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Potential impact of multiple interventions on HIV incidence in a hyperendemic region in Western Kenya: a modelling study.
BMC Infectious Diseases. 2016 Apr 29; 16:189.BACKGROUND: Multiple prevention interventions, including early antiretroviral therapy initiation, may reduce HIV incidence in hyperendemic settings. Our aim was to predict the short-term impact of various single and combined interventions on HIV spreading in the adult population of Ndhiwa subcounty (Nyanza Province, Kenya). METHODS: A mathematical model was used with data on adults (15-59 years) from the Ndhiwa HIV Impact in Population Survey to compare the impacts on HIV prevalence, HIV incidence rate, and population viral load suppression of various interventions. These interventions included: improving the cascade of care (use of three guidelines), increasing voluntary medical male circumcision (VMMC), and implementing pre-exposure prophylaxis (PrEP) use among HIV-uninfected women. RESULTS: After four years, improving separately the cascade of care under the WHO 2013 guidelines and under the treat-all strategy would reduce the overall HIV incidence rate by 46 and 58 %, respectively, vs. the baseline rate, and by 35 and 49 %, respectively, vs. the implementation of the current Kenyan guidelines. With conservative and optimistic scenarios, VMMC and PrEP would reduce the HIV incidence rate by 15-25 % and 22-28 % vs. the baseline, respectively. Combining the WHO 2013 guidelines with VMMC would reduce the HIV incidence rate by 35-56 % and combining the treat-all strategy with VMMC would reduce it by 49-65 %. Combining the WHO 2013 guidelines, VMMC, and PrEP would reduce the HIV incidence rate by 46-67 %. CONCLUSIONS: The impacts of the WHO 2013 guidelines and the treat-all strategy were relatively close; their implementation is desirable to reduce HIV spread. Combining several strategies is promising in adult populations of hyperendemic areas but requires regular, reliable, and costly monitoring.
Geneva, Switzerland, UNAIDS, 2016.  p.Efforts to reach fewer than 500 000 new HIV infections by 2020 are off track. This simple conclusion sits atop a complex and diverse global tapestry. Data from 146 countries show that some have achieved declines in new HIV infections among adults of 50% or more over the last 10 years, while many others have not made measurable progress, and yet others have experienced worrying increases in new HIV infections.
WHO prequalification of male circumcision devices. Public report. Product: PrePex. Number: PQMC 0001-001-00. Version 1.0.
[Geneva, Switzerland], WHO, 2013 May.  p. (PQMC 0001-001-00)PrePex with product codes DW0201, DW0202, DW0203, DW0204 and DW0205, manufactured by Circ MedTech Limited, CE-marked regulatory version, was accepted for the WHO list of prequalified male circumcision devices and was listed on 31 May 2013. PrePex is a single use, disposable device; indicated for circumcision of adult men, defined as circumferential excision of the foreskin or prepuce at or near the level of coronal sulcus, with minimal amount of preputial skin remaining. The device should not be used if the package has been compromised. Use by trained personnel only. All device components should not be reused at the risk of cross contamination. The device is intended for adults only and is not applicable for males under the age of 18. The device should be used only in settings where suitable surgical facilities and skills are available within a short time frame (6-12 hours) in order to manage potentially serious complications resulting from device displacements. Device displacement when wearing the device, may lead to the risk of adverse events. Informing the patient of safe behavior when wearing the device is critical. PrePex includes the following items: 1. Placement Ring 2. Elastic Ring 3. Inner Ring 4. Verification Thread Accessories: The PrePex Sizing Plate (PSP) is intended for single use for selecting an appropriate device size. The use of PrePex requires additional tools and materials which are not supplied with PrePex. For Placement: examination gloves, antiseptic solution, skin marker, gauze, 5% anesthetic cream and nurse utility scissors. For Removal: examination gloves, antiseptic solution, sterile harvey wire scissors, sterile forceps, sterile spatula, sterile scalpel, 2 wound dressings, nurse utility scissors and a cutter. Storage: The test kit should be stored at -10 to 55 °C. Shelf-life: 3 years.
New York, New York, World Youth Alliance, .  p.The World Youth Alliance’s White Paper on HIV / AIDS proposes evidence-based and person-centered treatment, such as the provision of antiretroviral drugs, and prevention strategies, such as a reduction in concurrent partners and a delay in sexual debut. These strategies reflect the capacity of the person to make responsible decisions and to stop the high-risk behavior that exposes him or her to HIV. The paper ends with an evaluation of UNAIDS' harm reduction strategies and a call for UNAIDS to start emphasizing a person-centered response that reflects science and culture.
