RESUMO
BACKGROUND: Young South Africans experience high rates of HIV infection. While nationally scaled medical male circumcision (MMC) can help to curb HIV infection rates in countries such as South Africa (SA), MMC uptake has not been consistent or universal, suggesting variable acceptability among men. Both MMC and traditional male circumcision (TMC) are practised in SA. For male circumcision to be most effective for HIV prevention, it should be performed prior to sexual debut with complete removal of the foreskin. OBJECTIVES: The MACHO (Male Adolescent Choices for HIV Prevention Options) study investigated uptake of and preference for MMC v. TMC in two culturally distinct settings in SA. METHODS: This observational, longitudinal, cohort study investigated circumcision preferences and uptake in 100 males (aged 14 - 17 years) and their legal guardians in Cape Town (Western Cape Province) and Soweto (Gauteng Province). Data were collected via surveys administered every 4 months over a 24-month period. RESULTS: A total of 100 uncircumcised adolescent boys (Cape Town n=50, Soweto n=50; mean (interquartile range) age 15 (14 - 16) years) and their guardians were enrolled. At baseline, 42 boys from Soweto (84%) and none from Cape Town expressed a preference for MMC over TMC. Sowetan participants were more likely to elect circumcision (MMC n=11 (22%), TMC n=1 (2%)) than those from Cape Town (TMC n=1 (2%), MMC n=0) over 13.6 months of follow-up (hazard ratio 18.9; 95% confidence interval 2.37 - 150.71; p=0.006). CONCLUSIONS: MMC was the preferred option for young men in Soweto compared with those in Cape Town, and this translated into practice. Despite knowledge of the benefits of early MMC, many participants delayed uptake, potentially reducing the MMC benefits before sexual debut. Programmes promoting circumcision should consider the influence of local practices. To realise full HIV prevention benefits, efforts should be made to ensure that circumcision is promoted, and that all circumcision is safe, performed prior to sexual debut, and contextually responsive.
Assuntos
Circuncisão Masculina/etnologia , Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Cultura , Utilização de Instalações e Serviços , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Estimativa de Kaplan-Meier , Estudos Longitudinais , Masculino , Motivação , Utilização de Procedimentos e Técnicas , Modelos de Riscos Proporcionais , Comportamento Sexual , Infecções Sexualmente Transmissíveis/prevenção & controle , África do Sul/epidemiologiaRESUMO
Botswana is one of the countries in Eastern and Southern Africa significantly impacted by the Human Immunodeficiency Virus (HIV). To control the spread of HIV, the government in 2009 rolled out the voluntary medical male circumcision (VMMC) programme as an additional HIV prevention strategy with the goal of circumcising 80% of HIV negative men by 2016. However, the country failed to achieve this goal as less than 30% of the targeted men were circumcised by 2016. A study was therefore conducted to explore and describe the factors that are perceived by men in Botswana to influence the uptake of VMMC in order to inform future policymaking and programming on VMMC. An exploratory descriptive, qualitative design was utilised to investigate perceived factors influencing the uptake of VMMC among men. Data were collected from 38 men, aged 18-49 years in Kweneng East, Botswana using semi-structured individual interviews and focus group discussions (FGDs). Tesch's method of qualitative data analysis was used to code and categorise transcribed data into meaningful themes. Upon analysis, three themes emerged as influencing the uptake of VMMC: (a) the influence of value systems associated with stakeholder consultation in the community; (b) the influence of value systems associated with cultural beliefs and (c) the influence of value systems associated with religious beliefs. The influence of value systems associated with stakeholder consultation in the community was found to manifest in the form of the lack of consultation with men at the inception of the VMMC; the lack of involvement of village elders during the service delivery process and the lack of involvement of women in VMMC. In addition, the influence of value systems associated with cultural beliefs was found to manifest in the form of the lack of openness between parents and children on sexual matters and the lack of traditional leadership support in VMMC. Lastly, the influence of value systems associated with religious beliefs was found to manifest in the form of religious views not in support of the VMMC and religious views in support of the VMMC. It is concluded that value systems associated with stakeholder consultation, cultural beliefs and religious beliefs were the factors influencing the uptake of VMMC among men in Kweneng East, Botswana, and these factors to a larger extent deterred men from using VMMC services. Based on these findings, it is therefore concluded that government and other providers of VMMC should consider the influence of value systems on the uptake of VMMC in order to provide culturally congruent VMMC services and boost of the uptake of VMMC among men in Kweneng East, Botswana.
