and which were lost-to-follow-up (LTFU). Clients in the LTFU group received clinical evaluations at home approximately 2 weeks postsurgery. Adverse events (AEs) and AE rates were compared between the ADFU and LTFU groups. RESULTS Of 4504 males approached in 50 VMMC sites, 1699 (37.7%) were eligible and enrolled and 1600 of 1699 (94.2%) contributed to follow-up and AE data. Medical record review indicated 897 of 1600 (56.1%) were LTFU, and 762 (84.9%) of these received home-based clinical evaluations. The rate of moderate or severe AE diagnosis was 6.8% in the LTFU group vs. 3.3% in the ADFU group (relative risk = 2.1, 95% confidence interval: 1.3 to 3.4). CONCLUSIONS The moderate or severe AE diagnosis rate was approximately 2 times higher in the LTFU group. National programs should consider instituting surveillance systems to detect AEs that might otherwise go unnoticed. Providers should emphasize the importance of follow-up and actively contact LTFU clients to ensure care is provided throughout the entire postoperative course for all.
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Affiliation(s)
- Jason Bailey Reed
- *Division of Global HIV AIDS, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA; †Division of Global HIV AIDS, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya; ‡ICAP, Columbia University, New York, NY; and §National AIDS and Sexually Transmitted Infection Control Programme, Ministry of Health, Nairobi, Kenya
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Circumcision Status and Risk of HIV Acquisition during Heterosexual Intercourse for Both Males and Females: A Meta-Analysis. PLoS One 2015; 10:e0125436. [PMID: 25942703 PMCID: PMC4420461 DOI: 10.1371/journal.pone.0125436] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 03/23/2015] [Indexed: 02/05/2023] Open
Abstract
In this study, we evaluated if male circumcision was associated with lower HIV acquisition for HIV (−) males and HIV (−) females during normal sexual behavior. We performed a systematic literature search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared HIV acquisition for the circumcised and uncircumcised groups. The reference lists of the included and excluded studies were also screened. Fifteen studies (4 RCTs and 11 prospective cohort studies) were included, and the related data were extracted and analyzed in a meta-analysis. Our study revealed strong evidence that male circumcision was associated with reduced HIV acquisition for HIV(−) males during sexual intercourse with females [pooled adjusted risk ratio (RR): 0.30, 95% CI 0.24 0.38, P < 0.00001] and provided a 70% protective effect. In contrast, no difference was detected in HIV acquisition for HIV (−) females between the circumcised and uncircumcised groups (pooled adjusted RR after sensitivity analysis: 0.68, 95%CI 0.40–1.15, P = 0.15). In conclusion, male circumcision could significantly protect males but not females from HIV acquisition at the population level. Male circumcision may serve as an additional approach toward HIV control, in conjunction with other strategies such as HIV counseling and testing, condom promotion, and so on.
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Tobian AAR, Kigozi G, Manucci J, Grabowski MK, Serwadda D, Musoke R, Redd AD, Nalugoda F, Reynolds SJ, Kighoma N, Laeyendecker O, Lessler J, Gray RH, Quinn TC, Wawer MJ. HIV shedding from male circumcision wounds in HIV-infected men: a prospective cohort study. PLoS Med 2015; 12:e1001820. [PMID: 25919012 PMCID: PMC4412625 DOI: 10.1371/journal.pmed.1001820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 03/17/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND A randomized trial of voluntary medical male circumcision (MC) of HIV-infected men reported increased HIV transmission to female partners among men who resumed sexual intercourse prior to wound healing. We conducted a prospective observational study to assess penile HIV shedding after MC. METHODS AND FINDINGS HIV shedding was evaluated among 223 HIV-infected men (183 self-reported not receiving antiretroviral therapy [ART], 11 self-reported receiving ART and had a detectable plasma viral load [VL], and 29 self-reported receiving ART and had an undetectable plasma VL [<400 copies/ml]) in Rakai, Uganda, between June 2009 and April 2012. Preoperative and weekly penile lavages collected for 6 wk and then at 12 wk were tested for HIV shedding and VL using a real-time quantitative PCR assay. Unadjusted prevalence risk ratios (PRRs) and adjusted PRRs (adjPRRs) of HIV shedding were estimated using modified Poisson regression with robust variance. HIV shedding was detected in 9.3% (17/183) of men not on ART prior to surgery and 39.3% (72/183) of these men during the entire study. Relative to baseline, the proportion shedding was significantly increased after MC at 1 wk (PRR = 1.87, 95% CI = 1.12-3.14, p = 0.012), 2 wk (PRR = 3.16, 95% CI = 1.94-5.13, p < 0.001), and 3 wk (PRR = 1.98, 95% CI = 1.19-3.28, p = 0.008) after MC. However, compared to baseline, HIV shedding was decreased by 6 wk after MC (PRR = 0.27, 95% CI = 0.09-0.83, p = 0.023) and remained suppressed at 12 wk after MC (PRR = 0.19, 95% CI = 0.06-0.64, p = 0.008). Detectable HIV shedding from MC wounds occurred in more study visits among men with an HIV plasma VL > 50,000 copies/ml than among those with an HIV plasma VL < 400 copies/ml (adjPRR = 10.3, 95% CI = 4.25-24.90, p < 0.001). Detectable HIV shedding was less common in visits from men with healed MC wounds compared to visits from men without healed wounds (adjPRR = 0.12, 95% CI = 0.07-0.23, p < 0.001) and in visits from men on ART with undetectable plasma VL compared to men not on ART (PRR = 0.15, 95% CI = 0.05-0.43, p = 0.001). Among men with detectable penile HIV shedding, the median log10 HIV copies/milliliter of lavage fluid was significantly lower in men with ART-induced undetectable plasma VL (1.93, interquartile range [IQR] = 1.83-2.14) than in men not on ART (2.63, IQR = 2.28-3.22, p < 0.001). Limitations of this observational study include significant differences in baseline covariates, lack of confirmed receipt of ART for individuals who reported ART use, and lack of information on potential ART initiation during follow-up for those who were not on ART at enrollment. CONCLUSION Penile HIV shedding is significantly reduced after healing of MC wounds. Lower plasma VL is associated with decreased frequency and quantity of HIV shedding from MC wounds. Starting ART prior to MC should be considered to reduce male-to-female HIV transmission risk. Research is needed to assess the time on ART required to decrease shedding, and the acceptability and feasibility of initiating ART at the time of MC.
