Understanding the socio-economic and sexual behavioural correlates of male circumcision across eleven voluntary medical male circumcision priority countries in southeastern Africa

Male circumcision uptake and misperceived norms about male circumcision: Cross-sectional, population-based study in rural Uganda

Background

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circumcision for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention. The prevalence of male circumcision in Uganda nearly doubled from 26% in 2011 to 43% in 2016, but remains below the 2020 target level. Little is known about how common male circumcision is perceived to be, how accurate such perceptions are, and whether they are associated with men's own circumcision uptake.

Methods

We conducted a cross-sectional study of all adult residents of eight villages in Rwampara District, southwestern Uganda in 2020-2022. We elicited their perceptions of the adult male circumcision prevalence within their village: >50% (most men), 10% to <50% (some), <10%, (few to none), or do not know. We compared their perceived norms to the aggregated prevalence of circumcision reported in these villages. We used a modified multivariable Poisson regression model to estimate the association between perceived norms and personal circumcision uptake among men.

Results

We surveyed 1566 participants (91% response rate): 698 men and 868 women. Among the men, 167 (27%) reported being circumcised, including 167/444 (38%) men <50 years of age. Approximately one-fourth of the population (189 (27%) men and 177 (20%) women) believed that few to no men in their own village had been circumcised. In a multivariable regression model, men who underestimated the prevalence of male circumcision were less likely to be circumcised themselves (adjusted relative risk (aRR) = 0.51; 95% confidence interval (CI) = 0.37-0.83).

Conclusions

In this population-based study in rural Uganda, one-fourth of men underestimated the prevalence of male circumcision. Men who underestimated the extent of circumcision uptake were themselves less likely to be circumcised. If the observed association is causal and underestimates within the population contribute to low uptake, then interventions correcting these misperceived norms could increase uptake of voluntary medical male circumcision.

Missed opportunity: low uptake of VMMC among men attending the OPD of a public health facility offering free VMMC services in Uganda

BACKGROUND

Studies in various countries including Uganda and Kenya have shown a much lower incidence of the human immunodeficiency virus (HIV) among men that underwent voluntary medical male circumcision (VMMC) compared to uncircumcised men. Wakiso district, the district with the highest prevalence of HIV in Uganda (7%), has a very low estimated proportion of men who have undergone VMMC (30.5%). Within the district, various public health facilities provide free VMMC services. This study examined the prevalence and factors associated with the uptake of VMMC among men attending the outpatient department (OPD) of a public facility offering VMMC services.

METHODS

We conducted a cross-sectional study between July to August 2021 using a sample of men attending the OPD at Kira Health Centre IV. We defined VMMC uptake as the removal of all or part of the foreskin of the penis by a trained healthcare professional. We determined factors independently associated with VMMC uptake using a modified Poisson regression analysis with robust standard errors at a 5% statistical significance level. Adjusted prevalence risk ratios (APRR) were reported as the measure of outcome.

RESULTS

Overall, 389 participants were enrolled in the study. The mean age of the participants was 27.2 (standard deviation ± 9.02) years. The prevalence of VMMC uptake was 31.4% (95% Confidence Interval [CI] 26.8-36.2). In the adjusted analysis, the uptake of VMMC among men attending the OPD of Kira HC IV was less likely among married participants compared to unmarried participants (APRR 0.64, 95% CI 0.48-0.88), among participants from Western tribes (APRR 0.50, 95% CI 0.41-0.86) or Eastern tribes (APPR 0.31, 95% CI 0.13-0.72) compared to participants from the Central tribes and among participants who didn't disclose their sexual partner number compared to those that had one or no sexual partner (APRR 0.62, 95% CI 0.40-0.97). On the other hand, the prevalence of uptake of VMMC was 7 times among participants who were aware of VMMC compared to those who were not aware of VMMC (APRR 7.85 95% CI 1.07-9.80) and 2.7 times among participants who knew their HIV status compared to those that didn't know (APRR 2.75, 95% CI 1.85-4.0). Also, the uptake of VMMC was 85% more among participants who knew that Kira HC IV provided free VMMC services compared to those that didn't (APRR 1.85, 95% CI 1.85-4.08).

CONCLUSION

VMMC among men attending the OPD at the largest public healthcare facility proving free VMMC services in Kira Municipality was low. The OPD may provide a quick win for improving VMMC uptake. Collaborative efforts among the administration of Kira HC IV, the Ministry of Health and VMMC implementation partners could work towards developing health-facility-based strategies that can improve VMMC awareness and uptake with emphasis on the OPD.

