Acceptability of male circumcision for prevention of HIV infection in Malawi

Knowledge, Attitudes, Practices, and Acceptability of Medical Male Circumcision among Males in Traditionally Circumcising Rural Communities of Alfred Nzo District, Eastern Cape, South Africa

Male circumcision (MC) reduces HIV transmission risk by up to 60% in heterosexual men. However, uptake of medical male circumcision (MMC) is low in traditionally circumcising communities of South Africa. We assessed knowledge, attitudes, and practices to identify factors predicting acceptability of MMC among males in the Alfred Nzo District. A cross-sectional study was conducted among males aged 15-49 years in this district. Logistic regression was used to identify factors predicting acceptability of MMC. We interviewed 343 males who had a median age of 19 years (interquartile range (IQR): 16-25 years). Of these, 77% (95% confidence interval (CI): 72-82) were circumcised: 77% (95% CI: 71-82) were circumcised in a traditional setting and 21% (95% CI: 16-26) in a medical setting. The median score of knowledge about the benefits of MMC was 62.5% (IQR: 37.5-75.0), with 59% (95% CI: 53-64) demonstrating a positive attitude towards MMC and 68% (95% CI: 63-73) accepting involvement of health workers in MC. Excellent knowledge (adjusted odds ratio (aOR): 3.07, 95% CI: 0.99-9.58, p = 0.053), awareness (aOR: 3.26, 95% CI: 1.08-9.86, p = 0.037), and positive attitude towards MMC (aOR: 2.35, 95% CI: 1.30-4.25, p = 0.005) were associated with acceptability of MMC. Participants demonstrated good knowledge and acceptance of the MMC programme. Knowledge, attitude, and awareness were significant predictors of MMC acceptability.

Anesthesia Analysis of Compound Lidocaine Cream Alone in Adult Male Device-Assisted Circumcision

OBJECTIVE

to evaluate the anesthetic effect among adult male patients with the single use of compound lidocaine cream in device-assisted circumcision, hoping to provide an anesthetic method for the simplification of the surgical process.

METHODS

Male adult patients undergoing device-assisted circumcision through prepuce local anesthesia using lidocaine cream in Xiangya Hospital of Central South University from December 2020 to August 2021 were selected. According to different age groups and different surgical procedures, the anesthetic effect of compound lidocaine cream was analyzed considering the aspects of anesthetic cost, anesthetic time, anesthetic duration, anesthetic effect, anesthetic side effects and anesthetic satisfaction.

RESULTS

In the study, 99.1% of 649 patients needed only 1 application of compound lidocaine cream to complete the operation. The time taken for anesthesia was short; the whole anesthesia process only required approximately 2-5 min. However, for patients with severe phimosis, the time to complete the anesthesia procedure was correspondingly longer. The pain degree caused by anesthesia was low, and the patients with a pain score of ≤3 points accounted for 96.7%. The anesthetic effect lasted for a sufficiently long period, and the time of algesia recovery from local anesthesia was almost 1 h after surgery. The anesthesia effect was sufficient, and patients with an intraoperative pain score of ≤3 accounted for 98.7%, which could meet the surgical requirements. There were few side effects of the anesthesia. The overwhelming majority of patients were pleased with the anesthesia, and 98.9% of patients had an anesthesia satisfaction score of ≥7.

CONCLUSION

The compound lidocaine cream, as a local anesthetic, is safe and effective for most adult male device-assisted circumcisions. More useful information needs to be corroborated by more advanced evidence, especially for severe phimosis.

Uptake of voluntary medical male circumcision among men with sexually transmitted infections in Lilongwe, Malawi: a protocol for a pre-interventional and post-interventional study

INTRODUCTION

Voluntary medical male circumcision (VMMC) is one of the key interventions for HIV prevention. However, its uptake among men in Malawi is low. Implementation science strategies for demand creation of VMMC increase uptake. We designed an implementation science demand-creation intervention to increase the uptake of VMMC among men with sexually transmitted infections (STIs).

METHODS AND ANALYSIS

We designed a pragmatic pre-interventional and post-interventional quasi-experimental study combined with a prospective observational design to determine the uptake, acceptability, appropriateness and feasibility of a multifaceted intervention for scale up of uptake of VMMC among men with STIs at Bwaila STI clinic in Lilongwe, Malawi. The intervention includes transport reimbursement (R), intensified health education (I) and short messaging service (SMS)/telephonic tracing (Te) (RITe). The intervention will be implemented in phases: pre-implementation and implementation. Pre-implementation phase will be used for collecting baseline data, while the RITe intervention will be rolled-out in the implementation phase. The RITe intervention will be implemented in a sequential and incremental manner called implementation blocks: block 1: intensified health education; block 2: intensified health education and SMS/telephonic tracing; and block 3: intensified health education, SMS/telephonic tracing and transport reimbursement. The target sample size is 80 uncircumcised men for each intervention block, including the pre-implementation sample, making a total of 320 men (280 total, 70 per block will be surveyed). The primary outcome is uptake of VMMC during the implementation period. Mixed methods assessments will be conducted to evaluate the acceptability, appropriateness and feasibility of the RITe intervention.

ETHICS AND DISSEMINATION

The study protocol was approved by the Malawi's National Health Sciences Research Ethics Committee (approval number: 19/10/2412), University of North Carolina at Chapel Hill's Institutional Review Board (approval number: 19-2559) and University of the Witwatersrand's Health Research Ethics Committee (approval number: M200328). Results will be disseminated via publication in a peer-reviewed journal and presentations at relevant scientific conferences and meetings.

TRIAL REGISTRATION NUMBER

NCT04677374.

Circumcision as an Intervening Strategy against HIV Acquisition in the Male Genital Tract

Unsafe sex with HIV-infected individuals remains a major route for HIV transmission, and protective strategies, such as the distribution of free condoms and pre-or post-prophylaxis medication, have failed to control the spread of HIV, particularly in resource-limited settings and high HIV prevalence areas. An additional key strategy for HIV prevention is voluntary male circumcision (MC). International health organizations (e.g., the World Health Organization, UNAIDS) have recommended this strategy on a larger scale, however, there is a general lack of public understanding about how MC effectively protects against HIV infection. This review aims to discuss the acquisition of HIV through the male genital tract and explain how and why circumcised men are more protected from HIV infection during sexual activity than uncircumcised men who are at higher risk of HIV acquisition.

Voluntary medical male circumcision and sexual practices among sexually active circumcised men in Mzuzu, Malawi: a cross-sectional study

BACKGROUND

Voluntary Medical Male Circumcision (VMMC) is one of the strategies being promoted to prevent sexual heterosexual transmission of HIV. It has been adopted by 14 countries with high HIV prevalence and low circumcision rates. The 60.0% protective efficacy of VMMC has come with misconceptions in some societies in Malawi, hence VMMC clients may opt for risky sexual practices owing to its perceived protective effect. The study estimated proportion of circumcised men engaging in risky sexual behaviors post-VMMC, assessed knowledge on VMMC protective effect and identified socio-demographic factors associated with risky sexual practices.

METHOD

A cross sectional study was conducted at two sites of Mzuzu city. Systematic random sampling was used to select 322 participants aged 18-49 who had undergone VMMC. The independent variables included age, location, occupation, religion, marital status and education. Outcome variables were non condom use, having multiple sexual partners and engaging in transactional sex. Data from questionnaires was analyzed using Pearson's chi square test and logistic regression.

RESULTS

Out of 322 respondents, 84.8% (273) understood the partial protection offered by VMMC in HIV prevention. Ninety-six percent of the participants self-reported continued use of condoms post VMMC. Overall 23.7-38.3% participants self-reported engaging in risky sexual practices post VMMC, 23.7% (76) had more than one sexual partner; 29.2% (94) paid for sex while 39.9% (n = 187) did not use a condom. Residing in high density areas was associated with non-condom use, (p = 0.043). Being single (p < 0.001), and residing in low density areas (p = 0.004) was associated with engaging in transactional sex.

