Medical Circumcision Research Articles

"What do You Mean I've Got to Wait for Six Weeks?!" Understanding the Sexual Behaviour of Men and Their Female Partners after Voluntary Medical Male Circumcision in the Western Cape.

BackgroundSeveral studies have shown that voluntary male medical circumcision (VMMC) reduces the incidence of the Type-1 human immunodeficiency virus (HIV) in heterosexual men by up to 60%. However, there is an increased risk of transmission of STIs, including HIV, in the immediate post-operative period after receiving VMMC. This study is to understand sexual practices of couples in the post-operative period in a Coloured population in the Western Cape Province of South Africa.MethodsColoured Males who had undergone VMMC in the previous six months in the Cape Town area and their partners participated in eight single-gender focus group discussions. The groups explored why the men decided to undergo VMMC, what kind of counselling they received, and how they experienced the 6-week post-operative period, including sexually.ResultsThe primary motivation to VMMC uptake included religious injunction and hygiene reasons and protection against sexually transmitted infections not necessarily HIV. There was some exploration of alternative sexual practices. During the period immediately post operation the respondents spoke of pain and fear of any sexual arousal, but towards the end of the six week period, sexual desire returned. Both men and women felt that sex was important to maintain the relationship. Gaps were identified in the pre- and post-MC procedure counselling.ConclusionsThere is a real risk that men in this population may begin sex before complete healing has occurred. VMMC counselling to encourage men to stay sexually safe in the wound-healing period, needs to take into account the real-life factors of the circumcised men. It is essential from a public health, and gender perspective that effective counselling strategies for the VMMC post-operative period, and the longer term, are developed and tested.

English

In recent years safe voluntary male medical circumcision (VMMC) has been recommended by the World Health Organization (WHO) as one of the preventive strategies for human immunodeficiency virus (HIV)-infection for those countries with high HIV prevalence and low medical male circumcision rates. This study aimed to assess the level of knowledge, attitude, and acceptance of safe VMMC among male university students attending Botswana University. A survey instrument was used to collect descriptive data in this study. Out of the total number of faculties within the university (8), we purposively selected our sample from the faculty of science due to its predominant male student population of 1,045. A total of 437 students were recruited from the various departments within the faculty. A semi-structured questionnaire was used for data collection. Study results indicate that 95.4% of the participants had heard about VMMC and 64.8% of those who had heard about VMMC were uncircumcised. About 31.4% knew about the complications of VMMC. Participants having undergone VMMC were twice as likely to be aware that VMMC reduces the risk of penile cancer and that it improves penile hygiene. Participants who knew that VMMC reduces the risk of other STIs were found to be four times more likely to accept VMMC as a preventive method for HIV infection. Participants having been medically circumcised were four times more likely to disagree with the statement that VMMC decreases sexual satisfaction and ten times more likely to disagree with the statement that the tip of the penis has to be covered by the foreskin. Study findings suggest that in terms of knowledge and attitude, the most significant factor associated with men’s acceptability of VMMC was their awareness that it reduces the risk of other STIs. It is therefore concluded that even though there exist a high-level of awareness and favourable attitude towards VMMC among the young male population; such awareness does not seem to influence individuals to become medically circumcized.   Key words: Voluntary male medical circumcision, human immunodeficiency virus (HIV) prevention, sexual transmitted infections, university students.

Trends in HIV acquisition, risk factors and prevention policies among youth in Uganda, 1999-2011.

The objective of this study is to understand how trends in HIV acquisition among youth can be influenced by change in HIV risk factors, social factors and prevention and treatment programmes. Trends in HIV incidence (per 1000 person-years), by sex and age group, were estimated using data from youth (15-24 years: n = 22,164) in the Rakai Community Cohort Study. Trends in HIV incidence were compared with trends in previously identified HIV risk factors, social factors and programmes. Poisson and linear regression were used to test for statistical significance and decomposition was used to calculate attribution of risk factors to HIV incidence. Substantial declines between 1999 and 2011 occurred in sexual experience, multiple partners and sexual concurrency among adolescents and young adults. HIV acquisition declined substantially (86%, P = 0.006) among adolescent women (15-19 years) but not among men or young adult women. Changes in HIV incidence and risk behaviours coincided with increases in school enrolment, decline in adolescent marriage, availability of antiretroviral therapy (ART) and increases in male medical circumcision (MMC). Much of the decline in HIV incidence among adolescent women (71%) was attributable to reduced sexual experience; the decline in sexual experience was primarily attributable to increasing levels of school enrolment. Dramatic decreases in HIV incidence occurred among adolescent women in Rakai. Changes in school enrolment and sexual experience were primarily responsible for declining HIV acquisition over time among adolescent women. Given limited improvement among young men and young adult women, the need for effective HIV prevention for young people remains critical.

