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Last week the CDC Advisory Committee on Immunization Practices voted to change the status of the male human papillomavirus (HPV) vaccination from permissive to routine. HPV is the most common sexually transmitted infection (STI) in the U.S.; it is also the main cause of cervical cancer, and research suggests it is the leading cause of other forms of cancer. The HPV vaccine, which is widely marketed for female adolescents, has been approved for males since 2009. However, HPV vaccination rates are low among female adolescents in theU.S. and even lower among males. It is estimated that only 1% of males in theU.S. have been vaccinated. The advisory committee is recommending that the vaccine become standard for all boys ages 11 and 12 and is advising the vaccination of young men ages 13 to 21 who have not yet received the vaccine.
Globally, the highest rates of STIs occur among youth (ages 15-24) and approximately 25% of young women under 24 years old have been infected with HPV. HPV is responsible for almost all cases of cervical cancer, 95% of anal cancer cases, 50% of all vulvar cancer cases, and 60% of all head and neck cancer cases. The previous focus of HPV vaccination campaigns on females sent the message that HPV is a single-sex issue, however these cancers affect both males and females. Expansion of the vaccination recommendations to include boys will help to change the public perception of the infection as one that mainly affects females to one that has negative effects on everyone. The change in the recommendation will likely lead to greater uptake among young men, not only protecting them from HPV-related cancers, but also helping them to prevent the spread of HPV to their partners.
October 16 was World Food Day. Worldwide, 925 million people do not have enough to eat, and 98% of those who are affected by food insecurity live in developing countries. The UN’s Food and Agriculture Organization estimates that in 2009, approximately 1 billion people worldwide were undernourished. While nutrition and food insecurity are not often discussed in the context of youth sexual and reproductive health, food insecurity has devastating effects on the lives of adolescents and can exacerbate many negative and sexual reproductive health outcomes among this age group.
Globally, adolescent females are at a greater risk of poor nutrition than adolescent males. According to this year’s State of the World’s Children Report, Adolescence in an Age of Opportunity, there is “a considerably higher incidence of anemia among female adolescents aged 15–19 as compared to their male counterparts.” In some countries, as many as half of the girls between the ages of 15 and 19 are anemic, and many more are underweight. The highest prevalence of underweight adolescent girls is inIndia, where 47% of girls are underweight. The implications of hunger for adolescent girls are serious, beyond the obvious health-related repercussions. For example, in developing countries, where many girls face high rates of early marriage and unintended pregnancy, poor nutrition increases the risk of maternal death or morbidity.
Food insecurity also has important implications for HIV prevention. According to OVC Support.net, lack of food security may lead to:
- Increased sexual risk-taking behavior, including transactional sex or intergenerational sex
- Increased school dropout
- Increased stress on traditional support networks
The effects of hunger on adolescents can be far-reaching, and the prevalence of poor nutrition among this age group puts young people at a greater risk of negative sexual and reproductive health outcomes. In honor of this year’s World Food Day, spread the word about the link between hunger and adolescent sexual and reproductive health and consider making a donation to your local food bank.
To learn more about World Food Day, visit the Food and Agriculture Organization of the United Nation’s World Food Day web page.
This is part two of a posting by Laura Engelman, an intern for the Male Circumcision Consortium at FHI 360. You can read part one here.
Some of the tensions that can arise when MMC is introduced were felt in Kenya when a national VMMC program was launched there. FHI 360 works closely with the Government of Kenya (GoK) on its national VMMC program. This program, launched in November 2008, focuses primarily on Nyanza Province, which has the highest HIV rates in Kenya coupled with the lowest rates of MC. The Kenya VMMC program shines light on the value of community-building and open dialogue when discussing controversies involving MMC.
In order to quell fears about MMC among skeptics of the intervention, GoK officials and the program’s partners held two large forums in Kisumu, Kenya before the official launch of the campaign. Community members and stakeholders at these forums voiced concerns over introducing the medical intervention in a traditionally non-circumcising community. Through honest discussion and a thorough presentation of the facts and the positive randomized control trial results, the GoK and their partners reassured the community leaders that circumcision is a strictly medical, rather than cultural, intervention. Reframing it in this way led to the community’s acceptance and endorsement for the medical procedure.
