Perceptions about medical male circumcision and sexual behaviours of adults in rural Uganda: a cross sectional study

Risk Compensation in Voluntary Medical Male Circumcision Programs

PURPOSE OF REVIEW

Evidence from clinical trials identified the effectiveness of voluntary medical male circumcision (VMMC) as an additional strategy to reduce the risk of HIV transmission from women to men. However, concerns about post-circumcision sexual risk compensation may hinder the scale-up of VMMC programs. We reviewed the evidence of changes in risky sexual behaviors after circumcision, including condomless sex, multiple sex partners, and early resumption of sex after surgery.

RECENT FINDINGS

Most clinical trial data indicate that condomless sex and multiple partners did not increase for men after circumcision, and early resumption of sex is rare. Only one post-trial surveillance reports that some circumcised men had more sex partners after surgery, but this did not offset the effect of VMMC. Conversely, qualitative studies report that a small number of circumcised men had increased risky sexual behaviors, and community-based research reports that more men resumed sex early after surgery. With the large-scale promotion and expansion of VMMC services, it may be challenging to maintain effective sexual health educations due to various restrictions. Misunderstandings of the effect of VMMC in preventing HIV infection are the main reason for increasing risky sexual behaviors after surgery. Systematic and practical sexual health counseling services should be in place on an ongoing basis to maximize the effect of VMMC.

Utilization of safe male circumcision among adult men in a fishing community in rural Uganda

Background

In Uganda, most-at-riskpopulations(MARPs) such as fishing communities remain vulnerable to preventable HIV acquisition. Safe Male Circumcision (SMC) has been incorporated into Uganda's HIV prevention strategies. This study aimed at determining SMC utilization and associated factors among adult men in a rural fishing community in Uganda.

Methods

A cross-sectional study was conducted in a rural fishing village in central Uganda. Stratified random sampling of 369 fishermen aged 18–54 yearswas used according to their occupational category; fish monger, boat crew and general merchandise. The dependent variable wasutilization of SMC.A forward fitting multivariable logistic regression model was fitted with variables significant at p≤0.05 controlling for confounding and effect modification.

Results

Respondents'mean(SD) age was 30.0(9.3) years. Only8.4%hadSMC and among non-circumcised men, 84.9% had adequate knowledge of SMC benefits while 79.3% did not know were SMC services were offered. Peer support(AOR0.17;95%-CI0.05–0.60) and perceived procedural safety (AOR6.8;95%CI2.16–21.17) were independently associated with SMC utilization.

Conclusion

In this rural fishing community, SMC utilization was low. These findings underscore the need to inform HIV preventionstrategies inthecontextof peer support and perceptionsheld by rural dwelling men.

Sexual behaviours, awareness and perceptions towards voluntary medical male circumcision among students in Dr Kenneth Kaunda District, South Africa

Background

Voluntary Medical Male Circumcision (VMMC) is regarded as the most cost-effective intervention in reducing female-to-male transmission of HIV in countries where heterosexual transmission is the most prevalent mode of infection.

Objectives

The aim of the study was to determine the awareness, sexual behaviours and perceptions of college students in Dr Kenneth Kaunda District, South Africa.

Method

A cross-sectional design was engaged among a sample of 400 students selected using a stratified random sampling method. Descriptive data analysis was engaged to analyse data using STATA 13.

Results

The mean age of the respondents was 23 years. About 50% of the respondents were below the age of 23 years. The majority among the ethnic groups were black people and or African people (87.5%), followed by people of mixed race (8.1%). Most of the students belonged to the Christian religion (94.7%), and about 91.3% were single, while only 6.0% lived with their partners. Among those who were circumcised, a majority (78.0%) had undergone the MMC. About 76.5% of those residing in urban areas, and 80.6% residing in rural areas were circumcised. About 90.3% of the participants had good awareness about VMMC. About 77.3% of the participants disagreed that VMMC reduces the size of the penis, while 57.0% felt that VMMC provides an individual with the status of being a real man in society. Only 14.3% felt that VMMC exposes the penis to environmental hazards. While almost half (47.7%) of the cohort had one sexual partner, about 20.9% had three or more sexual partners.

Conclusion

The findings suggest that there is a high level of awareness on VMMC among college students in relation to its positive role towards reducing STIs and the enhancement of penile hygiene.

Gender and cultural understandings in medical nonindicated interventions: A critical discussion of attitudes toward nontherapeutic male circumcision and hymen (re)construction

Hymen (re)construction and nontherapeutic male circumcision are medical nonindicated interventions that give rise to specific ethical concerns. In Europe, hymen (re)construction is generally more contested among medical professionals than male circumcision. Yet, from a standard biomedical framework, guided by the principles of autonomy, beneficence, nonmaleficence, and justice, circumcision of boys is, as this article explains, more problematic than hymen (re-) construction. While there is a growing debate on the acceptability of infant circumcision, in the case of competent minors and adults the surgery is not questioned. In the case of hymenoplasty, usually requested by a competent patient, it is recommended to only perform the operation after extensive counseling and if there are compelling conditions. The article further explores why attitudes of medical professionals toward both surgeries diverge and seeks to explain how this is largely informed by gendered and socio-cultural understandings. The article further raises critical questions on medical paternalism and the role of counseling.

Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized Sub-Saharan countries

Background

WHO and UNAIDS prioritized 14 eastern and southern African countries with high HIV and low male circumcision prevalence for a voluntary medical male circumcision (VMMC) scale-up in 2007. Because circumcision provides only partial protection against HIV infection to men, the issue of possible risk compensation in response to VMMC campaigns is of particular concern. In this study, we looked at population-level survey data from the countries prioritized by WHO for a VMMC scale-up. We compared the difference in sexual risk behaviours (SRB) between circumcised and uncircumcised men before and after the WHO’s official VMMC promotion.

Materials and methods

Ten countries (Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe) participating in the WHO’s VMMC scale-up had available data from the Demographic and Health Surveys (DHS). We used cumulative-link mixed models to investigate interactions between survey period and circumcision status in predicting SRB, in order to evaluate whether the difference between the behavior of the two groups changed before and after the scale-up, while controlling for socio-demographic and knowledge-related covariates. The main responses were condom use at last sex and number of non-cohabiting sexual partners, both in the last 12 months.

Results

There was little change in condom use by circumcised men relative to uncircumcised men from before the VMMC scale up to after the scale up. The relative odds ratio is 1.06 (95% CI, 0.95–1.18; interaction P = 0.310). Similarly, there was little change in the number of non-cohabiting partners in circumcised men (relative to uncircumcised men): the relative odds ratio of increasing the number of partners is 0.95 (95% CI, 0.86–1.05; interaction P = 0.319). Age, religion, education, job, marital status, media use and HIV knowledge also showed statistically significant association with the studied risk behaviours. We also found significant differences among countries, while controlling for covariates.

Conclusions

Overall, we find no evidence of sexual risk compensation in response to VMMC campaigns in countries prioritized by WHO. Changes in relative partner behaviour and the relative odds of condom use were small (and of uncertain sign). In fact, our estimates, though not significant, both suggest slightly less risky behavior. We conclude that sexual risk compensation in response to VMMC campaigns has not been a serious problem to date, but urge continued attention to local context, and to promulgating accurate messages about circumcision within and beyond the VMMC context.

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.