Perceptions about medical male circumcision and sexual behaviours of adults in rural Uganda: a cross sectional study.

IntroductionMedical male circumcision is currently recognized as an additional important HIV preventive intervention to reduce the risk of heterosexually acquired HIV infection in men. However, sexual behaviours after medical circumcision can potentially reduce the expected benefits of the practice. This study explored the perceptions about medical male circumcision and sexual behaviours of adults in Kayunga district, Uganda.MethodsA cross-sectional study was carried out among 393 respondents using a semi structured questionnaire. In addition, four focus group discussions were conducted. Quantitative data was analysed using STATA 12. Univariate, bivariate and multivariate analyses were carried out. Qualitative data was analysed thematically.ResultsThe study established various perceptions about medical male circumcision and sexual behaviours. Majority 247 (64.5%) did not perceive circumcision as a practice that can lead men to have multiple sexual partners. Males were 3 times more likely to think that circumcision would lead to having multiple sexual partners than females (AOR=2.99, CI: 1.93-4.61). Only 89 (23.2%) believed that circumcision would lead to complacency and compromise the use of condoms to prevent against infection with HIV. Respondents who had education above primary were less likely to think that circumcision would compromise the use of condoms (AOR=0.49, CI: 0.31- 0.79). The perception that circumcised youths were less likely to abstain from sexual intercourse was less held among those with education above primary (AOR=0.58, CI: 0.37-0.91) and those older than 30 years (AOR=0.59, CI: 0.38-0.92).ConclusionThere were gaps in knowledge and negative perceptions about MMC in the study community. Measures are needed to avert the negative perceptions by equipping communities with sufficient, accurate and consistent information about medical male circumcision and sexual behaviour.

Two-Pronged Intervention Increases Uptake Of Circumcision Among Men in Zambia

A sexual risk reduction intervention increased demand for male adult circumcision, according to a cluster randomized controlled trial conducted in 2012-2014 in Zambia. (1) Men who participated in a program designed to increase the supply of and demand for male medical circumcision were more likely to opt for the procedure by 12 months postintervention than were men in the control group (odds ratio, 2.5). In addition, after circumcision, condom use increased among men in the intervention group, but not among those in the control group, indicating that newly circumcised men did not start engaging in risky behavior that might have nullified the HIV-prevention benefits of the circumcision. The study was designed to assess the effects of combining increased availability of circumcision with a comprehensive sexual risk reduction and circumcision promotion intervention among men who had little interest in circumcision but were at high risk for HIV. The intervention, called Spear and Shield, is a culturally tailored program that addresses attitudes, beliefs and preferences related to male circumcision. The researchers recruited 13 urban community health centers in Lusaka District to take part in the trial. Centers were eligible if they had at least 50 HIV voluntary counseling and testing clients each month and had at least five health care providers and counselors available to receive circumcision training and sexual risk reduction training, but did not have trained personnel providing circumcisions on a regular basis. Five centers were randomly assigned to the experimental group, five to the control group and three to an observation-only group. Before randomization, providers at all centers received male circumcision training; after randomization, counselors at the intervention sites were trained to provide the Spear and Shield intervention to eligible clients, while those at the control sites were trained to provide a video-based endemic disease prevention program that focused on cholera, malaria, tuberculosis and waterborne diseases. No changes in services were instituted at clinics in the observation-only group, and outcomes for those centers are not reported here. Men who underwent voluntary HIV counseling and testing at the intervention or control sites were eligible to participate in the trial if they were 18 or older, uncircumcised and HIV negative; were not requesting circumcision at their current visit; and did not have diseases of the foreskin or penile abnormalities in need of repair. The Spear and Shield intervention consisted of four weekly 90-minute group sessions that discussed strategies to prevent HIV and other STIs, with an emphasis on circumcision; participants were given opportunities to interact with peers who had undergone the procedure as well as with circumcision providers. The disease prevention program for the control group also included four weekly sessions; in both the intervention and control groups, participants' female partners were invited to attend sessions held specifically for them. In addition, participants in both groups received a week's supply of male condoms, female condoms or both after the first three sessions; after the fourth session, all participants received a month's supply of condoms. At study entry, after completing their assigned program, and at follow-up evaluations six and 12 months later and (when applicable) three months after circumcision, participants completed assessments that included questions on sexual behavior. Circumcisions were verified by clinic record review, provider interviews and voluntary physical examinations. The 800 men who enrolled in the trial were recruited in 2012-2013 and completed follow-up in 2014. …