CONCLUSION

Risky sexual practices are evident among participants that have undergone VMMC. Messages on safer sexual practices and limitations of VMMC need to be emphasized to clients, especially unmarried or single and those residing in low density areas.

Male circumcision and global HIV/AIDS epidemic challenges

Background

Given the devastating mortality and morbidity associated with HIV/AIDS, many potential prevention measures against HIV infection continue to be explored. Most prevention methods are in the realm of sexual behavior change. However, of all aspects of human behavior, it is sexual behavior that is least amenable to change. Newer and simpler interventions are therefore required. Male circumcision, the surgical removal of some or all of the foreskin (or prepuce) from the penis, is one of the ways being promoted as a preventive measure. This paper reviews the scientific basis and evidence for the efficacy of male circumcision within the context of the global challenges involved.

Main body

We reviewed articles with emphasis on male circumcision and HIV/AIDS transmission. Published abstracts of presentations at international scientific meetings were also reviewed.

Conclusions

Current epidemiological evidence supports the promotion of male circumcision for HIV prevention, especially in populations with high HIV prevalence and low circumcision rates. Three notable randomized control trials strengthen the case for applied research studies to demonstrate that safe male circumcision is protective at the population level, particularly as ideal and well-resourced conditions of a randomized trial are often not replicated in other service delivery settings. Ethically and culturally responsive strategies in promoting circumcision in a culturally heterogenous world need to be developed, too. Male circumcision should also be viewed as a complementary measure along with other proven approaches to turn the HIV/AIDS epidemic around.

Knowledge and perceptions of male immigrants in Leeds (UK) towards male circumcision as an HIV prevention strategy

BACKGROUND

The World Health Organization has accepted and recommended medical male circumcision (MMC) as an HIV prevention strategy. Despite the advantages of MMC, the rate of uptake of this practice among immigrants and the general population in the United Kingdom (UK) is low, yet the procedure is provided in public and private health facilities. The role of negative perception and its contribution to low circumcision rates is unknown.

OBJECTIVES

Since immigrants are a key group that is vulnerable to HIV in the UK, this study aimed at understanding their knowledge and perceptions with regard to MMC.

METHODS

We enrolled 10 participants who were purposively selected using snowball recruitment methods. Data were collected during individual in-depth interviews using semi-structured interview guides. Responses were audio recorded, transcribed and analyzed using thematic analysis. Appropriate themes were generated from the data collected.

RESULTS

We found that the majority looked at male circumcision (MC) as a practice to fulfill their cultural and religious obligations rather than as an HIV protection method. Few participants showed belief and certainty that MC or MMC was effective in HIV prevention hence limited knowledge. They also expressed perceived danger. This included fear of pain, complications from the procedure and possible infections when carried out through traditional means. These dangers discouraged study participants from accessing MMC.

CONCLUSION

Male circumcision is mainly practiced to fulfill cultural and religious norms, but is not seen as a credible HIV prevention strategy.

Use of topical versus injectable anaesthesia for ShangRing circumcisions in men and boys in Kenya: Results from a randomized controlled trial

Background

The ShangRing is a disposable, collar clamp circumcision device pre-qualified for use in men and boys 13 years and above. It has been shown to be faster than conventional circumcision with comparable adverse event (AE) rates and high client satisfaction. Voluntary medical male circumcision (VMMC) has been shown to dramatically reduce the risk of HIV acquisition in males. However, the fear of pain during circumcision is an important barrier to uptake. Use of topical anesthesia thus presents an opportunity to address this.

Objectives

We sought to evaluate the safety, effectiveness and acceptability of the use of topical anaesthesia with ShangRing circumcision of men and boys 10 years of age and above.

Methods

Participants were randomised 2:1 to receive topical or injectable anaesthesia. All participants underwent no-flip ShangRing circumcision. The primary outcome measure was pain. Secondary outcomes included ease of use of topical versus injectable anaesthesia, AEs and participant satisfaction.

Results

Compared to the topical group, participants in the injectable group reported significantly more pain on administration of the anesthesia and at approximately 20 minutes after the procedure. In the topical group, sufficient anaesthesia with topical cream was not achieved in 21 (9.3%) cases before the start of the procedure; in another 6 (2.6%), supplementary injectable anaesthesia was required as the circumcision was being carried out. The AE rate was significantly lower (p<0.01) in the topical (0%) vs. the injectable group (4.2%). The most common AE was pain during the post-operative period. All AEs were managed conservatively and resolved without sequeale. 96.7% of participants were satisfied with the appearance of the healed penis and 100% would recommend the ShangRing to others. All seven male circumcision providers involved in the study preferred topical to injectable anaesthesia.

Conclusions

Our results demonstrate the safety, improved clinical experience, effectiveness, and acceptability of the use of topical anaesthesia in ShangRing circumcision using the no-flip technique. Topical anaesthesia effectively eliminates needlestick pain from the clients’ VMMC experience and thus has the potential to increase demand for the service.

Trial registration

ClinicalTrials.gov NCT02390310.

Risk perception and the influence on uptake and use of biomedical prevention interventions for HIV in sub-Saharan Africa: A systematic literature review

BACKGROUND

Risk perception has been found to be a crucial factor explaining inconsistent or non-use of HIV prevention interventions. Considerations of risk need to expand beyond risk of infection to also include the personal, social, emotional, and economic risks associated with prevention intervention use.

OBJECTIVES

This systematic review of qualitative peer-reviewed literature from sub-Saharan Africa examines perceptions of risk associated with HIV infection and HIV prevention intervention use.

DATA SOURCES

We searched Medline, Embase, PsychInfo, Africa Wide Info, CINAHL, and Global Health for publications and screened them for relevance.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed qualitative studies published since 2003 were eligible for inclusion if they examined risk perception or uncertainty in the context of a medically regulated intervention. Only studies focusing on adults were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Included publications were quality assessed using the Hawker method and coded thematically.

RESULTS

10318 unique papers were identified, of which 29 are included. Among the themes identified, a particularly salient one was the potential of HIV prevention interventions to threaten the stability of a relationship and impact on how and when people may-or may not-choose to use prevention interventions.

LIMITATIONS

This literature review excludes grey-literature, which may have distinct valuable insights. We also excluded quantitative studies that may have challenged or triangulated our findings.

CONCLUSIONS AND IMPLICATIONS

When considering the risk of HIV acquisition, it is insufficient to examine biological risk in isolation from the personal, relational and economic costs associated with intervention use. This loss of emotional, physical, or material support may be perceived as more consequential than the prevention of a potential infection.

Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement

Global experts recognize the need to transform conventional models of healthcare to create adolescent responsive health systems. As countries near 80% coverage of voluntary medical male circumcision (VMMC) for those aged 15-49 years, prioritization of younger men becomes critical to VMMC sustainability. This special supplement reporting 9 studies focusing on adolescent VMMC programming and services comes at a critical time. Eight articles report how well adolescents are reached with the World Health Organization's minimum package for comprehensive human immunodeficiency virus (HIV) prevention in South Africa, Zimbabwe, and Tanzania, analyzing motivation, counseling, wound healing, parental involvement, female peer support, quality of in-service communication, and providers' perceptions, and one presents models for achieving high VMMC coverage by 2021. One important finding is that adolescent boys, especially the youngest, experience gaps in their comprehension of key elements in the World Health Organization's minimum package. Although parents, counselors, and providers are involved and supportive, they are inadequately prepared to counsel youth, partly owing to discomfort with adolescent sexuality. At the country level, deliberately prioritizing young adolescents (aged 10-14 years) is likely to achieve national coverage targets more quickly and cost-effectively than continuing to focus on older, harder-to-reach men. The studies in this supplement point to areas where VMMC programs are achieving successes and they reveal areas for improvement. Given that prioritizing adolescents will be the best means of achieving sustainable VMMC for HIV prevention for the foreseeable future, applying the lessons learned here will increase the effectiveness of VMMC programs.