Assuntos
Circuncisão Masculina/etnologia , Circuncisão Masculina/psicologia , Infecções por HIV/etnologia , Infecções por HIV/prevenção & controle , Infecções por HIV/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Programas Voluntários/estatística & dados numéricos , Adolescente , Adulto , Atitude Frente a Saúde , Botsuana , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Adulto JovemRESUMO
This article presents a case study of Simon, a 25-year old Black South African male. According to his Pedi customs, Simon underwent traditional male circumcision (TMC) as a 12-year-old adolescent. He tells of his fears relative to this experience and how, over time, he transitioned from a belief in TMC to a strong preference for medical male circumcision (MMC). Using a single-case study design, the aim of the research was to explore the value of the exercise of choice in TMC, which may influence cultural perceptions of gender and masculinity. The study unpacks the way in which the meaning and experience of TMC is shaped by the social and cultural contexts of South Africa. This qualitative exploration complements conventional medical accounts of circumcision, which are often focused on the medical procedure while ignoring cultural and social factors. Issues of gender, particularly the construction of hegemonic masculinity and how it positions men, women, and young boys in relation to each other and their communities, are discussed. Simon's case study provides new insights and perspectives on personally and culturally sensitive issues which are not easily accessed nor commonly understood. Data collected via in-depth interviews were transcribed and analyzed thematically. Analysis applied information from the literature and key concepts from the theoretical standpoint of social constructivism. Case study analysis allowed space for unexpected, emergent themes to arise from the data. Four main themes were identified, notably language, silence, patriarchy, and masculinity.
Assuntos
Circuncisão Masculina/etnologia , Características Culturais , Conhecimentos, Atitudes e Prática em Saúde/etnologia , Masculinidade , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Adulto , Circuncisão Masculina/psicologia , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , África do SulRESUMO
OBJECTIVES: To determine caregiver-reported reasons for delay of desired neonatal circumcision. METHODS: Caregivers requesting elective outpatient circumcision at two urban tertiary care hospitals were surveyed from 1/2017 to 12/2018. Boys >3 years and those with abnormal penile anatomy were excluded. Patient/parent demographics, insurance status, comorbidities, birth history, family history, reasons circumcision was desired, and reasons for circumcision delay were obtained. RESULTS: Surveys were completed by 206/229 caregivers (90% response rate). Respondents were primarily mothers (74%) who identified as African-American (62%). Eligible boys presented at a median 7.5 months [0.3-35.6] and were predominantly African-American (63%), publicly-insured at birth (83%), and publicly-insured at present (86%). 80% were full-term. 83% had no comorbidities. Most caregivers (84%) requested inpatient circumcision, primarily for penile cleanliness (75%) and infection prevention (72%). Common reasons for delay included neonatal circumcision not being performed by the birth physician/hospital (26%) and prematurity (16%). Publicly-insured boys were more likely to encounter delays related birth physician/hospital not performing circumcisions (Pâ¯=â¯.02). Non-Caucasian/mixed race boys were less likely to be eligible for circumcision without general anesthesia (Pâ¯=â¯.004). In 108 cases (52%), circumcision was requested for full-term boys without comorbidities. Of these, 72 (35% of the cohort) now require general anesthesia to undergo circumcision. CONCLUSION: Among 206 boys experiencing circumcision delay, most were full-term, African-American, and publicly-insured. Common reasons for delay included neonatal circumcision not being performed by the birth hospital/physician and prematurity. General anesthesia could have been avoided in >35% of boys if circumcision was performed at birth.
