Dataset Information

Trends in the Marginal Cost of Male Circumcision in Rural Rakai Uganda.

ABSTRACT: INTRODUCTION:Male circumcision (MC) is an effective intervention to reduce HIV acquisition in men in Africa. We conducted a cost analysis using longitudinal data on expenditures on services and community mobilization to estimate the marginal cost of MC over time and understand cost drivers during scale-up. METHODS:We used a time series with monthly records from 2008 to 2013, for a total of 72 monthly observations, from the Rakai MC Program in Uganda. Generalized linear models were used to estimate the marginal cost of an MC procedure. RESULTS:The marginal cost per MC in a mobile camp was $23 (P < 0.01) and in static facilities was $35 (P < 0.1). Major cost drivers included supplies in mobile camps with increasing numbers of surgeries, savings due to task shifting from physicians to clinical officers, and increased efficiency as personnel became more experienced. CONCLUSIONS:As scale-up continues, marginal costs may increase because of mobilization needed for less motivated late adopters, but improved efficiency could contain costs.

SUBMITTER: Alfonso YN

PROVIDER: S-EPMC5110383 | biostudies-literature | 2016 Dec

REPOSITORIES: biostudies-literature

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Trends in the Marginal Cost of Male Circumcision in Rural Rakai Uganda.

Alfonso Yira N YN Bishai David D Nantongo Agnes A Kakembo Rebecca R Kobusinge Sarah S Kacker Seema S Kigozi Godfrey G Gray Ronald R

Journal of acquired immune deficiency syndromes (1999) 20161201 5

<h4>Introduction</h4>Male circumcision (MC) is an effective intervention to reduce HIV acquisition in men in Africa. We conducted a cost analysis using longitudinal data on expenditures on services and community mobilization to estimate the marginal cost of MC over time and understand cost drivers during scale-up.<h4>Methods</h4>We used a time series with monthly records from 2008 to 2013, for a total of 72 monthly observations, from the Rakai MC Program in Uganda. Generalized linear models were ...[more]

PMID: 27509246

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Project description:BackgroundThe objective of the study was to compare rates of adverse events (AEs) related to male circumcision (MC) in HIV-positive and HIV-negative men in order to provide guidance for MC programs that may provide services to HIV-infected and uninfected men.Methods and findingsA total of 2,326 HIV-negative and 420 HIV-positive men (World Health Organization [WHO] stage I or II and CD4 counts > 350 cells/mm3) were circumcised in two separate but procedurally identical trials of MC for HIV and/or sexually transmitted infection prevention in rural Rakai, Uganda. Participants were followed at 1-2 d and 5-9 d, and at 4-6 wk, to assess surgery-related AEs, wound healing, and resumption of intercourse. AE risks and wound healing were compared in HIV-positive and HIV-negative men. Adjusted odds ratios (AdjORs) were estimated by multiple logistic regression, adjusting for baseline characteristics and postoperative resumption of sex. At enrollment, HIV-positive men were older, more likely to be married, reported more sexual partners, less condom use, and higher rates of sexually transmitted disease symptoms than HIV-negative men. Risks of moderate or severe AEs were 3.1/100 and 3.5/100 in HIV-positive and HIV-negative participants, respectively (AdjOR 0.91, 95% confidence interval [CI] 0.47-1.74). Infections were the most common AEs (2.6/100 in HIV-positive versus 3.0/100 in HIV-negative men). Risks of other complications were similar in the two groups. The proportion with completed healing by 6 wk postsurgery was 92.7% in HIV-positive men and 95.8% in HIV-negative men (p = 0.007). AEs were more common in men who resumed intercourse before wound healing compared to those who waited (AdjOR 1.56, 95% CI 1.05-2.33).ConclusionsOverall, the safety of MC was comparable in asymptomatic HIV-positive and HIV-negative men, although healing was somewhat slower among the HIV infected. All men should be strongly counseled to refrain from intercourse until full wound healing is achieved.Trial registrationhttp://www.ClinicalTrials.gov; for HIV-negative men #NCT00425984 and for HIV-positive men, #NCT000124878.