Low Uptake of Voluntary Medical Male Circumcision Among High Risk Men in Malawi

Malawi is one of 14 priority countries for voluntary medical male circumcision (VMMC) initiatives with the lowest VMMC uptake. Using data from a study of 269 men accessing VMMC in southern Malawi and latent class analysis, men were classified based on four risk factors: ever tested for HIV, condom use at last sex, having casual/concurrent sexual partners, and using alcohol before sex. Two distinct classes were identified: 8% of men were classified as high risk, while 92% were classified as low/medium risk. Poisson regression modeling indicated that men who had lower education (risk ratio [RR] 1.07, p < 0.05) and were ages 19-26 (RR 1.07, p < 0.05) were more likely to be in the high risk group. The low numbers of men in the high risk category seeking services suggests the need to implement targeted strategies to increase VMMC uptake among such high risk men.

Long term post PrePex male circumcision outcomes in an urban population in Uganda: a cohort study

Objective

The objective of this study was to determine the long term adverse events profile at least a year after safe male circumcision.

Results

A cohort study, investigating patients who had undergone a non surgical circumcision procedure called Prepex. The study variables included scar appearance and sexual experiences. Clients were contacted for a phone interview and data were collected using a questionnaire, for some, a physical examination was done. We obtained ethical committee approval. Data from 304 out of a possible 625 men were analyzed, the rest was lost to follow up. The follow up period was 12–24 months. The mean age was 28 years. Up to 97% were satisfied with the penile scar appearance and the absence of pain. There was no keloids formation, though one developed a hypertrophic scar. Participants reported improved sexual intercourse enjoyment (post circumcision). Up to 17% resumed sexual intercourse before the 6-week long mandatory abstinence period. The average self-reported healing time was 4.7 weeks. There was a high level of scar appearance satisfaction, there was no keloids formation. There was a perceived improvement of sexual enjoyment after circumcision.

Trial registration ClinicalTrials. Gov Identifier: NCT02245126 (Date of registration: September 19, 2014)

Participant Experiences and Views of Odor and PrePex Device Removal Pain in a VMMC Pilot Study in Botswana

OBJECTIVE

To assess participant experiences and perceptions of removal pain and odor associated with the PrePex device procedure.

METHODS

We analyzed data from a PrePex device pilot implementation study of 802 male participants aged 18-49 years at 2 clinics in Botswana, 2013. Study staff administered survey questions on device-related odor and assessed pain using visual analog scale scores categorized as no pain (0), mild (1-4), moderate (5-7), or severe pain (8-10).

RESULTS

Mean participant age was 27.7 (range = 18-48) years. Of the 802 participants, 751 (94%) reported to have noticed an unusual or unpleasant odor while wearing the device. Of these, 193 (26%) participants tried something to combat the odor. A total of 84 (10%) participants reported no pain, 655 (82%) mild pain, 48 (6%) moderate pain, and 15 (2%) severe pain at 2 minutes after device removal. Pain reports at 15 minutes after removal were 553 (69%) no pain, 247 (31%) mild pain, and 2 (0.25%) moderate pain, with no report of severe pain at this time point. Of 740 participants interviewed on day 42 after device placement, 678 (92%) were satisfied with the procedure and 681 (92%) would recommend it to another man considering circumcision, including 488 (66%) who would recommend it strongly.

CONCLUSIONS

An unusual or unpleasant odor while wearing the PrePex device and mild self-limiting pain at device removal were common, but overall, these did neither seem to impair satisfaction nor deter participants from recommending PrePex to others, which could suggest good prospects for uptake of the device in this setting.

Multilevel influences on acceptance of medical male circumcision in Rakai District, Uganda

Despite access to safe medical male circumcision (MMC) and proven effectiveness of the procedure in reducing acquisition of HIV and other sexually transmitted infections, uptake remains suboptimal in many settings in sub-Saharan Africa, including Rakai District, Uganda. This study explored multilevel barriers and facilitators to MMC in focus group discussions (FGDs) (n = 35 groups) in Rakai. Focus groups were conducted from May through July 2012 with adolescent and adult males, with a range of HIV risk and reproductive health service use profiles, and with adolescent and adult females. Data were analyzed using Atlas.ti and an inductive approach. Participants' discussions produced several key themes representing multilevel influences that may facilitate or create barriers to uptake of MMC. These include availability of MMC services, economic costs, masculine ideals, religion, and social influence. Understanding how males and females view MMC is a crucial step towards increasing uptake of the procedure and reducing disease transmission.

Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic

BACKGROUND

Voluntary medical male circumcision (VMMC) is effective in decreasing the risk of HIV acquisition. As men resume sexual activity after circumcision, it will be important to study their satisfaction with the procedure, sexual pleasure and function, coital trauma, and risk compensation (RC), which can hamper or facilitate the long-term success of VMMC programs.

AIM

To assess men's satisfaction with VMMC, sexual pleasure and function, coital trauma, and RC after VMMC.

METHODS

This is a cohort study of circumcised men who presented for follow-up 6 to 24 months after VMMC. Logarithmic binomial regression was performed to explore factors associated with any increase in the number of sex partners after VMMC as a measurement of RC.

MAIN OUTCOME MEASURES

(i) Men's satisfaction with their VMMC; (ii) sexual pleasure and function after VMMC; (iii) coital trauma; and (iv) RC.

RESULTS

Of 454 circumcised men, 362 (80%) returned for a follow-up visit 6 to 24 months after VMMC. Almost all (98%) were satisfied with the outcome of their VMMC; most (95%) reported that their female partners were satisfied with their circumcision. Two thirds (67%) reported enjoying sex more after VMMC and most were very satisfied or somewhat satisfied (94%) with sexual intercourse after VMMC. Sexual function improved and reported sex-induced coital injuries decreased significantly in most men after VMMC. There was an increase in the proportion of men who reported at least two sexual partners after VMMC compared with baseline. In multivariate analysis, having sex with a woman they met the same day (adjusted relative risk = 1.7, 95% CI = 1.2-2.4) and having at least two sexual partners at baseline (adjusted relative risk = 0.5, 95% CI = 0.3-0.8) were associated with the outcome of any increase in the number of partners after VMMC.

CLINICAL IMPLICATIONS

VMMC can be offered to Dominican men for HIV prevention without adversely affecting sexual pleasure or function. The procedure substantially reduces coital trauma.

STRENGTHS & LIMITATIONS

This is the first report of long-term overall satisfaction, sexual pleasure/function and sex behaviors in the context of VMMC outside of Africa. Limitations of the study included the reliance on self-reported sex behaviors, the lack of physiologic measurement of penile sensitivity and the lack of follow up data beyond 24 months, which precludes the assessment of longer term RC.

CONCLUSION

The study confirmed men's long-term satisfaction with the outcome of their VMMC. VMMC improved sexual pleasure and function for most men and significantly decreased coital injuries. There was mixed evidence of RC. Brito MO, Khosla S, Pananookooln S, et al. Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic. J Sex Med 2017;14:526-534.

A cut above the rest? Private anthropometrics in marriage markets

A large body of economic research suggests that publicly observable anthropometric characteristics affect labor and marriage market outcomes. Private anthropometrics may not affect these outcomes. We examine male circumcision in marriage markets in Zambia. Our analysis reveals substantial variation across local marriage markets in circumcision prevalence relative to preference for circumcised partners, as well as excess aggregate demand for circumcised males. Regression estimates suggest a marriage market premium of approximately one-half to one year of additional schooling for matching with a partner of preferred anthropometric type in a local marriage market with excess demand for that anthropometric characteristic.

