Defining the Global Research and Programmatic Agenda and Priority Actions for Voluntary Medical Male Circumcision for HIV Prevention.

PURPOSE OF REVIEW: Since 2007, voluntary medical male circumcision (VMMC) programs have been associated with substantially reduced HIV incidence across 15 prioritized countries in Eastern and Southern Africa. Drawing on the programmatic experience of global VMMC leaders, this report reviews progress made in the first 15 years of the program, describes programmatic and research gaps, and presents considerations to maximize the impact of VMMC. RECENT FINDINGS: Overall, key programmatic and research gaps include a lack of robust male circumcision coverage estimates due to limitations to the data and a lack of standardized approaches across programs; challenges enhancing VMMC uptake include difficulties reaching populations at higher risk for HIV infection and men 30 years and older; limitations to program and procedural quality and safety including variations in approaches used by programs; and lastly, sustainability with limited evidence-based practices. Considerations to address these gaps include the need for global guidance on estimating coverage, conducting additional research on specific sub-populations to improve VMMC uptake, implementation of responsive and comprehensive approaches to adverse event surveillance, and diversifying financing streams to progress towards sustainability. This report's findings may help establish a global VMMC research and programmatic agenda to inform policy, research, and capacity-building activities at the national and global levels.

Predictors of HIV Among 1 Million Clients in High-Risk Male Populations in Tanzania.

The World Health Organization identified men as an essential group to target with HIV testing and treatment strategies;: men who have sex with men (MSM) and male clients of female sex workers (CFSW) account for 35% of new HIV infections globally. Using a cross-sectional design from a community-based HIV prevention project in Tanzania (October 2015-September 2018) and multivariable logistic regression, we identified predictors of HIV seropositivity among men. Of 1,041,343 men on their initial visit to the project, 36,905 (3.5%) were MSM; 567,005 (54.5%) were CFSW; and 437,343 (42.0%) were other men living near hotspots (OMHA). Three predictors of HIV seropositivity emerged across all three groups: being uncircumcised, having sexually transmitted infection symptoms, and harmful drinking of alcohol before sex. Any reported form of gender-based violence among MSM and OMHA and inconsistent condom use among CFSW were associated with HIV seropositivity. These findings may inform community HIV strategies like self-testing, delivery of pre-exposure prophylaxis and antiretroviral therapy, and behavioral change communication targeting men at higher risk of infection.

The Reproductive Impact of Eating Disorders in Adolescents.

Eating disorders are common, chronic illnesses that frequently arise during adolescence. Because of the impact on nutrition, individuals with eating disorders have significant health consequences, including effects on reproductive health. Adolescent women with eating disorders frequently have menstrual irregularities, though the causes of these abnormalities are complex and vary depending on the type of eating disorder. Teens with eating disorders may have changes in current and future fertility, and eating disorders during pregnancy can have medical and psychologic impacts for both mother and child. Though not well researched, eating disorders in men can affect reproductive health and potentially impact fertility. Lastly, eating disorders in adolescents can have significantly deleterious, irreversible effects on bone health.

HIV PrEP is more than ART-lite: Longitudinal study of real-world PrEP services data identifies missing measures meaningful to HIV prevention programming.

INTRODUCTION: Evidence indicates HIV oral pre-exposure prophylaxis (PrEP) is highly efficacious and effective. Substantial early discontinuation rates are reported by many programs, which may be misconstrued as program failure. However, PrEP use may be non-continuous and still effective, since HIV risk fluctuates. Real-world PrEP use phenomena, like restarting and cyclical use, and the temporal characteristics of these use patterns are not well described. The objective of our study was to characterize and identify predictors of use patterns observed in large PrEP scale-up programs in Africa. METHODS: We analysed demographic and clinical data routinely collected during client visits between 2017 and 2019 in three Jhpiego-supported programs in Kenya, Lesotho and Tanzania. We characterized duration on/off PrEP and, using ordinal regression, modelled the likelihood of spending additional time off and identified factors associated with increasing cycle number. The Andersen-Gill model was used to identify predictors of time to PrEP discontinuation. To analyse factors associated with a client's first return following initiation, we used a two-step Heckman probit. RESULTS: Among 47,532 clients initiating PrEP, approximately half returned for follow-up. With each increase in cycle number, time off PrEP between use cycles decreased. The Heckman first-step model showed an increased probability of returning versus not by older age groups and among key and vulnerable population groups versus the general population; in the second-step model older age groups and key and vulnerable populations were less likely in Kenya, but more likely in Lesotho, to return on-time (refill) versus delayed (restarting). CONCLUSIONS: PrEP users frequently cycle on and off PrEP. Early discontinuation and delays in obtaining additional prescriptions were common, with broad predictive variability noted. Time off PrEP decreased with cycle number in all countries, suggesting normalization of use with experience. More nuanced measures of use are needed than exist for HIV treatment if effective use of PrEP is to be meaningfully measured. Providers should be equipped with measures and counselling messages that recognize non-continuous and cyclical use patterns so that clients are supported to align fluctuating risk and use, and can readily restart PrEP after stopping, in effect empowering them further to make their own prevention choices.

