Integration of infant male circumcision with community health services in Kenya

描述（由申请人提供）：成年男性包皮环切术（AMC）减少了大约60%的女性向男性传播艾滋病毒。世卫组织建议将母婴监护作为高风险地区艾滋病毒预防战略的一个组成部分，并将新生儿母婴监护视为长期、可持续的艾滋病毒预防措施。男婴包皮环切术（IMC）在预防艾滋病毒和性传播感染方面具有与AMC相同的好处，而且更便宜和更安全。最近的成本效益分析结果发现，在许多非洲国家和其他地方普遍存在的情况下，IMC在长期预防艾滋病毒方面节省了成本。尽管IMC相对于AMC有着令人信服的优势，但很少有研究指导服务规模的扩大。我们最近在肯尼亚的尼扬扎成功地进行了一项关于接受或拒绝IMC的安全性和相关因素的试点研究。我们培训了17名IMC提供者，实施了1000多次IMC。我们具备开展高质量IMC研究的技术、科学和临床能力。肯尼亚的尼扬扎是开展这项研究的理想地点，因为成年男性包皮环切项目的成功（领先于其他实施包皮环切的国家）表明肯尼亚已经准备好向包皮环切过渡。为了提供必要的证据基础来指导IMC服务的实施，我们提出了一个同步的、前瞻性的比较两种可持续的、可扩展的IMC服务提供模式（目标1）。这些模型包括标准服务交付包（SDP）和标准包附加（SDPplus）。SDP模式将儿童综合护理教育和招聘纳入现有的社区围产期保健教育网络，并包括在保健设施提供综合儿童综合护理服务。SDPplus模式将实现标准包，并增加社区交付的IMC服务。这两种模式将在接受度、家长接受度、成本和安全性方面进行比较。此外，我们将对3750名年轻男婴的父母进行横断面调查，以评估在实施IMC服务之前（n=750）和实施干预之后（n=3000）的障碍和促进因素（目标2）。我们将研究我们的干预措施对IMC知识和吸收障碍的影响，确定与IMC吸收相关的因素，并确定这在SDP和SDPplus之间的差异。东非和南部非洲各国政府以及总统防治艾滋病紧急救援计划已经发出信号，向长期、可持续的艾滋病毒预防规划的lMC过渡。在本研究结束时，我们将确定两种可扩展的综合医疗服务提供模式的相对优势，并在许多非洲国家普遍存在的条件下将其整合到现有的妇幼保健结构中。这些发现将提供必要的证据，协助肯尼亚卫生部、总统防治艾滋病紧急救援计划和其他非洲国家政府合理地、以证据为基础分配资源，扩大为长期预防艾滋病毒而提供的IMC服务。

DESCRIPTION (provided by applicant): Adult male circumcision (AMC) decreases female to male transmission of HIV by approximately 60%. The WHO recommends MC be offered as one component of an HIV prevention strategy in high risk areas and that neonatal MC be considered for long-term, sustainable HIV prevention. Infant male circumcision (IMC) confers the same benefits of AMC for HIV and STI prevention, and is less expensive and safer. Results of recent cost- effectiveness analyses find IMC is cost-saving for long-term HIV prevention under conditions that prevail in many African nations and elsewhere. Despite the compelling advantages of IMC relative to AMC, little research has been conducted to guide scale-up of services. We recently conducted a successful pilot study of safety and factors associated with acceptance or refusal of IMC in Nyanza, Kenya. We have trained 17 IMC providers and have performed over 1,000 IMCs. We have the technical, scientific and clinical capacity to conduct high-quality research on IMC. Nyanza, Kenya is the ideal location to conduct this research because the success of the adult male circumcision program (ahead of every other country where MC has been implemented) indicates Kenya is ready to transition toward IMC. To provide the evidence-base necessary to guide implementation of IMC services, we propose a simultaneous, prospective comparison of two sustainable, scalable models of IMC service delivery (Aim 1). The models include a standard service delivery package (SDP) and a standard package plus (SDPplus). The SDP model integrates IMC education and recruitment into existing community-based perinatal health education networks and includes provision of comprehensive IMC services at health facilities. The SDPplus model will implement the standard package and add community- delivered IMC services. The two models will be compared in terms of uptake, parental acceptability, cost and safety. In addition, we will conduct a cross-sectional survey administered to 3,750 mothers and fathers of young male infants to assess barriers and facilitators to IMC prior to implementation (n=750) of IMC services, and after implementation (n=3000) of the intervention (Aim 2). We will examine the impact of our interventions on knowledge of IMC and barriers to uptake, identify factors associated with IMC uptake, and determine how this varies between SDP and SDPplus. Governments in East and southern Africa and PEPFAR have signaled a transition towards lMC for long-term, sustainable HIV prevention programming. At the conclusion of this study, we will have determined the relative advantages of two models of IMC service delivery that are scalable and can be integrated into existing MCH care structures under conditions that prevail in many African nations. These findings will provide the evidence necessary to assist the Kenyan MoH, PEPFAR and other African governments as to the rational, evidenced-based allocation of resources in the scale-up of IMC service delivery for long-term HIV prevention.