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Programme Science

Cultural constraints on the uptake of voluntary medical male circumcision in Eastern and Southern Africa

23 Jun, 14 | by Leslie Goode, Blogmaster

My previous blog spoke of the recent PLoS-Medicine Collection on the progress of a UNAIDS initiative for a five-year scale-up of Voluntary Male Medical Circumcision (VMMC) for HIV prevention in 14 high priority Eastern and Southern African countries.  Among the papers, Ashengo & Njeuhmeli (A&N) and Macintyre & Bertrand (M&B) deal with what the authors of the Collection Review identify as one of the two major obstacles to deployment of the initiative: the insufficiency of demand, especially amongst older (aged 25+) men.  They consider the cultural and social constraints on demand, as these are reflected in the very different cultural contexts of Zimbabwe and Tanzania/Iringa Province (A&N) and Kenya/Turkana County (M&B).

In Tanzania, where circumcision as a cultural practice is widespread, A&N’s figures show a proportion of older men presenting for VMMC through to 2013 of c.6%.  Very few of these were reached through campaigns, as opposed to routine services.  In Zimbabwe, by contrast, where circumcision is not widely practised, the proportion of aged 25+ circumcised through the program was c.33%.  There was much less difference in the age profiles of those accessed by campaign and routine service modalities.  Whereas, in Tanzania there is a cultural perception “that male circumcision is most appropriate before or during puberty” (and older men do not come to VMMC services in a setting that includes mostly adolescent clients) – in Zimbabwe there is less difference between age groups, either in respect to numbers circumcised or preferred mode of access.  Intriguingly, this suggests that the existence of a cultural norm of circumcision may be more of an obstacle than an asset where older clients are concerned.  Of course, this contrast has to be set in the context of the overall advantage in terms of HIV/AIDS prevention conferred on countries like Tanzania by the existence of the cultural norm.  On difficulties of demand in Zimbabwe specifically, see STI/Kaufman & Ross.

A further insight into the potentially negative impact of existing cultural practice is cast by M&B.  Focus group discussions and in-depth interviews in the rural, traditionally non-circumcising area of Turkana County, Kenya, draw attention to perceptions of circumcision amongst older men that are not favourable to their widespread up-take, especially by the older age-group.  The first is the identification of circumcision with the cultural values of other (potentially hostile) groups.  Interestingly, the negative impact of the perception of the practice as imposed from outside, or else non-traditional, has been demonstrated in other non-circumcising cultures (STI/David; STI/Madhivanan & Klausner). The second is the understandable perception that HIV/AIDS is a “new” problem among young urban dwellers (most Turkana sufferers belong in this category) and that circumcision, as a response to this “new” problem, is appropriate for the young, not for older, rural people (see also responses in a study on the acceptability of VMMC in Rwanda: STI/Mbabazi).

The impression that emerges from both studies is that the existence of a cultural practice of circumcision amongst certain groups in a region does not always confer an advantage where potential clients for VMMC are in the older age groups (25+).  In particular, good uptake of VMMC services by adolescents may actually prove an obstacle for older men, reinforcing the cultural perception of VMMC as primarily for younger men.  In this situation service providers may face a choice between strategies that yield the greatest number of circumcisions through an exclusive focus on the younger age-group, and strategies designed to attract a wider diversity of age-groups.


The roll-out of UNAIDS voluntary medical male circumcision programmes in sub-Saharan Africa: Is it working?

18 Jun, 14 | by Leslie Goode, Blogmaster

Voluntary medical male circumcision (VMMC) has been demonstrated to reduce HIV acquisition by 60% or more.  WHO and UNAIDS have recommended that VMMC form a part of comprehensive HIV prevention programming in regions of high prevalence, such as sub-Saharan Africa.  Mathematical modelling suggests that the achievement of 80% VMMC coverage within 5 years in 14 countries in Eastern and Southern Africa would avert 3.36m new HIV infections. In the light of this the UNAIDS Joint Strategic Action Framework (JSAF) has set out the goal of circumcising 20.2 million men in five years across these countries. The challenges this represents on both the supply and the demand side are comprehensively discussed by STI/Gray & Kigozi.

