Which New Health Technologies Do We Need to Achieve an End to HIV/AIDS?

In the last 15 years, antiretroviral therapy (ART) has been the most globally impactful life-saving development of medical research. Antiretrovirals (ARVs) are used with great success for both the treatment and prevention of HIV infection. Despite these remarkable advances, this epidemic grows relentlessly worldwide. Over 2.1 million new infections occur each year, two-thirds in women and 240,000 in children. The widespread elimination of HIV will require the development of new, more potent prevention tools. Such efforts are imperative on a global scale. However, it must also be recognised that true containment of the epidemic requires the development and widespread implementation of a scientific advancement that has eluded us to date—a highly effective vaccine. Striving for such medical advances is what is required to achieve the end of AIDS…

Even with all the biomedical and behavioural tools available today, HIV continues to be a formidable pathogen, altering the health economics and public health strategies of most countries worldwide. Of the 35 million HIV-infected individuals worldwide in 2014, more than half did not know their HIV status, and over a third were not receiving ARVs [1] despite the availability of affordable point-of-care diagnostics and treatments. Adoption of “universal test and treat” approaches, extension of medical male circumcision programs, universal access to basic harm reduction services for people who inject drugs, and more widespread use of PrEP in targeted populations can do much to “bend the curve” and initiate a process to slow the rate of new HIV infections (Table 4). Such efforts are imperative on a global scale. However, it must also be recognised that true containment of the epidemic requires the development and widespread implementation of a scientific advance that has eluded us to date—a highly effective vaccine. There are potential synergies that will accrue from an integrated approach involving treatment, microbicides, and HIV vaccines (Fig 2). Various mathematical models agree that treatment roll-out on its own will decrease HIV incidence over time. However, when a 30% preventative HIV vaccine was introduced to a model with expanding treatment access in southern Africa, incidence was predicted to be 67% lower over time compared to a scenario with no vaccine introduction [35].

Below: Medical interventions required to end the epidemic of HIV

Below:  The spectrum of biomedical innovation required to end AIDS

Full article at:   http://goo.gl/SmCmO6

By:  Glenda E. Gray,1,2,* Fatima Laher,2 Tanya Doherty,1,3,4 Salim Abdool Karim,5,6 Scott Hammer,7 John Mascola,8 Chris Beyrer,9,10 and Larry Corey11

¹South African Medical Research Council, Cape Town, South Africa

²Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

³School of Public Health, University of Western Cape, Bellville, South Africa

⁴School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

⁵Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa

⁶Mailman School of Public Health, Columbia University, New York City, New York, United States of America

⁷Columbia University Medical Center, New York City, New York, United States of America

⁸Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health. Bethesda, Maryland, United States of America

⁹Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

¹⁰The International AIDS Society, Geneva, Switzerland

¹¹HIV Vaccine Trials Network, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington

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Women’s Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia

Women’s perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women’s health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men’s risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman’s HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women’s misperception regarding MC. Programs should address women’s informational needs and continue to emphasize that condoms remain critical, regardless of male partner’s circumcision status…

Women potentially contribute substantially to MC uptake by playing an active role in their partner’s decision to obtain MC, assenting when their partner indicates an interest in circumcision, or participating in the decision about circumcising a son. They may also act as supportive partners in seeking MC services or in the post-operative period. Finally, women’s accurate knowledge of the protection MC does and does not afford is important to avoid risk compensation.

With respect to basic MC awareness and knowledge, some of our findings are encouraging. At baseline, during the very early periods of the VMMC program in Zambia, three-quarters of women had heard about MC and 64.0% of women correctly indicated that MC reduces males’ risk of HIV, increasing to 81.5% in Round 2. Similar proportions accurately responded that MC provides protection against some STIs.

However, women demonstrated a lack of more nuanced knowledge of MC’s protective effects, which is cause for concern. A strikingly large proportion of women in the quantitative survey incorrectly believed that MC fully protects men from HIV. The fact that this proportion significantly increased over time is particularly troubling. Moreover, this misperception is mirrored in the qualitative subsample, with close to half of the women not understanding that MC provides only partial protection for men. Even among those women in the subsample who had responded correctly in the quantitative survey, almost half expressed uncertainty or significant misperceptions about MC’s protective effect for men against HIV in their in-depth interviews.

