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Herman-Roloff A.,University of Illinois at Chicago | Herman-Roloff A.,Nyanza Reproductive Health Society | Llewellyn E.,Nyanza Reproductive Health Society | Obiero W.,Nyanza Reproductive Health Society | And 5 more authors.
PLoS ONE | Year: 2011

Background: In 2007, the World Health Organization endorsed male circumcision as an effective HIV prevention strategy. In 2008, the Government of Kenya (GoK) launched the national voluntary medical male circumcision (VMMC) program in Nyanza Province, the geographic home to the Luo, the largest non-circumcising ethnic group in Kenya. Currently, several other African countries are in the early stages of implementing this intervention. Methods and Results: This paper uses data from a health facility needs assessment (n = 81 facilities) and a study to evaluate the implementation of VMMC services in 16 GoK facilities (n = 2,675 VMMC clients) to describe Kenya's experience in implementing the national program. The needs assessment revealed that no health facility was prepared to offer the minimum package of services as outlined by the national guidelines, and partner organizations were called upon to fill this gap. The findings concerning human resource shortages facilitated the GoK's decision to endorse trained nurses to provide VMMCs, enabling more facilities to offer the service. Findings from the evaluation study resulted in replacing voluntary counseling and testing (VCT) with provider-initiated testing and counseling (PITC) and subsequently doubling the proportion of VMMC clients tested for HIV. Conclusions: This paper outlines how certain challenges, like human resource shortages and low HIV test rates, were addressed through national policy changes, while other challenges, like large fluctuations in demand, were addressed locally. Currently, the program requires significant support from partner organizations, but a strategic plan is under development to continue to build capacity in GoK staff and facilities. Coordination between all parties was essential and was facilitated through the formation of national, provincial, and district VMMC task forces. The lessons learned from Kenya's VMMC implementation experience are likely generalizable to other African countries. © 2011 Herman-Roloff et al.


Obiero W.,Nyanza Reproductive Health Society | Young M.R.,University of Illinois at Chicago | Bailey R.C.,Nyanza Reproductive Health Society | Bailey R.C.,University of Illinois at Chicago
PLoS ONE | Year: 2013

Background: Male circumcision (MC) reduces the risk of heterosexual HIV acquisition in men by approximately 60%. MC programs for HIV prevention are currently being scaled-up in fourteen countries in sub-Saharan Africa. The current standard surgical technique for MC in many sub-Saharan African countries is the forceps-guided male circumcision (FGMC) method. The PrePex male circumcision (PMC) method could replace FGMC and potentially reduce MC programming costs. We compared the potential costs of introducing the PrePex device into MC programming to the cost of the forceps-guided method. Methods: Data were obtained from the Nyanza Reproductive Health Society (NRHS), an MC service delivery organization in Kenya, and from the Kenya Ministry of Health. Analyses are based on 48,265 MC procedures performed in four Districts in western Kenya from 2009 through 2011. Data were entered into the WHO/UNAIDS Decision Makers Program Planning Tool. The tool assesses direct and indirect costs of MC programming. Various sensitivity analyses were performed. Costs were discounted at an annual rate of 6% and are presented in United States Dollars. Results: Not including the costs of the PrePex device or referral costs for men with phimosis/tight foreskin, the costs of one MC surgery were $44.54-$49.02 and $54.52-$55.29 for PMC and FGMC, respectively. Conclusion: The PrePex device is unlikely to result in significant cost-savings in comparison to the forceps-guided method. MC programmers should target other aspects of the male circumcision minimum package for improved cost efficiency. © 2013 Obiero et al.


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 | Otieno N.,Nyanza Reproductive Health Society | Agot K.,Impact Research and Development Organization | And 3 more authors.
PLoS ONE | Year: 2011

Background: Numerous studies have demonstrated that male circumcision (MC) reduces the incidence of the Type-1 human immunodeficiency virus (HIV) among heterosexual men by at least half. Methods: One year after the launch of a national Voluntary Medical Male Circumcision program in Kenya, this study conducted 12 focus group discussions among uncircumcised men in Nyanza Province to assess the revealed, non-hypothetical, facilitators and barriers to the uptake of MC. Results: The primary barriers to MC uptake included time away from work; culture and religion; possible adverse events; and the post-surgical abstinence period. The primary facilitators of MC uptake included hygiene; social pressure; protection against HIV and other sexually transmitted infections; and improved sexual performance and satisfaction. Conclusions: Some activities which might increase MC uptake include dispelling MC misconceptions; increasing involvement of religious leaders, women's groups, and peer mobilizers for MC promotion; and increasing the relevance of MC among men who are already practicing an HIV prevention method. © 2011 Herman-Roloff et al.


