Abstract
As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.
Highlights
Multiple studies, including three randomized control trials [1,2,3], have demonstrated the efficacy of voluntary medical male circumcision (VMMC) in preventing HIV acquisition in heterosexual men
Some men in Zambia expressed that circumcision is limited to the two traditionally circumcising tribes, the authors indicate that respondents were capable of making the distinction between traditional circumcision during adolescence and medical circumcision for HIV prevention purposes
The present study advances our understanding of VMMC uptake from both demand- and supply-side perspectives
Summary
Multiple studies, including three randomized control trials [1,2,3], have demonstrated the efficacy of voluntary medical male circumcision (VMMC) in preventing HIV acquisition in heterosexual men. In countries with high HIV burden and low circumcision levels, VMMC has been recommended as a key HIV prevention strategy and service delivery scale-up is underway in 14 priority countries in east and southern Africa [5]. Previous research has indicated high reported rates of acceptability of male circumcision for prevention of HIV [6,7,8]. In a review of the acceptability studies in nine countries in Eastern and Southern Africa, Westercamp and Bailey [8] found a median percentage of uncircumcised males willing to be circumcised at 65%, support varied from a low of 29% in Uganda to 87% in Swaziland. Some men in Zambia expressed that circumcision is limited to the two traditionally circumcising tribes, the authors indicate that respondents were capable of making the distinction between traditional circumcision during adolescence and medical circumcision for HIV prevention purposes
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