Journal of the International AIDS Society, Jan 5, 2017
Safe male circumcision is an important biomedical intervention in the comprehensive HIV preventio... more Safe male circumcision is an important biomedical intervention in the comprehensive HIV prevention programmes implemented in 14 sub-Saharan African countries with high HIV prevalence. To sustain its partial protective benefit, it is important that perceived reduced HIV risk does not lead to behavioural risk compensation among circumcised men and their sexual partners. This study explored beliefs that may influence post circumcision sexual behaviours among circumcised men in a programme setting. Forty-eight in-depth interviews were conducted with newly circumcised men in Wakiso district, central Uganda. Twenty-five men seeking circumcision services at public health facilities in the district were recruited from May to June 2015 and, interviewed at baseline and after 6 months. Participants' beliefs and sexual behaviours were compared just after circumcision and at follow up to explore changes. Data were managed using atlas.ti7 and analysed following a thematic network analysis fra...
About 2.5 million men have voluntarily been circumcised since Uganda started implementing the WHO... more About 2.5 million men have voluntarily been circumcised since Uganda started implementing the WHO recommendation to scale up safe male circumcision to reduce HIV transmission. This study sought to understand what influences men's circumcision decisions, their experiences with health education at health facilities and their knowledge of partial HIV risk reduction in Wakiso district. Data were collected in May and June 2015 at five public health facilities in Wakiso District. Twenty-five in-depth interviews were held with adult safe male circumcision clients. Data were analysed using thematic network analysis. Safe male circumcision decisions were mainly influenced by sexual partners, a perceived need to reduce the risk of HIV/STIs, community pressure and other benefits like hygiene. Sexual partners directly requested men to circumcise or indirectly influenced them in varied ways. Health education at facilities mainly focused on the surgical procedure, circumcision benefits especially HIV risk reduction, wound care and time to resumption of sex, with less focus on post-circumcision sexual behaviour. Five men reported no health education. All men reported that circumcision only reduces and does not eliminate HIV risk, and could mention ways it protects, although some extended the benefit to direct protection for women and prevention of other STIs. Five men thought social marketing messages were 'misleading' and feared risk compensation within the community. Participants reported positive community perception about safe male circumcision campaigns, influencing men to seek services and enabling female partners to impact this decision-making process. However, there seemed to be gaps in safe male circumcision health education, although all participants correctly understood that circumcision offers only partial protection from HIV. Standard health education procedures, if followed at health facilities offering safe male circumcision, would ensure all clients are well informed, especially about post-circumcision sexual behaviour that is key to prevention of risk compensation.
The aim of this study was to examine changes over time in the female: male HIV prevalence ratio i... more The aim of this study was to examine changes over time in the female: male HIV prevalence ratio in 18 countries in Sub-Saharan Africa, overall and when stratified by area of residence, educational attainment and marital status. We used data from the Demographic and Health Surveys, which are nationally representative household surveys. By using data from 18 countries with at least two survey rounds with HIV testing, and dividing the countries into three regions (Western/Central, Eastern and Southern) we were able to examine cross-country and regional changes in the female: male HIV prevalence ratio over time. Logistic regression was used to estimate female: male HIV prevalence ratios in urban versus rural areas and for different categories of education and marital status. To assess changes over time, we compared the confidence intervals of the prevalence ratios. The female: male HIV prevalence ratio was above one in all countries in at least one survey round for both ages 15-24 years and 25-49 years. In 13 out of 18 countries the prevalence ratio was higher for the younger age group compared to the age group 25-49 years (3 significant) and this difference in prevalence ratios between the age groups did not change over time. Overall, there was a higher frequency of increasing than decreasing prevalence ratios. The gender disparity was greater among those who were married/living together than among the never-married, and over time, the ratio was more stable among the married/living together. The study found no clear differential changes by education. Women continue to carry the greater burden of HIV in Sub-Saharan Africa and there is no clear pattern of change in the gap between men and women as the direction and magnitude of change in the prevalence ratios varied greatly.
