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At Staten Island University Hospital, our physicians have earned a reputation
for excellence and innovation in education,
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exceptional teams of nurses, technicians,
clinicians and support staff that deliver
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Staten Island University Hospital provides complete medical
and surgical services in inpatient and outpatient
settings at both our North and South site locations.
Read on to learn more about the full range of
services offered at SIUH, including
locations, contact information
and descriptions of programs.
At Staten Island University Hospital, we strive to provide
the best health care for our patients. We also seek
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That's why we provide many helpful
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Would you like to visit someone who is a patient at Staten Island University Hospital? If so, we welcome you. Family and friends
can play a key role in the healing process
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Staten Island University Hospital is part of the Staten Island community. In addition to providing state-of-the-art healthcare services, we educate our
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Providing quality health care for our patients is our greatest priority.
In order to do this, our hospital family is committed
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We provide accredited training and
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Primary Care II - Geriatrics
The curriculum ensures a foundation for competent compassionate care of older patients. It is focused on acquiring proficiencies in the attitudes, knowledge and skills needed for elder care. The goals include:
An appreciation of the heterogeneity of the aging population in terms of values, ambition, capabilities and personalities
An understanding of the importance of optimizing function for older patients, rather than an exclusively disease focused approach
An empathy towards issues related to death and dying including the principles of palliative care
A recognition of the essentially interdisciplinary nature of caring for the biopsychological needs of older patients.
Proficiency in knowledge will encompass an overview of the basic science of normal and abnormal aging as well as the essentials of clinical geriatrics. Knowledge and experience will be gained of the common geriatric syndromes including altered mental status, iatrogenesis, mobility including falls, sensory deficits, failure to thrive, sleep disorders, pressure ulcers, incontinence and non-specific presentation of disease. Risk reduction and preventive care will be emphasized. Also, emphasis will be placed on health promotion and disorder prevention of importance to the elderly as well as the ethical, legal, humanistic and financial aspects of geriatric care including advanced directives, decision-making capacity and end-of-life care.
The skills to be learned focus on geriatric assessment using standardized methods for assessing physical, cognitive, emotional and social functions as appropriate. These include screening for mental status, depression, functional status including mobility assessment, activities of daily living and instrumental activities of daily living.
There is no final examination in this clerkship. Grading is pass, high pass, honors or fail. To achieve honors, an honors project is required.
The Clerkship includes a lecture series on Palliative Care with emphasis on the EPEC Curriculum, a site visit to Calvary Hospital and direct clinical experiences at the individual sites. A palliative care website is available for student participation and will be an additional requirement for completion of this segment.
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Anybody have a pair of Momotaros? I just ordered some 0201's from BIG because I've seen the denim in person and it is some of the best I've seen. Even on sufu they aren't that popular so I doubt many, if anyone on here has some. http://blueingreensoho.com/site/inde...mart&Itemid=28
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8/7/09 at 12:57am
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subset: commoncrawl


text:
Charles Zwick
Speaker: Charles J. Zwick
Date: April 25, 1969
After extensive experience in consulting for a wide spectrum of federal organizations, Charles Zwick was involved in studies in Southeast Asia ? first for the AID and then for an economic assistance program in Vietnam (1964-1965) ? working for the Department of State, the White House, and the Department of Defense. Zwick was associated with the Bureau of the Budget and discusses his experience with reforming government organization at the federal level.


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The Emery County Progress office will be closed during the morning on April 3, for a training in Price. Please take any submissions to Dr. Tuttle's office.
Camp Dale DUP will host its montly meeting on April 14 at 1 p.m. at the Castle Dale Senior Citizen's Center.
April 10 will be youth protection training at 7 p.m., all leaders need this, Round Table at 7:30 p.m., Webelos leader outdoor training, both will be held in the Castle Dale Stake Center.
Habitat for Humanity is reselling the Wellington home. Deadline for application is April 15. For information call Sylvia at 687-9184 or the Habitat office at 636-3230.
Emery High Rodeo Team will host its annual high school rodeo April 18-19. They are looking for students interested in joining the team, anyone wishing to make a donation or to help sponsor the team. They will also be having a raffle, items to be raffled are on display at Ream's in Price. For more information, call Evelyn at 653-2413.
The Emery County Community Theater production of Joseph and the Amazing Technicolor Dreamcoat will be performed April 10-11-12 and 14 at the Emery County High School beginning at 7 p.m. Box office opens at 6:30 p.m.
The Canyonlands Field Institute and Elderhostel International are offering three programs this summer to active adults 55 and up. Arches National Park, May 31-June 5; Colorado River Rafting and Hiking, July 12-17; and San Juan Mountains Hiking with Llama Support, April 12-19. For all program information, visit the website www.canyonlandsfieldinst.org. or to register call Elderhostel at 877-426-8056.
If you snore, feel tired, fatigued or not quite up to par, sleep apnea may be your problem. Dr. Nicholas, Director of Castleview Hospital Sleep Disorder Clinic, and Dr. Peterson, ENT, will be speaking at the Emery Medical Center, April 15 at 6 p.m. At 5 p.m., community members can get their oxygen levels checked by Praxair and Woodwards Homecare.
The Emery County Archives is looking for your stories of service in the CCCs. To commemorate the 70th anniversary of the CCCs, the archives would like to assemble the stories of those either from this area who served or those who came here from other parts of the country. Please contact Shirley at the archives at 381-2671.
The Board of Utah State Parks and Recreation meets Apr. 2-4 in Vernal. The public is welcome to attend all or part of the meeting, which is scheduled at 7 p.m. April 2, and 8-10:30 a.m. on April 4 at Vernal City Hall located at 447 East Main Street.
One stop shopping for undecided students April 3 from 11:15 a.m. to 12:45 p.m. the College of Eastern Utah gives students the opportunity to get information on new majors, career counseling, career planning, course requirements, and academic services. For more information, contact the Academic Advising office at 613-5623 or 613-5311.
Brigham Young University's popular Family Expo is scheduled for April 7-8. Experts in all aspects of marriage and the family, parenting skills and Gospel-centered home life will give presentations during the Expo. To register call (801) 378-8925 or visit http://familyexpo.byu.edu. All lectures will take place at the BYU Conference Center located at 770 East University Parkway, northeast of the Marriott Center.
The American Legion Auxiliary, Ferron Unit 42 along wtih the San Rafael Piece Makers Quilting Guild would like to present those families who have loved ones serving in the military a Blue Star banner or poster to hang in their windows. It does not matter if the person is serving here in the US or abroad. Contact Jan Hess 384-2753, Dixie Swasey 384-3172, Carol Riddle 286-2453 after 6 p.m. (auxiliary) or Reva Fillmore 687-2649, June Maxwell at the Huntington Senior Center 687-2502 (quilting guild).
Huntington Heritage Days Rodeo Queen Contest will be held April 26 at 9 a.m. at the Huntington Rodeo Arena. Age groups; Lil Miss- 9 and under; Princess-10-14; Queen- 15 and up. Release forms necessary. For information, rules and forms call Beth, 687-2752.
Orangeville Pee-Wee league sign-ups will be held April 10, 3:30-5:30 p.m. at the Orangeville City Hall for ages 4-7. For more information call 748-2741 or 748-2444.
Off Highway Vehicle class will be held April 8 at 7 p.m. at the Emery County Recreation Center, 75 South 400 East in Castle Dale. Children ages 8-15 must be certified to operate ATVs on public lands. For more information contact Emery Rec, 381-2108 or Mark H. Williams, 381-2493.
Applications are being evaluated for the Ten Star All Star Summer Basketball Camp. The camp is by invitation only. Boys and girls ages 10 through 19 are eligible to apply. Past participants include Michael Jordan, Tim Duncan, Vince Carter, Jerry Stackhouse, Grant Hill, and Antawn Jamison. College basketball scholarships are possible for players selected to the All-American Team. For a free brochure call (704) 373-0873 anytime.
July 3-8, the Canyonlands Field Institute will host a river trip and writing workshop for five days of instruction, critique and private time for your writing. The river trip feature serene floats as well as rapids through Westwater Canyon. For more information or to register call 800-860-5262 or visit www.canyonlandsfieldinst.org.
Registration is now underway for all summer sports and dance camps at Brigham Young University. To receive a full listing of camps and workshops or to register, visit http://sportscamps.byu.edu or call 801-378-4851.
Season opening will be April 1. Schedule: Open swim-Monday and Wednesday from 4-7 p.m. and Saturdays noon-7 p.m. Family Night Monday from 7-9 p.m. Aquasize Monday-Friday from 8-9 a.m.
"Clued Into Reading" Castle Dale Elementary's book fair will be April 9 from 8:30 a.m.-3 p.m. and 6:30 p.m.-8 p.m., April 10 from 8:30 a.m.-3 p.m. and April 11 from 8:30a.m.-3 p.m. Dads and Donuts will be April 11 at 7:30 a.m.
