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Bosman S, Misra S, Flax-Nel LM, van Heerden A, Humphries H, Essack Z. A 5-Year Review of the Impact of Lottery Incentives on HIV-Related Services. Curr HIV/AIDS Rep 2024; 21:131-139. [PMID: 38573583 PMCID: PMC11130023 DOI: 10.1007/s11904-024-00694-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Lottery incentives are an innovative approach to encouraging HIV prevention, treatment initiation, and adherence behaviours. This paper reviews the latest research on lottery incentives' impact on HIV-related services, and their effectiveness for motivating behaviours to improve HIV service engagement and HIV health outcomes. RECENT FINDINGS Our review of ten articles, related to lottery incentives, published between 2018 and 2023 (inclusive) shows that lottery incentives have promise for promoting HIV-related target behaviours. The review highlights that lottery incentives may be better for affecting simpler behaviours, rather than more complex ones, such as voluntary medical male circumcision. This review recommends tailoring lottery incentives, ensuring contextual-relevance, to improve the impact on HIV-related services. Lottery incentives offer tools for improving uptake of HIV-related services. The success of lottery incentives appears to be mediated by context, the value and nature of the incentives, and the complexity of the target behaviour.
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Affiliation(s)
- Shannon Bosman
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, 1 Caluza Street, Sweetwaters, KwaZulu Natal, South Africa.
| | - Shriya Misra
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, 1 Caluza Street, Sweetwaters, KwaZulu Natal, South Africa
| | - Lili Marie Flax-Nel
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, 1 Caluza Street, Sweetwaters, KwaZulu Natal, South Africa
| | - Alastair van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, 1 Caluza Street, Sweetwaters, KwaZulu Natal, South Africa
- SAMRC/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Hilton Humphries
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, 1 Caluza Street, Sweetwaters, KwaZulu Natal, South Africa
- School of Applied Human Sciences, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Zaynab Essack
- Centre for Community Based Research, Human Sciences Research Council, Old Bus Depot, 1 Caluza Street, Sweetwaters, KwaZulu Natal, South Africa
- School of Law, University of KwaZulu Natal, Pietermaritzburg, South Africa
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Byaruhanga A, Mbona NT, Babirye S, Nalugoda F, Kankaka EN, Ampaire L, Migisha R, Kagaayi J. Women’s support for voluntary medical male circumcision in fishing communities on the shores of Lake Victoria, Uganda. BMC Health Serv Res 2022; 22:505. [PMID: 35421972 PMCID: PMC9012010 DOI: 10.1186/s12913-022-07842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/25/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Galiwango RM, Park DE, Huibner S, Onos A, Aziz M, Roach K, Anok A, Nnamutete J, Isabirye Y, Wasswa JB, Male D, Kigozi G, Tobian AAR, Prodger JL, Liu CM, Kaul R. Immune milieu and microbiome of the distal urethra in Ugandan men: impact of penile circumcision and implications for HIV susceptibility. MICROBIOME 2022; 10:7. [PMID: 35042542 PMCID: PMC8764836 DOI: 10.1186/s40168-021-01185-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 11/01/2021] [Indexed: 05/24/2023]
Abstract
BACKGROUND Coronal sulcus (CS) anaerobe abundance and IL-8 levels are linked to HIV acquisition, and are dramatically reduced after penile circumcision (PC). The distal urethra may be the site of some HIV acquisition before PC, and presumably most acquisition post PC. We describe the immune milieu and microbiome of the distal urethra in uncircumcised Ugandan men, and define the impact of PC. Participants consisted of HIV-negative, genital symptom-free adult Ugandan men undergoing PC (n = 51). Urethral and coronal sulcus swabs were collected at baseline and at 6- and 12-months post-PC. Soluble immune factors were quantified by multiplex ELISA, and bacterial abundance assessed by 16S rRNA qPCR and sequencing. RESULTS At baseline, the urethra was enriched compared to the CS for most cytokines (including IL-8 and MIP-1β) and soluble E-cadherin (sE-cadherin, an epithelial disruption marker), although CS levels of IL-1α and IL-1β were higher. Baseline total bacterial abundance was ≥ 20-fold higher in the CS than the urethra (median 27,100 vs. 1200 gene copies/swab, p = 0.001), and anaerobes comprised 58% of CS bacteria vs. 42% of urethral bacteria. PC did not alter urethral IL-8 (median 806 at baseline vs. 1130 pg/ml at 12 months; p = 0.062) and urethral sE-cadherin increased (113,223 vs. 158,385 pg/ml, p = 0.009), despite five- and sevenfold drops in total bacterial and anaerobe abundance after PC, respectively. However, PC dramatically reduced CS levels of sE-cadherin (15,843 vs. 837 pg/ml, p < 0.001) and most cytokines (IL-8; 34 vs. 3 pg/ml, p < 0.001), while reducing total bacterial and anaerobe abundance by 13-fold and 60-fold, respectively (both P ≤ 0.004). CONCLUSIONS The urethra is immunologically rich with characteristics of an HIV-susceptible tissue site. However, PC had no impact on urethral immunology and may have reduced epithelial integrity, despite modest reductions in total bacteria and anaerobes, suggesting that HIV protection from PC is not mediated via immune or microbiome alterations in the urethra. Video abstract.
