Circumcision preference among women and uncircumcised men prior to scale-up of male circumcision for HIV prevention in Kisumu, Kenya

Circumcision and Sexual Medicine

INTRODUCTION

Male circumcision is one of the most frequently performed and debated urological procedures due to its possible implications for sexual health.

OBJECTIVES

The objective of this article is to review the literature on male circumcision and reconcile the scientific evidence to improve the quality of care, patient education, and clinician decision-making regarding the effects on sexual function of this procedure.

METHODS

A review of the published literature regarding male circumcision was performed on PubMed. The criteria for selecting resources prioritized systematic reviews and cohort studies pertinent to sexual dysfunction, with a preference for recent publications.

RESULTS

Despite the conflicting data reported in articles, the weight of the scientific evidence suggests there is not sufficient data to establish a direct association between male circumcision and sexual dysfunction.

CONCLUSION

This review provides clinicians with an updated summary of the best available evidence on male circumcision and sexual dysfunction for evidenced-based quality of care and patient education.

Barriers and Facilitators to, and Experience of, Voluntary Medical Male Circumcision Among Men Who Have Sex with Men in China: A Mixed-Methods Study

Voluntary medical male circumcision (VMMC) may be incorporated into HIV prevention services for men who have sex with men (MSM). We conducted a mixed-methods study to elucidate barriers and facilitators to, and experience of, VMMC among MSM. Participants were MSM aged 18 years and older who were enrolled in an ongoing multicenter randomized controlled trial (RCT) to evaluate VMMC to prevent HIV among MSM in China. RCT participants completed a questionnaire before and after VMMC to assess perceptions of and complications after the procedure. A subset of RCT participants were selected for in-depth interviews. Interviewees answered open-ended questions about barriers and facilitators to and experience of undergoing VMMC. Six-step thematic analysis incorporating inductive and deductive approaches was used to interpret interview responses. A total of 457 MSM completed the pre-VMMC survey, 115 circumcised MSM completed post-VMMC surveys, and 30 MSM completed an interview. Main barriers to VMMC uptake were concerns about pain, length of wound healing, cost, lack of knowledge about or misconceptions of VMMC, and stigma related to surgery. Facilitators to VMMC could be categorized as internal factors (foreskin) and external factors (motivation and follow-up care). Interestingly, the VMMC experiences of others could be transformed from a barrier into a facilitator to VMMC in some circumstances. After VMMC participants transitioned from a negative state of pain, remorse, difficulty sleeping, and discomfort to a positive state of symptom alleviation and personal hygiene improvement. Optimizing facilitators and addressing barriers may encourage VMMC among MSM. Joint efforts should be made by relevant stakeholders to improve the awareness and uptake of VMMC among MSM.

A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa

Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.

Women’s support for voluntary medical male circumcision in fishing communities on the shores of Lake Victoria, Uganda

Background

Women’s support can improve uptake of voluntary medical male circumcision (VMMC). We assessed the level of women’s support for VMMC and associated factors in fishing settlements on the shores of Lake Victoria in Uganda, to inform interventions aimed at increasing the uptake of safe male circumcision services in such high-risk populations.

Methods

We conducted a cross-sectional study, employing mixed methods of data collection, at Kasenyi and Kigungu landing sites in April 2018. We included women aged 18–49 years, who had stayed at the landing sites for ≥3 months. We obtained qualitative data using focus group discussions (FGDs), and interviewer-administered semi-structured questionnaires for quantitative data. The tool captured demographic characteristics, community factors including cultural norms and beliefs, women’s experiences, and health facility-related factors. The dependent variable was derived from the response to the question: "Would you encourage your partner/husband to go for VMMC?", and used as a proxy for support of VMMC. We used modified Poisson regression to identify factors associated with women’s support for VMMC. Qualitative data were analysed using thematic content analysis.

Results

We enrolled 313 women with a mean age of 28 (SD±6.8) years. Of the 313 women, 230 (73.5%) supported VMMC. Belief that VMMC increases penile hygiene (Adjusted prevalence ratio [aPR]=1.9; CI: 1.8–3.2), performing VMMC for religious reasons (aPR=1.9; CI: 1.8–2.9), preference for a circumcised man (aPR=1.3; CI: 1.2–1.5), belief that vaginal fluids facilitate wound healing (aPR=1.9; CI: 1.3–2.7), and knowledge about when a man can resume sex (4 weeks) after circumcision (aPR=2.1; CI: 1.8–3.3) were associated with women’s support for VMMC. FGDs revealed that women were not adequately involved in VMMC activities for decision making.

Conclusion

The support for VMMC was high among women in the fishing communities. However, women perceived they were not involved in decision-making for VMMC and had several misconceptions, including a belief that vaginal fluids facilitate wound healing. The Ministry of Health and VMMC implementing partners should devise strategies to increase sensitization and involvement of women in VMMC decision-making without slowing service uptake.

Barriers, benefits, and behaviour: Voluntary medical male circumcision ideation in a population-based sample of Zambian men

Reaching ambitious voluntary medical male circumcision (VMMC) coverage targets requires a deeper understanding of the multifaceted processes shaping men's willingness to access VMMC. Guided by the Ideation Model for Health Communication, this population-based study identifies correlates of Zambian men's future VMMC intentions. Multistage cluster sampling was used to identify households with adult men in 14 districts. Multivariable Poisson regression with robust standard errors modelled associations of future VMMC intent with ideational factors (e.g. perceived benefits and barriers) and sexual behaviours respectively. Forty per cent (40%) of uncircumcised men (N = 1 204) expressed future VMMC intentions. In multivariable analysis, VMMC intent was associated with secondary education or higher (Adjusted Prevalence Ratio [APR] 1.30, 95% Confidence Interval [95% CI]: 1.02-1.66), perceiving VMMC to increase sexual satisfaction (APR 1.45, 95% CI: 1.11-1.89), reporting distance to services as a barrier to VMMC uptake (APR = 0.54, 95% CI: 1.27-1.87), unprotected last sex (APR 1.54, 95% CI: 1.11-2.14), and ≥ 2 sexual partners in the past 12 months (APR 1.45, 95% CI: 1.05-1.99). Being aged ≥ 45 years (vs 18-24 years: APR 0.23, 95% CI: 0.13-0.40) and perceiving that circumcision: (1) is unimportant (APR 0.71, 95% CI: 0.51-0.98); (2) is incompatible with local customs (APR 0.41, 95% CI: 0.18-0.94); or (3) reduces sexual satisfaction (APR 0.10, 95% CI: 0.02-0.62) were inversely associated with future VMMC intent. Demand-creation efforts must confront salient cognitive and social barriers to VMMC uptake, including concerns around incompatibility with local customs. Simultaneously, promotional efforts should emphasise relevant VMMC benefits beyond HIV prevention that resonate with men (e.g. penile hygiene) without reinforcing harmful gender norms.

