The INFO Project Blog

The last full day of sessions was great.  I was able to sit in on interesting lectures covering everything from male circumcision and HIV prevention to HIV prevention among injection drug users in Iran.  The highlight of the day - respondent driven sampling - a new way to recruit research subjects based on social networking!

Oh - Given my new found knowledge of vasectomy (see - Vasectomy: Reaching Out to New Users)  I asked if male circumcision programs have adopted any lessons learned from vasectomy programs in sub-Saharan Africa as vasectomy uptake is very low (less than 1 percent) and involves similar issues of gender-norms and culture.   I was told no, but now that I brought this to the panel’s attention, perhaps it would be investigated!

Male Circumcision: To cut or not to cut
Unfortunately my camera batteries went dead this morning so I wasn’t able to get photos of some of the great slides.   The session started with the conference chair from the International AIDS Alliance (whose name I unfortunately missed and is not in the program) discussing what we already know and don’t know about male circumcision (hereon referred to as MC) and HIV prevention.  WHO and UNAIDS have made a statement about the efficacy of male circumcision and recommends beyond a reasonable doubt male circumcision in countries where there is a generalized HIV epidemic and services cab be safely performed.  Three randomized trials in high prevalence countries, Uganda, South Africa and Kenya have shown that male circumcision reduced male-female heterosexual HIV transmission by 50-60 percent. There has already been high uptake in some clinics and lengthy waiting lists to receive services.  There is no direct evidence to show that male circumcision in effective in prevention transmission among men who have sex with men (MSM).

What we don’t know is the impact of  a large scale rollout of MC, as this has not yet been completed.  We also do not have evidence to show whether or not men would increase the amount of unprotected sex they engage in following circumcision, because they think it may be a magic cure or vaccine (the session emphasized that condoms still need to be used with MC as MC is only about 60 percent effective in preventing transmission).   It will be challenging to meet the demand for MC in already stretched health sectors. 

• The meaning of male circumcision for young men - M. Mafalapitsa, EngenderHealth, South Africa - Circumcision is a ritual, showing a covenant between man and God in Judaism, Islam and several African tribes.  The health MC has gender implications which need to be addressed as males who undergo ritual circumcision in sub-Saharan Africa  as a right of passage attend “circumcision schools” (classes received before ritual circumcision) that teach men that they have to be  a man, strong, and not feel pain, leading to increased incidents of violence against women.  MC should be part of a comprehensive SRH program and a gender approach to combat harmful masculinities must be incorporated where MC programs take place.
• Cultural and religious sensitivities - Karen Smith, Indonesia - Social relations and culture norms will influence attitudes toward mail circumcision.  Values are changeable (and thus may welcome circumcision, however this change does not occur over time. In terms of a public health perspective, MC should be performed, however you have to know the culture and people you are working with, give full considerations to their cultural concerns
•  The implications for women - Margaret Bewrer, Editor, Reproductive Health Matters:   MC is only partially protective for men and men and their partners a must use condoms in addition to MC.  MC is not beneficial for men who are already HIV+.  There is still no agreement on how to assess MC programs in real life - we must know how many men are being circumcised, where they are, why they sough circumcision, how many are positive/negative. MC programs should involve women and be for men and their partners.  Prevention programs should before men and their partners.  Priority setting may or may not include MC.  If men “get the snip” and there is no follow up to encourage safer sex, it will not be beneficial.  The partners of circumcised men have an equal right of protection. 

The question and answer session was a little controversial, as there were many advocates against medical circumcision, arguing that a man should remain whole and intact, and that circumcision is not necessary, since condoms will still need to be used.  

The Needle and the Damage Done: Addressing HIV among Injection Drug Users

This session addressed research from Iran and Mexico regarding IDUs and HIV.

• HIV and related risk behaviors of injecting drug users (IDU) in Iran: findings from the first-respondent driven sampling survey in IDU in Tehran, 2006-2007, George Rutherford, University of California, San Francisco:  This study used respondent driven sampling (RDS) which is awesome! Basically you start with a seed who you give three coupons to.  The seed then refers three more people, each of whom receive more coupons, and the process continues until you have a sample size.  The study discovered that there is a 25 percent prevalence of HIV among a large sample of IDUs in Tehran.
• Predictors of needle exchange program during its implementation and expansion in Tijuana, Mexico, Alicia Vera, University of California:  The study group of IDUs was once again recruited using respondent driven sampling.  People who participated in the needle-exchange program (NEP) were younger,  had lower income levels, had families who used drugs, were more likely to report having sex with men, and were more likely to report shooting drugs in a shooting gallery.  Uptake of NEP increased threefold in Tijuana after initiation of the program.
•  Evaluation of Harm Reduction program in Taiwan: Dr. Lu Chang Lan, National University, Taiwan:  The study conducted serologic tests of HIV on used needles exchanged as part of the syringe exchange program.  The program also consisted of education, counseling, anonymous testing, and a methadone maintenance program.  18 percent of subjects were HIV positive based upon serologic analysis.  Rates dropped in the second phase of the study, when increased incentives for participation were offered, to 9.4 percent.   A separate questionnaire of inmates also revealed that a large percentage of IDU inmates share syringes, and will benefit from expansion of syringe exchange programs.
•  HIV risk factors and injection drug use among men who have sex with men in Zanzibar (Ungunja, Uganda).  Abigail Holman, CDC Tanzania: Samples again were selected using RDS!  14 percent of the men who have sex with men (MSM) sample reported using injectable drugs.  50 percent of this MSM/ISU sample reported using shared needles or passing the needles onto someone else.  MSM IDU were more likely to have multiple sexual partners than non-MSM IDU.  HIV testing was low among the MSM IDU group and there was a high prevalence of hepatitis C in the MSM IDU group.  The study concluded that there needs to be targeted interventions for MSM IDU accounting for the high overlap of high risk sexual activity and drug using networks which includes HIV/STI treatment and care, counseling, testing and treatment.  RDS has been shown to be successful in recruiting IDUs for research studies.

