scholarly journals Comprehensive approach to HIV/AIDS testing and linkage to treatment among men who have sex with men in Curitiba, Brazil

PLoS ONE ◽  
2021 ◽  
Vol 16 (5) ◽  
pp. e0249877
Author(s):  
Marly Marques da Cruz ◽  
Vanda Lúcia Cota ◽  
Nena Lentini ◽  
Trista Bingham ◽  
Gregory Parent ◽  
...  
Keyword(s):  
Hiv Testing ◽  
Statistical Tests ◽  
Hiv Positive ◽  
Cross Sectional ◽  
Self Testing ◽  
Hiv Test ◽  
Test Kit ◽  
Hiv Rapid Testing ◽  
Sex With Men ◽  
Hiv Aids

Introduction The Curitiba (Brazil)-based Project, A Hora é Agora (AHA), evaluated a comprehensive HIV control strategy among men who have sex with men (MSM) aimed at expanding access to HIV rapid testing and linking HIV-positive MSM to health services and treatment. AHA’s approach included rapid HIV Testing Services (HTC) in one mobile testing unit (MTU); a local, gay-led, non-governmental organization (NGO); an existing government-run health facility (COA); and Internet-based HIV self-testing. The objectives of the paper were to compare a) number of MSM tested in each strategy, its positivity and linkage; b) social, demographic and behavioral characteristics of MSM accessing the different HTC and linkage services; and c) the costs of the individual strategies to diagnose and link MSM to services. Methods We used data for 2,681 MSM tested at COA, MTU and NGO from March 2015 to March 2017. This is a cross sectional comparison of the demographics and behavioral factors (age group, race/ethnicity, education, sexually transmitted diseases, knowledge of AHA services and previous HIV test). Absolute frequencies, percentage distributions and confidence intervals for the percentages were used, as well as unilateral statistical tests. Results and discussion AHA performed 2,681 HIV tests among MSM across three in-person strategies: MTU, NGO, and COA; and distributed 4,752 HIV oral fluid tests through the self-testing platform. MTU, NGO and COA reported 365 (13.6%) HIV positive diagnoses among MSM, including 28 users with previous HIV diagnosis or on antiretroviral treatment for HIV. Of these, 89% of MSM were eligible for linkage-to-care services. Linkage support was accepted by 86% of positive MSM, of which 66.7% were linked to services in less than 90 days. The MTU resulted in the lowest cost per MSM tested ($137 per test), followed by self-testing ($247). Conclusions AHA offered MSM access to HTC through innovative strategies operating in alternative sites and schedules. It presented the Curitiba HIV/AIDS community the opportunity to monitor HIV-positive MSM from diagnosis to treatment uptake. Self-testing emerged as a feasible strategy to increase MSM access to HIV-testing through virtual tools and anonymous test kit delivery and pick-up. Cost per test findings in both the MTU and self-testing support expansion to other regions with similar epidemiological contexts.

scholarly journals Prevalence and associated factors of HIV self-testing among men who have sex with men in Ningbo, China: a cross-sectional study

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Hang Hong ◽  
Hong-bo Shi ◽  
Hai-bo Jiang ◽  
Hong-jun Dong ◽  
Yun-liang Shen
Keyword(s):  
Hiv Testing ◽  
Cross Sectional Study ◽  
Sexual Contact ◽  
Categorical Variables ◽  
Sectional Study ◽  
Cross Sectional ◽  
The Past ◽  
Self Testing ◽  
Test Kit ◽  
Sex With Men