Integration of voluntary male medical circumcision for HIV prevention into norms of masculinity: findings from Kisumu, Kenya

While it is clear that in many communities ideas about masculinity and circumcision are connected, it is still unclear how young Kenyan men in the former Nyanza province from the traditionally non-circumcising Luo people perceive voluntary medical male circumcision as connected to masculinity and the role of voluntary medical male circumcision in the transition from boyhood to manhood. The objective of this study was to explore norms of masculinity and the decision-making process among Luo young men to provide a better understanding of how circumcision and masculinity relate to cultural norms within this community. The methodology consisted of eight FGDs with male peer groups and 24 in-depth interviews to elicit young men's perceptions of masculinity and voluntary medical male circumcision. Findings from thematic analysis reveal that young men described several key characteristics of masculinity including responsibility, bravery and sexual attractiveness. For some young men, voluntary medical male circumcision has embedded itself into cultural norms of masculinity by being a step in the transition from boyhood to manhood and by being a marker of some of these masculine characteristics. In the case of voluntary medical male circumcision, there may be opportunities to integrate other programming that helps men transition into healthy adulthood.

HIV Incidence by Male Circumcision Status From the Population-Based HIV Impact Assessment Surveys-Eight Sub-Saharan African Countries, 2015-2017

BACKGROUND

Male circumcision (MC) offers men lifelong partial protection from heterosexually acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally representative samples. Data from the population-based HIV impact assessments were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs.

METHODS

Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random-effects logistic regression model using pooled survey weights. Analyses were age stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men.

RESULTS

Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men [0.04% (95% CI: 0.00% to 0.10%) versus 0.34% (95% CI: 0.10% to 0.57%), respectively; P value = 0.01]; whereas among men 35-59 years, there was no significant incidence difference [1.36% (95% CI: 0.32% to 2.39%) versus 0.55% (95% CI: 0.14% to 0.67%), respectively; P value = 0.14].

DISCUSSION

Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa.

Voluntary Medical Male Circumcision and Perceived Sexual Functioning, Satisfaction, and Risk Behavior: A Qualitative Study in Botswana

This article examines perceptions of sexual functioning, satisfaction, and risk-taking related to voluntary medical male circumcision (VMMC) in Botswana. Twenty-seven focus group discussions were conducted in four purposively selected communities with community leaders, men, and women. Discussions were analyzed using an inductive content analytic approach. Perceptions of VMMC's impact on sexual functioning and satisfaction varied. Increased satisfaction was attributed to improved penile health and increased ejaculatory latency time, whereas decreased satisfaction was attributed to erectile dysfunction and increased vaginal irritation during sex. Most participants thought sexual disinhibition occurred after circumcision; nevertheless, some women said they used male circumcision status as a marker of HIV status, thereby influencing sexual decision-making and partner selection. Messaging should emphasize that VMMC does not afford complete HIV protection. Optimizing VMMC's impact requires increasing uptake while minimizing behavioral disinhibition, with a balance between potential messaging of improved sexual functioning and satisfaction and the potential impact on sexual disinhibition.

Traditional Male Circumcision is Associated with Sexual Risk Behaviors in Sub-Saharan Countries Prioritized for Male Circumcision

To understand the sexual risk behavior of men with traditional male circumcision and medical male circumcision in the context of the World Health Organization's (WHO) campaign for voluntary medical male circumcision (VMMC) scale-up, we investigated ten countries prioritized for the scale-up from the Demographic and Health Surveys. Male respondents aged 15-49 were selected. Ordinal regression was used to analyze the relationship between three sexual risk behaviors-condom use with non-cohabiting partners, number of non-cohabiting partners, and partner type-and circumcision status (traditionally circumcised before and after the VMMC scale-up, medically circumcised before and after the scale-up, and not circumcised), while controlling for social demographic covariates. We found evidence that some sexual risky behavior, specifically lower condom use and higher number of sexual partners, was associated with traditional circumcision. This finding suggests that messages about the protective effect of male circumcision may not have reached men with traditional circumcision. We suggest that WHO's VMMC campaign should include communities where traditional male circumcision is popular. We looked for, but did not find, evidence of differences between groups circumcised at different times, which could have indicated sexual risk compensation.

Enhancers and barriers to uptake of male circumcision services in Northern Uganda: a qualitative study

Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda.

Knowledge about male circumcision and perception of risk for HIV among youth in Harare, Zimbabwe

Background

Male circumcision will require high uptake among previously non-circumcising countries to realise the impact of circumcising in preventing HIV. Little is known about whether youths are knowledgeable about male circumcision and its relationship with HIV prevention and their perception of risk of HIV infection.

Objective

This article aimed to ascertain youth’s knowledge about male circumcision and perception of risk of HIV infection.

Methods

A quantitative study on 784 youth (men aged 15–35 years) was conducted in Harare, Zimbabwe, after obtaining their consent. Multivariate analysis examined the associations between background characteristics and knowledge about male circumcision and the perception of risk of HIV infection.

Results

The results revealed that age was a significant predictor of knowledge about male circumcision among youth in Harare, as was educational attainment and ever having tested for HIV. In addition, youth who had heard of voluntary medical male circumcision were more likely to have high knowledge of male circumcision compared to those who had never heard of it. The results also showed that male circumcision status was associated with higher knowledge about male circumcision compared to those who were not circumcised. The study also found that educational attainment, belonging to the Shona ethnic group, never having tested for HIV and disapproval of voluntary counselling and testing prior to male circumcision were associated with the perception of risk of HIV infection.

Conclusion

The study provides two recommendations: the need to strengthen perceived susceptibility to HIV among the youth and the need for advocacy on the health benefits of male circumcision.