Factors Associated with Preference for Early Infant Male Circumcision Among a Representative Sample of Parents in Homa Bay County, Western Kenya

Several countries scaling-up adult medical male circumcision (MMC) for HIV prevention intend to introduce early infant male circumcision (EIMC). To assess preference for EIMC in a community with a mature adult MMC program, we conducted a cross-sectional survey of a representative sample of mothers (n = 613) and fathers (n = 430) of baby boys ("index son") at 16 health facilities in western Kenya. Most (59 %) were for EIMC, generally. Just 29 % were for circumcising the index son. Pain and protection from HIV were the most frequently cited barrier and facilitator to EIMC, respectively. In multivariable logistic regression, ever talking with the partner about EIMC and positive serostatus were associated with preference for EIMC for the index son. Attitudes towards EIMC are favorable. Willingness to circumcise an infant son is modest. To facilitate EIMC uptake, education about EIMC pain management and encouraging discussion between parents about EIMC during pregnancy should be integrated into programs.

Factors associated with acceptability of child circumcision in Botswana -- a cross sectional survey

Background

Safe male child circumcision has been recently adopted as a potential strategy to prevent HIV/AIDS transmission in later life in Botswana.

Methods

Data used was derived from a cross-sectional survey, the Botswana AIDS Impact Survey (BAIS) IV, conducted in 2013. A total sample of 7984 respondents in ages 15–64 years who had successfully completed the individual questionnaire during the survey were selected and included for analysis. Both descriptive and multivariable analyses were used to explore factors associated with acceptability of child circumcision. Data was analysed using SPSS version 22 program.

Results

Results indicate that about 84 % of participants said they would circumcise their male children aged 18 years and below, while 93 % were aware of the safe male circumcision program. Bivariate analyses results show that acceptability of child circumcision was significantly associated with sex, age, education, religion, residence, HIV status of the parent, fathers circumcision status, father's intention to circumcise and parent's knowledge about the safe male circumcision program. Multivariable analyses results indicate positive association between respondent's HIV positive status (OR, 3.5), Men's circumcision status (OR, 3.7), men's intention to circumcise (OR, 9.3) and acceptability of child circumcision.

Conclusion

Results of this study indicate some relatively high acceptability levels for child circumcision. Some individual behavioural factors influencing acceptability of child circumcision were also identified. This study provides a proper understanding of factors associated with acceptability of child circumcision which will ultimately enhance the successful roll-out of the school going children circumcision program in Botswana.

Factors associated with married women's support of male circumcision for HIV prevention in Uganda: a population based cross-sectional study

BACKGROUND

Despite the protective effect of male circumcision (MC) against HIV in men, the acceptance of voluntary MC in priority countries for MC scale-up such as Uganda remains limited. This study examined the role of women's sociodemographic characteristics, knowledge of HIV and sexual bargaining power as determinants of women's support of male circumcision (MC).

METHODS

Data from the Uganda AIDS Indicator Survey, 2011 were analyzed (n = 4,874). Bivariate and multivariate logistic regression analyses with random intercept were conducted to identify factors that influence women's support of MC.

RESULTS

Overall, 67.0 % (n = 3,276) of the women in our sample were in support of MC but only 28.0 % had circumcised partners. Women who had the knowledge that circumcision reduces HIV risk were about 6 times as likely to support MC than women who lacked that knowledge [AOR (adjusted odds ratio) = 5.85, 95 % CI (confidence interval) = 4.83-7.10]. The two indicators of women's sexual bargaining power (i.e., ability to negotiate condom use and ability to refuse sex) were also positively associated with support of MC. Several sociodemographic factors particularly wealth index were also positively associated with women's support of MC.

CONCLUSIONS

The findings in this study will potentially inform intervention strategies to enhance uptake of male circumcision as a strategy to reduce HIV transmission in Uganda.

Voluntary medical male circumcision for HIV prevention in fishing communities in Uganda: the influence of local beliefs and practice

Local beliefs and practices about voluntary medical male circumcision (VMMC) may influence uptake and effectiveness. Data were gathered through interviews with 40 people from four ethnically mixed fishing communities in Uganda. Some men believed that wound healing could be promoted by contact with vaginal fluids while sex with non-regular partners could chase away spirits - practices which encouraged unsafe sexual practices. Information given by providers stressed that VMMC did not afford complete protection from sexually-transmitted infections, however, a number of male community members held the view that they were fully protected once circumcised. Both men and women said that VMMC was good not just for HIV prevention but also as a way of maintaining hygiene among the men. The implementation of VMMC in high-HIV prevalence settings needs to take account of local beliefs about circumcision, working with local religious/social group leaders, women and peers in the roll-out of the intervention.

Safety, Acceptability, and Feasibility of Early Infant Male Circumcision Conducted by Nurse-Midwives Using the AccuCirc Device: Results of a Field Study in Zimbabwe

Early infant male circumcision (EIMC) conducted by nurse-midwives using the AccuCirc device proved safe, feasible, and acceptable to parents in Zimbabwe. The AccuCirc device has the potential to facilitate widespread scale-up of safe EIMC in sub-Saharan Africa.

Background:

For prevention of HIV, early infant male circumcision (EIMC) needs to be scaled up in countries with high HIV prevalence. Routine EIMC will maintain the HIV prevention gains anticipated from current adult male circumcision initiatives. We present here the results of a field study of EIMC conducted in Zimbabwe.

Methods:

The study was observational and based on the World Health Organization (WHO) framework for clinical evaluation of male circumcision devices. We recruited parents of newborn male infants between August 2013 and July 2014 from 2 clinics. Nurse-midwives used the AccuCirc device to circumcise eligible infants. We followed participants for 14 days after EIMC. Outcome measures were EIMC safety, acceptability, and feasibility.

Results:

We enrolled 500 male infants in the field study (uptake 11%). The infants were circumcised between 6 and 60 days postpartum. The procedure took a median of 17 minutes (interquartile range of 5 to 18 minutes). Mothers’ knowledge of male circumcision was extensive. Of the 498 mothers who completed the study questionnaire, 91% knew that male circumcision decreases the risk of HIV acquisition, and 83% correctly stated that this prevention is partial. Asked about their community’s perception of EIMC, 40% felt that EIMC will likely be viewed positively in their community; 13% said negatively; and 47% said the perception could be both ways. We observed 7 moderate or severe adverse events (1.4%; 95% confidence interval, 0.4% to 2.4%). All resolved without lasting effects. Nearly all mothers (99%) reported great satisfaction with the outcome, would recommend EIMC to other parents, and would circumcise their next sons.

Conclusion:

This first field study in sub-Saharan Africa of the AccuCirc device for EIMC demonstrated that EIMC conducted by nurse-midwives with this device is safe, feasible, and acceptable to parents.

Adolescent Sexual and Reproductive Health Services and Implications for the Provision of Voluntary Medical Male Circumcision: Results of a Systematic Literature Review

Background

Voluntary medical male circumcision (VMMC) is a critical HIV prevention tool. Since 2007, sub-Saharan African countries with the highest prevalence of HIV have been mobilizing resources to make VMMC available. While implementers initially targeted adult men, demand has been highest for boys under age 18. It is important to understand how male adolescents can best be served by quality VMMC services.

Methods and Findings

A systematic literature review was performed to synthesize the evidence on best practices in adolescent health service delivery specific to males in sub-Saharan Africa. PubMed, Scopus, and JSTOR databases were searched for literature published between January 1990 and March 2014. The review revealed a general absence of health services addressing the specific needs of male adolescents, resulting in knowledge gaps that could diminish the benefits of VMMC programming for this population. Articles focused specifically on VMMC contained little information on the adolescent subgroup. The review revealed barriers to and gaps in sexual and reproductive health and VMMC service provision to adolescents, including structural factors, imposed feelings of shame, endorsement of traditional gender roles, negative interactions with providers, violations of privacy, fear of pain associated with the VMMC procedure, and a desire for elements of traditional non-medical circumcision methods to be integrated into medical procedures. Factors linked to effective adolescent-focused services included the engagement of parents and the community, an adolescent-friendly service environment, and VMMC counseling messages sufficiently understood by young males.

Conclusions

VMMC presents an opportune time for early involvement of male adolescents in HIV prevention and sexual and reproductive health programming. However, more research is needed to determine how to align VMMC services with the unique needs of this population.