The Rocky Mountain School of Baseball is accepting applications for the spring Super League 2003 season. Deadline for registration is April 1. The age divisions are as follows: 8-9, 10-u, 11-u, 12-u, 13-u, 14-u, and 15-u. For more information log on to www.rmsbb.com or call toll free, 1-877-272-0862.
Texas Mission 1967-1970 Pres. E.C. Howe Reunion April 4 at Taylorsville North Stake Center, 1250 West Atherton Drive, Taylorsville, 6 p.m. refreshments, 7:15 p.m. program. To Atherton Drive go to 4500 South; go west to approximately 4400 West, turn on to Atherton Drive. For information call 801-266-0915.
A Field Service Officer from the Veterans of Foreign Wars, Department Service Office in Salt Lake city, will be in your area to assist you in understanding and applying for rightful VA benefits. The VFW Officer will be working out of Price Workforce Service Center from 8:30-10:30 a.m on April 10.
The Utah AHEC program at Southern Utah University is looking for high school students interested in pursuing a health care career. On June 16-18, AHEC will host their fifth annual Health Career Exploration Camp on the campus of SUU. All high school students are welcome to attend. The registration fee includes housing, meals, workshop activities and a T-shirt. For more information or to receive an application, contact Carrie Torgersen at 435-638-7449 or email@example.com. A registration application can also be printed off the internet by visiting www.ahec.suu.edu.
College of Eastern Utah Alumni Association announces that there are two tuition scholarships available through the Alumni Association for the 2003-04 school year. These scholarships are made possible through proceeds from the CEU Alumni Wildman Golf Tournament held last fall. Applications and informational brochures are available at the counselors office at Emery High. The application deadline is April 1.
The Utah Shakespearean Festival's "Shakespeare-in-the-Schools" program will present its touring production of Romeo and Juliet April 15 at the Price Civic Auditoruim. The performance is sponsored by the Price City Culture Connection and the Carbon School District and is free to the public.
The Utah State Division of Veterans Affairs service officers will travel twice a month to assist veterans in the rural and outlying areas including the Price office. To find out when they will be in your area please contact The Utah Division of Veterans Affairs at 1-800-894-9497.
The Emery Company and County Camps of the Daughters of the Utah Pioneers are looking for young women that are eligible to compete in the Days of '47 Queen Pageant. You must be at least 18 years of age and have pioneer ancestors that came to Utah before 1869. If anyone is interested please contact Karen Huntsman at 381-5445 or any of the captains of the Emery County camps for further details.
If you are 45 years old or older and love to compete in sports activities, the Mesquite Senior Games are for you. The games will be held April 28-May 4 and present twelve sports for competition; basketball, tennis, golf, softball, bowling, fun walk, sporting clays, archery, horseshoes and track and field. For more information and to register, call 702-346-0244, or log on to www.mesquiteseniorgames.com.
Are you prepared for a terrorist attack in your community? If not, information in a new booklet might help. The New Era Survival Research Institute has published "Survival Resource Guide for a Nuclear, Biologic or Chemical Attack." The booklet gives information about what to do to improve personal safety in the event of a terrorist attack. For additional information call (202) 882-9000 or visit www.newerasurvival.org.
Through our hotline and website we offer free assessments and over 11,000 local referrals. If you or someone you know has a drug or alcohol addiction call Narconon today at (800) 468-6933 or email us at www.stopaddiction.com.
Residents wishing to have photos displayed during this event, please contact Mary Dickerson at 637-0964.
Retired and Senior Volunteer Prorgam we need you! If you are 55 of older and have time to serve your community call now. We are looking for seniors who would like to go to the schools and help with students. We are looking for seniors who would like to crochet booties and hats for babies in our hospitals. If you have time on your hands, even an hour a week we can use you. Call Laurie or Betty at RSVP 381-2765. Our hours are Tues.-Thurs., 11 a.m.-3:00 p.m.
New exhibit: Latter-day Saints Yesterday and Today, open through Labor Day; Primary Makes Me Happy: A Celebration of 125 Years of Primary is continuing. Museum hours: Mon.-Fri.-9 a.m.-9 p.m.; Sat., Sun. and most holidays-10 a.m.-7 p.m. For more information call 801-240-3310.
Apr. 15. Westminster College is open and Applied Technology Centers varies.
Students and parents may receive a full color publication on how to receive academic funding by sending an email to email@example.com and entering "Scholarship Information" in the subject line. The publication will automatically be sent to you. Those without computer acces can receive the publication by contacting NAFA, 188 Summer Street, Dept. 13, Portsmouth, NH 03801.
On Jan. 8 President Bush signed a bill extending Unemployment Insurance benefits through May 31. This new extension does not grant additional weeks for individuals who have exhausted their Temporary Extended Unemployment Compensation eligibility. To file for unemployment benefits, phone 1-888-848-0688. Claimants can also file for benefits on-line at jobs.utah.gov.
American Firefighter Today is an online news and information publication developed for firefighters and rescue personnel. Visitors to www.americanfirefightertoday.com may explore the site for one month free.
Get the information you need from the new Federal Citizen Information Center, formerly the Federal Consumer Information Center. When you need information on the programs, services and benefits of the federal government, just call 1-800-333-4636 or visit www.FirstGov.gov and get the answers you can trust.
Competition will be held June 16-21 at the Assembly Hall on Temple Square with the Bachauer International Piano Festival preceding it June 7-14. Applications due Feb. 1 and include a recorded audition. Applicants must be 33 or older and not derive their principal income as professional musicians. For more information, visit www.bachauer.com or call (801) 297-4250.
Intermountain Health Care has introduced an online resource center for information about cancer and the treatment of cancer. Log on to www.ihc.com and click on the IHC Cancer Services link.
The Emery County Progress is requesting everyone who has brought in photos to be used in the newspaper to pick up those photos. The hours are 9 a.m. -5 p.m. Mon.-Fri.
The Utah Foster Care Foundation is encouraging Utahns to strengthen families by becoming foster parents. For more information call 1-877-505-KIDS or log on to the website at www.utahfostercare.org.
Annual Spring concert, Apr. 24-26, classical dance forms, Apr. 25-28, contemporary dance forms, CEU Geary Theater at 7:30 p.m.
AARP Tax-Aide, the nation's largest, free, volunteer run tax counseling and prepartation service is seeking volunteers of all ages who want to learn tax law and prepare tax returns for taxpayers of low-to-moderate income, with special attention to those over 60. Call toll-free 1-888-227-7669. When prompted, select Tax-Aide program and the select Volunteer Recruitment program. Leave your name and number. You will be contacted by a Utah Tax-Aide volunteer.
150 South 500 East
Chairperson, Anthony Beals
Programs are on Thursdays and begin at 7:30 p.m.
Apr. 10, David E. Bokovoy - One Eternal Round: A Survey of God's Plan of Happiness
Registration codes for this series: 23659-03adult season pass, 23659-04student season pass
Huntington Stake Center
11 East 200 North
Programs are on Fridays and begin at 7:30 p.m.
Apr. 11, David E. Bokovoy - Modern Revelation and the Ancient World
Registration codes for this series: 23659-03adult season pass,23659-04 student season
Our American Heritage Education Foundation is launching a nationwide effort to place fact-based historical information on the Vietnam War era in high schools.
High school or college educators need only to provide their name, phone, details of their course including student load, as well as a physical mailing address to receive a free package of materials. Included are VHS tapes, DVD set, a CD-rom, and a bound Educator Guide. E-mail requests to firstname.lastname@example.com. To find out more, call Kate at 1-800-536-5920.
Epilepsy is among the most common neurological conditions of childhood. Yet young people and their families often find that age-old stereotypes and misconceptions about it can be more difficult to cope with than the disorder itself. To provide support and information, the Foundation offers a toll free number, 1-800-338-1000 or visit the website at www.epilepsyfoundation.org.
The Three Wishes Program makes available to Senior Citizens (65 years old and up) and the permanently disabled, power wheelchairs at no cost to the recipient, if they qualify. The wheelchairs are provided to those who cannot walk and cannot self-propel a manual wheelchair in their home, and who meet the additional guidelines of the program. No deposit required. 1-800-451-0971 for more information or to see if you qualify.
Members of the Utah Arts Council's Board of Directors are available to speak to local groups about the importance of utilizing economic tools found in the arts to strengthen Utah communities. If your group is interested in learning more about how the arts are important to economic prosperity, contact Jerald Holyoak, 801-328-5047, or the Utah Arts Council at 801-236-7552 for more information.
A new Consumer Information Catalog is available at no cost. This catalog contains a variety of information to help save you money and answer your questions. It can be obtained by calling 1-888-8PUEBLO, that's 1-888-878-3256, weekdays 8 a.m. -8 p.m. ET., or visit www.pueblo.gsa.gov to order.
