Female Partner Acceptance as a Predictor of Men's Readiness to Undergo Voluntary Medical Male Circumcision in Zambia: The Spear and Shield Project.
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SUBMITTER: Cook R
PROVIDER: S-EPMC4696907 | biostudies-literature | 2016 Nov
REPOSITORIES: biostudies-literature
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Female Partner Acceptance as a Predictor of Men's Readiness to Undergo Voluntary Medical Male Circumcision in Zambia: The Spear and Shield Project.
Cook Ryan R Jones Deborah D Redding Colleen A CA Zulu Robert R Chitalu Ndashi N Weiss Stephen M SM
AIDS and behavior 20161101 11
The World Health Organization has recommended the scale-up of voluntary medical male circumcision (VMMC) for HIV prevention in sub-Saharan Africa; however, men are often uninterested in undergoing VMMC. The Spear & Shield project enrolled 668 men and female partners from ten Zambian community health centers into parallel interventions promoting VMMC for HIV prevention or time-matched control conditions. A mediation model was utilized to examine the relationships between changes in women's accept ...[more]
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Project description:Voluntary medical male circumcision (VMMC) is an important HIV prevention strategy, particularly in regions with high HIV incidence and low rates of male circumcision. However, 88% of the Zambian male population remain uncircumcised, and of these 80% of men surveyed expressed little interest in undergoing VMMC.The Spear and Shield study (consisting of 4 weekly, 90-minute sexual risk reduction/VMMC promotion sessions) recruited and enrolled men (N = 800) who self-identified as at risk of HIV by seeking HIV testing and counseling at community health centers. Eligible men tested HIV-negative, were uncircumcised, and expressed no interest in VMMC. Participants were encouraged (but not required) to invite their female partners (N = 668) to participate in the program in a gender-concordant intervention matched to their partners'. Men completed assessments at baseline, post-intervention (about 2 months after baseline), and 6 and 12 months post-intervention; women completed assessments at baseline and post-intervention. For those men who underwent VMMC and for their partners, an additional assessment was conducted 3 months following the VMMC. The ancillary analysis in this article compared the pre- and post-VMMC responses of the 257 Zambian men who underwent circumcision during or following study participation, using growth curve analyses, as well as of the 159 female partners.Men were satisfied overall with the procedure (mean satisfaction score, 8.4 out of 10), and nearly all men (96%) and women (94%) stated they would recommend VMMC to others. Approximately half of the men reported an increase or no change in erections, orgasms, and time to achieve orgasms from pre-VMMC, while one-third indicated fewer erections and orgasms and decreased time to achieve orgasms post-VMMC. Nearly half (42%) of the men, and a greater proportion (63%) of the female partners, said their sexual pleasure increased while 22% of the men reported less sexual pleasure post-VMMC. Growth curve analysis of changes in sexual functioning and satisfaction over time revealed no changes in erectile functioning or intercourse satisfaction, but there were increases in orgasm functioning, overall sexual satisfaction, and sexual desire. The majority (61% to 70%) of men and women thought penile cleanliness and appearance had improved post-VMMC. Of the 69% of men who reported having sexual intercourse at least once between having the procedure and their 3-month post-VMMC assessment, the large majority (76%) waited at least 6 weeks before resuming sex. Sexual intercourse prior to the 6-week healing period was associated with adverse events and lower levels of post-VMMC sexual satisfaction.Both men and their partners can generally expect equal or improved sexual satisfaction and penile hygiene following VMMC. Future studies should consider innovative strategies to assist men in their efforts to abstain from sexual activities prior to complete healing.
