Medical Male Circumcision Research Articles

Effects of HIV voluntary medical male circumcision programs on sexually transmitted infections.

Evidence of the protective effect of voluntary medical male circumcision (VMMC) against HIV is well established. However, evidence of the protective effect of VMMC against other sexually transmitted infections (STIs) has been inconsistent or scarce across different populations and settings. This review summarizes the current evidence on the effect of VMMC for HIV prevention on acquisition and transmission of other STIs in heterosexual men, women, and men who have sex with men (MSM). Recent findings continue to strongly support the protective effect of male medical circumcision against acquisition and transmission of herpes simplex virus type 2 (HSV-2), human papillomavirus (HPV) and syphilis infections in heterosexual men and women, and bacterial vaginosis and trichomoniasis in women. There is emerging evidence on the protective effect of VMMC against acquisition of hepatitis B and Mycoplasma genitalium infections in heterosexual men, and HSV-2, HPV, and syphilis in MSM. Evidence on the protective effect of VMMC against acquisition and transmission of common STIs is available for heterosexual men and women but more evidence is required for MSM. This review supports policy recommendations for the protective benefits of VMMC against STIs.

Prevalence of Voluntary Medical MaleCircumcision and Factors Associated withLow Uptake amongMen Aged 20 Yearsand Older in Mpanda Municipal Council

Background: Voluntary Medical Male Circumcision (VMMC) is among the important and popular interventions for the prevention of new HIV infections. The overall coverage of male circumcision is still low to some of the regions especially Katavi region The situation is worse among adults this is known due to high numberof young boysattending VMMC clinicsThis study assessed prevalence and factors affecting VMMC uptake among 20 years and older in Mpanda Municipal Council. Methods: Cross-sectional community based study was undertaken in Mpanda Municipal council in Katavi Region , from August 2017 toSeptember 2018.Multistage sampling was used to obtainvillages then households with study participants. A total of 570 men were interviewed. Quantitative data were analyzed using logistic regression. Results: Overall uptake of VMMC among men aged 20 years and older islow only (53.5%). Majority of respondents were knowledgeable on VMMC with 92.2% (525).However, more than half of the respondents393 (69%) know health benefits of VMMC andreported that HIV could be prevented through medical Male Circumcision. 508(88%) of the respondents reported that the service was accepted by the community. Regarding on the Factorsreportedto affect VMMCincludes servicesdiscourages men to take the services (P-value= 0.001), Services conducted in few days per week (special days) (P-value<0.001) and cultural beliefs of not taking circumcision(P-value= 0.033.), services encourages other to go for the service (P- value <0.001). Regarding onhealth personnel negative behavior of not observing confidentiality(P-value 0.0250). Conclusion: In general, the Uptake of Voluntary Medical Male Circumcision was found to be high as compared to the TACAIDS report of 2013. Few days of the service, Health workers behavior was among the factors showed significant association in VMMC service provision. Therefore, there is a need of addressingand strengthening VMMC in all health facilities and equip health facilities with adequate and competent health workers.

The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models.

Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.

Voluntary Medical Male Circumcision (VMMC) Among Males in Zambezi Region, Namibia

Voluntary Medical Male Circumcision (VMMC) Among Males in Zambezi Region, Namibia

The Role of Nurses and Midwives in Expanding and Sustaining Voluntary Medical Male Circumcision Services for HIV Prevention: A Systematic and Policy Review.

Journal of the Association of Nurses in AIDS Care: January-February 2021 - Volume 32 - Issue 1 - p e1-e2 doi: 10.1097/JNC.0000000000000223

Communication-related factors influencing the uptake of voluntary medical male circumcision among men in Lilongwe Urban, Malawi

