Search

Background: We analyzed HIV testing rates, prevalence of undiagnosed HIV, and predictors of testing in the Kenya AIDS Indicator Survey (KAIS) 2007. Methods: KAIS was a nationally representative sero-survey that included demographic and behavioral indicators and testing for HIV, HSV-2, syphilis, and CD4 cell counts in the population aged 15-64 years. We used gender-specific multivariable regression models to identify factors independently associated with HIV testing in sexually active persons. Results: Of 19,840 eligible persons, 80% consented to interviews and blood specimen collection. National HIV prevalence was 7.1% (95% CI 6.5-7.7). Among ever sexually active persons, 27.4% (95% CI 25.6-29.2) of men and 44.2% (95% CI 42.5- 46.0) of women reported previous HIV testing. Among HIV-infected persons, 83.6% (95% CI 76.2-91.0) were unaware of their HIV infection. Among sexually active women aged 15-49 years, 48.7% (95% CI 46.8-50.6) had their last HIV test during antenatal care (ANC). In multivariable analyses, the adjusted odds ratio (AOR) for ever HIV testing in women $35 versus 15- 19 years was 0.2 (95% CI: 0.1-0.3; p,0.0001). Other independent associations with ever HIV testing included urban residence (AOR 1.6, 95% CI: 1.2-2.0; p = 0.0005, women only), highest wealth index versus the four lower quintiles combined (AOR 1.8, 95% CI: 1.3-2.5; p = 0.0006, men only), and an increasing testing trend with higher levels of education. Missed opportunities for testing were identified during general or pregnancy-specific contacts with health facilities; 89% of adults said they would participate in home-based HIV testing. Conclusions: The vast majority of HIV-infected persons in Kenya are unaware of their HIV status, posing a major barrier to HIV prevention, care and treatment efforts. New approaches to HIV testing provision and education, including home-based testing, may increase coverage. Targeted interventions should involve sexually active men, sexually active women without access to ANC, and rural and disadvantaged populations. [ABSTRACT FROM AUTHOR]

Background: In order to inform prevention programming, we analyzed HIV discordance and concordance within couples in the Kenya AIDS Indicator Survey (KAIS) 2007. Methods: KAIS was a nationally representative population-based sero-survey that examined demographic and behavioral indicators and serologic testing for HIV, HSV-2, syphilis, and CD4 cell counts in 15,853 consenting adults aged 15-64 years. We analyzed interview and blood testing data at the sexual partnership level from married or cohabitating couples. Multivariable regression models were used to identify factors independently associated with HIV discordant and concordant status. Results: Of 3256 couples identified in the survey, 2748 (84.4%) had interview and blood testing data. Overall, 3.8% of couples were concordantly infected with HIV, and in 5.8% one partner was infected, translating to 338,000 discordant couples in Kenya. In 83.6% of HIV-infected Kenyans living in married or cohabitating couples neither partner knew their HIV status. Factors independently associated with HIV-discordance included young age in women (AOR 1.5, 95% CI: 1.2-1.8; p<0.0001), increasing number of lifetime sexual partners in women (AOR 1.5, 95% CI: 1.3-1.8; p<0.0001), HSV-2 infection in either or both partners (AOR 4.1, 95% CI: 2.3-7.2; p<0.0001), and lack of male circumcision (AOR 1.6, 95% CI: 1.0-2.5; p = 0.032). Independent factors for HIV-concordance included HSV-2 infection in both partners (AOR 6.5, 95% CI: 2.3-18.7; p = 0.001) and lack of male circumcision (AOR 1.8, 95% CI: 1.0-3.3; p = 0.043). Conclusions: Couple prevention interventions should begin early in relationships and include mutual knowledge of HIV status, reduction of outside sexual partners, and promotion of male circumcision among HIV-uninfected men. Mechanisms for effective prevention or suppression of HSV-2 infection are also needed. [ABSTRACT FROM AUTHOR]

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.

