Agreement between self-reported and physically verified male circumcision status in Nyanza region, Kenya: Evidence from the TASCO study.

BACKGROUND: Self-reported male circumcision (MC) status is widely used to estimate community prevalence of circumcision, although its accuracy varies in different settings depending on the extent of misreporting. Despite this challenge, self-reported MC status remains essential because it is the most feasible method of collecting MC status data in community surveys. Therefore, its accuracy is an important determinant of the reliability of MC prevalence estimates based on such surveys. We measured the concurrence between self-reported and physically verified MC status among men aged 25-39 years during a baseline household survey for a study to test strategies for enhancing MC uptake by older men in Nyanza region of Kenya. The objective was to determine the accuracy of self-reported MC status in communities where MC for HIV prevention is being rolled out. METHODS: Agreement between self-reported and physically verified MC status was measured among 4,232 men. A structured questionnaire was used to collect data on MC status followed by physical examination to verify the actual MC status whose outcome was recorded as fully circumcised (no foreskin), partially circumcised (foreskin is past corona sulcus but covers less than half of the glans) or uncircumcised (foreskin covers half or more of the glans). The sensitivity and specificity of self-reported MC status were calculated using physically verified MC status as the gold standard. RESULTS: Out of 4,232 men, 2,197 (51.9%) reported being circumcised, of whom 99.0% were confirmed to be fully circumcised on physical examination. Among 2,035 men who reported being uncircumcised, 93.7% (1,907/2,035) were confirmed uncircumcised on physical examination. Agreement between self-reported and physically verified MC status was almost perfect, kappa (k) = 98.6% (95% CI, 98.1%-99.1%. The sensitivity of self-reporting being circumcised was 99.6% (95% CI, 99.2-99.8) while specificity of self-reporting uncircumcised was 99.0% (95% CI, 98.4-99.4) and did not differ significantly by age group based on chi-square test. Rate of consenting to physical verification of MC status differed by client characteristics; unemployed men were more likely to consent to physical verification (odds ratio [OR] = 1.48, (95% CI, 1.30-1.69) compared to employed men and those with post-secondary education were less likely to consent to physical verification than those with primary education or less (odds ratio [OR] = 0.61, (95% CI, 0.51-0.74). CONCLUSIONS: In this Kenyan context, both sensitivity and specificity of self-reported MC status was high; therefore, MC prevalence estimates based on self-reported MC status should be deemed accurate and applicable for planning. However MC programs should assess accuracy of self-reported MC status periodically for any secular changes that may undermine its usefulness for estimating community MC prevalence in their unique settings.

Predictors of voluntary medical male circumcision prevalence among men aged 25-39 years in Nyanza region, Kenya: Results from the baseline survey of the TASCO study.

INTRODUCTION: Uptake of voluntary medical male circumcision (VMMC) as an intervention for prevention of HIV acquisition has been low among men aged ≥25 years in Nyanza region, western Kenya. We conducted a baseline survey of the prevalence and predictors of VMMC among men ages 25-39 years as part of the preparations for a cluster randomized controlled trial (cRCT) called the Target, Speed and Coverage (TASCO) Study. The TASCO Study aimed to assess the impact of two demand creation interventions-interpersonal communication (IPC) and dedicated service outlets (DSO), delivered separately and together (IPC + DSO)-on VMMC uptake. METHODS: As part of the preparatory work for implementation of the cRCT to evaluate tailored interventions to improve uptake of VMMC, we conducted a survey of men aged 25-39 years from a traditionally non-circumcising Kenyan ethnic community within non-contiguous locations selected as study sites. We determined their circumcision status, estimated the baseline circumcision prevalence and assessed predictors of being circumcised using univariate and multivariate logistic regression. RESULTS: A total of 5,639 men were enrolled of which 2,851 (50.6%) reported being circumcised. The odds of being circumcised were greater for men with secondary education (adjusted Odds Ratio (aOR) = 1.65; 95% CI: 1.45-1.86, p<0.001), post-secondary education (aOR = 1.72; 95% CI: 1.44-2.06, p <0.001), and those employed (aOR = 1.32; 95% CI: 1.18-1.47, p <0.001). However, the odds were lower for men with a history of being married (currently married, divorced, separated, or widowed). CONCLUSION: Among adult men in the rural Nyanza region of Kenya, men with post-primary education and employed were more likely to be circumcised. VMMC programs should focus on specific sub-groups of men, including those aged 25-39 years who are married, divorced/separated/ widowed, and of low socio-economic status (low education and unemployed).

