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

Using the Nominal Group Technique to Inform Approaches for Enhancing Men's Utilization of Sexual and Reproductive Health Services

Sexual and reproductive health (SRH) services' underutilization by men remains a global public health challenge. SRH problems constitute major health challenges in that they form almost one-seventh of the disease burden and contribute to higher and earlier morbidity among men. We, therefore, invited subject matter experts to collaborate in co-creating intervention strategies to enhance men's utilization of SRH services. We employed the nominal group technique (NGT) for data collection. The NGT is a structured method that involves gathering a group of people to discuss a problem for the purpose of achieving a group consensus and planning actions for the selected problem. The participants who were purposively sampled included researchers, scientists, academics, clinicians, and policymakers. The participants suggested the need to improve men's knowledge, provide healthcare resources such as equipment, medical supplies, and SRH-trained male healthcare workers, deal with healthcare workers' negative attitudes through training and capacitation, and destigmatize socially constructed gender norms that deter men from seeking medical help. These important intervention strategies can be implemented to encourage men's use of SRH services. Men's current underutilization of SRH services requires the urgent implementation of evidence-based interventions. Collaborating with SRH experts in identifying appropriate intervention strategies can assist program managers and policymakers in designing SRH services tailored to men's sexual health needs.

Shifting reasons for older men remaining uncircumcised: Findings from a pre- and post-demand creation intervention among men aged 25-39 years in western Kenya

Voluntary medical male circumcision (VMMC) reduces men's risk of acquiring Human immunodeficiency virus (HIV) through vaginal sex. However, VMMC uptake remains lowest among Kenyan men ages 25-39 years among whom the impact on reducing population-level HIV incidence was estimated to be greatest at the start of the study in 2014. We conducted a pre- and post-intervention survey as part of a cluster randomized controlled trial to determine the effect of two interventions (interpersonal communication (IPC) and dedicated service outlets (DSO), delivered individually or together) on improving VMMC uptake among men ages 25-39 years in western Kenya between 2014 and 2016. The study had three intervention arms and a control arm. In arm one, an IPC toolkit was used to address barriers to VMMC. In arm two, men were referred to DSO that were modified to address their preferences. Arm three combined the IPC and DSO. The control arm had standard of care. At baseline, uncircumcised men ranked the top three reasons for remaining uncircumcised. An IPC demand creation toolkit was used to address the identified barriers and men were referred for VMMC at study-designated facilities. At follow-up, those who remained uncircumcised were again asked to rank the top three reasons for not getting circumcised. There was inconsistency in ranking of reported barriers at pre- and post- intervention: 'time/venue not convenient' was ranked third at baseline and seventh at follow-up; 'too busy to go for circumcision' was tenth at baseline but second at follow-up, and concern about 'what I/family will eat' was ranked first at both baseline and follow-up, but the proportion reduced from 62% to 28%. Men ages 25-39 years cited a variety of logistical and psychosocial barriers to receiving VMMC. After exposure to IPC, most of these barriers shifted while some remained the same. Additional innovative interventions to address on-going and shifting barriers may help improve VMMC uptake among older men.

Men's utilisation of sexual and reproductive health services in low- and middle-income countries: A narrative review

Background

Men have poor access to sexual and reproductive health (SRH) services globally, particularly in low- and middle-income countries (LMICs). Nevertheless, in LMIC and high-income countries (HICs), low SRH utilisation happens on account of several factors, such as individual, health system-related, and sociocultural factors. Identifying and addressing men's SRH service underutilisation remains essential to improving their sexual health and averting higher mortality and early morbidity associated with poor health seeking behaviour (HSB) among men.

Aim

This narrative review identifies factors influencing whether men do or do not utilise SRH services in LMICs.

Setting

We report on articles published in LMICs: Africa, Asia and South America.

Method

In this narrative review, we searched for quantitative and qualitative articles published between 2004 and 2021 from international databases, including Google Scholar, ScienceDirect, EBSCOhost, Scopus, PubMed, Medline, and reference lists of retrieved published articles.

