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1.
BMC Public Health ; 20(1): 211, 2020 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-32046686

RESUMO

BACKGROUND: Voluntary Medical Male Circumcision (VMMC) is one of the strategies being promoted to prevent sexual heterosexual transmission of HIV. It has been adopted by 14 countries with high HIV prevalence and low circumcision rates. The 60.0% protective efficacy of VMMC has come with misconceptions in some societies in Malawi, hence VMMC clients may opt for risky sexual practices owing to its perceived protective effect. The study estimated proportion of circumcised men engaging in risky sexual behaviors post-VMMC, assessed knowledge on VMMC protective effect and identified socio-demographic factors associated with risky sexual practices. METHOD: A cross sectional study was conducted at two sites of Mzuzu city. Systematic random sampling was used to select 322 participants aged 18-49 who had undergone VMMC. The independent variables included age, location, occupation, religion, marital status and education. Outcome variables were non condom use, having multiple sexual partners and engaging in transactional sex. Data from questionnaires was analyzed using Pearson's chi square test and logistic regression. RESULTS: Out of 322 respondents, 84.8% (273) understood the partial protection offered by VMMC in HIV prevention. Ninety-six percent of the participants self-reported continued use of condoms post VMMC. Overall 23.7-38.3% participants self-reported engaging in risky sexual practices post VMMC, 23.7% (76) had more than one sexual partner; 29.2% (94) paid for sex while 39.9% (n = 187) did not use a condom. Residing in high density areas was associated with non-condom use, (p = 0.043). Being single (p < 0.001), and residing in low density areas (p = 0.004) was associated with engaging in transactional sex. CONCLUSION: Risky sexual practices are evident among participants that have undergone VMMC. Messages on safer sexual practices and limitations of VMMC need to be emphasized to clients, especially unmarried or single and those residing in low density areas.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Assunção de Riscos , Comportamento Sexual/psicologia , Comportamento Sexual/estatística & dados numéricos , Programas Voluntários , Adolescente , Adulto , Preservativos/estatística & dados numéricos , Estudos Transversais , Infecções por HIV/epidemiologia , Humanos , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Autorrelato , Trabalho Sexual/estatística & dados numéricos , Parceiros Sexuais , Fatores Socioeconômicos , Inquéritos e Questionários , Adulto Jovem
2.
PLoS One ; 14(11): e0224548, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31682626

RESUMO

INTRODUCTION: Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President's Emergency Plan for AIDS Relief's (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. METHODS AND RESULTS: The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including "mobilizers", HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. CONCLUSION: Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Implementação de Plano de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde , Programas Voluntários/estatística & dados numéricos , Adolescente , Adulto , Circuncisão Masculina/normas , Feminino , Infecções por HIV/epidemiologia , Implementação de Plano de Saúde/organização & administração , Implementação de Plano de Saúde/normas , Humanos , Cooperação Internacional , Quênia/epidemiologia , Masculino , Prevalência , Participação dos Interessados , Padrão de Cuidado , Fatores de Tempo , Programas Voluntários/organização & administração , Programas Voluntários/normas , Carga de Trabalho/estatística & dados numéricos
3.
PLoS One ; 14(10): e0222180, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31581192

RESUMO

INTRODUCTION: Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission-the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. METHODS: We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. RESULTS: Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. CONCLUSIONS: No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Circuncisão Masculina/normas , África ao Sul do Saara/epidemiologia , Circuncisão Masculina/economia , Assistência à Saúde , Infecções por HIV/economia , Instalações de Saúde , Serviços de Saúde/normas , Humanos , Masculino
4.
PLoS One ; 14(9): e0222942, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31557208