Increasing Coverage of Antiretroviral Therapy and Male Medical Circumcision in HIV Hyperendemic Countries: A Cost-Benefit Analysis

HIV continues to cause the largest number of disability-adjusted life years of any disease in HIV hyperendemic countries (i.e., countries with an adult HIV prevalence >15%). We compare the benefits and costs of two proven biological interventions to reduce the health losses due to the HIV epidemic in hyperendemic countries from 2015 through 2030: 1) increasing ART coverage to 90% among HIV-infected adults with a CD4-cell count

The Art of HIV Elimination: Past and Present Science.

Remarkable strides have been made in controlling the HIV epidemic, although not enough to achieve epidemic control. More recently, interest in biomedical HIV control approaches has increased, but substantial challenges with the HIV cascade of care hinder successful implementation. We summarise all available HIV prevention methods and make recommendations on how to address current challenges. In the early days of the epidemic, behavioural approaches to control the HIV dominated, and the few available evidence-based interventions demonstrated to reduce HIV transmission were applied independently from one another. More recently, it has become clear that combination prevention strategies targeted to high transmission geographies and people at most risk of infections are required to achieve epidemic control. Biomedical strategies such as male medical circumcision and antiretroviral therapy for treatment in HIV-positive individuals and as pre-exposure prophylaxis in HIV-negative individuals provide immense promise for the future of HIV control. In resource-rich settings, the threat of HIV treatment optimism resulting in increased sexual risk taking has been observed and there are concerns that as ART roll-out matures in resource-poor settings and the benefits of ART become clearly visible, behavioural disinhibition may also become a challenge in those settings. Unfortunately, an efficacious vaccine, a strategy which could potentially halt the HIV epidemic, remains elusive. Combination HIV prevention offers a logical approach to HIV control, although what and how the available options should be combined is contextual. Therefore, knowledge of the local or national drivers of HIV infection is paramount. Problems with the HIV care continuum remain of concern, hindering progress towards the UNAIDS target of 90-90-90 by 2020. Research is needed on combination interventions that address all the steps of the cascade as the steps are not independent of each other. Until these issues are addressed, HIV elimination may remain an unattainable goal.