There has been substantial demand for safe male circumcision (SMC) in Uganda in the early program... more There has been substantial demand for safe male circumcision (SMC) in Uganda in the early programme scale-up phase. Research indicates that early adopters of new interventions often differ from later adopters in relation to a range of behaviours. However, there is limited knowledge about the risk profile of men who were willing to be circumcised at the time of launching the SMC programme, i.e., potential early adopters, compared to those who were reluctant. The aim of this study was to address this gap to provide indications on whether it is likely that potential early adopters of male circumcision were more in need of this new prevention measure than others. Data were from the 2011 Uganda AIDS Indictor Survey (UAIS), with a nationally representative sample of men 15 to 59 years. The analysis was based on generalized linear models, obtaining prevalence risk ratios (PRR) with 95% confidence intervals (CI) as measures of association between willingness to be circumcised and multiple sexual partners, transactional sex, non-marital sex and non-use of condoms at last non-marital sex. Of the 5,776 men in the survey, 44% expressed willingness to be circumcised. Willingness to be circumcised was higher among the younger, urban and educated men. In the unadjusted analyses, all the sexual risk behaviours were associated with willingness to be circumcised, while in the adjusted analysis, non-marital sex (Adj PRR 1.27; CI: 1.16-1.40) and non-use of condoms at last such sex (Adj PRR 1.18; CI: 1.07-1.29) were associated with higher willingness to be circumcised. Willingness to be circumcised was relatively high at the launch of the SMC programme and was more common among uncircumcised men reporting sexual risk behaviours. This indicates that the early adopters of SMC were likely to be in particular need of such additional HIV protective measures.
Although male circumcision reduces the heterosexual HIV transmission risk, its effect may be atte... more Although male circumcision reduces the heterosexual HIV transmission risk, its effect may be attenuated if circumcised men increase sexual risk behaviours (SRB) due to perceived low risk. In Uganda information about the protective effects of circumcision has been publicly disseminated since 2007. If increased awareness of the protection increases SRB among circumcised men, it is likely that differences in prevalence of SRB among circumcised versus uncircumcised men will change over time. This study aimed at comparing SRBs and HIV sero-status of circumcised and uncircumcised men before and after the launch of the safe male circumcision programme. Data from the 2004 and 2011 Uganda AIDS Indicator Surveys (UAIS) were used. The analyses were based on generalized linear models, obtaining prevalence ratios (PR) as measures of association between circumcision status and multiple sexual partners, transactional sex, sex with non-marital partners, condom use at last non-marital sex, and HIV infection. In addition we conducted multivariate analyses adjusted for sociodemographic characteristics, and the multivariate models for HIV status were also adjusted for SRB. Twenty six percent of men were circumcised in 2004 and 28 % in 2011. Prevalence of SRB was higher among circumcised men in both surveys. In the unadjusted analysis, circumcision was associated with having multiple sexual partners and non-marital partners. Condom use was not associated with circumcision in 2004, but in 2011 circumcised men were less likely to report condom use with the last non-marital partner. The associations between the other sexual risk behaviours and circumcision status were stable across the two surveys." In both surveys, circumcised men were less likely to be HIV positive (Adj PR 0.55; CI: 0.41-0.73 in 2004 and Adj PR 0.64; CI: 0.49-0.83 in 2011). There was higher prevalence of SRBs among circumcised men in both surveys, but the only significant change from 2004 to 2011 was a lower prevalence of condom use among the circumcised. Nevertheless, HIV prevalence was lower among circumcised men. Targeted messages for circumcised men and their sexual partners to continue using condoms even after circumcision should be enhanced to avoid risk compensation.
The use of census data to measure maternal mortality is a recent phenomenon, implemented in setti... more The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data. We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010. Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas. Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.
Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, fe... more Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, few studies have estimated the significance of eliminating maternal deaths on female life expectancy. We estimated, based on census data, the potential gains in female life expectancy assuming complete elimination of pregnancy-related mortality in Zambia. We used data on all-cause and pregnancy-related deaths of females aged 15-49 reported in the Zambia 2010 census, and evaluated, adjusted and smoothed them using existing and verified techniques. We used associated single decrement life tables, assuming complete elimination of pregnancy-related deaths to estimate the potential gains in female life expectancy at birth, at age 15, and over the ages 15-49. We compared these gains with the gains from eliminating deaths from accidents, injury, violence and suicide. Complete elimination of pregnancy-related deaths would extend life expectancy at birth among Zambian women by 1.35 years and life expectancy at age 15 by 1.65 years. In rural areas, this would be 1.69 years and 2.19 years, respectively, and in urban areas, 0.78 years and 0.85 years. An additional 0.72 years would be spent in the reproductive age group 15-49; 1.00 years in rural areas and 0.35 years in urban areas. Eliminating deaths from accidents, injury, suicide and violence among women aged 15-49 would cumulatively contribute 0.55 years to female life expectancy at birth. Eliminating pregnancy-related mortality would extend female life expectancy in Zambia substantially, with more gains among adolescents and females in rural areas. The application of life table techniques to census data proved very valuable, although rigorous evaluation and adjustment of reported deaths and age was necessary to attain plausible estimates. The collection of detailed high quality cause-specific mortality data in future censuses is indispensable.
Epidemiology: Principles and Practical Guidelines, 2013
ABSTRACT In the previous chapters we discussed specifications of research questions, general stud... more ABSTRACT In the previous chapters we discussed specifications of research questions, general study designs, and study size. The next step in developing a study proposal is to create a practical plan for how to find and enroll participants or other observation units. It is important to be clear about what particular characteristics are needed (inclusion and exclusion criteria), how to identify an appropriate number of participants (recruitment, sampling, and eligibility screening), and how to get the necessary permissions to access secondary data or to obtain new information after informed consent and enrollment. The principles and guidelines for each of these tasks are described in this chapter, except that we devote a separate chapter (Chapter 16) to the management of the informed consent process.
Journal of the International AIDS Society, Jan 5, 2017
Safe male circumcision is an important biomedical intervention in the comprehensive HIV preventio... more Safe male circumcision is an important biomedical intervention in the comprehensive HIV prevention programmes implemented in 14 sub-Saharan African countries with high HIV prevalence. To sustain its partial protective benefit, it is important that perceived reduced HIV risk does not lead to behavioural risk compensation among circumcised men and their sexual partners. This study explored beliefs that may influence post circumcision sexual behaviours among circumcised men in a programme setting. Forty-eight in-depth interviews were conducted with newly circumcised men in Wakiso district, central Uganda. Twenty-five men seeking circumcision services at public health facilities in the district were recruited from May to June 2015 and, interviewed at baseline and after 6 months. Participants' beliefs and sexual behaviours were compared just after circumcision and at follow up to explore changes. Data were managed using atlas.ti7 and analysed following a thematic network analysis fra...
About 2.5 million men have voluntarily been circumcised since Uganda started implementing the WHO... more About 2.5 million men have voluntarily been circumcised since Uganda started implementing the WHO recommendation to scale up safe male circumcision to reduce HIV transmission. This study sought to understand what influences men's circumcision decisions, their experiences with health education at health facilities and their knowledge of partial HIV risk reduction in Wakiso district. Data were collected in May and June 2015 at five public health facilities in Wakiso District. Twenty-five in-depth interviews were held with adult safe male circumcision clients. Data were analysed using thematic network analysis. Safe male circumcision decisions were mainly influenced by sexual partners, a perceived need to reduce the risk of HIV/STIs, community pressure and other benefits like hygiene. Sexual partners directly requested men to circumcise or indirectly influenced them in varied ways. Health education at facilities mainly focused on the surgical procedure, circumcision benefits especially HIV risk reduction, wound care and time to resumption of sex, with less focus on post-circumcision sexual behaviour. Five men reported no health education. All men reported that circumcision only reduces and does not eliminate HIV risk, and could mention ways it protects, although some extended the benefit to direct protection for women and prevention of other STIs. Five men thought social marketing messages were 'misleading' and feared risk compensation within the community. Participants reported positive community perception about safe male circumcision campaigns, influencing men to seek services and enabling female partners to impact this decision-making process. However, there seemed to be gaps in safe male circumcision health education, although all participants correctly understood that circumcision offers only partial protection from HIV. Standard health education procedures, if followed at health facilities offering safe male circumcision, would ensure all clients are well informed, especially about post-circumcision sexual behaviour that is key to prevention of risk compensation.