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Affiliation(s)
- Ronald M Galiwango
- Departments of Immunology and Medicine, University of Toronto, St. George Campus, Medical Sciences Building, 1 King's College Circle, Room 6356, Toronto, Ontario, M5S1A8, Canada
| | - Daniel E Park
- George Washington Milken Institute School of Public Health, Washington, DC, USA
| | - Sanja Huibner
- Departments of Immunology and Medicine, University of Toronto, St. George Campus, Medical Sciences Building, 1 King's College Circle, Room 6356, Toronto, Ontario, M5S1A8, Canada
| | - Abigail Onos
- George Washington Milken Institute School of Public Health, Washington, DC, USA
| | - Maliha Aziz
- Departments of Immunology and Medicine, University of Toronto, St. George Campus, Medical Sciences Building, 1 King's College Circle, Room 6356, Toronto, Ontario, M5S1A8, Canada
| | - Kelsey Roach
- George Washington Milken Institute School of Public Health, Washington, DC, USA
| | - Aggrey Anok
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | | | - Deo Male
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | | | - Cindy M Liu
- George Washington Milken Institute School of Public Health, Washington, DC, USA
| | - Rupert Kaul
- Departments of Immunology and Medicine, University of Toronto, St. George Campus, Medical Sciences Building, 1 King's College Circle, Room 6356, Toronto, Ontario, M5S1A8, Canada.
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Fleming PJ, Doshi M, Harper GW, Otieno F, Bailey RC. Integration of voluntary male medical circumcision for HIV prevention into norms of masculinity: findings from Kisumu, Kenya. CULTURE, HEALTH & SEXUALITY 2021; 23:1451-1463. [PMID: 33016854 DOI: 10.1080/13691058.2020.1829057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 09/22/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Paul J Fleming
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Monika Doshi
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | - Gary W Harper
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
| | | | - Robert C Bailey
- Nyanza Reproductive Health Society, Kisumu, Kenya
- Department of Epidemiology, University of Illinois at Chicago, Chicago, IL, USA
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Rennie S, Gilbertson A, Hallfors D, Luseno WK. The Ethics of Stigma in Medical Male Circumcision Initiatives Involving Adolescents in Sub-Saharan Africa. Public Health Ethics 2021; 14:79-89. [PMID: 34239604 DOI: 10.1093/phe/phab004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. VMMC programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity.
