Male circumcision uptake during the Botswana Combination Prevention Project.

INTRODUCTION: Voluntary medical male circumcision (VMMC) uptake has been slow in some countries, including Botswana. To inform demand creation efforts, we examined sociodemographic characteristics and referral procedures associated with VMMC uptake in the Botswana Combination Prevention Project (BCPP) and examined the effectiveness of referral of men to MC services from HIV testing venues. DESIGN: BCPP was a community-randomized trial evaluating the impact of a combination HIV prevention package which included VMMC on community HIV incidence. We conducted a sub-analysis of VMMC uptake in intervention communities. METHODS: During the initial VMMC campaign in 15 intervention communities, baseline male circumcision (MC) status was assessed among men eligible for HIV testing. Uncircumcised male community residents aged 16-49 years with negative/unknown HIV status were mobilized and linked to study VMMC services. Outcomes included MC baseline status and uptake through study services. Univariate and multivariate logistic regressions were performed to identify factors associated with MC uptake. RESULTS: Of 12,864 men eligible for testing, 50% (n = 6,448) were already circumcised. Among the uncircumcised men (n = 6,416), 10% (n = 635) underwent MC. Of the 5,071 men identified as eligible for MC through HIV testing services, 78% declined referral and less than 1% of those were circumcised. Of those accepting referral (n = 1,107), 16% were circumcised. Younger (16-24 years) (aOR: 1.51; 95%CI:1.22,1.85), unemployed men (aOR:1.34; 95%CI: 1.06,1.69), and those undergoing HIV testing at mobile venues (aOR: 1.88; 95%CI: 1.53,2.31) were more likely to get circumcised. Fear of pain was the most prevalent (27%) reason given for not being circumcised. CONCLUSION: Younger, unemployed men seeking HIV testing at mobile sites in Botswana were more likely to get VMMC. Addressing unique barriers for employed and older men may be necessary. Given the simplicity of VMMC as an intervention, the HIV testing programs offer a platform for identifying uncircumcised men and offering information and encouragement to access services.

Implementation and Operational Research: Strengthening HIV Test Access and Treatment Uptake Study (Project STATUS): A Randomized Trial of HIV Testing and Counseling Interventions.

OBJECTIVE: To determine which of 3 HIV testing and counseling (HTC) models in outpatient departments (OPDs) increases HIV testing and entry of newly identified HIV-infected patients into care. DESIGN: Randomized trial of HTC interventions. METHODS: Thirty-six OPDs in South Africa, Tanzania, and Uganda were randomly assigned to 3 different HTC models: (A) health care providers referred eligible patients (aged 18-49, not tested in the past year, not known HIV positive) to on-site voluntary counseling and testing for HTC offered and provided by voluntary counseling and testing counselors after clinical consultation; (B) health care providers offered and provided HTC to eligible patients during clinical consultation; and (C) nurse or lay counselors offered and provided HTC to eligible patients before clinical consultation. Data were collected from October 2011 to September 2012. We describe testing eligibility and acceptance, HIV prevalence, and referral and entry into care. Chi-square analyses were conducted to examine differences by model. RESULTS: Of 79,910 patients, 45% were age eligible and 16,099 (45%) age eligibles were tested. Ten percent tested HIV positive. Significant differences were found in percent tested by model. The proportion of age eligible patients tested by Project STATUS was highest for model C (54.1%, 95% confidence interval [CI]: 42.4 to 65.9), followed by model A (41.7%, 95% CI: 30.7 to 52.8), and then model B (33.9%, 95% CI: 25.7 to 42.1). Of the 1596 newly identified HIV positive patients, 94% were referred to care (96.1% in model A, 94.7% in model B, and 94.9% in model C), and 58% entered on-site care (74.4% in model A, 54.8% in model B, and 55.6% in model C) with no significant differences in referrals or care entry by model. CONCLUSIONS: Model C resulted in the highest proportion of all age-eligible patients receiving a test. Although 94% of STATUS patients with a positive test result were referred to care, only 58% entered care. We found no differences in patients entering care by HTC model. Routine HTC in OPDs is acceptable to patients and effective for identifying HIV-infected persons, but additional efforts are needed to increase entry to care.

