Circumcision For Prevention Research Articles

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

BackgroundVoluntary 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.SettingRural KwaZulu-Natal, South Africa.MethodsWe 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.ResultsBetween 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.ConclusionsCircumcision 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.

Assessment of willingness to uptake male circumcision and associated factors among male students, south west Ethiopia

Background: Male circumcision has been shown to reduce the risk of transmission of HIV. As there was low level of circumcision and high prevalence of HIV/AIDS in Gambella, this study intends to identify predictors of willingness to uptake circumcision among indigenous male college students. Methods: A cross-sectional study was conducted among randomly selected 314 male college students who were selected using simple random sampling technique with self-administered questionnaire from March 27-30, 2014. The data were entered in to computer and analyzed using SPSS for windows version 16.0. Finally, logistic regressions analyses were used to identify independent predictors of willingness to uptake circumcision. To determine any association between the variables; we computed confidence interval of 95% at P. value <0.05. Result: Three hundred fourteen [94%] of them completely filled and return the questionnaire; 99[31.6%] of them didn’t get circumcise and 130[41.4%] of male students believed that they could suffer rejection from their community if they would uptake circumcision. After multivariate logistic regression was employed, the result showed that; students who believed that they get rejected from society if circumcised were less likely to uptake circumcision 0.03 [AOR=.03, 95% CI: 0.01-0.12]. The other result showed that, as age of students increases by one year the odd of willingness to uptake circumcision also increases by 0.84 and the result was statistically significant [AOR=0.84, 95% CI: 0.71-0.99]. Perceived threat was also significantly associated and students who perceived HIV/AIDS as a high threat to them were about 1.28 times more likely willing to uptake circumcision [AOR=1.28, 95% CI: 1.10-1.53]. The other predictor variable was knowledge of students; per a unit increases in total score of knowledge the odds of willingness to uptake circumcision was increased by 1.5 folds [AOR=1.5, 95% CI: 1.13-2.08]. Conclusion: High perceived threat, knowledge, age and fear of rejection by society were the main predictors of willingness to uptake circumcision among male students. Therefore, designing communication strategies that directly address these factors should be implemented. Men who were willing to uptake circumcision should be provided access to high-quality male circumcision surgical services. It is also highly recommended providing accurate information that would increase the perceived threat of adolescents; reinforcement of messages regarding the importance of HIV risk-reduction strategies. Finally addressing these issues of adolescents at school or different institutional levels might be crucial and easier than shifting population-level norms around male circumcision in future strategies.

Strong association between higher-risk sex and HIV prevalence at the regional level: an ecological study of 27 sub-Saharan African countries.

Background: It is unclear why HIV prevalence varies by nearly two orders of magnitude between regions within countries in sub-Saharan Africa. In this ecological study, we assess if HIV prevalence by region is associated with any of four markers of higher risk sexual behavior: lifetime number of partners, multiple partners in past year, higher risk sex (defined as sex with non-cohabiting, non-marital partners) and age at debut. Methods: We performed Pearson's correlation between the 4 behavioral risk factors and HIV prevalence by region in 47 nationally representative surveys from 27 sub-Saharan African countries, separately by gender. In addition, principal components analysis was used to reduce the eight risk factors (four for each gender) to two principal components (PCs). Mixed effects linear regression was used to assess the relationship between the resulting two PCs and HIV prevalence after controlling for the prevalence of male circumcision. Results: HIV prevalence varied by a median 3.7 fold (IQR 2.9-7.9) between regions within countries. HIV prevalence was strongly associated with higher risk sex and, to a lesser extent, the other risk factors evaluated. Both PCs were strongly associated with HIV prevalence when assessed via linear regression. Conclusions: Differences in sexual behavior may underpin the large differences in HIV-prevalence between subpopulation within sub-Saharan African countries.