| S-EPMC4682585 | biostudies-literature
Project description:Widespread voluntary medical male circumcision in Africa could avert an estimated 3·436 million HIV infections and 300,000 deaths over the next 10 years. Most Zambian men have expressed little interest in the procedure. We tested the effect of the Spear and Shield intervention designed to increase demand for voluntary medical male circumcision among these hard-to-reach men.This cluster randomised controlled trial was done between Feb 1, 2012, and Oct 31, 2014, in Lusaka, Zambia, where HIV prevalence is 20·8%. 13 community health centres were stratified by HIV voluntary counselling and testing rates and patient census, and randomly assigned (5:5:3) to experimental (the intervention), control, or observation-only conditions. Community health centre health-care providers at all 13 sites received training in voluntary medical male circumcision. Eligible participants were aged at least 18 years, HIV-negative, uncircumcised, and had not proactively requested or planned for voluntary medical male circumcision at the time of enrolment. Trial statisticians did not participate in randomisation. After voluntary counselling and HIV testing, participants were recruited; female partners were invited to participate. The primary outcomes at the individual level were the likelihood of voluntary medical male circumcision by 12 months post-intervention, and condom use after voluntary medical male circumcision among participants receiving the intervention. The trial is registered with ClinicalTrials.gov, number NCT01688167.800 uncircumcised HIV-negative men (400 in the experimental group, 400 in the control group) were enrolled. 161 participants in the experimental group and 96 in the control group had voluntary medical male circumcision (adjusted odds ratio 2·45, 95% CI 1·24-4·90; p=0·02). Condom use was examined in participants who had voluntary medical male circumcision and reported sexual activity within 1 month of a post-circumcision assessment (88 in the experimental group and 64 in the control group). Condom use over time increased in the experimental group (p=0·03) but not in the control group (p=0·2). One patient died in each group; no adverse events related to study participation were reported.Comprehensive HIV prevention programmes can increase the demand for and uptake of voluntary medical male circumcision services.US National Institutes of Health/National Institute of Mental Health (R01MH095539).
| S-EPMC4478609 | biostudies-literature
Project description:As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.
| S-EPMC4222873 | biostudies-literature
Project description:Tumorigenesis is a complex process involving dynamic interactions between malignant cells and their surrounding stroma, including both the cellular and acellular components. Within the stroma, fibroblasts represent not only a predominant cell type, but also a major source of the acellular tissue microenvironment comprising the extracellular matrix (ECM) and soluble factors. Normal fibroblasts can exert diverse suppressive functions against cancer initiating and metastatic cells via direct cell-cell contact, paracrine signaling by soluble factors, and ECM integrity. The loss of such suppressive functions is an inherent step in tumor progression. A tumor cell-induced switch of normal fibroblasts into cancer-associated fibroblasts (CAFs), in turn, triggers a range of pro-tumorigenic signals accompanied by distraction of the normal tissue architecture, thus creating an optimal niche for cancer cells to grow extensively. To further support tumor progression and metastasis, CAFs secrete factors such as ECM remodeling enzymes that further modify the tumor microenvironment in combination with the altered adhesive forces and cell-cell interactions. These paradoxical tumor suppressive and promoting actions of fibroblasts are the focus of this review, highlighting the heterogenic molecular properties of both normal and cancer-associated fibroblasts, as well as their main mechanisms of action, including the emerging impact on immunomodulation and different therapy responses.
| S-EPMC5983719 | biostudies-literature
Project description:Voluntary Medical Male Circumcision (VMMC) is proven to reduce transmission of HIV/AIDS. Despite concerted efforts to scale up VMMC in men aged 18-49, the number of medically circumcised men in this age group remains suboptimal. Research has shown that several individual factors hinder and promote uptake of VMMC. The nature of these factors is not clearly understood within the dimensions of religion, culture and tradition, particularly in a low-income rural setting. This study aimed to analyze Zulu men's conceptions, understanding and experiences regarding VMMC in KwaZulu-Natal (KZN), South Africa. A qualitative phenomenographic study approach was used to collect data from 20 uncircumcised males at six different clinics that provide VMMC services. Ethical approval to collect data was obtained from the Biomedical Research Ethics Committee of the University of KZN (BREC - BE627/18). Individual in-depth face to face interviews were conducted using a semistructured interview guide. Audiotapes were used to record interviews which were transcribed verbatim and then analyzed manually. The conceptions regarding medical circumcision appeared to be related to religious and cultural beliefs surrounding circumcision and the historical traditional practice thereof. The understanding of males regarding VMMC was mainly attributed to HIV prevention; however, knowledge on the degree of partial protection appeared to be limited. An array of negative accounted in the form of complications such as poor wound healing and postoperative pain undergone by peers and other close influencers' accounted for participants' experiences of VMMC. Poor knowledge and negative experiences relating to VMMC could account for reasons why men choose not to undergo VMMC.