Geneva, Switzerland, UNAIDS, 2011 Oct.  p. (UNAIDS Issues Brief; UNAIDS Policy Document; UNAIDS/JC2244E)Over the past 30 years there have been tremendous gains in the global HIV response, but until now there has been only limited systematic effort to match needs with investments. The result is often a mismatch of the two, and valuable resources are stretched inefficiently across many objectives. To achieve an optimal HIV response, countries and their international partners must adopt a more strategic approach to investments. In June 2011 a policy paper was published in The Lancet (Schwartländer et al) that laid out a new framework for investment for the global HIV response. The new framework is based on existing evidence of what works in HIV prevention, treatment, care and support. It is intended to facilitate more focused and strategic use of scarce resources. Modelling of the framework’s impact shows that its implementation would avert 12.2 million new infections and 7.4 million AIDS-related deaths between 2011 and 2020. This modelling also indicates that implementation of the investment framework is highly cost-effective, with additional investment largely offset by savings in treatment costs alone, and enabling the HIV response to reach an inflection point in both investments and rates of HIV infection. (Excerpts)
Male circumcision: towards a World Health Organisation normative practice in resource limited settings.
Asian Journal of Andrology. 2010; 12(5):628-638.There is now grade 1 evidence that male circumcision (MC) reduces the risk of a man acquiring HIV. Modelling studies indicate MC could in the next 10 years save up to 2 million lives in those African countries with high HIV prevalence. Several African countries are now scaling up public health MC programmes. The most effective immediate public health MC programmes in Africa will need to target 18-20 years old men. In the longer term there is a need for infant circumcision programmes. In order to implement more widespread MC there is a need to make the surgical procedures as simple as possible so that safe operations can be performed by paramedical staff. The WHO Manual of Male Circumcision under local anaesthetic was written with these objectives in mind. Included in the manual are three adult techniques and four paediatric procedures. The adult procedures are the dorsal slit, the forceps guided and the sleeve resection methods. Paediatric methods included are the plastibell technique, the Mogen and Gomco shield method and a standard surgical dorsal slit procedure. Each method is described in a step by step manner with photographic and line drawing illustrations. In addition to the WHO manual of surgical technique a teaching course has been developed and using this course it has been possible in one week to train a circumcision surgeon who has had no or minimal previous surgical experience. Further scaling will require training of circumcision surgeons, monitoring performance, training the trainer workshops as well as advocacy at national, international and government meetings. In addition to proceeding with standardised methods work is in progress to assess novel techniques in adults such as stay on ring devices and policies are being formulated as to how to assess new devices. Also work is in progress to explore efficiencies in surgical processing by task sharing. Proper informed consent and safety remain paramount and great care has to be taken as programmes in Africa scale up. In continental China where the HIV epidemic is at a much earlier stage there may be a case for considering infant circumcision but great care will be needed to ensure that there is no harm.
Exchange. 2009; (3):14-15.Male circumcision is common in the Asia region, with high prevalence noted in eight out of 27 South and Southeast Asian and Pacific Island countries. Bangladesh, Indonesia, Pakistan and the Philippines have the highest number of circumcised men, estimated at 120 million. In these countries, circumcision is primarily for religious and cultural reasons with the exception in the Republic of Korea and the Philippines where circumcision is routine and widespread and with no linkages to religion.
[Geneva, Switzerland], WHO, 2009. 8 p.This report shows how countries with low prevalence of male circumcision but high prevalence of HIV have made progress to scale up male circumcision services.
Country experiences in the scale-up of male circumcision in the Eastern and Southern Africa Region: Two years and counting. A sub-regional consultation, Windhoek, Namibia, June 9-10 2009.
[Unpublished] 2009. 24 p.This report on a sub-regional consultation held in Windhoek, Namibia, 9-10 July 2009 summarises progress reports, lessons from programme experience, and priorities for the next year from nine countries.
South African Medical Journal. 2009 Jan; 99(1):12.Add to my documents.
