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）减少女性对男性的艾滋病毒传播约60%。世卫组织建议将MC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MC视为长期，可持续的艾滋病毒预防。婴儿男性包皮环切术（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，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可以节省长期艾滋病毒预防的成本。尽管IMC相对于AMC具有令人信服的优势，但很少有研究指导服务的规模扩大。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的安全性和因素的试点研究。我们已经培训了17名IMC提供者，并执行了1，000多个IMC。我们有技术、科学和临床能力对IMC进行高质量的研究。肯尼亚的尼扬扎是进行这项研究的理想地点，因为成年男性包皮环切计划的成功（领先于其他实施MC的国家）表明肯尼亚准备向IMC过渡。为了提供必要的证据基础，以指导实施IMC服务，我们提出了一个同步的，前瞻性的比较两个可持续的，可扩展的模型IMC服务提供（目标1）。这些模式包括标准服务交付包（SDP）和标准包+（SDPplus）。SDP模式将IMC教育和招募纳入现有的社区围产期健康教育网络，并包括在卫生设施提供综合IMC服务。SDPplus模式将实现标准包并添加社区交付的IMC服务。这两种模式将在吸收，父母的可接受性，成本和安全性方面进行比较。此外，我们将对3，750名有年幼男婴的母亲和父亲进行横断面调查，以评估在实施IMC服务之前（n=750）和实施干预措施之后（n=3000）（目标2）的IMC障碍和促进因素。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SDP和SDPplus之间的差异。东非和南部非洲各国政府以及总统艾滋病紧急救援计划已经表示，将向lMC过渡，以制定长期、可持续的艾滋病毒预防方案。在这项研究的结论，我们将确定两种模式的IMC服务提供的相对优势，是可扩展的，可以整合到现有的妇幼保健结构的条件下，在许多非洲国家普遍存在。这些调查结果将提供必要的证据，以协助肯尼亚卫生部、总统艾滋病紧急救援计划和其他非洲国家政府在扩大IMC长期艾滋病毒预防服务提供方面合理、循证地分配资源。

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.