Medical Male Circumcision Research Articles

Do False Beliefs Predict Increased Circumcision Satisfaction in Men?

Medical male circumcision has been adopted by the WHO, and other professional public health and medical bodies, as a vital weapon in the fight against HIV. This has prompted a large body of research into the acceptability of the procedure, attitudes to it, and barriers to it. A systematic review of these studies found that satisfaction with circumcision is strongly associated with having accurate knowledge about it. A survey-based paper by Earp, Sardi and Jellison entitled “False beliefs predict increased circumcision satisfaction in a sample of US American men” is the only one to find the opposite. It therefore merits scrutiny. The present article presents the results of a critical examination of the study. Serious flaws were discovered. Half of the small number of 10 “true/false” statements used in its survey are questionable. All the large body of literature that contradicts the findings of Earp and co-workers is ignored. Importantly, the crucial question about whether dissatisfied circumcised males hold false beliefs about circumcision is not considered. Unlike most of the research on the acceptability of circumcision, the study is not motivated by a desire to evaluate the likely effectiveness of a public health measure, or how best to implement it. Rather it appears to be an attempt by a prominent anti-circumcision activist and his associates to generate a body of literature that they can then cite to further their cause. Considering this, and the serious flaws it contains, the study should be dismissed as misleading, biased and undermining public health.

Perceived influence of value systems on the uptake of voluntary medical male circumcision among men in Kweneng East, Botswana

ABSTRACT Botswana is one of the countries in Eastern and Southern Africa significantly impacted by the Human Immunodeficiency Virus (HIV). To control the spread of HIV, the government in 2009 rolled out the voluntary medical male circumcision (VMMC) programme as an additional HIV prevention strategy with the goal of circumcising 80% of HIV negative men by 2016. However, the country failed to achieve this goal as less than 30% of the targeted men were circumcised by 2016. A study was therefore conducted to explore and describe the factors that are perceived by men in Botswana to influence the uptake of VMMC in order to inform future policymaking and programming on VMMC. An exploratory descriptive, qualitative design was utilised to investigate perceived factors influencing the uptake of VMMC among men. Data were collected from 38 men, aged 18–49 years in Kweneng East, Botswana using semi-structured individual interviews and focus group discussions (FGDs). Tesch's method of qualitative data analysis was used to code and categorise transcribed data into meaningful themes. Upon analysis, three themes emerged as influencing the uptake of VMMC: (a) the influence of value systems associated with stakeholder consultation in the community; (b) the influence of value systems associated with cultural beliefs and (c) the influence of value systems associated with religious beliefs. The influence of value systems associated with stakeholder consultation in the community was found to manifest in the form of the lack of consultation with men at the inception of the VMMC; the lack of involvement of village elders during the service delivery process and the lack of involvement of women in VMMC. In addition, the influence of value systems associated with cultural beliefs was found to manifest in the form of the lack of openness between parents and children on sexual matters and the lack of traditional leadership support in VMMC. Lastly, the influence of value systems associated with religious beliefs was found to manifest in the form of religious views not in support of the VMMC and religious views in support of the VMMC. It is concluded that value systems associated with stakeholder consultation, cultural beliefs and religious beliefs were the factors influencing the uptake of VMMC among men in Kweneng East, Botswana, and these factors to a larger extent deterred men from using VMMC services. Based on these findings, it is therefore concluded that government and other providers of VMMC should consider the influence of value systems on the uptake of VMMC in order to provide culturally congruent VMMC services and boost of the uptake of VMMC among men in Kweneng East, Botswana.