Assuntos
Assistência Ambulatorial , Cuidadores , Circuncisão Masculina , Comportamento do Consumidor/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos , Negro ou Afro-Americano/estatística & dados numéricos , Assistência Ambulatorial/métodos , Assistência Ambulatorial/estatística & dados numéricos , Atitude Frente a Saúde , Cuidadores/psicologia , Cuidadores/estatística & dados numéricos , Circuncisão Masculina/etnologia , Circuncisão Masculina/métodos , Circuncisão Masculina/psicologia , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/psicologia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Humanos , Lactente , Cobertura do Seguro , Masculino , Inquéritos e Questionários , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
Voluntary medical male circumcision (VMMC) is an HIV prevention priority in Lesotho, but uptake remains suboptimal. We analyzed the 2014 Lesotho Demographic and Health Survey to assess population-level social, behavioral, and serological correlates of circumcision status, specifically traditional and/or medical circumcision. Among 2931 men, approximately half were traditionally circumcised, and fewer than 25% were medically circumcised. Only 4% were dually (traditionally and medically) circumcised. In multivariate analysis, only medical circumcision emerged as significantly (p < 0.05) protective against HIV infection, whereas dual circumcision was significantly associated with past-year STI symptomology. Younger (ages 15-24), lower educated, rural-dwelling, and traditionally circumcised men, including those who never tested for HIV, had significantly lower odds of medical circumcision. Our findings indicate other unmeasured behavioral factors may mitigate VMMC's protective effect against HIV and STI infections in dually circumcised men. Further research can help identify counseling and demand creation strategies for traditionally circumcised men presenting for VMMC.
Assuntos
Circuncisão Masculina/etnologia , Infecções por HIV/prevenção & controle , Serviços de Saúde/estatística & dados numéricos , Comportamento Sexual/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/prevenção & controle , Adolescente , Adulto , Preservativos , Infecções por HIV/epidemiologia , Humanos , Lesoto/epidemiologia , Masculino , Pessoa de Meia-Idade , Vigilância da População , Assunção de Riscos , Infecções Sexualmente Transmissíveis/epidemiologia , Adulto JovemRESUMO
Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda.
Assuntos
Circuncisão Masculina/psicologia , Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Adolescente , Adulto , Atitude Frente a Saúde , Circuncisão Masculina/etnologia , Circuncisão Masculina/estatística & dados numéricos , Características Culturais , Grupos Focais , Infecções por HIV/epidemiologia , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Fatores Socioeconômicos , UgandaRESUMO
Voluntary medical male circumcision (VMMC) is an evidence-based biomedical HIV prevention but under-utilized by male sexually transmitted diseases patients (MSTDP) in China. A parallel-group, non-blinded randomized controlled trial was conducted. Participants were uncircumcised heterosexual MSTDP attending four sexually transmitted diseases (STD) clinics in three Chinese cities. A total of 244 MSTDP were randomized 1:1 into the intervention group (n = 108) and the control group (n = 136). In addition to the education booklet received by the control group, the intervention group watched a 10-min video clip and received a brief counseling delivered by clinicians in the STD clinics. The interventions were developed based on the Health Belief Model and the Theory of Planned Behavior. At Month 6, participants in the intervention group reported significantly higher uptake of VMMC (14.8% versus 2.9%; RR 5.03, 95% CI 1.73, 14.62, p = 0.001). The brief STD clinic-based intervention was effective in increasing VMMC uptake among MSTDP in China.Trial registry: This study is registered at ClinicalTrials.gov, number NCT03414710. https://clinicaltrials.gov/ct2/show/NCT03414710 .
Assuntos
Circuncisão Masculina/psicologia , Aconselhamento/métodos , Infecções por HIV/prevenção & controle , Promoção da Saúde/organização & administração , Heterossexualidade , Infecções Sexualmente Transmissíveis/prevenção & controle , Adolescente , Adulto , China , Circuncisão Masculina/etnologia , Circuncisão Masculina/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces HIV acquisition risk in men. We sought to identify subpopulations of Botswanan men with high levels of VMMC uptake by comparing an observational cohort of men presenting for circumcision services at two high-volume clinics in Botswana's capital city, Gabo-rone, with a matched, population-based random sample of uncircumcised men. Among these high uptake VMMC subpopulations, we then examined the immediate factors that play a role in men's decision to seek VMMC services. As compared to their population-based controls, men choosing to undergo circumcision were more likely to be ages 24-34, more highly educated, to have a religious affiliation, and in a serious relationship. Our results suggest that married men and highly educated men were more likely to pursue circumcision for personal hygiene reasons. These findings have direct implications for targeted demand creation and mobilization activities to increase VMMC uptake in Botswana.