A recent PLoS – Medicine Collection considers the progress thus far, and through to 2016, of this initiative.  The Collection Review (Sgaier & Njeuhmeli (S&G)) offers a useful survey. The year preceding the JSAF and the first two years of the initiative have seen yearly VMMC of 0.88m, 1.7m, and 2.9m respectively. If we assume current rates of growth, this would give a cumulative total of 17.5m circumcisions by 2016 – about 3m short of the 20.2m target; if we assume no growth, the cumulative total for this period would be 13.7m.  The scale-up of VMMC over the last three years has been impressive. Still, rates of year-on-year growth have fallen from 109% (2011) to 72% (2013).  S&G identify two factors impeding the achievement of the JSAF goal: first, insufficient funding, largely as a result of the failure of international donors to step in alongside the US President’s Emergency Plan for AIDS Relief (PEPFAR) (which currently bears 80% of the cost); second, the lack of – or failure to create – sufficient demand for VMMC in the targeted countries, especially amongst the older element (i.e. aged 25+) of the population.

The 13 papers in the collection deal with issues around supply of VMMC – such as maintaining quality of service during scale-up (Jennings & Njeuhmeli; Rech & Bertrand; Rech & Njeuhmeli) and optimizing efficiency in service delivery (Rech & Njeuhmeli;  Mahvu & Bertrand; Perry & Bertrand).  But, more interestingly, they also deal with the problem that S&G identify as one of the two main obstacles to achieving the JSAF goal – that of creation of demand (Macintyre & Bertrand; Ashengo & Njeuhmeli).  This important issue will be covered in my next blog.

Responding appropriately to differentials in HIV care outcomes – are local answers needed?

12 May, 14 | by Leslie Goode, Blogmaster

The recent discovery of the preventative potential of anti-retroviral therapy (ART) (STIs/blog/modelling ART impact)  throws into sharp relief the challenge represented for the US by the very inadequate proportion of its 1.2 million HIV+ citizens (<30%) who are virally suppressed.  Nunn & Mayer  use new geographical mapping tools to bring home forcibly the epidemiological dimension of the problem by visualizing the association which HIV+ incidence/mortality show with social status and ethnicity as reflected in residence.  The picture that emerges is of an enormous concentration of the problem in certain very circumscribed neighbourhoods.  To give just one example of what is best conveyed in the diagrams (figures 1 & 2), age-adjusted death rates rise from <11.2 per 1000 people living with AIDS (PLWHA) to 19.4-32.5 per 1000 PLWHA as one passes from a predominantly white neighbourhood with large gay population and high rates of HIV/AIDS (≥2142 per 100,000 population) to the predominantly Afro-Caribbean neighbourhood of Harlem.

For Nunn & Mayer (N&M), these visualizations raise the question whether either (1.) the allocation of resources to metropolitan areas, or (2.) the nature of the strategies employed by public health interventions, reflects the very geographically focussed nature of the problem of HIV/AIDS incidence and mortality.  Their response to the epidemiological dimension of the problem revealed by their mapping tools is to urge the importance of implementation research as a vital component of HIV initiatives.

N&M’s emphasis on viraemia suppression, rather than just HIV incidence, accords well with their insistence of the epidemiological importance of the local dimension.  Retention in care is a factor that is presumably amenable to initiatives at local level – whereas HIV incidence may owe much to transmission through sexual contacts external to the community (STI/blog/Grabowski & Gray).

Their message is in line with increasing public health interest over recent years in “program impact evaluation methods that take account of the complex interactions among interventions and between intervention packages and the context into which they are introduced” (STIs/Aral & Blanchard).  There is surely a strong argument in favour of designing interventions to take place within an evaluative framework allowing a reflection on the kind of program mix likely to be most effective in a given context.  On the other hand, N&M may be in danger of undervaluing the potential of interventions of a non-localized character that act on the socio-economic determinants of the HIV problem, and especially non-retention in care – for example, the wider provision of medical insurance (STI/blogs/ObamaCare).  It would be interesting to see how far a geographical mapping of the incidence of other health problems in New York or Philadelpia coincided with N&M’s mapping of HIV/AIDS mortality.  How far is the effect of “micro-epidemics”, conjured up by epidemiological language, just a reflection of socio-economic determinants that produce identical results wherever they happen to be present?