Masculine gender norms, male circumcision, and men’s engagement with health care in the Dominican Republic

ABSTRACTOverall, adult men are less likely to seek and receive health care than women, but male circumcision for HIV prevention has been successful in engaging men in health services. The purpose of this paper is to examine the relationship between masculine norms and health care-seeking among men participating in a voluntary male medical circumcision (VMMC) programme in the Dominican Republic (DR). We employed a mixed methods approach integrating survey data collected 6–12 months post-circumcision (n = 293) and in-depth interviews with a sub-sample of these men (n = 30). In our qualitative analysis, we found that health care-seeking is connected to masculine norms among men in the DR, including the perceptions of medical facilities as feminine spaces. Participants’ narratives demonstrate that male circumcision programmes may facilitate men overcoming masculinity-related barriers to health care engagement. In quantitative analysis, we found that being concerned about being perceived as masculine was associated with health care-seeking behaviour in the past five years, though this association was not retained in multivariable analyses. Findings indicate that male circumcision programmes can familiarise men with the healthcare system and masculinise health care-seeking and utilisation, easing associated discomfort.

An HIV-free generation: review of prevention strategies

Globally South Africa has the largest HIV epidemic, with an estimated 7.7 million people living with HIV (PLHIV). The burden of HIV in South Africa varies by age, gender and key population groups. Prevalence is highest among adults between the ages of 15 and 49 years and is higher among females than males. The prevalence rate also varies by province with the highest rates observed in KwaZulu-Natal, Free State, Eastern Cape, Mpumalanga and Northwest.While greater access to anti-retroviral treatment (ART) has significantly reduced the number of deaths and new infections, the number of new infections is still relatively high, highlighting the need for prevention.Initial prevention strategies focus on behavioural change through increased education and awareness to ensure safer sex, mainly through peer education, condom distribution and voluntary medical male circumcision (VMMC), all of which are in place with varying degrees of success. More recently newer approaches are being considered such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP). The major challenge is still behavioural change.This review sets out to critically evaluate the current and newer approaches. Studies suggest that to achieve greater impact, rather than targeting the general population, prevention strategies should focus on vulnerable populations and in provinces with the highest HIV burden.

HIV research in South Africa: Advancing life.

South African (SA) researchers have made both national and global contributions to HIV prevention and treatment. Research conducted in SA has contributed markedly to improved survival in HIV-infected infants, children and adults. The translation of clinical research into practice has enabled the curtailment of paediatric HIV in SA. Along with international collaborators, SA has made pivotal contributions to biomedical prevention modalities including medical male circumcision and oral and topical microbicides, and is undertaking pivotal HIV vaccine research. Research into the structural and psychosocial drivers of HIV infection will be critical for sustaining biomedical interventions, and necessary to end AIDS.

Enhancers and barriers to uptake of male circumcision services in Northern Uganda: a qualitative study

ABSTRACT Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda.

Meta-analysis of average costs of HIV testing and counselling and voluntary medical male circumcision across thirteen countries

Objective: Explore facility-level average costs per client of HIV testing and counselling (HTC) and voluntary medical male circumcision (VMMC) services in 13 countries.Methods: Through a literature search we identified studies that reported facility-level costs of HTC or VMMC programmes. We requested the primary data from authors and standardised the disparate data sources to make them comparable. We then conducted descriptive statistics and a meta-analysis to assess the cost variation among facilities. All costs were converted to 2017 US dollars ($).Results: We gathered data from 14 studies across 13 countries and 772 facilities (552 HTC, 220 VMMC). The weighted average unit cost per client served was $15 (95% CI 12, 18) for HTC and $59 (95% CI 45, 74) for VMMC. On average, 38% of the mean unit cost for HTC corresponded to recurrent costs, 56% to personnel costs, and 6% to capital costs. For VMMC, 41% of the average unit cost corresponded to recurrent costs, 55% to personnel costs, and 4% to capital costs. We observed unit cost variation within and between countries, and lower costs in higher scale categories in all interventions.

The only way is up: priorities for implementing long-acting antiretrovirals for HIV prevention and treatment.