Abstract: Voluntary Medical Male Circumcision (VMMC) has been promoted as an effective biomedical intervention in the reduction of the risk of new HIV and STI infections. The government of Malawi and its stakeholders including the World Health Organization have committed a lot of resources to VMMC programming. However, research shows that its uptake among men is still low in Malawi. This study, therefore, investigated the communication-related factors that influence decision-making in the uptake of VMMC among men in Lilongwe, Malawi. To achieve this aim, twenty-five men, aged between 18 and 35 years old were interviewed on what influenced them to undergo VMMC. The study found that the respondents were influenced to uptake VMMC mostly by peer pressure and the need for conformity; partner/girlfriend demand and considerations; and advice from health personnel. The paper concludes that although the final decision was theirs to make, the men in the study underwent circumcision under duress and/or coercion. It cannot be said to be voluntary. The medical necessity of VMMC can be said to be voluntary if it is negotiated and consented to without duress. Although the respondents mentioned the HIV and STI infection risk reduction properties, hygienic advantages, and cervical cancer reduction properties of VMMC as benefits of VMMC, these had very little influence on their decision. It is recommended that current intervention messages be reviewed and modified to incorporate new ideas that can address the shortcomings that the current crop of messages has with the aim of increasing the uptake of VMMC programmes or other health focused behaviour change programmes.

Fournier’s Gangrene: A Rare Post-Surgical Complication of Voluntary Medical Male Circumcision in Kwazulu-Natal Province, South Africa

Fournier’s Gangrene: A Rare Post-Surgical Complication of Voluntary Medical Male Circumcision in Kwazulu-Natal Province, South Africa

Individual and community-level benefits of PrEP in western Kenya and South Africa: Implications for population prioritization of PrEP provision.

Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV and has the potential to significantly impact the HIV epidemic. Given limited resources for HIV prevention, identifying PrEP provision strategies that maximize impact is critical. We used a stochastic individual-based network model to evaluate the direct (infections prevented among PrEP users) and indirect (infections prevented among non-PrEP users as a result of PrEP) benefits of PrEP, the person-years of PrEP required to prevent one HIV infection, and the community-level impact of providing PrEP to populations defined by gender and age in western Kenya and South Africa. We examined sensitivity of results to scale-up of antiretroviral therapy (ART) and voluntary medical male circumcision (VMMC) by comparing two scenarios: maintaining current coverage ("status quo") and rapid scale-up to meet programmatic targets ("fast-track"). The community-level impact of PrEP was greatest among women aged 15-24 due to high incidence, while PrEP use among men aged 15-24 yielded the highest proportion of indirect infections prevented in the community. These indirect infections prevented continue to increase over time (western Kenya: 0.4-5.5 (status quo); 0.4-4.9 (fast-track); South Africa: 0.5-1.8 (status quo); 0.5-3.0 (fast-track)) relative to direct infections prevented among PrEP users. The number of person-years of PrEP needed to prevent one HIV infection was lower (59 western Kenya and 69 in South Africa in the status quo scenario; 201 western Kenya and 87 in South Africa in the fast-track scenario) when PrEP was provided only to women compared with only to men over time horizons of up to 5 years, as the indirect benefits of providing PrEP to men accrue in later years. Providing PrEP to women aged 15-24 prevents the greatest number of HIV infections per person-year of PrEP, but PrEP provision for young men also provides indirect benefits to women and to the community overall. This finding supports existing policies that prioritize PrEP use for young women, while also illuminating the community-level benefits of PrEP availability for men when resources permit.

Medical male circumcision and HIV prevention among men in Kwazulu-Natal, South Africa: A propensity score analysis

IntroductionEpidemiological theory and many empirical studies support the hypothesis that there is a protective effect of medical male circumcision (MMC) against HIV infection. We aim to test this claim with evidence from a high endemic community in South Africa. MethodologyWe analysed a cross-sectional dataset, including HIV test outcome and MMC status of males aged 15–49, who participated in the HIV Incidence Provincial Surveillance System study between June 2014 and June 2015. We applied two propensity score methods, inverse probability of treatment weighting (IPTW) and full matching, to approximate a randomised trial investigating the hypothesis that MMC protects against HIV infection. We benchmarked our results using the conventional regression adjustment. Models were adjusted for identified confounders. ResultsThe adjusted odds ratios (OR) provided evidence of a protective effect of MMC against HIV acquisition: IPTW (OR = 0.623, 95% CI: 0.467 – 0.830); Full matching (OR = 0.607, 95% CI: 0.440 – 0.837); Regression (OR = 0.579, 95% CI: 0.426 – 0.789). ConclusionThere is a need to create more programmes that emphasise MMC as an important HIV preventive intervention.

