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Jacobs P, Feaster DJ, Pan Y, Gooden LK, Daar ES, Lucas GM, Jain MK, Marsh EL, Armstrong WS, Rodriguez A, del Rio C, Metsch LR. Initiation of Antiretroviral Therapy in the Hospital Is Associated With Linkage to Human Immunodeficiency Virus (HIV) Care for Persons Living With HIV and Substance Use Disorder. Clin Infect Dis 2021; 73:e1982-e1990. [PMID: 32569355 PMCID: PMC8492224 DOI: 10.1093/cid/ciaa838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 06/18/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies have demonstrated benefits of antiretroviral therapy (ART) initiation on the day of human immunodeficiency virus (HIV) testing or at first clinical visit. The hospital setting is understudied for immediate ART initiation. METHODS CTN0049, a linkage-to-care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the United States. This secondary analysis examined factors related to initiating (including reinitiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention, and viral suppression. RESULTS Of 801 participants, 124 (15%) initiated ART in the hospital, with more than two-thirds of these participants (80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively (P = .0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6 and 12 months. There was no association with ART initiation in the hospital and retention and viral suppression over a 12-month period. Participants recruited in Southern hospitals were less likely to initiate ART in the hospital (P < .001). CONCLUSIONS Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented. Research findings suggest that starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address barriers to early ART initiation in the hospital.
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Affiliation(s)
- Petra Jacobs
- National Institute on Drug Abuse, Bethesda, Maryland, USA
| | | | - Yue Pan
- University of Miami, Miami, Florida, USA
| | | | - Eric S Daar
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | | | - Mamta K Jain
- UT Southwestern Medical Center, Dallas, Texas, USA
| | | | | | | | - Carlos del Rio
- Emory University School of Medicine, Atlanta, Georgia, USA
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Ahmed I, Demissie M, Worku A, Gugsa S, Berhane Y. Virologic outcomes of people living with human immunodeficiency virus who started antiretroviral treatment on the same-day of diagnosis in Ethiopia: A multicenter observational study. PLoS One 2021; 16:e0257059. [PMID: 34478438 PMCID: PMC8415611 DOI: 10.1371/journal.pone.0257059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/21/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION There have been tremendous achievements in scaling-up antiretroviral therapy (ART) for treatment of human immunodeficiency virus (HIV), following universal "test and treat" policy implementation in low- and middle-income countries. However, its effects on virologic outcomes is not yet well investigated. We compared low viral load status in people living with HIV between those who were initiated on ART on the same-day and after 7 days of being diagnosed with HIV infection. METHODS We conducted a retrospective cohort study of persons age ≥15 years-old who were newly diagnosed and started on ART between October 2016 and July 2018 at 11 public health facilities in northwest Ethiopia. Exposure was initiation of ART on the same-day of HIV diagnosis. The outcome was low viral load at 12-months following ART initiation. We used double-robust estimator using inverse-probability-weighted regression adjustment to compare the groups. RESULTS A total of 398 people who started ART on the same-day of HIV diagnosis and 479 people who started 7 days after the initial diagnosis were included in this study. By 12-months following ART initiation, 73.4% (292) in the same-day group vs 83.7% (401) in the >7 days group achieved low viral load (absolute difference = 10.3% (95% CI: 4.9%, 15.8%)). After adjusting for baseline and follow-up covariates, there was statistically significant difference in low viral load status (adjusted difference = 8.3% (95% CI: 3.5%, 13.0%)) between the same-day group and the >7 days group. CONCLUSIONS Achievement of low viral load by 12-months post-initiation of ART was not optimal among participants who started ART on the same-day of HIV diagnosis. Efforts should be made to reinforce treatment adherence while initiating same-day ART.