Abstract Background HIV testing and early linkage to care are critical for reducing the risk of HIV transmission. HIV self-testing (HIVST) is a useful tool for increasing HIV testing frequency.This study aimed to investigate HIVST rates among men who have sex with men (MSM), the characteristics of MSM who had HIVST, and factors associated with HIVST uptake among MSM in Ningbo, China. Methods A cross-sectional study was conducted from April to October 2019 in Ningbo,China. Participants were aged at least 18 years and having had sexual contact with men in the past year. Proportions were used for categorical variables. Adjusted Odds Ratio (AOR) and 95% Confidence Interval (CI) for characteristics associated with HIVST uptake was processed by multivariable logistic regression models. Results Among a sample of 699 MSM recruited, 38.2% had reported previous use of an HIV self-test kit. A greater proportion of HIVST users had a higher frequency of HIV testing (≥ 2 times: 70.0% versus 41.2%, p < 0.001) in the past 1 year. The odds of older age (30–39 years: AOR = 0.49, CI 0.32–0.76; more than 40 years: AOR = 0.07, CI 0.04–0.14, compared to 18–29 years), bisexual (AOR = 0.49, CI 0.29–0.84) were lower among HIVST users,and were higher among MSM who were higher education level (high school: AOR = 2.82, CI 1.70–4.69, compared to middle school or less), gay apps use (AOR = 1.86, CI 1.13–3.05), multiple male sex partners (AOR = 1.90, CI 1.29–2.80), frequency of male–male sexual contact ≥ 1 times per week (AOR = 1.86, CI 1.30–2.66), syphilis infection (AOR = 5.48, CI 2.53–11.88). Conclusions Further HIVST education should be strengthened for school-aged children and teenagers, and free HIVST kits may be provided to high-risk MSM through gay apps and CBO to achieve the increased HIV testing frequency.

Feasibility of Indirect Secondary Distribution of HIV Self-Test Kits via WeChat Among Men Who Have Sex with Men: A National Cross-Sectional Study in China (Preprint)

2021 ◽  
Author(s):  
Li Shangcao ◽  
Jing Zhang ◽  
Xiang Mao ◽  
Tianyi Lu ◽  
Yangyang Gao ◽  
...  
Keyword(s):  
Social Media ◽  
Online Survey ◽  
Sexual Partners ◽  
Cross Sectional ◽  
Self Testing ◽  
Hiv Test ◽  
Condomless Anal Intercourse ◽  
Secondary Distribution ◽  
Self Test ◽  
Sex With Men

BACKGROUND The use of HIV self-test (HST) kits is commonplace in key sexually active populations. The direct secondary distribution of HST kits (DSDHK) is effective in improving the uptake of HIV self-testing. However, there are concerns about various limitations of DSDHK, including limited geographic location, payment problems, and face-to-face interaction. OBJECTIVE We evaluated the feasibility and characteristics of the indirect secondary distribution of HST kits (ISDHK) via WeChat (distributing HST application links and follow-up HST kits to partners) among men who have sex with men (MSM). METHODS From October 2017 to September 2019, an HIV self-testing (HIVST) recruitment advertisement was disseminated on the WeChat social media platform to invite MSM to apply for HST kits (referred to as “index participants” [Ips]). All of the MSM participants were encouraged to distribute the HST application link to their friends and sexual partners (referred to as “Alters”) through their social networks. All Alters were further encouraged to continue to distribute the HST application link. All participants paid a deposit (USD 7), refundable upon completion of the questionnaire and uploading of the test result via an online survey system. RESULTS 2,263 MSM met the criteria and successfully applied for HST. Of these, 1,816 participants returned their HST test results, including 1,422 (88.3%) IPs and 394 (21.7%) Alters. Compared with the IPs, the Alters practiced more condomless anal intercourse (CAI), a higher proportion of them never previously had an HIV test, and they had a greater willingness to distribute HST kits to sexual partners (all p < 0.05). After controlling for age, education, and income, the Alters had a greater proportion of MSM who had never tested for HIV before (aOR = 1.29, 95% CI 1.00–1.68), were more willing to distribute the HST application link (aOR = 1.71, 95% CI 1.21–2.40), had a lower number of sexual partners (aOR = 0.71, 95% CI 0.57–0.90), and were less likely to search for sexual partners via online means (aOR = 0.78, 95% CI 0.60–1.02). In comparison, the rates of reactive HST results, conducting HIV confirmatory tests, HIV seropositivity, and initiation of HIV antiretroviral therapy (ART) were similar for IPs and Alters. CONCLUSIONS The ISDHK mode of distributing HST application links via social media is feasible among the MSM population. The ISDHK mode should be used to supplement the DSDHK mode in order to enable a greater proportion of the MSM population to know their HIV infection status.

scholarly journals Uptake of HIV testing and HIV prevalence among men who have sex with men in Karnataka

