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Sudenga S.L.,University of Alabama at Birmingham | Otieno W.A.,Impact Research and Development Organization | Smith J.S.,University of North Carolina at Chapel Hill
International Journal of Gynecological Cancer | Year: 2013

Objectives: Eastern Africa has the highest incidence and mortality rates from cervical cancer worldwide. It is important to describe the differences among women and their perceived risk of cervical cancer to determine target groups to increase cervical cancer screening. Methods: In this cross-sectional study, we surveyed women seeking reproductive health services in Kisumu, Kenya to assess their perceived risk of cervical cancer and risk factors influencing cervical cancer screening uptake. W2 statistics and t tests were used to determine significant factors, which were incorporated into a logistic model to determine factors independently associated with cervical cancer risk perception. Results: Whereas 91% of the surveyed women had heard of cancer, only 29% of the 388 surveyed women had previously heard of cervical cancer. Most had received their information from health care workers. Few women (6%) had ever been screened for cervical cancer and cited barriers such as fear, time, and lack of knowledge about cervical cancer. Nearly all previously screened women (22/24 [92%]) believed that cervical cancer was curable if detected early and that screening should be conducted annually (86%). Most women (254/388 [65%]) felt they were at risk for cervical cancer. Women with perceived risk of cervical cancer were older (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02Y1.10), reported a history of marriage (OR, 2.08; CI, 1.00Y4.30), were less likely to feel adequately informed about cervical cancer by health care providers (OR, 0.76; CI, 0.18Y0.83), and more likely to intend to have cervical cancer screening in the future (OR, 10.59; CI, 3.96Y28.30). Only 5% of the women reported that they would not be willing to undergo screening regardless of cost. Conclusions: Cervical cancer is a major health burden for women in sub-Saharan Africa, yet only one third of the women had ever heard of cervical cancer in Kisumu, Kenya. Understanding factors associated with women's perceived risk of cervical cancer could guide future educational and clinical interventions to increase cervical cancer screening. © 2013 by IGCS and ESGO.


Weiss H.A.,London School of Hygiene and Tropical Medicine | Dickson K.E.,World Health Organization | Agot K.,Impact Research and Development Organization | Hankins C.A.,Joint United Nations Programme on HIV AIDS UNAIDS
AIDS | Year: 2010

Randomized controlled trials in sub-Saharan Africa have shown that adult male circumcision reduces the risk of HIV acquisition in men by about 60%. In this article, we review recent data on the association of male circumcision and HIV/sexually transmitted infection in men and women. This includes a summary of data showing some evidence of an effect of male circumcision against genital ulcer disease, HSV-2 infection, human papillomavirus and Trichomonas vaginalis, but not Chlamydia trachomatis or Neisseria gonorrhoea in men. Longitudinal studies among HIV discordant couples suggest that male circumcision may provide some direct long-term benefit to women, which may start after complete wound healing. Circumcision may also protect against HIV acquisition in men who have sex with men (MSM) and those who practice unprotected anal intercourse (either exclusively or predominantly), although these data are not consistent. To date, there is little evidence from the few studies available of either unsafe practices or reported increases in risky behaviour, or adverse changes in sexual satisfaction and function. As countries in southern and eastern Africa scale up services, operational research will likely be useful to iteratively improve programme delivery and impact while identifying the best methods of integrating safe male circumcision services into HIV prevention strategies and strengthening health systems. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Corneli A.,Social and Behavioral Health science | Wang M.,Quantitative science | Agot K.,Impact Research and Development Organization | Ahmed K.,Setshaba Research Center | And 3 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Background: FEM-PrEP was unable to demonstrate the effectiveness of oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) as preexposure prophylaxis for HIV prevention because of low adherence. We hypothesized that one reason for the poor adherence was low perceived HIV risk. Methods: At enrollment and at quarterly follow-up visits, we assessed participants' perceived HIV risk for the subsequent 4 weeks. We used logistic regression to assess factors associated with some (small, moderate, or high) perceived HIV risk. We also used logistic regression with robust variance estimation to assess the association between risk perceptions (none versus some) reported at enrollment and at weeks 12, 24, and 36 and good adherence based on drug concentrations of plasma tenofovir and intracellular tenofovir diphosphate in specimens collected 4 weeks later (at weeks 4, 16, 28, and 40) among 150 randomly selected participants assigned FTC/TDF. Results: Multiple factors were statistically associated with having some perceived risk, including having sex without a condom, having multiple partners, and not knowing if a partner has HIV. We observed a significant association between having some risk perception and good adherence (odds ratio: 2.0; 95% confidence interval: 1.1 to 3.5; P = 0.016). Conclusions: Data suggest that participants are likely knowledgeable about factors that increase their HIV risk. Perceived risk seemed to have influenced some participants' decisions to adhere to the study pill within the context of a placebo-controlled clinical trial. Future research can explore the role of risk perception in the uptake of and adherence to pre-exposure prophylaxis, now that FTC/TDF has been shown efficacious. Copyright © 2014 by Lippincott Williams & Wilkins.