Social, Behavioral, and Cultural factors of HIV in Malawi: Semi-Automated Systematic Review

BACKGROUND

Demographic and sociobehavioral factors are strong drivers of HIV infection rates in sub-Saharan Africa. These factors are often studied in qualitative research but ignored in quantitative analyses. However, they provide in-depth insight into the local behavior and may help to improve HIV prevention.

OBJECTIVE

To obtain a comprehensive overview of the sociobehavioral factors influencing HIV prevalence and incidence in Malawi, we systematically reviewed the literature using a newly programmed tool for automatizing part of the systematic review process.

METHODS

Due to the choice of broad search terms ("HIV AND Malawi"), our preliminary search revealed many thousands of articles. We, therefore, developed a Python tool to automatically extract, process, and categorize open-access articles published from January 1, 1987 to October 1, 2019 in the PubMed, PubMed Central, JSTOR, Paperity, and arXiV databases. We then used a topic modelling algorithm to classify and identify publications of interest.

RESULTS

Our tool extracted 22,709 unique articles; 16,942 could be further processed. After topic modelling, 519 of these were clustered into relevant topics, of which 20 were kept after manual screening. We retrieved 7 more publications after examining the references so that 27 publications were finally included in the review. Reducing the 16,942 articles to 519 potentially relevant articles using the software took 5 days. Several factors contributing to the risk of HIV infection were identified, including religion, gender and relationship dynamics, beliefs, and sociobehavioral attitudes.

CONCLUSIONS

Our software does not replace traditional systematic reviews, but it returns useful results to broad queries of open-access literature in under a week, without a priori knowledge. This produces a "seed dataset" of relevance that could be further developed. It identified known factors and factors that may be specific to Malawi. In the future, we aim to expand the tool by adding more social science databases and applying it to other sub-Saharan African countries.

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

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

Voluntary medical male circumcision and sexual practices among sexually active circumcised men in Mzuzu, Malawi: a cross-sectional study

BACKGROUND

Voluntary Medical Male Circumcision (VMMC) is one of the strategies being promoted to prevent sexual heterosexual transmission of HIV. It has been adopted by 14 countries with high HIV prevalence and low circumcision rates. The 60.0% protective efficacy of VMMC has come with misconceptions in some societies in Malawi, hence VMMC clients may opt for risky sexual practices owing to its perceived protective effect. The study estimated proportion of circumcised men engaging in risky sexual behaviors post-VMMC, assessed knowledge on VMMC protective effect and identified socio-demographic factors associated with risky sexual practices.

METHOD

A cross sectional study was conducted at two sites of Mzuzu city. Systematic random sampling was used to select 322 participants aged 18-49 who had undergone VMMC. The independent variables included age, location, occupation, religion, marital status and education. Outcome variables were non condom use, having multiple sexual partners and engaging in transactional sex. Data from questionnaires was analyzed using Pearson's chi square test and logistic regression.

RESULTS

Out of 322 respondents, 84.8% (273) understood the partial protection offered by VMMC in HIV prevention. Ninety-six percent of the participants self-reported continued use of condoms post VMMC. Overall 23.7-38.3% participants self-reported engaging in risky sexual practices post VMMC, 23.7% (76) had more than one sexual partner; 29.2% (94) paid for sex while 39.9% (n = 187) did not use a condom. Residing in high density areas was associated with non-condom use, (p = 0.043). Being single (p < 0.001), and residing in low density areas (p = 0.004) was associated with engaging in transactional sex.

CONCLUSION

Risky sexual practices are evident among participants that have undergone VMMC. Messages on safer sexual practices and limitations of VMMC need to be emphasized to clients, especially unmarried or single and those residing in low density areas.

Male circumcision and global HIV/AIDS epidemic challenges

Background

Given the devastating mortality and morbidity associated with HIV/AIDS, many potential prevention measures against HIV infection continue to be explored. Most prevention methods are in the realm of sexual behavior change. However, of all aspects of human behavior, it is sexual behavior that is least amenable to change. Newer and simpler interventions are therefore required. Male circumcision, the surgical removal of some or all of the foreskin (or prepuce) from the penis, is one of the ways being promoted as a preventive measure. This paper reviews the scientific basis and evidence for the efficacy of male circumcision within the context of the global challenges involved.