Harper G.W.,University of Michigan | Wade R.M.,University of Michigan | Onyango D.P.,Nyanza Rift Valley and Western Kenya NYARWEK Network | Abuor P.A.,Nyanza Reproductive Health Society | And 3 more authors.
AIDS | Year: 2015

Objective: To explore associations between intrapersonal and interpersonal factors and both sexual and psychosocial resilient outcomes among young gay, bisexual, and other men who have sex with men (GBMSM) in Western Kenya. Design: Cross-sectional observational study. Methods: Five hundred and eleven GBMSM ages 18-29 were recruited from nine communities in Western Kenya using community-based mobilization strategies. Participants completed an audio computer-assisted self-interview survey in English or Duhluo. We estimated four three-step hierarchical linear regression models to examine associations between predictors (intrapersonal and interpersonal factors) and four resilient outcomes (psychological well-being, self-esteem, condom use, HIV testing). Results: Psychosocial well-being model (modeled conversely as depression/anxiety) was significant (F(13, 424)=106.41, P0.001, R2=0.765) with loneliness, lesbian/gay/bisexual (LGB) difficult process, LGB identity superiority, and reactions to trauma as predictors. Self-esteem model was significant (F(12, 425)=6.40, P0.001, R2=0.153) with known HIV-seropositivity, perceived social support, internalized homonegativity, and LGB difficult process as predictors. Condom use model was significant (F(13, 379)=4.30, P0.001, R2=0.128) with perceived social support, self-esteem, and reactions to trauma as predictors. HIV testing model was significant (F(12, 377)=4.75, P0.001, R2=0.131) with loneliness, LGB identity uncertainty, LGB difficult process, and LGB identity superiority as predictors. Conclusion: This study demonstrates the variety of ways in which intrapersonal and interpersonal factors are associated with HIV-related resilient outcomes for young GBMSM in Western Kenya. HIV prevention programs for this population should be developed in collaboration with GBMSM and include intervention components that promote resilience. © 2015 Wolters Kluwer Health, Inc. All rights reserved.


Young M.R.,University of Illinois at Chicago | Odoyo-June E.,Nyanza Reproductive Health Society | Nordstrom S.K.,University of Illinois at Chicago | Irwin T.E.,University of Illinois at Chicago | And 5 more authors.
Pediatrics | Year: 2012

BACKGROUND AND OBJECTIVES: Three randomized trials demonstrated male circumcision decreases female-to-male HIV incidence by 60%. Male circumcision research in sub-Saharan Africa has focused on adolescents and adults. Modeling suggests infant male circumcision (IMC) will be cost saving for HIV prevention in high to moderate seroprevalent regions. This study examined parental decision-making and differences in characteristics of parents accepting and declining IMC services in western Kenya. METHODS: This case-control study was conducted in 2010 at 5 government hospitals in Nyanza Province, Kenya. Cases were mothers and fathers accepting circumcision for their son. Controls were parents who declined IMC services. A questionnaire comprising 41 questions was administered. RESULTS: A total of 627 mothers and 493 fathers enrolled. In multivariable logistic regression modeling, factors associated with accepting IMC among mothers were the following: father circumcised (odds ratio [OR] = 2.30, P < .001) and agreeing with the father about the IMC decision (OR = 4.38, P < .001). Among fathers, factors associated with accepting IMC were the following: being circumcised (OR = 1.77, P = .016) and agreeing with the mother about IMC (OR = 11.0, P < .001). Fathers were the primary decision makers in most instances (66%). Few parents (3%) reported they would prefer a future son to remain uncircumcised. CONCLUSIONS: Fathers are important in the IMC decision-making process. Fathers, as well as mothers, should be targeted for optimal scale-up of IMC services. Circumcision programs should offer services for males of all ages, as male circumcision at some age is highly acceptable to both men and women. Copyright © 2012 by the American Academy of Pediatrics.


