A conceptual framework to assess the effectiveness of HIV prevention

Aim: The relative effectiveness of different methods of prevention of HIV transmission is a subject of debate that is renewed with the integration of each new method. The relative weight of values and evidence in decision-making is not always clearly defined. Debate is often confused, as the proponents of different approaches address the issue at different levels of implementation. This paper defines and delineates the successive levels of analysis of effectiveness, and proposes a conceptual framework to clarify debate. Method / Issue: Initially inspired from work on contraceptive effectiveness, a first version of the conceptual framework was published in 1993 with definition of the Condom Effectiveness Matrix (Spencer, 1993). The framework has since integrated and further developed thinking around distinctions made between efficacy and effectiveness and has been applied to HIV prevention in general. Three levels are defined: theoretical effectiveness (ThE), use-effectiveness (UseE) and population use-effectiveness (PopUseE). For example, abstinence and faithfulness, as proposed in the ABC strategy, have relatively high theoretical effectiveness but relatively low effectiveness at subsequent levels of implementation. The reverse is true of circumcision. Each level is associated with specific forms of scientific enquiry and associated research questions: basic and clinical sciences with ThE; clinical and social sciences with UseE; epidemiology and social, economic and political sciences with PopUseE. Similarly, the focus of investigation moves from biological organisms, to the individual at the physiological and then psychological, social and ecological level, and finally takes as perspective populations and societies as a whole. The framework may be applied to analyse issues on any approach. Hence, regarding consideration of HIV treatment as a means of prevention, examples of issues at each level would be: ThE: achieving adequate viral suppression and non-transmission to partners; UseE: facility and degree of adherence to treatment and medical follow-up; PopUseE: perceived validity of strategy, feasibility of achieving adequate population coverage. Discussion: Use of the framework clarifies the questions that need to be addressed at all levels in order to improve effectiveness. Furthermore, the interconnectedness and complementary nature of research from the different scientific disciplines and the relative contribution of each become apparent. The proposed framework could bring greater rationality to the prevention effectiveness debate and facilitate communication between stakeholders.

A deterministic model to assess the impact of AIDS interventions in countries with generalized HIV epidemic. An application to Botswana

General introductionThe Human Immunodeficiency/Acquired Immunodeficiency Syndrome (HIV/AIDS) epidemic, despite recent encouraging announcements by the World Health Organization (WHO) is still today one of the world's major health care challenges.The present work lies in the field of health care management, in particular, we aim to evaluate the behavioural and non-behavioural interventions against HIV/AIDS in developing countries through a deterministic simulation model, both in human and economic terms. We will focus on assessing the effectiveness of the antiretroviral therapies (ART) in heterosexual populations living in lesser developed countries where the epidemic has generalized (formerly defined by the WHO as type II countries). The model is calibrated using Botswana as a case study, however our model can be adapted to other countries with similar transmission dynamics.The first part of this thesis consists of reviewing the main mathematical concepts describing the transmission of infectious agents in general but with a focus on human immunodeficiency virus (HIV) transmission. We also review deterministic models assessing HIV interventions with a focus on models aimed at African countries. This review helps us to recognize the need for a generic model and allows us to define a typical structure of such a generic deterministic model.The second part describes the main feed-back loops underlying the dynamics of HIV transmission. These loops represent the foundation of our model. This part also provides a detailed description of the model, including the various infected and non-infected population groups, the type of sexual relationships, the infection matrices, important factors impacting HIV transmission such as condom use, other sexually transmitted diseases (STD) and male circumcision. We also included in the model a dynamic life expectancy calculator which, to our knowledge, is a unique feature allowing more realistic cost-efficiency calculations. Various intervention scenarios are evaluated using the model, each of them including ART in combination with other interventions, namely: circumcision, campaigns aimed at behavioral change (Abstain, Be faithful or use Condoms also named ABC campaigns), and treatment of other STD. A cost efficiency analysis (CEA) is performed for each scenario. The CEA consists of measuring the cost per disability-adjusted life year (DALY) averted. This part also describes the model calibration and validation, including a sensitivity analysis.The third part reports the results and discusses the model limitations. In particular, we argue that the combination of ART and ABC campaigns and ART and treatment of other STDs are the most cost-efficient interventions through 2020. The main model limitations include modeling the complexity of sexual relationships, omission of international migration and ignoring variability in infectiousness according to the AIDS stage.The fourth part reviews the major contributions of the thesis and discusses model generalizability and flexibility. Finally, we conclude that by selecting the adequate interventions mix, policy makers can significantly reduce the adult prevalence in Botswana in the coming twenty years providing the country and its donors can bear the cost involved.Part I: Context and literature reviewIn this section, after a brief introduction to the general literature we focus in section two on the key mathematical concepts describing the transmission of infectious agents in general with a focus on HIV transmission. Section three provides a description of HIV policy models, with a focus on deterministic models. This leads us in section four to envision the need for a generic deterministic HIV policy model and briefly describe the structure of such a generic model applicable to countries with generalized HIV/AIDS epidemic, also defined as pattern II countries by the WHO.

