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: Introduction: Following HIV testing services (HTS), the World Health Organization recommends prompt linkage to prevention and treatment. Scale‐up of effective linkage strategies is essential to achieving the global 95‐95‐95 goals for maintaining low HIV incidence by 2030 and reducing HIV‐related morbidity and mortality. Whereas linkage to care including same‐day antiretroviral therapy (ART) initiation for all people with HIV is now routinely implemented in testing programmes, linkage to HIV prevention interventions including behavioural or biomedical strategies, for HIV‐negative individuals remains sub‐optimal. This review aims to evaluate effective post‐HTS linkage strategies for HIV overall, and highlight gaps specifically in linkage to prevention. Methods: Using the five‐step Arksey and O'Malley framework, we conducted a scoping review searching existing published and grey literature. We searched PubMed, Cochrane Library, CINAHL, Web of Science and EMBASE databases for English‐language studies published between 1 January 2010 and 30 November 2023. Linkage interventions included as streamlined interventions—involving same‐day HIV testing, ART initiation and point‐of‐care CD4 cell count/viral load, case management—involving linkage coordinators developing personalized HIV care and risk reduction plans, incentives—financial and non‐financial, partner services—including contact tracing, virtual—like social media, quality improvement—like use of score cards, and peer‐based interventions. Outcomes of interest were linkage to any form of HIV prevention and/or care including ART initiation. Results: Of 2358 articles screened, 66 research studies met the inclusion criteria. Only nine linkage to prevention studies were identified (n = 9/66, 14%)—involving pre‐exposure prophylaxis, voluntary medical male circumcision, sexually transmitted infection and cervical cancer screening. Linkage to care studies (n = 57/66, 86%) focused on streamlined interventions in the general population and on case management among key populations. Discussion: Despite a wide range of HIV prevention interventions available, there was a dearth of literature on HIV prevention programmes and on the use of messaging on treatment as prevention strategy. Linkage to care studies were comparatively numerous except those evaluating virtual interventions, incentives and quality improvement. Conclusions: The findings give insights into linkage strategies but more understanding of how to provide these effectively for maximum prevention impact is needed., INTRODUCTION Globally, linkage to HIV services, defined as a process to support people testing for HIV to engage with prevention, care, treatment and other relevant non‐HIV‐related services, is an important [...]

Abstract Background Ambitious UN goals to reduce the mother-to-child transmission of HIV have not been met in much of Sub-Saharan Africa. This paper focuses on the quality of information provision and counseling and disclosure patterns in Burkina Faso, Kenya, Malawi and Uganda to identify how services can be improved to enable better PMTCT outcomes. Methods Our mixed-methods study draws on data obtained through: (1) the MATCH (Multi-country African Testing and Counseling for HIV) study's main survey, conducted in 2008-09 among clients (N = 408) and providers at health facilities offering HIV Testing and Counseling (HTC) services; 2) semi-structured interviews with a sub-set of 63 HIV-positive women on their experiences of stigma, disclosure, post-test counseling and access to follow-up psycho-social support; (3) in-depth interviews with key informants and PMTCT healthcare workers; and (4) document study of national PMTCT policies and guidelines. We quantitatively examined differences in the quality of counseling by country and by HIV status using Fisher's exact tests. Results The majority of pregnant women attending antenatal care (80-90%) report that they were explained the meaning of the tests, explained how HIV can be transmitted, given advice on prevention, encouraged to refer their partners for testing, and given time to ask questions. Our qualitative findings reveal that some women found testing regimes to be coercive, while disclosure remains highly problematic. 79% of HIV-positive pregnant women reported that they generally keep their status secret; only 37% had disclosed to their husband. Conclusion To achieve better PMTCT outcomes, the strategy of testing women in antenatal care (perceived as an exclusively female domain) when they are already pregnant needs to be rethought. When scaling up HIV testing programs, it is particularly important that issues of partner disclosure are taken seriously.