Perceptions of Men regarding Voluntary Circumcision at a Male Clinic in Lesotho

The prevalence of medical male circumcision in Lesotho remains low even though efforts are made to encourage men to be circumcised. In Lesotho, as one of the countries with a high prevalence of the human immunodeficiency virus (HIV), male circumcision aims at reducing new infections and averting AIDS-related deaths. The aim of this study was to gain an understanding of the perceptions of men regarding voluntary medical male circumcision in Morija, Lesotho. A descriptive, explorative and contextual qualitative study was conducted using in-depth unstructured individual interviews with 10 uncircumcised men who are aged between 29 to 83 years. Tesch’s method of descriptive data analysis revealed the following themes: (1) perceived health beliefs (protection from diseases, sexual beliefs and personal hygiene), (2) perceived community-held beliefs (stigma, traditional and religious obligation), (3) men’s knowledge regarding circumcision, and (4) perceived misconceptions about circumcision (the right time for circumcision, myths and contraindications to circumcision). Men voiced their opinion that circumcision reduces their chances of being infected with HIV even though they are not circumcised. Improved sexual pleasure tends to be in the mindset of uncircumcised men as they perceive circumcision as improving sexual pleasure. It was therefore concluded that men’s perceptions of circumcision are diverse. The uptake of male circumcision depends on influencing the perceptions of men, facilitating access of circumcision services, and ensuring a supportive social support system for uncircumcised men. There is a need to upgrade already existing circumcision policies to include the above.

Knowledge on voluntary medical male circumcision in a low uptake setting in northern Uganda

BackgroundFree VMMC services have been available in Uganda since 2010. However, uptake in Northern Uganda remains disproportionately low. We aimed to determine if this is due to men’s insufficient knowledge on VMMC, and if women’s knowledge on VMMC has any association with VMMC status of their male sexual partners.MethodsIn this cross sectional study, participants were asked their circumcision status (or that of their male sexual partner for female respondents) and presented with 14 questions on VMMC benefits, procedure, risk, and misconceptions. Chi square tests or fisher exact tests were used to compare circumcision prevalence among those who gave correct responses versus those who failed to and if p < 0.05, the comparison groups were balanced with propensity score weights in modified poisson models to estimate prevalence ratios, PR.ResultsA total of 396 men and 50 women were included in the analyses. Circumcision was 42% less prevalent among males who failed to reject the misconception that VMMC reduces sexual performance (PR = 0.58, 95% CI 0.38–0.89, p = 0.012), and less prevalent among male sexual partners of females who failed to reject the same misconception (PR = 0.22, 95% CI = 0.07–0.76, p = 0.016). Circumcision was also 35% less prevalent among male respondents who failed to reject the misconception that VMMC increases a man’s desire for more sexual partners i.e. promiscuity (PR = 0.65, 95% CI = 0.46–0.92, p = 0.014).ConclusionMisconceptions regarding change in sexual drive or performance were associated with circumcision status in this population, while knowledge of VMMC benefits, risks and procedure was not.

Are circumcised men safer sex partners? Findings from the HAALSI cohort in rural South Africa.

IntroductionThe real-world association between male circumcision and HIV status has important implications for policy and intervention practice. For instance, women may assume that circumcised men are safer sex partners than non-circumcised men and adjust sexual partnering and behavior according to these beliefs. Voluntary medical male circumcision (VMMC) is highly efficacious in preventing HIV acquisition in men and this biological efficacy should lead to a negative association between circumcision and HIV. However, behavioral factors such as differential selection into circumcision based on current HIV status or factors associated with future HIV status could reverse the association. Here, we examine how HIV prevalence differs by circumcision status in older adult men in a rural South African community, a non-experimental setting in a time of expanding VMMC access.MethodsWe analyzed data collected from a population-based sample of 2345 men aged 40 years and older in a rural community served by the Agincourt Health and socio-Demographic Surveillance System site in Mpumalanga province, South Africa. We describe circumcision prevalence and estimate the association between circumcision and laboratory-confirmed HIV status with log-binomial regression models.ResultsOne quarter of older men reported circumcision, with slightly more initiation-based circumcisions (56%) than hospital-based circumcisions (44%). Overall, the evidence did not suggest differences in HIV prevalence between circumcised and uncircumcised men; however, those who reported hospital-based circumcision were more likely to test HIV-positive [PR (95% CI): 1.28 (1.03, 1.59)] while those who reported initiation-based circumcision were less likely to test HIV-positive [PR (95% CI): 0.68 (0.51, 0.90)]. Effects were attenuated, but not reversed after adjustment for key covariates.ConclusionsMedically circumcised older men in a rural South African community had higher HIV prevalence than uncircumcised men, suggesting that the effect of selection into circumcision may be stronger than the biological efficacy of circumcision in preventing HIV acquisition. The impression given from circumcision policy and dissemination of prior trial findings that those who are circumcised are safer sex partners may be incorrect in this age group and needs to be countered by interventions, such as educational campaigns.

