Integration of infant male circumcision with community health services in Kenya

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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.