BackgroundPeople who inject drugs (PWID) are at increased risk for HIV and hepatitis C virus (HCV) infection and also have high levels of homelessness and unstable housing. We assessed whether homelessness or unstable housing is associated with an increased risk of HIV or HCV acquisition among PWID compared with PWID who are not homeless or are stably housed.MethodsIn this systematic review and meta-analysis, we updated an existing database of HIV and HCV incidence studies published between Jan 1, 2000, and June 13, 2017. Using the same strategy as for this existing database, we searched MEDLINE, Embase, and PsycINFO for studies, including conference abstracts, published between June 13, 2017, and Sept 14, 2020, that estimated HIV or HCV incidence, or both, among community-recruited PWID. We only included studies reporting original results without restrictions to study design or language. We contacted authors of studies that reported HIV or HCV incidence, or both, but did not report on an association with homelessness or unstable housing, to request crude data and, where possible, adjusted effect estimates. We extracted effect estimates and pooled data using random-effects meta-analyses to quantify the associations between recent (current or within the past year) homelessness or unstable housing compared with not recent homelessness or unstable housing, and risk of HIV or HCV acquisition. We assessed risk of bias using the Newcastle-Ottawa Scale and between-study heterogeneity using the I2 statistic and p value for heterogeneity.FindingsWe identified 14 351 references in our database search, of which 392 were subjected to full-text review alongside 277 studies from our existing database. Of these studies, 55 studies met inclusion criteria. We contacted the authors of 227 studies that reported HIV or HCV incidence in PWID but did not report association with the exposure of interest and obtained 48 unpublished estimates from 21 studies. After removal of duplicate data, we included 37 studies with 70 estimates (26 for HIV; 44 for HCV). Studies originated from 16 countries including in North America, Europe, Australia, east Africa, and Asia. Pooling unadjusted estimates, recent homelessness or unstable housing was associated with an increased risk of acquiring HIV (crude relative risk [cRR] 1·55 [95% CI 1·23-1·95; p=0·0002]; I2= 62·7%; n=17) and HCV (1·65 [1·44-1·90; p

Polysubstance use (PSU), injection drug use (IDU), and equipment sharing are associated with bloodborne infection (BBI) transmission risk, particularly Hepatitis C Virus (HCV), yet data on PSU in low- and middle-income countries (LMICs) is limited. We report on baseline PSU, medication-assisted treatment (MAT) engagement, and motivation to reduce IDU among 95 people who inject drugs (PWID) who accessed needle and syringe programs (NSP) in Nairobi and Coastal Kenya prior to HCV treatment. Bivariate and multivariate logistic regression were used to examine the associations between PSU and behaviors that confer HCV transmission and acquisition risks. Most participants (70.5%) reported PSU in the last 30 days, and one-third (35.8%) reported PSU exclusive to just heroin and cannabis use. Common combinations were heroin and cannabis (49.3%), and heroin, cannabis, and bugizi (flunitrazepam) (29.9%). Participants at baseline were receiving MAT (69.5%), already stopped or reduced IDU (30.5%), and were HIV-positive (40%). PSU was significantly associated with IDU (p = 0.008) and the number of times (p = 0.016) and days (p = 0.007) injected in the last 30 days. Participants reported high PSU and equipment sharing, despite high MAT engagement. While co-locating BBI treatment within existing harm reduction services is necessary to promote uptake and curb re-infection, tailored services may be needed to address PSU, particularly in LMICs. [ABSTRACT FROM AUTHOR]