Sex and Male Circumcision: Women's Preferences Across Different Cultures and Countries: A Systematic Review

Introduction

Women’s choices for a sexual partner are influenced by numerous personal, cultural, social, political and religious factors, and may also include aspects of penile anatomy such as male circumcision (MC) status.

Aim

To perform a systematic review examining (i) whether MC status influences women’s preference for sexual activity and the reasons for this, and (ii) whether women prefer MC for their sons.

Methods

PRISMA-compliant searches were conducted of PubMed, Google Scholar, Embase, and the Cochrane Database of Systematic Reviews. Articles that met the inclusion criteria were rated for quality using the SIGN system.

Results

Database searches identified 29 publications with original data for inclusion, including 22 for aim (i) and 4 of these and 7 others pertaining to aim (ii). In the overwhelming majority of studies, women expressed a preference for the circumcised penis. The main reasons given for this preference were better appearance, better hygiene, reduced risk of infection, and enhanced sexual activity, including vaginal intercourse, manual stimulation, and fellatio. In studies that assessed mothers’ preference for MC of sons, health, disease prevention, and hygiene were cited as major reasons for this preference. Cultural differences in preference were evident among some of the studies examined. Nevertheless, a preference for a circumcised penis was seen in most populations regardless of the frequency of MC in the study setting.

Conclusion

Women’s preferences generally favor the circumcised penis for sexual activity, hygiene, and lower risk of infection. The findings add to the already well-established health benefits favoring MC and provide important sociosexual information on an issue of widespread interest.

Morris BJ, Hankins CA, Lumbers ER, et al. Sex and Male Circumcision: Women’s Preferences Across Different Cultures and Countries: A Systematic Review. Sex Med 2019;7:145–161.

Systematic review of the effect of economic compensation and incentives on uptake of voluntary medical male circumcision among men in sub-Saharan Africa

Voluntary medical male circumcision (VMMC) prevalence in priority countries in sub-Saharan Africa, particularly among men aged ≥20 years, has not yet reached the goal of 80% coverage recommended by the World Health Organization. Determining novel strategies to increase VMMC uptake among men ≥20 years is critical to reach HIV epidemic control. We conducted a systematic review to analyze the effectiveness of economic compensation and incentives to increase VMMC uptake among older men in order to inform VMMC demand creation programs. The review included five qualitative, quantitative, and mixed methods studies published in peer reviewed journals. Data was extracted into a study summary table, and tables synthesizing study characteristics and results. Results indicate that cash reimbursements for transportation and food vouchers of small nominal amounts to partially compensate for wage loss were effective, while enrollment into lotteries offering prizes were not. Economic compensation provided a final push toward VMMC uptake for men who had already been considering undergoing circumcision. This was in settings with high circumcision prevalence brought by various VMMC demand creation strategies. Lottery prizes offered in the studies did not appear to help overcome barriers to access VMMC and qualitative evidence suggests this may partially explain why they were not effective. Economic compensation may help to increase VMMC uptake in priority countries with high circumcision prevalence when it addresses barriers to uptake. Ethical considerations, sustainability, and possible externalities should be carefully analyzed in countries considering economic compensation as an additional strategy to increase VMMC uptake.

Male circumcision for HIV prevention: female risk compensatory behaviour in South Africa

South Africa promotes male circumcision (MC) as an HIV prevention method and implemented a national plan to scale-up MC in the country from 2012 to 2016. Literature has suggested that female risk compensatory behaviours (RCBs) are occurring in countries where these programmes have been implemented. Behaviours such as decreased condom use, concurrent sexual partners and sexual activity during the circumcision wound-healing period have the potential to jeopardise the campaigns' objectives. Literature has shown that directly providing women with MC information results in correct knowledge however, previous studies have not directly sought women's views and ideas on engagement with the information. This study aims to identify and explore female RCBs in relation to MC campaigns in South Africa, and to identify interventions that would result in greater female involvement in the campaigns. Snowball sampling was used to conduct twelve qualitative vignette-facilitated semi-structured interviews with women residing in a municipal housing estate in Durban, Kwa-Zulu Natal, South Africa. Interviews were audio-recorded, verbatim transcribed and analysed using framework analysis. MC knowledge and understanding varied, with some participants mistaking MC as direct HIV protection for females. Despite a lack in knowledge, the majority of women did not report signs of RCBs. Even with a lack of evidence of RCBs, misinterpretation of the MC protective effect has the potential to lead to RCBs; a concept acknowledged in the literature. Several women expressed that MC campaigns are directed to males only and expressed a keenness to be more involved. Suggested interventions include couple counselling and female information sessions in community clinics. Exploring women's attitude towards involvement in MC campaigns fills in a research knowledge gap that is important to international health, as women have a vital role to play in reducing the transmission of HIV.

Systematic review of barriers and facilitators to voluntary medical male circumcision in priority countries and programmatic implications for service uptake

Voluntary medical male circumcision (VMMC) is an effective biomedical HIV prevention strategy. There is a need to identify key barriers and facilitators to VMMC uptake in priority countries to improve uptake. In this paper, we report findings from a systematic review of the barriers and facilitators of VMMC uptake, comparing them across countries in order to provide programmers critical information to design effective VMMC uptake interventions. Our review followed PRISMA protocol. Twenty three articles from 10 of the 14 priority countries were included. The top three barriers cited were: MC negatively perceived as being practiced by other or foreign cultures and religions, fear of pain caused by the procedure, and perceptions of VMMC as not helpful/needed. The top four facilitators cited in most countries were: Belief that VMMC reduces health risks and improves hygiene, family and peer support of MC, and enhanced sexual performance and satisfaction. The barriers and facilitators highlighted in this paper can help inform programmatic strategies in these countries. More research is needed to ensure that all sub-populations are being adequately reached. By applying this information to new research and programming, these countries can achieve greater VMMC uptake - and thus reductions in HIV transmission and prevalence.