2019 ◽  
Vol 6 (2) ◽  
pp. 668
Author(s):  
Vani Srinivas ◽  
Rajesh T. Patil ◽  
M. Chandrakantha ◽  
T. L. N. Prasad ◽  
Sunil D. Khaparde
Keyword(s):  
Hiv Testing ◽  
Demographic Data ◽  
Cross Sectional Study ◽  
Hiv Prevalence ◽  
Consistent Condom ◽  
Cross Sectional ◽  
Human Immuno Deficiency Virus ◽  
Hiv Test ◽  
Post Test ◽  
Sex With Men

Background: This paper presents the prevalence of human immuno deficiency virus (HIV) infection among men who have sex with men (MSM) attending integrated counselling and testing Centres (ICTC) in selected districts of Karnataka.Methods: A cross sectional study was done at ICTCs. Men and transgenders coming with referral slips from targeted intervention (TI), non-government organizations (NGOs) were considered as MSMs. The basic demographic data, HIV test result and details of post- test counselling were collected in specific format. Data from 13 districts was obtained from April 2009 to March 2010 and comparing the prevalence of HIV among MSM in HIV sentinel surveillance (HSS).Results: Out of 8,276 MSMs in 13 districts, 2808 (33.9%) visited ICTCs with TI NGOs referral slips and were tested for HIV once in a year. The overall prevalence of HIV was 8.6%. Prevalence was highest (17.3%) among men in the age group of 41 to 45 years, illiterates (11.5%), unemployed (11.2%) and divorced and separated (13.3%) and widowed (13.6%) MSMs. Among those tested, 97.7% of MSM underwent post-test counselling and collected their report. The highest HIV prevalence was among MSMs from Mysore district (20.1%), followed by Udupi (19.9%) and Bagalkot (10.6%). Rest of all the other districts had less than 10% of HIV prevalence.Conclusions: The uptake of HIV testing among the MSM with referral slips was low in Karnataka. The prevalence level differs in various districts. There is need for more focused and effective counselling by peer educators for correct and consistent condom usage among illiterate, widowed and unemployed MSMs.

scholarly journals What happens after HIV self-testing? Results from a longitudinal cohort of Chinese men who have sex with men

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Weiming Tang ◽  
Wenting Huang ◽  
Haidong Lu ◽  
Bolin Cao ◽  
Dan Wu ◽  
...  
Keyword(s):  
Hiv Prevention ◽  
Condom Use ◽  
Hiv Testing ◽  
Consistent Condom ◽  
Consistent Condom Use ◽  
Longitudinal Cohort ◽  
Prevention Services ◽  
Self Testing ◽  
Hiv Test ◽  
Sex With Men

Abstract Background HIV self-testing (HIVST) is a promising approach to expand HIV testing. HIVST is a process in which a person performs an HIV test and interprets the result. Negative HIVST results may encourage men who have sex with men (MSM) to use HIV prevention services. The objective of this study was to examine behaviors (e.g., facility-based HIV testing, condom use) after a negative HIVST test result among Chinese MSM. Methods We collected data from MSM in eight Chinese cities over a 12-month period. This is a secondary analysis of longitudinal cohort data collected as part of an intervention trial to increase HIV testing. Men completed a survey that described sociodemographic information, sexual behaviors, HIV self-testing, and facility-based HIV testing. Men who completed at least one follow-up survey were included in this analysis. Generalized linear mixed models were used to evaluate whether HIVST increased subsequent facility-based HIV testing and consistent condom use. Results We included 1219 men. Most men (78.7%) were under 30 years old and had never been married (87.0%). 755 (61.9%) men tested for HIV and 593 (49.3%) men self-tested during the study period. At baseline, among men who had never been tested for HIV, 44.9% (314/699) initiated HIVST during the study period. HIVST was associated with subsequent facility-based testing (aOR of 1.87, 95% CI: 1.47–2.37). HIVST was also associated with subsequent consistent condom use (aOR = 1.53, 95% CI: 1.13–2.06). Conclusion HIVST was associated with subsequent facility-based HIV testing and consistent condom use. HIVST may enhance uptake of related HIV prevention services at facilities, suggesting the need for more implementation research.