Background: Nearly three decades into the epidemic, sub-Saharan Africa (SSA) remains the region most heavily affected by human immunodeficiency virus (HIV), with nearly 70% of the 34 million people living with HIV globally residing in the region. In SSA, female and male youth (15 to 24 years) are at a disproportionately high risk of HIV infection compared to adults. As such, there is a need to target HIV prevention strategies to youth and to tailor them to a gender-specific context. This protocol describes the process for the multi-staged approach in the design of the MP3 Youth pilot study, a gender-specific, combination, HIV prevention intervention for youth in Kenya. Objective: The objective of this multi-method protocol is to outline a rigorous and replicable methodology for a gender-specific combination HIV prevention pilot study for youth in high-burden settings, illustrating the triangulated methods undertaken to ensure that age, sex, and context are integral in the design of the intervention. Methods: The mixed-methods, cross-sectional, longitudinal cohort pilot study protocol was developed by first conducting a systematic review of the literature, which shaped focus group discussions around prevention package and delivery options, and that also informed age- and sex- stratified mathematical modeling. The review, qualitative data, and mathematical modeling created a triangulated evidence base of interventions to be included in the pilot study protocol. To design the pilot study protocol, we convened an expert panel to select HIV prevention interventions effective for youth in SSA, which will be offered in a mobile health setting. The goal of the pilot study implementation and evaluation is to apply lessons learned to more effective HIV prevention evidence and programming. Results: The combination HIV prevention package in this protocol includes (1) offering HIV testing and counseling for all youth; (2) voluntary medical circumcision and condoms for males; (3) pre-exposure prophylaxis (PrEP), conditional cash transfer (CCT), and contraceptives for females; and (4) referrals for HIV care among those identified as HIV-positive. The combination package platform selected is mobile health teams in an integrated services delivery model. A cross-sectional analysis will be conducted to determine the uptake of the interventions. To determine long-term impact, the protocol outlines enrolling selected participants in mutually exclusive longitudinal cohorts (HIV-positive, PrEP, CCT, and HIV-negative) followed by using mobile phone text messages (short message service, SMS) and in-person surveys to prospectively assess prevention method uptake, adherence, and risk compensation behaviors. Cross-sectional and sub-cohort analyses will be conducted to determine intervention packages uptake. Conclusions: The literature review, focus groups, and modeling indicate that offering age- and gender- specific combination HIV prevention interventions that include biomedical, behavioral, and structural interventions can have an impact on HIV risk reduction. Implementing this protocol will show the feasibility of delivering these services at scale. The MP3 Youth study is one of the few combination HIV prevention intervention protocols incorporating youth- and gender-specific interventions in one delivery setting. Lessons learned from the design of the protocol can be incorporated into the national guidance for combination HIV prevention for youth in Kenya and other high-burden SSA settings. Trial Registration: ClinicalTrials.gov NCT01571128; http://clinicaltrials.gov/ct2/show/NCT01571128?term=MP3+youth&rank=1 (Archived by WebCite at http://www.webcitation.org/6nmioPd54) [ABSTRACT FROM AUTHOR]

Background: Despite a doubling of HIV testing coverage in Kenya over the past decade, approximately 2 in 10 people with HIV remained unaware of their infection in 2018. HIV testing is most effective in identifying people with undiagnosed HIV through frequent and strategic testing in populations at high risk. An assessment of testing frequency and predictors of first-time and repeat testing is critical for monitoring effectiveness of testing strategies., Methods: We conducted a cross-sectional analysis of adults aged ≥18 years who tested HIV-positive at 4 HIV testing and counseling clinics in Kenya from February 2015 to February 2016. We categorized individuals based on testing history, used Wilcoxon rank-sum tests to assess differences in intervals between the most recent and current HIV test, and used log-binomial regression to determine characteristics associated with first-time and repeat testing., Results: Among 1136 people testing HIV-positive, 336 (30%) had never tested before and 800 (70%) had, of whom 208 (26%) had previously tested positive. Among previously negative repeat testers, the median intertest interval was 414 days in key/priority populations (interquartile range = 179-1072) vs. 538 in the general population (interquartile range = 228-1299) (P = 0.09). Compared with previously negative repeat testers, being a first-time tester was associated with being age ≥40 years [vs. 18-24; adjusted risk ratio = 1.67, 95% confidence interval (CI): 1.23 to 2.26], men (vs. women; adjusted risk ratio = 1.45, 95% CI: 1.21 to 1.71), and testing through provider-initiated testing and counseling (vs. client initiated; 1.19, 95% CI: 1.00 to 1.40)., Conclusions: There is a need to increase HIV testing among older individuals and men, increase testing frequency in key/priority populations, and maintain provider-initiated and facility-based testing to reach first-time testers.