Poor performance of the determine HIV-1/2 Ag/Ab combo fourth-generation rapid test for detection of acute infections in a National Household Survey in Swaziland.

Fourth-generation HIV rapid tests (RTs) claim to detect both p24 antigen (Ag) and HIV antibodies (Ab) for early identification of acute infections, important for targeting prevention and reducing HIV transmission. In a nationally representative household survey in Swaziland, 18,172 adults, age 18 to 49 years, received home-based HIV rapid testing in 2010 and 2011. Of the 18,172 individuals, 5,822 (32.0%) were Ab positive (Ab(+)) by the Determine HIV-1/2 Ab/Ab combo test, and 5,789 (99.4%) of those were confirmed to be reactive in the Uni-Gold test. Determine combo identified 12 individuals as having acute infections (Ag(+)/Ab negative [Ab(-)]); however, none had detectable HIV-1 RNA and 8 of 12 remained HIV negative at their 6-week follow-up visit (4 were lost to follow-up). All RT-nonreactive samples were pooled and tested by nucleic acid amplification testing (NAAT) to identify acute infections. NAAT identified 13 (0.1%) of the 12,338 HIV antibody-negative specimens as HIV RNA positive, with RNA levels ranging from 300 to >10,000,000 copies/ml. However, none of them were Ag(+) by Determine combo. Follow-up testing of 12 of the 13 NAAT-positive individuals at 6 months demonstrated 12 seroconversions (1 individual was lost to follow-up). Therefore, the Determine combo test had a sensitivity of 0% (95% confidence interval, 0 to 28) and positive predictive value of 0% for the detection of acute infections. The ability of the 4th-generation Determine combo to detect antigen was very poor in Swaziland. Thus, the Determine combo test does not add any value to the current testing algorithm; rather, it adds additional costs and complexity to HIV diagnosis. The detection of acute HIV infections may need to rely on other testing strategies.

"What took you so long?" The impact of PEPFAR on the expansion of HIV testing and counseling services in Africa.

HIV testing and counseling services in Africa began in the early 1990s, with limited availability and coverage. Fears of stigma and discrimination, complex laboratory systems, and lack of available care and treatment services hampered expansion. Use of rapid point-of-care tests, introduction of services to prevent mother-to-child transmission, and increasing provision of antiretroviral drugs were key events in the late 1990s and early 2000s that facilitated the expansion of HIV testing and counseling services. Innovations in service delivery included providing HIV testing in both clinical and community sites, including mobile and home testing. Promotional campaigns were conducted in many countries, and evolutions in policies and guidance facilitated expansion and uptake. Support from President's Emergency Plan for AIDS Relief and national governments, other donors, and the Global Fund for AIDS, Tuberculosis, and Malaria contributed to significant increases in the numbers of persons tested in many countries. Quality of both testing and counseling, limited number of health care workers, uptake by couples, and effectiveness of linkages and referral systems remain challenges. Expansion of antiretroviral treatment, especially in light of the evidence that treatment contributes to prevention of transmission, will require greater yet strategic coverage of testing services, especially in clinical settings and in combination with other high-impact HIV prevention strategies. Continued support from President's Emergency Plan for AIDS Relief, governments, and other donors is required for the expansion of testing needed to achieve international targets for the scale-up of treatment and universal access to knowledge of HIV status.

Hierarchical messages for introducing multiple HIV prevention options: promise and pitfalls.

In battling HIV, many interventionists advocate the use of hierarchical messages that present multiple prevention options in order of decreasing effectiveness. The purpose of the present study was to determine if hierarchical messages provide women with additional prevention options without reducing the perceived efficacy of and willingness to use the primary method mentioned (in this case, male condoms). African American and Mexican American women between 18 and 32 years of age (n=112) at risk for HIV were randomly assigned to receive either a male-condom-only message (use male condoms) or a hierarchical message (use male condoms; if not, use female condoms; if not, use spermicide). Compared with women in the male-condom-only condition, a significantly smaller percentage of women who received the hierarchical message perceived male condoms as highly effective against HIV. Women currently not using male condoms who received the hierarchical, rather than the male-condom-only, message were less likely to consider using male condoms in the future. Among current male condom users, however, the hierarchical message did not influence intent to use male condoms. These data point to the need for examining both the intended and unintended effects of hierarchical health care messages.