Sexual risk compensation following voluntary medical male circumcision: Results from a prospective cohort study amongst human immunodeficiency virus-negative adult men in Botswana.

BackgroundCircumcised men may increase sexual risk-taking following voluntary medical male circumcision (VMMC) because of decreased perceptions of risk, which may negate the beneficial impact of VMMC in preventing new human immunodeficiency virus (HIV) infections.ObjectivesWe evaluated changes in sexual behaviour following VMMC.MethodWe conducted a prospective cohort study amongst sexually active, HIV-negative adult men undergoing VMMC in Gaborone, Botswana, during 2013–2015. Risky sexual behaviour, defined as the number of sexual partners in the previous month and ≥ 1 concurrent sexual partnerships during the previous 3 months, was assessed at baseline (prior to VMMC) and 3 months post-VMMC. Change over time was assessed by using inverse probability weighted linear and conditional logistic regression models.ResultsWe enrolled 523 men; 509 (97%) provided sexual behaviour information at baseline. At 3 months post-VMMC, 368 (72%) completed the follow-up questionnaire. At baseline, the mean (95% confidence interval) number of sexual partners was 1.60 (1.48, 1.65), and 111 (31% of 353 with data) men reported engaging in concurrent partnerships. At 3 months post-VMMC, 70 (23% of 311 with data) reported fewer partners and 19% had more partners. Amongst 111 men with a concurrent partnership at baseline, 52% reported none post-VMMC. Amongst the 242 (69%) without a concurrent partnership at baseline, 19% reported initiating one post-VMMC. After adjustment for loss to follow-up, risky sexual behaviour post-VMMC (measured as mean changes in a number of partners and proportion engaging in concurrency) was similar to baseline levels.ConclusionWe found no evidence of sexual risk compensation in the 3 months following VMMC.

The Role of Nurses and Midwives in Expanding and Sustaining Voluntary Medical Male Circumcision Services for HIV Prevention: A Systematic and Policy Review.

Male circumcision reduces men's risk of acquiring HIV through heterosexual sex, and voluntary medical male circumcision (VMMC) is central to HIV prevention strategies in 15 sub-Saharan African countries. Nurses have emerged as primary VMMC providers; however, barriers remain to institutionalizing nurse-led VMMC. Patient safety concerns have hindered task sharing, and regulations governing nurse-performed VMMC are not always supportive or clear. We performed a systematic review on VMMC safety by provider cadre and a desk review of national policies governing the VMMC roles of nurses and midwives. Also, VMMC by nurses is safe and has become standard practice. Countries had multiple policy combinations among different documents, with only one disallowing VMMC by these cadres. Countries with alignment between policies often ensured that nursing workforces were equipped with clinical competencies through national certification. Regulatory clarity and formalized certification for nurse-performed VMMC can increase program sustainability and build nursing capacity to meet other critical basic surgical needs.

VMMC clients’ perception of increased risk of HIV infection, circumcision preferred choice of method, providers’ socio-demographics and mode of service delivery

Voluntary medical male circumcision (VMMC) is a scientifically proven HIV prevention intervention. Uganda, like many countries has been implementing VMMC for over 10 years but uptake is still low especially in northern Uganda. To attain 80% needed for public health impact, scale-up was recommended with many innovations implemented with sub-optimal results. This study therefore wanted to find out some of the correlates of VMMC uptake in Gulu district, northern Uganda. Two studies were conducted separately but data was analyzed for this study. For the quantitative study, proportions and frequencies were used to measure perception of increased risk of HIV infection using age, gender, occupation, marital and circumcision status. Qualitative study provided data from FGDs, IDIs and KIIs were first transcribed in Acholi and then translated in English. Transcripts were uploaded in MAXDQA software for data management. A code book for emerging themes was developed. A total of 548 respondents were interviewed for the quantitative study, where two thirds (66%) of the participants perceived themselves to be at increased risk of HIV infection. For the qualitative study, 149 participants from 19 FGDs, 11 KIIs and 9 IDIs were interviewed. Data were analyzed thematically using both inductive and deductive approaches. Devices were preferred to conventional surgery while mobile services were preferred to static services. However, there were divergent views regarding circumcision service providers' socio-demographics and these were influenced mainly by age, level of education and location. People in Northern Uganda perceived themselves to be at an increased risk of HIV infection. They preferred devices to conventional surgery, mobile services to static services but had varying views about the socio-demographics of the service providers.

