Abstract
In 2009, the Government of Tanzania embarked on scaling up voluntary medical male circumcision (VMMC) services for HIV prevention in 8 priority regions, with the aim of serving 2.8 million boys and men ages 10-34 years by 2013. By mid-2012, more than 110,000 boys and men in Iringa and Njombe regions had received VMMC. The majority (85%) of these VMMC clients were under 19 years old (average age, 16 years). This study aimed to identify potential barriers and facilitators to VMMC among older men. We conducted 16 focus group discussions, stratified by sex and age, with 142 purposefully selected participants in 3 districts of Iringa and Njombe regions. Both men and women generally had positive attitudes toward VMMC. Social and personal barriers to obtaining VMMC among adult men included shame associated with seeking services co-located with younger boys and perceived inappropriateness of VMMC after puberty, particularly after marriage and after having children. Additional barriers included concerns about partner infidelity during the post-surgical abstinence period, loss of income, and fear of pain associated with post-surgical erections. Facilitators included awareness of the HIV-prevention benefit and perceptions of cleanliness and enhanced attractiveness to women. While men and women in Iringa and Njombe regions in Tanzania generally view VMMC as a desirable procedure, program implementers need to address barriers to VMMC services among adult men. Selected service delivery sites in the Iringa and Njombe regions will be segregated by age to provide services that are "friendly" to adult men. Services will be complemented with behavior change communication initiatives to address concerns of older men, encourage women's support for circumcision and adherence to the post-surgical abstinence period, and change social norms that inhibit older men from seeking circumcision.
Highlights
Voluntary medical male circumcision (VMMC) has been shown to be a safe and effective method of reducing female-to-male HIV transmission by about 60% in randomized controlled trials and by up to 73% in post-trial observation.[1,2,3,4] Cost and impact modeling have shown that rapid scale up of voluntary medical male circumcision (VMMC) among men ages 15–49 years would drastically reduce HIV transmission.[5]We recognize 3 major contexts in Tanzania where male circumcision (MC) is performed: 1. Traditional MC—generally conducted around or before puberty as part of a traditional rite of passage2
The proportion of boys and most VMMC clients men ages 15–49 years who reported being are under 20 years of age
Participants and sampling locations were purposefully selected in close collaboration with local government Council HIV/AIDS Coordinators (CHACs)
Summary
In 2009, the Government of Tanzania embarked on scaling up voluntary medical male circumcision (VMMC) services for HIV prevention in 8 priority regions, with the aim of serving 2.8 million boys and men ages 10–34 years by 2013. Social and personal barriers to obtaining VMMC among adult men included shame associated with seeking services colocated with younger boys and perceived inappropriateness of VMMC after puberty, after marriage and after having children. Conclusions: While men and women in Iringa and Njombe regions in Tanzania generally view VMMC as a desirable procedure, program implementers need to address barriers to VMMC services among adult men. Selected service delivery sites in the Iringa and Njombe regions will be segregated by age to provide services that are ‘‘friendly’’ to adult men.
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