Installing computers in older adults' homes and teaching them to access a patient education web site: a systematic approach.

This article describes the experiences of nurses who, as part of a large clinical trial, brought the Internet into older adults' homes by installing a computer, if needed, and connecting to a patient education Web site. Most of these patients had not previously used the Internet and were taught even basic computer skills when necessary. Because of increasing use of the Internet in patient education, assessment, and home monitoring, nurses in various roles currently connect with patients to monitor their progress, teach about medications, and answer questions about appointments and treatments. Thus, nurses find themselves playing the role of technology managers for patients with home-based Internet connections. This article provides step-by-step procedures for computer installation and training in the form of protocols, checklists, and patient user guides. By following these procedures, nurses can install computers, arrange Internet access, teach and connect to their patients, and prepare themselves to install future generations of technological devices.

Persistence of inconsistent condom use: relation to abuse history and HIV serostatus.

This study longitudinally examines the relation between a history of experiencing childhood and adult physical or sexual abuse, and male condom use by women with or at risk for HIV. Abuse history and prospective condom use data were collected from 214 HIV infected and 189 uninfected women participating in the HIV Epidemiology Research Study (HERS) who were inconsistent condom users at baseline and received two safer sex counseling sessions. Analyses were conducted to assess the association between abuse history and condom use while controlling for sociodemographic variables and other risk factors. HIV-uninfected women with a history of adult physical abuse were five times less likely to report consistent condom use at 1-year follow-up than uninfected women without a history of abuse while holding control variables constant. Expectations of a negative reaction by the partner to suggested condom use did not explain this association. Though in the same direction as in uninfected women, abuse history was not significantly related to consistent condom use among HIV-infected women. These data indicate the need to develop risk prevention strategies tailored to uninfected women with a history of adult abuse. In lieu of specialized interventions, health care providers should assess women's abuse history and supplement HIV prevention counseling with mental health counseling when indicated.

Active rectal wall protection using direct transperineal cryo-needles for histologically proven prostate adenocarcinomas.

INTRODUCTION AND OBJECTIVES: Cryosurgical ablation of the prostate is a promising new modality for the treatment localized prostate cancer. However, better protection of the rectal wall during cryoablation of the peripheral zone of the prostate (PZP) may permit deeper freezing of the PZP and for longer time, rendering the procedure safer and more effective. We present a modified cryoablation technique of the prostate using the SeedNet system (Galil Medical, Uniondale, NY, USA), in which the rectum is actively protected during cryoablation. PATIENTS AND METHODS: During a 12-month period, 31 patients (32 procedures) with localized and histologically proven prostate adenocarcinoma of various stages and grades were treated in this fashion. We evaluated the feasibility of a new method of active rectal wall protection during cryoablation of the prostate. Fourteen ultrathin, 17-gauge, probes, cryo-needles were percutaneously introduced under transrectal ultrasound (TRUS) guidance into the prostate. Peripheral region of the prostate and the area between the prostate and rectal wall were real time monitored for temperature changes. Two cryo-needles placed between the prostate and rectal wall served for active warming using the thawing mode when the temperatures dropped to approximately 0 degrees C, and rectal lumen washing with hot water (+40 degrees C) when the temperature reading dropped further to -8 degrees C or -10 degrees C. RESULTS: Active protection of the rectal wall using the cryosurgical modification of active thawing by the two additional cryo-needles placed in the space between the prostate and rectum, while freezing the prostate was performed in every patient, thus enabling us a safe generation of an iceball at the peripheral zone of the prostate with an average temperature ranging from -35 degrees C to -60 degrees C, for 10 min per cycle. During a follow-up of up to 18 months (mean 13.2 months) there was a PSA decrease to values equal or less than 0.5ng/ml in 25 patients (80.6%) and to values equal or less than 1 ng/ml in 21 patients (67.7%). There were no cases of rectal injury or postoperative rectal pain in any of these patients. CONCLUSIONS: This new cryotechnique of active rectal wall protection during cryotherapy of the prostate was safe and simple to perform, resulting in no rectal injuries. It was also very effective in ablating the prostate gland, as expressed by the low follow up PSA values.