Data cleaning process for HIV-indicator data extracted from DHIS2 national reporting system: a case study of Kenya

BackgroundThe District Health Information Software-2 (DHIS2) is widely used by countries for national-level aggregate reporting of health-data. To best leverage DHIS2 data for decision-making, countries need to ensure that data within their systems are of the highest quality. Comprehensive, systematic, and transparent data cleaning approaches form a core component of preparing DHIS2 data for analyses. Unfortunately, there is paucity of exhaustive and systematic descriptions of data cleaning processes employed on DHIS2-based data. The aim of this study was to report on methods and results of a systematic and replicable data cleaning approach applied on HIV-data gathered within DHIS2 from 2011 to 2018 in Kenya, for secondary analyses.MethodsSix programmatic area reports containing HIV-indicators were extracted from DHIS2 for all care facilities in all counties in Kenya from 2011 to 2018. Data variables extracted included reporting rate, reporting timeliness, and HIV-indicator data elements per facility per year. 93,179 facility-records from 11,446 health facilities were extracted from year 2011 to 2018. Van den Broeck et al.’s framework, involving repeated cycles of a three-phase process (data screening, data diagnosis and data treatment), was employed semi-automatically within a generic five-step data-cleaning sequence, which was developed and applied in cleaning the extracted data. Various quality issues were identified, and Friedman analysis of variance conducted to examine differences in distribution of records with selected issues across eight years.ResultsFacility-records with no data accounted for 50.23% and were removed. Of the remaining, 0.03% had over 100% in reporting rates. Of facility-records with reporting data, 0.66% and 0.46% were retained for voluntary medical male circumcision and blood safety programmatic area reports respectively, given that few facilities submitted data or offered these services. Distribution of facility-records with selected quality issues varied significantly by programmatic area (p < 0.001). The final clean dataset obtained was suitable to be used for subsequent secondary analyses.ConclusionsComprehensive, systematic, and transparent reporting of cleaning-process is important for validity of the research studies as well as data utilization. The semi-automatic procedures used resulted in improved data quality for use in secondary analyses, which could not be secured by automated procedures solemnly.

Ethics of pursuing targets in public health: the case of voluntary medical male circumcision for HIV-prevention programs in Kenya

The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets...

Combined HIV Adolescent Prevention Study (CHAPS): comparison of HIV pre-exposure prophylaxis regimens for adolescents in sub-Saharan Africa\u2014study protocol for a mixed-methods study including a randomised controlled trial

BackgroundHIV remains a major public health issue, especially in Eastern and Southern Africa. Pre-exposure prophylaxis is highly effective when adhered to, but its effectiveness is limited by cost, user acceptability and uptake. The cost of a non-inferiority phase III trial is likely to be prohibitive, and thus, it is essential to select the best possible drug, dose and schedule in advance. The aim of this study, the Combined HIV Adolescent PrEP and Prevention Study (CHAPS), is to investigate the drug, dose and schedule of pre-exposure prophylaxis (PrEP) required for the protection against HIV and the acceptability of PrEP amongst young people in sub-Saharan Africa, and hence to inform the choice of intervention for future phase III PrEP studies and to improve strategies for PrEP implementation.MethodsWe propose a mixed-methods study amongst young people aged 13–24 years. The first component consists of qualitative research to identify the barriers and motivators towards the uptake of PrEP amongst young people in South Africa, Uganda and Zimbabwe. The second component is a randomised clinical trial (ClinicalTrials.gov NCT03986970, June 2019) using a novel ex vivo HIV challenge method to investigate the optimal PrEP treatment (FTC-TDF vs FTC-TAF), dose and schedule. We will recruit 144 amongst HIV-negative uncircumcised men aged 13–24 years from voluntary male medical circumcision clinics in two sites (South Africa and Uganda) and randomise them into one of nine arms. One group will receive no PrEP prior to surgery; the other arms will receive either FTC-TDF or FTC-TAF, over 1 or 2 days, and with the final dose given either 6 or 20 h prior to surgery. We will conduct an ex vivo HIV challenge on their resected foreskin tissue.DiscussionThis study will provide both qualitative and quantitative results to help decide the optimum drug, dose and schedule for a future phase III trial of PrEP. The study will also provide crucial information on successful strategies for providing PrEP to young people in sub-Saharan Africa.Trial registrationClinicalTrials.gov NCT03986970. Registered on 14 June 2019