Assuntos
Circuncisão Masculina/psicologia , Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Motivação , Adulto , Botsuana , Circuncisão Masculina/etnologia , Estudos de Coortes , Tomada de Decisões , Infecções por HIV/psicologia , Soronegatividade para HIV , Humanos , Masculino , Vigilância da População , Estudos Prospectivos , Fatores Socioeconômicos , População Urbana , Adulto JovemRESUMO
Employing voluntary medical male circumcision (VMMC) within traditional settings may increase patient safety and help scale up male circumcision efforts in sub-Saharan Africa. In Zimbabwe, the VaRemba are among the few ethnic groups that practice traditional male circumcision, often in suboptimal hygienic environments. ZAZIC, a local consortium, and the Zimbabwe Ministry of Health and Child Care (MoHCC) established a successful, culturally sensitive partnership with the VaRemba to provide safe, standardized male circumcision procedures and reduce adverse events (AEs) during traditional male circumcision initiation camps. The foundation for the VaRemba Camp Collaborative (VCC) was established over a 4-year period, between 2013 and 2017, with support from a wide group of stakeholders. Initially, ZAZIC supported VaRemba traditional male circumcisions by providing key commodities and transport to help ensure patient safety. Subsequently, 2 male VaRemba nurses were trained in VMMC according to national MoHCC guidelines to enable medical male circumcision within the camp. To increase awareness and uptake of VMMC at the upcoming August-September 2017 camp, ZAZIC then worked closely with a trained team of circumcised VaRemba men to create demand for VMMC. Non-VaRemba ZAZIC doctors were granted permission by VaRemba leaders to provide oversight of VMMC procedures and postoperative treatment for all moderate and severe AEs within the camp setting. Of 672 male camp residents ages 10 and older, 657 (98%) chose VMMC. Only 3 (0.5%) moderate infections occurred among VMMC clients; all were promptly treated and healed well. Although the successful collaboration required many years of investment to build trust with community leaders and members, it ultimately resulted in a successful model that paired traditional circumcision practices with modern VMMC, suggesting potential for replicability in other similar sub-Saharan African communities.
Assuntos
Circuncisão Masculina/etnologia , Participação da Comunidade , Cultura , Etnicidade , Serviços de Saúde do Indígena , Medicinas Tradicionais Africanas , Programas Voluntários , Adolescente , Adulto , Criança , Circuncisão Masculina/efeitos adversos , Comportamento Cooperativo , Humanos , Infecções/etiologia , Infecções/terapia , Liderança , Masculino , Pessoa de Meia-Idade , Enfermeiros , Segurança , Marketing Social , Participação dos Interessados , Confiança , Adulto Jovem , ZimbábueRESUMO
OBJECTIVE: To determine the safety and efficacy of advanced practice provider (APP)-performed newborn circumcisions (NBCs), we reviewed outcomes of NBCs performed by pediatric urologists and APPs. We hypothesize comparable clinical outcomes between the groups. METHODS: All urology performed NBCs during a 5-year period were reviewed, including time surrounding implementation of the APP-led clinic. Return to emergency department (ED) rates, return to operating room (OR) rates, and intraprocedure bleeding requiring intervention were reviewed. Fisher exact and Mann-Whitney testing were utilized. RESULTS: There were no statistically significant differences in rates of intraprocedure bleeding, return to ED in 30days, return to OR for revision or other related penile surgery, or the overall number of patients with complications between the groups. Thirteen patients had complications in the APP cohort, compared to 8 in the urologist cohort. There was a difference in age and weight, with urologists performing NBCs on older and heavier patients. There was no difference in clinical outcomes between children over and under 10 pounds (4.5 kg). There was a significant difference in the need for revision circumcision when comparing children older vs younger than 30days (1.9% vs 0%, Pâ¯=â¯0.034). CONCLUSION: An APP-led NBC clinic is both safe and feasible. The widely used age and weight cutoffs for NBC need to be further evaluated, as there was no significant difference in clinical outcomes. This practice design provides pediatric urologists more time to focus on the most complex patients, both in the clinic and OR.