Gains in Education May Explain Decline in HIV Among Ugandan Girls

Trends in HIV incidence among youth in Rakai, Uganda, during a recent 12-year period varied substantially by sex and age, according to a prospective population-based cohort study. (1) Among women aged 15-19, the rate of new infections declined by more than four-fifths during the study period; however, no change was found among women aged 20-24 or among men in either age-group. In addition, school enrollment increased, particularly among 15-19-year-olds, and rates of sexual initiation and marriage generally decreased; medical circumcision increased among males. The majority of the decline in HIV incidence among teenage women, according to the researchers, can be explained by the reduction in sexual initiation, which in turn was related to higher school enrollment. In the study, Santelli and colleagues analyzed data from 15-24-year-olds who took part in one or more of the nine rounds of the Rakai Community Cohort Study that were conducted between 1999 and 2011. This period--the third decade of the HIV epidemic in the district-saw implementation of multiple HIV prevention and treatment programs, and came soon after introduction of a new national policy of universal primary education that abolished tuition fees. During community surveys conducted roughly annually, participants completed questionnaires about their demographic, behavioral, reproductive and health characteristics, and provided specimens for HIV and STI testing. The investigators evaluated trends in HIV acquisition and in risk factors; used univariate and multivariate analyses to assess correlations between these trends; and performed decomposition analysis to determine the extent to which various risk factors may have contributed to changes in HIV incidence. Analyses were based on 22,164 participants aged 15-24 residing in 43 communities. The researchers found that the rate of new HIV infections acquired between survey rounds was consistently higher among female youth (10-16 per 1,000 person-years) than among their male counterparts (6-10 per 1,000 person-years). Over the study period, women aged 15-19 had an 86% reduction in HIV incidence (from 17 to 2 new infections per 1,000 person-years); in contrast, women aged 20-24 and men of either age-group had no change in HIV incidence. Overall, the prevalence of HIV infection fell among females (from 9% in 1999 to 6% in 2011), whereas it remained unchanged among males (2-3%). Trends in risk factors showed that the proportion of youth enrolled in school increased among all subgroups, but especially among teenage women (from 26% to 59%) and men (from 43% to 66%); similarly, the proportion who had ever had sex decreased among all youth, but the decline was greatest among 15-19-year-old women (from 76% to 50%) and men (from 63% to 41%). The proportion who had ever been married fell among teenage women (from 46% to 24%), teenage men (from 5% to 1%) and men aged 20-24 (from 52% to 37%). …

Knowledge of HIV and benefits of male medical circumcision amongst clients in an urban area.

BackgroundMale medical circumcision (MMC) has been shown to reduce the risk of HIV transmission in circumcised men by up to 60%. Following recommendations from the World Health Organization, South Africa adopted MMC as a preventative strategy against HIV in 2010 and set up circumcision camps across the country. Concerns have been raised about condom avoidance following MMC because of a mistaken belief about the benefits of MMC.Aim and settingThe aim of this study was to describe the profile and knowledge about HIV and circumcision amongst men presenting for MMC in an urban area in KwaZulu-Natal.MethodsThis was a cross-sectional descriptive study of 394 clients over the age of 18 years who presented to two MMC sites in Durban between November 2012 and March 2013. A validated questionnaire was used to collect data.ResultsThe mean age of clients presenting for MMC was 28 years. Most clients were black, single, unemployed and sexually active. The majority presented for MMC because they believed that MMC would reduce their risk of acquiring HIV infection. Knowledge about HIV transmission was very good and 86.3% of clients were aware that risky sexual behaviour such as condom avoidance could reverse the benefits of MMC.ConclusionThe knowledge of HIV and benefits of MMC was very good amongst those presenting for MMC. However as MMC is primarily a preventative strategy, innovative methods to promote MMC prior to first sexual encounter need to be explored. Further research is needed to determine whether the benefits of MMC on the reduction of HIV transmission are sustained in routine practice.

Male circumcision, alcohol use and unprotected sex among patrons of bars and taverns in rural areas of north-west province, South Africa

Strong research evidence has shown that medical male circumcision significantly reduces heterosexual HIV acquisition among men. However, its effectiveness is enhanced by behavioural factors such as condom use. Currently, little is known of unprotected sex associated with male circumcision (MC) among alcohol-drinking tavern-going men, or whether engagement in unprotected sex may differ between men who have been traditionally circumcised and those who have been medically circumcised. The study sought to determine the relative importance of alcohol consumption and MC as correlates of unprotected sex and to compare the risk of engaging in unprotected sex between traditionally circumcised and medically circumcised tavern-going men from two rural villages in North-West province, South Africa. Data from 314 adult men (≥18 years) were analysed. The men were recruited from four bars/taverns using systematic sampling. They responded to questions regarding their demographic characteristics, alcohol consumption, circumcision status and method (where applicable), and engagement in unprotected sex. Descriptive analyses and bivariate and multivariate logistic regression analyses were conducted. Age, education, relationship status, alcohol consumption and traditional male circumcision (TMC) were independently and significantly associated with unprotected sex. Specifically, probable alcohol dependence and traditional circumcision were independent risk factors for engaging in unprotected sex among tavern-going men. Traditionally circumcised men had a higher risk of engaging in unprotected sex than medically circumcised men. Interventions aimed at reducing alcohol consumption, encouraging protective behaviour among men who have undergone TMC, and increasing condom use are needed in bar/tavern settings. HIV prevention education must be urgently incorporated into TMC programmes.