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Feldacker C, Murenje V, Makunike-Chikwinya B, Hove J, Munyaradzi T, Marongwe P, Balachandra S, Mandisarisa J, Holec M, Xaba S, Sidile-Chitimbire V, Tshimanga M, Barnhart S. Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe. PLoS One 2020; 15:e0240425. [PMID: 33048977 PMCID: PMC7553309 DOI: 10.1371/journal.pone.0240425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background Since 2013, the ZAZIC consortium supported the Zimbabwe Ministry of Health and Child Care (MOHCC) to implement a high quality, integrated voluntary medical male circumcision (VMMC) program in 13 districts. With the aim of significantly lowering global HIV rates, prevention programs like VMMC make every effort to achieve ambitious targets at an increasingly reduced cost. This has the potential to threaten VMMC program quality. Two measures of program quality are follow-up and adverse event (AE) rates. To inform further VMMC program improvement, ZAZIC conducted a quality assurance (QA) activity to assess if pressure to do more with less influenced program quality. Methods Key informant interviews (KIIs) were conducted at 9 sites with 7 site-based VMMC program officers and 9 ZAZIC roving team members. Confidentiality was ensured to encourage candid conversation on adherence to VMMC standards, methods to increase productivity, challenges to target achievement, and suggestions for program modification. Interviews were recorded, transcribed and analyzed using Atlas.ti 6. Results VMMC teams work long hours in diverse community settings to reach ambitious targets. Rotating, large teams of trained VMMC providers ensures meeting demand. Service providers prioritize VMMC safety procedures and implement additional QA measures to prevent AEs among all clients, especially minors. However, KIs noted three areas where pressure for increased numbers of clients diminished adherence to VMMC safety standards. For pre- and post-operative counselling, MC teams may combine individual and group sessions to reach more people, potentially reducing client understanding of critical wound care instructions. Second, key infection control practices may be compromised (handwashing, scrubbing techniques, and preoperative client preparation) to speed MC procedures. Lastly, pressure for client numbers may reduce prioritization of patient follow-up, while client-perceived stigma may reduce care-seeking. Although AEs appear well managed, delays in AE identification and lack of consistent AE reporting compromise program quality. Conclusion In pursuit of ambitious targets, healthcare workers may compromise quality of MC services. Although risk to patients may appear minimal, careful consideration of the realities and risks of ambitious target setting by donors, ministries, and implementing partners could help to ensure that client safety and program quality is consistently prioritized over productivity.
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Affiliation(s)
- Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | - Joseph Hove
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Phiona Marongwe
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | - Shirish Balachandra
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - John Mandisarisa
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | | | | | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
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Nxumalo CT, Mchunu GG. Zulu Men's Conceptions, Understanding, and Experiences of Voluntary Medical Male Circumcision in KwaZulu-Natal, South Africa. Am J Mens Health 2020; 14:1557988319892437. [PMID: 32131678 PMCID: PMC7059234 DOI: 10.1177/1557988319892437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Voluntary Medical Male Circumcision (VMMC) is proven to reduce transmission of
HIV/AIDS. Despite concerted efforts to scale up VMMC in men aged 18–49, the
number of medically circumcised men in this age group remains suboptimal.
Research has shown that several individual factors hinder and promote uptake of
VMMC. The nature of these factors is not clearly understood within the
dimensions of religion, culture and tradition, particularly in a low-income
rural setting. This study aimed to analyze Zulu men’s conceptions, understanding
and experiences regarding VMMC in KwaZulu-Natal (KZN), South Africa. A
qualitative phenomenographic study approach was used to collect data from 20
uncircumcised males at six different clinics that provide VMMC services. Ethical
approval to collect data was obtained from the Biomedical Research Ethics
Committee of the University of KZN (BREC – BE627/18). Individual in-depth face
to face interviews were conducted using a semistructured interview guide.
Audiotapes were used to record interviews which were transcribed verbatim and
then analyzed manually. The conceptions regarding medical circumcision appeared
to be related to religious and cultural beliefs surrounding circumcision and the
historical traditional practice thereof. The understanding of males regarding
VMMC was mainly attributed to HIV prevention; however, knowledge on the degree
of partial protection appeared to be limited. An array of negative accounted in
the form of complications such as poor wound healing and postoperative pain
undergone by peers and other close influencers’ accounted for participants’
experiences of VMMC. Poor knowledge and negative experiences relating to VMMC
could account for reasons why men choose not to undergo VMMC.