IntroductionAt the individual level, there is clear evidence that Human Immunodeficiency Virus (HIV) transmission can be substantially reduced by lowering viral load. However there are few data describing population-level HIV viremia especially in high-burden settings with substantial under-diagnosis of HIV infection. The 2nd Kenya AIDS Indicator Survey (KAIS 2012) provided a unique opportunity to evaluate the impact of antiretroviral therapy (ART) coverage on viremia and to examine the risks for failure to suppress viral replication. We report population-level HIV viral load suppression using data from KAIS 2012.MethodsBetween October 2012 to February 2013, KAIS 2012 surveyed household members, administered questionnaires and drew serum samples to test for HIV and, for those found to be infected with HIV, plasma viral load (PVL) was measured. Our principal outcome was unsuppressed HIV viremia, defined as a PVL ≥ 550 copies/mL. The exposure variables included current treatment with ART, prior history of an HIV diagnosis, and engagement in HIV care. All point estimates were adjusted to account for the KAIS 2012 cluster sampling design and survey non-response.ResultsOverall, 61·2% (95% CI: 56·4-66·1) of HIV-infected Kenyans aged 15-64 years had not achieved virological suppression. The base10 median (interquartile range [IQR]) and mean (95% CI) VL was 4,633 copies/mL (0-51,596) and 81,750 copies/mL (59,366-104,134), respectively. Among 266 persons taking ART, 26.1% (95% CI: 20.0-32.1) had detectable viremia. Non-ART use, younger age, and lack of awareness of HIV status were independently associated with significantly higher odds of detectable viral load. In multivariate analysis for the sub-sample of patients on ART, detectable viremia was independently associated with younger age and sub-optimal adherence to ART.DiscussionThis report adds to the limited data of nationally-representative surveys to report population- level virological suppression. We established heterogeneity across the ten administrative and HIV programmatic regions on levels of detectable viral load. Timely initiation of ART and retention in care are crucial for the elimination of transmission of HIV through sex, needle and syringe use or from mother to child. Further refinement of geospatial mapping of populations with highest risk of transmission is necessary.

When HIV diagnostic tests first became available in 1985, HIV testing was offered with caution. No treatment was available, prevention options were limited, and stigma and discrimination against people with [...]

: Introduction: We have previously demonstrated that assisted partner services (aPS) increases HIV testing and case finding among partners of persons living with HIV (PLHIV) in a cluster randomized trial in Kenya. However, the efficacy of aPS may vary across populations. In this analysis, we explore differences in aPS efficacy by characteristics of index participants. Methods: Eighteen HIV testing sites were randomized to immediate versus 6‐week delayed aPS. Participants were PLHIV (or index participants) and their sexual partners. Partners of index participants were contacted for HIV testing and linked to care if HIV positive. Primary outcomes were the number of partners per index participant who: 1) tested for HIV, 2) tested HIV positive and 3) enrolled in HIV care. We used generalized estimating equations to assess differences in aPS efficacy by region, testing location, gender, age and knowledge of HIV status. Results: From 2013 to 2015, the study enrolled 1119 index participants, 625 of whom were in the immediate group. These index participants named 1286 sexual partners. Immediate aPS was more efficacious than delayed aPS in promoting HIV testing among partners in high compared to low HIV prevalence regions (Nyanza incidence rate ratio (IRR) 7.2; 95% confidence interval (CI) 5.4, 9.6 vs. Nairobi/Central IRR 3.4 95% CI 2.3, 4.8). Higher rates of partner HIV testing were also observed for index participants in rural/peri‐urban compared to urban sites (IRR 6.6; 95% CI 4.5, 9.6 vs. IRR 3.5 95% CI 2.5, 5.0 respectively), for female versus male index participants (IRR 5.8 95% CI 4.2, 7.9 vs. IRR 3.7; 95% CI 2.4, 5.8 respectively) and for newly diagnosed versus known HIV‐positive index participants (IRR 6.0 95% CI 4.2, 8.7 vs. IRR 3.3; 95% CI 2.0, 7.7 respectively). Providing aPS to female versus male index participants also had a significantly higher HIV case finding rate (IRR 9.1; 95% CI 4.0, 20.9 vs. IRR 3.2 95% CI 1.7, 6.0 respectively.) Conclusions: While it is known that aPS promotes increases in HIV testing and case finding, this is the first study to demonstrate significant differences in aPS efficacy across characteristics of the index participant. Understanding these differences and their drivers will be critical as aPS is brought to scale in order to ensure all PLHIV have access to these services., Introduction Knowledge of one's HIV status is a prerequisite to accessing HIV care and treatment. The United Nations global call to control the HIV epidemic, aims to have 90% of [...]