Medically assisted circumcision: a safer option for initiation rites.

[Extract] Culturally sensitive integration of medical circumcision could avert adverse effects at traditional male initiation rites. In many traditional cultures, male initiation rites involve circumcision practices that can sometimes result in medical complications. In a recent incident in the Northern Territory, three young men required airlifting from their Borroloola initiation site to Darwin for medical assistance. The risk of permanent harm and potentially fatal outcomes could be decreased if safer options were available during initiation ceremonies. In this article, we report that it is possible to provide safe circumcision at male initiation rites.

A cross-sectional study describing motivations and barriers to voluntary medical male circumcision in Lesotho.

BackgroundIn February 2012, the Lesotho Ministry of Health launched a national voluntary medical male circumcision (VMMC) program. To assess the motivations for seeking VMMC, a cross-sectional mixed methods study was conducted among clients aged 18 years and older at four sites.MethodsA total of 161 men participated in individual survey interviews and 35 participated in four focus group discussions.ResultsMen sought medical circumcision for the following main reasons: protection against HIV (73%), protection from other sexually transmitted infections (62%), and improved penile hygiene (47%). Forty percent learned about VMMC through friends who had already accessed services. According to these men, perceived concerns hindering service uptake include fear of pain (57%), a female provider (18%), and “compulsory” HIV testing (15%).ConclusionsThe study provides important insights into the motivations of clients seeking VMMC services. Findings can be used by the national VMMC program to attract more clients and address barriers to uptake.

Review: [corrected] The changing face of the HIV epidemic in sub-Saharan Africa.

The widespread roll-out of antiretroviral therapy (ART) has substantially changed the face of human immunodeficiency virus (HIV). Timely initiation of ART in HIV-infected individuals dramatically reduces mortality and improves employment rates to levels prior to HIV infection. Recent findings from several studies have shown that ART reduces HIV transmission risk even with modest ART coverage of the HIV-infected population and imperfect ART adherence. While condoms are highly effective in the prevention of HIV acquisition, they are compromised by low and inconsistent usage; male medical circumcision substantially reduces HIV transmission but uptake remains relatively low; ART during pregnancy, delivery and breastfeeding can virtually eliminate mother-to-child transmission but implementation is challenging, especially in resource-limited settings. The current HIV prevention recommendations focus on a combination of preventions approach, including ART as treatment or pre- or post-exposure prophylaxis together with condoms, circumcision and sexual behaviour modification. Improved survival in HIV-infected individuals and reduced HIV transmission risk is beginning to result in limited HIV incidence decline at population level and substantial increases in HIV prevalence. However, achievements in HIV treatment and prevention are threatened by the challenges of lifelong adherence to preventive and therapeutic methods and by the ageing of the HIV-infected cohorts potentially complicating HIV management. Although current thinking suggests prevention of HIV transmission through early detection of infection immediately followed by ART could eventually result in elimination of the HIV epidemic, controversies remain as to whether we can treat our way out of the HIV epidemic.

Kenya's voluntary male medical circumcision program: Translatable lessons for both domestic and international programs

As a case of translating a healthcare intervention from randomized controlled trial to public health program, Kenya's voluntary male medical circumcision (VMMC) program offers an example of demand generation through active engagement with the population and reducing barriers to uptake. It illustrates various means by which the Kenyan leadership focused on demand generation which have value both domestically and internationally to healthcare leaders. Community and public engagement must start early and continue focused on key stakeholders and spokespersons. Barriers including cost, time, culture, and personal preference must be identified and addressed. This engagement and overall program must constantly be re-evaluated and shaped iteratively based on data.