Agreement between self-reported and physically verified male circumcision status in Nyanza region, Kenya: Evidence from the TASCO study

BACKGROUND

Self-reported male circumcision (MC) status is widely used to estimate community prevalence of circumcision, although its accuracy varies in different settings depending on the extent of misreporting. Despite this challenge, self-reported MC status remains essential because it is the most feasible method of collecting MC status data in community surveys. Therefore, its accuracy is an important determinant of the reliability of MC prevalence estimates based on such surveys. We measured the concurrence between self-reported and physically verified MC status among men aged 25-39 years during a baseline household survey for a study to test strategies for enhancing MC uptake by older men in Nyanza region of Kenya. The objective was to determine the accuracy of self-reported MC status in communities where MC for HIV prevention is being rolled out.

METHODS

Agreement between self-reported and physically verified MC status was measured among 4,232 men. A structured questionnaire was used to collect data on MC status followed by physical examination to verify the actual MC status whose outcome was recorded as fully circumcised (no foreskin), partially circumcised (foreskin is past corona sulcus but covers less than half of the glans) or uncircumcised (foreskin covers half or more of the glans). The sensitivity and specificity of self-reported MC status were calculated using physically verified MC status as the gold standard.

RESULTS

Out of 4,232 men, 2,197 (51.9%) reported being circumcised, of whom 99.0% were confirmed to be fully circumcised on physical examination. Among 2,035 men who reported being uncircumcised, 93.7% (1,907/2,035) were confirmed uncircumcised on physical examination. Agreement between self-reported and physically verified MC status was almost perfect, kappa (k) = 98.6% (95% CI, 98.1%-99.1%. The sensitivity of self-reporting being circumcised was 99.6% (95% CI, 99.2-99.8) while specificity of self-reporting uncircumcised was 99.0% (95% CI, 98.4-99.4) and did not differ significantly by age group based on chi-square test. Rate of consenting to physical verification of MC status differed by client characteristics; unemployed men were more likely to consent to physical verification (odds ratio [OR] = 1.48, (95% CI, 1.30-1.69) compared to employed men and those with post-secondary education were less likely to consent to physical verification than those with primary education or less (odds ratio [OR] = 0.61, (95% CI, 0.51-0.74).

CONCLUSIONS

In this Kenyan context, both sensitivity and specificity of self-reported MC status was high; therefore, MC prevalence estimates based on self-reported MC status should be deemed accurate and applicable for planning. However MC programs should assess accuracy of self-reported MC status periodically for any secular changes that may undermine its usefulness for estimating community MC prevalence in their unique settings.

Male circumcision for HIV prevention: Awareness, risk compensation, and risk perceptions among South African women

Medical male circumcision (MMC) is a proven method of HIV risk reduction for men in southern Africa. MMC promotion campaigns and scale-up programmes are widely implemented throughout the Republic of South Africa. However, the impact of promoting MMC on women's awareness, beliefs, and behaviours has been understudied. We conducted a self-administered anonymous survey of 279 women receiving health services in an impoverished township located in Cape Town, South Africa. Results showed that two in three women were unaware that male circumcision partially protects men from contracting HIV. Women who were aware of MMC for HIV prevention also endorsed beliefs that male circumcision reduces the need for men to worry about HIV and reduces the need for men to use condoms. Male circumcision awareness was also related to reduced perceptions of HIV risk among women. Multivariable models showed that women's MMC awareness, circumcision risk compensation beliefs, and risk perceptions were associated with decreased condom use and higher HIV risk index scores defined as number of condomless vaginal intercourse X number of sex partners. These results suggest a need for MMC education efforts tailored for women living in communities with high-HIV prevalence where men are targeted for MMC.

The Association Between Male Circumcision and Condom Use Behavior - a Meta-Analysis

Introduction

The protective benefit of male circumcision against spreading HIV is well established.

Aim

The objective of this Meta-analysis was to investigate behavioral risk compensation measured as the change in condom use behavior in light of knowledge of the benefits of circumcision.

Material and Methods

A systematic search was conducted from 6 bibliographic databases for studies that quantitatively assessed a link between male circumcision and condom use behavior. Pooled odd ratios (OR) of condom use during any sexual activity were generated from three cohort studies and two Randomized Control Trails (RCT) that were included in the review.

Results

The pooled effects from cohort and RCTs were not statistically significant at 6 months follow-up (OR=0.91, 95% CI: 0.57-1.45), at 12 months (OR=1.08, 95% CI=0.87-1.34) and 24 or more months (OR=1.11, 95% CI: 0.85, 1.45).

Conclusion

Male circumcision does not influence condom use behavior in the medium and short term.

Correlates of Condom Use and Procedure Knowledge Among Men Accessing Voluntary Medical Male Circumcision in Malawi

PURPOSE

This study examined correlates of condom use (CU) and voluntary medical male circumcision (VMMC) knowledge among men accessing VMMC services in Malawi.

METHODS

Two hundred sixty-nine men ages 16 or older accessing VMMC were recruited at service sites. Bivariate and multivariate logistic regressions were used to determine associations, and the relative odds of CU at last sex with VMMC knowledge. Correlates included the following: education, age, location, religion, marital status, ever tested for HIV, having casual/concurrent sexual partners, and alcohol use before sex.

RESULTS

The multivariate analysis revealed CU was associated with having a casual/concurrent partner in the previous 3 months and negatively associated with being age 27 or older and single, with participants who had casual/concurrent partners being more likely to use condoms than counterparts who did not have casual/concurrent partners, and those who were over age 27 and single being less likely to do so. VMMC knowledge was associated with education and location, with men with higher education and living in urban areas more likely to know that VMMC partially protects against HIV.

CONCLUSION

Results highlight the need to ensure information about VMMC is appropriate for rural men with lower education. Further research is needed to understand the risk profile of men accessing VMMC and the reasons why men who do not know VMMC partially protects against HIV are seeking the service.

Predictors of voluntary medical male circumcision prevalence among men aged 25-39 years in Nyanza region, Kenya: Results from the baseline survey of the TASCO study

Introduction

Uptake of voluntary medical male circumcision (VMMC) as an intervention for prevention of HIV acquisition has been low among men aged ≥25 years in Nyanza region, western Kenya. We conducted a baseline survey of the prevalence and predictors of VMMC among men ages 25–39 years as part of the preparations for a cluster randomized controlled trial (cRCT) called the Target, Speed and Coverage (TASCO) Study. The TASCO Study aimed to assess the impact of two demand creation interventions—interpersonal communication (IPC) and dedicated service outlets (DSO), delivered separately and together (IPC + DSO)—on VMMC uptake.