Results

A total of 2219 articles were retrieved, from which 36 met the inclusion criteria. Factors contributing to poor uptake of SRH services by men included: a lack of access and availability of SRH services, poor health-seeking behaviour among men, and SRH facilities not being perceived as 'male-friendly spaces'. Furthermore, our review reveals that decreased use of SRH services is attributed to factors such as a lack of focus on men's SRH.

Conclusion

The current underutilised state of SRH services calls for urgent implementation of evidence-based interventions. Identifying men's SRH service inhibitors and enablers will assist programme managers and policymakers in designing SRH services tailored to their sexual health needs.

Contribution

Despite numerous global interventions to motivate men, the findings provide insight into the underutilisation of SRH services. The study also reveals the inadequate comprehensive investigation of men's SRH service utilisation, especially older men, to comprehend men's problems fully. Further research needs to be conducted on SRH issues, including vasectomy, mental health, and chronic conditions related to sexual and reproductive health. The analysis can assist SRH policymakers and program managers in strengthening the policies to motivate men to engage better with SRH services.

VMMC Programmatic Successes and Challenges: Western Kenya Case Study

PURPOSE OF REVIEW

The Nyanza region of western Kenya is lauded for impressive coverage of voluntary medical male circumcision (VMMC) and remains the bedrock of the VMMC program in Kenya. We conducted literature review on programmatic successes and challenges of implementing VMMC program in the region.

RECENT FINDINGS

Responsive stakeholders' engagement, robust policy environment, effective technical working groups, prompt capacity building of health facilities, government support, flexible implementation strategies, and sustained donor funding contributed to the successes of the program that saw circumcision prevalence in Nyanza reach between 75.6 and 85.3% among 15-29-year-olds by 2019. However, the lack of support for early infant circumcision, inadequate domestic financing, and slow pace of service integration into government health facilities continue to undermine the progress towards sustainability. While local ownership of the VMMC program has been demonstrated through its inclusion in county annual health workplans and progressive integration into routine health care, continued dependence on declining external funding threatens its sustainability. Furthermore, Kenya is experiencing a youth bulge with a projected high demand for VMMC which calls for increased resource inputs into the program. Strategies are therefore needed to increase domestic resource inflows into VMMC.

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.

Innovative demand creation strategies to increase voluntary medical male circumcision uptake: a pragmatic randomised controlled trial in Zimbabwe

INTRODUCTION

Reaching men aged 20-35 years, the group at greatest risk of HIV, with voluntary medical male circumcision (VMMC) remains a challenge. We assessed the impact of two VMMC demand creation approaches targeting this age group in a randomised controlled trial (RCT).

METHODS

We conducted a 2×2 factorial RCT comparing arms with and without two interventions: (1) standard demand creation augmented by human-centred design (HCD)-informed approach; (2) standard demand creation plus offer of HIV self-testing (HIVST). Interpersonal communication (IPC) agents were the unit of randomisation. We observed implementation of demand creation over 6 months (1 May to 31 October 2018), with number of men circumcised assessed over 7 months. The primary outcome was the number of men circumcised per IPC agent using the as-treated population of actual number of months each IPC agent worked. We conducted a mixed-methods process evaluation within the RCT.

RESULTS

We randomised 140 IPC agents, 35 in each arm. 132/140 (94.3%) attended study training and 105/132 (79.5%) reached at least one client during the trial period and were included in final analysis. There was no evidence that the HCD-informed intervention increased VMMC uptake versus no HCD-informed intervention (incident rate ratio (IRR) 0.87, 95% CI 0.38 to 2.02; p=0.75). Nor did offering men a HIVST kit at time of VMMC mobilisation (IRR 0.65, 95% CI 0.28 to 1.50; p=0.31). Among IPC agents that reported reaching at least one man with demand creation, both the HCD-informed intervention and HIVST were deemed useful. There were some challenges with trial implementation; <50% of IPC agents converted any men to VMMC, which undermined our ability to show an effect of demand creation and may reflect acceptability and feasibility of the interventions.

CONCLUSION

This RCT did not show evidence of an effect of HCD-informed demand intervention or HIVST on VMMC uptake. Findings will inform future design and implementation of demand creation evaluations.