RESUMO

INTRODUCTION: Since 2011, Kenya has been evaluating ShangRing device for use in its voluntary medical male circumcision (VMMC) program according to World Health Organization (WHO) guidelines. Compared to conventional surgical circumcision, the ShangRing procedure is shorter, does not require suturing and gives better cosmetic outcomes. After a pilot evaluation of ShangRing in 2011, Kenya conducted an active surveillance for adverse events associated with its use from 2016-2018 to further assess its safety, uptake and to identify any operational bottlenecks to its widespread use based on data from a larger pool of procedures in routine health care settings. METHODS: From December 2017 to August 2018, HIV-negative VMMC clients aged 13 years or older seeking VMMC at six sites across five counties in Kenya were offered ShangRing under injectable local anesthetic as an alternative to conventional surgical circumcision. Providers described both procedures to clients before letting them make a choice. Outcome measures recorded for clients who chose ShangRing included the proportions who were clinically eligible, had successful device placement, experienced adverse events (AEs), or failed to return for device removal. Clients failing to return for follow up were sought through phone calls, text messages or home visits to ensure removal and complete information on adverse events. RESULTS: Out of 3,692 eligible clients 1,079 (29.2%) chose ShangRing; of these, 11 (1.0%) were excluded due to ongoing clinical conditions, 17 (1.6%) underwent conventional surgery due to lack of appropriate device size at the time of the procedure, 97.3% (1051/1079) had ShangRing placement. Uptake of ShangRing varied from 11% to 97% across different sites. There was one severe AE, a failed ShangRing placement (0.1%) managed by conventional wound suturing, plus two moderate AEs (0.2%), post removal wound dehiscence and bleeding, that resolved without sequelae. The overall AE rate was 0.3%. All clients returned for device removal from fifth to eleventh day after placement. CONCLUSION: ShangRing circumcision is effective and safe in the Kenyan context but its uptake varies widely in different settings. It should be rolled out under programmatic implementation for eligible males to take advantage of its unique benefits and the freedom of choice beyond conventional surgical MMC. Public education on its availability and unique advantages is necessary to optimize its uptake and to actualize the benefit of its inclusion in VMMC programs.


Assuntos
Circuncisão Masculina/instrumentação , Monitoramento Epidemiológico , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Programas Voluntários/estatística & dados numéricos , Adolescente , Adulto , Circuncisão Masculina/efeitos adversos , Circuncisão Masculina/métodos , Circuncisão Masculina/estatística & dados numéricos , Humanos , Quênia/epidemiologia , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Adulto Jovem
5.
Ir Med J ; 112(7): 965, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31553146

RESUMO

Aim We aim to determine if the release of preputial adhesions (RPA) successfully managed symptoms related to physiological phimosis and prevented the need for circumcision. Methods We performed a retrospective review and analysed data on RPA procedures performed between January 2005 and December 2017. Results 534 RPA's were performed. Median age at RPA was 52.7 months (range: 3-197 months). Mean follow-up was 108 months (range: 4.7 to 152.4 months). 44 children and 1 child subsequently required a circumcision or preputioplasty respectively (8.4% incidence). There was no statistical difference in the circumcision rates in children who had RPA over 5 years vs those that had RPA under 5 years old (6.6% vs 9.8%; p = 0.21). The histology of the 44 excised foreskins showed BXO in 2 (4.5%) and chronic inflammation in 11 (25%). Conclusion RPA is an effective alternative to circumcision where either reassurance on the benign and self-limiting nature of physiologic phimosis or steroid treatment are unsuccessful in managing symptoms.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Fimose/cirurgia , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Masculino , Estudos Retrospectivos
6.
PLoS One ; 14(8): e0218066, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31412032

RESUMO

BACKGROUND: The ShangRing is a disposable, collar clamp circumcision device pre-qualified for use in men and boys 13 years and above. It has been shown to be faster than conventional circumcision with comparable adverse event (AE) rates and high client satisfaction. Voluntary medical male circumcision (VMMC) has been shown to dramatically reduce the risk of HIV acquisition in males. However, the fear of pain during circumcision is an important barrier to uptake. Use of topical anesthesia thus presents an opportunity to address this. OBJECTIVES: We sought to evaluate the safety, effectiveness and acceptability of the use of topical anaesthesia with ShangRing circumcision of men and boys 10 years of age and above. METHODS: Participants were randomised 2:1 to receive topical or injectable anaesthesia. All participants underwent no-flip ShangRing circumcision. The primary outcome measure was pain. Secondary outcomes included ease of use of topical versus injectable anaesthesia, AEs and participant satisfaction. RESULTS: Compared to the topical group, participants in the injectable group reported significantly more pain on administration of the anesthesia and at approximately 20 minutes after the procedure. In the topical group, sufficient anaesthesia with topical cream was not achieved in 21 (9.3%) cases before the start of the procedure; in another 6 (2.6%), supplementary injectable anaesthesia was required as the circumcision was being carried out. The AE rate was significantly lower (p<0.01) in the topical (0%) vs. the injectable group (4.2%). The most common AE was pain during the post-operative period. All AEs were managed conservatively and resolved without sequeale. 96.7% of participants were satisfied with the appearance of the healed penis and 100% would recommend the ShangRing to others. All seven male circumcision providers involved in the study preferred topical to injectable anaesthesia. CONCLUSIONS: Our results demonstrate the safety, improved clinical experience, effectiveness, and acceptability of the use of topical anaesthesia in ShangRing circumcision using the no-flip technique. Topical anaesthesia effectively eliminates needlestick pain from the clients' VMMC experience and thus has the potential to increase demand for the service. TRIAL REGISTRATION: ClinicalTrials.gov NCT02390310.