La Prevenció de la mutilació genital femenina a través del treball comunitari

Aquest treball de pràcticum pretén, a partir de l’anàlisi de la pràctica que hi ha tant a nivell de comarca del Baix Empordà com a nivell d’experiències a més generals, fer una proposta d’actuació a l’hora de prevenir la mutilació genital femenina mitjançant el treball comunitari com a eina d’intervenció preventiva i generadora d’espais de relació, que permeti treballar amb i per a la comunitat fent-la, així, responsable i participativa del propi procés de canvi. Té la voluntat de ser un recurs útil i generadora de noves idees d’actuació

Mutilations génitales féminines: l'adolescente en quête de réponses [Female genital mutilation: need for answers at the age of adolescence]

En Suisse, le nombre de filles et de femmes migrantes excisées au cours de leur enfance dans leur pays d'origine ou menacées de mutilations génitales rituelles est estimé à 6-7000. Les professionnels de la santé en tant qu'interlocuteurs privilégiés doivent donc être en mesure de répondre aux questions y relatives, non seulement durant l'adolescence, mais aussi dans toutes les phases de la vie. L'absence d'information ou de transmission par des aînées aussi bien avant l'excision qu'au moment de la maturité sexuelle en fait souvent un événement biographique traumatisant. Arrivées en Suisse, le décalage entre les attentes socioculturelles et familiales et le vécu individuel, influencé par le pays d'accueil, peut s'avérer particulièrement difficile à vivre pour les jeunes filles concernées. In Switzerland, the estimated number of survivors after traditional female genital mutilation in the country of origin or girls and adult women at risk is 6-7000. Health professionals must be able to respond adequately to their questions not only during adolescence but through out the different periods of life. The lack of information or transmission by the seniors as well before the excision as at the time of sexual maturity contributes in a large measure to the frequent biographic trauma. It can be very difficult for the girls to deal with the gap between socio cultural and family expectations and their individual life experience in Switzerland.

Cost-effectiveness of surgery in low- and middle-income countries: a systematic review.

BACKGROUND: There is increasing interest in provision of essential surgical care as part of public health policy in low- and middle-income countries (LMIC). Relatively simple interventions have been shown to prevent death and disability. We reviewed the published literature to examine the cost-effectiveness of simple surgical interventions which could be made available at any district hospital, and compared these to standard public health interventions. METHODS: PubMed and EMBASE were searched using single and combinations of the search terms "disability adjusted life year" (DALY), "quality adjusted life year," "cost-effectiveness," and "surgery." Articles were included if they detailed the cost-effectiveness of a surgical intervention of relevance to a LMIC, which could be made available at any district hospital. Suitable articles with both cost and effectiveness data were identified and, where possible, data were extrapolated to enable comparison across studies. RESULTS: Twenty-seven articles met our inclusion criteria, representing 64 LMIC over 16 years of study. Interventions that were found to be cost-effective included cataract surgery (cost/DALY averted range US$5.06-$106.00), elective inguinal hernia repair (cost/DALY averted range US$12.88-$78.18), male circumcision (cost/DALY averted range US$7.38-$319.29), emergency cesarean section (cost/DALY averted range US$18-$3,462.00), and cleft lip and palate repair (cost/DALY averted range US$15.44-$96.04). A small district hospital with basic surgical services was also found to be highly cost-effective (cost/DALY averted 1 US$0.93), as were larger hospitals offering emergency and trauma surgery (cost/DALY averted US$32.78-$223.00). This compares favorably with other standard public health interventions, such as oral rehydration therapy (US$1,062.00), vitamin A supplementation (US$6.00-$12.00), breast feeding promotion (US$930.00), and highly active anti-retroviral therapy for HIV (US$922.00). CONCLUSIONS: Simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMIC. We recommend an investment in surgical care and its integration with other public health measures at the district hospital level, rather than investment in single disease strategies.