What are the social and individual factors that are associated with undergoing male circumcision as an HIV prevention strategy? A mixed methods study in Malawi

BACKGROUND

There is compelling evidence that medical male circumcision (MMC) decreases transmission of HIV. Nevertheless, the uptake of MMC is generally very low. Understanding the characteristics of individuals who choose MMC could inform future strategies for scaling-up MMC. The main objective of this study was to explore the social and individual characteristics of men that are associated with the uptake of circumcision as an HIV prevention strategy.

METHODS

A mixed-methods study, comprising a cross-sectional survey and an exploratory qualitative study, was conducted in Malawi. A total number of 1644 men, of at least 18 years old, participated in this study. A multistage sampling approach was used in the survey while convenience sampling was adopted in the qualitative study. Descriptive statistics, bivariate analyses and multivariable logistic regression were performed to analyze the cross-sectional data and thematic content approach to analyze the qualitative data.

RESULTS

Individuals who chose MMC were more likely to be unemployed (AOR=1.65; 95% CI: 1.30-2.11), to be married (AOR=3.16; 95% CI: 2.21-4.52) and to have had exposure to MMC promotions (AOR=1.81; 95% CI: 1.41-2.33). They were also more likely to reside in rural areas (AOR=1.85; 95% CI: 1.44-2.38), to perceive themselves as more vulnerable to HIV (AOR=1.60; 95% CI: 1.19-2.15) and to be more knowledgeable about the benefits of MMC (AOR=1.51; 95% CI: 1.16-1.97).

CONCLUSIONS

The findings suggest that men who had certain social and individual characteristics (for example better knowledge of the benefits of MMC, greater perceived vulnerability to HIV, married and unemployed) were more likely to choose circumcision as a prevention strategy for HIV than those who lacked those characteristics. Strategies for increasing MMC take-up should recognize the current social/individual landscape of MMC uptake and ensure that deliberate efforts targeting marginalized categories of men are available.

Male circumcision and HIV infection among sexually active men in Malawi

BACKGROUND

The HIV epidemic remains a major health challenge all over the world. In 2013, an estimated 35million people were living with HIV globally. Male circumcision is increasingly being adopted as a method of HIV prevention. WHO and UNAIDS have advised that male circumcision be added to current HIV interventions. Malawi is one of the countries hardest hit by HIV/AIDS with a prevalence rate of 11 % and male circumcision prevalence of 21.6 % in 2010. Prior to 2011, traditional male circumcision in Malawi was the dominant form of male circumcision, mainly for cultural and religious reasons. This paper looks at male circumcision as a prevention method against HIV by examining the relationship between male circumcision and HIV status among Malawian men.

METHODS

The data used were collected as part of the 2010 Malawi Demographic and Health Survey. The methodology used in the 2010 MDHS has been comprehensively described by the National Statistical Office of Malawi and ICF Macro. Our analysis is based on men aged 15-54 years who were tested for HIV and responded to questions on circumcision during the survey. Sixty one percent of the 7175 men interviewed in the MDHS, qualified for this analysis. The sample was weighted to ensure representativeness. Frequencies, cross-tabulations, univariate and multivariate logistic regressions were conducted. Differences in the prevalence of HIV infection among circumcised and uncircumcised men were determined with Chi-squared tests.

RESULTS

There is no significant difference in HIV prevalence between circumcised (12 %) and uncircumcised men (10 %). Among circumcised men, age and number of lifetime partners are the dominant correlates of HIV status. Additionally, circumcised men who have had ritual sex are two times more likely (OR = 2.399) to be HIV+ compared to circumcised men who have never had ritual sex.

CONCLUSION

This study has demonstrated that traditional male circumcision was not associated with HIV infection in pre-2010 Malawi. Among circumcised men, age and number of lifetime partners are correlates to HIV status while circumcised men who have had ritual sex are more likely to be diagnosed with HIV than circumcised men who have not had ritual sex.

Acceptability of Male Circumcision among College Students in Medical Universities in Western China: A Cross-Sectional Study

Background

Male circumcision (MC) has been shown to reduce the risk of female to male transmission of HIV. The goal of this survey was to explore MC’s acceptability and the factors associated with MC among college students in medical universities in western China.

Methods

A cross-sectional study was carried out in three provinces in western China (Guangxi, Chongqing and Xinjiang) to assess the acceptability of MC as well as to discover factors associated with the acceptability among college students in medical universities. A total of 1,790 uncircumcised male students from three medical universities were enrolled in this study. In addition, 150 students who had undergone MC were also enrolled in the survey, and they participated in in-depth interviews.

Results

Of all the uncircumcised participants (n = 1,790), 55.2% (n = 988) were willing to accept MC. Among those who accepted MC, 67.3% thought that MC could improve their sexual partners’ hygiene, 46.3% believed that HIV and sexually transmitted diseases (STDs) could be partially prevented by MC. The multivariable logistic regression indicates that MC’s acceptability was associated with three factors: the redundant foreskin (OR = 10.171, 95% CI = 7.629–13.559), knowing the hazard of having a redundant foreskin (OR = 1.597, 95% CI = 1.097–2.323), and enhancing sexual pleasure (OR = 1.628, 95% CI = 1.312–2.021). The in-depth interviews for subjects who had undergone MC showed that the major reason for having MC was the redundant foreskin (87.3%), followed by the benefits and the fewer complications of having MC done. In addition, most of these participants (65.3%) said that the MC could enhance sexual satisfaction.

Conclusions

MC’s acceptance among college students in medical universities is higher than it is among other populations in western China. An implementation of an MC programme among this population is feasible in the future.

Reasons for the low uptake of adult male circumcision for the prevention of HIV transmission in Swaziland

Swaziland is currently experiencing the worst impact of HIV and AIDS of any country in the world. In an effort to curb further spread of the virus, the country adopted mass male circumcision (MC) as recommended by the World Health Organization in 2007. Despite intense campaigns to promote the procedure over the past three years, the uptake of circumcision remains very low for reasons that are not very clear. The purpose of this study was to explore the reasons for the low uptake of MC in Swaziland despite the massive national MC campaigns. A qualitative research design was used, in which all men who were targeted by the mass MC campaign were eligible. Participants were identified as they came for sexual and reproductive health services at the Family Life Association of Swaziland (FLAS) Clinic, Mbabane. In-depth, individual face-to-face unstructured interviews were conducted to elicit the reasons why men were not going for circumcision. A total of 17 men were interviewed. Results showed that these reasons include fear of the procedure and the possible outcome, perception of no significant benefit of the procedure, impatience about waiting for the procedure or the healing process, religious/cultural beliefs, and worries about the fate of the foreskin. These reasons were attributed to misconceptions and lack of accurate and specific information about some aspects of the circumcision strategy of HIV preventions. Physiological changes and economic activities associated with adulthood were also found to be hindrances to MC uptake. The study recommended that a comprehensive description of the procedure and more precise facts and scientific bases of the MC strategy be incorporated and emphasised in the MC campaigns. Involvement of religious leaders will also facilitate clarification of religious or cultural misunderstandings or misconceptions. A focus on neonatal MC would also help.

Informing the scaling up of voluntary medical male circumcision efforts through the use of theory of reasoned action: survey findings among uncircumcised young men in Swaziland

Assessing predictors of intention to circumcise can help to identify effective strategies for increasing uptake of voluntary medical male circumcision (VMMC). Grounded in the theory of reasoned action (TRA), the current study of uncircumcised males ages 13-29 in Swaziland (N = 1,257) employed multivariate logistic regression to determine predictors of VMMC intention. The strongest predictors were strongly disagreeing/disagreeing that sex was more painful for a circumcised man (odds ratio [OR] = 4.37; p = < .007), a Christian man should not get circumcised (OR = 2.47; p < .001), and circumcision makes penetration more painful and difficult (OR = 2.44; p = .007). Several beliefs about enhanced sexual performance, normative beliefs (parents, sexual partner, and friends), and non-TRA-related factors (e.g., importance of plowing season to daily schedule) were also statistically significant predictors. TRA proved a useful theory to explore young men's intention to circumcise and can help inform interventions aimed at increasing uptake of VMMC.

