Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets


Autoři: Adam Gilbertson aff001;  Barrack Ongili aff004;  Frederick S. Odongo aff004;  Denise D. Hallfors aff001;  Stuart Rennie aff002;  Daniel Kwaro aff004;  Winnie K. Luseno aff001
Působiště autorů: Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America aff001;  UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America aff002;  Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America aff003;  Kenya Medical Research Institute (KEMRI), Kisumu, Kenya aff004
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224548

Souhrn

Introduction

Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya.

Methods and results

The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care.

Conclusion

Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.

Klíčová slova:

Adolescents – Circumcision – HIV epidemiology – Kenya – Schools – Teachers – United States


Zdroje

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2019 Číslo 11