Carcinoma superficial multifocal do pênis: ênfase ao teste do azul de toluidina

The author reports a case of penile multifocal superficial carcinoma in a white 66 years old male. The lesions on glans penis and prepuce were asymptomatic. Their appearence were plain reddish ulceration, irregular margins which became evident after circumcision. There was no palpable groin lymph node. The toluidine blue test was useful for guiding biopsies. A partial penectomy was undertaken with free surgical margins of tumor. In a follow-up of two years, penil erectile function is preserve with no tumor recurrence.

Mistä on hyvät tytöt tehty? Somalitytöt ja maineen merkitykset

Tutkimus käsittelee islaminuskoisten somalityttöjen hyvään ja huonoon maineeseen liittyviä uskonnollisia, kulttuurisia ja etnisiä määrittelyjä ja niiden merkityksiä heidän arjessaan. Turussa hankittu etnografinen tutkimusaineisto koostuu osallistuvaan havainnointiin perustuvasta kenttäpäiväkirja-aineistosta sekä kahdestakymmenestäviidestä 17‒35-vuotiaiden somalityttöjen ja -naisten teemahaastattelusta vuosilta 2003–2006. Tutkimuksen tehtävänä on selvittää, minkälaista somalityttöä pidetään maineeltaan hyvänä ja miten tytön maine voi mennä. Tutkimuksessa tarkastellaan yhtäältä sitä, mikä merkitys sosiaalisilla verkostoilla on tyttöjen maineen määrittelyssä. Toisaalta kysytään, mitä somalitytöt ja nuoret naiset itse ajattelevat tytön maineeseen liittyvistä odotuksista ja miten he niistä tietoisina toimivat. Lähestymistapa rakentuu uskontotieteen, antropologian, sukupuolentutkimuksen, tyttötutkimuksen, nuorisotutkimuksen ja kulttuurimaantieteen näkökulmia yhdistelemällä. Ensimmäisessä aineistontulkintaluvussa tarkastellaan tyttöyteen ja maineen rakentumiseen liittyvää ruumiillista merkityksenantoa pukeutumisen, seksuaalisuuden, tyttöjen ympärileikkausta koskevan asennemuutoksen ja seurustelun teemojen kautta. Toisessa luvussa keskitytään kaupunkitilan ja tyttöjen vapaa-ajanvieton sosiotilallisiin tulkintoihin sekä tyttöjen käytöstä kodin ulkopuolella määritteleviin ja mainetta rakentaviin puheisiin. Haastatellut arvostivat islamiin ja somaliperinteeseen liittyviä arvoja ja pitivät niitä oman käytöksensä ohjenuorina. Omanarvontunto, itsekontrolli ja vastuuntunto omista teoista liitettiin ”hyvään tyttöyteen”. Tyttöjen toimijuus ilmeni heihin kohdistuvien odotusten suuntaisena käyttäytymisenä ja näiden ihanteiden arvostamisena. Toimijuus näkyi myös tiettyjen tyttöihin ja poikiin kohdistuvien erilaisten odotusten kyseenalaistamisena ja joissakin tapauksissa vastoin odotuksia toimimisena. Turkua myös verrattiin somalityttöjen käytöksen osalta pääkaupunkiseutuun. Tässä vertailussa Turku nimettiin kulttuurisen jatkuvuuden, pääkaupunkiseutu kulttuurisen muutoksen paikaksi. Haastateltujen mukaan yhteisöllisiä tulkintoja tyttöjen käytöksestä tehtiin puheissa ja juoruissa, usein suhteessa havaintoihin suomalaistyttöjen käytöksestä. Tyttöjen arkeen nämä etniset ja moraaliset eroteot eivät kuitenkaan vaikuttaneet aina samalla tavoin, koska tulkinnat tyttärille sopivasta ja mahdollisesta käytöksestä voivat vaihdella perheiden välillä. Tutkimus tuo esille, että tytön hyvä maine on eräs perheen hyvinvointiin vaikuttavista tekijöistä. Somalityttöjen käytös on myös eräs yhteisöllinen peili, jota vasten tehdään laajempia tulkintoja somalikulttuurin ja uskonnollisten arvojen tilasta diasporassa. Liiallinen muutos tyttöjen käyttäytymisessä uhkasi yhteisöllistä jatkuvuutta ja uskonnolliskulttuuristen arvojen välittymistä seuraaville sukupolville. Laajasti ymmärrettynä ”hyvä tyttöys” ja hyvä maine oli onnistuneen kulttuurisen neuvottelun tulosta diasporassa. Se tarkoitti, että tyttö kiinnittyi somalialaiseen taustaansa ja sen välittämiin arvoihin, osallistuen samalla kuitenkin myös suomalaiseen yhteiskuntaan.