We observe a similar pattern regarding women’s perception of the impact of MC on STI risk for men. Although the majority of survey respondents correctly replied that MC reduces men’s risk of some STIs, the qualitative data suggest that considerable misconceptions remain. Indeed, two-thirds of women in the qualitative subsample had misperceptions about the reduction in STI risk among men that is attributable to MC. The vast majority of these women mistakenly believed that MC completely, or almost completely, protects men against STIs. Thus, our findings indicate that even in cases where superficial knowledge is demonstrated, substantial confusion exists over the relationship between MC and men’s HIV/STI acquisition, and the degree of protection afforded. This is true even among our relatively more educated and wealthier qualitative subsample.

Full article at:   http://goo.gl/JgiHoa

By:  Nicole A. Haberland,1,* Christine A. Kelly,2 Drosin M. Mulenga,3 Barbara S. Mensch,1 and Paul C. Hewett4

Philip Anglewicz, Editor

¹Population Council, New York, United States of America

²London School of Hygiene and Tropical Medicine, London, United Kingdom

³Population Council, Lusaka, Zambia

⁴Population Council, Washington DC, United States of America

Tulane University School of Public Health, UNITED STATES

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Post-Coital Penile Washing & The Risk of HIV-Acquisition in Uncircumcised Men, in Rakai, Uganda

Post-coital genital washing by uncircumcised men may affect the risk of male HIV acquisition. We assessed the association between self-reported washing after sex in 2,976 initially HIV-negative, uncircumcised men enrolled in a prospective cohort study in Rakai, Uganda. 

Data from the 2,976 participants who reported sexual intercourse in the past 12 months contributed 4,290 visits, with 7316.6 person-years (py) of observation during the two-year follow-up. The overall HIV-incidence was 1.28/100py 95%CI (1.04-1.57). About 91.0% of men reported washing their penis after sex, and their HIV incidence was 1.34/100py (95%CI 1.08-1.66), compared to an incidence of 0.62 /100py (95%CI 0.17-1.60) in men who did not wash their penis after intercourse. 

Using Poisson multivariable regression, the adjusted incidence rate ratio (AdjIRR) of HIV acquisition associated with post-coital washing was 1.94(95%CI 0.71-5.29). Post-coital penile washing, as practiced in this rural African population does not afford protection from HIV acquisition among uncircumcised men, and may increase risk.

Purchase full article at:   http://goo.gl/BtC812

By:  Makumbi FE1, Ssempijja V, Sekasanvu J, Ssekubugu R, Kigozi G, Watya S, Nakigozi G, Serwadda D, Wawer M, Gray R.

• 1Makerere University, School of Public Health, College of Health Sciences, Kampala, Uganda 
• b Rakai Health Sciences Program, Entebbe, Uganda 
• c Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD. 
• AIDS. 2016 Mar 17.

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Adolescent Sexual and Reproductive Health Services and Implications for the Provision of Voluntary Medical Male Circumcision: Results of a Systematic Literature Review

Background

Voluntary medical male circumcision (VMMC) is a critical HIV prevention tool. Since 2007, sub-Saharan African countries with the highest prevalence of HIV have been mobilizing resources to make VMMC available. While implementers initially targeted adult men, demand has been highest for boys under age 18. It is important to understand how male adolescents can best be served by quality VMMC services.

Methods and Findings

A systematic literature review was performed to synthesize the evidence on best practices in adolescent health service delivery specific to males in sub-Saharan Africa. PubMed, Scopus, and JSTOR databases were searched for literature published between January 1990 and March 2014. The review revealed a general absence of health services addressing the specific needs of male adolescents, resulting in knowledge gaps that could diminish the benefits of VMMC programming for this population. Articles focused specifically on VMMC contained little information on the adolescent subgroup. The review revealed barriers to and gaps in sexual and reproductive health and VMMC service provision to adolescents, including structural factors, imposed feelings of shame, endorsement of traditional gender roles, negative interactions with providers, violations of privacy, fear of pain associated with the VMMC procedure, and a desire for elements of traditional non-medical circumcision methods to be integrated into medical procedures. Factors linked to effective adolescent-focused services included the engagement of parents and the community, an adolescent-friendly service environment, and VMMC counseling messages sufficiently understood by young males.