Assuntos
Instituições de Assistência Ambulatorial/normas , Procedimentos Cirúrgicos Ambulatórios/métodos , Circuncisão Masculina/métodos , Circuncisão Masculina/estatística & dados numéricos , Urologistas/normas , Fatores Etários , Circuncisão Masculina/etnologia , Estudos de Coortes , Pessoal de Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/fisiopatologia , Segurança do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Padrões de Prática Médica , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Resultado do Tratamento , Estados UnidosRESUMO
In every society where non-therapeutic female circumcision (FC) occurs, so too does non-therapeutic male circumcision (MC). In the past few decades, the norm in Euro-American societies has been to distinguish between the practices: FC is banned, while MC is condoned or encouraged. We explored Somalis' post-migration perceptions of FC and MC, while considering that they once lived in a society where both practices were widely accepted and now live in a society where there is a legal ban on FC alongside acceptance of MC. Eighteen individual interviews and seven focus group discussions were conducted with Somali men and women in three Swedish cities. There seemed to be a continuity of values across male and female forms of genital cutting concerning being a good Muslim, not inflicting harm and upholding respectability. Following migration, however, a renegotiation of how these values relate to MC and FC resulted in a conceptual split between the two: MC was perceived as an unquestionably required practice, but FC was viewed as a practice that can be adapted or abandoned. In a new cultural context after migration, perceptions of ideal male and female genitals, and what kinds of inscriptions on the body are desired, seem to have changed.
Assuntos
Circuncisão Feminina/etnologia , Circuncisão Masculina/etnologia , Islamismo/psicologia , Adulto , Circuncisão Feminina/efeitos adversos , Cultura , Feminino , Grupos Focais , Humanos , Entrevistas como Assunto , Masculino , Somália/etnologia , SuéciaRESUMO
Medical male circumcision (MMC) has expanded in sub-Saharan Africa, yet uptake remains sub-optimal. We sought to understand women's perceptions of and influence on MMC in Rakai, Uganda. We conducted in-depth interviews with 27 women in fishing and trading communities, including women married to circumcised and uncircumcised men, single women, and sex workers. Data analysis followed a team-based framework approach. All female participants preferred circumcised men because of perceived reduced HIV and sexually transmitted infection (STI) risk, improved penile hygiene, and increased sexual pleasure. Perceived negative aspects included abstinence during wound healing, potentially increased male sexual risk behaviors, fear of being blamed for HIV acquisition, and economic insecurity due to time off work. Participants felt women could persuade their partners to be circumcised, accompany them to the clinic, refuse sex with uncircumcised men, and participate in community MMC activities. Findings support women's important role in MMC acceptance.
Assuntos
Circuncisão Masculina/etnologia , Infecções por HIV/prevenção & controle , Infecções Sexualmente Transmissíveis/prevenção & controle , Mulheres/psicologia , Adolescente , Adulto , Circuncisão Masculina/psicologia , Feminino , Identidade de Gênero , Infecções por HIV/psicologia , Humanos , Entrevistas como Assunto , Masculino , Casamento , Pesquisa Qualitativa , Parceiros Sexuais/psicologia , Uganda , Adulto JovemRESUMO
Voluntary medical male circumcision (VMMC) uptake in Africa could prevent 3.4 million HIV infections across a 10 year span. In Zambia, however, ~80 per cent of uncircumcised men report no interest in undergoing VMMC. The Spear & Shield (S&S) intervention has been shown to be more effective than control or observation of only conditions at increasing the number of VMMCs. This study identified predictors of S&S implementation success or failure to create an "early warning" system to enable remedial action during implementation. Participants were n = 48 staff members from 12 community health facilities conducting the S&S program in Lusaka Province, Zambia. Quantitative assessments included demographics, provider attitudes, barriers to research uptake, staff burnout, and organizational readiness. Qualitative interviews were also conducted and quantified for analysis using the Consolidated Framework for Implementation Research (CFIR). Two-thirds (66%) of staff were women with a mean age of 37.67 years (SD = 7.51). Quantitatively, staff performance (p = .033) and decreased levels of staff burnout (p = .025) were associated with S&S implementation success. Qualitatively, constructs such as improved planning, executing, and self-reflection and evaluation were associated with S&S implementation success (p = .005). Identifying these factors facilitated remedial action across health facilities. This study illustrates the utility of the CFIR to guide program decision making in VMMC implementation in the Zambian context. Early identification of challenges to implementation may enable remedial action to enhance the likelihood of program sustainability. Effective monitoring strategies for HIV prevention interventions may thus enhance dissemination, implementation, and sustainability goals to bridge research and practice.