Eastern Mediterranean Health Journal. 2008; 14 Suppl:S90-6.Now, 28 years after acquired immune deficiency syndrome (AIDS) was first recognised, it has become a global pandemic affecting almost all countries. WHO/UNAIDS (Joint United Nations Programme on HIV/AIDS) estimate the number of people living with human immunodeficiency virus (HIV) worldwide in 2007 at 33.2 million. Every day 68 000 become infected and over 5700 die from AIDS; 95% of these infections and deaths have occurred in developing countries. The HIV pandemic remains the most serious of infectious disease challenges to public health. Sub-Saharan Africa remains the most seriously affected region, with AIDS the leading cause of death there. Although percentage prevalence has stabilized, continuing new infections (even at a reduced Estimated number of people living with HIV globally, 1990-2007, data from UNAIDS rate) contribute to the estimated number of persons living with HIV, 33.2 million (30.6-36.1 million). A defining feature of the pandemic in the current decade is the increasing burden of HIV infection in women, which has additional implications for mother-to-child transmission. In sub-Saharan Africa, almost 61% of adults living with HIV in 2007 were women. The impact of HIV mortality is greatest on people in their 20s and 30s; this severely distorts the shape of the population pyramid in affected societies. Globally, the number of children living with HIV increased from 1.5 million in 2001 to 2.5 million in 2007, 90% of them in sub-Saharan Africa. HIV/AIDS also poses a threat to economic growth in many countries already in distress. According to the World Bank analysis of 80 developing countries, as the prevalence of HIV infection increases from 15% to 30%, the per capita gross domestic product decreases 1.0%-1.5% per year. The powerful negative impact of AIDS on households, productive enterprises and countries stems partly from the high cost of treatment, which diverts resources from productive investments, but mostly from the fact that AIDS affects people during their economically productive adult years, when they are responsible for the support and care of others. This crisis has necessitated a unique and truly global response to meld the resources, political power, and technical capacity of all UN organizations, developing countries and others in a concerted manner to curb the pandemic. AIDS often engenders stigma, discrimination, and denial, because of its association with marginalized groups, sexual transmission and lethality, hence it requires a more comprehensive and holistic approach. During the past 10 years, many developments have occurred in response to this pandemic. WHO has played an important role in this response. This article reviews the major developments in treatment and prevention and the role of WHO in response to these developments.
Safe, voluntary, informed male circumcision and comprehensive HIV prevention programming. Guidance for decision-makers on human rights, ethical and legal considerations. Pre-publication.
Geneva, Switzerland, UNAIDS, 2008 Mar. 28 p. (UNAIDS/08.19E / JC1552E)Throughout the world, HIV prevalence is generally lower in populations that practise male circumcision than in populations where most men are uncircumcised. This has been observed over the years of the HIV epidemic and has now been confirmed through three randomized controlled trials concluded in 2005-2006. The trials showed that male circumcision reduces by 60% the transmission of HIV from women to circumcised men. The results have led to the conclusion that male circumcision is an effective risk-reduction measure for men, and should be used in addition to other known strategies for the prevention of heterosexually acquired HIV infection in men. (excerpt)
Lancet. 2007 Dec 1; 370(9602):1817-1818.Progress towards making male circumcision for HIV prevention a reality in Africa has been slow because of cultural hurdles in a few countries, financial constraints in most, and a serious shortage of skilled practitioners throughout the continent. Joint Programme on HIV and AIDS made one of the most important policy statements in recent times on the fight against HIV in developing countries. After a 2-day consultation in Montreaux, Switzerland, the UN agencies released a document that urged countries with high rates of heterosexually transmitted HIV to consider adding male circumcision to their armamentarium against AIDS. The recommendation had a sound scientific basis. The results of three randomised controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda, and Orange Farm, South Africa had shown that male circumcision reduces the risk of heterosexually acquired HIV infection in men by around 60%. (excerpt)
Baltimore, Maryland, Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, Information and Knowledge for Optimal Health [INFO], 2007 Oct 11.  p. (Global Health Technical Briefs; USAID Grant No. GPH-A-00-02-00003-00)Male circumcision reduces HIV transmission from women to men by approximately 60%. Men who have been recently circumcised must abstain from sex until the wound has completely healed. Male circumcision should be performed by trained personnel under hygienic conditions. Male circumcision is only partially protective. MC services must be accompanied by appropriate counseling and communication messages, including ABC (Abstain, Be Faithful/Reduce Number of Sexual Partners, Condom Use). (author's)