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Affiliation(s)
- Celenkosini Thembelenkosini Nxumalo
- KZN Department of Health, Ndwedwe Community Health Centre, Verulam, KwaZulu-Natal, South Africa.,Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Gugu Gladness Mchunu
- Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Wiginton JM, Fleming PJ, Barrington C, Donastorg Y, Lerebours L, Brito MO. Masculine gender norms, male circumcision, and men's engagement with health care in the Dominican Republic. Glob Public Health 2019; 15:654-665. [PMID: 31874065 DOI: 10.1080/17441692.2019.1704817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Overall, adult men are less likely to seek and receive health care than women, but male circumcision for HIV prevention has been successful in engaging men in health services. The purpose of this paper is to examine the relationship between masculine norms and health care-seeking among men participating in a voluntary male medical circumcision (VMMC) programme in the Dominican Republic (DR). We employed a mixed methods approach integrating survey data collected 6-12 months post-circumcision (n = 293) and in-depth interviews with a sub-sample of these men (n = 30). In our qualitative analysis, we found that health care-seeking is connected to masculine norms among men in the DR, including the perceptions of medical facilities as feminine spaces. Participants' narratives demonstrate that male circumcision programmes may facilitate men overcoming masculinity-related barriers to health care engagement. In quantitative analysis, we found that being concerned about being perceived as masculine was associated with health care-seeking behaviour in the past five years, though this association was not retained in multivariable analyses. Findings indicate that male circumcision programmes can familiarise men with the healthcare system and masculinise health care-seeking and utilisation, easing associated discomfort.
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Affiliation(s)
- John Mark Wiginton
- Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Paul J Fleming
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public HealthUniversity of North Carolina, Chapel Hill, NC, USA
| | - Yeycy Donastorg
- HIV Vaccine Trials Unit, Instituto Dermatológico y Cirugía de Piel, Santo Domingo, Dominican Republic
| | - Leonel Lerebours
- Centers for Disease Control and Prevention, Santo Domingo, Dominican Republic
| | - Maximo O Brito
- Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
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Galiwango RM, Yegorov S, Joag V, Prodger J, Shahabi K, Huibner S, Muyanja E, Kabuubi BR, Namuniina A, Nalutaaya A, Ssemaganda A, Lutwama F, Kitandwe PK, Nanvubya A, Mpendo J, Bagaya B, Kiwanuka N, Kaul R. Characterization of CD4 + T cell subsets and HIV susceptibility in the inner and outer foreskin of Ugandan men. Am J Reprod Immunol 2019; 82:e13143. [PMID: 31081958 DOI: 10.1111/aji.13143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 11/27/2022] Open
Abstract
PROBLEM Biological mechanisms of foreskin HIV acquisition are poorly defined. The inner foreskin is preferentially infected in explant models, so we hypothesized that this site would be enriched for HIV-susceptible CD4+ T cells and proinflammatory/chemoattractant cytokines. METHOD OF STUDY A total of 42 HIV-uninfected Ugandan men without genital symptoms provided foreskin tissues and swabs at the time of elective penile circumcision. The immune phenotype of foreskin-derived CD4+ T cells and entry of a CCR5-tropic HIV pseudovirus was characterized, and specific cytokine levels assayed by multiplexed chemiluminescent ELISA. RESULTS Unexpectedly, outer foreskin CD4+ T cells more frequently expressed CCR5 (median 29.2% vs 22.9%, P = 0.01) and CD69 (median 36.5% vs 15%, P < 0.01), and on a per-cell basis, HIV entry was higher. However, overall CD4+ T cell density was approximately twofold higher in the inner foreskin, and several highly susceptible T cell subsets were increased at this site, including Th17 cells (20.0% vs 14.1%, P = 0.0021). Specific pro-inflammatory cytokine levels were also higher on the inner foreskin surface (IL-17, IL-8, RANTES and IL-1β; all P < 0.05). CONCLUSION There was marked heterogeneity in CD4+ T cell populations and immune milieu between inner and outer foreskin tissues. Despite higher per-cell viral entry into CD4+ T cells from the outer foreskin, the higher target cell density and enriched pro-inflammatory cytokines of the inner foreskin suggest that this may be a preferential site for HIV acquisition.