Prevalence of Female Circumcision among Young Women in Beni-Suef, Egypt: A Cross-Sectional Study.

Female circumcision (FC) is a deeply rooted practice in Egypt with deblitating physical and psychological consequences. During the past 2decades there have been sincere efforts to reduce this practice. The objective of this study was to investigate the prevalence of circumcision. Cross-sectional study. Beni-Suef City, Egypt. Young women (12-25years of age). A survey was given to 3353 young women residing in Beni-Suef City. Data were collected using a questionnaire that included information about the sociodemographic characteristics of participants, their gynecological data, exposure to FC, and complaints associated with menses during the previous year. Prevalence of FC in rural areas in Beni Suef. Of the 3353 interviewed women, 1846 (55%) were circumcised. Women residing in rural areas, married women, and those who had illiterate parents were more likely to have experienced circumcision. Students were less likely to be circumcised (P<.05). The circumcised girls reported shorter menstrual cycles and dysuria with menses (P<.05). Dysmenorrhea, generalized aching, and nervousness were the most common complaints associated with menses in both groups, with no statistically significant differences (P>.05). FC is highly prevalent in rural areas in Beni-Suef, however, compared with previous reports it seems that the rates of circumcision have decreased markedly. Despite this decrease, the practice of female genital mutilation is still highly prevalent, suggesting that future research and intervention will be needed to eliminate this practice.

An Analysis on Adoption of Alternative Rites of Passage for Girls in Elgeiyo/Marakwet County, Kenya

Alternative rites of passage are modern cultural practices developed more than two decades ago to substitute the harmful tradition of female circumcision in many parts of Africa. Designed for girls aged 10-16, the model entails teaching teenagers marital skills, physical dangers of female cut, healthcare and prevention of sexually transmitted infections including HIV/AIDS . We carried out a study in 2015 in the Endo Ward of Elgeiyo/Marakwet County, Kenya, to appraise adoption of alternative rite of passage for girls in the region. The Endo Ward is a rural area predominantly inhabited by the Marakwet, a sub-group of Kalenjin speaking people which comprise the Kipsigis, Nandi, Tugen, Keiyo, Pokot and Sabaot. The region was purposely sampled for the study because it is one of the areas that often records high prevalence of circumcision of girls in Kenya. Twenty in-depth interviews, 10 with elderly men and 10 with elderly women, were conducted. The study also employed 10 units of focus group discussion and 16 key informant interviews with alternative rite of passage “teachers”, opinion and religious leaders, Non-governmental and community based organizations managers and a medical practitioner. Qualitative data were translated, transcribed, coded, and subjected to thematic analysis and presented in narrative and verbatim form. The study suggests that the Marakwet people of Endo Ward are slow in the uptake of alternative rite meaning that circumcision of girls could continue for long period before it is eradicated. For more adoption of the model, the study recommends more involvement of Marakwet women in the teaching of Marakwet traditional values, adequate support of Marakwet girls who denounce the tradition and a review of the alternative rite of passage programme so as to provide sufficient training on gender roles, and symbolic elements of the community.