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Affiliation(s)
- Aaron A. R. Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Rakai Health Sciences Program, Entebbe, Uganda
- * E-mail:
| | | | - Jordyn Manucci
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mary K. Grabowski
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda
- Institute of Public Health, Makerere University, Kampala, Uganda
| | | | - Andrew D. Redd
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Steven J. Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | | | - Oliver Laeyendecker
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Justin Lessler
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ronald H. Gray
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Thomas C. Quinn
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Maria J. Wawer
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Kamath V, Limaye RJ. Voluntary medical male circumcision for HIV prevention and early resumption of sexual activity: a literature review. AIDS Care 2015; 27:986-9. [PMID: 25738780 DOI: 10.1080/09540121.2015.1017797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A number of programs have focused on scale-up and implementation research regarding voluntary medical male circumcision; however, there is limited research with regard to factors and strategies related to abstinence compliance and the effects of resuming sex during the wound healing period (42-day post-circumcision). We searched the literature for peer-reviewed articles examining early resumption of sex during this period. This review identifies factors that may predispose a client to engage in sex during the 42-day postoperative period, examines how early resumption of sex can inhibit wound healing and increase seroconversion, and reviews strategies that may increase adherence to abstinence during the wound healing period. We found that the most common factor that may predispose a client to engage in sex before the end of the postoperative period is marriage or cohabitation with a sexual partner. With regard to the effect of sex during the postoperative period on wound healing and seroconversion, we found that adverse events incurred were mild, and there was an increased risk of seroconversion. The only strategy studied to increase compliance to abstinence during the postoperative period utilized text messaging, and the trial results indicate that text messaging did not increase abstinence compliance.
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Affiliation(s)
- Veena Kamath
- a Center for Communication Programs , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Field study of adult male circumcision using the ShangRing in routine clinical settings in Kenya and Zambia. J Acquir Immune Defic Syndr 2015; 67:430-7. [PMID: 25162816 DOI: 10.1097/qai.0000000000000321] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Circumcision devices can facilitate adult voluntary medical male circumcision programs for HIV prevention. The World Health Organization recommends field studies to confirm the safety of devices in local settings. METHODS We evaluated the safety of the ShangRing device in routine service delivery by measuring adverse event (AE) rates overall and by HIV status. We enrolled men aged 18-54 years and scheduled them for 2 post-circumcision follow-up visits at day 7 for device removal and days 35-42. Men were examined to document AEs and healing and to ascertain client acceptability. Provider preferences were also assessed. RESULTS We enrolled 1163 men (557 in Kenya and 606 in Zambia); the as-treated analysis population comprised 1149 men, including 84 HIV-positive men. There were no serious AEs and 2 severe AEs: 1 severe wound dehiscence and 1 severe pain, both of which resolved with treatment. There were 18 moderate/severe AEs among 16 men (1.4% of men; 95% confidence interval: 0.8% to 2.3%). The most common AE was wound dehiscence (9 men, 0.8%). Healing was similar between HIV-infected and uninfected men, with 85.7% and 87.3% completely healed at days 35-42. Most men (94.8%) were very satisfied with post-circumcision appearance of the penis, and almost all would recommend a ShangRing procedure. Nineteen of 21 providers preferred the ShangRing over conventional surgery. CONCLUSIONS The ShangRing has an excellent safety profile with few hemorrhagic and infectious complications. The ShangRing is well accepted by clients and preferred by providers, making it a potential boon to the scale-up of adult voluntary medical male circumcision in African countries.