Identifying risk factors for HIV-positive test results in walk-in and hospitalized patients in a Mexico City HIV clinic: a descriptive study

2019 ◽  
Vol 30 (6) ◽  
pp. 569-576
Author(s):  
Ester Gutiérrez-Velilla ◽  
Francisco J Quezada-Juárez ◽  
Ivonne N Pérez-Sánchez ◽  
Maria C Iglesias ◽  
Gustavo Reyes-Terán ◽  
...  
Keyword(s):  
Risk Factors ◽  
Hiv Testing ◽  
Mexico City ◽  
Hiv Risk ◽  
Hospitalized Patients ◽  
Hiv Positive ◽  
City Hospital ◽  
Cross Sectional ◽  
Hiv Test ◽  
Hiv Risk Factors

The objective of this study was to analyze risk factors for HIV-positive tests in walk-in users and in hospitalized patients in a Mexico City hospital. We undertook a cross-sectional study based on routine HIV testing and counseling service data in adults undergoing an HIV test from January 2015 to July 2017. Multivariate analysis was performed to determine risk factors for walk-in and hospitalized patients. The results showed that 2040 people tested during the period; hospitalized patients were more likely to test HIV-positive than walk-in users (18 versus 15%; p < 0.05). HIV risk factors for hospitalized patients included being men who have sex with men (MSM) (adjusted odds ratio [aOR] 7.2, 95% CI 2.0–26.5), divorced (aOR 4.4, 95% CI 1.3–14.4), having 3–5 lifetime sexual partners (aOR 2.7, 95% CI 1.0–7.4), and being in the emergency room (aOR 3.6, 95% CI 1.1–11.3), intensive care (aOR 27.2, 95% CI 3.4–217.2), or clinical pneumology wards (aOR 33.4, 95% CI 9.7–115.2). In the walk-in group, HIV risk factors included being male (aOR 2.8, 95% CI 1.3–5.9), being MSM (aOR 4.3, 95% CI 2.0–9.5), having sex while using drugs (aOR 2.3, 95% CI 1.3–4.0), being referred by a physician for testing (aOR 3.2, 95% CI 1.6–6.3), and perceiving oneself at risk (aOR 3.8, 95% CI 2.3–6.3). Differential risk factors found among hospitalized patients and walk-in testers can be helpful in designing better HIV testing strategies to increase early diagnosis and linkage to care.

scholarly journals Evaluation of Rapid Testing Algorithms for Venue-based Anonymous HIV Testing among Non-HIV-Positive Men Who Have Sex with Men, National HIV Behavioral Surveillance (NHBS), 2017

2020 ◽  
Vol 45 (6) ◽  
pp. 1228-1235
Author(s):  
Shamaya Whitby ◽  
◽  
Amanda Smith ◽  
Rebecca Rossetti ◽  
Johanna Chapin-Bardales ◽  
...  
Keyword(s):  
Hiv Testing ◽  
Confirmatory Test ◽  
Test Results ◽  
Rapid Testing ◽  
Behavioral Surveillance ◽  
National Hiv Behavioral Surveillance ◽  
Hiv Test ◽  
Hiv Rapid Testing ◽  
Testing Algorithms ◽  
Sex With Men

Abstract HIV rapid testing algorithms (RTAs) using any two orthogonal rapid tests (RTs) allow for on-site confirmation of infection. RTs vary in performance characteristics therefore the selection of RTs in an algorithm may affect identification of infection, particularly if acute. National HIV Behavioral Surveillance (NHBS) assessed RTAs among men who have sex with men recruited using anonymous venue-based sampling. Different algorithms were evaluated among participants who self-reported never having received a positive HIV test result prior to the interview. NHBS project areas performed sequential or parallel RTs using whole blood. Participants with at least one reactive RT were offered anonymous linkage to care and provided a dried blood spot (DBS) for testing at CDC. Discordant results (RT-1 reactive/RT-2 non-reactive) were tested at CDC with lab protocols modified for DBS. DBS were also tested for HIV-1 RNA (VL) and antiretroviral (ARV) drug levels. Of 6500 RTAs, 238 were RT-1 reactive; of those, 97.1% (231/238) had concordant results (RT-1/RT-2 reactive) and 2.9% (7/238) had discordant results. Five DBS associated with discordant results were available for confirmation at CDC. Four had non-reactive confirmatory test results that implied RT-1 false reactivity; one had ambiguous confirmatory test results which was non-reactive in further testing. Regardless of order and type of RT used, RTAs demonstrated high concordant results in the population surveyed. Additional laboratory testing on DBS following discordant results confirmed no infection. Implementing RTAs in the context of anonymous venue-based HIV testing could be an option when laboratory follow-up is not practicable.