The aim of this study was to examine changes over time in the female: male HIV prevalence ratio i... more The aim of this study was to examine changes over time in the female: male HIV prevalence ratio in 18 countries in Sub-Saharan Africa, overall and when stratified by area of residence, educational attainment and marital status. We used data from the Demographic and Health Surveys, which are nationally representative household surveys. By using data from 18 countries with at least two survey rounds with HIV testing, and dividing the countries into three regions (Western/Central, Eastern and Southern) we were able to examine cross-country and regional changes in the female: male HIV prevalence ratio over time. Logistic regression was used to estimate female: male HIV prevalence ratios in urban versus rural areas and for different categories of education and marital status. To assess changes over time, we compared the confidence intervals of the prevalence ratios. The female: male HIV prevalence ratio was above one in all countries in at least one survey round for both ages 15-24 years and 25-49 years. In 13 out of 18 countries the prevalence ratio was higher for the younger age group compared to the age group 25-49 years (3 significant) and this difference in prevalence ratios between the age groups did not change over time. Overall, there was a higher frequency of increasing than decreasing prevalence ratios. The gender disparity was greater among those who were married/living together than among the never-married, and over time, the ratio was more stable among the married/living together. The study found no clear differential changes by education. Women continue to carry the greater burden of HIV in Sub-Saharan Africa and there is no clear pattern of change in the gap between men and women as the direction and magnitude of change in the prevalence ratios varied greatly.
There has been substantial demand for safe male circumcision (SMC) in Uganda in the early program... more There has been substantial demand for safe male circumcision (SMC) in Uganda in the early programme scale-up phase. Research indicates that early adopters of new interventions often differ from later adopters in relation to a range of behaviours. However, there is limited knowledge about the risk profile of men who were willing to be circumcised at the time of launching the SMC programme, i.e., potential early adopters, compared to those who were reluctant. The aim of this study was to address this gap to provide indications on whether it is likely that potential early adopters of male circumcision were more in need of this new prevention measure than others. Data were from the 2011 Uganda AIDS Indictor Survey (UAIS), with a nationally representative sample of men 15 to 59 years. The analysis was based on generalized linear models, obtaining prevalence risk ratios (PRR) with 95% confidence intervals (CI) as measures of association between willingness to be circumcised and multiple sexual partners, transactional sex, non-marital sex and non-use of condoms at last non-marital sex. Of the 5,776 men in the survey, 44% expressed willingness to be circumcised. Willingness to be circumcised was higher among the younger, urban and educated men. In the unadjusted analyses, all the sexual risk behaviours were associated with willingness to be circumcised, while in the adjusted analysis, non-marital sex (Adj PRR 1.27; CI: 1.16-1.40) and non-use of condoms at last such sex (Adj PRR 1.18; CI: 1.07-1.29) were associated with higher willingness to be circumcised. Willingness to be circumcised was relatively high at the launch of the SMC programme and was more common among uncircumcised men reporting sexual risk behaviours. This indicates that the early adopters of SMC were likely to be in particular need of such additional HIV protective measures.