Status of voluntary medical male circumcision in Kenya: findings from 2 nationally representative surveys in Kenya, 2007 and 2012.

BACKGROUND: The Kenyan Ministry of Health initiated a voluntary medical male circumcision (VMMC) program in 2008. We used data from 2 nationally representative surveys to estimate trends in the number, demographic characteristics, and sexual behaviors of recently circumcised and uncircumcised HIV-uninfected men in Kenya. METHODS: We compared the proportion of circumcised men between the first and second Kenya AIDS Indicator Survey (KAIS 2007 and KAIS 2012) to assess the progress of Kenya's VMMC program. We calculated the number of uncircumcised HIV-uninfected men. We conducted descriptive analyses and used multivariable methods to identify the variables independently associated with HIV-uninfected uncircumcised men aged 15-64 years in the VMMC priority region of Nyanza. RESULTS: The proportion of men who reported being circumcised increased significantly from 85.0% in 2007 to 91.2% in 2012. The proportions of circumcised men increased in all regions, with the highest increases of 18.1 and 9.0 percentage points in the VMMC priority regions of Nyanza and Nairobi, respectively. Half (52.5%) of HIV-uninfected and uncircumcised men had never been married, and 84.6% were not using condoms at all times with their last sexual partner. CONCLUSIONS: VMMC prevalence has increased across Kenya demonstrating the success of the national program. Despite this accomplishment, the Nyanza region remains below the target to circumcise 80% of all eligible men aged 15-49 years between 2009 and 2013. As new cohorts of young men enter into adolescence, consistent focus is needed. To ensure sustainability of the VMMC program, financial resources and coordinated planning must continue.

Sexual violence and associated factors among women in HIV discordant and concordant relationships in Uganda.

HIV serodiscordance is a sexual partnership in which one partner is infected with HIV while the other is not. Managing emotional and sexual intimacy in HIV serodiscordant unions can be difficult due to concerns about HIV transmission and the challenge of initiating and maintaining safe sex. In situations where couples are jointly aware of their HIV status, women in serodiscordant unions may face increased risk of partner violence. We conducted an investigation to assess risk factors for HIV serodiscordance and determine if HIV serodiscordance is associated with incident sexual violence among a cohort of women attending HIV post-test club services at three AIDS Information Centers (AICs) in Uganda. Using a prospective study of 250 women, we elicited information about sexual violence using structured face-to-face interviews. Sexual violence and risk factors were assessed and compared among HIV positive women in HIV discordant unions, HIV negative women in discordant unions, and HIV negative women in negative concordant unions. Multivariable logistic regression was used to assess the association between participants' serostatus and sexual violence. HIV negative women in serodiscordant relationships (36.1±11.1 years, range: 19-65 years) were significantly older than either HIV positive women in serodiscordant relationships (32.2±9.0 years, range: 18-56 years), or HIV negative women in concordant relationships (32.3±11.0 years, range: 18-62), (p=0.033). Early age at sexual debut was associated with a 2.4-fold increased risk of experiencing sexual violence (OR 2.4, 95% CI 1.27-4.65). Based on unadjusted analysis, HIV positive women in discordant relationship were at highest risk for sexual violence compared to HIV negative women in discordant unions, and HIV negative women in negative concordant unions. HIV negative women in discordant relationships and those in concordant negative relationships showed no increased risk for sexual violence. However, couples' HIV serostatus was not significant related to incident sexual violence after controlling for potential confounding covariates. Nevertheless, the results were able to elucidate the sexual violence risk factor profile of participants based on couples' HIV serostatus. Couple counseling protocols at HIV voluntary counseling and testing centers in Uganda should identify those at risk for sexual violence and develop interventions to reduce its incidence.

Experience of sexual violence among women in HIV discordant unions after voluntary HIV counselling and testing: a qualitative critical incident study in Uganda.