Methods

As part of the preparatory work for implementation of the cRCT to evaluate tailored interventions to improve uptake of VMMC, we conducted a survey of men aged 25–39 years from a traditionally non-circumcising Kenyan ethnic community within non-contiguous locations selected as study sites. We determined their circumcision status, estimated the baseline circumcision prevalence and assessed predictors of being circumcised using univariate and multivariate logistic regression.

Results

A total of 5,639 men were enrolled of which 2,851 (50.6%) reported being circumcised. The odds of being circumcised were greater for men with secondary education (adjusted Odds Ratio (aOR) = 1.65; 95% CI: 1.45–1.86, p<0.001), post-secondary education (aOR = 1.72; 95% CI: 1.44–2.06, p <0.001), and those employed (aOR = 1.32; 95% CI: 1.18–1.47, p <0.001). However, the odds were lower for men with a history of being married (currently married, divorced, separated, or widowed).

Conclusion

Among adult men in the rural Nyanza region of Kenya, men with post-primary education and employed were more likely to be circumcised. VMMC programs should focus on specific sub-groups of men, including those aged 25–39 years who are married, divorced/separated/ widowed, and of low socio-economic status (low education and unemployed).

Attitudes, Beliefs and Predictors of Male Circumcision Promotion among Medical University Students in a Traditionally Non-Circumcising Region

Objective: To evaluate the beliefs of medical university students regarding male circumcision (MC), as well as attitudes and the predictors of its promotion in the case of adults at risk of HIV. Methods: A cross-sectional survey was conducted between 2013-2016 at the Medical University in Szczecin, Poland, among final year Polish/foreign students from Northern Europe, using a standardized questionnaire. Results: There were 539 participants, median age 25 years, 40.8% males, and 66.8% were Polish nationals. The MC rate was 16.7%. Regarding HIV/AIDS knowledge, 66.6% of the students scored more than 75%; and, 34.2% knew that MC reduces the risk of HIV infection. One in eleven respondents (9.1%) believed that circumcised men felt more intense sexual pleasure. More than half of the respondents (54.8%) declared that they would recommend MC to adult patients at risk for HIV. The belief that circumcised men felt more intense sexual pleasure, and knowledge on MC regarding HIV risk reduction was associated with greater odds of recommending adult MC (OR = 3.35 and OR = 2.13, respectively). Conclusions: Poor knowledge of its benefits and a low willingness to promote the procedure-strongly dependent on personal beliefs-suggest that medical students may need additional training to help them to discuss MC more openly with adult men at risk for HIV infection. Knowledge may be an effective tool when making decisions regarding MC promotion.

Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population, 2008-2013

BACKGROUND

Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors.

METHODS

Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference.

RESULTS

The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception.

CONCLUSIONS

The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.

Exploring drivers for safe male circumcision: Experiences with health education and understanding of partial HIV protection among newly circumcised men in Wakiso, Uganda

Introduction

About 2.5 million men have voluntarily been circumcised since Uganda started implementing the WHO recommendation to scale up safe male circumcision to reduce HIV transmission. This study sought to understand what influences men's circumcision decisions, their experiences with health education at health facilities and their knowledge of partial HIV risk reduction in Wakiso district.

Methods

Data were collected in May and June 2015 at five public health facilities in Wakiso District. Twenty-five in-depth interviews were held with adult safe male circumcision clients. Data were analysed using thematic network analysis.

Findings

Safe male circumcision decisions were mainly influenced by sexual partners, a perceived need to reduce the risk of HIV/STIs, community pressure and other benefits like hygiene. Sexual partners directly requested men to circumcise or indirectly influenced them in varied ways. Health education at facilities mainly focused on the surgical procedure, circumcision benefits especially HIV risk reduction, wound care and time to resumption of sex, with less focus on post-circumcision sexual behaviour. Five men reported no health education. All men reported that circumcision only reduces and does not eliminate HIV risk, and could mention ways it protects, although some extended the benefit to direct protection for women and prevention of other STIs. Five men thought social marketing messages were ‘misleading’ and feared risk compensation within the community.

Conclusions

Participants reported positive community perception about safe male circumcision campaigns, influencing men to seek services and enabling female partners to impact this decision-making process. However, there seemed to be gaps in safe male circumcision health education, although all participants correctly understood that circumcision offers only partial protection from HIV. Standard health education procedures, if followed at health facilities offering safe male circumcision, would ensure all clients are well informed, especially about post-circumcision sexual behaviour that is key to prevention of risk compensation.

Women's knowledge and perception of male circumcision before and after its roll-out in the South African township of Orange Farm from community-based cross-sectional surveys

The roll-out of medical male circumcision (MC) is progressing in Southern and Eastern Africa. Little is known about the effect of this roll-out on women. The objective of this study was to assess the knowledge and perceptions of women regarding MC in a setting before and after the roll-out. This study was conducted in the South African township of Orange Farm where MC prevalence among men increased from 17% to 53% in the period 2008–2010. Data from three community-based cross sectional surveys conducted in 2007, 2010 and 2012 among 1258, 1197 and 2583 adult women, respectively were studied. In 2012, among 2583 women, 73.7% reported a preference for circumcised partners, and 87.9% knew that circumcised men could become infected with HIV. A total of 95.8% preferred to have their male children circumcised. These three proportions increased significantly during the roll-out. In 2007, the corresponding values were 64.4%, 82.9% and 80.4%, respectively. Among 2581 women having had sexual intercourse with circumcised and uncircumcised men, a majority (55.8%, 1440/2581) agreed that it was easier for a circumcised man to use a condom, 20.5% (530/2581) disagreed; and 23.07 (611/2581) did not know. However, some women incorrectly stated that they were fully (32/2579; 1.2%; 95%CI: 0.9% to 1.7%) or partially (233/2579; 9.0%; 95%CI: 8.0% to 10.2%) protected when having unprotected sex with a circumcised HIV-positive partner. This study shows that the favorable perception of women and relatively correct knowledge regarding VMMC had increased during the roll-out of VMMC. When possible, women should participate in the promotion of VMMC although further effort should be made to improve their knowledge.

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.