USDA has developed an internet website for producers of livestock that "need/have" hay, haying or grazing available. The website is located at www.fsa.usda.gov and has a quick link titled FSA HayNet. This is available to assist livestock producers in finding needed hay or grazing.
The In Home Rx Program makes available breathing medications and Nebulizers to patients who may have Asthma, Emphysema or COPD at no cost to the recipient, if they qualify. If you are an oxygen user at home or have severe problems with breathing conditions, please call for more information to see if you qualify. 1-800-344-5764 or visit the website www.inhomerx.com.
Bringing hope to single moms support group and self-reliance class now being offered in Castle Dale. Open to the public free of charge. It will be held on Thursday evenings from 7-8 p.m. There will be on site child care available with prior notice. The course offers self-reliance skills, recourses, skills on setting up a safety net and starting a new life plan. For more information call Jennifer at 381-2827 or Jackie at 637-5542.
Southeastern Utah District Health Department is offering a clinic for women between the age 40- 64. Get a private check-up by a female provider. Get a pap test and breast exam. Receive a free mammogram voucher. Women must meet age and income guideline to qualify for a free exam and mammogram. For more information call 381-2252.
Business hours for the Emery County Landfill are Tuesday-Friday., 9 a.m.-5:15 p.m. and on Saturday, 8 a.m- 4:15 p.m. Closed on Mondays. For questions call 381-2719.


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There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data.
Methods and Findings
We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion.
This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs.
Citation: Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, Heard N, et al. (2011) Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa. PLoS Med 8(11): e1001132. doi:10.1371/journal.pmed.1001132
Academic Editor: Stephanie L. Sansom, Centers for Disease Control and Prevention, United States of America
Received: May 26, 2011; Accepted: October 19, 2011; Published: November 29, 2011
This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Funding: This work was funded by PEPFAR (through the USAID Health Policy Initiative) and UNAIDS (through the Technical Support Facility (TSF)). Technical staff from USAID (EN, DC), CDC (JR), WHO (TF), and UNAIDS (CH) had a role in study design, data collection and analysis, decision to publish, and preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: ART, antiretroviral therapy; CDC, Centers for Disease Control and Prevention; DMPPT, Decision Makers' Program Planning Tool; MOVE, Models for Optimizing Volume and Efficiencies; PEPFAR, United States President's Emergency Plan for AIDS Relief; STI, sexually transmitted infection; UNAIDS, Joint United Nations Programme on HIV/AIDS; USAID, United States Agency for International Development; VMMC, voluntary medical male circumcision; WHO, World Health Organization
Editors' Summary
Every year, about 2.5 million people (mainly in sub-Saharan Africa) become infected with HIV, the virus that causes AIDS. There is no cure for HIV/AIDS. Consequently, prevention of HIV transmission is very important. Because the most common HIV transmission route is through unprotected sex with an infected partner, individuals can reduce their risk of HIV infection by abstaining from sex, by having only one or a few partners, and by using male or female condoms. There is also strong evidence that voluntary medical male circumcision (VMMC)—the removal of the foreskin, the loose fold of skin that covers the head of the penis—reduces the heterosexual acquisition of HIV in men by about 60%. In 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that VMMC should be offered to men as part of comprehensive HIV risk reduction programs in settings with generalized HIV epidemics and low levels of male circumcision. They also prioritized 13 countries in eastern and southern Africa for VMMC program scale-up.
Why Was This Study Done?
The impact of VMMC scale-up in terms of HIV infections and AIDS deaths averted (epidemiologic impact) is expected to be large, and the intervention should also reduce the costs associated with the treatment, care, and support of infected individuals. However, VMMC scale-up will require substantial funding and considerable effort by countries—many of which have weak health systems and limited resources—to train personnel, equip facilities, and provide the necessary commodities. To support planning for VMMC scale-up, the United States Agency for International Development Health Policy Initiative has collaborated with UNAIDS to develop the Decision Makers' Program Planning Tool (DMPPT), a mathematical model that allows analysts and decision makers to estimate the epidemiologic impact and cost of alternative VMMC scale-up programs. In this study, the researchers use DMPPT to estimate the impact and cost of scaling up adult VMMC in the 13 priority countries in eastern and southern Africa.
What Did the Researchers Do and Find?
The researchers derived VMMC unit costs for each priority country based on a cost assessment undertaken in Zimbabwe, one of the first countries to scale up VMMC services using WHO's "Models for Optimizing Volume and Efficiencies" (MOVE) guidelines. They fed these costs and recent epidemiologic data (including HIV infection rates and the effectiveness of VMMC in preventing HIV transmission) and demographic data (including the adult population size and pre-scale-up male circumcision prevalence) collected in each country into the DMPPT, together with information on the lifetime costs of HIV treatment. Results from running the DMPPT model suggest that scaling up adult VMMC to reach 80% coverage in the 13 priority countries by 2015 would require 20.33 million circumcisions to be completed between 2011 and 2015. To maintain this coverage, a further 8.42 million circumcisions would be required between 2016 and 2025. Such a scale-up would avert 3.36 million new HIV infections through 2025 and would cost US$2,000,000,000 between 2011 and 2025. However, it would result in net savings (because of averted treatment and care costs) of US$16,510,000,000.
What Do These Findings Mean?
These findings suggest that rapid VMMC scale-up in eastern and southern Africa is warranted, given its likely impact on the region's HIV epidemics and the resultant cost savings. However, the accuracy of these findings depends on the assumptions built into the DMPPT and on the data fed into it. For example, there could be risk behavior changes after circumcision. That is, risky sexual behaviors may increase in men who have been circumcised. However, the researchers show that, except in Rwanda, post-circumcision risk behavior change is unlikely to completely reverse the benefits of VMMC. These modeling results also assume that men seeking out VMMC services are typical of the general male population, but if they are actually at unusually low risk of HIV infection, then the benefits of VMMC reported here are likely to be overestimated. Finally, these findings assume 80% VMMC coverage. This may be optimistic, although results from Kenya indicate that this target is achievable. Thus, countries and their international partners must allocate sufficient resources to VMMC scale-up to achieve high coverage rates if they are to take full advantage of the benefits predicted here for VMMC scale-up.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001132.
- This study is part of a PLoS Collection of articles on http://www.ploscollections.org/VMMC2011 and is further discussed in a PLoS Medicine Review Article by Hankins et al. (http://dx.doi.org/10.1371/journal.pmed.1001127)
- Information is available from WHO, UNAIDS, and PEPFAR on all aspects of HIV/AIDS; the 2011WHO/UNAIDS progress report on VMMC scale-up in the 13 priority countries is available
- NAM/aidsmap provides basic information about HIV/AIDS, summaries of recent research findings on HIV care and treatment, and information on male circumcision for the prevention of HIV transmission
- Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on all aspects of HIV prevention, and on HIV/AIDS in Africa (in English and Spanish)
- The Clearinghouse on Male Circumcision, a resource provided by WHO, UNAIDS, and other international bodies, provides information and tools for VMMC policy development and program implementation, including information on the DMPPT and the MOVE guidance
- Personal stories about living with HIV/AIDS are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline
Three randomized controlled trials have shown that voluntary medical male circumcision (VMMC) reduces heterosexual HIV acquisition in men by up to 60% [1]–[3]. On the basis of these trial results, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) now recommend that VMMC be offered to heterosexual men in combination with other effective HIV risk reduction interventions in settings with generalized HIV epidemics and where a substantial proportion of men are not circumcised [4].
The long-term population-level impact of implementing and scaling up VMMC services is expected to be considerable in terms of HIV infections averted, as well as net savings associated with the reduced need for treatment, care, and support of infected individuals. Previous model-based studies estimated that VMMC scale-up in countries with generalized HIV epidemics could result in substantial reductions in HIV transmission and prevalence over time among both men and women [3],[5]–[9]. A recent review of these studies concluded that one HIV infection could be averted for every five to 15 VMMCs performed [10]. Modeling studies also have found that expansion of VMMC services produces net savings when compared to lifetime HIV treatment costs [8],[9],[11]. In addition, studies have shown VMMC to be protective against some other sexually transmitted infections (STIs) in both men and women. VMMC has been found to reduce the risk of herpes simplex virus-2 in men [12] and human papillomavirus in men [12]–[15] and their female partners [16], and is associated with a reduction in the risk of genital ulcer disease [3],[17] and genital cancers [18]–[20] in both men and women.
In light of this evidence, in early 2007, WHO and UNAIDS identified the following priority countries for VMMC scale-up: Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya (Figure 1). Four years later, most of these 13 countries have developed plans for VMMC scale-up and are at various stages of program implementation. However, with a few exceptions (e.g., Nyanza Province in Kenya and the Iringa Region in Tanzania), progress in expanding VMMC services remains slow [21].