An Analysis of Male Circumcision Interpersonal Communication Messages within Uptake of Voluntary Medical Male Circumcision (VMMC) Among Married Men in Busia County, Kenya: A Quantitative Study

Voluntary Medical Male circumcision (VMMC) reduces risk of heterosexually acquired HIV. Kenya adopted VMMC as an HIV intervention in 2008 and has been making remarkable progress towards achieving its male circumcision target. However, its uptake is lowest among older and married men. The main objective of this paper is to examine the nature interpersonal communication messages and their influence on uptake of VMMC among married men in Teso South Sub County in Western Kenya. Teso Sub County is among the sub counties with low male circumcision prevalence and high HIV/AIDS prevalence thus a target of the VMMC programme. The survey was carried out between June 15 and July 13, 2017 targeting married men aged between 20 and 49 years. Key constructs and thematic frameworks were developed using health belief model (HBM) and Extended Parallel Process Model (EPPM) and presented verbatim using the participants own words. Based on male circumcision interpersonal communication messages, the findings show that majority respondents including those circumcised perceived HIV/AIDS to be severity and believed they were susceptibility to it. Self-efficacy (confidence in performing a behavior), and especially response efficacy (the belief of efficacious of message) regarding acceptance of VMMC as a preventive measure were the most important correlates of perception. Low response efficacy was the critical problems in adoption of VMMC. Majority of those who had sought VMMC did it for other reasons such as peer pressure, penis appearance, sexual satisfaction and penile hygiene and not for HIV prevention. Among the uncircumcised respondents, majority of those who expressed willingness to adopt male circumcision said it will be for other reasons, not HIV prevention.

Systematic review of the effect of economic compensation and incentives on uptake of voluntary medical male circumcision among men in sub-Saharan Africa

ABSTRACTVoluntary medical male circumcision (VMMC) prevalence in priority countries in sub-Saharan Africa, particularly among men aged ≥20 years, has not yet reached the goal of 80% coverage recommended by the World Health Organization. Determining novel strategies to increase VMMC uptake among men ≥20 years is critical to reach HIV epidemic control. We conducted a systematic review to analyze the effectiveness of economic compensation and incentives to increase VMMC uptake among older men in order to inform VMMC demand creation programs. The review included five qualitative, quantitative, and mixed methods studies published in peer reviewed journals. Data was extracted into a study summary table, and tables synthesizing study characteristics and results. Results indicate that cash reimbursements for transportation and food vouchers of small nominal amounts to partially compensate for wage loss were effective, while enrollment into lotteries offering prizes were not. Economic compensation provided a final push toward VMMC uptake for men who had already been considering undergoing circumcision. This was in settings with high circumcision prevalence brought by various VMMC demand creation strategies. Lottery prizes offered in the studies did not appear to help overcome barriers to access VMMC and qualitative evidence suggests this may partially explain why they were not effective. Economic compensation may help to increase VMMC uptake in priority countries with high circumcision prevalence when it addresses barriers to uptake. Ethical considerations, sustainability, and possible externalities should be carefully analyzed in countries considering economic compensation as an additional strategy to increase VMMC uptake.

Reproductive health profile and circumcision of females in the Hali semi-urban region, Saudi Arabia: A community-based cross-sectional survey.

BACKGROUNDImproving the reproductive health of females has become the focus of the developmental efforts of many nations.OBJECTIVESTo identify the reproductive health style of married females, and to determine the prevalence and predictors of circumcision among girls aged ≤18 years in Hali semi-urban region.DESIGNA cross-sectional household surveySETTINGHouses in Hali, Al-Qunfudhah governorate, western Saudi Arabia during 2017.SUBJECTS AND METHODSA multistage systematic cluster random sampling method was used to select participants. A validated questionnaire was used in interviewing the head of the selected houses.MAIN OUTCOME MEASURESReproductive health profile of women, and circumcision of girls.SAMPLE SIZE365 households.RESULTSReproductive life starts early in the Hali region as 41.4% of women are married at or before 18 years of age. Consanguinity was recorded in 57.0% of houses. The prevalence of grand multiparity (GMP) was 54.7%; it was significantly associated with current maternal age, age at marriage, low educational levels of both parents and husbands with non-professional jobs. Current use of birth control methods was reported by 28.9% of families, and oral contraceptives (OCs) were the commonest method. Contraceptive use was significantly associated with higher educational levels of both parents and with women having professional work. The prevalence of circumcision was 80.3%. Circumcision was most frequent (59.4%) at age 7 years or less, and almost always done by doctors (91.4%). Hemorrhage (2.9%) and fever (2.3%) were the minimal recorded complications. Girls with higher parental education, enough income, no parental consanguinity, and whose mothers married at an older age had slightly lower rates of circumcision, but the difference was without statistical significance.CONCLUSIONThe pattern of early female marriage, high consanguinity, GMP, low contraceptive use, and a high frequency of circumcision in girls was apparent in Hali. Public health education and legislative policies are needed.LIMITATIONSRecall bias may affect the reported frequency of circumcision, and related complications.