Health system adaptations and considerations to facilitate optimal oral pre-exposure prophylaxis scale-up in sub-Saharan Africa.

Following WHO's 2015 recommendation, countries in sub-Saharan Africa have progressively scaled up oral pre-exposure prophylaxis (PrEP) as part of combination HIV prevention. PrEP has potential to significantly reduce new HIV infections in sub-Saharan Africa if it is widely available, accessible, and effectively used. Initial scale-up efforts have generated progress, drawing lessons from existing HIV interventions, such as antiretroviral therapy and biomedical prevention. However, beset by unprepared health systems, scale-up has been slow, resulting in suboptimal coverage among priority groups at higher risk of HIV acqusition. Using the WHO health system building blocks framework, this Review synthesises literature on essential considerations for PrEP scale-up in sub-Saharan Africa, highlighting the importance of health system adaptability and responsiveness.

Characterizing a sexual health and HIV risk stratification scale for sexually active adolescent girls and young women (AGYW) in Tanzania.

Adolescent girls and young women (AGYW) aged 15 to 24 years face disproportionately high risks of acquiring HIV and other sexually transmitted infections (STIs). A sexual health risk stratification tool can support the development and implementation of tailored HIV and STI prevention services for sub-groups of at-risk AGYW. Data were collected among sexually active AGYW aged 15 to 24 years in Tanzania between April 2015 and March 2017. Exploratory and confirmatory factor analyses were conducted to construct and assess the latent structure of a ten-item scale for rapid assessment of sexual health risks. Items with high factor loadings and minimal cross loadings were retained in the final scale. Scale performance was appraised against condomless sex (defined as unprotected vaginal or anal intercourse) reported by AGYW for construct validity. A three-factor structure of vulnerability to HIV among AGYW was supported with subscales for socioeconomic vulnerability; lack of adult support; and sexual behavioral risks. The chi-square goodness-of-fit test, root mean square error of approximation, comparative fit index, and Tucker-Lewis index indicated a strong goodness-of-fit of the three-factor scale. Cronbach alphas (0.55 for socioeconomic vulnerability, 0.55 for lack of support, and 0.48 for sexual risk) indicated sub-optimal internal consistency for all sub-scales. The factor-item and factor-factor correlations identified in these analyses were consistent with the conceptual framework of vulnerability of HIV infection in AGYW, suggesting good construct validity. The scale also demonstrated a statistically significant association with condomless sex and could be potentially used for sexual health risk stratification (OR = 1.17, 95% CI: 1.12, 1.23). The sexual health and HIV risk stratification scale demonstrated potential in identifying sexually active AGYW at high risk for HIV and other STIs. Ultimately, all AGYW in Tanzania are not at equal risk for HIV and this scale may support directing resources towards those at highest risk of HIV.

A weighty issue: refeeding an adolescent patient on dialysis.

BACKGROUND: For malnourished patients with end stage renal disease (ESRD) on hemodialysis (HD), refeeding is complex; true weight (dry weight) gain must be accounted for as it accrues to safely dialyze. OBJECTIVE: This case describes the challenge of following true weight to appropriately adjust treatment for a patient with ESRD on HD requiring inpatient refeeding. METHODS: A 17-year-old female presented to an adolescent clinic after referral from her nephrologist for malnutrition and disordered eating. Her weight was 38.3 kg and height was 155.2 cm (76.2% of mean estimated body mass index, MEBMI). Her history was remarkable for a diagnosis of ESRD. The patient was admitted to the inpatient disordered eating program. The patient continued HD three times a week and was followed by nephrology. The team noted that the patient's dry weight for dialysis had not yet been adjusted, leading to increasingly aggressive dialysis. The nephrology team addressed the need for reassessments of dry weight by utilizing the "crit line" method. RESULTS: Frequent assessment allowed the nephrology team to account for intensive renourishment of the patient. After a 64 day hospital stay, the patient achieved 88.1% of MEBMI, calculated using her most up to date dry weight. CONCLUSION: Among patients with malnutrition and ESRD requiring HD, it is imperative to determine a patient's dry weight at the beginning of refeeding so the treatment plan can be adjusted according to the dynamic, true weight of the patient. This case illustrates the importance of interdisciplinary teamwork when managing a patient with malnutrition and ESRD on HD.