What can cost-effectiveness modelling tell us about the feasibility of eliminating congenital syphilis in sub-Saharan Africa?

20 Nov, 13 | by Leslie Goode, Blogmaster

The WHO global initiative for the elimination of congenital syphilis (2007) set the goal of expanding antenatal testing to >90% by 2015.  In sub-Saharan Africa (SSA) recent estimates place the number of mothers infected with active syphilis at 535,000 p.a..  Adverse outcomes – stillbirths, neo-natal morbidity and congenital disease – affect 53%-82% of these pregnancies, as compared with 10%-21% of women without syphilis.  Yet, perhaps surprisingly,  74% of pregnant women in SSA are reported to attend an antenatal clinic at least once.  Administration at the routine visit of a simple point-of-care test (POCT), plus, in the case of detection, an intra-muscular injection of benthazine penicillin, is all that, in most cases, would be required to deal with the problem.

A recent modelling study (Kuznik & Manabe ) seeks to make the economic case for universal POCT syphilis screening in 43 countries in SSA.  It estimates the cost of increasing syphilis testing at antenatal clinics from whatever it is at present to 100% through universal adoption of the immunochromatographic strip test (ICT), and the benefits that would result in terms of saved lives and reduced morbidity.  It then calculates the cost-benefit in US dollars per Disability Adjusted Life Year (DALY).

The findings are given for each of the 43 countries considered. Here are the aggregate findings for SSA as a whole.  In order to ensure screening coverage for the 23.5 million (74%) pregnant mothers attending ante-natal clinics, the cost is estimated at a comparatively modest US$20.8 million per year, and would, it is claimed, reduce incidence of still-birth, neo-natal death and congenital syphilis by 64,000, 25,000 and 32,000, respectively.  Of the 43 countries in the model the cost of such an intervention per DALY averted would be less than US$20 in 37 cases, and less than US$10 in 23 cases.

The study claims to be the first to have evaluated the cost-effectiveness of ICT across SSA.  What is the value of this exercise?  It seems to consist primarily in the extra rhetorical “punch” it can lend to the argument in favour of doing something – and something very cheap – in order to alleviate the deplorable ravages of perinatal mortality and morbidity due to syphilis.  One can only applaud the intentions of its authors.  At the same time, one is struck by the inadequacy of the measure employed (cost per DALY ) to capture any real sense of the economic (let alone human) cost of MCST.  The impressive figures they arrive at for cost-effectiveness of the proposed interventions owes not a little to the fact that the lost life-years averted happen to be those of the stillborn or neonatal deceased.  This does not belittle the cost, but feels a rather odd way of looking at perinatal outcomes.  Consequently the whole exercise, while it may be well-intentioned and ticks all the official boxes, strikes this reader at least as rather specious.  One wonders if it can offer any real ground for the prioritization of MCST as against other equally laudable interventions: if it does, one feels somehow that it ought not to!

Relevant to the real economic cost confronting any country deciding to switch to the ICT would presumably be the relative cost of the ICT compared to an established alternative (e.g. Rapid Plasma Reagin (RPR)).  After all, using ICT to make up the shortfall in current testing levels presupposes the country has made the switch from RPR to ICT – which may already have cost implications (Vickerman and Watts).  Ultimately, however, the main the challenge of making this switch, may not be economic cost at all, but a problem of institutional organization and training (STI blog/Peeling & Mabey).   Peeling & Mabey observe in relation to one area in which POCT for syphilis was being introduced as part of a trial “a 65% drop over the first six months in the percentage of antenatal clinics passing the quality assurance controls due to high staff turn-over: but, subsequently, with the HWC training mechanism kicking in, there was a return to 100% levels of proficiency”.  Here and elsewhere (Peeling & Mabey) make the case for the importance of “programme science” to “address the gap” between test performance and successful deployment.

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