| S-EPMC7059234 | biostudies-literature
Project description:BackgroundCountries in sub-Saharan Africa are scaling-up voluntary male medical circumcision (VMMC) as an HIV intervention. Emerging challenges in these programs call for increased focus on program efficiency (optimizing program impact while minimizing cost). A novel analytic approach was developed to determine how subpopulation prioritization can increase program efficiency using an illustrative application for Zambia.Methods and findingsA population-level mathematical model was constructed describing the heterosexual HIV epidemic and impact of VMMC programs (age-structured mathematical (ASM) model). The model stratified the population according to sex, circumcision status, age group, sexual-risk behavior, HIV status, and stage of infection. A three-level conceptual framework was also developed to determine maximum epidemic impact and program efficiency through subpopulation prioritization, based on age, geography, and risk profile. In the baseline scenario, achieving 80% VMMC coverage by 2017 among males 15-49 year old, 12 VMMCs were needed per HIV infection averted (effectiveness). The cost per infection averted (cost-effectiveness) was USD $1,089 and 306,000 infections were averted. Through age-group prioritization, effectiveness ranged from 11 (20-24 age-group) to 36 (45-49 age-group); cost-effectiveness ranged from $888 (20-24 age-group) to $3,300 (45-49 age-group). Circumcising 10-14, 15-19, or 20-24 year old achieved the largest incidence rate reduction; prioritizing 15-24, 15-29, or 15-34 year old achieved the greatest program efficiency. Through geographic prioritization, effectiveness ranged from 9-12. Prioritizing Lusaka achieved the highest effectiveness. Through risk-group prioritization, prioritizing the highest risk group achieved the highest effectiveness, with only one VMMC needed per infection averted; the lowest risk group required 80 times more VMMCs.ConclusionEpidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.
| S-EPMC4696770 | biostudies-literature
Project description:BackgroundIn this study, we described facility-level voluntary medical male circumcision (VMMC) unit cost, examined unit cost variation across facilities, and investigated key facility characteristics associated with unit cost variation.MethodsWe used data from 107 facilities in Kenya, Rwanda, South Africa, and Zambia covering 2011 or 2012. We used micro-costing to estimate economic costs from the service provider's perspective. Average annual costs per client were estimated in 2013 United States dollars (US$). Econometric analysis was used to explore the relationship between VMMC total and unit cost and facility characteristics.ResultsAverage VMMC unit cost ranged from US$66 (SD US$79) in Kenya to US$160 (SD US$144) in South Africa. Total cost function estimates were consistent with economies of scale and scope. We found a negative association between the number of VMMC clients and VMMC unit cost with a 3% decrease in unit cost for every 10% increase in number of clients and we found a negative association between the provision of other HIV services and VMMC unit cost. Also, VMMC unit cost was lower in primary health care facilities than in hospitals, and lower in facilities implementing task shifting.ConclusionsSubstantial efficiency gains could be made in VMMC service delivery in all countries. Options to increase efficiency of VMMC programs in the short term include focusing service provision in high yield sites when demand is high, focusing on task shifting, and taking advantage of efficiencies created by integrating HIV services. In the longer term, reductions in VMMC unit cost are likely by increasing the volume of clients at facilities by implementing effective demand generation activities.
| S-EPMC6136711 | biostudies-literature
Project description:Literature on Latino men and intervention for intimate partner violence/abuse (IPV/A) is slim. Over 100 men have voluntarily sought help for IPV/A perpetration from "The Men's Group" (TMG) at St. Pius V parish in Chicago, IL (US) and remained engaged for extended periods. Given the rarity of prolonged non-court mandated engagement in batterer intervention programs (BIPs), a case study was conducted to explore how TMG functions. Drawing on multiple data sources, this study examined development and implementation of TMG, while also investigating contextual factors, motivators and facilitators of participants' involvement. Data revealed that TMG functions within a supportive community context by using a mixture of traditional techniques and innovative practices, creating a unique treatment modality. The program was found to be culturally-sensitive and spirituality-based. Reasons for initial attendance varied but included: (1) fear of losing or actual loss of their partner/family; (2) acknowledging a problem and desiring to change for self or others; and (3) a desire to reach inner peace. Three themes shed light on why men remain engaged in TMG, including: (1) being met with respect by facilitators; (2) experiencing TMG as "family"; and (3) gaining benefits. Reliance upon the criminal justice system is not enough to address IPV/A perpetration. This program shows promise as an alternative or supplement to traditional BIPs, which typically rely on clients being court-mandated to attend treatment. Given the widespread nature of IPV/A, understanding the operation of potential community-based alternatives or supplements to BIPs is critical in widening access to treatment.