scholarly journals Barriers to Acceptance of Provider-Initiated Testing and Counseling among Men Who Have Sex with Men in Shenyang, China: A Cross-Sectional Study

2013 ◽  
Vol 2013 ◽  
pp. 1-7 ◽  
Author(s):  
Qinghai Hu ◽  
Junjie Xu ◽  
Zhenxing Chu ◽  
Jing Zhang ◽  
Ke Yun ◽  
...  
Keyword(s):  
Hiv Infection ◽  
Hiv Testing ◽  
Cross Sectional Study ◽  
Multivariate Logistic Regression Model ◽  
People Living With Hiv ◽  
Cross Sectional ◽  
Aids Knowledge ◽  
Sex With Men ◽  
Testing And Counseling ◽  
Hiv Aids

A high prevalence of HIV infection is present among men who have sex with men (MSM) in China, but many people living with HIV or AIDS (PLWHs) are unaware of their HIV infection status. Provider-initiated HIV testing and counseling (PITC) is a streamlined model that can significantly enhance HIV detection and detect infections earlier. However, PITC has not yet been widely applied, and no studies have been conducted on MSM’s attitudes towards PITC in China. In this study, a total of 438 MSM were recruited in Shenyang city. A multivariate logistic regression model showed that certain conditions made MSM more accepting of PITC: those who had attended VCT (voluntary counseling and testing) more than three times (odds ratio [OR]: 2.95, 95% CI: 1.36–6.37), those who considered PITC beneficial for family and friends (OR: 1.91, 95% CI: 1.25–2.92), those who obtained HIV/AIDS knowledge from brochures (OR: 2.52, 95% CI: 1.64–3.87), those who obtained HIV/AIDS knowledge from the Internet (OR: 1.66, 95% CI: 1.07–2.58), and those who were highly aware of their own risk of being infected with HIV (OR: 2.84, 95% CI: 1.37–5.91). To improve acceptance of PITC among MSM in China, stronger efforts are needed to lower the psychosocial barriers to receiving PITC, to promote HIV/AIDS awareness, and to encourage the extension of HIV testing.

scholarly journals HIV testing practices and the potential role of HIV self-testing among men who have sex with men in Mexico

2016 ◽  
Vol 28 (3) ◽  
pp. 242-249 ◽  
Author(s):  
Catherine E Oldenburg ◽  
Katie B Biello ◽  
Amaya G Perez-Brumer ◽  
Joshua Rosenberger ◽  
David S Novak ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Hiv Testing ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Intention To Use ◽  
Self Testing ◽  
Hiv Test ◽  
Self Test ◽  
Testing Practices ◽  
Sex With Men

The objective of this study was to characterize HIV testing practices among men who have sex with men in Mexico and intention to use HIV self-testing. In 2012, members of one of the largest social/sexual networking websites for men who have sex with men in Latin America completed an anonymous online survey. This analysis was restricted to HIV-uninfected men who have sex with men residing in Mexico. Multivariable logistic regression models were fit to assess factors associated with HIV testing and intention to use a HIV self-test. Of 4537 respondents, 70.9% reported ever having a HIV test, of whom 75.5% reported testing at least yearly. The majority (94.3%) indicated that they would use a HIV home self-test if it were available. Participants identifying as bisexual less often reported ever HIV testing compared to those identifying as gay/homosexual (adjusted odds ratio = 0.52, 95% confidence interval: 0.44–0.62). Having a physical exam in the past year was associated with increased ever HIV testing (adjusted odds ratio = 4.35, 95% confidence interval: 3.73–5.07), but associated with decreased interest in HIV self-testing (adjusted odds ratio = 0.66, 95% confidence interval: 0.48–0.89). The high intention to use HIV home self-testing supports the use of this method as an acceptable alternative to clinic- or hospital-based HIV testing.

scholarly journals Prevalence and Factors Associated With HIV Self-testing Uptake Among Men Who Have Sex With Men in Ningbo, China: A Cross-sectional Study