Assuntos
Anestesia Intravenosa/métodos , Anestésicos/administração & dosagem , Circuncisão Masculina/métodos , Circuncisão Masculina/estatística & dados numéricos , Administração Tópica , Adolescente , Adulto , Criança , Humanos , Masculino , Medição da Dor , Adulto Jovem
7.
AIDS Behav ; 23(9): 2453-2466, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31321636

RESUMO

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 , Doenças Sexualmente Transmissíveis/prevenção & controle , Adolescente , Adulto , China , Circuncisão Masculina/etnologia , Circuncisão Masculina/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
8.
N Engl J Med ; 381(3): 230-242, 2019 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-31314967

RESUMO

BACKGROUND: The feasibility of reducing the population-level incidence of human immunodeficiency virus (HIV) infection by increasing community coverage of antiretroviral therapy (ART) and male circumcision is unknown. METHODS: We conducted a pair-matched, community-randomized trial in 30 rural or periurban communities in Botswana from 2013 to 2018. Participants in 15 villages in the intervention group received HIV testing and counseling, linkage to care, ART (started at a higher CD4 count than in standard care), and increased access to male circumcision services. The standard-care group also consisted of 15 villages. Universal ART became available in both groups in mid-2016. We enrolled a random sample of participants from approximately 20% of households in each community and measured the incidence of HIV infection through testing performed approximately once per year. The prespecified primary analysis was a permutation test of HIV incidence ratios. Pair-stratified Cox models were used to calculate 95% confidence intervals. RESULTS: Of 12,610 enrollees (81% of eligible household members), 29% were HIV-positive. Of the 8974 HIV-negative persons (4487 per group), 95% were retested for HIV infection over a median of 29 months. A total of 57 participants in the intervention group and 90 participants in the standard-care group acquired HIV infection (annualized HIV incidence, 0.59% and 0.92%, respectively). The unadjusted HIV incidence ratio in the intervention group as compared with the standard-care group was 0.69 (P = 0.09) by permutation test (95% confidence interval [CI], 0.46 to 0.90 by pair-stratified Cox model). An end-of-trial survey in six communities (three per group) showed a significantly greater increase in the percentage of HIV-positive participants with an HIV-1 RNA level of 400 copies per milliliter or less in the intervention group (18 percentage points, from 70% to 88%) than in the standard-care group (8 percentage points, from 75% to 83%) (relative risk, 1.12; 95% CI, 1.09 to 1.16). The percentage of men who underwent circumcision increased by 10 percentage points in the intervention group and 2 percentage points in the standard-care group (relative risk, 1.26; 95% CI, 1.17 to 1.35). CONCLUSIONS: Expanded HIV testing, linkage to care, and ART coverage were associated with increased population viral suppression. (Funded by the President's Emergency Plan for AIDS Relief and others; Ya Tsie ClinicalTrials.gov number, NCT01965470.).