For the 13 countries included in the study, the map on the left indicates the prevalence of HIV in adults ages 15 to 49 y. The map on the right indicates the percentage of men who are circumcised.
There is consensus that VMMC scale-up will require substantial funding and massive efforts to adequately train personnel, equip facilities, and ensure the regular distribution of necessary commodities—mostly in settings with weak health systems and resource constraints. As background for the scale-up of safe VMMC, WHO, UNAIDS, and collaborating partners have developed a number of guidelines and toolkits, including a recommended minimum package of VMMC services [22] and clinical guidelines for the provision of these services [23]. In addition, to facilitate a more rapid scale-up of safe VMMC, WHO has outlined considerations for models to optimize the volume and efficiency (MOVE) of VMMC services [24]. Central to these considerations is the efficient use of facility space through the dedication of multiple surgical beds to one surgical team and the coordination of client flow; the efficient use of staff time through task shifting and task sharing, including deployment of non-physicians to complete all or specific steps in VMMC surgery; and the bundling of commodities and supplies required to perform VMMC, including consumable materials and surgical instruments [24].
To support decision making and planning for VMMC scale-up, the United States Agency for International Development (USAID) Health Policy Initiative collaborated with UNAIDS to develop the Decision Makers' Program Planning Tool (DMPPT) [25]. This modeling tool, which has been reviewed by an expert panel [10], allows analysts and decision makers to estimate the epidemiologic impact and cost of alternative programmatic options for scaling up VMMC.
The objective of this study is to estimate the country-specific epidemiologic impact and the cost and net savings associated with scaling up VMMC services based on MOVE considerations in the 13 priority countries in eastern and southern Africa. The perspective that is taken is that of governments and their international partners in their roles as health program funders. To do this, we run country-specific DMPPT models and explore how the results for each country vary by VMMC effectiveness, VMMC coverage level, time to scale-up, level of post-circumcision behavior change, VMMC unit cost, and antiretroviral therapy (ART) cost.
This study expands on previous related work [8],[9],[11] in several ways. All of our analyses are country-specific and based on the most recent data on HIV and male circumcision prevalence available. Our calculations provide more comprehensive estimates of VMMC-related costs than was the case in previous studies since they include costs for supply chain management and waste management, as per WHO's recent recommendations for efficient VMMC scale-up [24]. In addition, we provide country-specific results on impact (VMMC per HIV infection averted), cost-effectiveness (cost per HIV infection averted) and cost savings (cost of VMMC relative to the averted cost of lifetime provision of ART).
The Model
The DMPPT is a Microsoft-Excel-based modeling tool that estimates the epidemiologic impact (HIV infections averted) and the cost and net savings associated with different programming scenarios for VMMC scale-up. A list of all the equations used in the model can be found in Table S1. Additional details, including a copy of the workbook and the model manual [25], can be found at http://www.malecircumcision.org/programs/DMPPT.html.
The DMPPT is a compartmental deterministic model in which the population is disaggregated into four sex/age groups (females ages 15–24 y, males ages 15–24 y, females ages 25–49 y, and males ages 25–49 y). For each population group, a susceptible and infected population is described [26],[27]. The susceptible population is increased by people aging into it (15-y-olds entering the younger age group and 25-y-olds leaving the younger age group and entering the older age group) and decreased by non-AIDS deaths and new infections. The infected population is increased by new infections and decreased by non-AIDS deaths, AIDS deaths, and aging out.
In the model, HIV incidence (the proportion of the susceptible population becoming infected each year) is the product of HIV prevalence in the population and the force of infection. The force of infection is determined by the base rate of infection (which is a fitting parameter specific to each population group), changes in behavior, and changes due to male circumcision. Changes in behavior are assumed to occur as the epidemic progresses because of two key influences. Individuals with the riskiest behaviors are assumed to become infected first and die sooner than the rest of the population. Also, as AIDS deaths accumulate, a powerful effect on individual behavior is assumed, as those who know someone who has died from AIDS are motivated to adopt safer behaviors. Thus, the force of infection can drop over time as the cumulative number of AIDS deaths increases. The amount of the effect is determined by a fitting parameter that produces the best fit to the historical HIV prevalence trend. The impact of other prevention interventions is incorporated through exogenous reductions in the force of infection. The effect of male circumcision on the force of infection is simply the increase in the prevalence of male circumcision multiplied by the reduction in susceptibility due to circumcision.
For each scenario of interest, the DMPPT model generates two projections: a baseline projection, in which male circumcision coverage is held constant at the pre-scale-up level, and a scale-up projection where VMMC coverage is scaled up to the desired coverage level. In the baseline projection, new infections increase over time in response to the initial force of infection. This causes HIV prevalence to rise rapidly in early years. The force of infection then declines somewhat as AIDS deaths accumulate and prevalence stabilizes. Implementation of a male circumcision program can cause a further reduction in the force of infection (depending on the increase in male circumcision coverage), leading to a decline in new infections and HIV prevalence. There is some concern that men who undergo circumcision may develop a false sense of protection against HIV and thereafter decrease or even stop previously implemented protective behaviors [28],[29]. Post-circumcision behavior change is modeled in the DMPPT as a proportional change in the force of infection, with a VMMC scale-up scenario in which circumcision does not lead to any behavior change being modeled as having a 0% post-circumcision behavior change effect.
The DMPPT model calculates the yearly cost of the additional circumcisions (the number of VMMCs required above and beyond those occurring at pre-scale-up coverage levels) as the sum of the additional circumcisions performed per annum times the VMMC unit cost. The model also calculates the net savings associated with HIV infections averted and the subsequent treatment costs averted.
Demographic, Epidemiologic, and Sexual Behavior Data
The demographic and epidemiologic inputs required to estimate the epidemiologic impact of VMMC scale-up include the following:
- Demographic data—size of adult population by sex and age group, adult population growth rate, crude birth rate, crude death rate, proportion of population surviving to age 15 y, pre-scale-up male circumcision prevalence.
- Epidemiologic data—HIV prevalence among adults by sex and age group; effectiveness of male circumcision in preventing HIV infection; underlying HIV transmission factors based on scientific evidence, including probability of transmission from mother to child; fertility reduction due to HIV.
- Sexual behavior data—sexual mixing patterns by sex and age group, post-circumcision behavior change (change in condom use and/or change in number of sexual partners following VMMC resulting from lowered perceived risk).
We obtained the required demographic, epidemiologic, and sexual behavior data for each country from recent household surveys [30]–[42] and Spectrum, a modeling software package, which includes a demographic platform populated with UN population data [27],[43],[44]. Country-specific pre-scale-up population characteristics, including size of the adult population, adult population growth rate, male circumcision and adult HIV prevalence, and HIV incidence, are shown in Table 1. A complete listing of the data used for each country is available from the authors upon request.
Cost Data
A breakdown of the VMMC unit cost used in the model is provided in Table 2. With the exception of the waste management and supply chain costs, the unit cost components are derived from a VMMC costing study conducted in Zimbabwe in 2010 as part of a multi-country study that also included Kenya, Namibia, South Africa, Uganda, and Zambia [45]–[50]. Zimbabwe was chosen because it is one of the first countries to scale up VMMC services following WHO's MOVE considerations for more efficient use of facility space and staff time and for the bundling of the commodities required to perform VMMC [24]. Information on required inputs and costs was collected from sites providing VMMC in Zimbabwe. This includes data on both direct costs (consumables, staff costs, and training costs) and indirect costs (capital costs, maintenance and utility costs, support overhead, and management overhead). Because significant variations in labor costs were noted across countries, we vary the staff costs by country, adjusting them by after tax median monthly disposable salary. We also adjust the costing information collected in the Zimbabwe study for underreporting on waste management and other supply chain costs [51]. We base the waste management costs on a costing analysis conducted in Swaziland, a detailed description of which is provided elsewhere [52]. The VMMC unit cost used for each country is shown in Table 3.
For lifetime HIV treatment costs, we use the default discounted value in the DMPPT model (US$7,400) [25]; we use the same value for all countries. This value includes costs of AIDS treatment and care, including ART, treatment of major opportunistic infections, laboratory tests, and home-based care. The lifetime HIV treatment cost is based on a unit cost of US$155 for first-line antiretroviral drugs and US$1,678 for second-line antiretroviral drugs [53]. We also assume that need for treatment begins after 8 y of infection and that the annual continuation rate on ART is 97.5% [27].
Following common practice in economic evaluation, we apply an annual discount rate of 3% on future expenditures and savings [54] as well as on infections averted [55].