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Ediau M, Matovu JKB, Byaruhanga R, Tumwesigye NM, Wanyenze RK. Risk factors for HIV infection among circumcised men in Uganda: a case-control study. J Int AIDS Soc 2015; 18:19312. [PMID: 25556374 PMCID: PMC4283027 DOI: 10.7448/ias.18.1.19312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 11/16/2014] [Accepted: 11/21/2014] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Male circumcision (MC) reduces the risk of HIV infection. However, the risk reduction effect of MC can be modified by type of circumcision (medical, traditional and religious) and sexual risk behaviours post-circumcision. Understanding the risk behaviours associated with HIV infection among circumcised men (regardless of form of circumcision) is critical to the design of comprehensive risk reduction interventions. This study assessed risk factors for HIV infection among men circumcised through various circumcision approaches. METHODS This was a case-control study which enrolled 155 cases (HIV-infected) and 155 controls (HIV-uninfected), all of whom were men aged 18-35 years presenting at the AIDS Information Center for HIV testing and care. The outcome variable was HIV sero-status. Using SPSS version 17, multivariable logistic regression was performed to identify factors independently associated with HIV infection. RESULTS Overall, 83.9% among cases and 56.8% among controls were traditionally circumcised; 7.7% of cases and 21.3% of controls were religiously circumcised while 8.4% of cases and 21.9% of controls were medically circumcised. A higher proportion of cases than controls reported resuming sexual intercourse before complete wound healing (36.9% vs. 14.1%; p<0.01). Risk factors for HIV infection prior to circumcision were:being in a polygamous marriage (AOR: 6.6, CI: 2.3-18.8) and belonging to the Bagisu ethnic group (AOR: 6.1, CI: 2.6-14.0). After circumcision, HIV infection was associated with: being circumcised at >18 years (AOR: 5.0, CI: 2.4-10.2); resuming sexual intercourse before wound healing (AOR: 3.4, CI: 1.6-7.3); inconsistent use of condoms (AOR: 2.7, CI: 1.5-5.1); and having sexual intercourse under the influence of peers (AOR: 2.9, CI: 1.5-5.5). Men who had religious circumcision were less likely to have HIV infection (AOR: 0.4, 95% CI: 0.2-0.9) than the traditionally circumcised but there was no statistically significant difference between those who were traditionally circumcised and those who were medically circumcised (AOR: 0.40, 95% CI: 0.1-1.1). CONCLUSIONS Being circumcised at adulthood, resumption of sexual intercourse before wound healing, inconsistent condom use and having sex under the influence of peers were significant risk factors for HIV infection. Risk reduction messages should address these risk factors, especially among traditionally circumcised men.
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Affiliation(s)
- Michael Ediau
- Makerere University School of Public Health-CDC Fellowship Program, Kampala, Uganda;
| | - Joseph K B Matovu
- Makerere University School of Public Health-CDC Fellowship Program, Kampala, Uganda; Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Kampala, Uganda
| | | | - Nazarius M Tumwesigye
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Rhoda K Wanyenze
- Makerere University School of Public Health-CDC Fellowship Program, Kampala, Uganda; Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Phili R, Abdool-Karim Q, Ngesa O. Low adverse event rates following voluntary medical male circumcision in a high HIV disease burden public sector prevention programme in South Africa. J Int AIDS Soc 2014; 17:19275. [PMID: 25406951 PMCID: PMC4236629 DOI: 10.7448/ias.17.1.19275] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 09/09/2014] [Accepted: 09/29/2014] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The provision of voluntary medical male circumcision (VMMC) services was piloted in three public sector facilities in a high HIV disease burden, low circumcision rate province in South Africa to inform policy and operational guidance for scale-up of the service for HIV prevention. We report on adverse events (AEs) experienced by clients following the circumcision procedure. METHODS Prospective recruitment of HIV-negative males aged 12 and older volunteering to be circumcised at three select public health facilities in KwaZulu-Natal between November 2010 and May 2011. Volunteers underwent standardized medical screening including a physical assessment prior to the surgical procedure being performed. AEs were monitored at three time intervals over a 21-day period post-operatively to determine safety outcomes in this pilot demonstration programme. RESULTS A total of 602 volunteers participated in this study. The median age of the volunteers was 22 years (range 12-56). Most participants (75.6%) returned for the 48-hour post-operative visit; 51.0% for day seven visit and 26.1% for the 21st day visit. Participants aged 20-24 were most likely to return. The AE rate was 0.2% intra-operatively. The frequency of moderate AEs was 0.7, 0.3 and 0.6% at 2-, 7- and 21-day visits, respectively. The frequency of severe AEs was 0.4, 0.3 and 0.6% at 2-, 7- and 21-day visits, respectively. Swelling and wound infection were the most common AEs with mean appearance duration of seven days. Clients aged between 35 and 56 years presented with most AEs (3.0%). CONCLUSIONS VMMC can be delivered safely at resource-limited settings. The intensive three-visit post-operative review practice may be unfeasible due to high attrition rates over time, particularly amongst older men.
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Affiliation(s)
- Rogerio Phili
- Department of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa;
| | | | - Oscar Ngesa
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermarizburg, South Africa
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Ledikwe JH, Nyanga RO, Hagon J, Grignon JS, Mpofu M, Semo BW. Scaling-up voluntary medical male circumcision - what have we learned? HIV AIDS-RESEARCH AND PALLIATIVE CARE 2014; 6:139-46. [PMID: 25336991 PMCID: PMC4199973 DOI: 10.2147/hiv.s65354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15–49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008–2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.
