A model for the roll-out of comprehensive adult male circumcision services in African low-income settings of high HIV incidence: the ANRS 12126 Bophelo Pele Project.
A model for the roll-out of comprehensive adult male circumcision services in African low-income settings of high HIV incidence: the ANRS 12126 Bophelo Pele Project.
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DOI：
10.1371/journal.pmed.1000309
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发表时间：
2010-07-20
期刊：
影响因子：
15.8
通讯作者：
Auvert B
中科院分区：
文献类型：
--
作者：
Lissouba P;Taljaard D;Rech D;Doyle S;Shabangu D;Nhlapo C;Otchere-Darko J;Mashigo T;Matson C;Lewis D;Billy S;Auvert B
Bertrand Auvert和他的同事描述了在南非通过一个项目大规模推广成年男性包皮环切术的情况。世界卫生组织（世卫组织）/联合国艾滋病联合规划署（艾滋病规划署）建议，成年男性包皮环切术（AMC）用于预防来自艾滋病毒高流行区和AMC患病率低的社区的男性通过异性性行为获得艾滋病毒感染。这项研究的目的是调查根据艾滋病规划署/世卫组织业务准则在非洲目标环境中推广医疗化AMC的可行性。ANRS 12126“Bophelo Pele”项目于2008年在南非奥兰治农场镇实施。在获得当地和伦理授权后，它在5个月内开始运作。项目活动包括社区动员和外联，以及针对男子和妇女的沟通方法，其中包括更广泛的艾滋病毒预防战略和促进性健康。该项目主要中心为低收入人群设计，向15岁及以上的男性居民提供免费医疗AMC。通过建立一个创新的外科组织，每天可以由三个由一名医学包皮环切师和五名护士组成的任务分担小组在局部麻醉下进行多达150例包皮环切手术，并使用消毒的一次性包皮环切包和电疗。社区对该项目的支持度很高。截至2009年11月，14011名男性接受了包皮环切术，在过去12个月平均每月740人，27.5%的项目参与者同意接受艾滋病毒检测。不良事件发生率为1.8%，没有任何不良事件导致永久性损害或死亡。大多数接受调查的男性（92%）对所提供的服务给予了积极评价。据估计，39.1%的成年未割包皮的男性居民接受了手术，并且这一比例正在稳步上升。本研究表明，适合非洲低收入环境的高质量AMC推广是可行的，并且可以根据国际准则快速安全地实施。该项目可以成为扩大综合AMC服务的典范，为非洲东部和南部其他艾滋病毒流行率高、AMC率低的农村和城市社区量身定制。自1981年以来，获得性免疫缺陷综合症（艾滋病）已造成约2 500万人死亡，现在有3 000多万人（仅在撒哈拉以南非洲就有2 200万人）感染了导致艾滋病的人体免疫缺陷病毒（艾滋病毒）。艾滋病毒/艾滋病无法治愈。因此，预防艾滋病毒感染极为重要。由于艾滋病毒最常通过与受感染的伴侣发生无保护的性行为传播，个人可以通过禁欲、有一个或几个伴侣以及始终使用男用或女用避孕套来降低感染艾滋病毒的风险。此外，最近在撒哈拉以南非洲进行的三项试验报告称，医学上的成年男性包皮环切术（AMC）——通过手术切除包皮，包皮是覆盖阴茎头部的一层松弛的皮肤——可以将男性的艾滋病毒传播率降低一半以上。因此，AMC作为一项追赶运动——从长远来看，男婴包皮环切可能是一种更可持续的策略——有可能降低撒哈拉以南非洲地区艾滋病毒的流行率（感染艾滋病毒的人口比例）。世界卫生组织（WHO）和联合国艾滋病规划署（UNAIDS）现在建议，在艾滋病毒普遍流行且很少有男性接受包皮环切手术的地方，应该推行AMC计划。因此，这些组织已经定义了AMC服务的最低包，并发布了旨在吸引社区参与推广的指南和工具，并确保提供适当的AMC咨询和手术设施。但在现实生活中，AMC的快速推广可行吗？在这里，研究人员试图通过研究“Bophelo Pele”（健康第一）项目找到答案。该项目遵循世卫组织/联合国艾滋病规划署的AMC指南，旨在向居住在南非奥兰治农场镇的所有15岁或以上男性提供免费、安全的AMC服务，作为社区艾滋病毒干预的一部分。奥兰治农场位于南非的一个低收入地区，艾滋病毒患病率为15.2%，AMC患病率约为25%。在Bophelo Pele项目于2008年1月启动之前，研究人员就AMC的实施向社区进行了咨询，帮助建立了一个社区咨询委员会，组织了社区研讨会来讨论该项目，并调查了人们对AMC的了解程度和接受AMC的意愿。这些活动表明，社区对该项目的支持程度很高，男性也非常愿意接受人工授精。项目开始后，研究人员通过多种沟通渠道向奥兰治农场居民介绍AMC和更广泛的艾滋病毒预防策略，并在招募过程中为符合条件的男性提供有关AMC的咨询和自愿艾滋病毒咨询和检测。招募三天后，符合条件的男性在项目的主要中心免费接受包皮环切术，在那里，由一名医疗包皮环切师和五名护士组成的三个小组每天能够完成多达150次包皮环切术。到2009年11月，14011名男性接受了包皮环切手术（占全镇符合条件男性的三分之一以上），而且接受包皮环切手术的人数仍在稳步增长。在一项调查中，几乎所有接受过2个月包皮环切手术的男性对AMC服务的评价都是积极的，而不良反应（都是轻微的）发生在少于1 / 50的包皮环切手术后。这些发现表明，在奥兰治农场镇，快速推出高质量、免费的AMC作为艾滋病毒干预措施是成功的。然而，其他调查结果凸显了AMC推出面临的一些挑战。例如，只有四分之一的参与者同意自愿接受艾滋病毒咨询和检测，这令人担忧，因为新割过包皮的艾滋病毒阳性男性如果在手术后过早恢复性活动，传播艾滋病毒的风险会增加。同样，只有三分之二的参与者在包皮环切手术后回来做检查；这一比例需要提高，以确保AMC方案的安全性和有效性。然而，这些研究结果以及肯尼亚和乌干达类似干预项目的结果表明，至少在短期内，作为艾滋病毒高流行率和低AMC率的低收入社区的艾滋病毒预防策略，扩大AMC的规模应该是可行的。请通过本摘要的在线版本http://dx.doi.org/10.1371/journal.pmed.1000309访问这些网站。可从美国国家过敏和传染病研究所获得关于艾滋病毒感染和艾滋病的信息。艾滋病毒InSite有关于艾滋病毒/艾滋病所有方面的全面信息。国际艾滋病慈善机构Avert提供关于艾滋病毒/艾滋病许多方面的信息，包括关于南非艾滋病毒和艾滋病的信息。关于男性包皮环切的更多信息可从世卫组织和男性包皮环切信息交换所获得，包括世卫组织/联合国艾滋病规划署2010年6月发布的题为《扩大男性包皮环切的进展：国家实施和研究更新》的报告
Bertrand Auvert and colleagues describe the large-scale roll-out of adult male circumcision through a program in South Africa. World Health Organization (WHO)/Joint United Nations Programme on AIDS (UNAIDS) has recommended adult male circumcision (AMC) for the prevention of heterosexually acquired HIV infection in men from communities where HIV is hyperendemic and AMC prevalence is low. The objective of this study was to investigate the feasibility of the roll-out of medicalized AMC according to UNAIDS/WHO operational guidelines in a targeted African setting. The ANRS 12126 “Bophelo Pele” project was implemented in 2008 in the township of Orange Farm (South Africa). It