An implementation model for scaling up oral pre-exposure prophylaxis in Kenya: Jilinde project.

Oral pre-exposure prophylaxis (PrEP) is an efficacious way to lower the risk of HIV acquisition among high-risk individuals. Despite the World Health Organization's 2015 recommendation that all persons at substantial risk of HIV infection be provided with access to oral PrEP, the rollout has been slow in many low- and middle-income countries. Initiatives for national rollout are few, and subtle skepticism persists in several countries about the feasibility of national PrEP implementation. We describe the conceptual design of the Jilinde project, which is implementing oral PrEP as a routine service at a public health scale in Kenya. We describe the overlapping domains of supply, demand, and government and community ownership, which combine to produce a learning laboratory environment to explore the scale-up of PrEP. We describe how Jilinde approaches PrEP uptake and continuation by applying supply and demand principles and ensures that government and community ownership informs policy, coordination, and sustainability. We describe the "learning laboratory" approach that informs strategic and continuous learning, which allows for adjustments to the project. Jilinde's conceptual model illustrates how the coalescence of these concepts can promote scale-up of PrEP in real-world conditions and offers critical lessons on an implementation model for scaling up oral PrEP in low- and middle-income countries.

Correction to: Association of Male Circumcision with Women's Knowledge of its Biomedical Effects and With Their Sexual Satisfaction and Function: A Systematic Review.

The article Association of Male Circumcision with Women's Knowledge of its Biomedical Effects and With Their Sexual Satisfaction and Function: A Systematic Review, written by Jonathan M. Grund, Tyler S. Bryant, Carlos Toledo, Inimfon Jackson, Kelly Curran, Sheng Zhou, Jorge Martin del Campo, Ling Yang, Apollo Kivumbi, Peizi Li, Naomi Bock, Joanna Taliano, Stephanie M. Davis was originally published electronically on the publisher's internet portal (currently SpringerLink) on 24 October 2018 without open access.

Adverse events in a large-scale VMMC programme in Tanzania: findings from a case series analysis.

INTRODUCTION: Adverse events (AEs) rates in voluntary medical male circumcision (VMMC) are critical measures of service quality and safety. While these indicators are key, monitoring AEs in large-scale VMMC programmes is not without challenges. This study presents findings on AEs that occurred in eight years of providing VMMC services in three regions of Tanzania, to provide discussion both on these events and the structural issues around maintaining safety and quality in scaled-up VMMC services. METHODS: We look at trends over time, demographic characteristics, model of VMMC and type and timing of AEs for 1307 males who experienced AEs among all males circumcised in Tabora, Njombe and Iringa regions from 2009 to 2017. We analysed deidentified client data from a VMMC programme database and performed multivariable logistic regression with district clustering to determine factors associated with intraoperative and postoperative AEs among VMMC clients. RESULTS AND DISCUSSION: Among 741,146 VMMC clients, 0.18% (1307/741,146) experienced a moderate or severe AE. The intraoperative AE rate was 2.02 per 100,000 clients, and postoperative rate was 2.29 per 1000 return clients. Multivariable logistic regression showed that older age (20 to 29 years) was significantly associated with intraoperative AEs (aOR: 3.51, 95% CI: 1.17 to 10.6). There was no statistical significant difference in AE rates by surgical method. Mobile VMMC service delivery was associated with the lowest risk of experiencing postoperative AEs (aOR:0.64, 95% CI: 0.42 to 0.98). AE rates peaked in the first one to three  years of the programme and then steadily declined. CONCLUSIONS: In a programme with robust AE monitoring methodologies, AE rates reported in these three regions were very low and declined over time. While these findings support the safety of VMMC services, challenges in reporting of AEs in a large-scale VMMC programme are acknowledged. International and national standards of AE reporting in VMMC programmes are clear. As VMMC programmes transition to national ownership, challenges, strengths and learning from AE reporting systems are needed to support safety and quality of services.