Conclusions

VMMC presents an opportune time for early involvement of male adolescents in HIV prevention and sexual and reproductive health programming. However, more research is needed to determine how to align VMMC services with the unique needs of this population.

Full article at:   http://goo.gl/1p24IE

By:  Michelle R. Kaufman,#1,* Marina Smelyanskaya,#1 Lynn M. Van Lith,1 Elizabeth C. Mallalieu,1 Aliza Waxman,1 Karin Hatzhold,2 Arik V. Marcell,3 Susan Kasedde,4 Gissenge Lija,5 Nina Hasen,6 Gertrude Ncube,7 Julia L. Samuelson,8Collen Bonnecwe,9 Kim Seifert-Ahanda,10 Emmanuel Njeuhmeli,10 and Aaron A. R. Tobian3

1Johns Hopkins Center for Communication Programs, Baltimore, Maryland, United States of America

2Population Services International (PSI), Harare, Zimbabwe

3Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America

4United Nations Children's Fund (UNICEF), New York, New York, United States of America

5Ministry of Health, Dar es Salaam, Tanzania

6Office of the U.S. Global AIDS Coordinator, U.S. Department of State, Washington, DC, United States of America

7Ministry of Health and Child Welfare, Harare, Zimbabwe

8World Health Organization (WHO), Geneva, Switzerland

9National Department of Health, Pretoria, South Africa

10United States Agency for International Development (USAID) Washington/Global Health Bureau/Office of HIV/AIDS, Washington, DC, United States of America

1Johns Hopkins Center for Communication Programs, Baltimore, Maryland, United States of America

2Population Services International (PSI), Harare, Zimbabwe

3Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America

4United Nations Children's Fund (UNICEF), New York, New York, United States of America

5Ministry of Health, Dar es Salaam, Tanzania

6Office of the U.S. Global AIDS Coordinator, U.S. Department of State, Washington, DC, United States of America

7Ministry of Health and Child Welfare, Harare, Zimbabwe

8World Health Organization (WHO), Geneva, Switzerland

9National Department of Health, Pretoria, South Africa

10United States Agency for International Development (USAID) Washington/Global Health Bureau/Office of HIV/AIDS, Washington, DC, United States of America

¹Johns Hopkins Center for Communication Programs, Baltimore, Maryland, United States of America

²Population Services International (PSI), Harare, Zimbabwe

³Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America

⁴United Nations Children's Fund (UNICEF), New York, New York, United States of America

⁵Ministry of Health, Dar es Salaam, Tanzania

⁶Office of the U.S. Global AIDS Coordinator, U.S. Department of State, Washington, DC, United States of America

⁷Ministry of Health and Child Welfare, Harare, Zimbabwe

⁸World Health Organization (WHO), Geneva, Switzerland

⁹National Department of Health, Pretoria, South Africa

¹⁰United States Agency for International Development (USAID) Washington/Global Health Bureau/Office of HIV/AIDS, Washington, DC, United States of America

London School of Hygiene and Tropical Medicine, UNITED KINGDOM

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"I Feel Like More of a Man": A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention

Ethnographic studies from numerous societies have documented the central role of male circumcision in conferring masculinity and preparing boys for adult male sexuality. Despite this link between masculinity, sexuality, and circumcision, there has been little research on these dynamics among men who have been circumcised for HIV prevention. 

We employed a mixed methods approach with data collected from recently circumcised men in the Dominican Republic (DR) to explore this link. We analyzed survey data collected six to 12 months post-circumcision (N = 293) as well as in-depth interviews conducted with a subsample of those men (n = 30).

We found that 42% of men felt more masculine post-circumcision. In multivariate analysis, feeling more masculine was associated with greater concern about being perceived as masculine, feeling more potent erections post-circumcision, and reporting increased ability to satisfy their partners post-circumcision. 

In qualitative interviews, these factors were all related to masculine norms of sexually satisfying one's partner, and men's experiences of circumcision were shaped by social norms of masculinity. 

