Webster Mavhu - Academia.edu (original) (raw)

Papers by Webster Mavhu

Background: Early infant male circumcision (EIMC) has been identified as a key HIV prevention int... more Background: Early infant male circumcision (EIMC) has been identified as a key HIV prevention intervention. Exploring the decision-making process for adoption of EIMC for HIV prevention among parents and other key stakeholders is critical for designing effective demand creation interventions to maximize uptake, roll out and impact in preventing HIV. This paper describes key players, decisions and actions involved in the EIMC decision-making process.

Background: Male circumcision devices have the potential to accelerate voluntary medical male cir... more Background: Male circumcision devices have the potential to accelerate voluntary medical male circumcision roll-out, with PrePex being one promising device. Here, we present findings on safety and acceptability from active surveillance of the implementation of PrePex among 1000 males circumcised in Zimbabwe.

Early infant male circumcision (EIMC) conducted by nurse-midwives using the AccuCirc device prove... more Early infant male circumcision (EIMC) conducted by nurse-midwives using the AccuCirc device proved safe, feasible, and acceptable to parents in Zimbabwe. The AccuCirc device has the potential to facilitate widespread scale-up of safe EIMC in sub-Saharan Africa. ABSTRACT Background: For prevention of HIV, early infant male circumcision (EIMC) needs to be scaled up in countries with high HIV prevalence. Routine EIMC will maintain the HIV prevention gains anticipated from current adult male circumcision initiatives. We present here the results of a field study of EIMC conducted in Zimbabwe. Methods: The study was observational and based on the World Health Organization (WHO) framework for clinical evaluation of male circumcision devices. We recruited parents of newborn male infants between August 2013 and July 2014 from 2 clinics. Nurse-midwives used the AccuCirc device to circumcise eligible infants. We followed participants for 14 days after EIMC. Outcome measures were EIMC safety, acceptability, and feasibility. Results: We enrolled 500 male infants in the field study (uptake 11%). The infants were circumcised between 6 and 60 days postpartum. The procedure took a median of 17 minutes (interquartile range of 5 to 18 minutes). Mothers' knowledge of male circumcision was extensive. Of the 498 mothers who completed the study questionnaire, 91% knew that male circumcision decreases the risk of HIV acquisition, and 83% correctly stated that this prevention is partial. Asked about their community's perception of EIMC, 40% felt that EIMC will likely be viewed positively in their community; 13% said negatively; and 47% said the perception could be both ways. We observed 7 moderate or severe adverse events (1.4%; 95% confidence interval, 0.4% to 2.4%). All resolved without lasting effects. Nearly all mothers (99%) reported great satisfaction with the outcome, would recommend EIMC to other parents, and would circumcise their next sons. Conclusion: This first field study in sub-Saharan Africa of the AccuCirc device for EIMC demonstrated that EIMC conducted by nurse-midwives with this device is safe, feasible, and acceptable to parents.

Early infant male circumcision (EIMC) conducted by nurse-midwives using the AccuCirc device was s... more Early infant male circumcision (EIMC) conducted by nurse-midwives using the AccuCirc device was safe and less costly per procedure than when conducted by doctors: for nurse-midwives, US$38.87 in vertical programs and US$33.72 in integrated programs; for doctors, US$49.77 in vertical programs. ABSTRACT Background: The 14 countries that are scaling up voluntary male medical circumcision (VMMC) for HIV prevention are also considering early infant male circumcision (EIMC) to ensure longer-term reductions in HIV incidence. The cost of implementing EIMC is an important factor in scale-up decisions. We conducted a comparative cost analysis of EIMC performed by nurse-midwives and doctors using the AccuCirc device in Zimbabwe. Methods: Between August 2013 and July 2014, nurse-midwives performed EIMC on 500 male infants using AccuCirc in a field trial. We analyzed the overall unit cost and identified key cost drivers of EIMC performed by nurse-midwives and compared these with costing data previously collected during a randomized noninferiority comparison trial of 2 devices (AccuCirc and the Mogen clamp) in which doctors performed EIMC. We assessed direct costs (consumable and nonconsumable supplies, device, personnel, associated staff training, and waste management costs) and indirect costs (capital and support personnel costs). We performed one-way sensitivity analyses to assess cost changes when we varied key component costs. Results: The unit costs of EIMC performed by nurse-midwives and doctors in vertical programs were US$38.87 and US$49.77, respectively. Key cost drivers of EIMC were consumable supplies, personnel costs, and the device price. In this cost analysis, major cost drivers that explained the differences between EIMC performed by nurse-midwives and doctors were personnel and training costs, both of which were lower for nurse-midwives. Conclusions: EIMC unit costs were lower when performed by nurse-midwives compared with doctors. To minimize costs, countries planning to scale up EIMC should consider using nurse-midwives, who are in greater supply than doctors and are the main providers at the primary health care level, where most infants are born.