Rogers J.H.,University of Illinois at Chicago | Odoyo-June E.,Nyanza Reproductive Health Society | Odoyo-June E.,University of Nairobi | Jaoko W.,Nyanza Reproductive Health Society | And 3 more authors.
PLoS ONE | Year: 2013

Background:While voluntary medical male circumcision (VMMC) has been shown to be protective against HIV-acquisition, the procedure may place men and their partners at risk of HIV infection in the period following circumcision if sex is resumed before the wound is healed. This prospective cohort study evaluates post-circumcision wound healing to determine whether the 42-day post-circumcision abstinence period, recommended by the World Health Organization and adopted by VMMC programs, is optimal.Methods and Findings:Men were circumcised by forceps-guided method and their post-circumcision wounds examined weekly for seven weeks and at 12 weeks. Time to complete healing was recorded in completed weeks since circumcision, and its associations with baseline covariates were assessed by Kaplan-Meier methods and Cox Proportional Hazard Models. A total of 215 HIV-negative and 108 HIV-positive men aged 18-35 years (median 26, IQR 23-30) were enrolled. 97.1% of scheduled follow-up visits were completed. At week 4, 59.3% of HIV-positive men and 70.4% of age-matched HIV-negative men were healed. At week 6, these percentages rose to 93.4% in HIV-positive men and 92.6% in age-matched HIV-negative men. There was no difference in the hazard of healing between 108 HIV-positive and 108 age-matched HIV-negative men (HR 0.91 95% CI 0.70-1.20). Early post-operative infection was associated with delayed healing in both HIV-positive and HIV-negative men (HR 0.48 95% CI 0.23-1.00).Conclusions:Our results indicate that the WHO recommendation for 42-days post-circumcision sexual abstinence should be maintained for both HIV-positive and HIV-negative men. It is important to stress condom use upon resumption of sex in all men undergoing circumcision. © 2013 Rogers et al.


Odoyo-June E.,Nyanza Reproductive Health Society | Odoyo-June E.,University of Nairobi | Rogers J.H.,University of Illinois at Chicago | Jaoko W.,Nyanza Reproductive Health Society | And 3 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2013

BACKGROUND: We conducted a prospective cohort study of HIV-positive men aged 18-35 years in Kisumu, Kenya to determine if medical circumcision of ART-naive HIV-positive men leads to increased viral load and penile viral shedding. METHODS: From 108 HIV-positive men circumcised by forceps-guided method and followed up weekly for 6 weeks, 29 men were evaluated for penile viral shedding. HIV-1 RNA was measured in plasma from 19 men and in penile lavage samples from 29 men. Samples were collected before circumcision and at weekly intervals for 6 weeks or until the circumcision wound was healed. CD4 T-cell counts from 102 HIV-positive men were determined at baseline and at 2 weeks thereafter. Wounds with healthy scar, no scab or opening, and no suture tracks were deemed healed. RESULTS: Among 65 ART-naive men, mean CD4 T-cell count increased from 417 cells per cubic millimeter at baseline to 456 cells per cubic millimeter after 2 weeks (P = 0.04), but did not change in the 37 men on ART (P = 0.81). There was no change in HIV plasma viral load (P = 0.36), but penile viral shedding rose significantly within 1 week after circumcision then declined to undetectable levels by 6 weeks (multivariate analysis of variance; P < 0.001). In 28 of 29 men (96.6%), there was no detectable viral shedding after certification of wound healing. CONCLUSIONS: Medical circumcision among ART-naive HIV-infected men results in a transitory rise in penile viral shedding before complete wound healing, which should pose no additional risk of HIV transmission if men adhere to 6 weeks postcircumcision sexual abstinence and use condoms consistently. Copyright © 2013 by Lippincott Williams & Wilkins.


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.


Odoyo-June E.,Nyanza Reproductive Health Society | Odoyo-June E.,University of Nairobi | Rogers J.H.,University of Illinois at Chicago | Jaoko W.,Nyanza Reproductive Health Society | And 3 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2013

We evaluated time to resumption of sex in relation to wound healing following circumcision of adult males. The purpose was to assess factors associated with adherence to the WHO recommendation of 42-days postcircumcision sexual abstinence and with engaging in sex before complete healing. Methods: Participants were circumcised then followed weekly for 7 weeks and at 3 months. At each follow-up, participants were asked if they had engaged in sex since circumcision and their postcircumcision wounds examined to determine if they were fully healed. Log binomial regression identified risk factors for early sex before 42 days and sex before complete healing. Results: Overall, 37.7% (120/318) of men reported sex before 42 days and 18.8% (60/319) reported sex before complete healing. Only 7% of men had unprotected sex before complete healing. There were no differences between HIV-positive and HIV-negative men in either healing time or sex before healing. Risk factors for sex before healing were being married or having 2 or more sex partners in the last year. Among single men, age older than 24 years and consistent alcohol consumption were associated with sex before healing. Conclusion: The risk of HIV transmission because of unprotected sex before wound healing is low and transient, because most men reporting early sex either used a condom or had wound already healed. Adherence to the 42-day abstinence period and condom use at every sexual intercourse within 3 months postcircumcision should minimize risk of HIV spread because of sex before complete healing. Copyright © 2012 by Lippincott Williams & Wilkins.

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