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Affiliation(s)
- Jenny H Ledikwe
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Robert O Nyanga
- International Training and Education Center for Health, Botswana, Gaborone, Botswana
| | - Jaclyn Hagon
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jessica S Grignon
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
| | - Mulamuli Mpofu
- International Training and Education Center for Health, Botswana, Gaborone, Botswana
| | - Bazghina-Werq Semo
- International Training and Education Center for Health, Botswana, Gaborone, Botswana ; Department of Global Health, University of Washington, Seattle, WA, USA
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El Bcheraoui C, Zhang X, Cooper CS, Rose CE, Kilmarx PH, Chen RT. Rates of adverse events associated with male circumcision in U.S. medical settings, 2001 to 2010. JAMA Pediatr 2014; 168:625-34. [PMID: 24820907 PMCID: PMC4578797 DOI: 10.1001/jamapediatrics.2013.5414] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Approximately 1.4 million male circumcisions (MCs) are performed annually in US medical settings. However, population-based estimates of MC-associated adverse events (AEs) are lacking. OBJECTIVES To estimate the incidence rate of MC-associated AEs and to assess whether AE rates differed by age at circumcision. DESIGN We selected 41 possible MC AEs based on a literature review and on medical billing codes. We estimated a likely risk window for the incidence calculation for each MC AE based on pathogenesis. We used 2001 to 2010 data from SDI Health, a large administrative claims data set, to conduct a retrospective cohort study. SETTING AND PARTICIPANTS SDI Health provided administrative claims data from inpatient and outpatient US medical settings. MAIN OUTCOMES AND MEASURES For each AE, we calculated the incidence per million MCs. We compared the incidence risk ratio and the incidence rate difference for circumcised vs uncircumcised newborn males and for males circumcised at younger than 1 year, age 1 to 9 years, or 10 years or older. An AE was considered probably related to MC if the incidence risk ratio significantly exceeded 1 at P < .05 or occurred only in circumcised males. RESULTS Records were available for 1,400,920 circumcised males, 93.3% as newborns. Of 41 possible MC AEs, 16 (39.0%) were probable. The incidence of total MC AEs was slightly less than 0.5%. Rates of potentially serious MC AEs ranged from 0.76 (95% CI, 0.10-5.43) per million MCs for stricture of male genital organs to 703.23 (95% CI, 659.22-750.18) per million MCs for repair of incomplete circumcision. Compared with boys circumcised at younger than 1 year, the incidences of probable AEs were approximately 20-fold and 10-fold greater for males circumcised at age 1 to 9 years and at 10 years or older, respectively. CONCLUSIONS AND RELEVANCE Male circumcision had a low incidence of AEs overall, especially if the procedure was performed during the first year of life, but rose 10-fold to 20-fold when performed after infancy.
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Affiliation(s)
- Charbel El Bcheraoui
- Epidemic Intelligence Service, Division of Applied Sciences, Scientific Education and Professional Development Program, Office of Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA,Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA,Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
| | - Xinjian Zhang
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Charles E. Rose
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Peter H. Kilmarx
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Robert T. Chen
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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Randomized controlled trial of the shang ring versus conventional surgical techniques for adult male circumcision: safety and acceptability. J Acquir Immune Defic Syndr 2014; 65:447-55. [PMID: 24583615 DOI: 10.1097/qai.0000000000000061] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare clinical profiles of Shang Ring versus conventional circumcisions. DESIGN Parallel group open-label randomized controlled trial with one-to-one allocations in 2 sites. METHODS We enrolled HIV-negative men aged 18-54 years in Homa Bay, Kenya, and Lusaka, Zambia and followed them at 2, 7, 14, 21, 28, 42, and 60 days after Shang Ring versus conventional circumcision. We compared the duration of surgery, postoperative pain using a visual analog scale, adverse events rates, time to complete wound healing by clinical assessment, participant acceptability, and provider preferences between circumcision groups. RESULTS We randomized 200 men to each group; 197 and 201 contributed to the Shang Ring and conventional surgery analyses, respectively. Adverse event rates were similar between groups. Pain scores at most time points were similar, however, the Shang Ring group reported higher scores for worst pain during erections (3.5 ± 1.9 vs. 2.3 ± 1.7; P < 0.001). Significantly more men were satisfied with the cosmetic appearance following Shang Ring male circumcision (MC), 95.7% versus 85.9% (P = 0.02) in Kenya, and 96.8% versus 71.3% (P < 0.01) in Zambia. Although median time to complete wound healing was 43 days in both groups, conventional circumcisions healed on average 5.2 days sooner (P < 0.001). Shang Ring procedures took one-third the time of conventional MC, 7 versus 20 minutes. All circumcision providers preferred the Shang Ring. CONCLUSIONS Safety profiles of the 2 techniques were similar, all MC providers preferred the Shang Ring technique, and study participants preferred the Shang Ring's cosmetic results. The Shang Ring should be considered for adult MC as programs scale-up.