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Affiliation(s)
| | - Meaza Demissie
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Salem Gugsa
- Department of Global Health, University of Washington Seattle, Seattle, WA, United States of America
| | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Ahmed I, Demissie M, Worku A, Gugsa S, Berhane Y. Effectiveness of same-day antiretroviral therapy initiation in retention outcomes among people living with human immunodeficiency virus in Ethiopia: empirical evidence. BMC Public Health 2020; 20:1802. [PMID: 33243185 PMCID: PMC7690160 DOI: 10.1186/s12889-020-09887-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/13/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In August 2016, Ethiopia endorsed a universal "test and treat" strategy for people living with human immunodeficiency virus (PLHIV) based on World Health Organization recommendation. However, there is limited evidence on the routine application of the same-day "test and treat" recommendation in low-income settings. This study assessed the effect of same-day treatment initiation on individual-level retention at 6- and 12-months follow-up. METHODS A multicenter facility-based retrospective cohort study was conducted to compare retention-in-care between PLHIV who started antiretroviral therapy (ART) on the same-day and those started ART > 7 days following HIV diagnoses. Participants were at least 15 years-old and were newly diagnosed and started on ART between October 2016 and July 2018 in 11 health facilities in the Amhara region of Ethiopia. Multivariable logistic regression controlling for potential confounders and Kaplan-Meier survival analysis were used to assess differences in outcomes between the groups. RESULTS In total, 433 PLHIV started ART on the same-day of diagnosis and 555 PLHIV who started ART > 7 days after HIV diagnosis were included in the study. At 6-months, 82.0% (355) in the same-day group vs 89.4% (496) in the > 7 days group were retained-in-care (absolute risk difference (RD) = 7.4%; 95% confidence interval (CI): 2.9-11.8%). At 12-months, 75.8% (328) in the same-day group vs 82.0% (455) in the > 7 days group were retained-in-care (absolute RD = 6.2%; 95% CI: 1.1, 11.4%). The major drop in retention was in the first 30 days following ART initiation among same-day group. After adjusting for baseline and non-baseline covariates, the same-day group was less likely to be retained-in-care at 6- and 12-months (adjusted risk ratio (RR) = 0.89; 95% CI: 0.87, 0.90 and adjusted RR = 0.86; 95% CI: 0.83, 0.89, respectively). CONCLUSIONS Reduced retention-in-care can threaten the benefit of the same-day "test and treat" policy. The policy needs to be implemented cautiously with greater emphasis on assessment and preparation of PLHIV for ART to ensure treatment readiness before starting them on same-day ART and close monitoring of patients during early follow-up periods.
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Affiliation(s)
| | - Meaza Demissie
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Salem Gugsa
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Dai L, Yu X, Shao Y, Wang Y, Li Z, Ye J, Bai S, Guo X, Wang J, Su B, Jiang T, Zhang T, Wu H, Scott SR, Liu A, Sun L. Effect of a multi-dimensional case management model on anti-retroviral therapy-related outcomes among people living with human immunodeficiency virus in Beijing, China. BMC Infect Dis 2020; 20:489. [PMID: 32646373 PMCID: PMC7350672 DOI: 10.1186/s12879-020-05219-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper introduces a comprehensive case management model uniting doctors, nurses, and non-governmental organizations (NGOs) in order to shorten the time from HIV diagnosis to initiation of antiviral therapy, improve patients' adherence, and ameliorate antiretroviral treatment (ART)-related outcomes. METHODS All newly diagnosed human immunodeficiency virus (HIV) cases at Beijing YouAn Hospital from January 2012 to December 2013 were selected as the control group, while all newly diagnosed HIV-infected patients from January 2015 to December 2016 were selected as the intervention group, receiving the comprehensive case management model. RESULTS 4906 patients were enrolled, of which 1549 were in the control group and 3357 in the intervention group. The median time from confirming HIV infection to ART initiation in the intervention group was 35 (18-133) days, much shorter than the control group (56 (26-253) days, P < 0.001). Participants in the intervention group had better ART adherence compared to those in the control group (intervention: 95.3%; control: 89.2%; p < 0.001). During the 2 years' follow-up, those receiving case management were at decreased odds of experiencing virological failure (OR: 0.27, 95%CI: 0.17-0.42, P < 0.001). Observed mortality was 0.4 deaths per 100 patient-years of follow-up for patients in the control group compared with 0.2 deaths per 100 patient-years of follow-up in the intervention group. CONCLUSIONS People living with HIV engaged in the comprehensive case management model were more likely to initiate ART sooner and maintained better treatment compliance and improved clinical outcomes compared to those who received routine care. A comprehensive case management program could be implemented in hospitals across China in order to reduce the HIV disease burden in the country.