The Relationship Between Distance and Post-operative Visit Attendance Following Medical Male Circumcision in Nyanza Province, Kenya

To date, there is no research on voluntary medical male circumcision (VMMC) catchment areas or the relationship between distance to a VMMC facility and attendance at a post-operative follow-up visit. We analyzed data from a randomly selected subset of males self-seeking circumcision at one of 16 participating facilities in Nyanza Province, Kenya between 2008 and 2010. Among 1437 participants, 46.7 % attended follow-up. The median distance from residence to utilized facility was 2.98 km (IQR 1.31-5.38). Nearly all participants (98.8 %) lived within 5 km from a facility, however, 26.3 % visited a facility more than 5 km away. Stratified results demonstrated that among those utilizing fixed facilities, greater distance was associated with higher odds of follow-up non-attendance (OR_{5.01-10km vs. 0-1km} = 1.71, 95 % CI 1.08, 2.70, p = 0.02; OR_{>10km vs. 0-1 km} = 2.80, 95 % CI 1.26, 6.21, p = 0.01), adjusting for age and district of residence. We found 5 km marked the threshold distance beyond which follow-up attendance significantly dropped. These results demonstrate distance is an important predictor of attending follow-up, and this relationship appears to be modified by facility type.

Medical male circumcision: How does price affect the risk-profile of take-up?

OBJECTIVE

The benefit of male circumcision is greatest among men who are most at risk of HIV infection. Encouraging this population of men to get circumcised maximizes the benefit that can be achieved through the scale-up of circumcision programs. This paper examines how the price of circumcision affects the risk profile of men who receive a voluntary medical circumcision.

METHODS

In 2010, 1649 uncircumcised adult men in urban Malawi were interviewed and provided a voucher for a subsidized voluntary medical male circumcision, at randomly assigned prices. Clinical data were collected indicating whether the men in the study received a circumcision.

RESULTS

Men who took-up circumcision with a zero-priced voucher were 25 percentage points less likely than those who took-up with a positive-price voucher, to be from a tribe that traditionally circumcises (p=0.101). Zero-priced vouchers also brought in men with more sexual partners in the past year (p=0.075) and past month (p=0.003). None of the men who were most at risk of HIV at baseline (those with multiple partners and who did not use a condom the last time they had sex) received a circumcision if they were offered a positive-priced voucher. Lowering the price to zero increased circumcision take-up to 25% for men of this risk group. The effect of price on take-up was largest among those at highest risk (p=0.096).

CONCLUSIONS

Reducing the price of circumcision surgery to zero can increase take-up among those who are most at risk of HIV infection.

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.

Women's Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia

Women's perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women's health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men's risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman's HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women's misperception regarding MC. Programs should address women's informational needs and continue to emphasize that condoms remain critical, regardless of male partner's circumcision status.

Sexual Satisfaction, Performance, and Partner Response Following Voluntary Medical Male Circumcision in Zambia: The Spear and Shield Project

Most men and their partners reported increased or the same levels of sexual pleasure and improved or no change in penile hygiene post-VMMC. While half of men reported increased or no change in sexual functioning (orgasm, erections), one-third reported a decrease. Early resumption of sexual intercourse prior to complete healing was most closely associated with adverse outcomes, including decreased sexual functioning, satisfaction, and desire.

Background:

Voluntary medical male circumcision (VMMC) is an important HIV prevention strategy, particularly in regions with high HIV incidence and low rates of male circumcision. However, 88% of the Zambian male population remain uncircumcised, and of these 80% of men surveyed expressed little interest in undergoing VMMC.

Methods:

The Spear and Shield study (consisting of 4 weekly, 90-minute sexual risk reduction/VMMC promotion sessions) recruited and enrolled men (N = 800) who self-identified as at risk of HIV by seeking HIV testing and counseling at community health centers. Eligible men tested HIV-negative, were uncircumcised, and expressed no interest in VMMC. Participants were encouraged (but not required) to invite their female partners (N = 668) to participate in the program in a gender-concordant intervention matched to their partners’. Men completed assessments at baseline, post-intervention (about 2 months after baseline), and 6 and 12 months post-intervention; women completed assessments at baseline and post-intervention. For those men who underwent VMMC and for their partners, an additional assessment was conducted 3 months following the VMMC. The ancillary analysis in this article compared the pre- and post-VMMC responses of the 257 Zambian men who underwent circumcision during or following study participation, using growth curve analyses, as well as of the 159 female partners.

Results:

Men were satisfied overall with the procedure (mean satisfaction score, 8.4 out of 10), and nearly all men (96%) and women (94%) stated they would recommend VMMC to others. Approximately half of the men reported an increase or no change in erections, orgasms, and time to achieve orgasms from pre-VMMC, while one-third indicated fewer erections and orgasms and decreased time to achieve orgasms post-VMMC. Nearly half (42%) of the men, and a greater proportion (63%) of the female partners, said their sexual pleasure increased while 22% of the men reported less sexual pleasure post-VMMC. Growth curve analysis of changes in sexual functioning and satisfaction over time revealed no changes in erectile functioning or intercourse satisfaction, but there were increases in orgasm functioning, overall sexual satisfaction, and sexual desire. The majority (61% to 70%) of men and women thought penile cleanliness and appearance had improved post-VMMC. Of the 69% of men who reported having sexual intercourse at least once between having the procedure and their 3-month post-VMMC assessment, the large majority (76%) waited at least 6 weeks before resuming sex. Sexual intercourse prior to the 6-week healing period was associated with adverse events and lower levels of post-VMMC sexual satisfaction.

Conclusion:

Both men and their partners can generally expect equal or improved sexual satisfaction and penile hygiene following VMMC. Future studies should consider innovative strategies to assist men in their efforts to abstain from sexual activities prior to complete healing.

Sexual Risk Behaviours and Willingness to Be Circumcised among Uncircumcised Adult Men in Uganda

Background

There has been substantial demand for safe male circumcision (SMC) in Uganda in the early programme scale-up phase. Research indicates that early adopters of new interventions often differ from later adopters in relation to a range of behaviours. However, there is limited knowledge about the risk profile of men who were willing to be circumcised at the time of launching the SMC programme, i.e., potential early adopters, compared to those who were reluctant. The aim of this study was to address this gap to provide indications on whether it is likely that potential early adopters of male circumcision were more in need of this new prevention measure than others.