This study highlights that circumcision is not simply a biomedical intervention and that circumcision programs need to incorporate considerations of masculine norms and male sexuality into their programming.

Purchase full article at:   http://goo.gl/taOEyG

By:  Fleming PJ1,2, Barrington C2,3, Pearce LD4, Lerebours L5, Donastorg Y6, Brito MO7.

• 1 Division of Global Public Health , University of California , San Diego.
• 2 Department of Health Behavior , Gillings School of Global Public Health, University of North Carolina at , Chapel Hill.
• 3 Carolina Population Center , University of North Carolina at , Chapel Hill.
• 4 Carolina Population Center and the Department of Sociology , University of North Carolina at , Chapel Hill.
• 5 Clinica de Familia , La Romana , Dominican Republic.
• 6 HIV Vaccine Trials Unit , Instituto Dermatológico y Cirugía de Piel , Santo Domingo , Dominican Republic.
• 7 Division of Infectious Diseases , University of Illinois at Chicago. 

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In the Interests of Time: Improving HIV Allocative Efficiency Modelling Via Optimal Time-Varying Allocations

Introduction

International investment in the response to HIV and AIDS has plateaued and its future level is uncertain. With many countries committed to ending the epidemic, it is essential to allocate available resources efficiently over different response periods to maximize impact. The objective of this study is to propose a technique to determine the optimal allocation of funds over time across a set of HIV programmes to achieve desirable health outcomes.

Methods

We developed a technique to determine the optimal time-varying allocation of funds (1) when the future annual HIV budget is pre-defined and (2) when the total budget over a period is pre-defined, but the year-on-year budget is to be optimally determined. We use this methodology with Optima, an HIV transmission model that uses non-linear relationships between programme spending and associated programmatic outcomes to quantify the expected epidemiological impact of spending. We apply these methods to data collected from Zambia to determine the optimal distribution of resources to fund the right programmes, for the right people, at the right time.

Results and discussion

Considering realistic implementation and ethical constraints, we estimate that the optimal time-varying redistribution of the 2014 Zambian HIV budget between 2015 and 2025 will lead to a 7.6% (7.3% to 7.8%) decrease in cumulative new HIV infections compared with a baseline scenario where programme allocations remain at 2014 levels. This compares to a 5.1% (4.6% to 5.6%) reduction in new infections using an optimal allocation with constant programme spending that recommends unrealistic programmatic changes. Contrasting priorities for programme funding arise when assessing outcomes for a five-year funding period over 5-, 10- and 20-year time horizons.

Conclusions

Countries increasingly face the need to do more with the resources available. The methodology presented here can aid decision-makers in planning as to when to expand or contract programmes and to which coverage levels to maximize impact.

Below:  The percentage of infections averted between 2015 and 2025 for each of the scenarios shown in Figure 1 compared with a baseline of maintaining 2014 spending. The uncertainty bars were determined by repeating the optimization process 40 times using an ensemble of 40 projections within the uncertainty bounds of the model calibration with an ensemble of 40 cost-outcome curves within their respective uncertainty bounds (see the Supplementary file for figures illustrating the uncertainty in model calibration and the cost-outcome curves).

Below:  Annual spending on VMMC programmes and the associated change in prevalence of circumcised men. In both optimized scenarios (green and blue curves), implementation constraints (where programme scale-up/down is restricted to a maximum of 30% per year) and ethical constraints (where ART and PMTCT funding cannot be decreased) are applied. In the scenario represented by the green curve, total annual spending is fixed at 2014 levels. In this case, a large initial scale-up of the VMMC programme is not attainable because of the limited availability of unreserved funding and restrictions on programme scale-up/down. Thus, the optimal solution does not prioritize this programme. In the scenario represented by the blue curve, total annual spending is optimally determined such that total spending across the 2015 to 2025 period is the same as in all other scenarios. In this case, total annual spending is initially increased to allow for the initial rapid scale-up of the VMMC programme. Although VMMC spending is later rapidly scaled down, the proportion of circumcised men in this scenario remains considerably higher than in other scenarios.