Assuntos
Antirretrovirais/uso terapêutico , Circuncisão Masculina , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Programas de Rastreamento , Adolescente , Adulto , Botsuana/epidemiologia , Circuncisão Masculina/estatística & dados numéricos , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Humanos , Incidência , Masculino , Administração Massiva de Medicamentos , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , População Rural , Fatores Socioeconômicos , Carga Viral , Adulto Jovem
9.
AIDS Behav ; 23(Suppl 2): 195-205, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31214866

RESUMO

Voluntary Medical Male circumcision (VMMC) has been part of prevention in Namibia since 2009. Yet, as of 2013, VMMC coverage among 15- to 24-year-olds was estimated at less than 22%. Program data suggests uptake of VMMC below age 15 is lower than expected, given the age distribution of the eligible population. Nearly 85% of VMMCs were for males between ages 15 and 29, while boys 10-14 years were referred outside the program. This analysis uses the Decision Makers Program Planning Tool to understand the impact of age prioritization on circumcision in Namibia. Results indicate that circumcising males aged 20-29 reduced HIV incidence most rapidly, while focusing on ages 15-24 was more cost effective and produced greater magnitude of impact. Providing services to those under 15 could increase VMMC volume 67% while introducing Early Infant Medical Circumcision could expand coverage. This exercise supported a review of VMMC strategies and implementation, with Namibia increasing coverage among 10- to 14-year-olds nearly 20 times from 2016 to 2017.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Programas Voluntários/organização & administração , Adolescente , Adulto , Distribuição por Idade , Fatores Etários , Criança , Circuncisão Masculina/economia , Análise Custo-Benefício , Tomada de Decisões , Infecções por HIV/epidemiologia , Humanos , Incidência , Masculino , Namíbia/epidemiologia , Avaliação de Programas e Projetos de Saúde , Programas Voluntários/economia , Adulto Jovem
10.
Pediatr. aten. prim ; 21(82): e41-e45, abr.-jun. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-184585

RESUMO

Introducción: la realización de la circuncisión por motivos culturales o religiosos es una práctica cuya indicación no está bien definida dentro de nuestra práctica médica. El objetivo de nuestro trabajo es mostrar la diversidad de su práctica en España a fin de establecer un protocolo de actuación general con respecto a este tema. Material y métodos: se ha realizado una encuesta nacional en 49 centros públicos con disponibilidad de servicio de cirugía pediátrica, en la que se recogen datos epidemiológicos, descriptivos y de opinión tanto colectiva como del personal médico sobre las derivaciones recibidas para hacer circuncisión. Resultados: se enviaron 200 encuestas, de las que se obtuvieron un total de 142 respuestas, el 76,6% de los facultativos no realizan circuncisiones por motivo religioso en el ámbito público. El 89% de los pacientes vistos en consulta son derivados por su pediatra. Hasta el 65% de los médicos afirman que han tenido algún conflicto con la familia del paciente cuando rechazan la indicación de la circuncisión por esta razón. De los profesionales que aceptan la intervención, el 39% lo hace para evitar la cirugía en peores condiciones fuera del hospital. El 57% de los cirujanos desconoce si esta indicación está incluida en la cartera de servicios del Sistema Nacional de Salud. Conclusiones: en base a nuestra encuesta, la mayoría de los profesionales desconoce si esta indicación está dentro de la cartera de servicios y coinciden en la necesidad de tener un consenso de actuación. Es importante tener una actitud conjunta, conocer todas las opiniones, y crear un protocolo de manejo de esta situación


Introduction: the performance circumcision for cultural or religious reasons is a practice whose indication is not well defined within the scope of medical practice in Spain. The objective of this study was to illustrate the variability in its practice in Spain with the purpose of eventually establishing a general protocol on the subject. Material and methods: we conducted a nationwide survey of public hospitals with a paediatric surgery department to collect epidemiological and descriptive data and opinions, both general and from individual medical providers, on the referrals received for performance of circumcision. Results: we submitted 200 questionnaires and received 142 responses, and 76.6% of the responding physicians reported not performing circumcisions for religious reasons in their practice in the public health system. Of all patients seen for a consultation, 89% had been referred by their paediatricians. Up to 65% of doctors reported having conflict with families when they refused to perform circumcision for this indication. Of the professionals who agreed on religious reasons as an indication, 39% performed the surgery to prevent its being performed under poorer conditions outside a hospital. Of all paediatric surgeons, 57% did not know whether this indication is included among the services covered by the National Health System. Conclusions: based on our survey, most professionals do not know whether this indication is included in the services covered by the public health system and agree on the need of establishing a consensus guideline. We believe that it is important to have a homogeneous approach, to explore the opinions of the professional collective as a whole and to develop a general protocol for approaching this situation