TRIAL REGISTRATION NUMBER

PACTR201804003064160.

Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe

BACKGROUND

Supply and demand-side factors continue to undermine voluntary medical male circumcision (VMMC) uptake. We assessed relative economic costs of four VMMC demand creation/service-delivery modalities as part of a randomised controlled trial in Zimbabwe.

METHODS

Interpersonal communication agents were trained and incentivised to generate VMMC demand across five districts using four demand creation modalities (standard demand creation (SDC), demand creation plus offer of HIV self-testing (HIVST), human-centred design (HCD)-informed approach, HCD-informed demand creation approach plus offer of HIVST). Annual provider financial expenditure analysis and activity-based-costing including time-and-motion analysis across 15 purposively selected sites accounted for financial expenditures and donated inputs from other programmes and funders. Sites represented three models of VMMC service-delivery: static (fixed) model offering VMMC continuously to walk-in clients at district hospitals and serving as a district hub for integrated mobile and outreach services, (2) integrated (mobile) modelwhere staff move from the district static (fixed) site with their commodities to supplement existing services or to recently capacitated health facilities, intermittently and (3) mobile/outreach model offering VMMC through mobile clinic services in more remote sites.

RESULTS

Total programme cost was $752 585 including VMMC service-delivery costs and average cost per client reached and cost per circumcision were $58 and $174, respectively. Highest costs per client reached were in the HCD arm-$68 and lowest costs in standard demand creation ($52) and HIVST ($55) arms, respectively. Highest cost per client circumcised was observed in the arm where HIVST and HCD were combined ($226) and the lowest in the HCD alone arm ($160). Across the three VMMC service-delivery models, unit cost was lowest in static (fixed) model ($54) and highest in integrated mobile model ($63). Overall, economies of scale were evident with unit costs lower in sites with higher numbers of clients reached and circumcised.

CONCLUSIONS

There was high variability in unit costs across arms and sites suggesting opportunities for cost reductions. Highest costs were observed in the HCD+HIVST arm when combined with an integrated service-delivery setting. Mobilisation programmes that intensively target higher conversion rates as exhibited in the SDC and HCD arms provide greater scope for efficiency by spreading costs.

TRIAL REGISTRATION NUMBER

PACTR201804003064160.

Sexually transmitted infections (STI) and antenatal care (ANC) clinics in Malawi: effective platforms for improving engagement of men at high HIV risk with voluntary medical male circumcision services

Introduction

Voluntary medical male circumcision (VMMC), an effective HIV prevention programme for men, is implemented in East and Southern Africa. Approximately 50% of VMMC clients are aged below 15 years. More targeted interventions to reach older men and others at higher short-term HIV risk are needed.

Methods

We implemented a quality improvement project testing the effectiveness of an active referral-based VMMC recruitment approach, targeting men attending STI clinics and those escorting partners to antenatal care (ANC) clinics, at Bwaila Hospital in Lilongwe, Malawi. We compared the proportions aged older than 15 years among men who received VMMC following referral from STI and ANC clinics with those among men referred from standard community mobilisation. We also analysed referral cascades to VMMC.

Results

In total, 330 clients were circumcised after referral from STI (242) and ANC (88) clinics, as compared with 3839 other clients attributed to standard community mobilisation. All clients from ANC and STI clinics were aged over 15 years, as compared with 69% from standard community mobilisation. STI clinics had a higher conversion rate from counselling to VMMC than ANC (12% vs 9%) and a higher contribution to total circumcisions performed at the VMMC clinic (6% vs 2%).

Conclusions

Integrating VMMC recruitment and follow-up in STI and ANC clinics co-located with VMMC services can augment demand creation and targeting of men at risk of HIV, based on age and STI history. This approach can be replicated at least in similar health facilities with ANC and STI services in close proximity to VMMC service delivery.