Objective To provide guidance for male circumcision programmes in Kenya by estimating the population of uncircumcised men and investigating the association between circumcision and infection with the human immunodeficiency virus (HIV), with particular reference to uncircumcised, HIV-uninfected men. Methods Data on men aged 15 to 64 years were derived from the 2007 Kenya AIDS Indicator Survey, which involved interviews and blood collection to test for HIV and herpes simplex virus 2 (HSV-2). The prevalence of HIV infection and circumcision in Kenyan provinces was calculated and the demographic characteristics and sexual behaviour of circumcised and uncircumcised, HIV-infected and HIV-uninfected men were recorded. Findings The national prevalence of HIV infection in uncircumcised men was 13.2% (95% confidence interval, Cl: 10.8-15.7) compared with 3.9% (95% CI: 3.3-4.5) among circumcised men. Nyanza province had the largest estimated number of uncircumcised, HIV-uninfected men (i.e. 601 709), followed by Rift Valley, Nairobi and Western Province, respectively, and most belonged to the Luo ethnic tribe. Of these men, 77.8% did not know their HIV status and 33.2% were HSV-2-positive. In addition, 65.3% had had unprotected sex with a partner of discordant or unknown HIV status in the past 12 months and only 14.7% consistently used condoms with their most recent partner. However, only 21.8% of the uncircumcised, HIV-uninfected men aged 15 to 19 years were sexually active. Conclusion The Kenyan male circumcision strategy should focus on the provinces with the highest number of uncircumcised, HIV-uninfected men and target young men before or shortly after sexual debut. [TEXT NOT REPRODUCIBLE IN ASCII.] Programmes de circoncision masculine au Kenya: lecons tirees de l'enquete de 2007 sur les indicateurs du SIDA au Kenya Objectif Conseiller des programmes de circoncision masculine au Kenya en estimant le nombre d'hommes non circoncis et en recherchant l'association entre la circoncision et l'infection par le virus de l'immunodeficience humaine (VIH), avec une reference particuliere aux hommes non circoncis et non infectes par le VIH. Methodes Des donnees sur des hommes ages de 15 a 64 ans ont ete obtenues de l'enquete de 2007 sur les indicateurs du SIDA au Kenya, impliquant des entretiens et des prises de sang afin de rechercher la presence du VIH et du virus de l'herpes simplex 2 (VHS-2). La prevalence de l'infection par le VlH et la circoncision dans les provinces kenyanes a ete calculee, et les caracteristiques demographiques ainsi que le comportement sexuel des hommes circoncis et non circoncis, des hommes infectes et non infectes par le VIH ont ete enregistres. Resultats La prevalence nationale de l'infection par le VIH chez les hommes non circoncis s'elevait a 13,2% (intervalle de confiance de 95%, IC: 10,8-15,7) par rapport a un pourcentage de 3,9% (IC de 95%: 3,3-4,5) chez les hommes circoncis. La province de Nyanza presentait l'estimation du plus grand nombre d'homme non circoncis et d'hommes non infectes par le VIH (601 709), suivie de la vallee du Rift, de Nairobi et de la province occidentale, respectivement, dont la plus grande partie appartenait a la tribu ethnique des Luo. Chez ces hommes, 