Brief Report: Modeling the Impact of Voluntary Medical Male Circumcision on Cervical Cancer in Uganda.

In addition to providing millions of men with lifelong lower risk for HIV infection, voluntary medical male circumcision (VMMC) also provides female partners with health benefits including decreased risk for human papillomavirus (HPV) and resultant cervical cancer (CC). We modeled potential impacts of VMMC on CC incidence and mortality in Uganda as an additional benefit beyond HIV prevention. HPV and CC outcomes were modeled using the CC model from the Spectrum policy tool suite, calibrated for Uganda, to estimate HPV infection incidence and progression to CC, using a 50-year (2018-2067) time horizon. 2016 Demographic Health Survey data provided baseline VMMC coverage. The baseline (no VMMC scale-up beyond current coverage, minimal HPV vaccination coverage) was compared with multiple scenarios to assess the varying impact of VMMC according to different implementations of HPV vaccination and HPV screening programs. Without further intervention, annual CC incidence was projected to rise from 16.9 to 31.2 per 100,000 women in 2067. VMMC scale-up alone decreased 2067 annual CC incidence to 25.3, averting 13,000 deaths between 2018 and 2067. With rapidly-achieved 90% HPV9 vaccination coverage for adolescent girls and young women, 2067 incidence dropped below 10 per 100,000 with or without a VMMC program. With 45% vaccine coverage, the addition of VMMC scaleup decreased incidence by 2.9 per 100,000 and averted 8000 additional deaths. Similarly, with HPV screen-and-treat without vaccination, the addition of VMMC scaleup decreased incidence by 5.1 per 100,000 and averted 10,000 additional deaths. Planned VMMC scale-up to 90% coverage from current levels could prevent a substantial number of CC cases and deaths in the absence of rapid scale-up of HPV vaccination to 90% coverage.

Human Immunodeficiency Virus (HIV) and Treponema pallidum (Syphilis) Co-infection in Uyo, Nigeria

Aim: HIV/AIDS remains a leading cause of death and disability in Sub Saharan Africa and this accounts for almost half of the world’s HIV related deaths. On the other hand, bacterial sexually transmitted diseases (STDs) such as syphilis contributes to the morbidity and mortality obtained in developing countries. Co-infection of syphilis and HIV may increase the risk of HIV transmission and adversely affect reproductive health. Prompt diagnosis and treatment of STDs in HIV positive individuals can help prevent spread to their partners. There is also very little information about incidence and prevalence of HIV/Syphilis co-infection and their determinants. The aim of this study is to evaluate the HIV/Syphilis co-infection among HIV-infected individuals in Uyo, Nigeria.&#x0D; Methods: A total of 176 individuals living with HIV participated in this study. The average age of the study participants was 39.1 years from a range of 6-67 years. Plasma samples obtained from the human subjects were analysed for presence of HIV and Syphilis antibodies using enzyme-Linked immunosorbent Assay.&#x0D; Results: Our findings showed that the overall prevalence of HIV/Syphilis co-infection in Uyo was 1.7%. Analysis of the results revealed that the variables—sex and educational background—significantly influenced the rate of syphilis sero-positivity among the population under study. While variables- age, marital status and occupational skills non-significantly influenced the rate of syphilis sero-positivity among the population under study.&#x0D; Conclusion: This study confirmed the co-infection of HIV and Syphilis in Uyo, Nigeria. Early screening of Syphilis and other STDs contributes to the control of infection and reduces the spread of HIV to partners. A number of primary preventive interventions for HIV and syphilis need to be adopted including use of condoms and medical male circumcision in order to improve sexual and reproductive health amongst individuals.

Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe.

BackgroundSince 2013, the ZAZIC consortium supported the Zimbabwe Ministry of Health and Child Care (MOHCC) to implement a high quality, integrated voluntary medical male circumcision (VMMC) program in 13 districts. With the aim of significantly lowering global HIV rates, prevention programs like VMMC make every effort to achieve ambitious targets at an increasingly reduced cost. This has the potential to threaten VMMC program quality. Two measures of program quality are follow-up and adverse event (AE) rates. To inform further VMMC program improvement, ZAZIC conducted a quality assurance (QA) activity to assess if pressure to do more with less influenced program quality.MethodsKey informant interviews (KIIs) were conducted at 9 sites with 7 site-based VMMC program officers and 9 ZAZIC roving team members. Confidentiality was ensured to encourage candid conversation on adherence to VMMC standards, methods to increase productivity, challenges to target achievement, and suggestions for program modification. Interviews were recorded, transcribed and analyzed using Atlas.ti 6.ResultsVMMC teams work long hours in diverse community settings to reach ambitious targets. Rotating, large teams of trained VMMC providers ensures meeting demand. Service providers prioritize VMMC safety procedures and implement additional QA measures to prevent AEs among all clients, especially minors. However, KIs noted three areas where pressure for increased numbers of clients diminished adherence to VMMC safety standards. For pre- and post-operative counselling, MC teams may combine individual and group sessions to reach more people, potentially reducing client understanding of critical wound care instructions. Second, key infection control practices may be compromised (handwashing, scrubbing techniques, and preoperative client preparation) to speed MC procedures. Lastly, pressure for client numbers may reduce prioritization of patient follow-up, while client-perceived stigma may reduce care-seeking. Although AEs appear well managed, delays in AE identification and lack of consistent AE reporting compromise program quality.ConclusionIn pursuit of ambitious targets, healthcare workers may compromise quality of MC services. Although risk to patients may appear minimal, careful consideration of the realities and risks of ambitious target setting by donors, ministries, and implementing partners could help to ensure that client safety and program quality is consistently prioritized over productivity.

Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda.

The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President's Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited. A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men. A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21-35 years) to 22 years (IQR, 18-29 years) (P for trend < .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28-.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time. VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.

The influence of branding on the uptake of voluntary medical male circumcision: a case study of “Ndife Otsogola” in Lilongwe, Malawi

Background: “Ndife Otsogola” [We are forward thinkers] is the voluntary male medical circumcision (VMMC) campaign in Malawi that is part of the HIV and AIDS health promotion strategy. In 2012, the government of Malawi and its VMMC stakeholders developed communication strategies to advance the uptake of VMMC using the “Ndife Otsogola” brand to increase uptake of the service among the target population. However, since the campaign was scaled up country wide, the uptake of VMCC remains at 28%, well below the target of 80%. Therefore, this study aimed to evaluate whether the “Ndife Otsogola” brand and its associated communications achieved its intended aim. Method: Data for this study were collected through face-to-face interviews with 25 men aged between18 and 35 years, all of whom were linked to the circumcision services. Data were also collected from five key informants through a self-administered questionnaire. Results: The “Ndife Otsogola” campaign had limited influence on the uptake of VMMC among men in urban Lilongwe, Malawi. Conclusion: Branding can sometimes obscure the main message that is intended to be conveyed. Target audiences can sometimes fail to link a brand name to the product being promoted, as was the case with “Ndife Otsogola”. We recommend that more research be undertaken in Malawi to determine the relevance and influence of the entire VMMC communication strategy.