Westercamp M.,Nyanza Reproductive Health Society | Westercamp M.,University of Illinois at Chicago | Agot K.E.,Impact Research and Development Organization | Ndinya-Achola J.,University of Nairobi | Bailey R.C.,University of Illinois at Chicago
AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV | Year: 2012

Following the endorsement by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) of male circumcision as an additional strategy to HIV prevention, initiatives to introduce safe, voluntary medical male circumcision (VMMC) services commenced in 2008 in several sub-Saharan African communities. Information regarding perceptions of circumcision as a method of HIV prevention, however, is largely limited to data collected before this important endorsement and the associated increase in the availability of VMMC services. To address this, we completed a community-based survey of male circumcision (MC) perceptions in the major non-circumcising community in Kenya, which is the current focus of VMMC programs in the country. Data was collected between November 2008 and April 2009, immediately before VMMC program scale-up commenced. Here we present results limited to women (n = 1088) and uncircumcised males (n = 460) to provide insight into factors contributing to the acceptability and preference for MC in those targeted by VMMC programs. Separate multivariable models examining preference for circumcision were defined for married men, unmarried men, and women. Belief in the protective effect of circumcision on HIV risk was strongly associated with preference for MC in all models. Other important factors included education, perceived improvement in sexual pleasure, and perceptions of impact on condom utilization. Identified barriers to circumcision were the belief that circumcision was not part of the local culture, the perception of a long healing period following the procedure, the lack of a specific impetus to seek out services, and the general fear of pain associated with becoming circumcised. A minority of participants expressed beliefs suggesting that behavioral risk compensation with increased MC prevalence and awareness is a possibility. This work describes the early impact of a large-scale VMMC program on beliefs and behaviors regarding MC and HIV risk. It is hoped that our findings may offer guidance into anticipating potential impacts that similar programs may observe in populations throughout Eastern Africa. © 2012 Taylor and Francis Group, LLC.


Herman-Roloff A.,University of Illinois at Chicago | Herman-Roloff A.,Nyanza Reproductive Health Society | Bailey R.C.,University of Illinois at Chicago | Bailey R.C.,Nyanza Reproductive Health Society | Agot K.,Impact Research and Development Organization
AIDS and Behavior | Year: 2012

Research has established that voluntary medical male circumcision (VMMC) reduces HIV acquisition in heterosexual men by approximately 60%; however, engaging in sexual activity before the wound is healed may attenuate this protective effect. This prospective study included VMMC clients who were circumcised in Kenya between November, 2008 and March, 2010, agedC18 years, and randomly selected for an interview and genital examination 28-45 days post-VMMC (N = 1,344). At the time of the interview, 91.3% participants were healed. Overall, 30.7% reported engaging in early sexual activity, usually 3-4 weeks post-VMMC. In a multivariable analysis, being married or cohabitating was the strongest predictor of engaging in early sexual activity. Strategies to reduce engaging in sexual activity during the recommended 42-day abstinence period following VMMC should be explored including re-energizing the effort to include female partners in counseling, mass education campaigns, and targeted text messaging programs for VMMC clients. © Springer Science+Business Media, LLC 2011.


Thirumurthy H.,University of North Carolina at Chapel Hill | Masters S.H.,University of North Carolina at Chapel Hill | Rao S.,Impact Research and Development Organization | Bronson M.A.,University of North Carolina at Chapel Hill | And 4 more authors.
JAMA - Journal of the American Medical Association | Year: 2014

Importance: Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy. OBJECTIVE To determine whether small economic incentives could increase circumcision prevalence by addressing reported economic barriers to VMMC and behavioral factors such as present-biased decision making. Design, Setting, and Participants: Randomized clinical trial conducted between June 22, 2013, and February 4, 2014, among 1504 uncircumcised men aged 25 to 49 years in Nyanza region, Kenya. VMMC services were provided free of charge and participants were randomized to 1 of 3 intervention groups or a control group. Interventions: Participants in the 3 intervention groups received varying amounts of compensation conditional on undergoing circumcision at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth 200 Kenya shillings (∼US $2.50), 700 Kenya shillings (∼US $8.75), or 1200 Kenya shillings (∼US $15.00), which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation. Main Outcomes and Measures: VMMC uptake within 2 months. RESULTS Analysis of data for 1502 participants with complete data showed that VMMC uptake within 2 months was higher in the US $8.75 group (6.6%; 95%CI, 4.3%-9.5%[25 of 381]) and the US $15.00 group (9.0%; 95%CI, 6.3%-12.4%[34 of 377]) than in the US $2.50 group (1.9%; 95%CI, 0.8%-3.8% [7 of 374]) and the control group (1.6%; 95%CI, 0.6%-3.5% [6 of 370]). In logistic regression analysis, the US $8.75 group had significantly higher VMMC uptake than the control group (adjusted odds ratio [AOR] 4.3; 95%CI, 1.7-10.7), as did the US $15.00 group (AOR 6.2; 95%CI, 2.6-15.0). Effect sizes for the US $8.75 and US $15.00 groups did not differ significantly (P = .20). CONCLUSIONS AND RELEVANCE Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation. Copyright © 2014 American Medical Association. All rights reserved.