Comprehensive Condom Programming: So Much Potential, Yet so Little Progress.  This satellite session was sponsored by the UNAIDS interagency task force on comprehensive condom programming.  The mandate of the task force is to come up with solutions for sustainable male and female condom programming.  The task force consists of bilateral agencies (DFID, Sida, Danish development agency), multilateral organizations (WHO, UNAIDS, UNESCO, UNFPA), development partners (PSI, PAI, WYWCA) and the private sector (Durex International and Female Health Company).

• Zimbabwe: Marketing of female and male condoms: Dr. Krishna Jafa, PSI Zimbabwe and Daisy Nyamukaba, UNFPA, Zimbabwe: Comprehensive condom programming (CCP) has been a key component of the national HIV response in Zimbabwe, Zimbabwe, despite harsh economic and political conditions has been the first South African country to experience a decline in HIV prevalence (from 29.3 percent in 1999 to 15.6 percent in 2006).  Condom use is low in stable  non-casual relationships/. The presentation outlined what makes up CCP.  CCP is a multifaceted approach to condom programming which includes condom promotion, behavior change communication, market research and coordinated supply management.  CCP makes optimal use of different entry points which include voluntary HIV testing and counseling (VCT).  CCP utilizes a complete market approach which involves the public and private sector and includes social marketing.  There is a 10 step framework for CCP which includes formation of a commodity security plan, condom promotion plan, HR capacity strengthening, and ongoing monitoring and evaluation.In Zimbabwe, CCP utilized capacity building which including training the public sector (police, educators, and the private sector (hair salon owners) on correct condom use and condom counseling.  Condoms were part of a comprehensive HIV prevention strategy that included partner reduction, prevention of mother to child transmission (PMCTC), provision of antiretroviral (ART) drugs,  STI testing and family planning counseling.   Condom demand was generated through branded communications (”PSI Protector Plus”) such as wall murals and stickers, community events, road show condom demonstrations and interpersonal communications at points of VCT, family planning counseling and peer networks. CCP has been successful in Zimbabwe as there have been over 60 million condoms purchased through social marketing.  There has also been a steady increase in the number of female condoms sold and provided through social marketing schemes since implementation of CCP.   The Ministry of Health and Child Welfare led the CCP effort through ensuring an ongoing supply of affordable condoms and ensuring that CCP was based on sound scientific evidence showing the efficacy of condoms in both preventing HIV transmission and pregnancy.

• Male and female condoms: Effective barriers against HIV, Bidia Deperthes, HIV/AIDS Technical Advisor on CCP, UNFPA and lead of interagency task force on CCP:  This presentation discussed why there has been so little progress made with regard to CCP.  In order for CCP to be successful there needs to be strong political will and strong leadership and coordination. Restrictive national policies that prevent condom distribution and promotion need to be removed and stakeholders need to be involved in the process of CCP. 
  In order for CCP to be successfully, we need to stop compartmentalizing the way we work.  Citizens need to encourage policy makers to support integration of CCP into family planning programs, VCT programs. Prevention programs for men who have sex with men and various other sexual and reproductive health services.   International funding for CCP has not been very high, and has remained flat from 2001-2007.   International donors only provide about 80 million dollars a year for CCP.  Male and female condoms are not on policy maker’s agendas - an analysis performed in 100 countries showed that only 56 percent of countries have make and female condoms on their domestic essential drug lists and only 45 percent of countries analyzed have a national budget line for CCP. There is also a gap in condom supply.  In 2005 there was a gap of 6.5 million condoms needed to fulfill estimated worldwide HIV prevention and family planning needs.  There was also a gap in the female condom supply.  Only 20 million of the estimated 37 million female condoms needed to meet demand were distributed.  One half of one percent of all condoms produced were female condoms. To scale up CCP, one national approach needs to be implemented by one national authority with one monitoring and evaluation plan.

The question and answer session for this presentation was lively and touched upon issues such as the church’s role in CCP, how to encourage CCP for men who have sex with men and male involvement in promotion of female condoms.