Similarly, discussing the medical benefits of the procedure with stakeholders in communities that practice traditional circumcision as a rite of passage for adolescents is important in reassuring concerned community members. In these communities, partners are exploring ways in which traditional MC can be made safer. There is also discussion about how other rituals can be combined with medical circumcision so that a rite of passage ritual survives. In addition to community discussion about the procedure, peer-to-peer communication also helps to allay fears about the procedure. One adolescent in Kenya reported that the youth in his community thought of traditional circumcision as a “brutal” practice until one of their friends underwent MMC. After hearing from the trusted friend that the procedure did not hurt, other boys his age opted for the medical intervention.
Adolescents throughout sub-Saharan Africa undergoing MMC receive counseling along with “the cut.” Counseling must be tailored to an adolescent audience to reinforce the idea that MMC is only partially protective from HIV and that other protective behaviors, such as correct and consistent condom use, must also be employed. Counseling must discourage sexual disinhibition after undergoing MMC. Circumcision only provides men with partial protection from HIV and is by no means a free pass to engage in unsafe sex. Though medically circumcised men are 60% less likely to contract HIV from an HIV-positive woman, it is imperative that these men do not counteract the benefits of MMC by engaging in risky sexual behavior. MMC should be viewed as part of a comprehensive HIV prevention package that includes use of condoms, regular testing for STIs and HIV, open communication about sexual behavior and sexual health, and reducing the number of sexual partners.
Through research, communications efforts, and collaboration with other organizations, FHI 360 is working to improve and expand access to safe, VMMC services in sub-Saharan Africa. Kenya’s national VMMC program is the most comprehensive to date and has led the way for others to engage in national VMMC scale-up programs as well.
Laura Engelman is an intern for the Male Circumcision Consortium at FHI 360, where she collaborates with a team to conduct research and apply findings on male circumcision as a biomedical tool in the fight against the spread of HIV in sub-Saharan Africa. In this two-part piece, she discusses the benefits of and controversies surrounding medical male circumcision.
Voluntary medical male circumcision (VMMC) has been proven to reduce men’s risk of HIV acquisition and is recommended as part of a comprehensive HIV prevention strategy for communities heavily affected by HIV and with low rates of male circumcision. Three randomized controlled trials (RCTs) conducted in Kenya, South Africa, and Uganda (published between 2005 and 2007) showed overwhelming evidence in favor of male circumcision as a risk reduction strategy against female to male HIV transmission. These studies found that removing the foreskin of the penis, where HIV receptor cells thrive, reduces a man’s chances of contracting HIV through vaginal sex by approximately 60 percent.
VMMC is especially important for males in their late teens and early 20s as many men in this age group have recently or will soon become sexually active. Also, because many men in this age group are not yet married, they may have multiple sexual partners. Furthermore, adolescents might not yet have learned ways to reduce their risk of acquiring HIV or other sexually transmitted infections. The counseling component of a comprehensive package of MC services is thus especially relevant for adolescents.
Medical male circumcision (MMC) does sometimes raise some controversial questions and concerns, particularly in regards to adolescents. For example, many non-circumcising communities view MMC as an affront on their cultural traditions. Other communities hold circumcision sacred as a rite of passage or religious tradition and do not want this ancient ritual taken over by medical professionals.
Whereas infant Jewish males are typically circumcised on their eighth day, Muslim boys can undergo the procedure anytime between birth and puberty. In many sub-Saharan African communities, circumcision is not performed for religious reasons but rather as a cultural rite of passage for adolescents. Combined with other rituals meant to test maturity, strength, and wisdom, circumcision represents a passage from boyhood into adulthood. This traditional circumcision, however, oftentimes involves only a small cut to or partial removal of the foreskin and may not effectively reduce the risk the HIV acquisition. Furthermore, these traditional circumcision ceremonies can be associated with unsafe practices and negative health outcomes.
On Monday, September 12, we will post part two of this piece, which illustrates how community concerns over VMMC can be allayed and how community members become valuable advocates of the procedure.