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Affiliation(s)
| | - Sergey Yegorov
- Department of Immunology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vineet Joag
- Department of Immunology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Prodger
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kamnoosh Shahabi
- Department of Immunology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sanja Huibner
- Department of Immunology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Enoch Muyanja
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Brian Roy Kabuubi
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Annmarie Namuniina
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Annet Nalutaaya
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Aloysius Ssemaganda
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda.,Laboratory of Vaccines for the Developing World, Institute for Glycomics, Griffith University, Mount Gravatt, Queensland, Australia
| | - Fredrick Lutwama
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Paul Kato Kitandwe
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Annet Nanvubya
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Juliet Mpendo
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Bernard Bagaya
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Noah Kiwanuka
- HIV Vaccine Program, Uganda Virus Research Institute - International AIDS Vaccine Initiative, Entebbe, Uganda
| | - Rupert Kaul
- Department of Immunology and Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Carrasco MA, Wilkinson J, Kasdan B, Fleming P. Systematic review of barriers and facilitators to voluntary medical male circumcision in priority countries and programmatic implications for service uptake. Glob Public Health 2018; 14:91-111. [PMID: 29695201 DOI: 10.1080/17441692.2018.1465108] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Maria A Carrasco
- a Department of Health, Behavior and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , USA.,b Office of HIV/AIDS, United States Agency for International Development , Washington, DC , USA
| | - Jessica Wilkinson
- b Office of HIV/AIDS, United States Agency for International Development , Washington, DC , USA
| | - Benjamin Kasdan
- b Office of HIV/AIDS, United States Agency for International Development , Washington, DC , USA
| | - Paul Fleming
- c Department of Health Behavior and Health Education , University of Michigan School of Public Health , Ann Arbor , USA
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Semo BW, Wirth KE, Ntsuape C, Barnhart S, Kleinman NJ, Ramabu N, Broz J, Ledikwe JH. Modifying the health system to maximize voluntary medical male circumcision uptake: a qualitative study in Botswana. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2017; 10:1-8. [PMID: 29296100 PMCID: PMC5739115 DOI: 10.2147/hiv.s144407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Background In 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS endorsed voluntary medical male circumcision (VMMC) as an add-on HIV-prevention strategy. Similar to many other sub-Saharan countries, VMMC uptake in Botswana has been low; as of February 2016, only 42.7% of the program target had been achieved. Previous work has examined how individual-level factors, such as knowledge and attitudes, influence the update of VMMC. This paper examines how factors related to the health system can be leveraged to maximize uptake of circumcision services, with a focus on demand creation, access to services, and service delivery. Methods Twenty-seven focus group discussions with 238 participants were conducted in four communities in Botswana among men (stratified by circumcision status and age), women (stratified by age), and community leaders. A semi-structured guide was used by a trained same-gender interviewer to facilitate discussions, which were audio recorded, transcribed, translated to English, and analyzed using an inductive analytic approach. Results Participants felt demand creation activities utilizing age- and gender-appropriate mobilizers and community leaders were more effective than mass media campaigns. Participants felt improved access to VMMC clinics would facilitate service uptake, as would designated men’s clinics with male-friendly providers for VMMC service delivery. Additionally, providing comprehensive pre-procedure counseling and education, outlining the benefits and disadvantages of the surgical procedure, and explaining the differences between the surgical and non-surgical procedures, were suggested by participants to increase understanding and uptake of VMMC. Conclusion Cultural acceptability of circumcision services can be improved by engaging age- and gender-appropriate community mobilizers. Involving influential community leaders, providing a forum for men to discuss health issues, and bringing services closer to people can increase VMMC utilization. Service delivery can be improved by communicating the pros and cons of the procedure to the clients for informed decision-making.