Appropriate Technology. 2007 Jun; 34(2):31.There is now strong evidence from three randomized controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda (funded by the US National Institutes of Health) and Orange Farm, South Africa (funded by the French National Agency for Research on AIDS) that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60 per cent. This evidence supports the findings of numerous observational studies that have also suggested that the areas with lower HIV prevalence occur where there are high rates of male circumcision in some countries in Africa. Currently, an estimated 665 million men, or 30 per cent of men worldwide, are estimated to be circumcised. (excerpt)
Lancet Infectious Diseases. 2007 Aug; 7(8):508.A report from the Global HIV Prevention Working Group, a panel of leading AIDS experts, warns that prevention efforts are not keeping pace with the gains being made in treating people infected with HIV. New data outlined in the report show that by fully scaling up all scientifically proven prevention strategies, an estimated 30 million of the 60 million HIV infections expected to occur by 2015 could be averted. With expanded prevention, the annual number of new infections would drop to 2 million per year by 2015-a level that may cause the epidemic to move into long-term decline. "It is widely assumed that HIV continues to spread because prevention isn't effective, and that's simply not true", said David Serwadda (Institute of Public Health, Makerere University, Uganda). "The problem is that effective prevention isn't reaching the people who need it". According to the report, prevention strategies including those to reduce the risk of mother-to-child HIV transmission are accessible to fewer than one in five people who could benefit from them. (excerpt)
African Human Rights Law Journal. 2005; 5(1):171-181.The adoption of the United Nations Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child strengthened the protection of the rights of children. Although Kenya has ratified both instruments and enacted the Children's Act, all instruments prohibiting practices that are prejudicial to the rights of children, circumcision of the boy-child for purely cultural reasons still takes place in the country, sometimes with severe consequences, such as deaths. This article demonstrates that the circumcision of non-consenting boys under the age of 18 violates their basic human rights, particularly the right not to be discriminated against, the right to health, the right to privacy and bodily integrity, and the right not to be subjected to cruel and inhuman treatment. The article concludes that the human rights implications stemming from male circumcision necessitate positive action against this practice by the government. (author's)
Reproductive Health Matters. 2007 May; 15(29):49-52.INTEREST in male circumcision as an HIV prevention intervention is focused on the promise it holds to reduce the risk of HIV infection for men engaged in heterosexual, vaginal intercourse. Following an international consultation on 6-8 March 2007, WHO and UNAIDS released "Conclusions and Recommendations" on the policy and programmatic implications of the existing data on male circumcision and HIV prevention. This is a welcome step in what will inevitably be a long process to ensure male circumcision is appropriately implemented as part of the response to HIV. Beyond simply the offer of the service, if male circumcision is to be an effective strategy over the long term, these conclusions and recommendations will need to be translated into guidelines and adapted and adopted at national and local level. Policies and programmes will need to be developed, and appropriate monitoring and evaluation systems created. In doing so, the devil, as they say, will be in the details. Some issues to be considered as this process moves forward are outlined below. (excerpt)
Lancet Infectious Diseases. 2007 May; 7(5):313.Male circumcision should now be recognised as an important intervention to reduce the risk of heterosexually acquired HIV infection in men in high-prevalence countries, said WHO and UNAIDS in a position statement published in March. In a keynote speech at the European Congress of Clinical Microbiology and Infectious Diseases in Munich (April 2), George Schmid (WHO, Geneva, Switzerland) said "combined data from three randomised controlled trials undertaken in Kenya, Uganda, and South Africa show that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. This makes male circumcision the biggest news for tackling HIV prevention that we have had in years". Circumcision is one of the oldest surgical procedures in the world and about 30% of the global adult male population is circumcised. Research shows that countries or regions in Africa with low rates of male circumcision correlate with a higher incidence of HIV infection. According to Schmid, "Modelling data show that widespread implementation of male circumcision in southern sub-Saharan Africa, a high prevalence area, could prevent 2 million infections over a 10-year period. We therefore need to target adolescent men in these areas to see an immediate public-health benefit". He added, "this is not an appropriate public-health intervention strategy for Europe". Unpublished data from Uganda, said Schmid, shows that with half of all males circumcised, there would be a 25-30% reduction in new HIV cases in Uganda. (excerpt)
New data on male circumcision and HIV prevention: policy and programme implications. WHO / UNAIDS Technical Consultation. Male Circumcision and HIV Prevention: Research Implications for Policy and Programming, Montreux, 6-8 March 2007. Conclusions and recommendations.