Base Case and Sensitivity Analysis
Our analyses are limited to the scale-up of VMMC services among males ages 15 to 49 y who are HIV-negative. For all models, we assume that the scale-up begins in 2011 and that the pace of scale-up is slower at first, followed by a more rapid scale-up, and then another slow period of scale-up, to allow for training and other logistic developments likely to occur in the early stages of implementation. The model observation period for all models is 2011 to 2025. This allows us to evaluate the 15-y impact of VMMC more comprehensively.
For the base case, we assume the following:
- VMMC effectiveness—we use 60% for the protective effect of VMMC and assume that the effect is constant over the model simulation period [1],[56].
- Target VMMC coverage level—male circumcision coverage is increased from pre-scale-up levels to 80% of HIV-negative males ages 15 to 49 y.
- Time to 80% scale-up—male circumcision coverage is increased from pre-scale-up levels to 80% of HIV-negative males ages 15 to 49 in 5 y, with the coverage target reached by 2015 and maintained at 80% thereafter.
- Post-circumcision behavior change—no post-circumcision behavior change is associated with VMMC scale-up.
- VMMC unit cost—the VMMC unit cost used for each country is shown in Table 3.
Given uncertainty in model inputs, we also conduct sensitivity analyses, exploring various alternative scenarios. We vary VMMC effectiveness, VMMC coverage level, time to scale-up, level of post-circumcision behavior change, VMMC unit cost, and lifetime HIV treatment cost as follows:
- VMMC effectiveness—34% and 77% (versus 60%) [1].
- Target VMMC coverage levels—50% and 100% (versus. 80%).
- Time to 80% scale-up—1, 10, and 15 y (versus 5 y).
- Post-circumcision behavior change—a 30% post-circumcision behavior change effect is associated with MMC scale-up (versus no post-circumcision behavior change, or 0%).
- VMMC unit cost—country base case unit cost ±20% as shown in Table 3.
- Lifetime ART cost—ART cost is assumed to decline over time, leading to a lifetime cost of US$3,400 (versus US$7,400) [53].
Base Case—80% VMMC Coverage by 2015
The number of additional VMMCs required to achieve 80% male circumcision coverage by 2015 is presented in Table 4. A total of 20.34 million VMMCs are required to scale up male circumcision coverage to 80% by 2015 in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. When taking the longer-term view (to 2025), an additional 8.42 million VMMCs are required between 2016 and 2025, for a total of almost 29 million VMMCs in the model's full study period (2011–2025). The number of VMMCs needed to achieve 80% male circumcision by 2015 varies by country, with the largest number of VMMCs required in South Africa (the country with the largest population and a high adult HIV prevalence) followed by Uganda (the country with a large and fast-growing population and low baseline VMMC prevalence), Malawi, Zambia, and Zimbabwe (also countries low baseline VMMC prevalence).
We find a strong impact of scaling up VMMC to achieve 80% coverage by 2015 on the number of adult HIV infections averted. A total of 430,000 HIV infections are averted in the 13 countries between 2011 and 2015, while almost 3.36 million HIV infections are averted by 2025 (Table 4). South Africa is the country with the largest number of HIV infections averted (with more than 1 million infections averted between 2011 and 2025) followed by Zimbabwe, Zambia, and Uganda. More than 20% of new HIV infections are averted between 2011 and 2025 in all countries except Mozambique, Nyanza Province (Kenya), South Africa, and Tanzania (the countries with the highest baseline VMMC prevalence). Zimbabwe is the country with the highest percentage of new HIV infections averted, with 42% of new infections averted between 2011 and 2025. The large benefit of VMMC in Zimbabwe is largely driven by the currently low prevalence of VMMC (10.3%) and high HIV prevalence (17.9%) and incidence (2.2%).
The number of VMMCs required to avert one HIV infection is calculated by dividing the additional number of VMMCs required by the number of HIV infections averted over the relevant time period. For the period 2011–2015, the number of VMMCs per HIV infection averted ranges from 25 in Swaziland to 239 in Rwanda, while for the full study period (2011–2025), the number of VMMCs per HIV infection averted ranges from four in Zimbabwe to 44 in Rwanda (Table 4). For the period 2011–2025, the number of VMMCs per HIV infection averted is ten or less in all countries except Malawi, Namibia, Rwanda, and Uganda, each of which has a relatively low incidence of HIV.
Although circumcision of HIV-infected men has not been found to directly reduce HIV transmission to their female partners [57], and the primary impact of increasing VMMC coverage is to reduce the number of new HIV infections in men, the number of new infections in women is also reduced. This occurs by reducing the exposure of women to HIV-infected men. That is, as HIV incidence decreases in men following VMMC scale-up, the probability of women encountering infected male partners decreases, with a consequent reduction in HIV incidence among women. The HIV infections averted (presented in Table 4) thus represent infections averted in both men and women. Figure 2 illustrates the male and female HIV infections averted over time, by country, for 2011–2025. In all countries, the cumulative number of male HIV infections averted between 2011 and 2025 is higher than the cumulative number of female HIV infections averted. In the early years, the HIV infections averted occur mostly among men, but over time, the proportion of HIV infections averted in women steadily increases, with new HIV infections averted in women representing almost half of the total HIV infections averted in 2025.
Figure 2 provides data for males and females for 2011–2025 for the base case scenario in which 80% coverage of VMMC is reached in 2015 and maintained thereafter, and there is no post-circumcision risk behavior change.
Figure 3 shows the discounted cost of scaling up VMMC to achieve 80% coverage by 2015 for each of the 13 priority countries for the period 2011–2015. The cost ranges from US$12.53 million in Swaziland (the country with the smallest number of additional VMMCs required) to US$376.55 million in South Africa (the country with the highest number of additional VMMCs required), with a total of US$1,520,000,000 needed to scale up VMMC coverage to 80% in the 13 countries by 2015. The cost for the period 2011–2025 is shown in the first column of Table 5. A total of over US$2,000,000,000 is needed to scale up VMMC coverage to 80% by 2015 and maintain this level of coverage in the 13 countries until 2025.
Figure 3 provides the discounted cost of scaling up VMMC coverage for 2011–2015 for the base case scenario in which 80% coverage of VMMC is reached in 2015 and maintained thereafter, and there is no post-circumcision risk behavior change.
Combining the cost data with the number of HIV infections averted, we obtain the discounted cost per HIV infection averted. The cost per HIV infection averted for the period 2011–2025 ranges from US$369 in Zimbabwe, where adult HIV prevalence is 17.9%, to US$4,096 in Rwanda, where adult HIV prevalence is lower than in any of the other 13 countries studied (3.1%). The overall cost per HIV infection averted for 2011–2025 for all 13 countries is US$809.
Finally, we calculate the net savings associated with VMMC scale-up. The savings due to future ART costs avoided (with the discounted value of lifetime HIV treatment costs estimated at US$7,400 per infection) minus the discounted VMMC costs amount to US$16,510,000,000 for the 13 countries from 2011 to 2025 (Table 5). The net savings can also be combined with the number of HIV infections averted to obtain the net savings per HIV infection averted. For 2011–2025, this value ranges from US$3,304 in Rwanda to US$7,031 in Zimbabwe. The overall net savings per HIV infection averted for 2011–2025 for all 13 countries is US$6,608.
Sensitivity Analysis
Table 6 presents the results of the sensitivity analysis. The table provides the values for the HIV infections averted, the number of VMMCs per HIV infection averted, the cost per HIV infection averted, and the net savings per HIV infection averted for 2011–2025 for each parameter examined. The values for the base scenario (80% male circumcision coverage within 5 y) are shown in the third column of Table 6.
The results help to confirm the internal consistency of the DMPPT model and show that, in large measure, the VMMC impact, cost, and savings results that we observe in the base case are robust to changes in VMMC effectiveness, VMMC coverage, time to scale-up, level of post-circumcision behavior change, VMMC unit cost, and lifetime HIV treatment cost.
Our analysis varying VMMC effectiveness shows that even if we assume much reduced effectiveness (34% instead of 60%), high numbers of infections are averted and net savings per infection averted are obtained. The same is true if the VMMC coverage target is reduced from 80% to 50% or if the time to achieve 80% VMMC coverage is increased to 10 or 15 y.
To assess the potential impact of post-circumcision risk behavior change, the model calculates the impact of risky sexual behaviors reverting to patterns that existed earlier in the epidemic, prior to the scale-up of VMMC services. It should be noted that this impact is different from the early resumption of sexual activity before complete wound healing that can also be an issue of concern in the context of expanding VMMC services. The impact is the result of behavior change due to a false perception that VMMC has eliminated the risk of HIV transmission. As compared to no post-circumcision risk behavior change, assuming 30% post-circumcision risk behavior change results in a decrease in the HIV infections averted, an increase in the numbers of VMMCs per HIV infection averted, an increase in the cost per HIV infection averted, and a decrease in net savings. In all of the countries studied except Rwanda, VMMC scale-up remains cost saving, even with 30% post-circumcision risk behavior change. In Rwanda, the country with the lowest HIV prevalence, scaling up VMMC in the presence of this level of post-circumcision risk behavior leads to an increase in the number of new HIV infections.