Although male circumcision reduces the heterosexual HIV transmission risk, its effect may be atte... more Although male circumcision reduces the heterosexual HIV transmission risk, its effect may be attenuated if circumcised men increase sexual risk behaviours (SRB) due to perceived low risk. In Uganda information about the protective effects of circumcision has been publicly disseminated since 2007. If increased awareness of the protection increases SRB among circumcised men, it is likely that differences in prevalence of SRB among circumcised versus uncircumcised men will change over time. This study aimed at comparing SRBs and HIV sero-status of circumcised and uncircumcised men before and after the launch of the safe male circumcision programme. Data from the 2004 and 2011 Uganda AIDS Indicator Surveys (UAIS) were used. The analyses were based on generalized linear models, obtaining prevalence ratios (PR) as measures of association between circumcision status and multiple sexual partners, transactional sex, sex with non-marital partners, condom use at last non-marital sex, and HIV infection. In addition we conducted multivariate analyses adjusted for sociodemographic characteristics, and the multivariate models for HIV status were also adjusted for SRB. Twenty six percent of men were circumcised in 2004 and 28 % in 2011. Prevalence of SRB was higher among circumcised men in both surveys. In the unadjusted analysis, circumcision was associated with having multiple sexual partners and non-marital partners. Condom use was not associated with circumcision in 2004, but in 2011 circumcised men were less likely to report condom use with the last non-marital partner. The associations between the other sexual risk behaviours and circumcision status were stable across the two surveys." In both surveys, circumcised men were less likely to be HIV positive (Adj PR 0.55; CI: 0.41-0.73 in 2004 and Adj PR 0.64; CI: 0.49-0.83 in 2011). There was higher prevalence of SRBs among circumcised men in both surveys, but the only significant change from 2004 to 2011 was a lower prevalence of condom use among the circumcised. Nevertheless, HIV prevalence was lower among circumcised men. Targeted messages for circumcised men and their sexual partners to continue using condoms even after circumcision should be enhanced to avoid risk compensation.
The use of census data to measure maternal mortality is a recent phenomenon, implemented in setti... more The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data. We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010. Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas. Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.
Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, fe... more Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, few studies have estimated the significance of eliminating maternal deaths on female life expectancy. We estimated, based on census data, the potential gains in female life expectancy assuming complete elimination of pregnancy-related mortality in Zambia. We used data on all-cause and pregnancy-related deaths of females aged 15-49 reported in the Zambia 2010 census, and evaluated, adjusted and smoothed them using existing and verified techniques. We used associated single decrement life tables, assuming complete elimination of pregnancy-related deaths to estimate the potential gains in female life expectancy at birth, at age 15, and over the ages 15-49. We compared these gains with the gains from eliminating deaths from accidents, injury, violence and suicide. Complete elimination of pregnancy-related deaths would extend life expectancy at birth among Zambian women by 1.35 years and life expectancy at age 15 by 1.65 years. In rural areas, this would be 1.69 years and 2.19 years, respectively, and in urban areas, 0.78 years and 0.85 years. An additional 0.72 years would be spent in the reproductive age group 15-49; 1.00 years in rural areas and 0.35 years in urban areas. Eliminating deaths from accidents, injury, suicide and violence among women aged 15-49 would cumulatively contribute 0.55 years to female life expectancy at birth. Eliminating pregnancy-related mortality would extend female life expectancy in Zambia substantially, with more gains among adolescents and females in rural areas. The application of life table techniques to census data proved very valuable, although rigorous evaluation and adjustment of reported deaths and age was necessary to attain plausible estimates. The collection of detailed high quality cause-specific mortality data in future censuses is indispensable.
Epidemiology: Principles and Practical Guidelines, 2013
ABSTRACT In the previous chapters we discussed specifications of research questions, general stud... more ABSTRACT In the previous chapters we discussed specifications of research questions, general study designs, and study size. The next step in developing a study proposal is to create a practical plan for how to find and enroll participants or other observation units. It is important to be clear about what particular characteristics are needed (inclusion and exclusion criteria), how to identify an appropriate number of participants (recruitment, sampling, and eligibility screening), and how to get the necessary permissions to access secondary data or to obtain new information after informed consent and enrollment. The principles and guidelines for each of these tasks are described in this chapter, except that we devote a separate chapter (Chapter 16) to the management of the informed consent process.
Uploads
Papers by Ingvild Sandoy