Purpose of reviewLong-acting HIV treatment and prevention (LAHTP) can address some of the achievement gaps of daily oral therapy to bring us closer to achieving Joint United Nations Programme on HIV/AIDS Fast-track goals. Implementing these new technologies presents individual-level, population-level, and health systems-level opportunities and challenges.Recent findingsTo optimize LAHTP implementation and impact, decision-makers should define and gather relevant data to inform their investment case within the existing health systems context. Programmatic observations from scale-up of antiretroviral therapy, oral preexposure prophylaxis, voluntary medical male circumcision, and family planning offer lessons as planning begins for implementation of LAHTP. Additional data intelligence should be derived from formative studies, pragmatic clinical trials, epidemiologic and economic modeling of LAHTP. Key implementation issues that need to be addressed include optimal communication strategies for demand creation; target setting; logistics and supply chain of commodities needed for LAHTP delivery; human resource planning; defining and operationalizing monitoring and evaluating metrics; integration into health systems.SummarySuccessful LAHTP implementation can bolster treatment and prevention coverage levels if implementation issues outlined above are proactively addressed in parallel with research and development so that health systems can more rapidly integrate new technologies as they gain regulatory approval.

Need for improved detection of voluntary medical male circumcision adverse events in Mozambique: a mixed-methods assessment

BackgroundAdverse events (AE) resulting from voluntary medical male circumcision (VMMC) are commonly used to measure program quality. Mozambique’s VMMC program data reports a combined moderate and severe AE rate of 0.2% through passive surveillance. With active surveillance, similar programs report AE rates ranging from 1.0 to 17.0%. The objective of this activity was to assess potential underreporting of AEs via the passive surveillance system in Mozambique.MethodsThis mixed-methods assessment randomly selected one third (16) of all 46 VMMC clinics through stratified sampling, based on volume. A retrospective record review was conducted including patient clinical files, stock records of Amoxicillin/Clavulanic Acid (the choice antibiotic for VMMC-related infections), and clinic-level AE rates from the national database. Records from the month of April 21 to May 20, 2017 were analyzed to identify both reported and potentially unreported AEs. In addition, external, expert clinicians observed post-operative visits (n = 167). Descriptive statistics were calculated, including difference between reported and identified AEs, an adjusted retrospective AE rate, and an observed prospective AE rate in each clinic.ResultsA total of 5352 circumcisions were performed in the 16 clinics: 8 (0.15%) AEs were reported. Retrospective clinical record reviews identified 36 AEs (0.67%); AE severity or type was unknown. Using Amoxicillin/Clavulanic Acid dispensation as a proxy for VMMC-related infections, 39 additional AEs infections were identified, resulting in an adjusted AE rate of 1.4%, an 8.3 fold increase from the reported AE rate. Prospective, post-operative visit observations of 167 clients found 10 AEs (5.9%); infection was common and boys 10–14 years old represented 80% of AE clients.ConclusionsEvidence suggests underreporting of AEs in the Mozambican VMMC program. Quality improvement efforts should be implemented in all VMMC sites to improve AE identification, documentation and prevention efforts.

Medical Male Circumcision and Associations Among Sexually Transmitted Infections Service Attendees.