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Affiliation(s)
- Lili Dai
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Xiaochun Yu
- School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Ying Shao
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yali Wang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Zaicun Li
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Jiangzhu Ye
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Shaoli Bai
- Lanzhou Municipality Pulmonary Hospital, Lanzhou, 730046, Gan Su, China
| | - Xiaoling Guo
- Lanzhou Municipality Pulmonary Hospital, Lanzhou, 730046, Gan Su, China
| | - Jianyun Wang
- Lanzhou Municipality Pulmonary Hospital, Lanzhou, 730046, Gan Su, China
| | - Bin Su
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Taiyi Jiang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Tong Zhang
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Sarah Robbins Scott
- The National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, 100037, China
| | - An Liu
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
| | - Lijun Sun
- Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
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Partial Achievement of the 90-90-90 UNAIDS Target in a Cohort of HIV Infected Patients from Central Italy. Mediterr J Hematol Infect Dis 2020; 12:e2020017. [PMID: 32180912 PMCID: PMC7059746 DOI: 10.4084/mjhid.2020.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/14/2020] [Indexed: 01/02/2023] Open
Abstract
Background Despite progress in the prevention and treatment of HIV, persistent issues concerning the evaluation of continuum in care from the serological diagnosis to virologic success remains. Considering the 2020 UNAIDS target 90-90-90 for diagnosis, treatment, and viral suppression of people living with HIV (PLWH), our purpose was to verify if, starting from new diagnoses, the viral suppression rate of our cohort of new PLWH satisfied the second and the third steps. Methods This retrospective study regards all patients aged ≥15 undergoing HIV test at our clinic between January 2005 and December 2017. We evaluated the second and the third ‘90 UNAIDS targets and the unclaimed tests, linkage to care, retention in ART, and the viral suppression at 1 and 2 years. Logistic regression (odds ratio, 95% confidence interval) was performed. Results We observed 592 new diagnoses for HIV infection: 61.4% on Italians, 38.5% on foreigners. An antiretroviral treatment was started on 78.8% of the new diagnoses (467/592) (second UNAIDS target), and a viral suppression was obtained at 2 years on 82% of PLWH who had started ART (383/467) (third UNAIDS target), namely only 64.7% of the new diagnoses instead of the hoped-for 81% of the UNAIDS target. Logistic regressions demonstrated that second and third ‘90 UNAIDS targets were unrelated to sex, nationality, CD4 cells count, HIV-RNA and CDC stage (p>0.05). The age class 25–50 years (OR=2.24; 95% CI = 1.06–4.37; p=0.04) achieves more likely viral suppression when compared with patients <25 years. Considering the continuum of care, 88 (15%) PLWH were lost to engagement in care (55 unclaimed tests and 33 unlinked to care), 37 didn’t start ART, 51 were LFTU at 2 years. Conclusions UNAIDS goal was far to be reached. The main challenges were unreturned tests as well as the retention in ART. Rapid tests for a test-treat strategy and frequent phone communications in the first ART years could facilitate UNAIDS target achievement.
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Pell C, Vernooij E, Masilela N, Simelane N, Shabalala F, Reis R. False starts in 'test and start': a qualitative study of reasons for delayed antiretroviral therapy in Swaziland. Int Health 2018; 10:78-83. [PMID: 29342259 DOI: 10.1093/inthealth/ihx065] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/30/2017] [Indexed: 11/14/2022] Open
Abstract
Background Test and start, antiretroviral therapy (ART) for all HIV-positive individuals, is a WHO-recommended treatment guideline. In Swaziland, test and start has been evaluated through the MaxART implementation study. This article examines why, in MaxART, some newly diagnosed HIV-positive clients delayed initiating ART. Methods Thirteen HIV-positive clients who delayed ART for ≥90 d after testing were identified from the MaxART study database and interviewed. Interviews were audio recorded, transcribed and translated into English for qualitative content analysis. Results Respondents had often tested positive several times before initiating ART, with the initial diagnosis sometimes completely unexpected. Repeat testing-and delayed ART-was linked to a desire to come to terms with their diagnosis and prepare for a lifelong treatment course. Clients previously enrolled in pre-ART, particularly with high CD4 counts, had internalized past messages about ART as being non-essential and taking care of oneself through other means. Concerns about ART-related adverse events were weighed against these messages. Worries about inadvertent disclosure and its impact on social and economic relationships also discouraged initiation. Conclusion Although potentially reducing logistical barriers, expedited ART initiation does not necessarily accommodate some clients' need for time to come to terms with the diagnosis and the prospect of lifelong treatment.