77,8% ne connaissaient pas leur seropositivite et 33,2% etaient positifs au VHS-2. De plus, 65.3% d'entre eux avaient eu des rapports sexuels non proteges avec une partenaire de statut HIV inconnu ou discordant au cours des 12 derniers mois, et seuls 14,7% d'entre eux utilisaient constamment des preservatifs avec leur derniere partenaire. Cependant, seuls 21,8% des hommes non circoncis et non infectes par le VIH ages de 15 a 19 ans etaient sexuellement actifs. Conclusion La strategie de circoncision des hommes kenyans doit s'orienter sur les provinces presentant le plus grand nombre d'hommes non circoncis et non infectes par le VIH, mais aussi cibler les jeunes hommes avant ou peut de temps apres leur premiere experience sexuelle. [TEXT NOT REPRODUCIBLE IN ASCII.] Los programas de circuncision masculina en Kenia: lecciones de la Encuesta de indicadores del SIDA en Kenia 2007 Objetivo Proporcionar orientacion para las programas de circuncision masculina en Kenia calculando la poblacion de hombres circuncidados e investigando la relacion entre la circuncision y la infeccion con el virus de la inmunodeficiencia humana (VIH), haciendo alusion especial a las hombres no circuncidados ni infectados par el VIH. Metodos Las datos acerca de las hombres con edades comprendidas entre 15 y 64 anos se obtuvieron de la Encuesta de indicadores del SIDA en Kenya del ano 2007, que incluyo entrevistas y la recogida de muestras de sangre para realizar las pruebas del VIH y del virus del herpes simple de tipo 2 (VHS-2). Se calculo la prevalencia de la infeccion par el VIH y la circuncision en las provincias de Kenia y se registraron las caracteristicas demograficas y el comportamiento sexual de las hombres circuncidados y no circuncidados, infectados y no infectados con el VIH. Resultados La prevalencia nacional de la infeccion par VIH en las hombres circuncidados fue del 13,2% (intervalo de confianza del 95%, IC: 10,8 -15,7) comparada con el 3,9% (IC 95%: 3,3 - 4,5) entre los hombres circuncidados. La provincia de Nyanza tuvo el mayor numero estimado de hombres no circuncidados y no infectados par el VIH (esto es, 601 709), seguida par la provincia Rift Valley, Nairobi y la provincia Occidental, respectivamente, y la mayoria de ellos pertenecia a la tribu etnica Luo. De esos hombres, el 77,8% no canada su estado serologico y el 33,2% estaba infectado con el VHS-2. Ademas, el 65,3% habia mantenido relaciones sexuales sin proteccion con una pareja serodiscordante o que no canada su estado serologico en las ultimos 12 meses y solo el 14,7% habia empleado preservativos de manera sistematica con su pareja mas reciente. No obstante, solo el 21,8% de las hombres circuncidados e infectados par el VIH con edades entre los 15 y las 19 anos era sexualmente activo. Conclusion La estrategia de circuncision masculina en Kenya deberia centrarse en las provincias con el mayor numero de hombres no circuncidados y no infectados por el VIH y dirigirse a las hombres jovenes antes o poco despues de la primera relacion sexual., Introduction Of an estimated 33.4 million people living with human immunodeficiency virus (HIV) infections worldwide, approximately 22.4 million live in sub-Saharan Africa and, of these, 1.5 million live in Kenya. [...]