Parents who opted for early infant male circumcision (EIMC) and health care workers felt EIMC was... more Parents who opted for early infant male circumcision (EIMC) and health care workers felt EIMC was a safe and acceptable procedure that would likely become more widely adopted over time. Barriers to EIMC uptake such as parental fears of harm and cultural beliefs are potentially surmountable with adequate education and support. ABSTRACT Background: The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend early infant male circumcision (EIMC) for prevention of HIV. Here, we present findings from a qualitative study in Zimbabwe that assessed parental and health care workers' perspectives of EIMC conducted using devices. Methods: This qualitative study was nested within a trial of EIMC devices. Between January and May 2013, we held 4 focus group discussions (FGDs) and 12 in-depth interviews with parents and 12 in-depth interviews with clinicians (7 trial clinicians and 5 non-trial clinicians). We also conducted 95 short telephone interviews with parents who had arranged to bring their sons for EIMC but then defaulted. Results: Parents who had adopted EIMC spoke of their initial anxieties about the procedure. Additionally, they commented on both the procedure and outcome. Parents who decided against EIMC cited fear of harm, specifically the infant's death, penile injury, and excessive pain. Misperceptions about male circumcision in general and EIMC specifically were a significant barrier to EIMC adoption and were prevalent among health care workers as well as parents. In particular, the findings suggest strong parental concerns about the fate of the discarded foreskin. Parents who chose EIMC for their newborn sons felt that the procedure was safe and expressed satisfaction with the outcome. For their part, health care workers largely thought that EIMC was safe and that the outcome was aesthetically pleasing. They also felt that it would be feasible to offer wide-scale EIMC for HIV prevention in the public sector; they recommended strategies to increase EIMC uptake, in addition to highlighting a few concerns. Conclusions: The qualitative study enables us to better understand parental and health care workers' perspectives of EIMC conducted using devices, especially their perspectives on EIMC safety, feasibility, acceptability, and barriers. These findings will be used to design demand-generation activities that support wider adoption of EIMC.

AIDS Care, 2011

Concurrent sexual partnerships are important in understanding the evolution and maintenance of th... more Concurrent sexual partnerships are important in understanding the evolution and maintenance of the HIV heterosexual epidemic in sub-Saharan Africa. While it is possible to measure individual attitudes around sensitive behaviours through questionnaire surveys, studies suggest that responses may be subject to social desirability bias and may not reflect community norms. This study used a novel tool to collect data on community norms relating to the acceptability of concurrency in rural Zimbabwe. Six questions exploring general concurrency concepts and 28 scenarios in which multiple-partnerships might occur were developed and translated into Shona. Participatory attitudinal ranking (PAR), an approach adapted from participatory wealth ranking, was used to conduct group discussions (n=24) with 170 participants recruited in a household survey. Participants discussed and ranked scenarios according to the acceptability of the multiple-partnering described in the short accounts. Data analysis followed grounded theory principles. Qualitative data were examined against quantitative survey data collected from a representative sample of 18-44-year olds. While discussants indicated that concurrency was common among both males and females, self-reports from survey participants indicated that 37.1% of males (n=717/1931; 95% CI: 35.0-39.3%) and only 7.3% of females (n=215/2948; 95% CI: 6.4-8.3%) were in concurrent relationships suggesting under-reporting of this behaviour, particularly by women. We found that concurrency is an accepted community norm for men but never for women. Concurrency is considered more acceptable in specific social contexts, including infertility and lack of a male heir. Having protected rather than unprotected sex with a concurrent partner does not render this behaviour more acceptable. Using PAR, we managed to gain a more nuanced understanding of socially sanctioned concurrency, knowledge that could prove useful for improving behaviour change interventions targeting this behaviour. PAR allowed us to rank attitudes in terms of acceptability, which would enable us to compare attitudes between communities and evaluate changes over time.