HIV-serodiscordant relationships are those in which one partner is infected with HIV while the other is not. We investigated experiences of sexual violence among women in HIV discordant unions attending HIV post-test club services in Uganda. A volunteer sample of 26 women from three AIDS Information Centres in Uganda who reported having experienced sexual violence in a larger epidemiological study were interviewed, using the qualitative critical incident technique. Data were analysed using TEXTPACK, a software application for computer-assisted content analysis. Incidents of sexual violence narrated by the women included use of physical force and verbal threats. Overall, four themes that characterise the women's experience of sexual violence emerged from the analysis: knowledge of HIV test results, prevalence of sexual violence, vulnerability and proprietary views and reactions to sexual violence. Alcohol abuse by the male partners was an important factor in the experience of sexual violence among the women. Their experiences evoked different reactions and feelings, including concern over the need to have children, fear of infection, desire to separate from their spouses/partners, helplessness, anger and suicidal tendencies. HIV counselling and testing centres should be supported with the capacity to address issues related to sexual violence for couples who are HIV discordant.

Interventions to increase children's booster seat use: a review.

BACKGROUND: In children aged 4 to 8 years, booster seats are estimated to reduce by 59% the odds of sustaining clinically significant injuries during a motor vehicle crash, compared to using ordinary vehicle seat belts. Given the safety benefits of booster seats, public health and traffic safety agencies recommend their use for children aged 4 to 8 years traveling in motor vehicles, until the vehicle seat belt can fit them properly. Despite these benefits, booster seat use remains low. Interventions aimed at promoting the use of booster seats for children aged 4 to 8 years have been implemented, but there is little evidence regarding their effects. METHODS: The Cochrane methodology was used to assess the effects of interventions to increase booster seat use for children aged 4 to 8 years. The reviewers searched online databases, scanned reference lists, hand-searched journals, and contacted relevant agencies and researchers for both randomized controlled trials and controlled before-and-after evaluation studies. The search concluded in 2005 and was not restricted by publication status or language. RESULTS: The search yielded 1350 potential studies. Of these, five studies involving 3070 individuals met the inclusion criteria. Interventions were generally effective in increasing booster seat use among children aged 4 to 8 years. Education paired with incentive or distribution programs produced more consistent results than education-only interventions that targeted parents, children, or both. CONCLUSIONS: Incentives or the distribution of free booster seats combined with education increase the use of booster seats.

Parity effect on preterm birth and growth outcomes among infants with isolated omphalocele.

OBJECTIVE: To assess the association between parity and fetal morbidity outcomes among omphalocele-affected fetuses. STUDY DESIGN: We carried out a retrospective study of 498 cases of isolated omphalocele (210 born to nulliparous and 288 to multiparous mothers) in New York State from 1983 through 1999. Infants of nulliparous mothers were compared to those of multiparous gravidas using adjusted odds ratios generated from a logistic regression. RESULTS: Omphalocele-affected fetuses of nulliparous mothers had a lower risk of being delivered preterm (odds ratio (OR)=0.49; 95% CI=0.27-0.90) but comparable risks for low birth weight (OR=1.01; 95% CI=0.60-1.72), very low birth weight (OR=0.33; 95% CI=0.09-1.20), very preterm birth (OR=0.42; 95% CI=0.15-1.16), and small size for gestational age (SGA) [OR=0.61; 95% CI=0.23-1.63]. CONCLUSION: Omphalocele-affected fetuses of multiparous mothers have double the risk for preterm birth compared to their nulliparous counterparts. This information is potentially useful in counseling parents whose fetuses have omphaloceles.

Gastroschisis, low maternal age, and fetal morbidity outcomes.

OBJECTIVE: To determine if the risk for fetal growth inhibition among gastroschisis-afflicted fetuses is heightened among younger gravidas (teen mothers). METHOD: This was a retrospective cohort study on live-born infants with isolated gastroschisis delivered in New York State from 1983 through 1999. We compared infants of mature (>20 years) mothers with those of younger (<20 years) mothers with respect to the following indices of fetal morbidity outcomes: low birth weight and very low birth weight, preterm and very pre-term, and small for gestational age. We used adjusted odds ratios to approximate relative risks. RESULTS: A total of 368 infants with isolated gastroschisis were analyzed. The two groups differed in terms of mean gestational age at delivery [Mean + standard deviation(SD) for infants with gastroschisis born to mature mothers = 37.2 weeks +/- 2.8 versus 36.3 weeks + 3.6 for those of teenage mothers(p = 0.01)], as well as mean birth weight [mean birth weight +/- SD for infants with gastroschisis born to mature mothers = 2562.4 grams +548.8 versus 2367.9 grams +/- 645.2 for those of younger mothers (p = 0.004)]. Infants of teen mothers were about twice as likely to be of low birth weight (OR = 1.70; 95% CI = 1.05-2.77) and about three times as likely to be born very preterm when compared to those of mature mothers (OR = 2.80; 95% Cl = 1.02-8.00). No significant differences were observed with respect to very low birth weight, pre-term and small for gestational age. CONCLUSION: Low maternal age appears to be a risk factor for low birth weight and very preterm birth among gastroschisis-affected fetuses. This information is potentially useful for planning by care providers and in counseling affected parents.