Medical male circumcision (MMC) is a proven intervention for preventing HIV acquisition among males. We describe the circumcision status, eligibility for MMC referral and associations with HIV positivity among symptomatic males attending sexually transmitted infections (STI) services. This study was a secondary analysis of cross-sectional data collected during sentinel surveillance for STI aetiologies. In the sentinel surveillance conducted at primary care facilities located in six South African provinces, an anonymous questionnaire was administered followed by collection of appropriate genital and blood specimens for laboratory testing including HIV, rapid plasma reagin (RPR) and HSV-2 serological testing. During analysis, multivariable logistic regression was used to determine association between prevalent HIV infection and male circumcision among males who were HSV-2 AND/OR RPR serology positive and among those who were negative. A total of 847 males were included the analysis, among whom the median age was 28years (IQR 24-32years) with 26.3% aged < 25years. Of these, 166 (19.6%) were medically circumcised, 350 (41.4%) traditionally circumcised while 324 (39%) were not circumcised. The yield of assessment for MMC referral was 27.7%. Overall HIV positivity was 23.1%. Compared to no circumcision, MMC had a statistically insignificant 62% lower odds of being HIV positive -among males who were HSV-2 and RPR negative- adjusted odds ratio [aOR] 0.38 [95% confidence interval (CI) 0.12-1.18], p = 0.094. Among those HSV-2 AND/OR RPR positive, MMC had a statistically insignificant 26% lower odds of being HIV positive- aOR 0.74 (95% CI 0.41-1.36), p = 0.334. In both groups HIV positivity increased with age but was positively associated with condom use at last sexual encounter [aOR 3.41 (95% CI 1.43-8.15)] and previous treatment for an STI syndrome [aOR 3.81 (95% CI 1.60-9.05)] among those HSV-2 and RPR negative. High HIV positivity and high yield of eligibility for VMMC referral among males attending STI services points to the need for better integration of HIV prevention and treatment with STI care.

Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets.

IntroductionVoluntary 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 resultsThe 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.ConclusionOur 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.

Geospatial assessment of the voluntary medical male circumcision programme in Tanzania, 2011–2016

IntroductionTanzania is one of the 14 priority countries in sub-Saharan Africa scaling up voluntary medical male circumcision (VMMC) for HIV prevention. In this study, we assessed the progress of VMMC...

Trends in HIV Prevention, Treatment, and Incidence in a Hyperendemic Area of KwaZulu-Natal, South Africa

In Africa, the persistently high HIV incidence rate among young women is the major obstacle to achieving the goal of epidemic control. To determine trends in coverage of HIV prevention and treatment programs and HIV incidence. This cohort study consisted of 2 sequential, community-based longitudinal studies performed in the Vulindlela and Greater Edendale area in KwaZulu-Natal, South Africa. Participants enrolled from June 11, 2014, to June 22, 2015 (2014 survey), with a single follow-up visit from June 24, 2016, to April 3, 2017 (2016 cohort), or enrolled from July 8, 2015, to June 7, 2016 (2015 survey), with a single follow-up visit from November 7, 2016, to August 30, 2017 (2017 cohort). Men and women aged 15 to 49 years were enrolled in the 2014 and 2015 surveys, and HIV-seronegative participants aged 15 to 35 years were followed up in the 2016 and 2017 cohorts. Analysis was conducted from January 1 through December 31, 2018. HIV prevention and treatment programs in a real-world, nontrial setting. Trends in sex- and age-specific HIV incidence rates, condom use, voluntary medical male circumcision, knowledge of HIV-seropositive status, uptake of antiretroviral therapy, and viral suppression. A total of 9812 participants (6265 women [63.9%]; median age, 27 years [interquartile range, 20-36 years]) from 11 289 households were enrolled in the 2014 survey, and 10 236 participants (6341 women [61.9%]; median age, 27 years [interquartile range, 20-36 years]) from 12 247 households were enrolled in the 2015 survey. Of these, 3536 of 4539 (annual retention rate of 86.7%) completed follow-up in the 2016 cohort, and 3907 of 5307 (annual retention rate of 81.4%) completed follow-up in the 2017 cohort. From 2014 to 2015, condom use with last sex partner decreased by 10% from 24.0% (n = 644 of 3547) to 21.6% (n = 728 of 3895; P = .12) in men and by 17% from 19.6% (n = 1039 of 6265) to 16.2% (n = 871 of 6341; P = .002) in women. Voluntary medical male circumcision increased by 13% from 31.9% (1102 of 3547) to 36.1% (n = 1472 of 3895); P = .007) in men, and the proportion of women reporting that their partner was circumcised increased by 35% from 35.7% (n = 1695 of 4766) to 48.2% (n = 2519 of 5207; P < .001). Knowledge of HIV-seropositive status increased by 21% from 51.8% (n = 504 of 3547) to 62.9% (n = 570 of 3895; P < .001) in men and by 14% from 64.6% (n = 1833 of 6265) to 73.4% (n = 2182 of 6341; P < .001) in women. Use of antiretroviral therapy increased by 32% from 36.7% (n = 341 of 3547) to 48.6% (n = 432 of 3895; P < .001) in men and by 29% from 45.6% (n = 1251 of 6265) to 58.8% (n = 1743 of 6341; P < .001) in women; HIV viral suppression increased by 20% from 41.9% (n = 401 of 3547) to 50.3% (n = 456 of 3895; P = .005) in men and by 13% from 54.8% (n = 1547 of 6265) to 61.9% (n = 1828 of 6341; P < .001) in women. Incidence of HIV declined in women aged 15 to 19 years from 4.63 (95% CI, 3.29-6.52) to 2.74 (95% CI, 1.84-4.09) per 100 person-years (P = .04) but declined marginally or remained unchanged among men and women in other age groups. This study showed a significant decline in HIV incidence in young women; however, to further reduce HIV incidence, HIV prevention and treatment program coverage must be intensified and scaled up.