Medical Child Abuse: An Unusual "Source" of Vaginal Bleeding.

BACKGROUND: Medical child abuse (MCA) is challenging to diagnose. Although young children are often affected, adolescents can be victims through caregiver coercion. Presentation is highly variable. Diagnosis is essential because of high associated morbidity and mortality. CASE: We describe the case of a 12-year-old girl who presented to multiple subspecialty clinics with reported menorrhagia. Despite reassuring clinical examinations, the family described menorrhagia that failed to respond to standard treatment. After an urgent evaluation for reported heavy bleeding revealed only scant blood, the diagnosis of MCA was made. SUMMARY AND CONCLUSION: Vaginal bleeding is a rare presentation of MCA, but must be considered whenever reported symptomatology does not follow physiologic patterns, respond to standard medical treatment, or correspond to clinical evaluation. Prompt identification is important to prevent further harm.

Case Report: Persistent Genital Arousal Disorder in an Adolescent Woman.

BACKGROUND: After several visits with unrelated complaints, a 16-year-old female patient disclosed symptoms of unwanted genital arousal and was diagnosed with persistent genital arousal disorder (PGAD). CASE: A 16-year-old female patient with history of depression, sexual abuse, and dysmenorrhea insistently requested etonogestrel rod removal. At 2 visits after implant removal, the patient disclosed the reason for her insistence: PGAD symptoms developed after implant insertion, although they worsened with removal. Chart review revealed selective serotonin reuptake inhibitor discontinuation before symptom onset. Normalization of sexual arousal occurred with counseling, selective serotonin reuptake inhibitor treatment, and hormonal contraception. SUMMARY AND CONCLUSION: This case highlights the importance of clinician recognition of PGAD symptoms, which adolescents might not openly disclose. Clinicians must nonjudgmentally collect medication history and sexual history, including sexual arousal and satisfaction, to make this diagnosis.

Association of Male Circumcision with Women's Knowledge of its Biomedical Effects and With Their Sexual Satisfaction and Function: A Systematic Review.

Male circumcision (MC) is a key HIV prevention intervention for men in countries with high HIV prevalence. Women's understanding of MC is important but poorly understood. We conducted a systematic review including women's knowledge of MC's biomedical impacts and its association with female sexual satisfaction and function through October 2017. Thirty-eight articles were identified: thirty-two with knowledge outcomes, seven with sexual satisfaction, and four with sexual function (N = 38). Respondent proportions aware MC protects men from HIV were 9.84-91.8% (median 60.0%). Proportions aware MC protects men from STIs were 14.3-100% (72.6%). Proportions aware MC partially protects men from HIV were 37.5-82% (50.7%). Proportions aware MC is not proven to protect women from infection by an HIV-positive partner were 90.0-96.8% (93.0%). No increases over time were noted. Women's MC knowledge is variable. Education could help women support MC and make better-informed sexual decisions.

Trends and Substance Use Associations With E-Cigarette Use in US Adolescents.

Concerns exist that e-cigarette use may introduce adolescents to drugs. This study explores trends and associations of inhaled tobacco use with drug use. We performed a secondary data analysis on the National Youth Risk Behavior Survey examining the inhaled tobacco and drug use patterns among US teens. Adjusted odds ratios were calculated using bivariate and multivariate analyses between inhaled tobacco use with other drug use, adjusting for age, race/ethnicity, and gender. When adjusting for gender, age, and race/ethnicity, teens who use only e-cigarettes had a higher odds than peers who do not use any inhaled tobacco products to have ever tried marijuana or alcohol, currently use marijuana or alcohol, have lifetime drug use, and misused prescription medications. Drug risk behavior appears stratified with type of inhaled tobacco used, with generally exclusive e-cigarette use linked to lowest risk and conventional and e-cigarette use associated with highest risk of drug use.

Extending beyond Policy: Reaching UNAIDS' Three "90"s in Malawi.

Malawi, like other countries with a generalized HIV epidemic, is striving to reach the ambitious targets set by UNAIDS known as the three 90's for testing, provision of antiretroviral therapy and viral suppression. Assisted by Malawi's progressive policies on HIV/AIDS, it appears possible that Malawi will attain these targets, but only by employing innovative program approaches to service delivery which help fill policy gaps. This article describes how a dedicated cadre of layperson testers and HIV-positive peers appears to have helped attain increases in HIV and viral load testing and retention in care in four districts in Malawi, and situates these innovations in a policy framework analysis.