Medically, Traditionally, and Dually Circumcised Men in Lesotho: Population-Based Measurements of HIV/STI Infections, Sexual Risk Behaviors, and Service Use Patterns

Voluntary medical male circumcision (VMMC) is an HIV prevention priority in Lesotho, but uptake remains suboptimal. We analyzed the 2014 Lesotho Demographic and Health Survey to assess population-level social, behavioral, and serological correlates of circumcision status, specifically traditional and/or medical circumcision. Among 2931 men, approximately half were traditionally circumcised, and fewer than 25% were medically circumcised. Only 4% were dually (traditionally and medically) circumcised. In multivariate analysis, only medical circumcision emerged as significantly (p < 0.05) protective against HIV infection, whereas dual circumcision was significantly associated with past-year STI symptomology. Younger (ages 15-24), lower educated, rural-dwelling, and traditionally circumcised men, including those who never tested for HIV, had significantly lower odds of medical circumcision. Our findings indicate other unmeasured behavioral factors may mitigate VMMC's protective effect against HIV and STI infections in dually circumcised men. Further research can help identify counseling and demand creation strategies for traditionally circumcised men presenting for VMMC.

Circumcised men's perceptions, understanding and experiences of voluntary medical male circumcision in KwaZulu-Natal, South Africa

Background

KwaZulu-Natal, South Africa, has rolled out voluntary medical male circumcision (VMMC) in response to recommendations that regions with a high human immunodeficiency virus (HIV) prevalence adopt VMMC as an additional HIV prevention strategy. There is a paucity of South African data on the motivators, barriers and experiences of adult male candidates regarding VMMC. This study was conducted to analyse circumcised men’s perceptions, understanding and experiences of VMMC in KwaZulu-Natal, South Africa.

Methods

A qualitative phenomenographic design was used. Ethical clearance was obtained from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BE 627/18). Data were collected from 12 circumcised male candidates. Individual interviews were conducted and recorded by using an audiotape. Data were transcribed verbatim and analysed manually.

Results

Participants’ perceptions regarding VMMC are health related and appear to be the motivators for the uptake of medical circumcision. Circumcised men in this study appeared to misunderstand VMMC in terms of healing and performance time and the nature of the procedure. Negative experiences in terms of quality of care received were reported.

Conclusion

The study findings imply that practice interventions to promote demand generation for VMMC in KwaZulu-Natal, South Africa, should incorporate the perceptions and experiences of male candidates regarding the procedure. Tailored messaging to address misunderstanding related to the nature of VMMC should also be provided. Regular in-service training on standardised VMMC implementation practices should be provided to ensure the delivery of optimum quality VMMC services.

Cost and Cost-Effectiveness of a Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision in Tanzania: Spending More to Spend Less

Supplemental Digital Content is Available in the Text.

Background:

Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20–34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20–34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness.

Setting:

Tanzania (Njombe and Tabora regions).

Methods:

Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios.

Results:

Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and $130 in Njombe, and in the control arms $70 and $191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed.

Conclusions:

Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving.

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.

Application of an HIV Prevention Cascade to Identify Gaps in Increasing Coverage of Voluntary Medical Male Circumcision Services in 42 Rural Zambian Communities

Increased coverage of voluntary medical male circumcision (VMMC) is needed in countries with high HIV prevalence. We applied an HIV-prevention cascade to identify gaps in male circumcision coverage in Zambia. We used survey data collected in 2013 and 2014/15 to describe circumcision coverage at each time-point, and prevalence of variables related to demand for and supply of VMMC. We explored whether circumcision coverage in 2014/15 was associated with demand and supply among uncircumcised men in 2013. Results show that circumcision coverage was 11.5% in 2013 and 18.0% in 2014/15. Levels of having heard of circumcision and agreeing with prevention benefits was similar at both time-points (79.8% vs 83.2%, and 49.7% vs 50.7%, respectively). In 2013, 39.3% of men perceived services to be available compared to 54.7% in 2014/15. Levels of having heard of circumcision in 2013 was correlated with and higher perceived service availability associated with coverage in 2014/15. VMMC coverage was low in these study sites. Knowledge of prevention tools and of service availability are necessary to increase coverage but alone are insufficient.

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.

Age Differences in Perceptions of and Motivations for Voluntary Medical Male Circumcision Among Adolescents in South Africa, Tanzania, and Zimbabwe

Background

The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have set a Fast-Track goal to achieve 90% coverage of voluntary medical male circumcision (VMMC) among boys and men aged 10-29 years in priority settings by 2021. We aimed to identify age-specific facilitators of VMMC uptake among adolescents.