Full article at:   http://goo.gl/PdjqPJ

By:  Andrew J Shattock,§,1 Cliff C Kerr,1,2,3 Robyn M Stuart,1,2,4 Emiko Masaki,5 Nicole Fraser,5 Clemens Benedikt,5Marelize Gorgens,5 David P Wilson,1,2 and Richard T Gray1

¹The Kirby Institute, University of New South Wales, Sydney, Australia

²The Burnet Institute, Melbourne, Australia

³School of Physics, University of Sydney, Sydney, Australia

⁴Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark

⁵The World Bank Group, Washington DC, USA

^§Corresponding author: Andrew J Shattock, The Kirby Institute, University of New South Wales, Level 6, Wallace Wurth Building, Kensington, Sydney, NSW 2052, Australia. Tel: +61 (0)2 9385 0900. (Email: ua.ude.wsnu.ybrik@kcottahsa)

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The When & How of Male Circumcision & the Risk of HIV: A Retrospective Cross-Sectional Analysis of Two HIV Surveys from Guinea-Bissau

Introduction: Male circumcision (MC) reduces the risk of HIV, and this risk reduction may be modified by socio-cultural factors such as the timing and method (medical and traditional) of circumcision. Understanding regional variations in circumcision practices and their relationship to HIV is crucial and can increase insight into the HIV epidemic in Africa.

Methods: We used data from two retrospective HIV surveys conducted in Guinea-Bissau from 1993 to 1996 (1996 cohort) and from 2004 to 2007 (2006 cohort). Multivariate logistical models were used to investigate the relationships between HIV risk and circumcision status, age, method of circumcision, and socio-demographic factors.

Results: MC was protective against HIV infection in both cohorts, with adjusted odds ratios (AORs) of 0.28 (95% CI 0.12-0.66) and 0.30 (95% CI 0.09-0.93), respectively. We observed that post-pubertal (<13 years) circumcision provided the highest level of HIV risk reduction in both cohorts compared to non-circumcised. However, the difference between pre-pubertal (<13) and post-pubertal circumcision was not significant in the multivariate analysis. Seventy-six percent (678/888) of circumcised males in the 2006 cohort were circumcised traditionally, and 7.7% of those males were HIV-infected compared to 1.9% of males circumcised medically, with AOR of 2.7 (95% CI 0.91-8.12).

Conclusion: MC is highly prevalent in Guinea-Bissau, but ethnic variations in method and timing may affect its protection against HIV. Our findings suggest that sexual risk behaviour and traditional circumcision may increases HIV risk. The relationship between circumcision age, sexual behaviour and HIV status remains unclear and warrants further research.

Full article at:   http://goo.gl/iSGk3P

By:  Dlama Nggida Rasmussen^1,2,3,&, Christian Wejse^1,4,5, Olav Larsen^1,2, Zacarias Da Silva¹, Peter Aaby^1,6, Morten Sodemann^1,2,3

¹Bandim Health Project, Indepth Network, Apartado 861, 1004 Bissau Codex, Bissau, Guinea-Bissau, ²Department of Infectious Diseases, Odense University Hospital, DK-5000 Odense, Denmark, ³Center for Global Health, Institute of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark, ⁴Department of Infectious Diseases, Aarhus University Hospital, DK-8200 Aarhus, Denmark, ⁵Center for Global Health, Department of Public Health, Aarhus University, DK-8000 Aarhus, Denmark, ⁶Statens Serums Institute, DK-2300 Copenhagen, Denmark

^&Corresponding author
Dlama Nggida Rasmussen, Department of Infectious Diseases, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark

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Plastibell Circumcision of 2,276 Male Infants: A Multi-Centre Study

Introduction: the World Health Organization's manual on male circumcision listed Plastibell technique as a well-proven paediatric method with respect to the results and complications. Although, literatures abound on its wide acceptability, there are few multi- centered reports from this environment. The objective was to evaluate the cases of infant circumcision by Plastibell device from two medical institutions.

Methods: all consecutive infants who had Classical Plastibell Circumcision (PC) at the Federal Staff Medical Centre, Abuja and the Lagos State University Teaching Hospital, Ikeja between February 2011 and June 2015 were included in this cross-sectional study. The procedures were performed by surgical registrars and medical officers after ninety minutes of topical anesthesia to the penis. Data harvested from the standard proforma were analysed using Statistical Package for Social Science 20.0 for window.