became functional in 5 mo once local and ethical authorizations were obtained. Project activities involved community mobilization and outreach, as well as communication approaches aimed at both men and women incorporating broader HIV prevention strategies and promoting sexual health. Free medicalized AMC was offered to male residents aged 15 y and over at the project's main center, which had been designed for low-income settings. Through the establishment of an innovative surgical organization, up to 150 AMCs under local anesthesia, with sterilized circumcision disposable kits and electrocautery, could be performed per day by three task-sharing teams of one medical circumciser and five nurses. Community support for the project was high. As of November 2009, 14,011 men had been circumcised, averaging 740 per month in the past 12 mo, and 27.5% of project participants agreed to be tested for HIV. The rate of adverse events, none of which resulted in permanent damage or death, was 1.8%. Most of the men surveyed (92%) rated the services provided positively. An estimated 39.1% of adult uncircumcised male residents have undergone surgery and uptake is steadily increasing. This study demonstrates that a quality AMC roll-out adapted to African low-income settings is feasible and can be implemented quickly and safely according to international guidelines. The project can be a model for the scale-up of comprehensive AMC services, which could be tailored for other rural and urban communities of high HIV prevalence and low AMC rates in Eastern and Southern Africa. Please see later in the article for the Editors' Summary Acquired immunodeficiency syndrome (AIDS) has killed about 25 million people since 1981, and more than 30 million people (22 million in sub-Saharan Africa alone) are now infected with the human immunodeficiency virus (HIV), which causes AIDS. There is no cure for HIV/AIDS. Consequently, prevention of HIV infection is extremely important. Because HIV is most often spread through unprotected sex with an infected partner, individuals can reduce their risk of HIV infection by abstaining from sex, by having one or a few partners, and by always using a male or female condom. In addition, three trials in sub-Saharan Africa recently reported that medicalized adult male circumcision (AMC)—the surgical removal of the foreskin, a loose fold of skin that covers the head of the penis—can reduce HIV transmission rates in men by more than a half. Thus, AMC delivered as a catch-up campaign—in the long-term, circumcision of male infants is likely to be a more sustainable strategy—has the potential to reduce the prevalence of HIV (the proportion of the population infected with HIV) in sub-Saharan Africa. The World Health Organization (WHO) and the Joint United Nations Programme on AIDS (UNAIDS) now recommend that AMC programs should be rolled-out wherever there is a generalized HIV epidemic and few men are circumcised. Accordingly, these organizations have defined a minimum package of AMC services and have issued guidelines and tools designed to engage communities in the roll-out and to ensure that appropriate AMC counseling and surgical facilities are available. But is rapid AMC roll-out feasible in real-life settings? Here, the researchers try to find out by studying the “Bophelo Pele” (Health First) project. This project, which follows the WHO/UNAIDS guidelines for AMC, aims to offer free, safe AMC services to all men aged 15 years or more living in the Orange Farm township in South Africa as part of a community-based intervention against HIV. Orange Farm is in a low-income region of South Africa where HIV prevalence is 15.2% and AMC prevalence is about 