Female Genital Mutilation in Sudan.

BACKGROUND:Female genital mutilation or female circumcision (FGM) is a serious health problem in Sudan. This procedure is harmful to women and causes many complications during pregnancy and childbirth.OBJECTIVE:This study aims to determine the female genital mutilation (FGM) and its associated factors in Sudan.SUBJECTS AND METHODS:Data from Sudan Multiple Indicator Cluster Survey (MICS - UNICEF) was used in this research. The survey was carried out in 2014 and included women aged between 14 – 49 years. A logistic regression model was used to find an association between dependent and independent variables.RESULT:Total numbers of 21947 women were included in the survey and out of the 6249 (28.5 %) from urban and 15698 (71.5%) from rural areas. The prevalence of female circumcision was 89%. Women who had circumcised daughters were 32.1 %. The highest prevalence of FGM was reported from South Kordofan state with 7.8%, and lowest was in Red Sea state (7.6%). A significant association was observed between circumcised women and their marital status, daughter circumcision, and the level of education.CONCLUSION:The practice of female genital mutilation is spread all over the country. Poor women with low level of education are at high risk for this phenomenon. More efforts have to be provided to end this dangerous practice.

Agreement between self-reported and physically verified male circumcision status in Nyanza region, Kenya: Evidence from the TASCO study

BackgroundSelf-reported male circumcision (MC) status is widely used to estimate community prevalence of circumcision, although its accuracy varies in different settings depending on the extent of misreporting. Despite this challenge, self-reported MC status remains essential because it is the most feasible method of collecting MC status data in community surveys. Therefore, its accuracy is an important determinant of the reliability of MC prevalence estimates based on such surveys. We measured the concurrence between self-reported and physically verified MC status among men aged 25–39 years during a baseline household survey for a study to test strategies for enhancing MC uptake by older men in Nyanza region of Kenya. The objective was to determine the accuracy of self-reported MC status in communities where MC for HIV prevention is being rolled out.MethodsAgreement between self-reported and physically verified MC status was measured among 4,232 men. A structured questionnaire was used to collect data on MC status followed by physical examination to verify the actual MC status whose outcome was recorded as fully circumcised (no foreskin), partially circumcised (foreskin is past corona sulcus but covers less than half of the glans) or uncircumcised (foreskin covers half or more of the glans). The sensitivity and specificity of self-reported MC status were calculated using physically verified MC status as the gold standard.ResultsOut of 4,232 men, 2,197 (51.9%) reported being circumcised, of whom 99.0% were confirmed to be fully circumcised on physical examination. Among 2,035 men who reported being uncircumcised, 93.7% (1,907/2,035) were confirmed uncircumcised on physical examination. Agreement between self-reported and physically verified MC status was almost perfect, kappa (k) = 98.6% (95% CI, 98.1%-99.1%. The sensitivity of self-reporting being circumcised was 99.6% (95% CI, 99.2–99.8) while specificity of self-reporting uncircumcised was 99.0% (95% CI, 98.4–99.4) and did not differ significantly by age group based on chi-square test. Rate of consenting to physical verification of MC status differed by client characteristics; unemployed men were more likely to consent to physical verification (odds ratio [OR] = 1.48, (95% CI, 1.30–1.69) compared to employed men and those with post-secondary education were less likely to consent to physical verification than those with primary education or less (odds ratio [OR] = 0.61, (95% CI, 0.51–0.74).ConclusionsIn this Kenyan context, both sensitivity and specificity of self-reported MC status was high; therefore, MC prevalence estimates based on self-reported MC status should be deemed accurate and applicable for planning. However MC programs should assess accuracy of self-reported MC status periodically for any secular changes that may undermine its usefulness for estimating community MC prevalence in their unique settings.

