Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011

Zebedee Mwandi and colleagues discuss Kenya's scale-up of voluntary medical male circumcision services, highlighting government leadership, a clear implementation strategy, and program flexibility and innovation as keys to Kenya's success

Single low-dose primaquine for blocking transmission of Plasmodium falciparum malaria - a proposed model-derived age-based regimen for sub-Saharan Africa.

BACKGROUND: In 2012, the World Health Organization recommended blocking the transmission of Plasmodium falciparum with single low-dose primaquine (SLDPQ, target dose 0.25 mg base/kg body weight), without testing for glucose-6-phosphate dehydrogenase deficiency (G6PDd), when treating patients with uncomplicated falciparum malaria. We sought to develop an age-based SLDPQ regimen that would be suitable for sub-Saharan Africa. METHODS: Using data on the anti-infectivity efficacy and tolerability of primaquine (PQ), the epidemiology of anaemia, and the risks of PQ-induced acute haemolytic anaemia (AHA) and clinically significant anaemia (CSA), we prospectively defined therapeutic-dose ranges of 0.15-0.4 mg PQ base/kg for children aged 1-5 years and 0.15-0.5 mg PQ base/kg for individuals aged ≥6 years (therapeutic indices 2.7 and 3.3, respectively). We chose 1.25 mg PQ base for infants aged 6-11 months because they have the highest rate of baseline anaemia and the highest risks of AHA and CSA. We modelled an anthropometric database of 661,979 African individuals aged ≥6 months (549,127 healthy individuals, 28,466 malaria patients and 84,386 individuals with other infections/illnesses) by the Box-Cox transformation power exponential and tested PQ doses of 1-15 mg base, selecting dosing groups based on calculated mg/kg PQ doses. RESULTS: From the Box-Cox transformation power exponential model, five age categories were selected: (i) 6-11 months (n = 39,886, 6.03%), (ii) 1-5 years (n = 261,036, 45.46%), (iii) 6-9 years (n = 20,770, 3.14%), (iv) 10-14 years (n = 12,155, 1.84%) and (v) ≥15 years (n = 328,132, 49.57%) to receive 1.25, 2.5, 5, 7.5 and 15 mg PQ base for corresponding median (1st and 99th centiles) mg/kg PQ base of: (i) 0.16 (0.12-0.25), (ii) 0.21 (0.13-0.37), (iii) 0.25 (0.16-0.38), (iv) 0.26 (0.15-0.38) and (v) 0.27 (0.17-0.40). The proportions of individuals predicted to receive optimal therapeutic PQ doses were: 73.2 (29,180/39,886), 93.7 (244,537/261,036), 99.6 (20,690/20,770), 99.4 (12,086/12,155) and 99.8% (327,620/328,132), respectively. CONCLUSIONS: We plan to test the safety of this age-based dosing regimen in a large randomised placebo-controlled trial (ISRCTN11594437) of uncomplicated falciparum malaria in G6PDd African children aged 0.5 - 11 years. If the regimen is safe and demonstrates adequate pharmacokinetics, it should be used to support malaria elimination

Women's roles in voluntary medical male circumcision in Nyanza Province, Kenya.

Women are an important audience for voluntary medical male circumcision (VMMC) communication messages so that they know that VMMC provides only partial protection against HIV. They may also be able to influence their male partners to get circumcised and practice other HIV protective measures after VMMC. This study was conducted in two phases of qualitative data collection. Phase 1 used in-depth interviews to explore women's understanding of partial protection and their role in VMMC. Phase 2 built on the findings from the Phase 1, using focus groups to test VMMC communication messages currently used in Nyanza Province and to further explore women's roles in VMMC. Sixty-four sexually active women between the ages of 18 and 35 participated. In Phase 1, all women said they had heard of partial protection, though some were not able to elaborate on what the concept means. When women in Phase 2 were exposed to messages about partial protection, however, participants understood the messages well and were able to identify the main points. In Phases 1 and 2, many participants said that they had discussed VMMC with their partner, and for several, it was a joint decision for the man to go for VMMC. These findings suggest that current VMMC messaging is reaching women, though communications could more effectively target women to increase their ability to communicate about partial HIV protection from VMMC. Also, women seem to be playing an important role in encouraging men to get circumcised, so reaching out to women could be a valuable intervention strategy for increasing VMMC uptake and promoting use of other HIV protective measures after VMMC

Identifying and addressing barriers to uptake of voluntary medical male circumcision in Nyanza, Kenya among men 18-35: a qualitative study.

BACKGROUND: Uptake of VMMC among adult men has been lower than desired in Nyanza, Kenya. Previous research has identified several barriers to uptake but qualitative exploration of barriers is limited and evidence-informed interventions have not been fully developed. This study was conducted in 2012 to 1) increase understanding of barriers to VMMC and 2) to inform VMMC rollout through the identification of evidence-informed interventions among adult men at high risk of HIV in Nyanza Province, Kenya. METHODS: Focus groups (n = 8) and interviews were conducted with circumcised (n = 8) and uncircumcised men (n = 14) from the two districts in Nyanza, Kenya. Additional interviews were conducted with female partners (n = 20), health providers (n = 12), community leaders (n = 12) and employers (n = 12). Interview and focus group guides included questions about individual, interpersonal and societal barriers to VMMC uptake and ways to overcome them. Inductive thematic coding and analysis were conducted through a standard iterative process. RESULTS: Two primary concerns with VMMC emerged 1) financial issues including missing work, losing income during the procedure and healing and family survival during the recovery period and 2) fear of pain during and after the procedure. Key interventions to address financial concerns included: a food or cash transfer, education on saving and employer-based benefits. Interventions to address concerns about pain included refining the content of demand creation and counseling messages about pain and improving the ways these messages are delivered. CONCLUSIONS: Men need accurate and detailed information on what to expect during and after VMMC regarding both pain and time away from work. This information should be incorporated into demand creation activities for men considering circumcision. Media content should frankly and correctly address these concerns. Study findings support scale up and/or further improvement of these ongoing educational programs and specifically targeting the demand creation period

Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up: adoption of efficiency elements in Kenya, South Africa, Tanzania, and Zimbabwe.

SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency-use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery--as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe.This multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays.SYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement

Proportion of sites adopting each efficiency element by year and by country.

<p>Proportion of sites adopting each efficiency element by year and by country.</p

Proportion of VMMC sites using pre-packaged kits with consumables and disposable instruments, January 2010 – mid-2012.

<p>The number of sites on which these data are based varies markedly by month over the observation period, as shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0082518#pone-0082518-g001" target="_blank">Figure 1</a>.</p

Number of VMMC procedures performed by month, type of site, and country, January 2010 – mid-2012.

<p>Number of VMMC procedures performed by month, type of site, and country, January 2010 – mid-2012.</p

Task-sharing: percentage of providers reporting that secondary providers complete certain clinical tasks in the VMMC operating theater, by year and by country.

1<p>95% confidence intervals;</p><p>*p value (of difference between years) <0.05;</p><p>**p value (of difference between years) <0.001. Countries differed significantly (p<.001) on both variables.</p

Surgical beds per site, by country and by year, based on site assessment.

<p>% confidence intervals;¹ 95</p><p>**p value (of differences between countries) <0.001; p value (of difference between years) <0.05.</p