Main body

We reviewed articles with emphasis on male circumcision and HIV/AIDS transmission. Published abstracts of presentations at international scientific meetings were also reviewed.

Conclusions

Current epidemiological evidence supports the promotion of male circumcision for HIV prevention, especially in populations with high HIV prevalence and low circumcision rates. Three notable randomized control trials strengthen the case for applied research studies to demonstrate that safe male circumcision is protective at the population level, particularly as ideal and well-resourced conditions of a randomized trial are often not replicated in other service delivery settings. Ethically and culturally responsive strategies in promoting circumcision in a culturally heterogenous world need to be developed, too. Male circumcision should also be viewed as a complementary measure along with other proven approaches to turn the HIV/AIDS epidemic around.

Critical evaluation of arguments opposing male circumcision: A systematic review

OBJECTIVE

To systematically evaluate evidence against male circumcision (MC).

METHODS

We searched PubMed, Google Scholar, EMBASE and Cochrane databases.

RESULTS

Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems.

CONCLUSIONS

Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.

Predictors of male circumcision incidence in a traditionally non-circumcising South African population-based cohort

BACKGROUND

Voluntary medical male circumcision has been promoted in high HIV prevalence settings to prevent HIV acquisition in males. However, the uptake of circumcision in many sub-Saharan African settings remains low. While many studies have measured circumcision prevalence, understanding circumcision incidence and its predictors is vital to achieving ambitious circumcision prevalence targets.

SETTING

Rural KwaZulu-Natal, South Africa.

METHODS

We measured circumcision incidence over the period 2009-2014 in a longitudinal population-based cohort with high HIV prevalence and low circumcision prevalence. Multivariable survival models with Weibull distributions were used to assess socio-demographic, behavioral and biological predictors of circumcision incidence.

RESULTS

Between 2009 and 2014, circumcision prevalence among males 15-49 years in the cohort increased from 3% to 24%. Among 6,203 males 15-49 years, 873 new circumcisions occurred over 13,678 person-years (incidence rate: 6.4/100 person-years, 95% CI 6.0-6.8). Circumcision incidence was substantially higher amongst young males: 15-19 year olds were twice as likely to circumcise as older males. In the survival model, shorter household distance to the nearest healthcare facility, knowledge of HIV status and biological HIV-negative status were associated with an increased likelihood of circumcision incidence.

CONCLUSIONS

Circumcision prevalence among males in rural KwaZulu-Natal remains well below South Africa's national 80% coverage target across age groups. In this population, distance to the nearest healthcare facility and knowledge of HIV status were important independent predictors of circumcision incidence. Mobile circumcision clinics and innovative HIV testing services may be important tools to help achieve circumcision targets.

The impact of market segmentation and social marketing on uptake of preventive programmes: the example of voluntary medical male circumcision. A literature review

Background: The business world has long recognized the power of defining discrete audiences within a target population. However, market segmentation's full potential has not been applied to the public health context. While some broad elements of market segmentation (e.g., age, geography) are considered, a nuanced look at behavioural and psychographic segmentation, which could greatly enhance the possibility of lasting behaviour change, is often missing.   Segmentation, and the associated mindset which acknowledges the multi-dimensional differences between people, allows service providers, implementers, policymakers, and government officials to target initiatives and lead to a greater likelihood of lasting behavioural change. This paper investigates what segmentation is, how it has been applied to voluntary medical male circumcision (VMMC), how it can be applied in development, and the challenges in both measuring and adopting segmentation as part of program design. Methods: We performed a detailed search of peer-reviewed literature using PubMed, ProQuest, ScienceDirect, Google Scholar, and the abstract directories of the International AIDS Society (IAS) published between January 2015 and September 2018. We also accessed articles from business databases such as the Harvard Business Review.   Results: Results from a VMMC-focused intervention that successfully designed and delivered segmentation-based programs in two countries demonstrated that it is possible to adapt private sector approaches. However, within the sector of global development that is most familiar with segmentation, these efforts rarely go beyond basic demographic segments. Conclusions: Existing published material tends not to measure the impact of segmentation itself, but the impact of the intervention to which segmentation was applied, which makes it challenging for the development sector to invest in the approach without evidence that it works. Nonetheless, the experiences of segmentation and demand creation for VMMC do highlight the opportunity for better integrating this approach in HIV prevention and in global development and measurement initiatives.

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.