Early infant male circumcision for human immunodeficiency virus prevention: knowledge and attitudes of women attending a rural hospital in Swaziland, Southern Africa

Swaziland has the highest prevalence of human immunodeficiency virus (HIV) in the world at 26% of the adult population. Medical male circumcision (MMC) has been shown to reduce the risk of acquiring HIV from heterosexual sex by up to 60% and the Government of Swaziland has been promoting adult male circumcision. Infant circumcision commenced in 2013 so it is important to understand the knowledge and views of women as potential mothers, around infant circumcision for medical purposes to inform the development of the service. This study interviewed 14 women of reproductive age attending the outpatient department of Good Shepherd Mission Hospital (GSMH), a rural district hospital, on their knowledge of and attitudes to early infant male circumcision (EIMC). Participants were highly knowledgeable about the health benefits of medical circumcision, although knowledge of the comparative risks and benefits of EIMC to adult circumcision was poor. All participants would have a son circumcised; the preferred age varied from early infancy to adolescence. Complications and pain were the main barriers whilst religious and cultural reasons were mentioned both for and against circumcision. A variety of family members are important in the decision to circumcise a young boy. Acceptability of medical circumcision was high in this study, but concerns about safety, pain, autonomy and cultural factors reduce the acceptability of infant circumcision more specifically. It will be important to provide accurate, culturally sensitive information about infant circumcision to mothers, fathers and grandparents using existing hospital and community services provided at GSMH and throughout Swaziland. Where possible services for MMC should be available to males of all ages so that families and young men may choose the most favourable age for circumcision.

Changes in Plasma Viral Load and Penile Viral Shedding After Circumcision Among HIV-Positive Men in Kisumu, Kenya

We conducted a prospective cohort study of HIV-positive men aged 18-35 years in Kisumu, Kenya to determine if medical circumcision of ART-naive HIV-positive men leads to increased viral load and penile viral shedding. From 108 HIV-positive men circumcised by forceps-guided method and followed up weekly for 6 weeks, 29 men were evaluated for penile viral shedding. HIV-1 RNA was measured in plasma from 19 men and in penile lavage samples from 29 men. Samples were collected before circumcision and at weekly intervals for 6 weeks or until the circumcision wound was healed. CD4 T-cell counts from 102 HIV-positive men were determined at baseline and at 2 weeks thereafter. Wounds with healthy scar, no scab or opening, and no suture tracks were deemed healed. Among 65 ART-naive men, mean CD4 T-cell count increased from 417 cells per cubic millimeter at baseline to 456 cells per cubic millimeter after 2 weeks (P = 0.04), but did not change in the 37 men on ART (P = 0.81). There was no change in HIV plasma viral load (P = 0.36), but penile viral shedding rose significantly within 1 week after circumcision then declined to undetectable levels by 6 weeks (multivariate analysis of variance; P < 0.001). In 28 of 29 men (96.6%), there was no detectable viral shedding after certification of wound healing. Medical circumcision among ART-naive HIV-infected men results in a transitory rise in penile viral shedding before complete wound healing, which should pose no additional risk of HIV transmission if men adhere to 6 weeks postcircumcision sexual abstinence and use condoms consistently.

Current drivers and geographic patterns of HIV in Lesotho: implications for treatment and prevention in Sub-Saharan Africa