Background: Early infant male circumcision (EIMC) is a potential key HIV prevention intervention,... more Background: Early infant male circumcision (EIMC) is a potential
key HIV prevention intervention, providing it can be safely and
efficiently implemented in sub-Saharan Africa. Here, we present
results of a randomized noninferiority trial of EIMC comparing the AccuCirc device with Mogen clamp in Zimbabwe.
Methods: Between January and June 2013, eligible infants were
randomized to EIMC through either AccuCirc or Mogen clamp
conducted by a doctor, using a 2:1 allocation ratio. Participants were followed for 14 days post-EIMC. Primary outcomes for the trial were EIMC safety and acceptability.
Results: One hundred fifty male infants were enrolled in the trial and circumcised between 6 and 54 days postpartum (n = 100 AccuCirc; n = 50 Mogen clamp). Twenty-six infants (17%) were born to HIV-infected mothers. We observed 2 moderate adverse events (AEs) [2%, 95% confidence interval (CI): 0.2 to 7.0] in the AccuCirc arm and none (95% CI: 0.0 to 7.1) in the Mogen clamp arm. The cumulative incident risk of AEs was 2.0% higher in the AccuCirc arm compared with the Mogen Clamp arm (95% CI: 20.7 to 4.7). As the 95% CI excludes the predefined noninferiority margin of 6%, the result provides evidence of noninferiority of AccuCirc compared with the Mogen clamp. Nearly all mothers (99.5%) reported great satisfaction with the outcome. All mothers, regardless of arm said they would recommend EIMC to other parents, and would circumcise their next son.
Conclusions: This first randomized trial of AccuCirc versus
Mogen clamp for EIMC demonstrated that EIMC using these
devices is safe and acceptable to parents. There was no difference in the rate of AEs by device.
Key Words: AccuCirc, early infant male circumcision, HIV, Mogen
clamp, Zimbabwe

Abstract Background: Safe and cost-effective programs for implementing early infant male circumci... more Abstract
Background: Safe and cost-effective programs for implementing early infant male circumcision (EIMC) in Africa need to be piloted. We present results on a relative cost analysis within a randomized noninferiority trial of EIMC comparing the AccuCirc device with Mogen clamp in Zimbabwe.
Methods: Between January-June 2013, male infants who met inclusion criteria were randomized to EIMC through either AccuCirc or Mogen clamp conducted by a doctor, using a 2:1 allocation ratio. We evaluated the overall unit cost plus the key cost drivers of EIMC using both AccuCirc and Mogen clamp. Direct costs included consumable and non-consumable supplies, device, personnel, associated staff training, and environmental costs. Indirect costs comprised capital and support personnel costs. In one-way sensitivity analyses, we assessed potential changes in unit costs due to variations in main parameters, one at a time, holding all other values constant.
Results: The unit costs of EIMC using AccuCirc and Mogen clamp were 49.53and49.53 and 49.53and55.93, respectively. Key cost drivers were consumable supplies, capacity utilization, personnel costs, and device price. Unit prices are likely to be lowest at full capacity utilization and increase as capacity utilization decreases. Unit prices also fall with lower personnel salaries and increase with higher device prices.
Conclusions: EIMC has a lower unit cost when using AccuCirc compared to Mogen clamp. In order to minimize unit costs, countries planning to scale-up EIMC using AccuCirc need to control costs of consumables and personnel. There is also need to negotiate a reasonable device price, and maximize capacity utilization.

Key Words: AccuCirc, cost, early infant male circumcision, Mogen clamp, Zimbabwe

Despite a recent decline, Zimbabwe still has the fifth highest adult HIV prevalence in the world ... more Despite a recent decline, Zimbabwe still has the fifth highest adult HIV prevalence in the world at 14.7%; 56% of the population are currently living in extreme poverty.