La transmission religieuse et culturelle au sein de familles maghrébo-québécoises à Montréal

Cette recherche porte sur la transmission religio-culturelle aux enfants de couples maghrébo-québécois islamo-chrétiens à Montréal. À la suite de l’analyse de 10 entrevues semi-directives réalisées auprès de couples parentaux, nous tenterons de répondre aux questions suivantes : Quelle appartenance religieuse les parents veulent-ils transmettre à leur(s) enfant(s) ? Comment se manifestent leurs choix dans leur pratique religieuse ? Quels compromis les parents font-ils pour l’équilibre familial et identitaire de leur(s) enfant(s) ? Comment légitiment-ils leurs choix parentaux ? Afin de répondre à ces questions, nous nous sommes donné les objectifs spécifiques suivants : 1) documenter les choix des parents concernant la transmission religio-culturelle aux enfants; 2) cerner les façons dont les pratiques et les croyances religieuses des parents influencent leurs choix; 3) expliquer en quoi ces choix se manifestent dans leurs pratiques rituelles avec les enfants; 4) dégager les légitimations que les parents font vis-à-vis de leur choix de transmission. Les résultats de notre recherche ne nous ont pas permis de trouver une logique de transmission qui s’applique à tous nos parents. Cependant, nous retenons que les enfants de notre échantillon sont identifiés par leurs parents soit comme musulmans (5 familles sur 10) soit sans religion (5 familles sur 10). Aucun couple n’a choisi, en effet, le catholicisme pour leur enfant, et ce, même dans le cas où le conjoint catholique est pratiquant. À l’aide des choix parentaux concernant plus particulièrement le rite de la circoncision et la célébration des principales fêtes religieuses, nous dégageons quelques points d’ancrages communs face à la transmission symbolique. Quelle que soit la position du parent musulman face à la religion (pratiquant, non pratiquant, athée), celui-ci reste profondément attaché au rite de la circoncision pour son enfant dans un souci de transmission culturelle. La transmission biculturelle où les fêtes des deux lignées sont célébrées en famille est la plus pratiquée.

La incidencia del Fondo de Población de las Naciones Unidas en la abolición de la ablación femenina en la comunidad Emberá Chamí de Risaralda (2007-2012). Una disyuntiva entre derechos humanos y derechos culturales

La ablación femenina es una problemática a nivel mundial. En Colombia se "descubrió" que se realizaba la práctica hasta 2007. Lo que el Estudio de Caso plantea es la disyuntiva que la autora ve al estudiar la ablación entre los derechos humanos y los derechos culturales.

Análisis de la ayuda oficial al desarrollo. estudio de caso: programa conjunto de UNICEF y UNFPA sobre la mutilación genital femenina en Kenia (2008-2012)

El interés de este estudio de caso es analizar el Programa Conjunto de UNFPA y UNICEF sobre MGF/E en Kenia bajo la luz de los postulados poscolonialistas. Partiendo de la idea de que la MGF es una manifestación de las desigualdades de género, se argumenta que el PC reproduce la imagen de la mujer keniana como una víctima del poder masculino. A partir de esta imagen se deslegitima el orden cultural de los grupos que siguen esta tradición, afectando las lógicas de unidad y cohesión de la sociedad. El análisis de este tipo de dinámicas permite comprender mejor los procesos de intervención de las organizaciones internacionales sobre las estructuras sociales de actores frágiles del sistema internacional.

Sexual blinging of women : Alice Walker's african character tashi and issue of female genital cutting

This thesis provides a reading of the different forms of representation that can be attributed to the character Tashi, the protagonist of the novel Possessing the Secret of Joy (1992), written by the African American writer Alice Walker. Before this work Tashi had already appeared in two previous novels by Walker, first, in The Color Purple (1982) and then, as a mention, in The Temple of My Familiar (1989). With Tashi, the author introduces the issue of female circumcision, a ritual Tashi submits herself to at the beginning of her adult life. The focus of observation lies in the ways in which the author’s anger is transformed into a means of creative representation. Walker uses her novel Possessing the Secret of Joy openly as a political instrument so that the expression “female mutilation” (term used by the author) receives ample attention from the media and critics in general. The aim of this investigation is to evaluate to what extent Walker’s social engagement contributes to the development of her work and to what extent it undermines it. For the analysis of the different issues related to “female genital cutting”, the term I use in this thesis, the works of feminist critics and writers such as Ellen Gruenbaum, Lightfoot-Klein, Nancy Hartsock, Linda Nicholson, Efrat Tseëlon and the Egyptian writer and doctor Nawal El Saadawi will be consulted. I hope that this thesis can contribute as an observation about Alice Walker’s use of her social engagement in the creation of her fictional world.