Geneva, Switzerland, WHO, 2007 Mar 28. 10 p.At the end of 2006, an estimated 39.5 million people were living with HIV and 4.3 million became newly infected with the virus that year. Prevention must be greatly prioritized in the response to AIDS and efforts are being made to find new prevention technologies to bolster the package of already known effective prevention methods. Male circumcision is one of these new potential methods, along with vaginal microbicides, pre-exposure prophylaxis with antiretroviral medication, herpes suppressive therapy, cervical barrier methods and HIV vaccines. A number of observational studies indicate that circumcised men have lower levels of HIV infection than uncircumcised men. On 13 December 2006, the United States of America National Institutes of Health announced that two trials assessing the impact of male circumcision on HIV risk would be stopped on the recommendation of the Data Safety and Monitoring Board. The trials being carried out in Kisumu, Kenya, and Rakai District, Uganda revealed at least a 53%and 51% reduction in risk of acquiring HIV infection, respectively. These results support findings published in 2005 from the South Africa Orange Farm Intervention Trial, sponsored by the French National Agency for Research on AIDS, which demonstrated at least a 60% reduction in HIV infection among men who were circumcised. WHO and UNAIDS convened an international consultation to review the results of the three randomised controlled trials and other evidence on male circumcision and HIV prevention, to discuss the policy and programme implications, and to make recommendations regarding public health issues. This document summarizes the principal conclusions and recommendations of the meeting. (excerpt)
Statement on Kenyan and Ugandan trial findings regarding male circumcision and HIV. Male circumcision reduces the risk of becoming infected with HIV, but does not provide complete protection.
Geneva, Switzerland, WHO, 2006 Dec 13.  p.The Joint United Nations Programme on HIV/AIDS and its Cosponsors, WHO, UNFPA, UNICEF and the World Bank, note with considerable interest today's announcement by the US National Institutes of Health that two trials assessing the impact of male circumcision on HIV risk are being stopped on the recommendation of the NIH Data Safety and Monitoring Board (DSMB). The two trials, funded by the US National Institutes of Health, were carried out in Kisumu, Kenya, among men aged 18-24 years and in Rakai, Uganda, among men aged 15-49 years. The trials, which completed enrolment of patients in 2005, were stopped by the DSMB evaluating the results of interim analyses. The role of the DSMB is to assess progress of the trials and recommend whether to continue, modify or terminate them. Although no detailed results have been released at this time, the National Institutes of Health statement makes it clear that the studies are being stopped because they revealed an approximate halving of risk of HIV infection in men who were circumcised. The results support the findings of the South Africa Orange Farm Intervention Trial, funded by the French Agence Nationale de Recherches sur le SIDA (ANRS) and published in late 2005, which demonstrated at least a 60% reduction in HIV infection among circumcised men. (excerpt)
Trends in antenatal human immunodeficiency virus prevalence in western Kenya and eastern Uganda: evidence of differences in health policies?
International Journal of Epidemiology. 2004 Jun; 33(3):542-548.The objective was to observe recent trends in human immunodeficiency virus (HIV) prevalence in antenatal clinic attendees to determine if previously noted falls in HIV prevalence are occurring on both sides of the Kenyan-Ugandan border. An ecologic study was conducted at the district level comparing HIV prevalence rates over time using data available through reports published by the Kenyan and Ugandan Ministries of Health and UNAIDS. Sentinel sites were compared with respect to population, ethnicity, language group, and the prevalence of circumcision practice. The prevalence of HIV found at each sentinel site was recorded for the years 1990–2000 and analysed visually and by conducting bivariate correlations. Ethnographic analysis revealed a wide mix of ethnic and language groups and circumcision rates on both sides of the border. All sentinel surveillance sites in Uganda showed trends towards decreasing HIV prevalence, with three of five sites showing statistically significant declines (r = -0.87, -0.85, -0.86, P <0.05). In contrast, all of the surveillance sites in Kenya showed trends toward increasing HIV prevalence, with two of the five sites showing statistically significant increases (r = 0.62, 0.84, P <0.05). The declines in HIV prevalence occurring in Uganda are not being seen in geographically proximal districts of Kenya. No obvious differences in ethnic groupings or their associated prevalence of circumcision appeared to explain these differences. This suggests that decreasing HIV prevalence in Uganda is not due to the natural course of the epidemic but reflects real success in terms of HIV control policies. (author's)