Assuntos
Humanos , Masculino , Lactente , Circuncisão Masculina/estatística & dados numéricos , Religião e Medicina , Recusa Consciente em Tratar-se/estatística & dados numéricos , Fimose/cirurgia , Assistência à Saúde/tendências , Circuncisão Masculina/etnologia , Conhecimentos, Atitudes e Prática em Saúde , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos
11.
PLoS One ; 14(3): e0210719, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30917121

RESUMO

OBJECTIVE: We assessed feasibility of an HIV-combination-prevention trial among fishing communities in Uganda. DESIGN: Cluster randomised trial in four fishing communities on Lake Victoria, Uganda. Two intervention communities received a combination-prevention-package (behaviour change communication, condom promotion, HIV testing, voluntary male medical circumcision and referral for anti-retroviral therapy if HIV-positive). All four communities received routine government HIV care services. METHODS: Using household census data we randomly selected a cohort of consenting residents aged ≥18 years. A baseline sero-survey in July 2014 was followed by two repeat surveys in March and December 2015. We measured uptake of HIV prevention methods, loss-to-follow-up and HIV incidence, accounting for multistage survey design. RESULTS: A total of 862 participants were enrolled and followed for 15 months. Participation was 62% and 74% in the control and intervention arms respectively; Overall loss to follow up (LTFU) was 21.6% and was similar by arm. Self-reported abstinence/faithfulness increased between baseline and endline in both arms from 53% to 73% in the control arm, and 55% to 67% in the intervention arm. Reported condom use throughout the study period was 36% in the intervention arm vs 28% in the control arm; number of male participants reporting circumsicion in both arms from 58% to 79% in the intervention arm, and 39% to 46% in the control arm. Independent baseline predictors of loss-to-follow-up were: being HIV positive, residence in the community for <1 year, younger age, living in an urban area, and being away from the area for >1 month/year. CONCLUSIONS: Recruitment and retention of participants in longitudinal trials in highly mobile HIV fishing communities is challenging. Future research should investigate modes for locating and retaining participants, and delivery of HIV-combination prevention.


Assuntos
Infecções por HIV/prevenção & controle , Promoção da Saúde/métodos , Adulto , Circuncisão Masculina/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Infecções por HIV/epidemiologia , Comportamentos Relacionados com a Saúde , Humanos , Incidência , Perda de Seguimento , Masculino , Projetos Piloto , Saúde da População Rural , Uganda/epidemiologia , Adulto Jovem
12.
PLoS One ; 14(3): e0213605, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30883583

RESUMO

BACKGROUND: Modeling contributes to health program planning by allowing users to estimate future outcomes that are otherwise difficult to evaluate. However, modeling results are often not easily translated into practical policies. This paper examines the barriers and enabling factors that can allow models to better inform health decision-making. DESCRIPTION: The Decision Makers' Program Planning Tool (DMPPT) and its successor, DMPPT 2, are illustrative examples of modeling tools that have been used to inform health policy. Their use underpinned Voluntary Medical Male Circumcision (VMMC) scale-up for HIV prevention in southern and eastern Africa. Both examine the impact and cost-effectiveness of VMMC scale-up, with DMPPT used initially in global advocacy and DMPPT 2 then providing VMMC coverage estimates by client age and subnational region for use in country-specific program planning. Their application involved three essential steps: identifying and engaging a wide array of stakeholders from the outset, reaching consensus on key assumptions and analysis plans, and convening data validation meetings with critical stakeholders. The subsequent DMPPT 2 Online is a user-friendly tool for in-country modeling analyses and continuous program planning and monitoring. LESSONS LEARNED: Through three iterations of the DMPPT applied to VMMC, a comprehensive framework with six steps was identified: (1) identify a champion, (2) engage stakeholders early and often, (3) encourage consensus, (4) customize analyses, (5), build capacity, and (6) establish a plan for sustainability. This framework could be successfully adapted to other HIV prevention programs to translate modeling results to policy and programming. CONCLUSIONS: Models can be used to mobilize support, strategically plan, and monitor key programmatic elements, but they can also help inform policy environments in which programs are conceptualized and implemented to achieve results. The ways in which modeling has informed VMMC programs and policy may be applicable to an array of other health interventions.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Sistemas de Apoio a Decisões Clínicas , Infecções por HIV/prevenção & controle , Política de Saúde , Programas Nacionais de Saúde , Programas Voluntários , Adolescente , Adulto , África Oriental , África Austral , Criança , Circuncisão Masculina/economia , Análise Custo-Benefício , Tomada de Decisões , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Projetos de Pesquisa , Adulto Jovem
13.
Int J STD AIDS ; 30(7): 630-638, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30890118