Assuntos
Circuncisão Masculina/etnologia , Medicina Baseada em Evidências/métodos , Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde/etnologia , Pessoal de Saúde/educação , Ciência da Implementação , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Zâmbia/etnologiaRESUMO
BACKGROUND: HIV prevalence varies from 1.7% to 14.8% between ethnic groups in Uganda. Understanding the factors responsible for this heterogeneity in HIV spread may guide prevention efforts. METHODS: We evaluated the relationship between HIV prevalence by ethnic group and a range of risk factors as well as the prevalence of herpes simplex virus-2 (HSV-2), syphilis and symptomatic STIs in the 2004/2005 Uganda HIV/AIDS Sero-Behavioural Survey-a two stage, nationally representative, population based survey of 15-59-year-olds. Spearman's correlation was used to assess the relationship between HIV prevalence and each variable. RESULTS: There was a positive association between HIV prevalence and HSV-2, symptomatic STIs and high-risk sex (sex with a non-cohabiting, non-marital partner) for women. Non-significant positive associations were present between HIV and high-risk sex for men and lifetime number of partners for men and women. CONCLUSION: Variation in sexual behavior may contribute to the variations in HIV, HSV-2 and other STI prevalence by ethnic group in Uganda. Further work is necessary to delineate which combinations of risk factors determine differential STI spread in Uganda.
Assuntos
Infecções por HIV/etnologia , Herpes Simples/etnologia , Herpesvirus Humano 2 , Sexo sem Proteção/etnologia , Adolescente , Adulto , Circuncisão Masculina/etnologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Fatores Sexuais , Sífilis/etnologia , Uganda/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Despite increased support for voluntary medical male circumcision (VMMC) to reduce HIV incidence, current VMMC progress falls short. Slow progress in VMMC expansion may be partially attributed to emphasis on vertical (stand-alone) over more integrated implementation models that are more responsive to local needs. In 2013, the ZAZIC consortium began implementation of a 5-year, integrated VMMC program jointly with Ministry of Health and Child Care (MoHCC) in Zimbabwe. OBJECTIVE: To explore ZAZIC's approach emphasizing existing healthcare workers and infrastructure, increasing program sustainability and resilience. METHODS: A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses. METHODS: A process evaluation utilizing routine quantitative data. Interviews with key MoHCC informants illuminate program strengths and weaknesses. RESULTS: In start-up and year 1 (March 2013-September, 2014), ZAZIC expanded from two to 36 static VMMC sites and conducted 46,011 VMMCs; 39,840 completed from October 2013 to September 2014. From October 2014 to September 2015, 44,868 VMMCs demonstrated 13% increased productivity. In October, 2015, ZAZIC was required by its donor to consolidate service provision from 21 to 10 districts over a 3-month period. Despite this shock, 57,282 VMMCs were completed from October 2015 to September 2016 followed by 44,414 VMMCs in only 6 months, from October 2016 to March 2017. Overall, ZAZIC performed 192,575 VMMCs from March 2013 to March, 2017. The vast majority of VMMCs were completed safely by MoHCC staff with a reported moderate and severe adverse event rate of 0.3%. CONCLUSION: The safety, flexibility, and pace of scale-up associated with the integrated VMMC model appears similar to vertical delivery with potential benefits of capacity building, sustainability and health system strengthening. These models also appear more adaptable to local contexts. Although more complicated than traditional approaches to program implementation, attention should be given to this country-led approach for its potential to spur positive health system changes, including building local ownership, capacity, and infrastructure for future public health programming.