Knowledge and perceptions of male immigrants in Leeds (UK) towards male circumcision as an HIV prevention strategy.

BackgroundThe World Health Organization has accepted and recommended medical male circumcision (MMC) as an HIV prevention strategy. Despite the advantages of MMC, the rate of uptake of this practice among immigrants and the general population in the United Kingdom (UK) is low, yet the procedure is provided in public and private health facilities. The role of negative perception and its contribution to low circumcision rates is unknown.ObjectivesSince immigrants are a key group that is vulnerable to HIV in the UK, this study aimed at understanding their knowledge and perceptions with regard to MMC.MethodsWe enrolled 10 participants who were purposively selected using snowball recruitment methods. Data were collected during individual in-depth interviews using semi-structured interview guides. Responses were audio recorded, transcribed and analyzed using thematic analysis. Appropriate themes were generated from the data collected.ResultsWe found that the majority looked at male circumcision (MC) as a practice to fulfill their cultural and religious obligations rather than as an HIV protection method. Few participants showed belief and certainty that MC or MMC was effective in HIV prevention hence limited knowledge. They also expressed perceived danger. This included fear of pain, complications from the procedure and possible infections when carried out through traditional means. These dangers discouraged study participants from accessing MMC.ConclusionMale circumcision is mainly practiced to fulfill cultural and religious norms, but is not seen as a credible HIV prevention strategy.

Voluntary medical male circumcision versus religio-cultural circumcision and initiation rites: The case of Varemba of Mwenezi district in response to the prevention of human immunodeficiency virus and acquired immunodeficiency syndrome in Zimbabwe

Male circumcision has long been associated with religious or cultural rituals which bestow culturally valuable status. In some communities, circumcision is believed to provide concomitant access to economic and spiritual resources such as land and the ability to communicate with the ancestors. However, the recent promotion of voluntary medical male circumcision (VMMC) in 2009 as an additional dimension for reducing the spread of human immunodeficiency virus (HIV) was received with mixed feelings by different people in Zimbabwe. The resistance was more pronounced in those districts where male circumcision was a traditional norm. It is considering this background where this article examines whether VMMC and religio-cultural male circumcision are distant cousins or siamese twins. This is performed by taking a leaf from the Varemba of Mwenezi district in Zimbabwe. Data collection was performed between May and October 2017 using in-depth individual interviews within the context of the hermeneutics paradigm which emphasises the existence of multiple realities across time and culture. Our analysis of data shows that the Varemba of Mwenezi district does not believe in the efficacy of VMMC because it is void of the ritualistic cultural–spiritual dimension that usually accompanies male circumcision. The study recommended that VMMC should contextualise the cultural value to achieve set targets for HIV prevention.