Problem In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end of 2005. By July 2005, 45 000 adults and more than 2000 children were on treatment. A study was conducted to determine the barriers to identification of HIV-infected children. Approach Existing government policies were reviewed and the ART register of the Kenya National AIDS Control Programme was used to identify facilities providing ART. This paper reports the findings around diagnosis and staging of HIV infection in children. Local setting At the time of the study, 58 health facilities were providing ART to children. Only one institution had achieved universal HIV testing in the antenatal clinics. Six facilities systematically followed up HIV-exposed children. HIV antibody testing was not readily available to the children. Although four research centres were capable of carrying out diagnostic HIV polymerase chain reaction (PCR), the services were restricted to research purposes. Other constraints were inadequate physical infrastructure, inadequate systems for quality control in the laboratories and shortage of staff. Lessons learnt The policy framework to support identification of HIV-infected children had been established, albeit with narrow focus on sick children. The assessment identified the weaknesses in the structures for systematic diagnosis of HIV through laboratory or clinical-based algorithms. The researchers concluded that health staff training and implementation of a systematic standard approach to identification of HIV-infected children is urgently required. Problematique En 2003, Le Ministere de la sante kenyan s'etait donne pour objectif de faire beneficier d'ici fin 2005 d'un traitement antiretroviral (ART) 50 % des 250 000 personnes qui pourraient y pretendre d'apres les estimations. En juillet 2005, 45 000 adultes et plus de 2000 enfants etaient sous traitement. Une etude a ete menee pour determiner les obstacles s'opposant a l'identification des enfants infectes par le VIH. Demarche Les politiques gouvernementales existantes ont ete examinees et le registre de delivrance du traitement ART du programme kenyan anti-VIH/sida a ete utilise pour identifier les etablissements distribuant ce traitement. Le present article rapporte les resultats en rapport avec le diagnostic et le stadage de l'infection a VIH chez l'enfant. Contexte local Lors de la realisation de l'etude, 58 etablissements de sante dispensaient le traitement ART a des enfants. Un seul de ces etablissements appliquait un depistage systematique du VIH dans son service antenatal. Six etablissements pratiquaient un suivi systematique des enfants exposes au VIH. On ne disposait pas facilement d'un test de recherche des anticorps applicabie aux enfants. Si quatre centres de recherche etaient en mesure de diagnostiquer le VIH/sida par une technique de type PCR, lis n'exercaient ces capacites qu'a des fins de recherche. L'etude a revele d'autres contraintes : infrastructure materielie inadequate, insuffisance des systemes de controle de la qualite des laboratoires et penurie de personnel. Enseignements tires Un cadre politique pour l'identification des enfants infectes par le VIH a ete etabli, meme s'il est trop etroitement axe sur les enfants malades. L'evaluation a mis en evidence les faiblesses des structures de diagnostic systematique du VIH par des examens en laboratoire ou par des algorithmes partant de donnees cliniques. Les chercheurs ont conclu qu'une formation du personnel de sante et que l'application de la demarche standard d'identification systematique des enfants infectes par le VIH s'imposaient d'urgence. Problema En 2003 la meta del Ministerio de Salud de Kenya para fines de 2005 era proporcionar tratamiento antirretroviral (TAR) a un 50% de las 250 000 personas que se estimaba que debian recibirlo. En julio de 2005, 45 000 adultos y mas de 2000 ninos estaban recibiendo tratamiento. Se realizo un estudio para determinar los obstaculos que dificultaban la identificacion de los ninos infectados por el VIH. Enfoque Se revisaron las politicas nacionales en vigor y se utilizo el registro de TAR del Programa Nacional de Lucha contra el SIDA de Kenya para localizar los centros que ofrecian ese tratamiento. En este articulo se informa sobre los resultados relativos al diagnostico y la estadificacion de la infeccion por VIH en los ninos. Contexto local En el momento de realizar el estudio, 58 establecimientos de salud proporcionaban TARa pacientes infantiles. Solo una institucion habia logrado implantar de forma universal las pruebas de deteccion del VIH en los dispensarios prenatales. Seis establecimientos sometieron a seguimiento sistematico a los ninos expuestos al VIH, pero estos no tenian facil acceso a la prueba de deteccion de anticuerpos contra el VIH. Aunque habia cuatro centros de investigacion que podian llevar a cabo la prueba diagnostica del VIH basada en la reaccion en cadena de la polimerasa (PRC), esos servicios se limitaban a los trabajos de investigacion. Otras restricciones eran una infraestructura fisica inadecuada, unos sistemas insuficientes de control de la calidad en los laboratorios y la escasez de personal. Ensenanzas extraidas Se habia establecido el marco normativo de apoyo a la identificacion de los ninos infectados por el VIH, si bien focalizando estrechamente esa actividad en los ninos enfermos. La evaluacion permitio identificar las deficiencias de que adolecian las estructuras de diagnostico sistematico de la infeccion por VIH mediante algoritmos clinicos o de laboratorio. Los investigadores llegaron a la conclusion de que urge emprender actividades de capacitacion del personal sanitario y aplicar un procedimiento normalizado sistematico de identificacion de los ninos infectados por el VIH. [TEXT NOT REPRODUCIBLE IN ASCII], Background Kenya's population of 30 million people has nearly 1.2 million people living with HIV/AIDS with at least 250 000 in need of immediate antiretroviral therapy (ART). In 2003, the [...]