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Odeny TA, Bailey RC, Bukusi EA, Simoni JM, Tapia KA, Yuhas K, Holmes KK, McClelland RS. Effect of text messaging to deter early resumption of sexual activity after male circumcision for HIV prevention: a randomized controlled trial. J Acquir Immune Defic Syndr 2014; 65:e50-7. [PMID: 23846561 PMCID: PMC3867588 DOI: 10.1097/qai.0b013e3182a0a050] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resumption of sex before complete wound healing after male circumcision may increase risk of postoperative surgical complications, and HIV acquisition and transmission. We aimed to determine the effect of text messaging to deter resumption of sex before 42 days postcircumcision. METHODS We conducted a randomized trial where men older than18 years who owned mobile phones and had just undergone circumcision were randomized to receive a series of text messages (n = 600) or usual care (n = 600). The primary outcome was self-reported resumption of sex before 42 days. RESULTS Sex before 42 days was reported by 139 of 491 (28.3%) men in the intervention group and 124 of 493 (25.2%) men in the control group [relative risk = 1.13, 95% confidence interval (CI): 0.91 to 1.38, P = 0.3]. Men were more likely to resume early if they were married or had a live-in sexual partner [adjusted relative risk (aRR) 1.57, 95% CI: 1.18 to 2.08, P < 0.01]; in the month before circumcision had 1 (aRR: 1.50, 95% CI: 1.07 to 2.12, P = 0.02) or more than 1 (aRR: 1.81, 95% CI: 1.24 to 2.66, P < 0.01) sexual partner(s); had primary school or lower education (aRR: 1.62, 95% CI: 1.33 to 1.97, P< 0.001); were employed (aRR: 1.35, 95% CI: 1.05 to 1.72, P = 0.02); or were 21-30 years old (aRR: 1.58, 95% CI: 1.01 to 2.47, P = 0.05), 31-40 years old (aRR: 1.91, 95% CI: 1.18 to 3.09, P < 0.01), or older than 40 years (aRR: 1.76, 95% CI: 1.04 to 2.97, P = 0.03) compared with younger than 21 years. CONCLUSIONS Text messaging as used in this trial did not reduce early resumption of sex after circumcision. We identified key risk factors for early resumption that need to be considered in circumcision programs.
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Affiliation(s)
- Thomas A Odeny
- *Department of Epidemiology, University of Washington, Seattle, WA; †Kenya Medical Research Institute (KEMRI), Nairobi, Kenya; ‡Chicago Developmental Center for AIDS Research, University of Illinois at Chicago; Departments of §Global Health; ‖Obstetrics and Gynecology; and ¶Psychology, University of Washington, Seattle, WA; #Center for AIDS and STD, University of Washington, Seattle, WA; and **Department of Medicine, University of Washington, Seattle, WA
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Frajzyngier V, Odingo G, Barone M, Perchal P, Pavin M. Safety of adult medical male circumcision performed by non-physician clinicians in Kenya: a prospective cohort study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2014; 2:93-102. [PMID: 25276565 PMCID: PMC4168600 DOI: 10.9745/ghsp-d-13-00120] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/10/2013] [Indexed: 01/01/2023]
Abstract
Trained, experienced nurses and clinical officers provided safe voluntary medical male circumcision (VMMC) in public health facilities in Nyanza Province, Kenya, as evidenced by the low 2% adverse event rate (most commonly, excess swelling). Task shifting for male circumcision can improve access to quality VMMC services. Background: Male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. The Government of Kenya is rolling out voluntary medical male circumcision (VMMC) services, but struggles with health worker shortages, particularly with physician shortages. Objective: To evaluate the safety of male circumcision performed by non-physician clinicians in Kenya. Methods: Between December 2009 and December 2010, we conducted a prospective study of VMMC procedures performed by 15 nurses and 11 clinical officers, all trained to competence, in 11 public health facilities in Nyanza Province, Kenya. Providers reported surgical complications and adverse events (AEs), based on standardized definitions, immediately after the procedure and at 7 days and 60 days post-circumcision. We also assessed clients' satisfaction with the circumcision at 60 days. Results: We recruited 2,244 men and boys, ages 13–54. The retention rate was high, with 2,192 participants (98%) returning for the 7-day follow-up visit and 1,845 (82%) for the 60-day visit. There was no difference in rates of moderate and severe AEs between participants whose circumcision was performed by a nurse (2.1%) or a clinical officer (1.9%) at 7 days post-circumcision. The most common AE was excess swelling (1.1%). Risk factors associated with an AE at 7 days post-circumcision included being employed and participant age ≥ 18 years. Participants circumcised by a provider with ≥ 6 years of professional experience were less likely to have an AE. Nearly all participants reported being satisfied with their circumcision at the 60-day follow-up visit. Conclusions: Trained nurses and clinical officers provided safe VMMC in Nyanza Province, Kenya. AE rates in this study were similar to those reported in typical service-delivery settings. These results add to the current body of evidence suggesting that trained non-physicians can provide safe medical male circumcision, thereby facilitating increased availability and access to circumcision services.