A systems-based assessment of the PrePex device adverse events active surveillance system in Zimbabwe.

BackgroundVoluntary Medical Male Circumcision (VMMC) is an effective method for HIV prevention and the World Health Organization (WHO) has recommended its expansion in 14 African countries with a high prevalence of HIV and low prevalence of male circumcision. The WHO has recently pre-qualified the PrePex device, a non-surgical male circumcision device, which reduces procedure time, can increase acceptability of VMMC, and can expand the set of potential provider cadres. The PrePex device was introduced in Zimbabwe as a way to scale-up VMMC services in the country. With the rapid scale-up of the PrePex device, as well as other similar devices, a strong surveillance system to detect adverse events (AE) is needed to monitor the safety profile of these devices. We performed a systems-based evaluation of the PrePex device AE active surveillance system in Zimbabwe.MethodsThe evaluation was based on the Centers for Disease Control and Prevention’s Updated Guidelines for Evaluating Public Health Surveillance Systems. We adapted these guidelines to fit our local context. The evaluation incorporated the review of the standard operating procedures and surveillance system documents. Additionally, structured, in-person interviews were performed with key stakeholders who were users of the surveillance system at various levels. These key stakeholders were from the Ministry of Health, implementing partners, and health facilities in Harare.ResultsClients were requested to return to the facility for follow-up on days 7, 14 and 49 after placement of the device. In the event of a severe AE, a standard report was generated by the health facility and relayed to the Ministry of Health Child and Care and donor agencies through predefined channels within 24 hours of diagnosis. Clinic staff reported difficulties with the amount of documentation required to follow up with clients and to report AEs. The surveillance system’s acceptability among users interviewed was high, and users were motivated to identify all possible AEs related to this device. The surveillance system was purely paper-based and both duplicate and discrepant reporting forms between sites were identified.ConclusionThe PrePex AE active surveillance system was well accepted among participants in the health system. However, the amount of documentation which was required to follow-up with patients was a major barrier within the system, and might lead to decreased timeliness and quality of reporting. A passive surveillance system supported by electronic reporting would improve acceptance of the program.

Scale-Up of Voluntary Medical Male Circumcision Services for HIV Prevention - 12 Countries in Southern and Eastern Africa, 2013-2016.

Countries in Southern and Eastern Africa have the highest prevalence of human immunodeficiency virus (HIV) infection in the world; in 2015, 52% (approximately 19 million) of all persons living with HIV infection resided in these two regions.* Voluntary medical male circumcision (VMMC) reduces the risk for heterosexually acquired HIV infection among males by approximately 60% (1). As such, it is an essential component of the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy for ending acquired immunodeficiency syndrome (AIDS) by 2030 (2). Substantial progress toward achieving VMMC targets has been made in the 10 years since the World Health Organization (WHO) and UNAIDS recommended scale-up of VMMC for HIV prevention in 14 Southern and Eastern African countries with generalized HIV epidemics and low male circumcision prevalence (3).† This has been enabled in part by nearly $2 billion in cumulative funding through the President's Emergency Plan for AIDS Relief (PEPFAR), administered through multiple U.S. governmental agencies, including CDC, which has supported nearly half of all PEPFAR-supported VMMCs to date. Approximately 14.5 million VMMCs were performed globally during 2008-2016, which represented 70% of the original target of 20.8 million VMMCs in males aged 15-49 years through 2016 (4). Despite falling short of the target, these VMMCs are projected to avert 500,000 HIV infections by the end of 2030 (4). However, UNAIDS has estimated an additional 27 million VMMCs need to be performed by 2021 to meet the Fast Track targets (2). This report updates a previous report covering the period 2010-2012, when VMMC implementing partners supported by CDC performed approximately 1 million VMMCs in nine countries (5). During 2013-2016, these implementing partners performed nearly 5 million VMMCs in 12 countries. Meeting the global target will require redoubling current efforts and introducing novel strategies that increase demand among subgroups of males who have historically been reluctant to undergo VMMC.