Background: Recommendations about scaling up HIV testing and counseling highlight the need to provide key services and to protect clients' rights, but it is unclear to what extent different modes of testing differ in this respect. This paper examines whether practices regarding consent, confidentiality, and referral vary depending on whether testing is provided through voluntary counseling and testing (VCT) or provider-initiated testing. Methods and Findings: The MATCH (Multi-Country African Testing and Counseling for HIV) study was carried out in Burkina Faso, Kenya, Malawi, and Uganda. Surveys were conducted at selected facilities. We defined eight outcome measures related to pre- and post-test counseling, consent, confidentiality, satisfactory interactions with providers, and (for HIV-positive respondents) referral for care. These were compared across three types of facilities: integrated facilities, where testing is provided along with medical care; stand-alone VCT facilities; and prevention of mother-to-child transmission (PMTCT) facilities, where testing is part of PMTCT services. Tests of bivariate associations and modified Poisson regression were used to assess significance and estimate the unadjusted and adjusted associations between modes of testing and outcome measures. In total, 2,116 respondents tested in 2007 or later reported on their testing experience. High percentages of clients across countries and modes of testing reported receiving recommended services and being satisfied. In the unadjusted analyses, integrated testers were less likely to meet with a counselor before testing (83% compared with 95% of VCT testers; p < 0.001), but those who had a pre-test meeting were more likely to have completed consent procedures (89% compared with 83% among VCT testers; p < 0.001) and pre-test counseling (78% compared with 73% among VCT testers; p = 0.015). Both integrated and PMTCT testers were more likely to receive complete post-test counseling than were VCT testers (59% among both PMTCT and integrated testers compared with 36% among VCT testers; p < 0.001). Adjusted analyses by country show few significant differences by mode of testing: only lower satisfaction among integrated testers in Burkina Faso and Uganda, and lower frequency of referral among PMTCT testers in Malawi. Adjusted analyses of pooled data across countries show a higher likelihood of pre-test meeting for those testing at VCT facilities (adjusted prevalence ratio: 1.22, 95% CI: 1.07-1.38) and higher satisfaction for stand-alone VCT facilities (adjusted prevalence ratio: 1.15; 95% CI: 1.06-1.25), compared to integrated testing, but no other associations were statistically significant. Conclusions: Overall, in this study most respondents reported favorable outcomes for consent, confidentiality, and referral. Provider-initiated ways of delivering testing and counseling do not appear to be associated with less favorable outcomes for clients than traditional, client-initiated VCT, suggesting that testing can be scaled up through multiple modes without detriment to clients' rights. Please see later in the article for the Editors' Summary., Introduction Since HIV tests became available in the mid-1980s, concerns about human rights have led to heated discussions among those promoting wider testing and those who fear the social consequences [...]