An Introduction to Cochlear Implant Technology, Activation, and Programming.

Over the last decade, cochlear implantation has become an increasingly viable alternative for the treatment of profound sensorineural hearing loss in children. Although speech and hearing professionals play an important role in the communicative, social, and academic development of children with cochlear implants, many may be unfamiliar with recent advances in implant technology. This article provides an overview of the components of cochlear implant systems and the speech processing strategies that are currently being used by toddlers, preschoolers, and school-age children. A brief description of cochlear implant surgery and the procedures for programming these devices are also included. Finally, information regarding the use of assistive listening technology in the classroom is presented.

School-Based Services for Children With Cochlear Implants.

School-based speech, language, and hearing professionals are instrumental in the provision of rehabilitative, consultative, and support services for children with cochlear implants. This article reviews current candidacy requirements as well as factors that are considered when a child is evaluated for a cochlear implant. Following implantation, school professionals play a pivotal role in providing an appropriate educational program that should include auditory training and the integration of listening into the child's daily routine. The article presents procedures for maintaining and troubleshooting the device, and suggestions for establishing routines for device use and for improving the listening environment for children in classrooms.

Role of infant vocal development in candidacy for and efficacy of cochlear implantation.

Previous research has documented the importance of audition in the development of typical infant vocalization. Of particular interest is the development of canonical babbling, which is related to mastery of the timing elements of speech. Children with severe to profound hearing loss who use hearing aids have demonstrated both delayed and deviant canonical babbling. The vocal development of 12 children has been followed as they have been considered for cochlear implantation. Nine of these children have undergone implantation, and 5 of these children have been followed for more than 1 year after implantation. On average, canonical babbling emerged at 6.5 months after implantation. The time frame in which some children developed words was accelerated in terms of length of auditory experience as compared with normal-hearing peers. Mature oral-motor development is likely the primary contributing factor in this time course. One child who received a cochlear implant began to babble with hearing aids. It is not known whether normal canonical babbling is sufficient evidence on which to base candidacy decisions; however, our data suggest that children who produce canonical babbling maintain and build upon those skills after implantation.

Weight management and weight loss strategies of professional jockeys.

Jockeys are required to maintain very low body weight and precise weight control during competition. This study examined the weight loss and weight management strategies of professional horseracing jockeys in the state of Victoria, Australia. An anonymous, self-completed questionnaire was administered (55% response rate, n = 116). Almost half (43%) reported that maintaining riding weight was difficult or very difficult, with 75% routinely skipping meals. In preparation for racing, 60% reported that they typically required additional weight loss, with 81% restricting food intake in the 24 hours prior to racing. Additionally, sauna-induced sweating (29%) and diuretics (22%) were frequently employed to further aid in weight loss prior to racing. These rapid weight loss methods did not differ between the 51% of jockeys who followed a weight management plan compared to those who did not. The impact of these extreme weight loss practices on riding performance and health remains unknown.

Heterosexual Risk for HIV Among Puerto Rican Women: Does Power Influence Self-Protective Behavior?

Lack of power in relationships has been offered as an explanation for why women do not always engage in safer sex behavior with male partners. However, few studies have empirically tested the association between power and self-protective behavior. Causal modeling procedures were used to examine the interrelations of seven measures of power and to examine the effects of power on women's HIV-related communication and condom use with male partners. Power was measured by education, employment, decision making, perceived alternatives to the relationship, commitment to the relationship, investment in the relationship, and absence of abuse in the relationship. The sample comprised 187 Puerto Rican women, aged 18-35 years, attending a comprehensive health clinic in the Bronx, New York, who were at risk for heterosexual transmission of HIV. Women who were currently employed and those who were more committed to their relationships reported less HIV-related communication. Condom use was predicted by shorter length of the relationship, more education, current employment, less investment in the relationship, and more HIV-related communication.