Herman-Roloff A.,University of Illinois at Chicago | Bailey R.C.,University of Illinois at Chicago | Agot K.,Impact Research and Development Organization
Bulletin of the World Health Organization | Year: 2012

Objective To determine factors associated with the incidence of adverse events associated with voluntary medical male circumcision (VMMC) for the prevention of HIV infection in Nyanza province, Kenya. Methods Males aged 12 years or older who underwent VMMC between November 2008 and March 2010 in 16 clinics in three districts were followed through passive surveillance to monitor the incidence of adverse events during and after surgery. A subset of clinic participants was randomly selected for active surveillance post-operatively and was monitored for adverse events through a home-based, in-depth interview and a genital exam 28 to 45 days after surgery. Performance indicators were assessed for 167 VMMC providers. Findings The adverse event rate was 0.1% intra-operatively and 2.1% post-operatively among clinic system participants (n = 3705), and 7.5% post-operatively among participants under active surveillance (n = 1449). Agreement between systems was moderate (κ: 0.20; 95% confidence interval, CI: 0.09-0.32). Providers who performed more than 100 procedures achieved an adverse event rate of 0.7% and 4.3% in the clinic and active surveillance systems, respectively, and had decreased odds of performing a procedure resulting in an adverse event. With provider experience, the mean duration of the procedure also dropped from 24.0 to 15.5 minutes. Among providers who had performed at least 100 procedures, nurses and clinicians provided equivalent services. Conclusion To reduce the adverse event rate, one must ensure that providers achieve a desired level of experience before they perform unsupervised procedures. Adverse events observed by the provider as well as those perceived by the client should both be monitored.


Mehta S.D.,University of Illinois at Chicago | Moses S.,University of Manitoba | Agot K.,Impact Research and Development Organization | Odoyo-June E.,University of Manitoba | And 4 more authors.
AIDS | Year: 2013

Background: In three randomized trials, medical male circumcision (MMC) reduced HIV acquisition in heterosexual men in sub-Saharan Africa by approximately 60%, after 21-24 months of follow-up. We estimated the 72-month efficacy of MMC against HIV among men retained in the Kisumu randomized trial, in which HIV acquisition was reduced by 60% after 24 months. Methods: From 2002 to 2005, 2784 men aged 18-24 were enrolled and randomized 1 : 1 to immediate circumcision or control. At trial end in December 2006, control men were offered free circumcision. Follow-up continued to September 2010. Cox proportional hazards regression incorporating stabilized inverse probability of treatment and censoring weights generated through marginal structural modeling, was used to account for potential time-varying confounding and censoring to estimate the efficacy of MMC on HIV risk. Results: The cumulative 72-month HIV incidence was 7.21% [95% confidence interval (CI): 5.98-8.68%]: 4.81% among circumcised men, 11.0% among uncircumcised men. The crude hazard ratio of HIV seroconversion for circumcised vs. uncircumcised men was 0.38 [95% CI: 0.26-0.55]. In weight-adjusted Cox regression, the hazard ratio was 0.42 [95% CI: 0.26-0.66]. Conclusion: The efficacy ofMMCwas sustained at 58% at 72 months, similar to overall findings of the three trials under conditions of randomization. These findings provide an estimate of the long-term efficacy of circumcision against HIV acquisition. Our results support programmatic scale-up recommendations that are based on assumptions of sustained efficacy. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Westercamp N.,University of Illinois at Chicago | Agot K.,Impact Research and Development Organization | Jaoko W.,University of Nairobi | Bailey R.C.,University of Illinois at Chicago
AIDS and Behavior | Year: 2014

We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30-14 vs. 24-21 % in controls) and increased sexual activity among the youngest participants (18-24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives. © 2014 Springer Science+Business Media New York.


Becker-Dreps S.,University of North Carolina at Chapel Hill | Otieno W.A.,Impact Research and Development Organization | Brewer N.T.,University of North Carolina at Chapel Hill | Agot K.,Impact Research and Development Organization | Smith J.S.,University of North Carolina at Chapel Hill
Vaccine | Year: 2010

As human papillomavirus (HPV) vaccines become available in less-developed countries, understanding women's attitudes towards HPV vaccines can help guide approaches to immunization programs. We assessed knowledge and interest in prophylactic HPV vaccines among Kenyan women seeking women's health services (N= 147). They knew little about cervical cancer or HPV vaccine. Most women (95%, 95% confidence interval [CI]: 92%, 99%), however, were willing to have their daughters vaccinated with a vaccine that would prevent cervical cancer, with preference for an inexpensive vaccine requiring fewer doses. © 2010 Elsevier Ltd.

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