Outcomes and Experiences of Men and Women with Partner Notification for HIV Testing in Tanzania: Results from a Mixed Method Study.

A growing evidence base supports expansion of partner notification in HIV testing services (HTS) in sub-Saharan Africa. In 2015, a cross-sectional study was conducted in Njombe region, Tanzania, to evaluate partner notification within facility-based HTS. Men and women newly diagnosed with HIV were enrolled as index clients and asked to list current or past sexual partners for referral to HTS. Successful partner referral was 2.5 times more likely among married compared to unmarried index clients and 2.2 times more likely among male compared to female index clients. In qualitative analysis, male as well as female index clients mentioned difficulties notifying past or casual partners, and noted disease symptoms as a motivating factor for HIV testing. Female index clients mentioned gender-specific challenges to successful referral. Women may need additional support to overcome challenges in the partner notification process. In addition to reducing barriers to partner notification specific to women, a programmatic emphasis on social strengths of males in successfully referring partners should be considered.

Delay in an Eating Disorder Diagnosis: The Reason Was a "Shox".

BACKGROUND: Patients' underlying medical conditions might affect the presentation and progression of an eating disorder. CASE: We describe a patient with an undiagnosed, rare, genetic skeletal dysplasia with effects on body mass index that likely led to body image distortion and delayed the diagnosis of an eating disorder. SUMMARY AND CONCLUSION: It is critical to fully assess disordered eating in the context of each patient's clinical status.

Association between male circumcision and women's biomedical health outcomes: a systematic review.

BACKGROUND: Male circumcision reduces men's risk of acquiring HIV and some sexually transmitted infections from heterosexual exposure, and is essential for HIV prevention in sub-Saharan Africa. Studies have also investigated associations between male circumcision and risk of acquisition of HIV and sexually transmitted infections in women. We aimed to review all evidence on associations between male circumcision and women's health outcomes to benefit women's health programmes. METHODS: In this systematic review we searched for peer-reviewed and grey literature publications reporting associations between male circumcision and women's health outcomes up to April 11, 2016. All biomedical (not psychological or social) outcomes in all study types were included. Searches were not restricted by year of publication, or to sub-Saharan Africa. Publications without primary data and not in English were excluded. We extracted data and assessed evidence on each outcome as high, medium, or low consistency on the basis of agreement between publications; outcomes found in fewer than three publications were indeterminate consistency. FINDINGS: 60 publications were included in our assessment. High-consistency evidence was found for five outcomes, with male circumcision protecting against cervical cancer, cervical dysplasia, herpes simplex virus type 2, chlamydia, and syphilis. Medium-consistency evidence was found for male circumcision protecting against human papillomavirus and low-risk human papillomavirus. Although the evidence shows a protective association with HIV, it was categorised as low consistency, because one trial showed an increased risk to female partners of HIV-infected men resuming sex early after male circumcision. Seven outcomes including HIV had low-consistency evidence and six were indeterminate. INTERPRETATION: Scale-up of male circumcision in sub-Saharan Africa has public health implications for several outcomes in women. Evidence that female partners are at decreased risk of several diseases is highly consistent. Synergies between male circumcision and women's health programmes should be explored. FUNDING: US Centers for Disease Control and Prevention and Jhpiego.

Addressing the First 90: A Highly Effective Partner Notification Approach Reaches Previously Undiagnosed Sexual Partners in Tanzania.

To meet UNAIDS' 90-90-90 treatment goals, effective approaches to HIV testing services (HTSs) are urgently needed. In 2015, a cross-sectional study was conducted to evaluate effectiveness and feasibility of partner notification for HTS in Tanzania. Men and women newly diagnosed with HIV were enrolled as index clients, listed sexual partners, and given options to notify and link their partners to HTS. Of 653 newly diagnosed individuals, 390 index clients were enrolled, listed 438 sexual partners, of whom 249 (56.8%) were successfully referred. Of 249 partners reaching the facilities, 96% tested for HIV, 148 (61.9%) tested HIV+ (all newly diagnosed), and 104 (70.3%) of partners testing positive were enrolled into HIV care and treatment. Results showed good acceptability, feasibility and effectiveness, as evidenced by high uptake of partner notification among newly diagnosed individuals, over half of listed partners successfully referred, and a very high positivity rate among referred sexual partners.