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Kigozi G, Musoke R, Kighoma N, Watya S, Serwadda D, Nalugoda F, Kiwanuka N, Nkale J, Wabwire-Mangen F, Makumbi F, Sewankambo NK, Gray RH, Wawer MJ. Male circumcision wound healing in human immunodeficiency virus (HIV)-negative and HIV-positive men in Rakai, Uganda. BJU Int 2013; 113:127-32. [PMID: 24053645 DOI: 10.1111/bju.12406] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess completed wound healing after medical male circumcision (MMC) among human immunodeficiency virus (HIV)-negative and HIV-positive men with cluster of differentiation 4 (CD4) counts of <350 and ≥350 cells/mm(3) , as minimal data are available on the safety of MMC among HIV-positive men with low CD4 counts. PATIENTS AND METHODS In all, 262 HIV-negative and 177 HIV-positive consenting males aged ≥12 years accepted MMC using the dorsal slit procedure and were enrolled in the study. Socio-demographic and behavioural data and blood for HIV testing and CD4 counts were collected at baseline. Participants were followed weekly to collect information on resumption of sex, condom use and both self-reported and clinically assessed wound healing. The proportions healed among HIV-positive men were compared with HIV-negative men. Time to complete wound healing was assessed by Kaplan-Meier survival analysis. RESULTS There were no statistically significant differences in the proportion of men healed by HIV status. At 4 weeks, the proportions healed were 85.9% in HIV-negative men, 77.4% in HIV-positive men with a CD4 count of ≥350 cells/mm(3) and 87.1% in HIV-positive men with a CD4 count of <350 cells/mm(3) . The median time to healing was 4 weeks and did not vary by HIV or CD4 status. All men had certified complete wound healing at 6 weeks after MMC. In all, 1.4% of HIV-positive men with a CD4 count of <350 cells/mm(3) resumed sex before healing, compared with 8.5% among HIV-positive men with a CD4 count of ≥350 cells/mm(3) (P = 0.052) and 7.8% (P = 0.081) among HIV-negative men. CONCLUSION Inclusion of HIV-positive men with low CD4 counts in MMC services is not deleterious to postoperative wound healing.
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Kigozi G, Musoke R, Kighoma N, Kiwanuka N, Makumbi F, Nalugoda F, Wabwire-Mangen F, Serwadda D, Wawer MJ, Gray RH. Safety of medical male circumcision in human immunodeficiency virus-infected men in Rakai, Uganda. Urology 2013; 83:294-7. [PMID: 24286598 DOI: 10.1016/j.urology.2013.08.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 08/14/2013] [Accepted: 08/17/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the safety of medical male circumcision (MMC) among human immunodeficiency virus (HIV)-infected men with CD4 levels <350 cells/mm(3), CD4 counts ≥ 350 cells/mm(3), and HIV-negative men. METHODS Two hundred forty-two HIV-infected men and a sample of 262 HIV-negative consenting men aged 12 years or older who requested free MMC were enrolled in a prospective study. Blood for HIV testing and a CD4 count were collected before surgery. During weekly follow-up over 6 weeks, data were collected on wound healing and adverse events (AEs) by examination, and resumption of sex and condom use ascertained by interview. Surgery-related AEs were characterized by type, severity, management, and resolution. Chi-square and Fisher's exact tests were used to test for differences in AE proportions. RESULTS Overall, only 2 of the 453 men experienced moderate AEs, a rate of 0.44 per 100 surgeries. No AE occurred among HIV-negative men, whereas the AE rate among HIV-infected men with CD4 counts ≥ 350 cells/mm(3) was 0.79 per 100 surgeries, and among men with CD4 counts <350 cells/mm(3) the rate was 1.19 per 100 surgeries (P = .214). AE rates were comparable for all characteristics (P >.05). CONCLUSION HIV-positive men can be safely included in MMC roll out programs without necessitating presurgery CD4 counts determination.
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Affiliation(s)
| | | | | | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, the School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred Makumbi
- Rakai Health Sciences Program, Entebbe, Uganda; Department of Epidemiology and Biostatistics, the School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Fred Wabwire-Mangen
- Department of Epidemiology and Biostatistics, the School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Entebbe, Uganda; Department of Epidemiology and Biostatistics, the School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maria Joan Wawer
- Rakai Health Sciences Program, Entebbe, Uganda; Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
| | - Ronald Henry Gray
- Rakai Health Sciences Program, Entebbe, Uganda; Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD
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The acceptability and safety of the Shang Ring for adult male circumcision in Rakai, Uganda. J Acquir Immune Defic Syndr 2013; 63:617-21. [PMID: 23614991 DOI: 10.1097/qai.0b013e3182968dda] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medical male circumcision (MMC) is recommended for HIV prevention in men. We assessed the acceptability and safety of the Shang Ring device compared with those of the dorsal slit method. METHODS HIV-negative, uncircumcised men aged 18 years or older who requested free MMC services in rural Rakai, Uganda, were informed about the Shang Ring and dorsal slit procedures and offered a free choice of procedure. Men were followed at 7 days postoperatively to assess adverse events related to surgery and to remove the Shang Ring. Wound healing was assessed at 4 weeks postoperatively. RESULTS Six hundred twenty-one men were enrolled, of whom 508 (81.8%) chose the Shang Ring and 113 the dorsal slit. The Shang Ring was provided to 504 men, among whom there were 4 failures of Ring placement (0.8%) that required surgical hemostasis and wound closure. Five hundred men received the Shang Ring and postoperative surgery-related moderate adverse events were 1.0%, compared with 0.8% among dorsal slit recipients. Complete wound healing at 4 weeks was 84% with the Ring and 100% with the dorsal slit (P < 0001). Resumption of intercourse before 4 weeks was 7.0% with the Ring and 15.0% with the dorsal slit (P = 0.01.) The mean time for surgery was 6.1 minutes with the Ring and 17.7 minutes with the dorsal slit. The mean time for Ring removal was 2.2 minutes. CONCLUSIONS The Shang Ring is highly acceptable and safe in this setting, and could improve the efficiency of MMC services. However, back-up surgical services are needed in cases of Ring placement failures.