| S-EPMC7025425 | biostudies-literature
Project description:BackgroundVoluntary Medical Male Circumcision (VMMC) is a key intervention in HIV/AIDS. Improving VMMC program uptake in Zambia requires careful monitoring of adverse events (AE) to inform program quality and safety. We investigate the prevalence of VMMC AE and their associated factors among adult males in Ndola, Copperbelt Province, Zambia.MethodsWe performed a cross-sectional study using secondary clinical data collected in 2015 using two validated World Health Organisation/Ministry of Health reporting forms. We reviewed demographics and VMMC surgical details from 391 randomly sampled adult males aged ≥18 years at Ndola Teaching Hospital, a specialised VMMC fixed site in Zambia. Non-parametric tests (Fisher's exact test or Chi-square depending on assumptions being met) and logistic regression were conducted to determine the relationships between associated factors and VMMC AE.ResultsThe overall VMMC AE prevalence was 3.1% (95% CI 1.60%- 5.30%) and most AEs occurred postoperatively. In decreasing order, the commonly reported VMMC AE included; bleeding (47.1%), swelling (29.4%), haematoma (17.6%), and delayed wound healing (5.9%). There was an inversely proportional relationship between VMMC volume (as measured by the number of surgeries conducted per VMMC provider) and AEs. Compared to the highest VMMC volume of 63.2% (247/391) as reference, as VMMC volume reduced to 35.0% (137/391) and then 1.8% (7/391), the likelihood of AEs increased by five times (aOR 5.08; 95% CI 1.33-19.49; p = 0.018) and then sixteen times (aOR 16.13; 95% CI 1.42-183.30; p = 0.025) respectively.ConclusionsOur study found a low prevalence of VMMC AEs in Ndola city, Copperbelt Province of Zambia guaranteeing the safety of the VMMC program. We recommend more surgically proficient staff to continue rendering this service. There is a need to explore other high priority national/regional areas of VMMC program safety/quality, such as adherence to follow-up visits.
| S-EPMC8415607 | biostudies-literature
Project description:BACKGROUND:Men's understanding of counseling messages after voluntary medical male circumcision (VMMC) plays an important role in whether they follow them. Data on triggers for early resumption of sex may be useful as scale-up of VMMC for HIV prevention continues in sub-Saharan Africa. METHODS:Data on understanding of post-VMMC abstinence recommendations, resumption of sex, condom use, and triggers for resuming sex were collected from participants during a follow-up interview 35-42 days after ShangRing circumcision in Kenya and Zambia. RESULTS:Of 1149 men who had ShangRing circumcision, 1096 (95.4%) completed follow-up. Nearly all (99.2%) reported being counseled to abstain from sex post-VMMC; among those, most (92.2%) recalled the recommended abstinence period was 6 weeks. Most men (94.1%) reported that the counselor gave reasons for post-VMMC abstinence and recalled appropriate reasons. Few (13.4%) men reported resuming sex at 35-42 days' follow-up. Among those, 54.8% reported never using a condom post-VMMC. Younger participants (odds ratio 0.3, 95% confidence interval: 0.2 to 0.5, P < 0.0001) and those reporting at least some condom use at baseline (odds ratio 0.5, 95% confidence interval: 0.3 to 0.7, P = 0.0003) were less likely to report resuming sex. Among men who reported some condom use, most (71.5%) said condoms were much easier or easier to use after circumcision. Men reported various reasons for early resumption of sex, primarily strong sexual desire (76.4%). CONCLUSIONS:Most men reported awareness of and adherence to the counseling recommendations for post-VMMC abstinence. A minority reported early resumption of sex, and, among those, condom use was low. Results could be used to improve post-VMMC counseling.
| S-EPMC4936421 | biostudies-literature