To meet UNAIDS’ 90–90–90 treatment goals, effective approaches to HIV testing services (HTSs) are urgently needed. In 2015, a cross-sectional study was conducted to evaluate effectiveness and feasibility of partner notification for HTS in Tanzania. Men and women newly diagnosed with HIV were enrolled as index clients, listed sexual partners, and given options to notify and link their partners to HTS. Of 653 newly diagnosed individuals, 390 index clients were enrolled, listed 438 sexual partners, of whom 249 (56.8%) were successfully referred. Of 249 partners reaching the facilities, 96% tested for HIV, 148 (61.9%) tested HIV+ (all newly diagnosed), and 104 (70.3%) of partners testing positive were enrolled into HIV care and treatment. Results showed good acceptability, feasibility and effectiveness, as evidenced by high uptake of partner notification among newly diagnosed individuals, over half of listed partners successfully referred, and a very high positivity rate among referred sexual partners.
A growing evidence base supports expansion of partner notification in HIV testing services (HTS) in sub-Saharan Africa. In 2015, a cross-sectional study was conducted in Njombe region, Tanzania, to evaluate partner notification within facility-based HTS. Men and women newly diagnosed with HIV were enrolled as index clients and asked to list current or past sexual partners for referral to HTS. Successful partner referral was 2.5 times more likely among married compared to unmarried index clients and 2.2 times more likely among male compared to female index clients. In qualitative analysis, male as well as female index clients mentioned difficulties notifying past or casual partners, and noted disease symptoms as a motivating factor for HIV testing. Female index clients mentioned gender-specific challenges to successful referral. Women may need additional support to overcome challenges in the partner notification process. In addition to reducing barriers to partner notification specific to women, a programmatic emphasis on social strengths of males in successfully referring partners should be considered.
BackgroundScaling up voluntary medical male circumcision (VMMC) to 80% of men aged 15–49 within five years could avert 3.4 million new HIV infections in Eastern and Southern Africa by 2025. Since 2009, Tanzania and Zimbabwe have rapidly expanded VMMC services through different delivery (fixed, outreach or mobile) and intensity (routine services, campaign) models. This review describes the modality and intensity of VMMC services and its influence on the number and age of clients.Methods and FindingsProgram reviews were conducted using data from implementing partners in Tanzania (MCHIP) and Zimbabwe (PSI). Key informant interviews (N = 13 Tanzania; N = 8 Zimbabwe) were conducted; transcripts were analyzed using Nvivo. Routine VMMC service data for May 2009–December 2012 were analyzed and presented in frequency tables. A descriptive analysis and association was performed using the z-ratio for the significance of the difference. Key informants in both Tanzania and Zimbabwe believe VMMC scale-up can be achieved by using a mix of service delivery modality and intensity approaches. In Tanzania, the majority of clients served during campaigns (59%) were aged 10–14 years while the majority during routine service delivery (64%) were above 15 (p<0.0001). In Zimbabwe, significantly more VMMCs were done during campaigns (64%) than during routine service delivery (36%) (p<0.00001); the difference in the age of clients accessing services in campaign versus non-campaign settings was significant for age groups 10–24 (p<0.05), but not for older groups.ConclusionsIn Tanzania and Zimbabwe, service delivery modalities and intensities affect client profiles in conjunction with other contextual factors such as implementing campaigns during school holidays in Zimbabwe and cultural preference for circumcision at a young age in Tanzania. Formative research needs to be an integral part of VMMC programs to guide the design of service delivery modalities in the face of, or lack of, strong social norms.
