Abstract
BackgroundSouth Africa introduced medical male circumcision (MMC) to reduce HIV incidence. Mathematical modeling suggested that targeting MMC services to men aged 20–34 years could provide the most immediate impact on HIV incidence. However the majority of MMCs performed have been among males aged ≤25 years. We evaluated an intervention package to increase MMC uptake among men aged 25–49 years.MethodsWe conducted a pre-post study to compare the proportion of men (aged 25–49 years) presenting for MMC during the formative (Phase 1) and intervention (Phase 2) phases in Ekurhuleni, Johannesburg, South Africa. The intervention included infrastructure changes that separated adults from adolescents at the MMC site, an exclusive men’s health club, adult-specific demand generation materials, and discussions with community members.ResultsOverall 2817 enrolled in the study with 1601 from Phase 1 and 1216 in Phase 2. A higher proportion of participants aged 25–49 years accessed MMC in Phase 2 compared to Phase 1 (59.4% vs. 54.9%; Prevalence Ratio = 1.08; 95% Confidence Interval: 1.01–1.15; p = 0.019). Participants with multiple partners in the past 12 months in Phase 2 were more likely to access MMC services compared to participants in Phase 1 (unadjusted Odds Ratio, 1.37; 95% CI:1.17–1.61; p < 0.001). After adjusting for age, multiple partners remained a risk factor in Phase 2 (adjusted OR, 1.39; 95% CI: 1.18–1.63; p < 0.001).ConclusionsThe “Exclusive Intervention Strategy” was associated with a slight increase in the proportion of participants aged 25–49 years accessing MMC services, and an increase in those with HIV risk behaviors, during the intervention phase. These findings may provide important insights to overcoming barriers for accessing MMC services among men aged 25–49 years.Trial registrationThe study is registered at ClinicalTrials.gov, number NCT02352961.
Highlights
South Africa introduced medical male circumcision (MMC) to reduce Human Immunodeficiency Virus (HIV) incidence
This implementation science study was embedded within the routine MMC service delivery program that included HIV testing services (HTS), registration for MMC, physical and genital examination, group counselling, one-on-one counselling, the MMC surgical procedure, post-operative observations, and discharge
The primary aim of Phase 2 was to determine if the “Exclusive Intervention Strategy” would increase the proportion of men (25–49 years) who accessed MMC services when compared to Phase 1
Summary
South Africa introduced medical male circumcision (MMC) to reduce HIV incidence. Mathematical modeling suggested that targeting MMC services to men aged 20–34 years could provide the most immediate impact on HIV incidence. Three randomized controlled trials confirmed that medical male circumcision (MMC) prevents HIV infection in men through heterosexual sex by at least 60% [1,2,3,4]. In 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended male circumcision as a compelling HIV prevention intervention. Their recommendations specified that MMC should be offered in settings with low male circumcision coverage and high HIV prevalence [5]. It was estimated that providing 20.3 million MMCs among HIV-negative males aged 15– 49 years in the fourteen priority countries could avert 3.36 million new HIV infections and result in $16.5 million in averted HIV treatment costs [6]. Working with Ministries of Health and MMC service delivery implementing partners, WHO estimates that nearly 12 million MMCs have been conducted through 2015, and 61% of those are among males aged ≥15 years [7]
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