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)可将艾滋病毒的女性传播率降低约60%。世界卫生组织建议将MC作为高危地区HIV预防战略的一个组成部分，并建议考虑将新生儿MC用于长期、可持续的HIV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与AMC具有相同的好处，而且成本更低，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条件下，IMC在长期预防艾滋病毒方面节省了成本。尽管与AMC相比，IMC具有令人信服的优势，但很少有人进行研究来指导服务的扩大。我们最近在肯尼亚的Nyanza成功地进行了一项关于安全性和与接受或拒绝接受IMC相关的因素的初步研究。我们已经培训了17个IMC供应商，并执行了1000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Nyanza是进行这项研究的理想地点，因为成年男性包皮环切术计划的成功(领先于所有其他实施MC的国家)表明肯尼亚已经准备好向IMC过渡。为了提供必要的证据基础来指导IMC服务的实施，我们提出了两种可持续、可扩展的IMC服务交付模式的同步、前瞻性比较(目标1)。这些模式包括标准服务交付包(SDP)和标准包加(SDPplus)。SDP模式将IMC教育和招募纳入现有的以社区为基础的围产期健康教育网络，并包括在卫生设施提供全面的IMC服务。SDPplus模式将实施标准包，并增加社区交付的IMC服务。这两种模式将在摄取率、父母可接受性、成本和安全性方面进行比较。此外，我们将对3,750名男婴的父母进行横断面调查，以评估在实施综合管理中心服务之前(n=750)和实施干预措施(目标2)之后(n=3000)对综合管理中心的障碍和促进者。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。东非和南部非洲的政府以及PEPFAR已经发出信号，向LMC过渡，以便进行长期、可持续的艾滋病毒预防规划。在这项研究的结论中，我们将确定两种提供综合保健服务的模式的相对优势，这两种模式是可扩展的，并且可以在许多非洲国家普遍存在的条件下整合到现有的妇幼保健结构中。这些调查结果将提供必要的证据，以协助肯尼亚卫生部、非洲艾滋病紧急救援计划和其他非洲国家政府合理地、基于证据地分配资源，扩大IMC服务的规模，以长期预防艾滋病毒。

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.