Factors associated with uptake of voluntary medical male circumcision among University of Botswana undergraduate male students

Background: The human immunodeficiency virus (HIV)/AIDS prevalence in Botswana of 18.4% is the third highest in the world. Thus, the Voluntary Medical Male Circumcision strategy was rolled out with a target of 80% uptake by year 2016. The programme targets mainly young people (15–24 years) as they account for 40% of all new adult infections. We, therefore, aimed at identifying the factors associated with uptake of voluntary medical male circumcision among University of Botswana undergraduate male students as well as to establish the male circumcision prevalence among the same group so as measure the success of the male circumcision (MC) strategy. Methods: A cross-sectional study was conducted amongst 303 undergraduate male students. Data were collected through self-administered questionnaires using stratified sampling. Data were captured and analysed using Statistical Package for the Social Sciences version 23, where adjusted odds ratios and p-values were calculated. Results: Uptake of male circumcision was 47.9%. Respondents’ knowledge on male circumcision was high (88%). However, a large majority of those uncircumcised (52.1%) indicated unwillingness to get circumcised although they were knowledgeable about the benefits MC. Believing that there are no risks in MC surgery [AOR:1.02; 95% CI: 1.004–1.037] and knowing that an injection is given before undergoing surgery (AOR: 1.072; 95% CI: 1.057–1.087) were positively associated with circumcision status. The main reasons stated for being circumcised were hygiene (49.7%) and protection from HIV (22.1%). Conclusions: There is need for a combination of factors to induce motivation for students to be circumcised. Referent others need to be targeted as well as they are role models and able to positively influence their peers and children.

Predictors of voluntary medical male circumcision prevalence among men aged 25-39 years in Nyanza region, Kenya: Results from the baseline survey of the TASCO study.

IntroductionUptake of voluntary medical male circumcision (VMMC) as an intervention for prevention of HIV acquisition has been low among men aged ≥25 years in Nyanza region, western Kenya. We conducted a baseline survey of the prevalence and predictors of VMMC among men ages 25–39 years as part of the preparations for a cluster randomized controlled trial (cRCT) called the Target, Speed and Coverage (TASCO) Study. The TASCO Study aimed to assess the impact of two demand creation interventions—interpersonal communication (IPC) and dedicated service outlets (DSO), delivered separately and together (IPC + DSO)—on VMMC uptake.MethodsAs part of the preparatory work for implementation of the cRCT to evaluate tailored interventions to improve uptake of VMMC, we conducted a survey of men aged 25–39 years from a traditionally non-circumcising Kenyan ethnic community within non-contiguous locations selected as study sites. We determined their circumcision status, estimated the baseline circumcision prevalence and assessed predictors of being circumcised using univariate and multivariate logistic regression.ResultsA total of 5,639 men were enrolled of which 2,851 (50.6%) reported being circumcised. The odds of being circumcised were greater for men with secondary education (adjusted Odds Ratio (aOR) = 1.65; 95% CI: 1.45–1.86, p<0.001), post-secondary education (aOR = 1.72; 95% CI: 1.44–2.06, p <0.001), and those employed (aOR = 1.32; 95% CI: 1.18–1.47, p <0.001). However, the odds were lower for men with a history of being married (currently married, divorced, separated, or widowed).ConclusionAmong adult men in the rural Nyanza region of Kenya, men with post-primary education and employed were more likely to be circumcised. VMMC programs should focus on specific sub-groups of men, including those aged 25–39 years who are married, divorced/separated/ widowed, and of low socio-economic status (low education and unemployed).

Powerlessness, Normalization, and Resistance: A Foucauldian Discourse Analysis of Women's Narratives On Obstetric Fistula in Eastern Sudan.

Eastern Sudan has high prevalence of female circumcision and child marriage constituting a risk for developing obstetric fistula. Few studies have examined gender roles' relation with obstetric fistula in Sudan. To explore the associated power-relations that may put women at increased risk for developing obstetric fistula, we conducted nine interviews with women living with obstetric fistula in Kassala in eastern Sudan. Using a Foucauldian discourse analysis, we identified three discourses: powerlessness, normalization, and covert resistance. Existing power-relations between the women and other societal members revealed their internalization of social norms as absolute truth, and influenced their status and decision-making power in regard to circumcision, early marriage, and other transformative decisions as well as women's general behaviors. The women showed subtle resistance to these norms and the harassment they encountered because of their fistula. These findings suggest that a more in-depth contextual assessment could benefit future maternal health interventions.