Background: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement., Methods: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV., Results: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW., Discussion: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

Background: HIV assisted partner services (APS) are a notification and testing strategy for sex partners of HIV-infected index patients. This cluster-randomized controlled trial secondary data analysis investigated whether history of intimate partner violence (IPV) modified APS effectiveness and risk of relationship dissolution., Setting: Eighteen HIV testing and counseling sites in Kenya randomized to provide immediate APS (intervention) or APS delayed for 6 weeks (control)., Methods: History of IPV was ascertained at study enrollment and defined as reporting ever experiencing physical or sexual IPV. Those reporting IPV in the month before enrollment were excluded. We tested whether history of IPV modified intervention effectiveness and risk of relationship dissolution using population-averaged Poisson and log-binomial generalized estimating equation models. Exploratory analyses investigated associations between history of IPV and events that occurred after HIV diagnosis using log-binomial generalized estimating equation models., Results: The study enrolled 1119 index participants and 1286 partners. Among index participants, 81 (7%) had history of IPV. History of IPV did not modify APS effectiveness in testing, newly diagnosing, or linking partners to care. History of IPV did not modify the association between receiving immediate APS and relationship dissolution during the study., Conclusions: Among participants who had not experienced IPV in the last month but had experienced IPV in their lifetimes, our results suggest that APS is an effective and safe partner notification strategy in Kenya. As APS is scaled up in different contexts, these data support including those reporting past IPV and closely monitoring adverse events.

Objectives: To explore factors associated with healing requiring more than 6 weeks after placement of the PrePex device for adult medical male circumcision., Methods: We enrolled 427 men ages 18-49 years in an observational study of PrePex at 1 urban and 2 peripheral clinics in western Kenya. Participants were scheduled for device removal at day 7 and a follow-up visit at day 42 (allowable range, 40-44) at which the provider recorded wound status, with complete healing defined as a dry wound without any scab, later confirmed by site investigator review of digital penile photographs. We performed univariate and multivariate logistic regression to explore associations between selected demographic, surgical, and follow-up factors and delayed healing (not healed by day 42 visit)., Results: Of the 427 men, 341 completing a day 42 visit with physical examination and recorded healing status were included. Fifty-four percent of included men were healed by day 42 visit. Factors associated with delayed healing in univariate analysis and remaining significant in the multivariate analysis were as follows: age 25 years or older [odds ratio (OR): 1.8; 95% confidence interval (CI): 1.4 to 2.4], an adverse event by day 44 (OR: 1.4; 95% CI: 1.03 to 2.0), and severe pain during device removal (protective association: OR: 0.7; 95% CI: 0.5 to 0.99)., Conclusions: Older age (25+ years), occurrence of an adverse event, and lesser self-reported pain at device removal were associated with delayed wound healing. If confirmed by larger surveillance studies, these results should be incorporated into the counseling given to male circumcision clients.