Background: Following confirmation of the effectiveness of voluntary medical male circumcision (VMMC) for HIV prevention, the World Health Organization and the Joint United Nations Programme on HIV/AIDS issued recommendations in 2007. Less than 5 y later, priority countries are at different stages of program scale-up. This paper analyzes the progress towards the scale-up of VMMC programs. It analyzes the adoption of VMMC as an additional HIV prevention strategy and explores the factors may have expedited or hindered the adoption of policies and initial program implementation in priority countries to date. Methods and Findings: VMMCs performed in priority countries between 2008 and 2010 were recorded and used to classify countries into five adopter categories according to the Diffusion of Innovations framework. The main predictors of VMMC program adoption were determined and factors influencing subsequent scale-up explored. By the end of 2010, over 550,000 VMMCs had been performed, representing approximately 3% of the target coverage level in priority countries. The 'early adopter' countries developed national VMMC policies and initiated VMMC program implementation soon after the release of the WHO recommendations. However, based on modeling using the Decision Makers' Program Planning Tool (DMPPT), only Kenya appears to be on track towards achievement of the DMPPT-estimated 80% coverage goal by 2015, having already achieved 61.5% of the DMPPT target. None of the other countries appear to be on track to achieve their targets. Potential predicators of early adoption of male circumcision programs include having a VMMC focal person, establishing a national policy, having an operational strategy, and the establishment of a pilot program. Conclusions: Early adoption of VMMC policies did not necessarily result in rapid program scale-up. A key lesson is the importance of not only being ready to adopt a new intervention but also ensuring that factors critical to supporting and accelerating scale-up are incorporated into the program. The most successful program had country ownership and sustained leadership to translate research into a national policy and program. Please see later in the article for the Editors' Summary., Introduction In 2009, more than 25 y after HIV was first identified, 2.6 million people had become infected, and there were an estimated 33.3 million people living with HIV worldwide [...]

Since the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended implementation of medical male circumcision (MC) as part of HIV prevention in areas with low MC and high HIV prevalence rates in 2007, the government of Kenya has developed a strategy to circumcise 80% of uncircumcised men within five years. To facilitate the quick translation of research to practice, a national MC task force was formed in 2007, a medical MC policy was implemented in early 2008, and Nyanza Province, the region with the highest HIV burden and low rates of circumcision, was prioritized for services under the direction of a provincial voluntary medical male circumcision (VMMC) task force. The government's early and continuous engagement with community leaders/elders, politicians, youth, and women's groups has led to the rapid endorsement and acceptance of VMMC. In addition, several innovative approaches have helped to optimize VMMC scale-up. Since October 2008, the Kenyan VMMC program has circumcised approximately 290,000 men, mainly in Nyanza Province, an accomplishment made possible through a combination of governmental leadership, a documented implementation strategy, and the adoption of appropriate and innovative approaches. Kenya's success provides a model for others planning VMMC scale-up programs., Introduction In the past two decades, observational studies have provided increasing evidence that male circumcision (MC) has an HIV prevention effect [1]. Moreover, three randomized controlled trials have reported that [...]

Voluntary medical male circumcision (VMMC) reduces female-to-male HIV transmission by approximately 60%;modeling suggests that scaling up VMMC to 80% of men 15- to 49-years-old within five years would avert over 3.3 million new HIV infections in 14 high priority countries/regions in southern and eastern Africa by 2025 and would require 20.33 million circumcisions. However, the shortage of health professionals in these countries must be addressed to reach these proposed coverage levels. To identify human resource approaches that are being used to improve VMMC volume and efficiency, we looked at previous literature and conducted a program review. We identified surgical efficiencies, non-surgical efficiencies, task shifting, task sharing, temporary redeployment of public sector staff during VMMC campaign periods, expansion of the health workforce through recruitment of unemployed, recently retired, newly graduating, or on-leave health care workers, and the use of volunteer medical staff from other countries as approaches that address human resource constraints. Case studies from Kenya, Tanzania, and Swaziland illustrate several innovative responses to human resource challenges. Although the shortage of skilled personnel remains a major challenge to the rapid scale-up of VMMC in the 14 African priority countries/regions, health programs throughout the region may be able to replicate or adapt these approaches to scale up VMMC for public health impact., Introduction Observational and experimental studies have shown that volunteer medical male circumcision (VMMC) reduces HIV acquisition among heterosexual men by approximately 60% [1-4]. In 2007, after the completion of three [...]