ObjectiveWe compared the impact and costs of HIV prevention strategies focusing on youth (15–24 year-old persons) versus on adults (15+ year-old persons), in a high-HIV burden context of a large generalized epidemic.DesignCompartmental age-structured mathematical model of HIV transmission in Nyanza, Kenya.InterventionsThe interventions focused on youth were high coverage HIV testing (80% of youth), treatment at diagnosis (TasP, i.e., immediate start of antiretroviral therapy [ART]) and 10% increased condom usage for HIV-positive diagnosed youth, male circumcision for HIV-negative young men, pre-exposure prophylaxis (PrEP) for high-risk HIV-negative females (ages 20–24 years), and cash transfer for in-school HIV-negative girls (ages 15–19 years). Permutations of these were compared to adult-focused HIV testing coverage with condoms and TasP.ResultsThe youth-focused strategy with ART treatment at diagnosis and condom use without adding interventions for HIV-negative youth performed better than the adult-focused strategy with adult testing reaching 50–60% coverage and TasP/condoms. Over the long term, the youth-focused strategy approached the performance of 70% adult testing and TasP/condoms. When high coverage male circumcision also is added to the youth-focused strategy, the combined intervention outperformed the adult-focused strategy with 70% testing, for at least 35 years by averting 94,000 more infections, averting 5.0 million more disability-adjusted life years (DALYs), and saving US$46.0 million over this period. The addition of prevention interventions beyond circumcision to the youth-focused strategy would be more beneficial if HIV care costs are high, or when program delivery costs are relatively high for programs encompassing HIV testing coverage exceeding 70%, TasP and condoms to HIV-infected adults compared to combination prevention programs among youth.ConclusionFor at least the next three decades, focusing in high burden settings on high coverage HIV testing, ART treatment upon diagnosis, condoms and male circumcision among youth may outperform adult-focused ART treatment upon diagnosis programs, unless the adult testing coverage in these programs reaches very high levels (>70% of all adults reached) at similar program costs. Our results indicate the potential importance of age-targeting for HIV prevention in the current era of ‘test and start, ending AIDS’ goals to ameliorate the HIV epidemic globally.

BackgroundNearly three decades into the epidemic, sub-Saharan Africa (SSA) remains the region most heavily affected by human immunodeficiency virus (HIV), with nearly 70% of the 34 million people living with HIV globally residing in the region. In SSA, female and male youth (15 to 24 years) are at a disproportionately high risk of HIV infection compared to adults. As such, there is a need to target HIV prevention strategies to youth and to tailor them to a gender-specific context. This protocol describes the process for the multi-staged approach in the design of the MP3 Youth pilot study, a gender-specific, combination, HIV prevention intervention for youth in Kenya.ObjectiveThe objective of this multi-method protocol is to outline a rigorous and replicable methodology for a gender-specific combination HIV prevention pilot study for youth in high-burden settings, illustrating the triangulated methods undertaken to ensure that age, sex, and context are integral in the design of the intervention.MethodsThe mixed-methods, cross-sectional, longitudinal cohort pilot study protocol was developed by first conducting a systematic review of the literature, which shaped focus group discussions around prevention package and delivery options, and that also informed age- and sex- stratified mathematical modeling. The review, qualitative data, and mathematical modeling created a triangulated evidence base of interventions to be included in the pilot study protocol. To design the pilot study protocol, we convened an expert panel to select HIV prevention interventions effective for youth in SSA, which will be offered in a mobile health setting. The goal of the pilot study implementation and evaluation is to apply lessons learned to more effective HIV prevention evidence and programming.ResultsThe combination HIV prevention package in this protocol includes (1) offering HIV testing and counseling for all youth; (2) voluntary medical circumcision and condoms for males; (3) pre-exposure prophylaxis (PrEP), conditional cash transfer (CCT), and contraceptives for females; and (4) referrals for HIV care among those identified as HIV-positive. The combination package platform selected is mobile health teams in an integrated services delivery model. A cross-sectional analysis will be conducted to determine the uptake of the interventions. To determine long-term impact, the protocol outlines enrolling selected participants in mutually exclusive longitudinal cohorts (HIV-positive, PrEP, CCT, and HIV-negative) followed by using mobile phone text messages (short message service, SMS) and in-person surveys to prospectively assess prevention method uptake, adherence, and risk compensation behaviors. Cross-sectional and sub-cohort analyses will be conducted to determine intervention packages uptake.ConclusionsThe literature review, focus groups, and modeling indicate that offering age- and gender- specific combination HIV prevention interventions that include biomedical, behavioral, and structural interventions can have an impact on HIV risk r...