Objective: HIV infection in sub-Saharan Africa increasingly occurs among people who inject drugs (PWID). Kenya is one of the first to implement a national needle and syringe program. Our study undertook a baseline assessment as part of evaluating needle and syringe program in a seek, test, treat, and retain approach., Methods: Participants enrolled between May and December 2012 from 10 sites. Respondent-driven sampling was used to reach 1785 PWID for HIV-1 prevalence and viral load determination and survey data., Results: Estimated HIV prevalence, adjusted for differential network size and recruitment relationships, was 14.5% in Nairobi (95% CI: 10.8 to 18.2) and 20.5% in the Coast region (95% CI: 17.3 to 23.6). Viral load (log10 transformed) in Nairobi ranged from 1.71 to 6.12 (median: 4.41; interquartile range: 3.51-4.94) and in the Coast from 1.71 to 5.88 (median: 4.01; interquartile range: 3.44-4.72). Using log10 viral load 2.6 as a threshold for HIV viral suppression, the percentage of HIV-infected participants with viral suppression was 4.2% in Nairobi and 4.6% in the Coast. Heroin was the most commonly injected drug in both regions, used by 93% of participants in the past month, typically injecting 2-3 times/day. Receptive needle/syringe sharing at last injection was more common in Nairobi (23%) than in the Coast (4%). Estimated incidence among new injectors was 2.5/100 person-years in Nairobi and 1.6/100 person-years in the Coast., Conclusions: The HIV epidemic is well established among PWID in both Nairobi and Coast regions. Public health scale implementation of combination HIV prevention has the potential to greatly limit the epidemic in this vulnerable and bridging population.

Background: More than 4.7 million voluntary medical male circumcisions (VMMCs) had been provided by HIV prevention programs in sub-Saharan Africa through 2013. All VMMC clients are recommended to return to the clinic for postoperative follow-up, although adherence is variable. The clinical status of clients who do not return is largely unknown., Methods: VMMC clients from Nyanza Province, Kenya, aged older than or equal to 13 years, were recruited immediately after surgery from April to October 2012 from high-volume sites. Medical record reviews at 13-14 days after surgery indicated which clients had been adherent with recommended follow-up (ADFU) and which were lost-to-follow-up (LTFU). Clients in the LTFU group received clinical evaluations at home approximately 2 weeks postsurgery. Adverse events (AEs) and AE rates were compared between the ADFU and LTFU groups., Results: Of 4504 males approached in 50 VMMC sites, 1699 (37.7%) were eligible and enrolled and 1600 of 1699 (94.2%) contributed to follow-up and AE data. Medical record review indicated 897 of 1600 (56.1%) were LTFU, and 762 (84.9%) of these received home-based clinical evaluations. The rate of moderate or severe AE diagnosis was 6.8% in the LTFU group vs. 3.3% in the ADFU group (relative risk = 2.1, 95% confidence interval: 1.3 to 3.4)., Conclusions: The moderate or severe AE diagnosis rate was approximately 2 times higher in the LTFU group. National programs should consider instituting surveillance systems to detect AEs that might otherwise go unnoticed. Providers should emphasize the importance of follow-up and actively contact LTFU clients to ensure care is provided throughout the entire postoperative course for all.

Background: Intentional childbearing may place heterosexual couples at risk of HIV infection in resource-limited settings with high HIV prevalence areas where society places great value on having children., Objective: To explore cognitive, cultural, and spatial mapping of sexual and reproductive health domains and services in western Kenya among men and women., Design: Community-based formative qualitative study design., Setting: Five administrative/geographical divisions of Nyando District, western Kenya., Subjects: Adult men 18 years and older and women who were of reproductive-potential ages (15 to 49 years for females) (n=90)., Results: Men and women have disparate goals for number of children and engage in gendered patterns of protective method use (contraceptives used by women often in secret, condoms by men but rarely)., Conclusion: HIV infection was still seen as stigmatizing. These study results are relevant to design of effective integrated delivery for reproductive and HIV services in high-burden sub-Saharan African countries.