Postectomia com dispositivo plástico versus postectomia convencional para circuncisão em crianças: revisão sistemática e metanálise

Pós-graduação em Bases Gerais da Cirurgia - FMB

Protease-inhibiting, molecular modeling and antimicrobial activities of extracts and constituents from Helichrysum foetidum and Helichrysum mechowianum (compositae)

Background Helichrysum species are used extensively for stress-related ailments and as dressings for wounds normally encountered in circumcision rites, bruises, cuts and sores. It has been reported that Helichysum species are used to relief abdominal pain, heart burn, cough, cold, wounds, female sterility, menstrual pain. Results From the extracts of Helichrysum foetidum (L.) Moench, six known compounds were isolated and identified. They were 7, 4′-dihydroxy-5-methoxy-flavanone (1), 6′-methoxy-2′,4, 4′-trihydroxychalcone (2), 6′-methoxy-2′,4-dihydroxychalcone -4′-O-β-D-glucoside (3), apigenin (4), apigenin-7-O-β-D-glucoside (5), kaur-16-en-18-oic acid (6) while two known compounds 3,5,7-trihydroxy-8-methoxyflavone (12), 4,5-dicaffeoyl quinic acid (13) together with a mixture of phytosterol were isolated from the methanol extract of Helichrysum mechowianum Klatt. All the compounds were characterized by spectroscopic and mass spectrometric methods, and by comparison with literature data. Both extracts and all the isolates were screened for the protease inhibition, antibacterial and antifungal activities. In addition, the phytochemical profiles of both species were investigated by ESI-MS experiments. Conclusions These results showed that the protease inhibition assay of H. foetidum could be mainly attributed to the constituents of flavonoids glycosides (3, 5) while the compound (13) from H. mechowianum contributes to the stomach protecting effects. In addition, among the antibacterial and antifungal activities of all the isolates, compound (6) was found to possess a potent inhibitor effect against the tested microorganisms. The heterogeneity of the genus is also reflected in its phytochemical diversity. The differential bioactivities and determined constituents support the traditional use of the species. Molecular modelling was carried out by computing selected descriptors related to drug absorption, distribution, metabolism, excretion and toxicity (ADMET).

Health and Growth: Causality through Education

Purpose--The paper theoretically and empirically investigates the impact on human capital investment decisions and income growth of lowered life expectancy as a result of HIV/AIDS and other diseases. Design/methodology/approach--The theoretical model is a three-period overlapping generations model where individuals go through three stages in their life, namely, young, adult and old. The model extends existing theoretical models by allowing the probability of premature death to differ for individuals at different life stage, and by allowing for stochastic technological advances. The empirical investigation focuses on the effect of HIV/AIDS on life expectancy and on the role of health on educational investments and growth. We address potential endogeneity by using various strategies, such as controlling for country specific time-invariant unobservables and by using the male circumcision rate as an instrumental variable for HIV/AIDS prevalence. Findings--We show theoretically that an increased probability of premature death leads to less investment in human capital, and consequently slower growth. Empirically we show that HIV/AIDS has resulted in a substantial decline in life expectancy in African countries and these falling life expectancies are indeed associated with lower educational attainment and slower economic growth world wide. Originality/value--The theoretical and empirical findings reveal a causal link flowing from health to growth, which has been largely overlooked by the existing literature. The main implication is that health investments, that decrease the incidence of diseases like HIV/AIDS resulting on increases in life expectancy, through its complementarity with human capital investments lead to long run growth..

Sexually transmissible diseases, sexual factors and prostate cancer: A review of literature

A review of literature was carried out regarding sexually related factors, sexually transmissible diseases (STD's) and infections with prostate cancer (PC) development risk. The review of literature, in conjunction with the tabulation of studies, suggested that ejaculation and circumcision may play a protective role in the development of PC and that multiple sex partners and an active sex life may play a causal role in the development of PC which may negate and counteract the protective effects of ejaculation and circumcision. HIV infection may plausibly play a function in deteriorating and compromising immune controls on carcinogenesis. Because of the coexistence of a highly active sexual lifestyle and sexual promiscuity with the growing occurence of STD's, their maybe a correlation with the high incidence of prostate cancer in the United States. Potential multi-institutional studies are warranted to confirm the high incidence of this neoplasm with the increasing cases of STD's and if in fact there is a proportional association to further elucidate the factors responsible for its high incidence.^