Survival of "pre-viable" infants in the United States.

OBJECTIVE: We investigated temporal trend in survival of pre-viable (200-499 g) fetuses over the previous decade, and estimated future survival rates based on previous and current survival thresholds. DESIGN, SETTING AND PARTICIPANTS: This was a retrospective cohort study on live-born pre-viable fetuses (200-499 g) in the United States comparing two period cohorts; 1985-1988 versus 1995-1999. We computed survival of pre-viable babies (who were still alive at 24 hours) during the two periods and based on these results, we estimated future survival rates for the coming decades. MAIN OUTCOMES: Survival beyond the neonatal period. RESULTS: About 35 million live births were analyzed for the two periods. In the first period (1985-1988), 927 live births among pre-viable fetuses were recorded while in the second period (1995-1999) 2585 were counted, equivalent to a birth rate of 60.6 and 131.9 per million live births respectively. This corresponds to an increase of more than 100% across the decade (p for trend < 0.0001). Survival improved by about 50% across the period, from 12.0% to 17.4% (p < 0.0001). Based on these results, the survival rate among pre-viable fetuses will be expected to rise to about 24.0% within the next 6 years (2010). CONCLUSIONS: Survival among pre-viable fetuses is increasing in the United States. This raises ethical, legal and medical issues concerning the defined viability status of these babies, which is currently described as "non-viable".

Perinatal mortality in the normal siblings of anomalous triplets.

OBJECTIVE: To estimate the risk of survival of unaffected cofetuses of anomalous triplets. METHODS: Retrospective cohort study of triplets delivered in the United States from 1995 through 1998. Four triplet clusters were identified: cluster A (all members anomaly-free); cluster B (1 anomalous member); cluster C (2 anomalous members), and cluster D (all 3 members anomalous). We compared the risk for stillbirth and infant mortality among nonanomalous fetuses in clusters A, B, and C after adjusting for intracluster correlations. RESULTS: A total of 7,560 triplet clusters (98.9%) were analyzed after excluding cluster D (1.1%). The total stillbirth rate was 20.9 (cluster A), 61.0 (cluster B), and 81.1 (cluster C) per 1,000 (P for trend < .001), and infant mortality rate was 56.4 (cluster A), 108.8 (cluster B), and 196.1 (cluster C) per 1,000 (P for trend < .001). Using cluster A as the referent category, the risk for stillbirth among anomaly-free clustermates climbed with increase in the number of siblings with anomalies in a dose-response pattern (adjusted odds ratio, 95% confidence interval 1.5, 0.7-3.1, for cluster B; and 5.2, 1.4-18.8, for cluster C; P for trend = .03). For infant mortality, the only rise in risk was in cluster C (3.3, 1.6-6.7), whereas cluster B showed comparable risk with the referent category (0.8, 0.5-1.4; P for trend > .05). CONCLUSION: The presence of anomalous fetuses compromises the survival of normal cotriplets. These findings could prove useful for counseling affected parents and highlight the need for follow-up of normal coinfants of anomalous fetuses.

Omphalocele, advanced maternal age, and fetal morbidity outcomes.