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Affiliation(s)
- Bazghina-Werq Semo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Kathleen E Wirth
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Conrad Ntsuape
- Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health, Gaborone, Botswana
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Nora J Kleinman
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.,NJK Consulting, Seattle, WA, USA
| | - Nankie Ramabu
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Jessica Broz
- Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
| | - Jenny H Ledikwe
- Department of Global Health, University of Washington, Seattle, WA, USA.,Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana
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12
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Tshimanga M, Makunike-Chikwinya B, Mangwiro T, Tapiwa Gundidza P, Chatikobo P, Murenje V, Herman-Roloff A, Kilmarx PH, Holec M, Gwinji G, Mugurungi O, Murwira M, Xaba S, Barnhart S, Feldacker C. Safety and efficacy of the PrePex device in HIV-positive men: A single-arm study in Zimbabwe. PLoS One 2017; 12:e0189146. [PMID: 29220392 PMCID: PMC5722373 DOI: 10.1371/journal.pone.0189146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/17/2017] [Indexed: 11/21/2022] Open
Abstract
Male circumcision (MC) for sexually active, HIV-negative men reduces HIV transmission and averts HIV infections. Excluding HIV-positive men from MC decreases access to additional health and hygiene benefits. In settings where HIV-testing is, or is perceived to be, required for MC, testing may reduce MC uptake. Reducing promotion of HIV testing within MC settings and promoting device-based MC may speed MC scale-up. To assess safety and efficacy of PrePex MC device among HIV-positive men, we conducted a one-arm, open-label, prospective study in otherwise healthy HIV-positive men in Zimbabwe.
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Affiliation(s)
- Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | | | | | | | - Pesanai Chatikobo
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | - Peter H. Kilmarx
- U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
| | | | | | | | | | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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13
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Shumba K, Lubombo M. Cultural competence: a framework for promoting voluntary medical male circumcision among VaRemba communities in Zimbabwe. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017; 16:165-173. [PMID: 28712347 DOI: 10.2989/16085906.2017.1337040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Almost a decade after the formal introduction of voluntary medical male circumcision (VMMC) as an important technology for HIV prevention, its implementation is still fraught with acceptability challenges. This is especially true among ethnic groups where male circumcision is conducted as a rite of passage into adulthood. In this article we question why VMMC is being met with resistance despite widespread awareness of its promise to reduce HIV incidence in a culturally circumcising community in Zimbabwe. In-depth and key informant interviews were conducted with selected VaRemba initiation graduates and surgeons respectively in Mposi area in Mberengwa to explore why VMMC has not been readily accepted in their community. Findings suggest that male circumcision among VaRemba is not only the removal of prepuce but comprises a secretive and rich curriculum rooted in their culture and identity. Such a conceptualisation renders some social and programmatic impediments for VMMC uptake. To scale up VMMC uptake among VaRemba, we argue for a reorganisation and adaptation of VMMC services in a culturally competent way that accounts for local conceptions of circumcision and respect for the cultural beliefs and practices of VaRemba communities.
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Affiliation(s)
- Kemist Shumba
- a Department of Science and Technology (DST)\-National Research Foundation (NRF) Centre of Excellence, Human Development , University of KwaZulu-Natal , Durban , South Africa
| | - Musara Lubombo
- b Centre for Communication, Media & Society , University of KwaZulu-Natal , Durban , South Africa
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14
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Fleming PJ, Barrington C, Pearce LD, Lerebours L, Donastorg Y, Brito MO. "I Feel Like More of a Man": A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention. JOURNAL OF SEX RESEARCH 2017; 54:42-54. [PMID: 26942550 PMCID: PMC5011023 DOI: 10.1080/00224499.2015.1137539] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Ethnographic studies from numerous societies have documented the central role of male circumcision in conferring masculinity and preparing boys for adult male sexuality. Despite this link between masculinity, sexuality, and circumcision, there has been little research on these dynamics among men who have been circumcised for HIV prevention. We employed a mixed methods approach with data collected from recently circumcised men in the Dominican Republic (DR) to explore this link. We analyzed survey data collected six to 12 months post-circumcision (N = 293) as well as in-depth interviews conducted with a subsample of those men (n = 30). We found that 42% of men felt more masculine post-circumcision. In multivariate analysis, feeling more masculine was associated with greater concern about being perceived as masculine (OR = 1.70, 95% CI: 1.25-2.32), feeling more potent erections post-circumcision (OR = 2.25, 95% CI: 1.26-4.03), and reporting increased ability to satisfy their partners post-circumcision (OR = 2.30, 95% CI: 1.11-4.77). In qualitative interviews, these factors were all related to masculine norms of sexually satisfying one's partner, and men's experiences of circumcision were shaped by social norms of masculinity. This study highlights that circumcision is not simply a biomedical intervention and that circumcision programs need to incorporate considerations of masculine norms and male sexuality into their programming.