Predictably, decreasing (increasing) the base case VMMC unit cost by 20% results in a decrease (increase) in the cost per HIV infection averted and an increase (decrease) in the net savings per HIV infection averted in countries. Assuming the lower VMMC unit cost for each country, the cost and net savings associated with scaling up VMMC coverage to 80% by 2015 and maintaining this level of coverage in the 13 countries until 2025 are US$1,620,000,000 and US$16,900,000,000 instead of US$2,020,000,000 and US$16,510,000,000 in the base case. Assuming the higher VMMC unit cost, the cost of scaling up VMMC services in the 13 countries is US$2,430,000,000, resulting in net savings of US$16,090,000,000.
Reducing lifetime ART cost from US$7,400 to US$3,400 does significantly reduce the net savings per infection averted in all countries, although it remains well above US$2,000 in almost all countries. Rwanda is the only country where such a reduction in lifetime ART cost would lead to net losses per infection averted. Net savings associated with scaling up VMMC coverage is reduced to US$6,480,000,000 in the 13 countries if lifetime ART cost is US$3,400.
To support decision making and planning for VMMC scale-up in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya, we estimate the country-specific impact and cost of scaling up VMMC services using the DMPPT model developed by the USAID and UNAIDS. Our study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and the resultant cost savings.
Model results also show that, although the primary impact of scaling up VMMC coverage is to reduce the number of new HIV infections in men, the intervention also prevents HIV infections in women. While the cumulative number of male HIV infections averted between 2011 and 2025 is higher than the cumulative number of female HIV infections averted, the proportion of HIV infections averted in women steadily increases until HIV infections averted in women represent almost half of the new HIV infections averted in 2025.
Our results show that the costs per infection averted are comparable to the estimated cost per infection averted of a number of key HIV prevention interventions implemented in the region. The cost per HIV infection averted, which ranges from US$369 in Zimbabwe to US$4,096 in Rwanda, is below US$1,000 in all countries except Malawi, Namibia, Rwanda, and Uganda. These costs per infection averted are comparable to those of prevention of vertical transmission (US$663 per HIV-positive birth averted), voluntary counseling and testing (US$1,315 per HIV infection averted), and prevention of STIs (US$321–US$1,665) [58].
Our results are somewhat sensitive to changes in VMMC effectiveness, VMMC coverage targets, time to scale-up, and VMMC cost. Nonetheless, all of the values tested for these parameters resulted in lives saved and cost savings for all countries. It is especially important to note that even if VMMC coverage is scaled up to 50% in 5 y instead of to 80%, high numbers of infections will be averted and net savings per infection averted will be obtained in all countries except Mozambique and Tanzania—the two countries where pre-scale-up coverage is higher than 50%. This is critical because even though there is no evidence available yet on the feasibility of scaling up VMMC coverage to 80%, there is evidence that VMMC coverage rates of above 50% can be reached through VMMC scale-up efforts [56].
Similar to the results reported by other authors, our results suggest that post-circumcision risk behavior change is unlikely to completely reverse the benefits of male circumcision, with the possible exception of Rwanda. In the case of Rwanda, the low incidence of HIV (0.3%) means that risk compensation associated with male circumcision could actually make the epidemic worse. In the remaining countries, the negative consequences from a 30% risk compensation would be insufficient to fully reverse the benefits of VMMC. In all countries, it is critical that VMMC programs emphasize that male circumcision is not 100% protective and that condom use and other behavioral risk reductions remain essential [8],[59]. Effective messaging in this regard is critical to ensure that men and their sexual partners do not increase their sexual risk behaviors following VMMC scale-up.
This study has a number of limitations. Because this model was designed primarily for advocacy purposes, certain elements are not modeled, including treatment, a more fully articulated age structure, and force of infection, which probably leads to an overestimate of the impact of male circumcision.
Another limitation is that we use pre-scale-up male circumcision coverage estimates based on men's self-reported circumcision status in household surveys. There is some evidence that uncircumcised and partially circumcised men may report being circumcised in some populations [60]. Unfortunately, there is no information available on the prevalence of this phenomenon in the countries studied. In the one country where partial circumcision is known to be widely practiced (Lesotho), we assume baseline VMMC prevalence to be at 0% rather than using the self-reported data.
Additional limitations relate to our cost assumptions. Ideally, we would have obtained country-specific VMMC unit cost estimates based on the MOVE model instead of only adjusting the staff costs by country based on after-tax median monthly disposable salary. However, this model for delivering VMMC was available in only a limited number of sites. Our VMMC unit cost, which is higher than that used in previous studies [8],[11],[59],[61],[62], reflects a better understanding of the service delivery components required for such a program, including waste management and logistics associated with the scaling up of VMMC services [52]. It should also be noted that countries are procuring the same circumcision kits and are adopting the same service delivery model that was costed in this study. If possible, we would also have adjusted VMMC unit cost over time and scale [63],[64]. However, no information is currently available on how VMMC unit cost might vary over time and with scale. Another limitation is that we do not include costs associated with demand creation in our study [65]. Finally, it would have been preferable for us to obtain country-specific ART costs; however, country-specific data for the 13 countries studied were not available.
HIV prevalence and incidence estimates used in the model and how they compare to the actual present and projected prevalence and incidence in each of the selected countries is another factor that affects the accuracy of our findings. A steeper decline in baseline incidence, for example, will result in fewer infections averted as a result of VMMC. Conversely, if these incidence trends are overly optimistic, then the number of infections available to be averted by VMMC may in turn be larger than estimated here.
We also recognize that our modeling assumes that males seeking out VMMC services are typical of the general male population in the selected age range. If, for example, those seeking out VMMC services are in fact those who are at least risk of becoming infected (perhaps VMMC clients already disproportionately use condoms), then the benefits of VMMC are likely to be overestimated. Conversely, if those who are at most risk of infection (those with a large number of partners and/or low condom use) are disproportionately attracted to VMMC services, then the modeling presented in this paper may underestimate the value of VMMC scale-up. Given that VMMC client sexual behavior, relative to the behavior of the general male population, remains unknown, it is not possible to determine whether our projections are underestimated or overestimated.
There are also a number of prevention benefits that are indirectly associated with seeking out VMMC services. These include the benefits of counseling and testing, STI treatment, and early antiretroviral treatment. For example, for those males who seek out VMMC services but find that they are already HIV-infected, there could be societal prevention benefits if these men subsequently are able to access early treatment and reduce their infectivity. Since we focus only on the direct benefits received by those receiving VMMC and do not quantify any additional benefits of counseling and testing, STI treatment, and early antiretroviral treatment as a result of seeking VMMC services, it is possible that the prevention benefits of VMMC could be underestimated.
The past year has been marked by important advances in HIV prevention, including the finding that early treatment initiation reduces sexual transmission by as much as 96% in stable serodiscordant couples [66]. However, the population-level impact of treatment is not currently well known. And coverage of those eligible for antiretroviral treatment under WHO guidelines remains low, with less than half of people needing treatment having access to it in eastern and southern Africa in 2010 [67].
VMMC is a one-time surgical procedure with the promise of substantial impact on population-level HIV incidence. Its effects accrue to both men and women, and it compares favorably with other HIV prevention programs in terms of cost-effectiveness. Countries are adopting WHO/UNAIDS recommendations to incorporate VMMC within their HIV prevention portfolios. Best practices from Kenya [68], Tanzania [69], and South Africa [56] show that with government leadership, community involvement, and collaboration among partners, it is possible to scale up rapidly by implementing service delivery models that take into consideration available resources, efficiency, and quality to achieve the maximum public health impact. To ensure that high coverage rates are achievable, countries and their international partners should allocate enough resources to take advantage of the returns on investment predicted for this biomedical HIV prevention modality.
Supporting Information
Table S1.
Model details and equations.
The views expressed in this paper are those of the authors and do not necessarily reflect the official policy or position of the US Government.
Author Contributions
Conceived and designed the experiments: EN SF JR LB CH. Performed the experiments: EN SF LB MO VM. Analyzed the data: EN SF LB MO VM. Contributed reagents/materials/analysis tools: EN SF LB MO VM JR DC CH JS NH TF. Wrote the first draft of the manuscript: MO. Contributed to the writing of the manuscript: EN SF JR MO LB NH DC JS TF VM CH. ICMJE criteria for authorship read and met: EN SF JR MO LB NH DC JS TF VM CH. Agree with manuscript results and conclusions: EN SF JR MO LB NH DC JS TF VM CH.
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- 15. Serwadda D, Wawer MJ, Makumbi F, Kong X, Kigozi G, et al. (2010) Circumcision of HIV-infected men: effects on high-risk human papillomavirus infections in a randomized trial in Rakai, Uganda. J Infect Dis 201: 1463–1469.