Background: Populations with higher risks for HIV exposure contribute to the HIV epidemic in Kenya. We present data from the second Kenya AIDS Indicator Survey to estimate the size and HIV prevalence of populations with high-risk characteristics., Methods: The Kenya AIDS Indicator Survey 2012 was a national survey of Kenyans aged 18 months to 64 years which linked demographic and behavioral information with HIV results. Data were weighted to account for sampling probability. This analysis was restricted to adults aged 18 years and older., Results: Of 5088 men and 6745 women, 0.1% [95% confidence interval (CI): 0.03 to 0.14] were persons who inject drugs (PWID). Among men, 0.6% (CI: 0.3 to 0.8) had ever had sex with other men, and 3.1% (CI: 2.4 to 3.7) were males who had ever engaged in transactional sex work (MTSW). Among women, 1.9% (CI: 1.3 to 2.5) had ever had anal sex, and 4.1% (CI: 3.5 to 4.8) were women who had ever engaged in transactional sex work (FTSW). Among men, 17.6% (CI: 15.7 to 19.6) had been male clients of transactional sex workers (TSW). HIV prevalence was 0% among men who have sex with men, 6.3% (CI: 0 to 18.1) among persons who injected drugs, 7.1% (CI: 4.8 to 9.4) among male clients of TSW, 7.6% (CI: 1.8 to 13.4) among MTSW, 12.1% (CI: 7.1 to 17.1) among FTSW, and 12.1% (CI: 5.0 to 19.2) among females who ever had engaged in anal sex., Conclusions: Population-based data on high-risk populations can be used to set realistic targets for HIV prevention, care, and treatment for these groups. These data should inform priorities for high-risk populations in the upcoming Kenyan strategic plan on HIV/AIDS.

Background: The Kenyan Ministry of Health initiated a voluntary medical male circumcision (VMMC) program in 2008. We used data from 2 nationally representative surveys to estimate trends in the number, demographic characteristics, and sexual behaviors of recently circumcised and uncircumcised HIV-uninfected men in Kenya., Methods: We compared the proportion of circumcised men between the first and second Kenya AIDS Indicator Survey (KAIS 2007 and KAIS 2012) to assess the progress of Kenya's VMMC program. We calculated the number of uncircumcised HIV-uninfected men. We conducted descriptive analyses and used multivariable methods to identify the variables independently associated with HIV-uninfected uncircumcised men aged 15-64 years in the VMMC priority region of Nyanza., Results: The proportion of men who reported being circumcised increased significantly from 85.0% in 2007 to 91.2% in 2012. The proportions of circumcised men increased in all regions, with the highest increases of 18.1 and 9.0 percentage points in the VMMC priority regions of Nyanza and Nairobi, respectively. Half (52.5%) of HIV-uninfected and uncircumcised men had never been married, and 84.6% were not using condoms at all times with their last sexual partner., Conclusions: VMMC prevalence has increased across Kenya demonstrating the success of the national program. Despite this accomplishment, the Nyanza region remains below the target to circumcise 80% of all eligible men aged 15-49 years between 2009 and 2013. As new cohorts of young men enter into adolescence, consistent focus is needed. To ensure sustainability of the VMMC program, financial resources and coordinated planning must continue.

Disclosure of HIV status is routinely promoted as a public health measure to prevent transmission and enhance treatment adherence support. While studies show a range of positive and negative outcomes associated with disclosure, it has also been documented that disclosing is a challenging and ongoing process. This article aims to describe the role of health-care workers in Central and Nairobi provinces in Kenya in facilitating disclosure in the contexts of voluntary counselling and testing and provider-initiated testing and counselling and includes a discussion on how participants perceive and experience disclosure as a result. We draw on in-depth qualitative research carried out in 2008-2009 among people living with HIV (PLHIV) and the health workers who provide care to them. Our findings suggest that in everyday practice, there are three models of disclosure at work: (1) voluntary-consented disclosure, in alignment with international guidelines; (2) involuntary, non-consensual disclosure, which may be either intentional or accidental; and (3) obligatory disclosure, which occurs when PLHIV are forced to disclose to access services at health facilities. Health-care workers were often caught between the three models and struggled with the competing demands of promoting prevention, adherence, and confidentiality. Findings indicate that as national and global policies shift to normalize HIV testing as routine in a range of clinical settings, greater effort must be made to define suitable best practices that balance the human rights and the public health perspectives in relation to disclosure.

Unlabelled: HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP)., Trial Registration: ClinicalTrials.gov NCT01256463.