BackgroundSub-Saharan Africa is the region with the highest HIV burden. Adolescent girls and young women (AGYW) in the age range of 15 to 24 years are twice as likely as their male peers to be infected, making females in sub-Saharan Africa the most at-risk group for HIV infection. It is therefore critical to prioritize access to HIV testing, prevention, and treatment for this vulnerable population.ObjectiveUsing an implementation science framework, the purpose of this research protocol was to describe the approaches we propose to optimize engagement of AGYW in both the HIV prevention and care continuum and to determine the recruitment and testing strategies that identify the highest proportion of previously undiagnosed HIV infections.MethodsWe will compare two seek recruitment strategies, three test strategies, and pilot adaptive linkage to care interventions (sequential multiple assignment randomized trial [SMART] design) among AGYW in the age range of 15 to 24 years in Homa Bay County, western Kenya. AGYW will be recruited in the home or community-based setting and offered three testing options: oral fluid HIV self-testing, staff-aided rapid HIV testing, or referral to a health care facility for standard HIV testing services. Newly diagnosed AGYW with HIV will be enrolled in the SMART trial pilot to determine the most effective way to support initial linkage to care after a positive diagnosis. They will be randomized to standard referral (counseling and a referral note) or standard referral plus SMS text message (short message service, SMS); those not linked to care within 2 weeks will be rerandomized to receive an additional SMS text message or a one-time financial incentive (approximately US $4). We will also evaluate a primary prevention messaging intervention to support identified high-risk HIV-negative AGYW to reduce their HIV risk and adhere to HIV retesting recommendations. We will also conduct analyses to determine the incremental cost-effectiveness of the seek, testing and linkage interventions.ResultsWe expect to enroll 1200 participants overall, with a random selection of 100 high-risk HIV-negative AGYW for the SMS prevention intervention (HIV-negative cohort) and approximately 108 AGYW who are living with HIV for the SMART design pilot of adaptive linkage to care interventions (HIV-positive cohort). We anticipate that the linkage to care interventions will be feasible and acceptable to implement. Lastly, the use of SMS text messages to engage participants will provide pilot data to the Kenyan government currently exploring a national platform to track and support linkage, adherence to treatment, retention, and prevention interventions for improved outcomes.ConclusionsLessons learned will inform best approaches to identify new HIV diagnoses to increase AGYW’s uptake of HIV prevention, testing, and linkage to care services in a high HIV-burden African setting.Trial RegistrationClinicalTrials.gov NCT02735642; https://clinicaltrials.gov/ct2/show/NCT02735642 (Archived by WebCite at http://www.webcitation...

Background Male circumcision can protect against sexually transmitted infections, HIV, and urinary tract infections. The procedure is easier to perform during the neonatal period (< 28 days), with fewer complications and rarely requiring general anaesthesia. Few studies have estimated the number of circumcisions, or indications for the procedure, in the post-neonatal period (ages 1-18 years). Our objective was to compare these for neonatal and post-neonatal circumcisions. Methods We analysed MarketScan data, a database of billing claims from commercial health plans. We used circumcision procedural codes to identify all circumcisions in 2010, including neonatal circumcisions of males born to women enrolled in the health plans, and circumcisions of males aged 1-18 years. We assessed reasons for circumcision using diagnostic codes, and stratified the number of circumcisions and associated diagnosis by age. We estimated the neonatal circumcision rate. Results Overall, 120,994 circumcisions were performed in 2010, with 113,740 (94%) in neonates and 7,254 (6.0%) in post-neonates. Among post-neonatal circumcisions, 67% were performed for boys < 3 years of age and of these 28% were elective. In contrast, among males 3 years and older, only 8% were elective. The neonatal circumcision rate was 113,740/182,503 (62%), and 92% were elective. Among 16,457 non-elective circumcisions for both neonates and post-neonates, the most frequent indications were phimosis (92%), balanitis (3%), hidden penis (2%), chordee (2%), and hypospadias (2%). Conclusion Most post-neonatal circumcisions were performed among males < 3 years, and were 8.6 times higher than circumcisions among males 3 years and older. The large number of elective post-neonatal circumcisions in males < 3 years suggest that neonatal circumcision might be a missed opportunity for these boys. Delaying elective circumcision results in greater risk for the child, and a more costly procedure. Discussions with parents early in pregnancy might help them make an informed decision about circumcision of their child. Background All youth in Sri Lanka are not at risk of HIV/AIDS. However, certain socio-economic and behaviour factors are present among youth which make them vulnerable. There are subsets of especially vulnerable youth (EVY) and most-at-risk youth who need to be identified for targeted interventions. Identification of types of subsets and size are essential for interventions. The Objective of this is to identify the subsets of EVY and estimate the size according to the geographical area in the Western Province, Method Groups of EVY in the western province were identified using participatory approach with broad based consultation of various stakeholders in the public, private and civil society organisation including youth organisations. MaPPing and Size eStiMation of VulnerableGeographic mapping and size estimation was done using the participatory method in group consensus with the key partners. Previous studies, ad hoc surveys, programmatic data from the various organi...