25%. Before the Bophelo Pele project started in January 2008, the researchers consulted the community about the implementation of AMC, helped to create a community advisory board, organized community workshops to discuss the project, and surveyed people's knowledge about AMC and willingness to undergo AMC. These activities indicated a high level of community support for the project and a high level of willingness among men to undergo AMC. Once the project started, the researchers used multiple communication channels to tell the Orange Farm residents about AMC and broader HIV prevention strategies and provided eligible men with counseling about AMC and with voluntary HIV counseling and testing during the recruitment process. Three days after recruitment, eligible men were circumcised free-of-charge at the project's main center, where three teams of one medical circumciser and five nurses were able to complete up to 150 AMCs per day. By November 2009, 14,011 men had been circumcised (more than a third of the eligible men in the township), and AMC uptake was still increasing steadily. Nearly all the men circumcised over one 2-month period rated the AMC services positively in a survey and adverse effects (all mild) occurred after fewer than 1 in 50 circumcisions. These findings suggest that the rapid roll-out of high-quality, free AMC as an intervention against HIV has been successful in the Orange Farm township. However, other findings highlight some of the challenges that face AMC roll-out. For example, only a quarter of the participants agreed to voluntary HIV counseling and testing, which is worrying because newly circumcised HIV-positive men have an increased risk of transmitting HIV if they resume sexual activity too soon after the operation. Similarly, only two-thirds of the participants returned for a check-up after circumcision; this proportion needs to be increased to ensure the safety and efficacy of AMC programs. Nevertheless, these findings and those from similar intervention programs in Kenya and Uganda indicate that AMC scale-up should be feasible, at least in the short term, as an HIV prevention strategy in low-income communities where there is a high HIV prevalence and a low AMC rate. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000309. Information is available from the US National Institute of Allergy and infectious diseases on HIV infection and AIDS HIV InSite has comprehensive information on all aspects of HIV/AIDS Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on HIV and AIDS in South Africa, and on circumcision and HIV (in English and Spanish) More information about male circumcision is available from WHO and from the Clearinghouse on Male Circumcision, including a June 2010 report from WHO/UNAIDS entitled Progress in male circumcision scale-up: country implementation and research update More information about the Bophelo Pele project is available
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DOI：
10.1097/00126334-200405010-00010
发表时间：
2004-05-01
影响因子：
3.6
作者：
Auvert, B;Males, S;Williams, B
通讯作者：
Williams, B
DOI：
10.1097/qai.0b013e3181893ed0
发表时间：
2008-11-01
期刊：
Journal of acquired immune deficiency syndromes (1999)
影响因子：
--
作者：
Genberg BL;Kulich M;Kawichai S;Modiba P;Chingono A;Kilonzo GP;Richter L;Pettifor A;Sweat M;Celentano DD;NIMH Project Accept Study Team (HPTN 043)
通讯作者：
NIMH Project Accept Study Team (HPTN 043)
影响因子：
3.7
作者：
Nagelkerke, Nico J. D.;Moses, Stephen;Bailey, Robert C.
通讯作者：
Bailey, Robert C.
影响因子：
4.5
作者：
Peltzer K;Matseke G;Mzolo T;Majaja M
通讯作者：
Majaja M
DOI：
10.1097/qai.0b013e31814277c8
发表时间：
2007-10-01
影响因子：
3.6
作者：
Bassett, Ingrid V.;Giddy, Janet;Walensky, Rochelle P.
通讯作者：
Walensky, Rochelle P.