RESUMO

Voluntary medical male circumcision (VMMC) among men who have sex with men (MSM) may protect against HIV acquisition. We conducted a series of analyses to assess if expanded VMMC might reduce HIV incidence among MSM effectively and economically. We used a deterministic compartmental model to project new HIV cases (2016-2026) under annual VMMC coverage rates (λ) ranging from 0.0001 to 0.15. The 'number needed to avert' (NNA) is defined as the cumulative number of VMMCs conducted up to that year divided by the cumulative number of HIV cases averted in that specific year. Compared with the baseline circumcision coverage rate, we projected that new HIV cases would be reduced with increasing coverage. By 2026 (last year simulated), the model generated the lowest ratio (11.10) when the annual circumcision rate was the most optimistic (λ = 0.15). The breakeven point was observed at the year of 2019 with the annual VMMC coverage rate of 0.001. The total cost saved by averting HIV cases would range from 2.5 to 811 million US dollars by the end of 2026 with different hypothetical coverage rates. Our model suggests that acceleration in VMMC implementation among MSM could help stem the HIV/AIDS epidemic.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Custos e Análise de Custo/economia , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Homossexualidade Masculina/estatística & dados numéricos , Programas Voluntários , Adolescente , Adulto , Pequim/epidemiologia , Circuncisão Masculina/economia , Infecções por HIV/economia , Humanos , Incidência , Masculino
14.
Urology ; 127: 97-101, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30817958

RESUMO

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%, P = 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 Unidos
15.
PLoS One ; 14(2): e0211958, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30794561

RESUMO

BACKGROUND: The voluntary medical male circumcision (VMMC) program in Mozambique aimed to increase male circumcision (MC) coverage to 80 percent among males ages 10 to 49 by 2018. Given the difficulty in attracting adult men over age 20 for circumcision, Mozambique became interested in assessing its age-targeting strategy and progress at the provincial level to inform program planning. METHODS: We examined the impact and cost-effectiveness of circumcising different age groups of men using the Decision Makers' Program Planning Toolkit, Version 2.1 (DMPPT 2). We also applied the model to assess the scale-up efforts through the end of September 2017 and project their impact on HIV incidence through 2030. The DMPPT 2 is a compartmental Excel-based model that analyzes the effects of age at circumcision on program impact and cost-effectiveness. The model tracks changes in age-specific MC coverage due to VMMC program circumcisions. Baseline MC prevalence was based on data from the 2011 Demographic and Health Survey. The DMPPT 2 was populated with HIV incidence projections from Spectrum/Goals under an assumption that Mozambique would reach its national targets for HIV treatment and prevention by 2022. RESULTS: We estimate the VMMC program increased MC coverage among males ages 10 to 49 from 27 percent in 2009 to 48 percent by end of September 2017. Coverage increased primarily in males ages 10 to 29. VMMCs conducted in the national program through the end of September 2017 are projected to avert 67,076 HIV infections from 2010 to 2030. Scaling up circumcisions in males ages 20 to 29 will have the most immediate impact on HIV incidence, while the greatest impact over a 15-year period is obtained by circumcising males ages 15 to 24 in the majority of priority provinces. Circumcising 80 percent of males ages 10 to 29 can achieve 77 percent of the impact through 2030 compared with circumcising 80 percent of males ages 10 to 49. CONCLUSION: The VMMC program in Mozambique has made great strides in increasing MC coverage, particularly for males ages 10 to 29. Scaling up and maintaining MC coverage in this age group offers an attainable and cost-effective target for VMMC in Mozambique.