Assuntos
Circuncisão Masculina/etnologia , Programas Governamentais/organização & administração , Adulto , Fortalecimento Institucional/organização & administração , Criança , Saúde da Criança , Infecções por HIV/prevenção & controle , Pessoal de Saúde/educação , Pessoal de Saúde/organização & administração , Humanos , Incidência , Masculino , Avaliação de Programas e Projetos de Saúde , Saúde Pública , Análise de Sistemas , ZimbábueRESUMO
Malawi is one of 14 priority countries for voluntary medical male circumcision (VMMC) initiatives with the lowest VMMC uptake. Using data from a study of 269 men accessing VMMC in southern Malawi and latent class analysis, men were classified based on four risk factors: ever tested for HIV, condom use at last sex, having casual/concurrent sexual partners, and using alcohol before sex. Two distinct classes were identified: 8% of men were classified as high risk, while 92% were classified as low/medium risk. Poisson regression modeling indicated that men who had lower education (risk ratio [RR] 1.07, p < 0.05) and were ages 19-26 (RR 1.07, p < 0.05) were more likely to be in the high risk group. The low numbers of men in the high risk category seeking services suggests the need to implement targeted strategies to increase VMMC uptake among such high risk men.
Assuntos
Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Infecções por HIV/transmissão , Conhecimentos, Atitudes e Prática em Saúde , Adolescente , Adulto , Circuncisão Masculina/etnologia , Circuncisão Masculina/psicologia , Infecções por HIV/epidemiologia , Humanos , Malaui , Masculino , Pessoa de Meia-Idade , Razão de Chances , Sexo Seguro , Comportamento Sexual/psicologia , Adulto JovemRESUMO
Slow adult male circumcision uptake is one factor leading some to recommend increased priority for infant male circumcision (IMC) in sub-Saharan African countries. This research, guided by the integrated behavioral model (IBM), was carried out to identify key beliefs that best explain Zimbabwean parents' motivation to have their infant sons circumcised. A quantitative survey, designed from qualitative elicitation study results, was administered to independent representative samples of 800 expectant mothers and 795 expectant fathers in two urban and two rural areas in Zimbabwe. Multiple regression analyses found IMC motivation among fathers was explained by instrumental attitude, descriptive norm and self-efficacy; while motivation among mothers was explained by instrumental attitude, injunctive norm, descriptive norm, self-efficacy, and perceived control. Regression analyses of beliefs underlying IBM constructs found some overlap but many differences in key beliefs explaining IMC motivation among mothers and fathers. We found differences in key beliefs among urban and rural parents. Urban fathers' IMC motivation was explained best by behavioral beliefs, while rural fathers' motivation was explained by both behavioral and efficacy beliefs. Urban mothers' IMC motivation was explained primarily by behavioral and normative beliefs, while rural mothers' motivation was explained mostly by behavioral beliefs. The key beliefs we identified should serve as targets for developing messages to improve demand and maximize parent uptake as IMC programs are rolled out. These targets need to be different among urban and rural expectant mothers and fathers.
Assuntos
Circuncisão Masculina/psicologia , Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Motivação , Pais/psicologia , Adulto , Circuncisão Masculina/etnologia , Medicina Baseada em Evidências , Feminino , Humanos , Lactente , Masculino , Análise de Regressão , População Rural , Autoeficácia , Inquéritos e Questionários , Zimbábue/epidemiologiaRESUMO
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.
Assuntos
Circuncisão Masculina/psicologia , Infecções por HIV/prevenção & controle , Adolescente , Adulto , Circuncisão Masculina/etnologia , Atenção à Saúde/métodos , Infecções por HIV/etnologia , Humanos , Masculino , Tanzânia , Adulto JovemRESUMO
The spectrum of practices termed "Female Genital Mutilation" (or FGM) by the World Health Organization is sometimes held up as a counterexample to moral relativism. Those who advance this line of thought suggest the practices are so harmful in terms of their physical and emotional consequences, as well as so problematic in terms of their sexist or oppressive implications, that they provide sufficient, rational grounds for the assertion of a universal moral claim--namely, that all forms of FGM are wrong, regardless of the cultural context. However, others point to cultural bias and moral double standards on the part of those who espouse this argument, and have begun to question the received interpretation of the relevant empirical data on FGM as well. In this article I assess the merits of these competing perspectives. I argue that each of them involves valid moral concerns that should be taken seriously in order to move the discussion forward. In doing so, I draw on the biomedical "enhancement" literature in order to develop a novel ethical framework for evaluating FGM (and related interventions--such as female genital "cosmetic" surgery and nontherapeutic male circumcision) that takes into account the genuine harms that are at stake in these procedures, but which does not suffer from being based on cultural or moral double standards.