- 16. Wawer MJ, Tobian AA, Kigozi G, Kong X, Gravitt PE, et al. (2011) Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda. Lancet 377: 209–218.
- 17. Gray RH, Kigozi G, Serwadda D, Makumbi F, Nalugoda F, et al. (2009) The effects of male circumcision on female partners' genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. Am J Obstet Gynecol 200: 42.e41–42.e47.
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- 68. Mwandi Z, Murphy A, Reed J, Chesang K, Njeuhmeli E, et al. (2011) Voluntary medical male circumcision: translating research into the rapid expansion of services in Kenya, 2008–2011. PLoS Med 8: e1001130. doi:10.1371/journal.pmed.1001130.
- 69. Mahler HR, Kileo B, Curran K, Plotkin M, Adamu T, et al. (2011) Voluntary medical male circumcision: matching demand and supply with quality and efficiency in a high-volume campaign in Iringa Region, Tanzania. PLoS Med 8: e1001131. doi:10.1371/journal.pmed.1001131.


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Style # 203759
Perfect mate to weekend pieces, this bebe sweater features soft medium knit and asymmetric hemline. Try it over denim, a cami and a statement necklace for an effortlessly-chic look.
- 85% silk, 15% cashmere.
- Center back to hem: 38" (97 cm).
- Dry clean.
- Imported.
- Model is 5'9" and is wearing a size S.
Rated 5 out of 5�by 1 reviewer.
Rated 5 out of 5�by Shar Great sweater!! Runs small because it is very fitted! I usually wear a medium but ordered a large and its perfect!! I love this sweater because its thin and not bulky! I wore it with a dress as well as jeans and it looks great!! January 1, 2013
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Results 16 to 20 of 25
Thread: tavn's BNG
November 14th, 2011 11:11 PM #16Senior Member
- Join Date
- Sep 2011
- Posts
- 6,204
Your name [age 56]: Echo Evangeline Winters Criss
DH�s name [age 56]: Darren Everett Criss
--- Jonah Matthew Criss [age 37]
--- Mackenzie Alyssa *Kenzie* Wright [age 37]
------ Wilder Darren Criss [age 14]
November 14th, 2011 11:11 PM #18Senior Member
- Join Date
- Sep 2011
- Posts
- 6,204
--- Juno Miranda Criss [age 37]
--- Jericho Daniel Criss [age 36]
--- Daniella Paige *Dani* Williams [age 36]
------ Hallie Echo Criss [age 12]
--- Kojo Jafari *Jo* Criss [age 33]
November 14th, 2011 11:12 PM #20Senior Member
- Join Date
- Sep 2011
- Posts
- 6,204
--- Ojori Puma *Jori* Criss [age 33]
--- Justina Jane *JJ* Criss [age 25]
--- Jemima Jean *Jemma* Criss [age 25]
--- Julia Jade *Julie* Criss [age 25]
November 14th, 2011 11:13 PM #22Senior Member
- Join Date
- Sep 2011
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- 6,204
January 11th, 2013 08:23 PM #24
Today is your wedding day. Your parents aren't too happy that you're marrying at 18, but they're being supportive. In fact, they're to blame. If they hadn't become friends with his parents when you were 6, you probably wouldn't even know who he was. You're just the girl next door, but he, he is a famous actor. He's remained very down to earth, the two of you are so in love, and he wants to do it all the right way, no sex before marriage. And since girls are now being thrown at him left and right, you feel the pressure to marry, now. So here you are, getting ready to walk down the aisle and become Mrs. Macfadyen.
You've been married for 3 weeks now. You had the most amazing honeymoon in Derbyshire. You're feeling a little down, though. You're tired and moody. You're more than happy, so it's not any sort of depression. You decide to sneak a pregnancy test, just for ease of mind, you know? You're honestly shocked by the result. Those are two pink lines. You're pregnant! Oh, how do you tell Matthew, let alone your parents. They thought that marrying him would make your life complicated enough, and at such a young age. What will they think about having a child with him? Oh well. What's done is done. You calm yourself down and take on the task ahead. You tell Matthew and decide that you don't want to know the gender of your child until he/she is born. And 9 months later you give birth.
1. 1 boy, brown hair, blue eyes, DH's MN as his MN
Baby 1's name: Dalton Matthew
Baby 1's picture: http://www.theparentszone.com/wp-con...eight-gain.jpg
You gave birth almost 4 months ago. Dalton has stopped nursing. You don't know why. You complain to your mom who tells you that you stopped nursing when she got pregnant with your little sister. You and your little sister are exactly one year apart in age. So you tell Matthew and take a test. Looks like your mom was right. You're pregnant. You vow that next time you will get on birth control right away. No more procrastinating. Clearly you and Matthew are natural baby makers. Again, you decide to wait to find out the sex. 9 months later on the day you first gave birth, you give birth again.
What'd you roll? Girl, brown hair, blue eyes
Baby 2's name: Vivienne Maria
Baby 2's picture: http://i00.i.aliimg.com/wsphoto/v0/4...ute-infant.jpg
Baby 1's name [age 1]: Dalton Matthew
Baby 1's current picture: http://www.theyogaofparenting.com/wp...epingBoy21.jpg
3 years later, you're traveling to Africa with Matthew for non-profit work. The kids are back home with your parents. Your heart goes out to these children. You wish you could help them so bad. You express this to Matthew and he suggests adopting. Your eyes light up. You decide to adopt one or two babies (age 1 or under) that need medical help, as DH's profession will allow you to pay for it. You will not change their names (choose African names for them, you may come up with a NN).
What'd you roll? 1 boy and 1 girl
Adopted 3A's name: Desta William "Des"
Adopted 3A's picture: http://static9.depositphotos.com/140...n-american.jpg
Adopted 3B's name: Adaeze Elizabeth "Ada"
Adopted 3B's picture: http://www.portlandnewbornbabyphotog...rican-baby.jpg
Baby 2's name [age 3]: Vivienne Maria
Baby 2's current picture: http://images2.fanpop.com/images/pho...27-326-368.jpg
Baby 1A's name [age 4]: Dalton Matthew
Baby 1A's current picture: http://steamykitchen.com/wp-content/.../andrewpic.jpg
It's been 5 years since you adopted your LO. You enjoy nothing more than being a stay at home mom to your children. But it's been a while since you've had an actual baby in the house and you're itching for one. You discuss this with Matthew and agree to begin trying. When you first got married, it was far too easy to get pregnant. But now, it's more difficult (especially with Matthew's crazy work schedule). 2 years go by and no baby. You decide to try fertility treatments. Your first try works!
What'd you roll? Two boys, two girls, blue eyes and brown hair
Baby 4As name: Alice Genevieve
Baby 4As picture: http://www.libbyannphotography.com/b...grapher-02.jpg
Baby 4Bs name: Arthur Duncan
Baby 4Bs picture: http://www.lynnquinlivan.com/blog/wp...er-Webster.jpg
Baby 4Cs name: Alexia Prudence
Baby 4Cs picture: http://2.bp.blogspot.com/_-XCYjEmYdo...ctures+026.JPG
Baby 4Ds name: Aaron Connor
Baby 4Ds picture: http://1.bp.blogspot.com/_fgHr6EqW5s...+1+%281%29.jpg
Adopted 3As name [age 8]: Desta William "Des"
Adopted 3A's current picture: http://www.istockphoto.com/stock-pho...php?st=315eaee
Adopted 3B's name [age 8]: Adaeze Elizabeth "Ada"
Adopted 3B's current picture: http://www.istockphoto.com/stock-pho...php?st=315eaee
Baby 2's name [age 11]: Vivienne Maria
Baby 2's current picture: http://www.istockphoto.com/stock-pho...php?st=315eaee
Baby 1's name [age 12]: Dalton Matthew
Baby 1's current picture: http://www.istockphoto.com/stock-pho...php?st=315eaee
11 years later, Dalton tells you he's having a baby. It's a boy! He has blue eyes just like Dalton and Matthew. His hair is the same color as Alina. His grandfather's FN will be his MN.
Grandchild 1's name: David Jethro
Grandchild 1's picture: http://www.vitamedica.com/wp-content.../12/Infant.jpg
Baby 1's name [age 23]: Dalton Matthew
Baby 1's current picture: http://www.istockphoto.com/stock-pho...php?st=e27d579
CIL 1's name [age 23]: Alina Hannah
CIL 1's current picture: http://www.istockphoto.com/stock-pho...php?st=e27d579
2 years after your first grandchild was born, Vivienne has a child as well. It's a girl! She has hair & eyes just like Alexander. She Your FN will be her MN.