Methods

Younger (aged 10-14 years; n = 967) and older (aged 15-19 years; n = 559) male adolescents completed structured interviews about perceptions of and motivations for VMMC before receiving VMMC counseling at 14 service provision sites across South Africa, Tanzania, and Zimbabwe. Adjusted prevalence ratios (aPRs) were estimated using multivariable modified Poisson regression models with generalized estimating equations and robust standard errors.

Results

The majority of adolescents reported a strong desire for VMMC. Compared with older adolescents, younger adolescents were less likely to cite protection against human immunodeficiency virus (HIV) or other sexually transmitted infections (aPR, 0.77; 95% confidence interval [CI], .66-.91) and hygienic reasons (aPR, 0.55; 95% CI, .39-.77) as their motivation to undergo VMMC but were more likely to report being motivated by advice from others (aPR, 1.88; 95% CI, 1.54-2.29). Although most adolescents believed that undergoing VMMC was a normative behavior, younger adolescents were less likely to perceive higher descriptive norms (aPR, 0.79; .71-.89), injunctive norms (aPR, 0.86; 95% CI, .73-1.00), or anticipated stigma for being uncircumcised (aPR, 0.79; 95% CI, .68-.90). Younger adolescents were also less likely than older adolescents to correctly cite that VMMC offers men and boys partial HIV protection (aPR, 0.73; 95% CI, .65-.82). Irrespective of age, adolescents' main concern about undergoing VMMC was pain (aPR, 0.95; 95% CI, .87-1.04). Among younger adolescents, fear of pain was negatively associated with desire for VMMC (aPR, 0.89; 95% CI, .83-.96).

Conclusions

Age-specific strategies are important to consider to generate sustainable demand for VMMC. Programmatic efforts should consider building on the social norms surrounding VMMC and aim to alleviate fears about pain.

Pre-exposure prophylaxis (PrEP) in an era of stalled HIV prevention: Can it change the game?

Pre-exposure prophylaxis (PrEP) for HIV prevention has evolved significantly over the years where clinical trials have now demonstrated the efficacy of oral PrEP, and the field is scaling-up implementation. The WHO and UNAIDS have made PrEP implementation a priority for populations at highest risk, and several countries have developed guidelines and national plans accordingly, largely based on evidence generated by demonstration projects. PrEP presents the opportunity to change the face of HIV prevention by offering a new option for protection against HIV and disrupting current HIV prevention systems. Nevertheless, as with all new technologies, both practical and social requirements for implementation must be taken into account if there is to be sustained and widespread adoption, which will also apply to forthcoming prevention technologies. Defining and building success for PrEP within the scope of scale-up requires careful consideration. This review summarises where the PrEP field is today, lessons learned from the past, the philosophy and practicalities of how successful programming may be defined, and provides perspectives of costs and affordability. We argue that a successful PrEP programme is about effective intervention integration and ultimately keeping people HIV negative.

Safety and efficacy of the PrePex device in HIV-positive men: A single-arm study in Zimbabwe

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.

Improving voluntary medical male circumcision standards adherence and post-procedure follow-up in Uganda: A mixed methods study

Voluntary medical male circumcision (VMMC) has been demonstrated to reduce the transmission of HIV by 60%. Scaling up VMMC services requires that they be of high quality, socially accepted, and effective. We evaluated an intervention aimed at improving VMMC standards adherence and patient follow-up rates in nine facilities in Uganda. We also qualitatively explored why some men return for follow-up care and others do not. The completeness and quality of clinical documentation was poor at baseline, but significantly improved at endline. We observed significant improvements in management systems; supplies, equipment, and environment; and monitoring and evaluation. Due to the volume of missing data, results were less clear for registration, group education, and information, education and communication; individual counselling and HIV testing; and infection prevention. Significant improvements were also observed in follow-up rates at 48 hours and 7 days, and 6 weeks. Interviews revealed the importance of peers, including female partners, in deciding to get circumcised and in seeking follow-up care. Among the men who did not return for follow-up services, most reported they had no problems and did not see it as necessary. For those who did have mild or moderate adverse events, follow-up care was often sought at a facility closer to the patients' home rather than the circumcising facility. However, information systems were unable to capture this. Applying improvement approaches to VMMC services can promote improved standards adherence and follow-up rates and should be integrated into scale-up plans.