Barriers and facilitators to the uptake of voluntary medical male circumcision (VMMC) among adolescent boys in KwaZulu-Natal, South Africa

Epidemiological modelling has concluded that if voluntary medical male circumcision (VMMC) is scaled up in high HIV prevalence settings it would lead to a significant reduction in HIV incidence rates. Following the adoption of this evidence by the WHO, South Africa has embarked on an ambitious VMMC programme. However, South Africa still falls short of meeting VMMC targets, particularly in KwaZulu-Natal, the epicentre of the HIV/AIDS epidemic. A qualitative study was conducted in a high HIV prevalence district in KwaZulu-Natal to identify barriers and facilitators to the uptake of VMMC amongst adolescent boys. Focus group discussions with both circumcised and uncircumcised boys were conducted in 2012 and 2013. Analysis of the data was done using the framework approach and was guided by the Social Cognitive Theory focussing on both individual and interpersonal factors influencing VMMC uptake. Individual cognitive factors facilitating uptake included the belief that VMMC reduced the risk of HIV infection, led to better hygiene and improvement in sexual desirability and performance. Cognitive barriers related to the fear of HIV testing (and the subsequent result and stigmas), which preceded VMMC. Further barriers related to the pain associated with the procedure and adverse events. The need to abstain from sex during the six-week healing period was a further prohibiting factor for boys. Timing was crucial, as boys were reluctant to get circumcised when involved in sporting activities and during exam periods. Targeting adolescents for VMMC is successful when coupled with the correct messaging. Service providers need to take heed that demand creation activities need to focus on the benefits of VMMC for HIV risk reduction, as well as other non-HIV benefits. Timing of VMMC interventions needs to be considered when targeting school-going boys.

Men's attitudes: A hindrance to the demand for voluntary medical male circumcision--a qualitative study in rural Mhondoro-Ngezi, Zimbabwe

Male circumcision has witnessed a paradigm shift from being regarded as a religious and cultural practice to a global intervention strategy meant to curb transmission of HIV. This is particularly evident in sub-Saharan African countries where the HIV prevalence is greater than 15%. Zimbabwe adopted the voluntary medical male circumcision (VMMC) strategy in 2009; however, since then the uptake of the intervention has only 10% of the adult male population has reported having been circumcised. To better understand this limited uptake of VMMC, we conducted a qualitative study with uncircumcised men aged 15-79 years in Mhondoro-Ngezi, Zimbabwe. Through assessing men's attitudes towards VMMC in seven focus group discussions, conducted between July and August 2012, this article seeks to provide improved strategies for delivering this intervention in Zimbabwe. These data reveal that, in general, men have a negative attitude towards VMMC. Specific barriers to the uptake of VMMC included the perceived challenge to masculinity, post-circumcision stigma, lack of reliable and adequate information and perceptions about the appropriateness of VMMC. These results suggest that structural interventions aimed at reducing stigma related to circumcision, in addition to increased efforts to disseminate accurate information about VMMC, are required in order to dispel men's attitudes that hinder demand for VMMC.

Perceptions of voluntary medical male circumcision among circumcising and non-circumcising communities in Malawi

Three randomised controlled trials in Africa indicated that voluntary medical male circumcision (VMMC) is an effective method to reduce a man's risk of becoming infected through sex with an HIV-positive female partner. The success of recent public health initiatives to increase numbers of circumcised men in Malawi has been very limited. We conducted in-depth interviews and focus group discussions (FGDs) with men, women and male adolescents from non-circumcising and circumcising communities in southern Malawi to better understand their beliefs about male circumcision and the promotion of VMMC for HIV prevention. Results revealed that beliefs about male circumcision, in general, are strongly mediated by Malawian culture and history. Participants have attempted to develop a new meaning for circumcision in light of the threat of HIV infection and the publicised risk reduction benefits of VMMC. Several study participants found it difficult to distinguish VMMC from traditional circumcision practices (jando and lupanda), despite awareness that the new form of circumcision was an expression of (western) modern medicine performed largely for public health purposes. Greater recognition of background cultural beliefs and practices could inform future efforts to promote medical male circumcision as an HIV prevention strategy in this context.

A cross-sectional study describing motivations and barriers to voluntary medical male circumcision in Lesotho

Background

In February 2012, the Lesotho Ministry of Health launched a national voluntary medical male circumcision (VMMC) program. To assess the motivations for seeking VMMC, a cross-sectional mixed methods study was conducted among clients aged 18 years and older at four sites.

Methods

A total of 161 men participated in individual survey interviews and 35 participated in four focus group discussions.

Results

Men sought medical circumcision for the following main reasons: protection against HIV (73%), protection from other sexually transmitted infections (62%), and improved penile hygiene (47%). Forty percent learned about VMMC through friends who had already accessed services. According to these men, perceived concerns hindering service uptake include fear of pain (57%), a female provider (18%), and “compulsory” HIV testing (15%).

Conclusions

The study provides important insights into the motivations of clients seeking VMMC services. Findings can be used by the national VMMC program to attract more clients and address barriers to uptake.

Hesitance towards voluntary medical male circumcision in Lesotho: reconfiguring global health governance

Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention - voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the country's high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of 'partnerships' has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesotho's domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesotho's resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture.

Factors associated with parental non-adoption of infant male circumcision for HIV prevention in Sub-Saharan Africa: a systematic review and thematic synthesis

Infant male circumcision (IMC) may be more effective at preventing HIV than adult male circumcision as the procedure is carried out before the individual becomes sexually active. Successful scale-up will depend on identifying and overcoming parental concerns that may act as barriers for IMC. We conducted a systematic review to identify qualitative studies reporting on parental reasons for non-adoption of IMC for HIV prevention in sub-Saharan Africa. Thematic synthesis was subsequently conducted. Five descriptive themes were identified; these were later condensed into two main analytical themes: "poor knowledge" and "social constructs". While barriers and motivators are to some degree context specific, this review suggests that there are common themes that need to be addressed across the region if uptake of IMC for HIV prevention is to be widely adopted. Study findings are therefore likely to have broad implications for IMC roll out.

Risk compensation following male circumcision: results from a two-year prospective cohort study of recently circumcised and uncircumcised men in Nyanza Province, Kenya

We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30-14 vs. 24-21 % in controls) and increased sexual activity among the youngest participants (18-24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.

Prevalence and acceptability of male circumcision in South Africa

BACKGROUND

The objectives of the current national study were to determine the rates of self-reported circumcision among South African men and, more importantly, evaluate the acceptability of male circumcision in South Africa by uncircumcised adult men and all adult women.

MATERIALS AND METHODS

The study based on a population-based survey included a nationally representative subgroup of 6654 men aged 15 years and older who where included in the analysis on male circumcision prevalence, and a subgroup of 6796 women aged 15 to 49 years who were included in the analysis on male circumcision acceptance.

RESULTS

An overall prevalence of self-reported male circumcision of 42.8% was found. Among the Black African population group the prevalence of male circumcision was 48.2%, 32.1% were traditionally and 13.4% were medically circumcised. Among males not circumcised 45.7% of 15-24 years olds indicated that they would consider being circumcised compared to 28.3% among 25-49 years olds. In multivariate analysis among non-circumcised men Black African and Coloured population groups and having heard of the HIV protective effect of male circumcision were significant predictors for male circumcision acceptability, and among women with a non-circumcised sexual partner, Black African and Coloured population groups and higher education were predictors for male circumcision acceptability.

CONCLUSION

The study found high rates and high acceptability of male circumcision. Findings associated with the acceptability of male circumcision can be used to increase awareness of the benefits of male circumcision for HIV prevention.

