Adult male circumcision: reflections on successes and challenges

Black Women's Perceptions Towards Infant and Child Male Circumcision

OBJECTIVE

The objective of this article was to analyse women's perceptions of ICMC and to propose a framework for ICMC decision-making that can inform ICMC policies.

METHOD

Using qualitative interviews, this study investigated twenty-five Black women's perceptions of ICMC decisionmaking in South Africa. Black women who had opted not to circumcise their sons, were selected through purposive and snowball sampling. Underpinned by the Social Norms Theory, their responses were analysed through in-depth interviews and a framework analysis. We conducted the study in the townships of Diepsloot and Diepkloof, Gauteng, South Africa.

RESULTS

Three major themes emerged: medical mistrust, inaccurate knowledge leading to myths and misconceptions, and cultural practices related to traditional male circumcision. Building Black women's trust in the public health system is important for ICMC decision-making.

CONCLUSIONS FOR PRACTICE

Policies should address misinformation through platforms that Black women share. There should be an acknowledgement of the role that cultural differences play in the decision-making process. This study developed an ICMC perception framework to inform policy.

Parental decision-making in infant and child male circumcision: a case study in two townships in Gauteng, South Africa

Parental decision-making in infant and child male circumcision is influenced by complex, interrelated factors on many levels. Several studies have highlighted reasons for the acceptance and non-acceptance of child male circumcision. This study investigates the factors that influence parental decision-making in this matter and proposes a parental decision-making framework. The study was conducted in the townships of Diepsloot and Diepkloof in Gauteng, South Africa, using 48 in-depth interviews with parents, grandparents and uncles of the boys, as well as government officials and members of civil society as part of an explorative case study. Purposive and snowball sampling were used to select the participants. Thematic analysis was used to analyse the data by applying the conceptual framework of Bronfenbrenner's ecological systems theory. Three main themes emerged from the data: microsystem factors related to health and hygiene, the father's circumcision status, cultural expectations, pain, the child's autonomy and the extended family; mesosystem factors related to early childhood development centres; and exosystem factors related to circumcision policies and financial considerations.

Using surrogate vaccines to assess feasibility and acceptability of future HIV vaccine trials in men: a randomised trial in inner-city Johannesburg, South Africa

BACKGROUND

Developing an effective HIV vaccine is the overriding priority for HIV prevention research. Enrolling and maintaining cohorts of men into HIV vaccine efficacy trials is a necessary prerequisite for the development and licensure of a safe and efficacious vaccine.

METHODS

One hundred-fifty consenting HIV-negative men were enrolled into a pilot 1:1 randomised controlled trial of immediate vaccination with a three-dose hepatitis B vaccine compared to deferred vaccination (at 12 months) to investigate feasibility and acceptability of a future HIV vaccine trial in this population. Adverse events, changes in risk behaviour, acceptability of trial procedures and motivations for participation in future trials were assessed.

RESULTS

Men were a median 25 years old (inter-quartile range = 23-29), 53% were employed, 90% secondary school educated and 67% uncircumcised. Of the 900 scheduled study visits, 90% were completed in the immediate vaccination arm (405/450) and 88% (396/450) in the delayed arm (P = 0.338). Acceptability of trial procedures and services was very high overall. However, only 65% of the deferred group strongly liked being randomised compared to 90% in the immediate group (P = 0.001). Informed consent processes were viewed favourably by 92% of the delayed and 82% of the immediate group (P = 0.080). Good quality health services, especially if provided by a male nurse, were rated highly. Even though almost all participants had some concern about the safety of a future HIV vaccine (98%), the majority were willing to participate in a future trial. Future trial participation would be motivated mainly by the potential for accessing an effective vaccine (81%) and altruism (75%), rather than by reimbursement incentives (2%).

CONCLUSIONS

Recruitment and retention of men into vaccine trials is feasible and acceptable in our setting. Findings from this surrogate vaccine trial show a high willingness to participate in future HIV vaccine trials. While access to potentially effective vaccines is important, quality health services are an equally compelling incentive for enrolment.

Unpacking early infant male circumcision decision-making using qualitative findings from Zimbabwe

Background

Early infant male circumcision (EIMC) has been identified as a key HIV prevention intervention. Exploring the decision-making process for adoption of EIMC for HIV prevention among parents and other key stakeholders is critical for designing effective demand creation interventions to maximize uptake, roll out and impact in preventing HIV. This paper describes key players, decisions and actions involved in the EIMC decision-making process.