HIV epidemic drivers in South Africa: A model-based evaluation of factors accounting for inter-provincial differences in HIV prevalence and incidence trends.

BackgroundHIV prevalence differs substantially between South Africa’s provinces, but the factors accounting for this difference are poorly understood.ObjectivesTo estimate HIV prevalence and incidence trends by province, and to identify the epidemiological factors that account for most of the variation between provinces.MethodsA mathematical model of the South African HIV epidemic was applied to each of the nine provinces, allowing for provincial differences in demography, sexual behaviour, male circumcision, interventions and epidemic timing. The model was calibrated to HIV prevalence data from antenatal and household surveys using a Bayesian approach. Parameters estimated for each province were substituted into the national model to assess sensitivity to provincial variations.ResultsHIV incidence in 15–49-year-olds peaked between 1997 and 2003 and has since declined steadily. By mid-2013, HIV prevalence in 15–49-year-olds varied between 9.4% (95% CI: 8.5%–10.2%) in Western Cape and 26.8% (95% CI: 25.8%–27.6%) in KwaZulu-Natal. When standardising parameters across provinces, this prevalence was sensitive to provincial differences in the prevalence of male circumcision (range 12.3%–21.4%) and the level of non-marital sexual activity (range 9.5%–24.1%), but not to provincial differences in condom use (range 17.7%–21.2%), sexual mixing (range 15.9%–19.2%), marriage (range 18.2%–19.4%) or assumed HIV prevalence in 1985 (range 17.0%–19.1%).ConclusionThe provinces of South Africa differ in the timing and magnitude of their HIV epidemics. Most of the heterogeneity in HIV prevalence between South Africa’s provinces is attributable to differences in the prevalence of male circumcision and the frequency of non-marital sexual activity.

Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized Sub-Saharan countries.

BackgroundWHO and UNAIDS prioritized 14 eastern and southern African countries with high HIV and low male circumcision prevalence for a voluntary medical male circumcision (VMMC) scale-up in 2007. Because circumcision provides only partial protection against HIV infection to men, the issue of possible risk compensation in response to VMMC campaigns is of particular concern. In this study, we looked at population-level survey data from the countries prioritized by WHO for a VMMC scale-up. We compared the difference in sexual risk behaviours (SRB) between circumcised and uncircumcised men before and after the WHO’s official VMMC promotion.Materials and methodsTen countries (Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe) participating in the WHO’s VMMC scale-up had available data from the Demographic and Health Surveys (DHS). We used cumulative-link mixed models to investigate interactions between survey period and circumcision status in predicting SRB, in order to evaluate whether the difference between the behavior of the two groups changed before and after the scale-up, while controlling for socio-demographic and knowledge-related covariates. The main responses were condom use at last sex and number of non-cohabiting sexual partners, both in the last 12 months.ResultsThere was little change in condom use by circumcised men relative to uncircumcised men from before the VMMC scale up to after the scale up. The relative odds ratio is 1.06 (95% CI, 0.95–1.18; interaction P = 0.310). Similarly, there was little change in the number of non-cohabiting partners in circumcised men (relative to uncircumcised men): the relative odds ratio of increasing the number of partners is 0.95 (95% CI, 0.86–1.05; interaction P = 0.319). Age, religion, education, job, marital status, media use and HIV knowledge also showed statistically significant association with the studied risk behaviours. We also found significant differences among countries, while controlling for covariates.ConclusionsOverall, we find no evidence of sexual risk compensation in response to VMMC campaigns in countries prioritized by WHO. Changes in relative partner behaviour and the relative odds of condom use were small (and of uncertain sign). In fact, our estimates, though not significant, both suggest slightly less risky behavior. We conclude that sexual risk compensation in response to VMMC campaigns has not been a serious problem to date, but urge continued attention to local context, and to promulgating accurate messages about circumcision within and beyond the VMMC context.