In this study we wanted to determine if the risk for adverse neonatal outcome among omphalocele-affected fetuses is increased among older gravidas. This was a retrospective cohort study on live-born infants with omphalocele delivered in New York State from 1983 through 1999. We compared infants of older (>or=35 years) with those of younger (<35 years) mothers with respect to the following fetal morbidity indices: low birth weight and very low birth weight, preterm and very preterm, and small for gestational age. We used adjusted odds ratios to approximate relative risks. Data on a total of 1,010 infants with omphalocele were analyzed. Mean gestational age and birth weight were similar in both maternal age categories: mean+/-standard deviation (SD) for infants with omphalocele born to older mothers=37.4 weeks+/-3.9 versus 38.0 weeks+/-5.1 for those of younger mothers (P=0.2); mean birth weights+/-SD for infants with omphalocele born to older mothers=2,813+/-871.1 versus 2,958+/-809.9 for those of younger mothers (P=0.08). Also, the two maternal age sub-groups did not differ with respect to the fetal morbidity outcome: low birth weight (OR=0.95; 95% CI=0.60-1.51), very low birth weight (OR=0.78; 95% CI=0.36-1.69), preterm (OR=0.95; 95% CI=0.58-1.57), very preterm (OR=0.73; 95% CI=0.34-1.58), and SGA (OR=1.00; 95% CI=0.44-2.27). Thus, advanced maternal age does not appear to be a risk factor for fetal morbidity outcomes among omphalocele-affected fetuses. This information is potentially useful in counseling affected parents.

Mode of delivery and neonatal survival of infants with isolated gastroschisis.

OBJECTIVE: We sought to compare neonatal survival of infants with gastroschisis by mode of delivery. METHODS: We conducted a retrospective cohort study on infants with gastroschisis who were delivered in New York State from 1983 through 1999. We compared neonatal mortality between infants born vaginally and those delivered by cesarean using adjusted hazard ratios derived from Cox proportional hazards regression models. RESULTS: A total of 354 infants were found to have isolated gastroschisis. Of these, 174 were delivered vaginally, whereas 180 were delivered by cesarean. Neonatal mortality was registered among 18 infants (5.1%); 12 (6.9%) in the vaginal and 6 (3.3%) in the cesarean group. After controlling for potential confounders, the risk for neonatal demise was similar in both the vaginal and cesarean subcohorts (adjusted hazard ratio 0.84, 95% confidence interval [CI] 0.29-2.43). Preterm birth was the morbidity pathway that explained the early demise of infants with gastroschisis, irrespective of mode of delivery (adjusted hazard ratio 3.4, 95% CI 1.10-10.4) whereas small for gestational age did not predict mortality (adjusted hazard ratio 1.04, 95% CI 0.13-8.14). CONCLUSION: In this study the mode of delivery was not found to be associated with neonatal survival of infants with gastroschisis. Preterm birth rather than small for gestational age was the predictor of neonatal death among gastroschisis infants. LEVEL OF EVIDENCE: III

Low maternal age and neonatal survival of extremely preterm twins (20-28 weeks of gestation).

OBJECTIVE: We investigated the relationship between low maternal age and neonatal survival among extremely preterm twins. METHODS: This was a retrospective cohort study on live births of extremely preterm twins delivered to teenaged mothers (aged 15-19 years) in the United States within the period 1995 through 1998. Overall neonatal and early and late neonatal mortality in this category was compared with that of a similar group of twins born to young adult mothers (aged 20-29 years). We used the generalized estimating equation framework in computing relative risks after adjusting for intracluster correlations. RESULTS: Analysis involved 2,290 extremely preterm liveborn twins of teenaged mothers and 8,709 born to young adult mothers. Overall, neonatal mortality was 29% higher among the extremely preterm twins born to teenaged mothers (adjusted odds ratio [OR] 1.29; 95% confidence interval [CI] 1.04%, 1.59%). The disparity in neonatal survival was chiefly in the early neonatal period (adjusted OR 1.34; 95% CI 1.07%, 1.67%), while late neonatal mortality was comparable (adjusted OR 0.91; 95% CI 0.58%, 1.42%). In addition, twins of teenaged mothers had significantly higher level of mortality, except for the birth weight category of 1,000-1,499 g. CONCLUSION: Low maternal age was found to be associated with elevated risk of neonatal death among extremely preterm twins. The preponderance of deaths among extremely preterm twins of teenaged mothers in the early neonatal period appeared to be responsible for the disparity in survival. This information may be useful for targeted interventions aimed at enhancing survival of extremely preterm twins born to teenagers, as well as for instituting optimal management options in the clinical setting. LEVEL OF EVIDENCE: II-2