BackgroundThe most severe HIV epidemics worldwide occur in Lesotho, Botswana and Swaziland. Here we focus on the Lesotho epidemic, which has received little attention. We determined the within-country heterogeneity in the severity of the epidemic, and identified the risk factors for HIV infection. We also determined whether circumcised men in Lesotho have had a decreased risk of HIV infection in comparison with uncircumcised men. We discuss the implications of our results for expanding treatment (current coverage is only 60%) and reducing transmission.MethodsWe used data from the 2009 Lesotho Demographic and Health Survey, a nationally representative survey of 3,849 women and 3,075 men in 9,391 households. We performed multivariate analysis to identify factors associated with HIV infection in the sexually active population and calculated age-adjusted odds ratios (aORs). We constructed cartographic country-level prevalence maps using geo-referenced data.ResultsHIV is hyperendemic in the general population. The average prevalence is 27% in women and 18% in men, but shows substantial geographic variation. Throughout the country prevalence is higher in urban centers (31% in women; 21% in men) than in rural areas (25% in women; 17% in men), but the vast majority of HIV-infected individuals live in rural areas. Notably, prevalence is extremely high in women (18%) and men (12%) with only one lifetime sex partner. Women with more partners have a greater risk of infection: aOR 2.3 (2 to 4 partners), aOR 4.4 (≥5 partners). A less substantial effect was found for men: aOR 1.4 (3 to 6 partners), aOR 1.8 (≥7 partner). Medical circumcision protected against infection (aOR 0.5), traditional circumcision did not (aOR 0.9). Less than 5% of men in Lesotho have been medically circumcised; approximately 50% have been circumcised using traditional methods.ConclusionsThere is a substantial need for treatment throughout Lesotho, particularly in rural areas where there is the greatest burden of disease. Interventions aimed at reducing the number of sex partners may only have a limited effect on reducing transmission. Substantially increasing levels of medical circumcision could be very effective in reducing transmission, but will be very difficult to achieve given the current high prevalence of traditional circumcision.

Understanding and addressing socio-cultural barriers to medical male circumcision in traditionally non-circumcising rural communities in sub-Saharan Africa

Given recent clinical trials establishing the safety and efficacy of adult medical male circumcision (MMC) in Africa, attention has now shifted to barriers and facilitators to programmatic implementation in traditionally non-circumcising communities. In this study, we attempted to develop a fuller understanding of the role of cultural issues in the acceptance of adult circumcision. We conducted four focus-group discussions with 28 participants in Mutoko, Zimbabwe, and 33 participants in Vulindlela, KwaZulu-Natal, South Africa, as well as 19 key informant interviews in both settings. We found the concept of male circumcision to be an alien practice, particularly as expressed in the context of local languages. Cultural barriers included local concepts of ethnicity, social groups, masculinity and sexuality. On the other hand, we found that concerns about the impact of HIV on communities resulted in willingness to consider adult male circumcision as an option if it would result in lowering the local burden of the epidemic. Adult MMC-promotional messages that create a synergy between understandings of both traditional and medical circumcision will be more successful in these communities.

Global HIV epidemiology: specific patterns of the epidemic in the North and South.

Thirty years after the identification of the first cases of AIDS, it was estimated that 34 million of people were living with HIV worldwide in 2011. The incidence is declining but remains high, with 2.5 million of new HIV infections per year. Africa is the region of the world most heavily affected, accounting for three-quarters of the global burden of HIV infection and the same proportion for new infections. The incidence declines in most parts of the world while heterosexual transmission remains the dominant mode of HIV acquisition followed by homosexual transmission. Intravenous drug use continues to drive the epidemic in Eastern Europe and parts of Asia. Condom use remains the cornerstone of prevention of sexual transmission. Male medical circumcision has now been proven an effective public health intervention to prevent sexual transmission. Antiretroviral treatment may reduce sexual transmission at population level while improving the conditions of life and survival of those harbouring the virus. Harm-reduction together with blood safety prevent blood transmission. The prevention of mother-to-child transmission is now moving its global objective to elimination by the end of 2015. At least 20 years will be necessary for achieving HIV control at the worldwide level with currently available interventions.

Contextual Barriers and Motivators to Adult Male Medical Circumcision in Rakai, Uganda

Medical male circumcision (MMC) is a central component of HIV prevention. In this study we examined barriers to and facilitators of MMC in Rakai, Uganda. Interviews and focus groups with MMC acceptors, decliners, and community members were collected and analyzed iteratively. Themes were developed based on immersion, repeated reading, sorting, and coding of data using grounded theory. Pain, medical complications, infertility, lack of empirical efficacy, waiting time before resumption of sex, and religion were identified as obstacles to MMC acceptance. Prevention and healing of sexually transmitted infections (STIs), access to HIV and other ancillary care, penile hygiene, and peer influence were key motivators. Voluntary counseling and testing for HIV, partner influence, and sexual potency were both barriers and motivators. Individual and societal factors, such as pain and religion, might slow MMC scale up. Health benefits, such as HIV/STI prevention and penile hygiene, are essential in motivating men to accept MMC.