Community and healthcare providers' perspectives on male circumcision: a multi-centric qualitative study in India

BACKGROUND

Although male circumcision (MC) is recommended as an HIV prevention option, the religious, cultural and biomedical dimensions of its feasibility, acceptability and practice in India have not been explored till date. This study explores beliefs, experiences and understanding of the community and healthcare providers (HCPs) about adult MC as an HIV prevention option in India.

METHODS

This qualitative study covered 134 in-depth interviews from Belgaum, Kolkata, Meerut and Mumbai cities of India. Of these, 62 respondents were the members of circumcising (CC)/non-circumcising communities (NCC); including medically and traditionally circumcised men, parents of circumcised children, spouses of circumcised men, and religious clerics. Additionally, 58 registered healthcare providers (RHCPs) such as general and pediatric surgeons, pediatricians, skin and venereal disease specialists, general practitioners, and operation theatre nurses were interviewed. Fourteen traditional circumcisers were also interviewed. The data were coded and analyzed in QSR NUD*IST ver. 6.0. The study has not explored the participants' views about neonatal versus adult circumcision.

RESULTS

Members of CC/NCC, traditional circumcisers and RCHPs expressed sharp religious sensitivities around the issue of MC. Six themes emerged: Male circumcision as the religious rite; Multiple meanings of MC: MC for 'religious identity/privilege/sacrifice' or 'hygiene'; MC inflicts pain and cost; Medical indications outweigh faith; Hesitation exists in accepting 'foreign' evidence supporting MC; and communication is the key for acceptance of MCs. Medical indications could make members of NCC accept MC following appropriate counseling. Majority of the RHCPs demanded local in-country evidence.

CONCLUSION

HCPs must educate high-risk groups regarding the preventive and therapeutic role of MC. Communities need to discuss and create new social norms about male circumcision for better societal acceptance especially among the NCC. Feasibility studies on MC as an individual specific option for the high risk groups in health care setting needs to be explored.

Ethnic identity, region and attitudes towards male circumcision in a high HIV-prevalence country

We study how considerations of male circumcision (MC) as both a favourable practice and as protective against HIV are linked with ethnicity in sub-Saharan Africa, where many ethnic groups do not traditionally circumcise. We focus on Malawi, a country with a high HIV prevalence but low MC prevalence. Survey data from a population-based random sample in rural Malawi (N =3400) were analysed for ethnoregional patterns in attitudes towards MC. We used logit regression models to measure how reported circumcision status, region of residence and ethnic identity relate to attitudes towards circumcision. Overall, Malawians reported more negative than positive opinions about MC, but attitudes towards circumcision varied by ethnicity and region. The implications for agencies and governments aggressively scaling up the provision of MC are clear; acceptance of circumcision as a tool for HIV prevention could be low in societies divided by ethnoregional identities that also shape the practice of circumcision.

Acceptance of male circumcision among male rural-to-urban migrants in western China

To describe the acceptability of male circumcision (MC) and explore potential factors associated with MC acceptability among male rural-to-urban migrants in western China, a cross-sectional survey of MC acceptability was conducted with 1,904 subjects in three western provinces with high HIV prevalence (Guangxi, Chongqing, and Xinjiang) in China between June 2009 and November 2009. Through face-to-face interviews, the participants completed a self-administered questionnaire about demographics, MC knowledge, willingness and reasons to accept or refuse MC, sexual behaviors, and other psychosocial variables. Factors associated with acceptability of MC were identified by multiple logistic regression analysis. Of the participants (n=1,904), 710 men were willing to accept MC (37.3%); the reasons included promotion of the partners' genital hygiene (54.9%), redundant prepuce or phimosis (43.1%), enhancement of sexual pleasure (40.6%), prevention of penile inflammation or cancer (35.5%), and protection against HIV and sexual transmitted diseases (STDs)(31.1%). A multivariable logistic regression showed that four factors were associated with acceptability of MC, including education level (OR=1.286, 95% CI=1.025~1.614), redundant prepuce or phimosis (OR=13.751, 95% CI=10.087~18.745), having one or more circumcised friends (OR=2.468, 95% CI=1.953~3.119), and having sexual intercourse with a temporary partner in the past year (OR=1.543, 95% CI=1.101~2.162). Compared with previously published data among the general population in China or worldwide, the acceptability of MC (37.3%) was low among the male rural-to-urban migrants in western China. Nevertheless, appropriate education could greatly improve the acceptability of MC. More public campaigns and health education on MC are needed to increase the rate of MC in China.

Perceptions of Male Circumcision among Married Couples in Rural Malawi

Voluntary medical male circumcision (VMMC) is being suggested as an essential HIV prevention strategy in high-prevalence areas. These analyses reflect data collected from 360 married couples, 50% of which included a circumcised husband and the other 50% uncircumcised, in rural Malawi. Regardless of their circumcision status, men were more likely to perceive that being circumcised was less painful than having a tooth pulled, giving birth, and having malaria. Men reported having the same sexual pleasure regardless of the circumcision status, while women were 2.0 times more likely to report greater sexual pleasure with a circumcised partner. Participants identified the medical benefits of VMMC and highlighted the potential personal benefits of VMMC. As VMMC has become a promising method of HIV prevention, this study revealed opportunities for intervention development to increase rates of VMMC among men.

Impediments for the uptake of the Botswana government's male circumcision initiative for HIV prevention

Botswana remains one of the countries with high prevalence of HIV infection with a population prevalence rate of 17.6 in 2008. In 2009, the Ministry of Health launched male circumcision as an additional strategy to the already existing HIV preventive efforts. The purpose of this paper is to share what the participants of a survey to evaluate a short-term male circumcision communication strategy in seven health districts of Botswana reported as impediments for the program's uptake. Qualitative data were obtained from 32 key informants and 36 focus group discussions in 2011. Content analysis method was used to analyze data and to derive themes and subthemes. Although male circumcision was generally acceptable to communities in Botswana, the uptake of the program was slow, and participants attributed that to a number of challenges or impediments that were frustrating the initiative. The impediments were organized into sociocultural factors, knowledge/informational factors, and infrastructural and system factors.

Factors associated with the acceptability of male circumcision among men in Jamaica

OBJECTIVES

To determine the prevalence of male circumcision (MC) among men in the western region of Jamaica, and to identify factors associated with acceptability of MC for self, infants (<1 year) and older sons (1-17 years).

METHODS

A cross-sectional, interviewer-administered questionnaire survey of 549 men aged 19-54 years was conducted in the western region of Jamaica. The survey included questions about the acceptance of MC for self, infants, and sons before and after an information session about the benefits of MC in preventing HIV/STI transmission. Logistic regression models were used to identify factors that were associated with acceptability of MC. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated from the models.

RESULTS

Fourteen percent of the men reported that they were circumcised. In the multivariable model, which adjusted for age, education, religion and income, there were increased odds of accepting MC for infants/sons among uncircumcised men who accepted MC for self (AOR=8.1; 95% CI = 4.1-15.9), believed they would experience more pleasure during sex if circumcised (AOR=4.0; 95% CI = 2.0-8.2), and reported having no concerns regarding MC (AOR=3.0; 95% CI = 1.8-4.8). Similarly, uncircumcised men who reported no concerns about MC or who believed that they would experience more pleasure during sex if circumcised were more likely to accept MC for self.

CONCLUSION

Providing men with information about MC increased acceptance of MC for self, infants (<17 years) and sons (1-17 years). Since targeted education on the benefits of male circumcision for prevention of HIV/STI can be effective in increasing acceptability of MC, health professionals should be trained, and willing to discuss MC with men in healthcare facilities and in the community.

Foreskin cutting beliefs and practices and the acceptability of male circumcision for HIV prevention in Papua New Guinea

BACKGROUND

Male circumcision (MC) reduces HIV acquisition and is a key public health intervention in settings with high HIV prevalence, heterosexual transmission and low MC rates. In Papua New Guinea (PNG), where HIV prevalence is 0.8%, there is no medical MC program for HIV prevention. There are however many different foreskin cutting practices across the country's 800 language groups. The major form exposes the glans but does not remove the foreskin. This study aimed to describe and quantify foreskin cutting styles, practices and beliefs. It also aimed to assess the acceptability of MC for HIV prevention in PNG.