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Factors associated with resumption of sex before complete wound healing in circumcised HIV-positive and HIV-negative men in Kisumu, Kenya. J Acquir Immune Defic Syndr 2013; 62:465-70. [PMID: 23242159 DOI: 10.1097/qai.0b013e3182800710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We evaluated time to resumption of sex in relation to wound healing following circumcision of adult males. The purpose was to assess factors associated with adherence to the WHO recommendation of 42-days postcircumcision sexual abstinence and with engaging in sex before complete healing. METHODS Participants were circumcised then followed weekly for 7 weeks and at 3 months. At each follow-up, participants were asked if they had engaged in sex since circumcision and their postcircumcision wounds examined to determine if they were fully healed. Log binomial regression identified risk factors for early sex before 42 days and sex before complete healing. RESULTS Overall, 37.7% (120/318) of men reported sex before 42 days and 18.8% (60/319) reported sex before complete healing. Only 7% of men had unprotected sex before complete healing. There were no differences between HIV-positive and HIV-negative men in either healing time or sex before healing. Risk factors for sex before healing were being married or having 2 or more sex partners in the last year. Among single men, age older than 24 years and consistent alcohol consumption were associated with sex before healing. CONCLUSION The risk of HIV transmission because of unprotected sex before wound healing is low and transient, because most men reporting early sex either used a condom or had wound already healed. Adherence to the 42-day abstinence period and condom use at every sexual intercourse within 3 months postcircumcision should minimize risk of HIV spread because of sex before complete healing.
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Translation of biomedical prevention strategies for HIV: prospects and pitfalls. J Acquir Immune Defic Syndr 2013; 63 Suppl 1:S12-25. [PMID: 23673881 DOI: 10.1097/qai.0b013e31829202a2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.
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Ssekubugu R, Leontsini E, Wawer MJ, Serwadda D, Kigozi G, Kennedy CE, Nalugoda F, Sekamwa R, Wagman J, Gray RH. Contextual barriers and motivators to adult male medical circumcision in Rakai, Uganda. QUALITATIVE HEALTH RESEARCH 2013; 23:795-804. [PMID: 23515302 DOI: 10.1177/1049732313482189] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Medical male circumcision (MMC) is a central component of HIV prevention. In this study we examined barriers to and facilitators of MMC in Rakai, Uganda. Interviews and focus groups with MMC acceptors, decliners, and community members were collected and analyzed iteratively. Themes were developed based on immersion, repeated reading, sorting, and coding of data using grounded theory. Pain, medical complications, infertility, lack of empirical efficacy, waiting time before resumption of sex, and religion were identified as obstacles to MMC acceptance. Prevention and healing of sexually transmitted infections (STIs), access to HIV and other ancillary care, penile hygiene, and peer influence were key motivators. Voluntary counseling and testing for HIV, partner influence, and sexual potency were both barriers and motivators. Individual and societal factors, such as pain and religion, might slow MMC scale up. Health benefits, such as HIV/STI prevention and penile hygiene, are essential in motivating men to accept MMC.
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Gray RH, Wawer MJ, Kigozi G. Programme science research on medical male circumcision scale-up in sub-Saharan Africa. Sex Transm Infect 2013; 89:345-9. [DOI: 10.1136/sextrans-2012-050595] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Time to complete wound healing in HIV-positive and HIV-negative men following medical male circumcision in Kisumu, Kenya: a prospective cohort study. PLoS One 2013; 8:e61725. [PMID: 23613918 PMCID: PMC3626701 DOI: 10.1371/journal.pone.0061725] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/11/2013] [Indexed: 11/19/2022] Open
Abstract
Background While voluntary medical male circumcision (VMMC) has been shown to be protective against HIV-acquisition, the procedure may place men and their partners at risk of HIV infection in the period following circumcision if sex is resumed before the wound is healed. This prospective cohort study evaluates post-circumcision wound healing to determine whether the 42-day post-circumcision abstinence period, recommended by the World Health Organization and adopted by VMMC programs, is optimal. Methods and Findings Men were circumcised by forceps-guided method and their post-circumcision wounds examined weekly for seven weeks and at 12 weeks. Time to complete healing was recorded in completed weeks since circumcision, and its associations with baseline covariates were assessed by Kaplan-Meier methods and Cox Proportional Hazard Models. A total of 215 HIV-negative and 108 HIV-positive men aged 18–35 years (median 26, IQR 23–30) were enrolled. 97.1% of scheduled follow-up visits were completed. At week 4, 59.3% of HIV-positive men and 70.4% of age-matched HIV-negative men were healed. At week 6, these percentages rose to 93.4% in HIV-positive men and 92.6% in age-matched HIV-negative men. There was no difference in the hazard of healing between 108 HIV-positive and 108 age-matched HIV-negative men (HR 0.91 95% CI 0.70–1.20). Early post-operative infection was associated with delayed healing in both HIV-positive and HIV-negative men (HR 0.48 95% CI 0.23–1.00). Conclusions Our results indicate that the WHO recommendation for 42-days post-circumcision sexual abstinence should be maintained for both HIV-positive and HIV-negative men. It is important to stress condom use upon resumption of sex in all men undergoing circumcision.