Results: a total of 2,276 infants had classical PC within the study period. Their ages at circumcision ranged from 4 days to 3 months with a mean age of 17 days. Majority of the boys were circumcised at second week of life (n=1,394,61.2%). All the cases were performed for religious (53%) and cultural (47%)reasons. The most common Plastibell size deployed was 1.3cm (n=1,040, 45.7%) while 1.6cm was the least commonly used ring (n=10, 0.4%). The mean time for device to fall-off was 6 days (range 4- 12 days). There was no correlation between the age at circumcision and Plastibell size. We recorded an overall complication rate of 1.1% with postoperative bleeding leading the pack (n=12, 48%). No case of urethrocutaneous fistula was seen. We detected 17 cases (0.7%) of distal hypospadias in whom circumcisions were postponed till the time of hypospadias repairs.

Conclusion: the main indication for infant circumcision in our environment was religious. The PC has good safety profile with few easily correctable early complications. Detailed attention to placement of ligature, selection of appropriate Plastibell size and adequate parental education are key to preventing post-procedure mishaps.

Below:  Plastibell size deployed

Full article at:   http://goo.gl/p9316L

By:  Bioku Muftau Jimoh^1,&, Ikuerowo Stephen Odunayo², Igwilo Chinwe³, Omisanjo Olufunmilade Akinfolarin², Adewumi Oluwafemi³, Esho Julius Olusanmi²

¹Department of Surgery, Federal Staff Medical Centre, Abuja, ²Urology Unit, Department of Surgery, Lagos State University Teaching Hospital, Ikeja, ³Department of Obstetrics and Gynecology, Federal Staff Medical Centre, Abuja

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Triggering the Decision to Undergo Medical Male Circumcision: A Qualitative Study of Adult Men in Botswana

In 2007, the World Health Organization endorsed voluntary medical male circumcision (VMMC) as part of comprehensive HIV-prevention strategies. A major challenge facing VMMC programs in sub-Saharan Africa remains demand creation; there is urgent need for data on key elements needed to trigger the decision among eligible men to seek VMMC. 

Using qualitative methods, we sought to better understand the circumcision decision-making process in Botswana related to VMMC. From July to November 2013, we conducted 27 focus group discussions in four purposively selected communities in Botswana with men (stratified by circumcision status and age), women (stratified by age) and community leaders. All discussions were facilitated by a trained same-sex interviewer, audio recorded, transcribed and translated to English, and analyzed for key themes using an inductive content analytic approach. 

Improved hygiene was frequently cited as a major benefit of circumcision and many participants believed that cleanliness was directly responsible for the protective effect of VMMC on HIV infection. While protection against HIV was frequently noted as a benefit of VMMC, the data indicate that increased sexual pleasure and perceived attractiveness, not fear of HIV infection, was an underlying reason why men sought VMMC. 

Data from this qualitative study suggest that more immediate benefits of VMMC, such as improved hygiene and sexual pleasure, play a larger role in the circumcision decision compared with protection from potential HIV infection. 

These findings have immediate implications for targeted demand creation and mobilization activities for increasing uptake of VMMC among adult men in Botswana.

Purchase full article at:   http://goo.gl/md8EE0

By:  Wirth KE1,2,3, Semo BW1,4, Ntsuape C5, Ramabu NM1, Otlhomile B1, Plank RM3,6,7, Barnhart S4, Ledikwe JH1,4.

• 1 Botswana International Training and Education Center for Health (I-TECH) , Gaborone , Botswana.
• 2 Department of Epidemiology , Harvard T. H. Chan School of Public Health , Boston , Massachusetts , USA.
• 3 Department of Immunology and Infectious Diseases , Harvard T. H. Chan School of Public Health , Boston , Massachusetts , USA.
• 4 Department of Global Health , University of Washington , Seattle , Washington , USA.
• 5 Department of HIV/AIDS Prevention and Care , Botswana Ministry of Health , Gaborone , Botswana.
• 6 Division of Infectious Diseases , Brigham and Women's Hospital , Boston , Massachusetts , USA.
• 7 Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education , Gaborone , Botswana.
• AIDS Care. 2016 Jan 11:1-6.  

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