Methods

Data were from the 2011 Uganda AIDS Indictor Survey (UAIS), with a nationally representative sample of men 15 to 59 years. The analysis was based on generalized linear models, obtaining prevalence risk ratios (PRR) with 95% confidence intervals (CI) as measures of association between willingness to be circumcised and multiple sexual partners, transactional sex, non-marital sex and non-use of condoms at last non-marital sex.

Results

Of the 5,776 men in the survey, 44% expressed willingness to be circumcised. Willingness to be circumcised was higher among the younger, urban and educated men. In the unadjusted analyses, all the sexual risk behaviours were associated with willingness to be circumcised, while in the adjusted analysis, non-marital sex (Adj PRR 1.27; CI: 1.16–1.40) and non-use of condoms at last such sex (Adj PRR 1.18; CI: 1.07–1.29) were associated with higher willingness to be circumcised.

Conclusion

Willingness to be circumcised was relatively high at the launch of the SMC programme and was more common among uncircumcised men reporting sexual risk behaviours. This indicates that the early adopters of SMC were likely to be in particular need of such additional HIV protective measures.

"If You Are Not Circumcised, I Cannot Say Yes": The Role of Women in Promoting the Uptake of Voluntary Medical Male Circumcision in Tanzania

Voluntary Medical Male Circumcision (VMMC) for HIV prevention in Tanzania was introduced by the Ministry of Health and Social Welfare in 2010 as part of the national HIV prevention strategy. A qualitative study was conducted prior to a cluster randomized trial which tested effective strategies to increase VMMC up take among men aged ≥20 years. During the formative qualitative study, we conducted in-depth interviews with circumcised males (n = 14), uncircumcised males (n = 16), and participatory group discussions (n = 20) with men and women aged 20–49 years in Njombe and Tabora regions of Tanzania. Participants reported that mothers and female partners have an important influence on men’s decisions to seek VMMC both directly by denying sex, and indirectly through discussion, advice and providing information on VMMC to uncircumcised partners and sons. Our findings suggest that in Tanzania and potentially other settings, an expanded role for women in VMMC communication strategies could increase adult male uptake of VMMC services.

Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies

By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits.

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.

Association between wanting circumcision and risky sexual behaviour in Zimbabwe: evidence from the 2010-11 Zimbabwe demographic and health survey

BACKGROUND

Zimbabwe adopted voluntary medical male circumcision (VMMC) as an additional HIV prevention strategy in 2009. A number of studies have been conducted to understand the determinants of VMMC uptake but few studies have examined the characteristics of men who are willing to get circumcised or the link between wanting circumcision and risky sexual behaviour. This study investigated the relationship between wanting male circumcision and engaging in risky sex behaviours. This was based on the assumption that those who are willing to undergo circumcision are already engaging in risky sexual behaviours.

DATA AND METHODS

Data from men age 15-45 years who were interviewed during the 2010-11 Zimbabwe Demographic and Health Survey of 2010-11 was used. A total of 7480 men were included in the sample for this study. Logistic regression was used to assess the association between wanting circumcision and risky sexual behaviours.

FINDINGS

Men in the highest wealth tercile were significantly more likely to want circumcision compared to men in lower wealth terciles (OR=1.36, p<0.01). Wanting circumcision was also significantly associated with age. Men in the 25-34 age category reported wanting circumcision more (OR=1.21, p < 0.05) while older men were significantly less likely to want circumcision (OR=0.63, p<0.01). Christian men and those residing in rural areas were also less likely to want circumcision (OR=0.74, p<0.05 and OR = 0.75, p < 0.001 respectively). The findings of this study indicate a strong association between wanting circumcision and having had risky sex (OR=1.36, p<0.01), having multiple partners (OR=1.35, p<0.01) and having paid for sex (OR=1.42, p < 0.001) However, wanting circumcision was negatively associated with having used a condom at the last risky sex (OR=0.76, p<0.001).

CONCLUSIONS

The association between demand for VMMC and risky sexual behaviour need continuous monitoring. We emphasise that the promotion of VMMC for HIV prevention should not overshadow the promotion of existing methods of HIV prevention such as condoms and reduction of sexual partners.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

'If you are circumcised, you are the best': understandings and perceptions of voluntary medical male circumcision among men from KwaZulu-Natal, South Africa

While the uptake of voluntary medical male circumcision (VMMC) is increasing, South Africa has only attained 20% of its target to circumcise 80% of adult men by 2015. Understanding the factors influencing uptake is essential to meeting these targets. This qualitative study reports on findings from focus-group discussions with men in rural KwaZulu-Natal, South Africa, about what factors influence their perceptions of VMMC. The study found that VMMC is linked to perceptions of masculinity and male gender identity including sexual health, sexual performance and pleasure, possible risk compensation and self-identity. Findings highlight the need to understand how these perceptions of sexual health and performance affect men's decisions to undergo circumcision and the implications for uptake of VMMC. The study also highlights the need for individualised and contextualised information and counselling that can identify, understand and address the perceptions men have of VMMC, and the impacts they believe it will have on them.

Scaling-up voluntary medical male circumcision - what have we learned?

In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15–49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008–2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.

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.

Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods

Background

In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high.

Methods and Findings

Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their “protection by marriage,” cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men.

Conclusions

Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy.

Achieving the HIV prevention impact of voluntary medical male circumcision: lessons and challenges for managing programs

Voluntary medical male circumcision (VMMC) is capable of reducing the risk of sexual transmission of HIV from females to males by approximately 60%. In 2007, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended making VMMC part of a comprehensive HIV prevention package in countries with a generalized HIV epidemic and low rates of male circumcision. Modeling studies undertaken in 2009-2011 estimated that circumcising 80% of adult males in 14 priority countries in Eastern and Southern Africa within five years, and sustaining coverage levels thereafter, could avert 3.4 million HIV infections within 15 years and save US$16.5 billion in treatment costs. In response, WHO/UNAIDS launched the Joint Strategic Action Framework for accelerating the scale-up of VMMC for HIV prevention in Southern and Eastern Africa, calling for 80% coverage of adult male circumcision by 2016. While VMMC programs have grown dramatically since inception, they appear unlikely to reach this goal. This review provides an overview of findings from the PLOS Collection "Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up." The use of devices for VMMC is also explored. We propose emphasizing management solutions to help VMMC programs in the priority countries achieve the desired impact of averting the greatest possible number of HIV infections. Our recommendations include advocating for prioritization and funding of VMMC, increasing strategic targeting to achieve the goal of reducing HIV incidence, focusing on programmatic efficiency, exploring the role of new technologies, rethinking demand creation, strengthening data use for decision-making, improving governments' program management capacity, strategizing for sustainability, and maintaining a flexible scale-up strategy informed by a strong monitoring, learning, and evaluation platform.