Methods

Two complementary qualitative studies explored hypothetical and actual acceptability of EIMC in Zimbabwe. The first study (conducted 2010) explored hypothetical acceptability of EIMC among parents and wider family through focus group discussions (FGDs, n = 24). The follow-up study (conducted 2013) explored actual acceptability of EIMC among parents through twelve in-depth interviews (IDIs), four FGDs and short telephone interviews with additional parents (n = 95). Short statements from the telephone interviews were handwritten. FGDs and IDIs were audio-recorded, transcribed and translated into English. All data were thematically coded.

Results

Study findings suggested that EIMC decision-making involved a discussion between the infant’s parents. Male and female participants of all age groups acknowledged that the father had the final say. However, discussions around EIMC uptake suggested that the infant’s mother could sometimes covertly influence the father's decision in the direction she favoured. Discussions also suggested that fathers who had undergone voluntary medical male circumcision were more likely to adopt EIMC for their sons, compared to their uncircumcised counterparts. Mothers-in-law/grandparents were reported to have considerable influence. Based on study findings, we describe key EIMC decision makers and attempt to illustrate alternative outcomes of their key actions and decisions around EIMC within the Zimbabwean context.

Conclusions

These complementary studies identified critical players, decisions and actions involved in the EIMC decision-making process. Findings on who influences decisions regarding EIMC in the Zimbabwean context highlighted the need for EIMC demand generation interventions to target fathers, mothers, grandmothers, other family members and the wider community.

Age Targeting of Voluntary Medical Male Circumcision Programs Using the Decision Makers' Program Planning Toolkit (DMPPT) 2.0

BACKGROUND

Despite considerable efforts to scale up voluntary medical male circumcision (VMMC) for HIV prevention in priority countries over the last five years, implementation has faced important challenges. Seeking to enhance the effect of VMMC programs for greatest and most immediate impact, the U. S. President's Plan for AIDS Relief (PEPFAR) supported the development and application of a model to inform national planning in five countries from 2013-2014.

METHODS AND FINDINGS

The Decision Makers' Program Planning Toolkit (DMPPT) 2.0 is a simple compartmental model designed to analyze the effects of client age and geography on program impact and cost. The DMPPT 2.0 model was applied in Malawi, South Africa, Swaziland, Tanzania, and Uganda to assess the impact and cost of scaling up age-targeted VMMC coverage. The lowest number of VMMCs per HIV infection averted would be produced by circumcising males ages 20-34 in Malawi, South Africa, Tanzania, and Uganda and males ages 15-34 in Swaziland. The most immediate impact on HIV incidence would be generated by circumcising males ages 20-34 in Malawi, South Africa, Tanzania, and Uganda and males ages 20-29 in Swaziland. The greatest reductions in HIV incidence over a 15-year period would be achieved by strategies focused on males ages 10-19 in Uganda, 15-24 in Malawi and South Africa, 10-24 in Tanzania, and 15-29 in Swaziland. In all countries, the lowest cost per HIV infection averted would be achieved by circumcising males ages 15-34, although in Uganda this cost is the same as that attained by circumcising 15- to 49-year-olds.

CONCLUSIONS

The efficiency, immediacy of impact, magnitude of impact, and cost-effectiveness of VMMC scale-up are not uniform; there is important variation by age group of the males circumcised and countries should plan accordingly.

Sex is never the same: men's perspectives on refusing circumcision from an in-depth qualitative study in Kwaluseni, Swaziland

Faced with an HIV prevalence of 31% among 18- to 49-year-olds, Swaziland developed a male circumcision policy in 2009, following compelling scientific evidence from three randomised controlled trials. Utilising United States Agency for International Development funds, the state set out to circumcise 80% of adult men in 2011. Only 8667 of the targeted 150,000 men were circumcised during the campaign. This paper presents findings from a 2012 to 2013 in-depth qualitative study among Swazi men. Methods included 13 focus group discussions, 20 in-depth interviews, 16 informal interviews and participant observation. We argue that the campaign's failure can be partly explained by the fact that circumcision was perceived as a threat to Swazi masculinities, a factor hardly considered in the planning of the intervention. Results show that men believed circumcision resulted in reduced penis sensitivity, reduced sexual pleasure and adverse events such as possible mistakes during surgery and post-operative complications that could have negative effects on their sexual lives. Given the conflicting state of scientific data about the effects of circumcision on sexuality or sexual pleasure, this study addresses important lacunae, while also demonstrating the need for more research into the relationship between sexuality, masculinity and health interventions seeking to involve men.

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.

HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel

IMPORTANCE

Emerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings.

OBJECTIVE

To provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings.

DATA SOURCES, STUDY SELECTION, AND DATA SYNTHESIS

Data published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society-USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus.

RESULTS

Testing for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible.

CONCLUSIONS AND RELEVANCE

Data support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.