Infant male circumcision (IMC) may be more effective at preventing HIV than adult male circumcisi... more Infant male circumcision (IMC) may be more effective at preventing HIV than adult male circumcision as the procedure is carried out before the individual becomes sexually active. Successful scale-up will depend on identifying and overcoming parental concerns that may act as barriers for IMC. We conducted a systematic review to identify qualitative studies reporting on parental reasons for non-adoption of IMC for HIV prevention in sub-Saharan Africa. Thematic synthesis was subsequently conducted. Five descriptive themes were identified; these were later condensed into two main analytical themes: ''poor knowledge'' and ''social constructs''. While barriers and motivators are to some degree context specific, this review suggests that there are common themes that need to be addressed across the region if uptake of IMC for HIV prevention is to be widely adopted. Study findings are therefore likely to have broad implications for IMC roll out.

Acquir Immune Defic Syndr 2014;66:S193–S199

"Background and Methods: By December 2013, it was estimated that close to 6 million men had been ... more "Background and Methods: By December 2013, it was estimated that close to 6 million men had been circumcised in the 14 priority countries for scaling up voluntary medical male circumcision (VMMC), the majority being adolescents (10–19 years). This article discusses why efforts to scale up VMMC should prioritize adolescent men, drawing from new evidence and experiences at the international, country, and service delivery levels. Furthermore, we review the extent to which VMMC programs have reached adolescents, addressed their specific needs, and can be linked to their sexual and reproductive health and other key services.

Results and Discussion: In priority countries, adolescents represent 34%–55% of the target population to be circumcised, whereas program data from these countries show that adolescents represent between 35% and 74% of the circumcised men. VMMC for adolescents has several advantages: uptake of services among adolescents is culturally and socially more acceptable than for adults; there are fewer barriers regarding sexual abstinence during healing or female partner pressures; VMMC performed before the age of sexual debut has maximum long-term impact on reducing HIV risk at the individual level and consequently reduces the risk of transmission in the population. Offered as a comprehensive package, adolescent VMMC can potentially increase public health benefits and offers opportunities for addressing gender norms. Additional research is needed to assess whether current VMMC services address the specific needs of adolescent clients, to test adapted tools, and to assess linkages between VMMC and other adolescent-focused HIV, health, and social services.
"

Background: SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-u... more Background: SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency-use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery-as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe.

Background: Countries participating in voluntary medical male circumcision (VMMC) scale-up have a... more Background: Countries participating in voluntary medical male circumcision (VMMC) scale-up have adopted most of six elements of surgical efficiency, depending on national policy. However, effective implementation of these elements largely depends on providers' attitudes and subsequent compliance. We explored the concordance between recommended practices and providers' perceptions toward the VMMC efficiency elements, in part to inform review of national policies.

Background: We conducted quantitative and qualitative studies to explore barriers and motivating ... more Background: We conducted quantitative and qualitative studies to explore barriers and motivating factors to VMMC for HIV prevention, and to assess utilization of existing VMMC communication channels.

Background: Human resource capacity is vital to the scale-up of voluntary medical male circumcisi... more Background: Human resource capacity is vital to the scale-up of voluntary medical male circumcision (VMMC) services. VMMC providers are at risk of ''burnout'' from performing a single task repeatedly in a high volume work environment that produces long work hours and intense work effort.

Background: There is a recognized gap in the evidence base relating to the nature and components ... more Background: There is a recognized gap in the evidence base relating to the nature and components of interventions to address the psycho-social needs of HIV positive young people. We used mixed methods research to strengthen a community support group intervention for HIV positive young people based in Harare, Zimbabwe.

Background: Early infant male circumcision (EIMC) is simpler, safer and more cost-effective than ... more Background: Early infant male circumcision (EIMC) is simpler, safer and more cost-effective than adult circumcision. In sub-Saharan Africa, there are concerns about acceptability of EIMC which could affect uptake. In 2009 a quantitative survey of 2,746 rural Zimbabweans (aged 18-44) indicated that 60% of women and 58% of men would be willing to have their newborn son circumcised. Willingness was associated with knowledge of HIV and male circumcision. This qualitative study was conducted to better understand this issue.

objective To explore male circumcision (MC) prevalence, knowledge, attitudes and intentions among... more objective To explore male circumcision (MC) prevalence, knowledge, attitudes and intentions among rural Zimbabweans.

AIDS Care, 2011

Key Words: AccuCirc, cost, early infant male circumcision, Mogen clamp, Zimbabwe

Acquir Immune Defic Syndr 2014;66:S193–S199