Introduction Adverse events (AEs) rates in voluntary medical male circumcision (VMMC) are critical measures of service quality and safety. While these indicators are key, monitoring AEs in large‐scale VMMC programmes is not without challenges. This study presents findings on AEs that occurred in eight years of providing VMMC services in three regions of Tanzania, to provide discussion both on these events and the structural issues around maintaining safety and quality in scaled‐up VMMC services. Methods We look at trends over time, demographic characteristics, model of VMMC and type and timing of AEs for 1307 males who experienced AEs among all males circumcised in Tabora, Njombe and Iringa regions from 2009 to 2017. We analysed deidentified client data from a VMMC programme database and performed multivariable logistic regression with district clustering to determine factors associated with intraoperative and postoperative AEs among VMMC clients. Results and discussion Among 741,146 VMMC clients, 0.18% (1307/741,146) experienced a moderate or severe AE. The intraoperative AE rate was 2.02 per 100,000 clients, and postoperative rate was 2.29 per 1000 return clients. Multivariable logistic regression showed that older age (20 to 29 years) was significantly associated with intraoperative AEs (aOR: 3.51, 95% CI: 1.17 to 10.6). There was no statistical significant difference in AE rates by surgical method. Mobile VMMC service delivery was associated with the lowest risk of experiencing postoperative AEs (aOR:0.64, 95% CI: 0.42 to 0.98). AE rates peaked in the first one to three years of the programme and then steadily declined. Conclusions In a programme with robust AE monitoring methodologies, AE rates reported in these three regions were very low and declined over time. While these findings support the safety of VMMC services, challenges in reporting of AEs in a large‐scale VMMC programme are acknowledged. International and national standards of AE reporting in VMMC programmes are clear. As VMMC programmes transition to national ownership, challenges, strengths and learning from AE reporting systems are needed to support safety and quality of services.
Introduction Evidence indicates HIV oral pre‐exposure prophylaxis (PrEP) is highly efficacious and effective. Substantial early discontinuation rates are reported by many programs, which may be misconstrued as program failure. However, PrEP use may be non‐continuous and still effective, since HIV risk fluctuates. Real‐world PrEP use phenomena, like restarting and cyclical use, and the temporal characteristics of these use patterns are not well described. The objective of our study was to characterize and identify predictors of use patterns observed in large PrEP scale‐up programs in Africa. Methods We analysed demographic and clinical data routinely collected during client visits between 2017 and 2019 in three Jhpiego‐supported programs in Kenya, Lesotho and Tanzania. We characterized duration on/off PrEP and, using ordinal regression, modelled the likelihood of spending additional time off and identified factors associated with increasing cycle number. The Andersen‐Gill model was used to identify predictors of time to PrEP discontinuation. To analyse factors associated with a client's first return following initiation, we used a two‐step Heckman probit. Results Among 47,532 clients initiating PrEP, approximately half returned for follow‐up. With each increase in cycle number, time off PrEP between use cycles decreased. The Heckman first‐step model showed an increased probability of returning versus not by older age groups and among key and vulnerable population groups versus the general population; in the second‐step model older age groups and key and vulnerable populations were less likely in Kenya, but more likely in Lesotho, to return on‐time (refill) versus delayed (restarting). Conclusions PrEP users frequently cycle on and off PrEP. Early discontinuation and delays in obtaining additional prescriptions were common, with broad predictive variability noted. Time off PrEP decreased with cycle number in all countries, suggesting normalization of use with experience. More nuanced measures of use are needed than exist for HIV treatment if effective use of PrEP is to be meaningfully measured. Providers should be equipped with measures and counselling messages that recognize non‐continuous and cyclical use patterns so that clients are supported to align fluctuating risk and use, and can readily restart PrEP after stopping, in effect empowering them further to make their own prevention choices.
Voluntary medical male circumcision (VMMC) has been shown to be an effective prevention strategy against HIV infection in males [1–3]. Since 2007, the President’s Emergency Plan for AIDS Relief (PEPFAR) has supported VMMC programs in 14 priority countries in Africa. Today several of these countries are preparing to transition their VMMC programs from a scale-up and expansion phase to a maintenance phase. As they do so, they must consider the best approaches to sustain high levels of male circumcision in the population. The two alternatives under consideration are circumcising adolescents 10–14 years old over the long term or integrating early infant male circumcision (EIMC) into maternal and child health programs. The paper presents an analysis, using the Decision Makers Program Planning Tool, Version 2.0 (DMPPT 2.0), of the estimated cost and impact of introducing EIMC into existing VMMC programs in several countries in eastern and southern Africa. Limited cost data exist for the implementation of EIMC, but preliminary studies, such as the one detailed in Mangenah, et al. [4–5], suggest that the cost of EIMC may be less than that of adolescent and adult male circumcision. If this is the case, then adding EIMC to the VMMC program will increase the number of circumcisions that need to be performed but will not increase the total cost of the program over the long term. In addition, we found that a delayed or slow start-up of EIMC would not substantially reduce the impact of adding it to the program or increase cumulative long-term costs, which should make introduction of EIMC more feasible and attractive to countries contemplating such a program innovation.
To maintain high circumcision prevalence, voluntary medical male circumcision programs in East and Southern Africa need to plan for sustainability and conduct transition assessments early on, rather than waiting until the saturation of priority targets at the end of the program.
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