Grandchild 2's name: Elinor Molly
Grandchild 2's picture: http://a248.e.akamai.net/origin-cdn....s/FHBM00-2.jpg
Baby 2's name [age 24]: Vivienne Maria
Baby 2's current picture: http://www.heatherkincaid.com/blog/w...on_blog_16.jpg
CIL 2's name [age 24]: Alexander Matthew
CIL 2's current picture: http://www.istockphoto.com/stock-pho...php?st=e27d579
You're 51 years old now. You have eight children and 2 grandchildren. But none live in your house. Your house feels empty as all your children have moved out. Most of them are focusing on their careers and are not planning on having any children for a while. Your grandchildren are 6 and 8. They're still children, but definitely not babies. You're feeling depressed. So you and Matthew decide to adopt. You don't think you can handle a newborn fulltime at your age, so you decide to adopt a 2 year old, still a baby, but more independent. You will again keep their given name, but you may create a NN for them.
What'd you roll? Girl from Russia
Adopted 5's name [age 2]: Magdalena Nikolevna
Adopted 5's picture: http://3.bp.blogspot.com/_jYJS8_oVB6...10_01_logo.jpg
Your name [age 56]: Molly Anna Macfadyen
DH's name [age 56]: David Matthew Macfadyen
--- Baby 1's name [age 37]: Dalton Matthew
--- Baby 1's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- CIL 1's name [age 37]: Alina Hannah
--- CIL 1's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
------ Grandchild 1's name [age 14]: David Jethro
------ Grandchild 1's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- Baby 2's name [age 36]: Vivienne Maria
--- Baby 2's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- CIL 2's name [age 36]: Alexander Nicholas
--- CIL 2's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
------ Grandchild 2's name [age 12]: Elinor Molly
------ Grandchild 2's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- Adopted 3A's name [age 33]: Desta William "Des"
--- Adopted 3A's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- Adopted 3B's name [age 33]: Adaeze Elizabeth "Ada"
--- Adopted 3B's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- Baby 4A's name [age 25]: Alice Genevieve
--- Baby 4A's picture: http://www.istockphoto.com/stock-pho...php?st=5e7e8a3
--- Baby 4B's name [age 25]: Arthur Duncan
--- Baby 4B's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- Baby 4C's name [age 25]: Alexia Prudence
--- Baby 4C's picture: http://www.istockphoto.com/stock-pho...php?st=5e7e8a3
--- Baby 4D's name [age 25]: Aaron Connor
--- Baby 4D's picture: http://www.istockphoto.com/stock-pho...php?st=296ae97
--- Adopted 5's name [age 7]: Magdalena Nikolevna "Magda"
--- Adopted 5's picture: http://www.istockphoto.com/stock-pho...php?st=5e7e8a3Girls
Abhla | Alice | Audrey | Avila | Beatrice | Cecilia | Constance | Cordelia | EilĂs | Evangeline | Fidelis | Genevieve | Gráinne | Harriet | Helena | Honora | Iris | Ivy | Maud | Moira | Orla | Rosalind | SĂomha | Tuathla | Veronica
Alexander | Amargein | Ciaran | Cillian | Elias | Ephraim | Everett | Fionn | Isaac | James | Joseph | Josiah | Jude | Julian | Kellan | Leander | Lonan | Nolan | OisĂn | Orson | Patrick | Ronan | RuaidrĂ | Thomas | Vincent


text:
HTCE Fast: Bone-In Chicken Noodle Soup
Every other Wednesday, I'm featuring one of my favorite recipes from How to Cook Everything Fast. If you cook it, too, I want to see it—tag it on social media with #HTCEFast. And enjoy!
It doesn't take long for bone-in chicken to turn water into a flavorful broth. Start with whole pieces, don't overcook the meat or fuss with the bones, and you'll have real chicken noodle soup on the table in 30 minutes.
2 tablespoons olive oil
4 bone-in chicken thighs
4 chicken drumsticks
1 large onion
2 large carrots
3 celery stalks, plus any leaves
4 garlic cloves
5 bay leaves
8 ounces egg noodles or any cut pasta
How Should We Eat?
The recommendations of the Dietary Guidelines Advisory Committee, a nutrition panel that helps update and revise federal dietary guidelines,were announced last week and are easy to parse: The panel, a collection of 14 health experts with dozens of specialists in support, emphasizes things that just about everyone agrees upon: that we need a diet more oriented toward plants, that we should reduce calorie consumption in general, and that less sugar would be a good thing. Not much new there, or surprising.
But on some levels the report is disappointing: For one thing, it's 571 pages (not surprisingly, it stumbles over itself). And it focuses on individual nutrients at the expense of sending simpler messages. No one wants to think about "eating" (or, even worse, "consuming") cholesterol or saturated fat or sodium or "sweeteners." We want to think about eating food.
A Family Affair
Gianni Piscitelli, a home cook I met on a recent trip to Naples, grew up cooking with his grandmother, Maria d'Orsi, and later with his father, Attilio, in Montesanto, a residential neighborhood of the city. His grandparents were smart: They bought a sprawling place high on a hill with a view of the sea in 1933, when the area was still countryside — a home where the extended family could all live and cook together. What this family has always cooked is the food of Naples. Which is not what I thought it was.
If you grew up in Lower Manhattan when I did, 50 years ago, you might have thought you knew the food of southern Italy: Pizza, meat ragu, lasagna, stuffed shells and seafood "fra diavolo."
Read the rest of this column and get the recipes here. Photo by Grant Cornett.
How to Cook: Roasted Salmon
HTCE Fast: Molten Chocolate Cake
Every other Wednesday, I'm featuring one of my favorite recipes from How to Cook Everything Fast. If you cook it, too, I want to see it—tag it on social media with #HTCEFast. And enjoy!
A four-star dessert that bakes in less than 10 minutes.
1 stick unsalted butter, plus more for greasing the ramekins
4 ounces bittersweet or semisweet chocolate
4 eggs
1/4 cup sugar
2 teaspoons flour, plus more for dusting the ramekins
What Is the Purpose of Society?
The world of food and agriculture symbolizes most of what's gone wrong in the United States. But because food is plentiful for most people, and the damage that conventional agriculture does isn't readily evident to everyone, it's important that we look deeper, beyond food, to the structure that underlies most decisions: the political economy.
Progressives are not thinking broadly or creatively enough. By failing to pressure Democrats to take strong stands on everything from environmental protection to gun control to income inequality, progressives allow the party to use populist rhetoric while making America safer for business than it is for Americans. No one seriously believes that Hillary Clinton will ever put the interests of Main Street before those of her donors from Wall Street, do they? At least not unless she's pushed, and hard.
It's clear to most everyone, regardless of politics, that the big issues — labor, race, food, immigration, education and so on — must be "fixed," and that fixing any one of these will help with the others. But this kind of change must begin with an agreement about principles, specifically principles of human rights and well-being rather than principles of making a favorable business climate.
Read the rest of this column here.
How to Cook: Poached Eggs
HTCE Fast: Cheddar Waffles with Bacon Maple Syrup
Every Wednesday, I'm featuring one of my favorite recipes from How to Cook Everything Fast. If you cook it, too, I want to see it—tag it on social media with #HTCEFast. And enjoy!
These cheddar waffles are an addictive mix of sweet and savory. They bake up crisp and rich like grilled cheese sandwiches, only with the classic flavors of breakfast on top.
Vegetable oil
6 slices bacon
4 ounces sharp cheddar cheese (1 cup grated)
2 cups flour
1 tablespoon baking powder
1/4 teaspoon salt
2 eggs
1 cup milk
3/4 cup maple syrup
Good Riddance to the Foam Take-Out Carton
Strike another blow against so-called convenience and bring back the paper coffee cup with the Greek columns: foam cups and other polystyrene foam packaging, even packing "peanuts," are going bye-bye in New York City.
They're already banned, or will be, in over 100 jurisdictions in the United States, including the District of Columbia; Seattle; Portland, Ore.; Minneapolis and San Francisco, and some 90 other municipalities in California. But the New York City move may signal the death knell for the stuff most of us call by its common (and technically misapplied) name, Styrofoam.
Read the rest of this column here.


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The stories in the "Celebrity" section of Literotica are all fictional parodies - none are true, nor are they approved of by the celebrities named in the stories. Authors write these fictitious stories about famous people for the same reason that Larry Flynt made fun of Jerry Falwell, because they can. The Supreme Court of the United States, the country where this site is located, has ruled that parodies involving famous people are perfectly and totally legal under the United States Constitution. The specific case law on this was decided in the case of "Hustler Magazine, Inc. et al. v. Jerry Falwell" in 1988. No harm is intended toward the celebrities featured in these stories, but they are public figures and in being so, they must accept that they are fair target for parodies by the public. We believe in the first amendment, and more broadly, in the basic principle of free speech and this section may push the boundaries of that principle, but the United States Supreme Court has approved of this type of material. We believe that the Supreme Court was correct in their decision.
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