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Factors Associated With Resumption of Sex Before Complete Wound Healing in Circumcised HIV-Positive and HIV-Negative Men in Kisumu, Kenya. J Acquir Immune Defic Syndr 2013. [DOI: 10.1097/qai] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Factors Associated With Resumption of Sex Before Complete Wound Healing in Circumcised HIV-Positive and HIV-Negative Men in Kisumu, Kenya. J Acquir Immune Defic Syndr 2013. [DOI: 10.1097/qai.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Male Circumcision. Sex Transm Dis 2013. [DOI: 10.1016/b978-0-12-391059-2.00006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Herman-Roloff A, Bailey RC, Agot K. Factors associated with the safety of voluntary medical male circumcision in Nyanza province, Kenya. Bull World Health Organ 2012; 90:773-81. [PMID: 23109745 PMCID: PMC3471059 DOI: 10.2471/blt.12.106112] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 07/02/2012] [Accepted: 07/31/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine factors associated with the incidence of adverse events associated with voluntary medical male circumcision (VMMC) for the prevention of HIV infection in Nyanza province, Kenya. METHODS Males aged 12 years or older who underwent VMMC between November 2008 and March 2010 in 16 clinics in three districts were followed through passive surveillance to monitor the incidence of adverse events during and after surgery. A subset of clinic participants was randomly selected for active surveillance post-operatively and was monitored for adverse events through a home-based, in-depth interview and a genital exam 28 to 45 days after surgery. Performance indicators were assessed for 167 VMMC providers. FINDINGS The adverse event rate was 0.1% intra-operatively and 2.1% post-operatively among clinic system participants (n = 3705), and 7.5% post-operatively among participants under active surveillance (n = 1449). Agreement between systems was moderate (κ: 0.20; 95% confidence interval, CI: 0.09-0.32). Providers who performed more than 100 procedures achieved an adverse event rate of 0.7% and 4.3% in the clinic and active surveillance systems, respectively, and had decreased odds of performing a procedure resulting in an adverse event. With provider experience, the mean duration of the procedure also dropped from 24.0 to 15.5 minutes. Among providers who had performed at least 100 procedures, nurses and clinicians provided equivalent services. CONCLUSION To reduce the adverse event rate, one must ensure that providers achieve a desired level of experience before they perform unsupervised procedures. Adverse events observed by the provider as well as those perceived by the client should both be monitored.
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Affiliation(s)
- Amy Herman-Roloff
- University of Illinois, 1603 W Taylor Street (M/C 923, Office 959), Chicago, IL, 60612, United States of America.
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Kacker S, Frick KD, Gaydos CA, Tobian AAR. Costs and effectiveness of neonatal male circumcision. ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2012; 166:910-8. [PMID: 22911349 PMCID: PMC3640353 DOI: 10.1001/archpediatrics.2012.1440] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage. DESIGN We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty. SETTING United States. PARTICIPANTS Birth cohort of men and women. INTERVENTION Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited). OUTCOMES MEASURED Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections. RESULTS Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses. CONCLUSION Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.
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Affiliation(s)
- Seema Kacker
- Department of Pathology, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21287, USA
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Abstract
INTRODUCTION Task-shifting for male medical circumcision is proposed as a strategy to overcome the lack of surgeons and doctors in high HIV prevalence settings. We undertook a systematic review and meta-analysis to review the safety of task-shifting for circumcision in Africa. METHODS We searched online databases and conference websites up to July 2011 without language restriction for studies reporting outcomes of task-shifting for circumcision in Africa. Information was extracted independently and in duplicate on study characteristics, quality, and outcome data. Case reports and case series were excluded. RESULTS Ten studies met our inclusion criteria, providing outcome data on 25119 circumcisions. The proportion of adverse events ranged from 0.70 [95% confidence interval (CI) 0.44-1.02%] to 37.36% (95% CI 27.54-47.72%), with an overall pooled proportion of 2.31% (95% CI 1.46-3.16%; τ = 1.21; P < 0.001). Two studies reported outcomes separately for both doctors and non-physicians; there was no difference in the risk of adverse events by provider (pooled relative risk 1.18; 95% CI 0.78-1.78). The frequency of excessive bleeding ranged from 0.30 (0.09-0.65%) to 24.71% (16.27-34.26%) with an overall pooled prevalence of 0.55% (95% CI 0.13-0.97%). Infection occurred in 0.30 (0.14-1.47%) to 1.85% (0.07-5.96%) of cases, with an overall pooled proportion of 0.88% (95% CI 0.29-1.47%). All adverse events were reported to be non-severe. CONCLUSION Task-shifting of male medical circumcision to non-physician clinicians can be done safely, with reported rates of adverse events similar to doctors and specialists.
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Morris BJ, Waskett JH, Banerjee J, Wamai RG, Tobian AAR, Gray RH, Bailis SA, Bailey RC, Klausner JD, Willcourt RJ, Halperin DT, Wiswell TE, Mindel A. A 'snip' in time: what is the best age to circumcise? BMC Pediatr 2012; 12:20. [PMID: 22373281 PMCID: PMC3359221 DOI: 10.1186/1471-2431-12-20] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 02/28/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves. DISCUSSION We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used. SUMMARY Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, NSW 2006, Australia.
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