Project description:BackgroundOver the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circumcision for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention. The prevalence of male circumcision in Uganda nearly doubled from 26% in 2011 to 43% in 2016, but remains below the 2020 target level. Little is known about how common male circumcision is perceived to be, how accurate such perceptions are, and whether they are associated with men's own circumcision uptake.MethodsWe conducted a cross-sectional study of all adult residents of eight villages in Rwampara District, southwestern Uganda in 2020-2022. We elicited their perceptions of the adult male circumcision prevalence within their village: >50% (most men), 10% to <50% (some), <10%, (few to none), or do not know. We compared their perceived norms to the aggregated prevalence of circumcision reported in these villages. We used a modified multivariable Poisson regression model to estimate the association between perceived norms and personal circumcision uptake among men.ResultsWe surveyed 1566 participants (91% response rate): 698 men and 868 women. Among the men, 167 (27%) reported being circumcised, including 167/444 (38%) men <50 years of age. Approximately one-fourth of the population (189 (27%) men and 177 (20%) women) believed that few to no men in their own village had been circumcised. In a multivariable regression model, men who underestimated the prevalence of male circumcision were less likely to be circumcised themselves (adjusted relative risk (aRR) = 0.51; 95% confidence interval (CI) = 0.37-0.83).ConclusionsIn this population-based study in rural Uganda, one-fourth of men underestimated the prevalence of male circumcision. Men who underestimated the extent of circumcision uptake were themselves less likely to be circumcised. If the observed association is causal and underestimates within the population contribute to low uptake, then interventions correcting these misperceived norms could increase uptake of voluntary medical male circumcision.

Project description:ImportanceMedical male circumcision (MMC) and antiretroviral therapy (ART) are proven HIV prevention interventions, but there are limited data on the population-level effect of scale-up of these interventions in sub-Saharan Africa. Such evaluation is important for planning and resource allocation.ObjectiveTo examine whether increasing community MMC and ART coverage was associated with reduced community HIV incidence in Rakai District, Uganda.Design, setting, and participantsUsing person-level data from population-based surveys conducted from 1999 through 2013 in 45 rural Rakai communities, community-level ART and MMC coverage, sociodemographics, sexual behaviors, and HIV prevalence and incidence were estimated in 3 periods: prior to the availability of ART and MMC (1999-2004), during early availability of ART and MMC (2004-2007), and during mature program scale-up (2007-2013).ExposuresCommunity MMC coverage in males and ART coverage in HIV-positive persons of the opposite sex based on self-reported MMC status and ART use.Main outcomes and measuresAdjusted incidence rate ratios (IRRs) for sex-specific community HIV incidence estimated using multivariable Poisson regression with generalized estimating equations.ResultsFrom 1999 through 2013, 44,688 persons participated in 1 or more surveys (mean age at the first survey, 24.6 years [range, 15-49]; female, 56.5%; mean survey participation rate, 92.6% [95% CI, 92.4%-92.7%]). Median community MMC coverage increased from 19% to 39%, and median community ART coverage rose from 0% to 21% in males and from 0% to 26% in females. Median community HIV incidence declined from 1.25 to 0.84 per 100 person-years in males, and from 1.25 to 0.99 per 100 person-years in females. Among males, each 10% increase in community MMC coverage was associated with an adjusted IRR of 0.87 (95% CI, 0.82-0.93). Comparing communities with MMC coverage more than 40% (mean male community incidence, 1.03 per 100 person-years) with communities with coverage of 10% or less (mean male incidence, 1.69 per 100 person-years), the adjusted IRR was 0.61 (95% CI, 0.43-0.88). For each 10% increase in female self-reported ART coverage, there was no significant reduction in male HIV incidence (adjusted IRR, 0.95 [95% CI, 0.81-1.13]). Comparing communities with female ART coverage more than 20% (mean male incidence, 0.87 per 100 person-years) to communities with female ART coverage of 20% or less (mean male incidence, 1.17 per 100 person-years), the adjusted IRR was 0.77 (95% CI, 0.61-0.98). Neither MMC nor male ART coverage was associated with lower female community HIV incidence.Conclusions and relevanceIn Rakai, Uganda, increasing community MMC and female ART coverage was associated with lower community HIV incidence in males. If similar associations are found elsewhere, this would support further scale-up of MMC and ART for HIV prevention in sub-Saharan Africa.

Dataset Information

Trends in the Marginal Cost of Male Circumcision in Rural Rakai Uganda.

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Trends in the Marginal Cost of Male Circumcision in Rural Rakai Uganda.

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