Kenya's voluntary male medical circumcision program: Translatable lessons for both domestic and international programs

As a case of translating a healthcare intervention from randomized controlled trial to public health program, Kenya's voluntary male medical circumcision (VMMC) program offers an example of demand generation through active engagement with the population and reducing barriers to uptake. It illustrates various means by which the Kenyan leadership focused on demand generation which have value both domestically and internationally to healthcare leaders. Community and public engagement must start early and continue focused on key stakeholders and spokespersons. Barriers including cost, time, culture, and personal preference must be identified and addressed. This engagement and overall program must constantly be re-evaluated and shaped iteratively based on data.

Acceptability, knowledge, beliefs, and partners as determinants of Zambian men's readiness to undergo medical male circumcision

There is limited information about the influence of partners on medical male circumcision (MMC) uptake. This study aimed to evaluate attitudes, knowledge, and preferences about MMC among men and their partners, and their relative impact on male readiness to undergo the MMC procedure. Male participants (n = 354) and their partners (n = 273) were recruited from community health centers in Lusaka, Zambia. Men reported their readiness to undergo MMC, and both men and women were assessed regarding their attitudes and knowledge regarding MMC. Men who had discussed MMC with their partners, those who endorsed MMC for HIV risk reduction, and those viewing MMC as culturally acceptable reported increased readiness to undergo MMC. Additionally, endorsement of MMC by female partners was associated with increased men's readiness. Results support promotion of cultural acceptability of MMC, and efforts to increase MMC uptake may benefit from incorporating partners in the decision making process.

'He is proud of my courage to ask him to be circumcised': experiences of female partners of male circumcision clients in Iringa region, Tanzania

Male circumcision programmes in Tanzania seek to increase demand among older, married clients who are more likely to have steady female sexual partners. Understanding women's roles throughout their partners' circumcision and any resultant changes in relationship dynamics are important considerations as efforts are made to scale up male circumcision. We conducted interviews with 32 wives of male circumcision clients from November 2011 to February 2012 in Iringa, Tanzania. Transcripts were digitally recorded, transcribed and translated into English and codes were developed based on emerging themes. Women were instrumental in convincing their husbands to be circumcised, but early resumption of sexual activity was common and a minority of women reported their husbands' emotional abuse or risk compensation following circumcision. These findings suggest that married women play a key role in their husbands' decisions to be circumcised, but women's needs for information and education are not being met and gender inequalities further decrease women's abilities to reduce their risk of HIV in this context. Strategies to more meaningfully engage women in male circumcision programmes are needed.

Is Sex Like Driving? HIV Prevention and Risk Compensation

Risk compensation has been called the "Achilles' heel" of HIV prevention policies (Cassell et al 2006). This paper examines the behavioral response to male circumcision, a major HIV prevention policy currently being implemented throughout much of Sub-Saharan Africa. Contrary to the presumption of risk compensation, we find that the response due to the perceived reduction in HIV transmission appears to have been a reduction in risky sexual behavior. We suggest a mechanism for this finding: circumcision may reduce fatalism about acquiring HIV/AIDS and increase the salience of the tradeoff between engaging in additional risky behavior and avoiding acquiring HIV. We also find what appears to be a competing effect that does not operate through the circumcision recipient's belief about the reduction in the risk of acquiring HIV.

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.

"After my husband's circumcision, I know that I am safe from diseases": women's attitudes and risk perceptions towards male circumcision in Iringa, Tanzania

While male circumcision reduces the risk of female-to-male HIV transmission and certain sexually transmitted infections (STIs), there is little evidence that circumcision provides women with direct protection against HIV. This study used qualitative methods to assess women's perceptions of male circumcision in Iringa, Tanzania. Women in this study had strong preferences for circumcised men because of the low risk perception of HIV with circumcised men, social norms favoring circumcised men, and perceived increased sexual desirability of circumcised men. The health benefits of male circumcision were generally overstated; many respondents falsely believed that women are also directly protected against HIV and that the risk of all STIs is greatly reduced or eliminated in circumcised men. Efforts to engage women about the risks and limitations of male circumcision, in addition to the benefits, should be expanded so that women can accurately assess their risk of HIV or STIs during sexual intercourse with circumcised men.

Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea

BACKGROUND

The success of health programs is influenced not only by their acceptability but also their ability to meet and respond to community expectations of service delivery. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended medical male circumcision (MC) as an essential component of comprehensive HIV prevention programs in high burden settings. This study investigated community-level perceptions of MC for HIV prevention in Papua New Guinea (PNG), a setting where diverse traditional and contemporary forms of penile foreskin cutting practices have been described.

METHODS

A multi-method qualitative study was undertaken in four provinces in two stages from 2009 to 2011. A total of 82 in-depth interviews, and 45 focus group discussions were completed during Stage 1. Stage 2 incorporated eight participatory workshops that were an integral part of the research dissemination process to communities. The workshops also provided opportunity to review key themes and consolidate earlier findings as part of the research process. Qualitative data analysis used a grounded theory approach and was facilitated using qualitative data management software.

RESULTS

A number of diverse considerations for the delivery of MC for HIV prevention in PNG were described, with conflicting views both between and within communities. Key issues included: location of the service, service provider, age eligibility, type of cut, community awareness and potential shame amongst youth. Key to developing appropriate health service delivery models was an appreciation of the differences in expectations and traditions of unique cultural groups in PNG. Establishing strong community coalitions, raising awareness and building trust were seen as integral to success.

CONCLUSIONS

Difficulties exist in the implementation of new programs in a pluralistic society such as PNG, particularly if tensions arise between biomedical knowledge and medico-legal requirements, compared to existing socio-cultural interests. Community participatory approaches offer important opportunities to explore and design culturally safe, specific and accessible programs.