Assuntos
Circuncisão Masculina/economia , Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Adolescente , Adulto , Distribuição por Idade , Criança , Análise Custo-Benefício , Programas Governamentais , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Moçambique/epidemiologia , Programas Voluntários , Adulto Jovem
16.
AIDS Behav ; 23(5): 1095-1103, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30737610

RESUMO

Increased coverage of voluntary medical male circumcision (VMMC) is needed in countries with high HIV prevalence. We applied an HIV-prevention cascade to identify gaps in male circumcision coverage in Zambia. We used survey data collected in 2013 and 2014/15 to describe circumcision coverage at each time-point, and prevalence of variables related to demand for and supply of VMMC. We explored whether circumcision coverage in 2014/15 was associated with demand and supply among uncircumcised men in 2013. Results show that circumcision coverage was 11.5% in 2013 and 18.0% in 2014/15. Levels of having heard of circumcision and agreeing with prevention benefits was similar at both time-points (79.8% vs 83.2%, and 49.7% vs 50.7%, respectively). In 2013, 39.3% of men perceived services to be available compared to 54.7% in 2014/15. Levels of having heard of circumcision in 2013 was correlated with and higher perceived service availability associated with coverage in 2014/15. VMMC coverage was low in these study sites. Knowledge of prevention tools and of service availability are necessary to increase coverage but alone are insufficient.


Assuntos
Circuncisão Masculina , Assistência à Saúde/organização & administração , Infecções por HIV/prevenção & controle , Serviços Preventivos de Saúde/organização & administração , Adolescente , Adulto , Circuncisão Masculina/estatística & dados numéricos , Análise por Conglomerados , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , População Rural , Programas Voluntários , Adulto Jovem , Zâmbia/epidemiologia
17.
PLoS One ; 14(1): e0210480, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30682057

RESUMO

INTRODUCTION: Voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men and has long-term indirect protection for women, yet VMMC uptake in South Africa remains low (49.8%) in men (25-49 years). We explored the attitude and willingness of women to start conversations on VMMC with their sexual partners in a South African peri-urban setting to increase VMMC uptake. METHODS: Thirty women with median age of 30 years (inter-quartile range 26-33 years) were interviewed in a language of their choice. Key questions included: types of approach to use, gender roles, benefits and barriers to introducing the topic of VMMC, and perceptions of VMMC. Interviews were digitally-recorded, transcribed, and translated. Through a standard iterative process, a codebook was developed (QSR NVIVO 10 software) and inductive thematic analysis applied. RESULTS: Most women were willing talk to their sexual partners about circumcision, but indicated that the decision to circumcise remained that of their sexual partner. Women felt that they should encourage their partners, show more interest in circumcision, be patient, speak in a caring and respectful tone, choose a correct time when their partner was relaxed and talk in a private space about VMMC. Using magazine/newspaper articles, pamphlets or advertisements were identified as tools that could aid their discussion. Substantial barriers to initiating conversations on VMMC included accusations by partner on infidelity, fear of gender-based violence, cultural restrictions and hesitation to speak to a mature partner about circumcision. CONCLUSIONS: Women need to ensure that before talking to their partner about circumcision, the environment and approach that they use are conducive. Female social network forums could be used to educate women on conversation techniques, skills to use when talking to their partners and how to address communication challenges about circumcision. Involvement of women in VMMC awareness campaigns could encourage circumcision uptake among men.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Comunicação , Tomada de Decisões , Infecções por HIV/prevenção & controle , Parceiros Sexuais , População Suburbana/estatística & dados numéricos , Adulto , Circuncisão Masculina/métodos , Circuncisão Masculina/psicologia , Feminino , Humanos , Relações Interprofissionais , Masculino , Pessoa de Meia-Idade , África do Sul
18.
AIDS Behav ; 23(5): 1104-1114, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30357642

RESUMO

Male circumcision (MC) is a key HIV prevention intervention for men in countries with high HIV prevalence. Women's understanding of MC is important but poorly understood. We conducted a systematic review including women's knowledge of MC's biomedical impacts and its association with female sexual satisfaction and function through October 2017. Thirty-eight articles were identified: thirty-two with knowledge outcomes, seven with sexual satisfaction, and four with sexual function (N = 38). Respondent proportions aware MC protects men from HIV were 9.84-91.8% (median 60.0%). Proportions aware MC protects men from STIs were 14.3-100% (72.6%). Proportions aware MC partially protects men from HIV were 37.5-82% (50.7%). Proportions aware MC is not proven to protect women from infection by an HIV-positive partner were 90.0-96.8% (93.0%). No increases over time were noted. Women's MC knowledge is variable. Education could help women support MC and make better-informed sexual decisions.