2020 ◽  
Author(s):  
Hang Hong ◽  
Hong-bo Shi ◽  
Hai-bo Jiang ◽  
Hong-jun Dong ◽  
Yun-liang Shen
Keyword(s):  
Hiv Testing ◽  
Cross Sectional Study ◽  
Sexual Contact ◽  
Categorical Variables ◽  
Sectional Study ◽  
Cross Sectional ◽  
Factors Associated ◽  
The Past ◽  
Self Testing ◽  
Sex With Men

Abstract BackgroundHIV testing and early linkage to care are critical for reducing the risk of HIV transmission. HIV self-testing (HIVST) is an useful tool for increasing HIV testing frequency.This study aimed to investigate HIVST rates among men who have sex with men (MSM), the characteristics of MSM who had HIVST, and factors associated with HIVST uptake among MSM in Ningbo, China. MethodsA cross-sectional study was conducted from April to October 2019 in Ningbo,China. Participants were aged at least 18 years and having had sexual contact with men in the past year. Proportions were used for categorical variables. Adjusted Odds Ratio (AOR) and 95% Confidence Interval (CI) for characteristics associated with HIVST uptake was processed by multiple logistic regression models.ResultsAmong a sample of 699 MSM recruited, 38.2% had reported previous use of an HIV self-test kit. A greater proportion of HIVST Users had a higher frequency of HIV testing(≥2 times: 70.0% versus 41.2%, p<0.001) in the past one year. Factor associated with HIVST uptake was gay apps use(AOR=1.86,CI=1.13-3.05), multiple male sex partners (AOR=1.90,CI=1.29-2.80), frequency of male-male sexual contact ≥1 times per week(AOR=1.86, CI=1.30-2.66), syphilis infection(AOR=5.48, CI=2.53-11.88).ConclusionsFurther HIVST education should be strengthened for school-aged children and teenagers, and free HIVST kits may be provided to low-income high-risk MSM through gay apps and NGOs to achieve the increased HIV testing frequency.

scholarly journals HUBUNGAN JUMLAH KUNJUNGAN ANC DAN STIGMATISASI DENGAN KEIKUTSERTAAN IBU HAMIL DALAM TES HIV SETELAH KONSELING OLEH PETUGAS KESEHATAN (Di Wilayah Kerja Puskesmas Turi Lamongan)

2017 ◽  
Vol 11 (1) ◽  
pp. 89
Author(s):  
Ponco Indah Arista Sari ◽  
Agus Sulistyono ◽  
Hari Basuki Notobroto
Keyword(s):  
Pregnant Women ◽  
Hiv Testing ◽  
Health Workers ◽  
Sampling Technique ◽  
Antenatal Visit ◽  
Cross Sectional ◽  
Significance Level ◽  
Hiv Test ◽  
Antenatal Visits ◽  
Hiv Aids

HIV AIDS is considered as global threat due to the adverse impacts it brings to all sectors. The number of person with HIV-AIDS increases both in men and women. For pregnant women, HIV is not just a threat to the mother but also for the infant, therefore as to prevent the transmission and complication during pregnancy, screening should be made through an HIV test. The purpose of this study was to analyze the relationship between the number ofantenatal care and stigmatization on participation of pregnant women for HIV testing after counseling by Health Workers in the working area of Turi Public Health Center, Lamongan. This study applied cross sectional study. The population in this study consisted of 80 pregnant women. Simple random sampling was chosen for Sampling Technique and it was obtained as many as 42 respondents. Data collection was done using a questionnaire and interviews. Data were analyzed using frequency distribution tables and chi square test with significance level of 5% (p = 0.05). The results revealed that from as many as 42 pregnant women who made antenatal visit > 4 times, 100% of these pregnant women did not take HIV test while pregnant women who made only 2–4 times antenatal visit was as many as 16 individuals (64%) took the test, and only one pregnant woman who took the test on the first visit. Pregnant women who did not have the stigmatization, 100% took the HIV test. Statistical analysis showed no correlation between the number of antenatal visits (p = 0.000) and stigmastization (p = 0.000) of pregnant women for HIV testing after counseling by Health Workers. It is necessary to increase the provision of information and education for the pregnant women through health promotion concerning the importance of HIV testing and antenatal visits to the Health Care.Keywords: HIV test, Number of antenatal care, Stigmatization 

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