Circumcision and its effects in Africa

Male circumcision is one of the most commonly performed procedures in Africa, with a wide variation between the different regions on the practice. This is because circumcision is often done for religious and cultural or traditional reasons, which includes being part of rituals or rite of passage to adulthood. There had been few medical indications for the procedure until the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) pandemic, which is prevalent in many of the countries in the region. Evidence from randomized controlled trials conducted in the continent had shown that male circumcision could be instrumental to reducing the transmission of HIV/AIDS in heterosexual couples in high disease prevalent and low circumcision prevalent areas. This had led to the roll-out of large population-based adult male circumcisions as well as the development of tools to facilitate the procedure. Circumcision, however, is not without complications and the incidence appears related to the age of the patient, where the procedure was done, technique used and level of proficiency of the practitioners. This article reviews the practice of circumcision in Africa and highlights the impact of the procedure on the continent.

"I Feel Like More of a Man": A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention

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.

Scale-Up of Early Infant Male Circumcision Services for HIV Prevention in Lesotho: A Review of Facilitating Factors and Challenges

BACKGROUND

The World Health Organization and the Joint United Nations Programme on HIV/AIDS recommend early infant male circumcision (EIMC) as a component of male circumcision programs in countries with high HIV prevalence and low circumcision rates. Lesotho began incorporating EIMC into routine maternal, newborn, and child health (MNCH) services in 2013 with funding from the United States Agency for International Development and United Nations Children's Fund. This presented unique challenges: Lesotho had no previous experience with EIMC and cultural traditions link removal of the foreskin to rites of passage. This process evaluation provides an overview of EIMC implementation.

METHODOLOGY

The Lesotho Ministry of Health and Jhpiego conducted a baseline assessment before service implementation. Baseline information from an initial assessment was used to develop and implement an EIMC program that had a pilot and a scale-up phase. Key program activities such as staff training, quality assurance, and demand creation were included at the program design phase. Facilitating factors and challenges were identified from a review of information collected during the baseline assessment as well as the pilot.

RESULTS

Between September 2013 and March 2015, 592 infants were circumcised at 9 sites: 165 (28%) between 1 day and 6 days after birth; 196 (33%) between 7 and 30 days, and 231 (39%) between 31 and 60 days. Facilitating factors included strong support from the Ministry of Health, collaboration with stakeholders, and donor funding. Providers were enthusiastic about the opportunity to offer new services and receive training. Challenges included gaining consent from family members other than mothers, and parents' concern about pain and complications. The EIMC program also had to manage providers' expectations of compensation because overtime was paid to providers who took part in adult circumcision programming but not for EIMC. Limited human resources, including authorization only for doctors to perform EIMC, impeded provision of services.

CONCLUSION

Despite communication, compensation, and task-shifting challenges, integrating EIMC services with MNCH services could be a sustainable model for EIMC service delivery in Lesotho.

Triggering the decision to undergo medical male circumcision: a qualitative study of adult men in Botswana

In 2007, the World Health Organization endorsed voluntary medical male circumcision (VMMC) as part of comprehensive HIV-prevention strategies. A major challenge facing VMMC programs in sub-Saharan Africa remains demand creation; there is urgent need for data on key elements needed to trigger the decision among eligible men to seek VMMC. Using qualitative methods, we sought to better understand the circumcision decision-making process in Botswana related to VMMC. From July to November 2013, we conducted 27 focus group discussions in four purposively selected communities in Botswana with men (stratified by circumcision status and age), women (stratified by age) and community leaders. All discussions were facilitated by a trained same-sex interviewer, audio recorded, transcribed and translated to English, and analyzed for key themes using an inductive content analytic approach. Improved hygiene was frequently cited as a major benefit of circumcision and many participants believed that cleanliness was directly responsible for the protective effect of VMMC on HIV infection. While protection against HIV was frequently noted as a benefit of VMMC, the data indicate that increased sexual pleasure and perceived attractiveness, not fear of HIV infection, was an underlying reason why men sought VMMC. Data from this qualitative study suggest that more immediate benefits of VMMC, such as improved hygiene and sexual pleasure, play a larger role in the circumcision decision compared with protection from potential HIV infection. These findings have immediate implications for targeted demand creation and mobilization activities for increasing uptake of VMMC among adult men in Botswana.