Assuntos
Circuncisão Masculina , Coito/psicologia , Infecções por HIV/prevenção & controle , Parceiros Sexuais/psicologia , Adulto , Circuncisão Masculina/educação , Circuncisão Masculina/psicologia , Circuncisão Masculina/estatística & dados numéricos , Feminino , Educação em Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Satisfação Pessoal
19.
AIDS Res Ther ; 15(1): 24, 2018 11 29.
Artigo em Inglês | MEDLINE | ID: mdl-30497481

RESUMO

BACKGROUND: Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents. SETTING: We present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya. METHODS: We used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period. RESULTS: The total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267. CONCLUSION: The VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations.


Assuntos
Circuncisão Masculina/economia , Circuncisão Masculina/estatística & dados numéricos , Custos de Cuidados de Saúde , Jovens em Situação de Rua , Adolescente , Adulto , Análise Custo-Benefício , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Humanos , Quênia/epidemiologia , Masculino , Projetos Piloto , Vigilância em Saúde Pública
20.
PLoS One ; 13(12): e0209385, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30562394

RESUMO

BACKGROUND: Kenya is 1 of 14 priority countries in Africa scaling up voluntary medical male circumcision (VMMC) for HIV prevention following the recommendations of the World Health Organization and the Joint United Nations Programme on HIV/AIDS. To inform VMMC target setting, we modeled the impact of circumcising specific client age groups across several Kenyan geographic areas. METHODS: The Decision Makers' Program Planning Tool, Version 2 (DMPPT 2) was applied in Kisumu, Siaya, Homa Bay, and Migori counties. Initial modeling done in mid-2016 showed coverage estimates above 100% in age groups and geographic areas where demand for VMMC continued to be high. On the basis of information obtained from country policy makers and VMMC program implementers, we adjusted circumcision coverage for duplicate reporting, county-level population estimates, migration across county boundaries for VMMC services, and replacement of traditional circumcision with circumcisions in the VMMC program. To address residual inflated coverage following these adjustments we applied county-specific correction factors computed by triangulating model results with coverage estimates from population surveys. RESULTS: A program record review identified duplicate reporting in Homa Bay, Kisumu, and Siaya. Using county population estimates from the Kenya National Bureau of Statistics, we found that adjusting for migration and correcting for replacement of traditional circumcision with VMMC led to lower estimates of 2016 male circumcision coverage especially for Kisumu, Migori, and Siaya. Even after addressing these issues, overestimation of 2016 male circumcision coverage persisted, especially in Homa Bay. We estimated male circumcision coverage in 2016 by applying correction factors. Modeled estimates for 2016 circumcision coverage for the 10- to 14-year age group ranged from 50% in Homa Bay to approximately 90% in Kisumu. Results for the 15- to 19-year age group suggest almost complete coverage in Kisumu, Migori, and Siaya. Coverage for the 20- to 24-year age group ranged from about 80% in Siaya to about 90% in Homa Bay, coverage for those aged 25-29 years ranged from about 60% in Siaya to 80% in Migori, and coverage in those aged 30-34 years ranged from about 50% in Siaya to about 70% in Migori. CONCLUSIONS: Our analysis points to solutions for some of the data issues encountered in Kenya. Kenya is the first country in which these data issues have been encountered because baseline circumcision rates were high. We anticipate that some of the modeling methods we developed for Kenya will be applicable in other countries.


Assuntos
Circuncisão Masculina/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Programas Nacionais de Saúde/estatística & dados numéricos , Formulação de Políticas , Programas Voluntários/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Análise Custo-Benefício , Tomada de Decisões Gerenciais , Técnicas de Apoio para a Decisão , Humanos , Quênia , Masculino , Modelos Estatísticos , Programas Nacionais de Saúde/economia , Programas Voluntários/economia , Adulto Jovem
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