METHODS

Cross-sectional multicentre study, at two university campuses (Madang Province and National Capital District) and at two 'rural development' sites (mining site Enga Province; palm-oil plantation in Oro Province). Structured questionnaires were completed by participants originating from all regions of PNG who were resident at each site for study or work.

RESULTS

Questionnaires were completed by 861 men and 519 women. Of men, 47% reported a longitudinal foreskin cut (cut through the dorsal surface to expose the glans but foreskin not removed); 43% reported no foreskin cut; and 10% a circumferential foreskin cut (complete removal). Frequency and type of cut varied significantly by region of origin (p < .001). Most men (72-82%) were cut between the ages of 10-20 years. Longitudinal cuts were most often done in a village by a friend, with circumferential cuts most often done in a clinic by a health professional. Most uncut men (71%) and longitudinal cut men (84%) stated they would remove their foreskin if it reduced the risk of HIV infection. More than 95% of uncut men and 97% of longitudinal cut men would prefer the procedure in a clinic or hospital. Most men (90%) and women (74%) stated they would remove the foreskin of their son if it reduced the risk of HIV infection.

CONCLUSION

Although 57% of men reported some form of foreskin cut only 10% reported the complete removal of the foreskin, the procedure on which international HIV prevention strategies are based. The acceptability of MC (complete foreskin removal) is high among men (for themselves and their sons) and women (for their sons). Potential MC services need to be responsive to the diversity of beliefs and practices and consider health system constraints. A concerted research effort to investigate the potential protective effects of longitudinal cuts for HIV acquisition is essential given the scale of longitudinal cuts in PNG.

Factors associated with acceptability of circumcision among male drug users in western China: a cross-sectional study

This study is aimed to investigate whether male circumcision (MC) is feasible among IDUs in China. 1304 drug users who attended methadone maintenance therapy clinics in Guangxi, Chongqing and Xinjiang were selected for participation by using convenience sampling, and completed a self-administered questionnaire. The factors associated with the acceptability of MC were examined via multiple logistic regression models. 45.2% (589/1304) of the participants reported an acceptance of MC. Many of the participants who were initially not willing to accept MC (715/1304) had changed their mind when they were informed that MC would reduce the risk of HIV and STDs (43.4%; 310/715), that MC is associated with few surgery-related complications (23.1%; 165/715), that the surgical procedure could be arranged free of charge (20.1%, 144/715). In the multivariate analysis, higher acceptability of MC was associated with knowledge of the hazards of phimosis (OR=2.22), the presence of phimosis (OR=14.87), and knowledge that MC can prevent AIDS and STDs (OR=1.49); while lower acceptability was associated with residing in Chongqing province (OR=0.41) and an educational level of junior (OR=0.64) and senior high (OR=0.63) school. The MC policy targeting IDUs in China should take into account these factors associated with MC acceptability.

Circumcision status and time to first sex among never-married young men in Malawi: evidence from the demographic and health survey

This study examines the association between circumcision status and the timing of first sexual intercourse among adolescents in Malawi. Results of survival models applied to nationally representative sample of never-married young men aged between 15 and 24 obtained from the Demographic and Health Survey data show that being circumcised is associated with earlier initiation of sexual activity in Malawi. Young men who reported being circumcised experienced their first sexual intercourse earlier in life than their uncircumcised counterparts. Although the introduction of theoretically relevant knowledge, socio-cultural, demographic, and socioeconomic variables in the multivariate models attenuated the association between circumcision and earlier sexual initiation, the relationship nonetheless remained robust. The study concludes by discussing the implications of these findings and suggests relevant policy recommendations.

Understanding and addressing socio-cultural barriers to medical male circumcision in traditionally non-circumcising rural communities in sub-Saharan Africa

Given recent clinical trials establishing the safety and efficacy of adult medical male circumcision (MMC) in Africa, attention has now shifted to barriers and facilitators to programmatic implementation in traditionally non-circumcising communities. In this study, we attempted to develop a fuller understanding of the role of cultural issues in the acceptance of adult circumcision. We conducted four focus-group discussions with 28 participants in Mutoko, Zimbabwe, and 33 participants in Vulindlela, KwaZulu-Natal, South Africa, as well as 19 key informant interviews in both settings. We found the concept of male circumcision to be an alien practice, particularly as expressed in the context of local languages. Cultural barriers included local concepts of ethnicity, social groups, masculinity and sexuality. On the other hand, we found that concerns about the impact of HIV on communities resulted in willingness to consider adult male circumcision as an option if it would result in lowering the local burden of the epidemic. Adult MMC-promotional messages that create a synergy between understandings of both traditional and medical circumcision will be more successful in these communities.

Effects of household shocks and poverty on the timing of traditional male circumcision and HIV risk in South Africa

Poverty may influence HIV risk by increasing vulnerability to economic shocks and thereby preventing key health investments. We explored this possibility by examining the relationship between household shocks and the timing of traditional male circumcision, a practice associated with considerable expense and whose HIV-prevention benefits are larger when done earlier, even within young adulthood. Using unique data on a sample of Xhosa men, a group that almost universally practices traditional circumcision, we found that respondents in the poorest households delayed circumcision by 2 years if a household member experienced loss of income or death and/or illness. The impact of these shocks declined with increasing household income. Our findings suggest that interventions that work to mitigate the impact of shocks among the poor may be useful in HIV prevention efforts. More generally, they illustrate that the relationship between HIV and wealth may be more nuanced than assumed in previous work.

"Man, what took you so long?" Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania

BACKGROUND

In 2009, the Government of Tanzania embarked on scaling up voluntary medical male circumcision (VMMC) services for HIV prevention in 8 priority regions, with the aim of serving 2.8 million boys and men ages 10-34 years by 2013. By mid-2012, more than 110,000 boys and men in Iringa and Njombe regions had received VMMC. The majority (85%) of these VMMC clients were under 19 years old (average age, 16 years). This study aimed to identify potential barriers and facilitators to VMMC among older men.

METHODS

We conducted 16 focus group discussions, stratified by sex and age, with 142 purposefully selected participants in 3 districts of Iringa and Njombe regions.

RESULTS

Both men and women generally had positive attitudes toward VMMC. Social and personal barriers to obtaining VMMC among adult men included shame associated with seeking services co-located with younger boys and perceived inappropriateness of VMMC after puberty, particularly after marriage and after having children. Additional barriers included concerns about partner infidelity during the post-surgical abstinence period, loss of income, and fear of pain associated with post-surgical erections. Facilitators included awareness of the HIV-prevention benefit and perceptions of cleanliness and enhanced attractiveness to women.

CONCLUSIONS

While men and women in Iringa and Njombe regions in Tanzania generally view VMMC as a desirable procedure, program implementers need to address barriers to VMMC services among adult men. Selected service delivery sites in the Iringa and Njombe regions will be segregated by age to provide services that are "friendly" to adult men. Services will be complemented with behavior change communication initiatives to address concerns of older men, encourage women's support for circumcision and adherence to the post-surgical abstinence period, and change social norms that inhibit older men from seeking circumcision.

The accuracy of women's reports of their partner's male circumcision status in Rakai, Uganda

We assessed whether women had accurate knowledge of their partners' male circumcision status using survey data (2010-2011) from Rakai, Uganda, and examined characteristics of women who misreported male circumcision status. Among couples in which men were uncircumcised (n = 1744), 8.2% women misreported; and among couples in which men were confirmed circumcised (n = 759), 1.2% women misreported. Younger women were 2.2 times more likely to misreport compared with older women. Misreporting was not associated with other sociodemographics or behavioural characteristics. If women are to act as advocates for male circumcision acceptance, there is a need to educate women, particularly younger women about the nature and recognition of male circumcision.