1657. Notes From the Field: A Survey of Mobile Device Usage Among Individuals in KwaZulu-Natal, South Africa

BackgroundmHealth (mobile health) is a promising tool to deliver healthcare interventions to underserved populations. Across low- and middle-income countries (LMIC), the prevalence of smartphones has risen to 42%. Effective mHealth deployment in LMIC requires an understanding of how LMIC populations use mobile technology. We characterized the use of mobile devices in rural KwaZulu-Natal, South Africa to tailor mHealth interventions for people living with HIV and at risk for acquiring HIV.MethodsWe surveyed participants in community settings and offered free HIV counseling and testing. Participants self-reported their gender, age, relationship status, living distance from preferred clinic, receipt of monthly grant, condomless sex frequency, and circumcision status (if male). Outcomes included cell phone and smartphone ownership, private data access, health information seeking, and willingness to receive healthcare messages. We performed multivariable logistic regression to assess the relationship between demographic factors and outcomes.ResultsAmong 788 individuals surveyed, the median age was 28 (IQR 22–40) years, 75% were male, and 86% owned personal cell phones, of which 43% were smartphones. The majority (59%) reported having condomless sex and most (59%) males reported being circumcised. Although only 10% used the phone to seek health information, 93% of cell phone owners were willing to receive healthcare messages. Being young, female, and in a relationship were associated with cell phone ownership. Smartphone owners were more likely to be young and female, less likely to live 10–30 minutes from preferred clinic, and less likely to receive a monthly grant. Those reporting condomless sex or lack of circumcision were significantly less likely to have private data access.ConclusionMost participants were willing to receive healthcare messages via phone, indicating that mHealth interventions may be feasible in rural KwaZulu-Natal. Smartphone-based mHealth interventions specifically geared to prevent or support the care of HIV in young women in KwaZulu-Natal may be feasible. mHealth interventions encouraging condom use and medical male circumcision should consider the use of non-smartphone SMS and be attuned to mobile data limitations.Disclosures All authors: No reported disclosures.

Identifying population segments for effective intervention design and targeting using unsupervised machine learning: an end-to-end guide.

One-size-fits-all interventions that aim to change behavior are a missed opportunity to improve human health and well-being, as they do not target the different reasons that drive people's choices and behaviors. Psycho-behavioral segmentation is an approach to uncover such differences and enable the design of targeted interventions, but is rarely implemented at scale in global development. In part, this may be due to the many choices program designers and data scientists face, and the lack of available guidance through the process. Effective segmentation encompasses conceptualization and selection of the dimensions to segment on, which often requires the design of suitable qualitative and quantitative primary research. The choice of algorithm and its parameters also profoundly shape the resulting output and how useful the results are in the field. Analytical outputs are not self-explanatory and need to be subjectively evaluated and described. Finally, segments can be prioritized and targeted with matching interventions via appropriate channels. Here, we provide an end-to-end overview of all the stages from planning, designing field-based research, analyzing, and implementing a psycho-behavioral segmentation solution. We illustrate the choices and critical steps along the way, and discuss a case study of segmentation for voluntary medical male circumcision that implemented the method described here. Though our examples mostly draw on health interventions in the developing world, the principles in this approach can be used in any context where understanding human heterogeneity in driving behavior change is valuable.

Early resumption of sex after voluntary medical male circumcision for HIV prevention within a programmatic delivery setting in Botswana.