Perceptions of HIV and Safe Male Circumcision in High HIV Prevalence Fishing Communities on Lake Victoria, Uganda

Background

In 2010, the Uganda Ministry of Health introduced its Safe Male Circumcision (SMC) strategy for HIV prevention with the goal of providing 4.2 million voluntary medical male circumcisions by 2015. Fishing communities, where HIV prevalence is approximately 3–5 times higher than the national average, have been identified as a key population needing targeted HIV prevention services by the National HIV Prevention Strategy. This study aimed to understand perceptions of HIV and identify potential barriers and facilitators to SMC in fishing communities along Lake Victoria.

Methods

We conducted 8 focus group discussions, stratified by sex and age, with 67 purposefully sampled participants in 4 communities in Kalangala District, Uganda.

Results

There was universal knowledge of the availability of SMC services, but males reported high uptake in the community while females indicated that it is low. Improved hygiene, disease prevention, and improved sexual performance and desirability were reported facilitators. Barriers included a perceived increase in SMC recipients’ physiological libido, post-surgical abstinence, lost income during convalescence, and lengthier recovery due to occupational hazards. Both males and females reported concerns about spousal fidelity during post-SMC abstinence. Reported misconceptions and community-held cultural beliefs include fear that foreskins are sold after their removal, the belief that a SMC recipient’s first sexual partner after the procedure should not be his spouse, and the belief that vaginal fluids aid circumcision wound healing.

Conclusions

Previous outreach efforts have effectively reached these remote communities, where availability and health benefits of SMC are widely understood. However, community-specific intervention strategies are needed to address the barriers identified in this study. We recommend the development of targeted counseling, outreach, and communication strategies to address barriers, misconceptions, and community-held beliefs. Interventions should also incorporate female partners into the SMC decision-making process and develop compensation strategies to address lost income during SMC recovery.

Men in Papua New Guinea accurately report their circumcision status

Background

Male circumcision (MC) is a well-established component of HIV prevention in countries with high HIV prevalence and heterosexually driven epidemics. Delivery and monitoring of MC programs are reliant on good quality MC data. Such data are often generated through self-reported MC status surveys. This study examined self-reported MC status in comparison with genital photographs from men in Papua New Guinea (PNG).

Methods

This retrospective non-interventional study collated self-reported MC status data from the ‘acceptability and feasibility of MC’ study at 4 sites in PNG during 2010–2011. Participants reported their MC status based on an 8-category photographic classification covering the range of foreskin cutting practices in PNG. Genital photographs of 222 participants from this study were independently classified by 2 investigators. The 8-category photographic classification was simplified into a 3 category classification of ‘no cut’, ‘straight cut’ and ‘round cut’ before comparing for agreement between self-reporting and investigator assessment using Cohen’s Kappa measure.

Results

Using the 3-category classification, there was 90.6% (201/222) agreement between self-assessment and investigator classification (κ value 0.805). Of the discordant 9.4% (21/222), 3.6% (8/222) self-classified as having a cut foreskin (5 straight cut; 3 round cut) while investigators classified as having no cut; 4.1% (9/222) self-classified as having no cut while investigators classified them as having had a cut (6 straight cut; 3 round cut) and 1.8% (4/222) self-classified as having a round cut while investigators classified as having a straight cut. Given the great variety of foreskin cutting practices and appearances, feasible explanations are suggested for two-thirds (13/21) of these discordant results.

Conclusions

This study demonstrates a high level of agreement between self-reporting and investigator assessment of MC status in PNG and suggests self-reporting of MC status to be highly reliable among men in PNG.