Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries

Njeuhmeli, Emmanuel; Opuni, Marjorie; Schnure, Melissa; Tchuenche, Jean M.; Stegman, Peter; Gold, Elisabeth; Kiggundu, Valerian; Parks, Nida; Ahanda, Kim Seifert; Carrasco, María; Kripke, Katharine

doi:10.1093/cid/cix969

Cited by 16 publications

(15 citation statements)

References 23 publications

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“…Better counseling on Visit 2 would further remind men to pay attention to their continued healing process and return immediately for any concerns. Third, as MC coverage aims to reach 90% of men ages 10–29 by 2021 in Zimbabwe [ 42 ], precautions should be taken to ensure safety for the 10–14 year old age group. For these youngest clients, especially, age-appropriate MC counseling and post-operative care materials are needed.…”

Section: Discussionmentioning

confidence: 99%

Timing of adverse events among voluntary medical male circumcision clients: Implications from routine service delivery in Zimbabwe

Feldacker¹,

Bochner²,

Murenje³

et al. 2018

PLoS ONE

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BackgroundTiming of routine follow-up visits after adult male circumcision (MC) differs by country and method. Most men do not attend all routine follow-up visits. This cross-sectional study aimed to further understanding of AE timing within a large-scale, routine, MC program to improve patient safety.MethodsFrom 2013–2017, ZAZIC consortium performed 192,575 MCs in Zimbabwe; the reported adverse event (AE) rate was 0.3%. Three scheduled, routine, follow-up visits intend to identify AEs. For surgical MC, visits were days 2, 7 and 42 post-procedure. For PrePex (device-based), visits were days 7, 14 and 49. Descriptive statistics explored characteristics of those patients with AEs. For each MC method, chi-square tests were used to evaluate associations between AE timing (days from MC to AE diagnosis) and factors of interest (age, AE type, severity).ResultsOf 421 AEs, 290 (69%) were surgical clients: 55 (19%) AEs were ≤2 days post-MC; 169 (58%) between 3–7 days; 47 (16%) between days 8–14; and 19 (7%) were ≥15 post-MC. Among surgical clients, bleeding was most common AE on/before Day 2 while infections predominated in other follow-up periods (p<0.001). Younger surgical MC patients with AEs experienced AEs later than older clients (p<0.001). Among 131 (31%) PrePex clients with AEs, 46 (35%) were ≤2 days post-MC; 59 (45%) between 3–7 days; 16 (12%) between days 8–14; and 10 (7%) ≥15 post-MC. For PrePex clients, device displacements were more likely to occur early while late AEs were most commonly infections (p<0.001).ConclusionAlmost 23% of surgical and 8% of PrePex AEs occurred after Visit 2. Later AEs were likely infections. Clinicians, clients, and caregivers should be more effectively counseled that complications may arise after initial visits. Messages emphasizing attention to wound care until complete healing could help ensure client safety. Younger boys, ages 10–14, and their caregivers would benefit from improved, targeted, post-operative counseling.

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Section: Discussionmentioning

confidence: 99%

Timing of adverse events among voluntary medical male circumcision clients: Implications from routine service delivery in Zimbabwe

Feldacker¹,

Bochner²,

Murenje³

et al. 2018

PLoS ONE

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“…Mathematical modeling provides insights into potential outcomes based on today’s programmatic decisions, including immediacy of impact, cost-effectiveness, and differences between alternative strategies for VMMC. The modeling for this supplement investigated different scenarios for increasing circumcision coverage by 2021 among men aged 10–29 years in 9 priority countries [ 18 ]. A country that has already attained high coverage among 10–14-year-olds (ie, Tanzania) has a much better chance of achieving 90% coverage among 10–29-year-olds, because historical coverage affects future coverage.…”

Section: Lessons Learnedmentioning

confidence: 99%

“…The modeling used by Njeuhmeli et al [ 18 ] does not factor in the cultural acceptability of adolescent circumcision nor the ease and lower cost of recruiting this age group. Although challenging, models should try to incorporate acceptability and ease of implementation into their estimates.…”

Section: Lessons Learnedmentioning

confidence: 99%

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Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement

Lane

Bailey

Luo

et al. 2018

Clinical Infectious Diseases

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Global experts recognize the need to transform conventional models of healthcare to create adolescent responsive health systems. As countries near 80% coverage of voluntary medical male circumcision (VMMC) for those aged 15–49 years, prioritization of younger men becomes critical to VMMC sustainability. This special supplement reporting 9 studies focusing on adolescent VMMC programming and services comes at a critical time. Eight articles report how well adolescents are reached with the World Health Organization’s minimum package for comprehensive human immunodeficiency virus (HIV) prevention in South Africa, Zimbabwe, and Tanzania, analyzing motivation, counseling, wound healing, parental involvement, female peer support, quality of in-service communication, and providers’ perceptions, and one presents models for achieving high VMMC coverage by 2021. One important finding is that adolescent boys, especially the youngest, experience gaps in their comprehension of key elements in the World Health Organization’s minimum package. Although parents, counselors, and providers are involved and supportive, they are inadequately prepared to counsel youth, partly owing to discomfort with adolescent sexuality. At the country level, deliberately prioritizing young adolescents (aged 10–14 years) is likely to achieve national coverage targets more quickly and cost-effectively than continuing to focus on older, harder-to-reach men. The studies in this supplement point to areas where VMMC programs are achieving successes and they reveal areas for improvement. Given that prioritizing adolescents will be the best means of achieving sustainable VMMC for HIV prevention for the foreseeable future, applying the lessons learned here will increase the effectiveness of VMMC programs.

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“…The effectiveness of VMMC scale-up, especially in combination with other HIV prevention services, has empirically been shown to be associated with reductions in community-level HIV incidence [ 6 , 7 ]. Recent mathematical models suggest that increasing and sustaining uptake of VMMC among male adolescents, including 10–14-year-olds, will be critical in maximizing impact of VMMC on the HIV epidemic in sub-Saharan Africa [ 8 ]. With a longer sexual history trajectory before them, adolescents stand to gain the most benefit from VMMC uptake—especially if the procedure is conducted before sexual debut.…”

mentioning

confidence: 99%

Age Differences in Perceptions of and Motivations for Voluntary Medical Male Circumcision Among Adolescents in South Africa, Tanzania, and Zimbabwe

Patel

Kaufman

Dam

et al. 2018

Clinical Infectious Diseases

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BackgroundThe World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have set a Fast-Track goal to achieve 90% coverage of voluntary medical male circumcision (VMMC) among boys and men aged 10–29 years in priority settings by 2021. We aimed to identify age-specific facilitators of VMMC uptake among adolescents.MethodsYounger (aged 10–14 years; n = 967) and older (aged 15–19 years; n = 559) male adolescents completed structured interviews about perceptions of and motivations for VMMC before receiving VMMC counseling at 14 service provision sites across South Africa, Tanzania, and Zimbabwe. Adjusted prevalence ratios (aPRs) were estimated using multivariable modified Poisson regression models with generalized estimating equations and robust standard errors.ResultsThe majority of adolescents reported a strong desire for VMMC. Compared with older adolescents, younger adolescents were less likely to cite protection against human immunodeficiency virus (HIV) or other sexually transmitted infections (aPR, 0.77; 95% confidence interval [CI], .66–.91) and hygienic reasons (aPR, 0.55; 95% CI, .39–.77) as their motivation to undergo VMMC but were more likely to report being motivated by advice from others (aPR, 1.88; 95% CI, 1.54–2.29). Although most adolescents believed that undergoing VMMC was a normative behavior, younger adolescents were less likely to perceive higher descriptive norms (aPR, 0.79; .71–.89), injunctive norms (aPR, 0.86; 95% CI, .73–1.00), or anticipated stigma for being uncircumcised (aPR, 0.79; 95% CI, .68–.90). Younger adolescents were also less likely than older adolescents to correctly cite that VMMC offers men and boys partial HIV protection (aPR, 0.73; 95% CI, .65–.82). Irrespective of age, adolescents’ main concern about undergoing VMMC was pain (aPR, 0.95; 95% CI, .87–1.04). Among younger adolescents, fear of pain was negatively associated with desire for VMMC (aPR, 0.89; 95% CI, .83–.96).ConclusionsAge-specific strategies are important to consider to generate sustainable demand for VMMC. Programmatic efforts should consider building on the social norms surrounding VMMC and aim to alleviate fears about pain.

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Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries

Cited by 16 publications

References 23 publications

Timing of adverse events among voluntary medical male circumcision clients: Implications from routine service delivery in Zimbabwe

Timing of adverse events among voluntary medical male circumcision clients: Implications from routine service delivery in Zimbabwe

Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement

Age Differences in Perceptions of and Motivations for Voluntary Medical Male Circumcision Among Adolescents in South Africa, Tanzania, and Zimbabwe

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