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Affiliation(s)
- Christopher Pell
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Amsterdam Institute for Global Health and Development (AIGHD), AHTC, Tower C4, Paasheuvelweg 25, 1105 BP, Amsterdam, The Netherlands
| | - Eva Vernooij
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Theory and History of Psychology, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands
| | | | | | - Fortunate Shabalala
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Department of Community Health Nursing Sciences, Faculty of Health Sciences, University of Swaziland, Mbabane, Swaziland
| | - Ria Reis
- Amsterdam Institute for Social Science Research, University of Amsterdam, Nieuwe Achtergracht 166, 1018 WV, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands.,Children's Institute, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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Sabapathy K, Hensen B, Varsaneux O, Floyd S, Fidler S, Hayes R. The cascade of care following community-based detection of HIV in sub-Saharan Africa - A systematic review with 90-90-90 targets in sight. PLoS One 2018; 13:e0200737. [PMID: 30052637 PMCID: PMC6063407 DOI: 10.1371/journal.pone.0200737] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 05/25/2018] [Indexed: 12/03/2022] Open
Abstract
Introduction We aimed to establish how effective community-based HIV testing services (HTS), including home and community location based (non-health facility) HIV testing services (HB-/CLB-HTS), are in improving care in sub-Saharan Africa (SSA), with a view to achieving the 90-90-90 targets. Methods We conducted a systematic review of published literature from 2007–17 which reported on the proportion of individuals who link-to-care and/or initiate ART after detection with HIV through community-based testing. A meta-analysis was deemed inappropriate due to heterogeneity in reporting. Results and discussion Twenty-five care cascades from 6 SSA countries were examined in the final review– 15 HB-HTS, 8 CLB-HTS, 2 combined HB-/CLB-HTS. Proportions linked-to-care over 1–12 months ranged from 14–96% for HB-HTS and 10–79% for CLB-HTS, with most studies reporting outcomes over short periods (3 months). Fewer studies reported ART-related outcomes following community-based testing and most of these studies included <50 HIV-positive individuals. Proportions initiating ART ranged from 23–93%. One study reported retention on ART (76% 6 months after initiation). Viral suppression 3–12 months following ART initiation was 77–85% in three studies which reported this. There was variability in definitions of outcomes, numerators/denominators and observation periods. Outcomes varied between studies even for similar time-points since HTS. The methodological inconsistencies hamper comparisons. Previously diagnosed individuals appear more likely to link-to-care than those who reported being newly-diagnosed. It appears that individuals diagnosed in the community need time before they are ready to link-to-care/initiate ART. Point-of-care (POC) CD4-counts at the time of HTS did not achieve higher proportions linking-to-care or initiating ART. Similarly, follow-up visits to HIV-positive individuals did not appear to enhance linkage to care overall. Conclusion This systematic review summarises the available data on linkage to care/ART initiation following community-based detection of HIV, to help researchers and policy makers evaluate findings. The available evidence suggests that different approaches to community-based HTS including HB-HTS and CLB-HTS, are equally effective in achieving linkage to care and ART initiation among those detected. Engagement and support for newly diagnosed individuals may be key to achieving all three UNAIDS 90-90-90 targets. We also recommend that standardised measures of reporting of steps on the cascade of care are needed, to measure progress against targets and compare across settings.
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Affiliation(s)
- Kalpana Sabapathy
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Bernadette Hensen
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Olivia Varsaneux
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Richard Hayes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Gilbert HN, Wyatt MA, Asiimwe S, Turyamureeba B, Tumwesigye E, Van Rooyen H, Barnabas RV, Celum CL, Ware NC. Messaging Circumstances and Economic Pressures as Influences on Linkage to Medical Male Circumcision following Community-Based HIV Testing for Men in Rural Southwest Uganda: A Qualitative Study. AIDS Res Treat 2018; 2018:8387436. [PMID: 29854445 PMCID: PMC5960566 DOI: 10.1155/2018/8387436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/26/2018] [Indexed: 12/03/2022] Open
Abstract
Voluntary medical male circumcision (MMC) reduces risk of HIV infection, but uptake remains suboptimal among certain age groups and locations in sub-Saharan Africa. We analysed qualitative data as part of the Linkages Study, a randomized controlled trial to evaluate community-based HIV testing and follow-up as interventions promoting linkage to HIV treatment and prevention in Uganda and South Africa. Fifty-two HIV-negative uncircumcised men participated in the qualitative study. They participated in semistructured individual interviews exploring (a) home HTC experience; (b) responses to test results; (c) efforts to access circumcision services; (d) outcomes of efforts; (e) experiences of follow-up support; and (f) local HIV education and support. Interviews were audio-recorded, translated, transcribed, and summarized into "linkage summaries." Summaries were analysed inductively to identify the following three thematic experiences shaping men's circumcision choices: (1) intense relief upon receipt of an unanticipated seronegative diagnosis, (2) the role of peer support in overcoming fear, and (3) anticipation of missed economic productivity. Increased attention to the timing of demand creation activities, to who delivers information about the HIV prevention benefits of MMC, and to the importance of missed income during recovery as a barrier to uptake promises to strengthen and sharpen future MMC demand creation strategies.
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Affiliation(s)
- Hannah N. Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Monique A. Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Harvard Global, Cambridge, MA, USA
| | | | | | | | - Heidi Van Rooyen
- Human Sciences Research Council, Durban, South Africa
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruanne V. Barnabas
- Department of Global Health, School of Medicine and School of Public Health, University of Washington, Seattle, WA, USA
| | - Connie L. Celum
- Department of Global Health, School of Medicine and School of Public Health, University of Washington, Seattle, WA, USA
| | - Norma C. Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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