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Affiliation(s)
- Paul J. Fleming
- Division of Global Public Health, University of California, San Diego, La Jolla, CA, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Lisa D. Pearce
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Sociology, University of North Carolina, Chapel Hill, NC, USA
| | | | - Yeycy Donastorg
- HIV Vaccine Trials Unit, Instituto Dermatológico y Cirugía de Piel, Santo Domingo, Dominican Republic
| | - Maximo O. Brito
- Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL
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15
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Mbonye M, Kuteesa M, Seeley J, Levin J, Weiss H, Kamali A. Voluntary medical male circumcision for HIV prevention in fishing communities in Uganda: the influence of local beliefs and practice. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2016; 15:211-8. [PMID: 27450591 DOI: 10.2989/16085906.2016.1179652] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Martin Mbonye
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda
| | - Monica Kuteesa
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda
| | - Janet Seeley
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda.,b Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , United Kingdom
| | - Jonathan Levin
- c School of Public Health, Faculty of Health Sciences , University of Witwatersrand , Johannesburg , South Africa
| | - Helen Weiss
- d MRC Tropical Epidemiology Group , London School of Hygiene & Tropical Medicine , London , United Kingdom
| | - Anatoli Kamali
- a MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda.,e Faculty of Epidemiology and Population Health , London School of Hygiene & Tropical Medicine , London , United Kingdom
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16
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Zamawe COF, Kusamula F. 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. Int Health 2015; 8:170-8. [PMID: 26503362 DOI: 10.1093/inthealth/ihv061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/31/2015] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Collins O F Zamawe
- Blantyre International University, Community Health Department, Private Bag 98, Blantyre, Malawi Parent and Child Health Initiative (PACHI), Research Centre, P.O. Box 31686, Lilongwe, Malawi
| | - Fatsani Kusamula
- Parent and Child Health Initiative (PACHI), Research Centre, P.O. Box 31686, Lilongwe, Malawi
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17
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Chikutsa A, Maharaj P. Social representations of male circumcision as prophylaxis against HIV/AIDS in Zimbabwe. BMC Public Health 2015; 15:603. [PMID: 26133368 PMCID: PMC4489047 DOI: 10.1186/s12889-015-1967-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 06/25/2015] [Indexed: 11/14/2022] Open
Abstract
Background The World Health Organisation recommended the scale-up of voluntary medical male circumcision (VMMC) as an additional HIV prevention method in 2007 and several countries with high HIV prevalence rates including Zimbabwe have since adopted the procedure. Since then researchers have been preoccupied with establishing the level of knowledge and acceptability of circumcision in communities that did not traditionally circumcise. Despite evidence to suggest that knowledge and acceptability of voluntary medical male circumcision is high, there is also emerging evidence that suggest that uptake of circumcision among men has been below expectations. The purpose of this study was thus to investigate people’s representations of male circumcision that may influence its uptake. Methods Data for this study was collected through focus group discussions with men and women aged between 18 and 49 years. This age group was selected because they are still very sexually active and are within the target population of the upscale of voluntary medical male circumcision programme. Women were included in the study because they would be directly involved in a decision to have their son(s) get circumcised for HIV prevention. The study was carried out in Harare, Zimbabwe. Obtained qualitative data was analysed using thematic content analysis. Results Results suggest that circumcision is perceived as an alien culture or something for “younger” men or “boys” who are not yet married. The findings also suggest that there are beliefs that circumcision maybe associated with satanic rituals. The issue of condom use after circumcision was also discussed and it was found that some men do not see the need for using condoms after getting circumcised. Conclusions There is an urgent need for the development of communications that directly address the misconceptions about voluntary medical male circumcision. There is need for communication that encourages circumcised men to continue using condoms.
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Affiliation(s)
- Antony Chikutsa
- School of Built Environment and Development Studies, University of KwaZulu Natal, Durban, South Africa. .,Department of Development Studies, Zimbabwe Open University, Harare, Zimbabwe.
| | - Pranitha Maharaj
- School of Built Environment and Development Studies, University of KwaZulu Natal, Durban, South Africa
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