To maximize the public health benefits of voluntary medical male circumcision (VMMC) in real-world settings, sexual abstinence is recommended for six weeks following VMMC to ensure complete wound healing. We determined the frequency and predictors of early resumption of sex among a cohort of HIV-negative, sexually active men 18–49 years who underwent VMMC within a public-sector clinic in Botswana. Multivariate robust Poisson regression methods were used to identify predictors of having any sexual intercourse in the last six weeks since undergoing VMMC. In total, 433/519 (83%) men had data available on sexual activity at six weeks post-VMMC. Median age was 27 years, 57% had a higher than secondary education, 72% were employed, and 9% were married. Overall, 122/433 (28%) men had sexual intercourse within the six weeks since VMMC, of whom 36% reported inconsistent condom use. Compared to men ≥34 years, men aged &lt;30 years (adjusted risk ratio [aRR] = 1.71, 95% CI 0.95–3.08) and men 30–34 years had a two-fold higher likelihood of resuming sexual activity early in multivariate analyses (aRR = 2.31, 95% CI 1.26–4.25, Wald p = 0.018). Employed men were more likely to resume sexual activity early than unemployed men (aRR = 1.58, 95% CI 1.02–2.44, p = 0.039). Additional interventions are needed to encourage abstinence until complete wound healing.

Reducing Provider Workload While Preserving Patient Safety: A Randomized Control Trial Using 2-Way Texting for Postoperative Follow-up in Zimbabwe's Voluntary Medical Male Circumcision Program.

Voluntary medical male circumcisions (MCs) are safe: the majority of men heal without complication. However, guidelines require multiple follow-up visits. In Zimbabwe, where there is high mobile phone ownership, severe health care worker shortages, and rapid MC scale up intersect, we tested a 2-way texting (2wT) intervention to reduce provider workload while safeguarding patient safety. Two high-volume facilities providing MC near Harare, Zimbabwe. A prospective, unblinded, noninferiority, randomized control trial of 722 adult MC clients with cell phones randomized 1:1. 2wT clients (n = 362) responded to a daily text with in-person follow-up only if desired or an adverse event (AE) was suspected. The control group (n = 359) received routine in-person visits. All men were asked to return on postoperative day 14 for review. AEs at ≤day 14 visit and the number of in-person visits were compared between the groups. Cumulative AEs were identified in 0.84% [95% confidence interval (CI): 0.28 to 2.43] among routine care men as compared with 1.88% (95% CI: 0.86 to 4.03) of 2wT participants. Noninferiority cannot be ruled out (95% CI: -∞ to +2.72); however, AE rates did not differ between the groups (P = 0.32). 2wT men attended an average of 0.30 visits as compared with 1.69 visits among routine care men, a significant reduction (P < 0.001). Although noninferiority cannot be demonstrated, increased AEs in the 2wT arm likely reflect improved AE ascertainment. 2wT serves as a proxy for active surveillance, improving the quality of MC patient care. 2wT also reduced provider workload. 2wT provides an option for men to heal safely at home, returning to care when desired or if complications arise. 2wT should be further tested to enable widespread scale-up.

Impact of chemokine C\u2013C ligand 27, foreskin anatomy and sexually transmitted infections on HIV-1 target cell availability in adolescent South African males

We compared outer and inner foreskin tissue from adolescent males undergoing medical male circumcision to better understand signals that increase HIV target cell availability in the foreskin. We measured chemokine gene expression and the impact of sexually transmitted infections (STIs) on the density and location of T and Langerhans cells. Chemokine C–C ligand 27 (CCL27) was expressed 6.94-fold higher in the inner foreskin when compared with the outer foreskin. We show that the density of CD4+CCR5+ cells/mm2 was higher in the epithelium of the inner foreskin, regardless of STI status, in parallel with higher CCL27 gene expression. In the presence of STIs, there were higher numbers of CD4+CCR5+ cells/mm2 cells in the sub-stratum of the outer and inner foreskin with concurrently higher number of CD207+ Langerhans cells (LC) in both tissues, with the latter cells being closer to the keratin surface of the outer FS in the presence of an STI. When we tested the ability of exogenous CCL27 to induce T-cell migration in foreskin tissue, CD4 + T cells were able to relocate to the inner foreskin epithelium in response. We provide novel insight into the impact CCL27 and STIs on immune and HIV-1 target cell changes in the foreskin.