As the science demonstrating strong evidence for voluntary medical male circumcision (VMMC) for HIV prevention has evolved, the President's Emergency Plan for AIDS Relief (PEPFAR) has collaborated with international agencies, donors, and partner country governments supporting VMMC programming. Mathematical models forecast that quickly reaching a large number of uncircumcised men with VMMC in strategically chosen populations may dramatically reduce community-level HIV incidence and save billions of dollars in HIV care and treatment costs. Because VMMC is a 1-time procedure that confers life-long partial protection against HIV, programs for adult men are vital short-term investments with long-term benefits. VMMC also provides a unique opportunity to reach boys and men with HIV testing and counseling services and referrals for other HIV services, including treatment. After formal recommendations by WHO in 2007, priority countries have pursued expansion of VMMC. More than 1 million males have received VMMC thus far, with the most notable successes coming from Kenya's Nyanza Province. However, a myriad of necessary cultural, political, and ethical considerations have moderated the pace of overall success. Because many millions more uncircumcised men would benefit from VMMC services now, US President Barack Obama committed PEPFAR to provide 4.7 million males with VMMC by 2014. Innovative circumcision methods-such as medical devices that remove the foreskin without injected anesthesia and/or sutures-are being rigorously evaluated. Incorporation of safe innovations into surgical VMMC programs may provide the opportunity to reach more men more quickly with services and dramatically reduce HIV incidence for all.

Objectives: To assess healing with Shang Ring removal at different prespecified times; whether spontaneous detachment occurs with delayed removal; problems, complaints, and acceptability of wearing the device; satisfaction among participants; and acceptability of the procedure among providers., Methods: Fifty HIV-negative men underwent a Shang Ring circumcision in Kenya. Men were randomly assigned for device removal at 7 (15 men), 14 (15 men), or 21 days (20 men). Follow-up visits were at 7, 14, 21, 28, and 42 days after circumcision and 2 days after removal., Results: Circumcision and device removal were conducted without significant problems. Mean times for circumcision and device removal were 6.5 (SD = 2.4) and 2.5 (SD = 0.8) minutes, respectively. Complete detachment of the device occurred in 22 (66.7%) men who wore it more than 7 days. Seven men (14.0%) with partial detachments requested removal 8-14 days postcircumcision due to pain/discomfort. Healing progressed normally in all participants; cumulative probabilities of complete healing were similar across groups. No severe or serious adverse events occurred. Acceptability among participants was high. Providers reported that Shang Ring circumcision was "very easy" compared with the forceps-guided procedure., Conclusion: The Shang Ring is safe and easy to use according to label instructions (7 day removal). Detachments occurred without significant problems, although some men requested removal of partially detached rings. Removal time had little effect on healing. These data help allay concerns about men not returning for ring removal and expand the evidence base suggesting the Shang Ring could facilitate rapid male circumcision rollout in sub-Saharan Africa.

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.

Objective: To assess safety, preliminary efficacy, and acceptability of the Shang Ring, a novel disposable device for adult male circumcision in Kenya., Methods: Forty HIV-negative men were recruited in Homa Bay, Kenya. Circumcisions were performed by a trained physician or nurse working with 1 assistant. Follow-up was conducted at 2, 7, 9, 14, 21, 28, 35, and 42 days after circumcision. Rings were removed on day 7. Pain was assessed using a visual analog scale (VAS) (0 = no pain, 10 = worst possible). Men were interviewed at enrollment and on days 7 and 42., Results: All 40 procedures were completed successfully. Mean procedure and device removal times were 4.8 (SD ± 2.0) and 3.9 (SD ± 2.6) minutes, respectively. There were 6 mild adverse events, including 3 penile skin injuries, 2 cases of edema, and 1 infection; all resolved with conservative management. In addition, there were 3 partial ring detachments between days 2-7. None required treatment or early ring removal. Erections with the ring were well tolerated, with a mean pain score of 3.5 (SD ± 2.3). By day 2, 80% of men were back to work. At 42 days, all participants were very satisfied with their circumcision and would recommend the procedure to others., Conclusions: Our results demonstrate that the Shang Ring is safe for further study in Africa. Acceptability of the Shang Ring among participants was excellent. With short procedure times, less surgical skill required, and the ease with which it can be used by nonphysicians, the Shang Ring could facilitate rapid roll-out of male circumcision in sub-Saharan Africa.