Voluntary Medical Male Circumcision Uptake Research Articles

Age Differences in Perceptions of and Motivations for Voluntary Medical Male Circumcision Among Adolescents in South Africa, Tanzania, and Zimbabwe.

BackgroundThe World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have set a Fast-Track goal to achieve 90% coverage of voluntary medical male circumcision (VMMC) among boys and men aged 10–29 years in priority settings by 2021. We aimed to identify age-specific facilitators of VMMC uptake among adolescents.MethodsYounger (aged 10–14 years; n = 967) and older (aged 15–19 years; n = 559) male adolescents completed structured interviews about perceptions of and motivations for VMMC before receiving VMMC counseling at 14 service provision sites across South Africa, Tanzania, and Zimbabwe. Adjusted prevalence ratios (aPRs) were estimated using multivariable modified Poisson regression models with generalized estimating equations and robust standard errors.ResultsThe majority of adolescents reported a strong desire for VMMC. Compared with older adolescents, younger adolescents were less likely to cite protection against human immunodeficiency virus (HIV) or other sexually transmitted infections (aPR, 0.77; 95% confidence interval [CI], .66–.91) and hygienic reasons (aPR, 0.55; 95% CI, .39–.77) as their motivation to undergo VMMC but were more likely to report being motivated by advice from others (aPR, 1.88; 95% CI, 1.54–2.29). Although most adolescents believed that undergoing VMMC was a normative behavior, younger adolescents were less likely to perceive higher descriptive norms (aPR, 0.79; .71–.89), injunctive norms (aPR, 0.86; 95% CI, .73–1.00), or anticipated stigma for being uncircumcised (aPR, 0.79; 95% CI, .68–.90). Younger adolescents were also less likely than older adolescents to correctly cite that VMMC offers men and boys partial HIV protection (aPR, 0.73; 95% CI, .65–.82). Irrespective of age, adolescents’ main concern about undergoing VMMC was pain (aPR, 0.95; 95% CI, .87–1.04). Among younger adolescents, fear of pain was negatively associated with desire for VMMC (aPR, 0.89; 95% CI, .83–.96).ConclusionsAge-specific strategies are important to consider to generate sustainable demand for VMMC. Programmatic efforts should consider building on the social norms surrounding VMMC and aim to alleviate fears about pain.

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.

Cost and Cost-Effectiveness of a Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision in Tanzania: Spending More to Spend Less.

Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20-34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20-34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness. Tanzania (Njombe and Tabora regions). Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios. Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and $130 in Njombe, and in the control arms $70 and $191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed. Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving.

Modifying the health system to maximize voluntary medical male circumcision uptake: a qualitative study in Botswana.

BackgroundIn 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS endorsed voluntary medical male circumcision (VMMC) as an add-on HIV-prevention strategy. Similar to many other sub-Saharan countries, VMMC uptake in Botswana has been low; as of February 2016, only 42.7% of the program target had been achieved. Previous work has examined how individual-level factors, such as knowledge and attitudes, influence the update of VMMC. This paper examines how factors related to the health system can be leveraged to maximize uptake of circumcision services, with a focus on demand creation, access to services, and service delivery.MethodsTwenty-seven focus group discussions with 238 participants were conducted in four communities in Botswana among men (stratified by circumcision status and age), women (stratified by age), and community leaders. A semi-structured guide was used by a trained same-gender interviewer to facilitate discussions, which were audio recorded, transcribed, translated to English, and analyzed using an inductive analytic approach.ResultsParticipants felt demand creation activities utilizing age- and gender-appropriate mobilizers and community leaders were more effective than mass media campaigns. Participants felt improved access to VMMC clinics would facilitate service uptake, as would designated men’s clinics with male-friendly providers for VMMC service delivery. Additionally, providing comprehensive pre-procedure counseling and education, outlining the benefits and disadvantages of the surgical procedure, and explaining the differences between the surgical and non-surgical procedures, were suggested by participants to increase understanding and uptake of VMMC.ConclusionCultural acceptability of circumcision services can be improved by engaging age- and gender-appropriate community mobilizers. Involving influential community leaders, providing a forum for men to discuss health issues, and bringing services closer to people can increase VMMC utilization. Service delivery can be improved by communicating the pros and cons of the procedure to the clients for informed decision-making.

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).

Increasing voluntary medical male circumcision uptake among adult men in Tanzania.

Objective:We evaluated a demand-creation intervention to increase voluntary medical male circumcision (VMMC) uptake among men aged 20–34 years in Tanzania, to maximise short-term impact on HIV incidence.Methods:A cluster randomized controlled trial stratified by region was conducted in 20 outreach sites in Njombe and Tabora regions. The sites were randomized 1 : 1 to receive either a demand-creation intervention package in addition to standard VMMC outreach, or standard VMMC outreach alone. The intervention package included enhanced public address messages, peer promotion by recently circumcised men, facility setup to increase privacy, and engagement of female partners in demand creation. The primary outcome was the proportion of VMMC clients aged 20–34 years.Findings:Overall, 6251 and 3968 VMMC clients were enrolled in intervention and control clusters, respectively. The proportion of clients aged 20–34 years was slightly greater in the intervention than control arm [17.7 vs. 13.0%; prevalence ratio = 1.36; 95% confidence intervals (CI):0.9–2.0]. In Njombe region, the proportion of clients aged 20–34 years was similar between arms but a significant two-fold difference was seen in Tabora region (P value for effect modification = 0.006). The mean number of men aged 20–34 years (mean difference per cluster = 97; 95% CI:40–154), and of all ages (mean difference per cluster = 227, 95% CI:33–420) were greater in the intervention than control arm.Conclusion:The intervention was associated with a significant increase in the proportion of clients aged 20–34 years in Tabora but not in Njombe. The intervention may be sensitive to regional factors in VMMC programme scale-up, including saturation.

Cultural competence: a framework for promoting voluntary medical male circumcision among VaRemba communities in Zimbabwe

Almost a decade after the formal introduction of voluntary medical male circumcision (VMMC) as an important technology for HIV prevention, its implementation is still fraught with acceptability challenges. This is especially true among ethnic groups where male circumcision is conducted as a rite of passage into adulthood. In this article we question why VMMC is being met with resistance despite widespread awareness of its promise to reduce HIV incidence in a culturally circumcising community in Zimbabwe. In-depth and key informant interviews were conducted with selected VaRemba initiation graduates and surgeons respectively in Mposi area in Mberengwa to explore why VMMC has not been readily accepted in their community. Findings suggest that male circumcision among VaRemba is not only the removal of prepuce but comprises a secretive and rich curriculum rooted in their culture and identity. Such a conceptualisation renders some social and programmatic impediments for VMMC uptake. To scale up VMMC uptake among VaRemba, we argue for a reorganisation and adaptation of VMMC services in a culturally competent way that accounts for local conceptions of circumcision and respect for the cultural beliefs and practices of VaRemba communities.

Could Circumcision of HIV-Positive Males Benefit Voluntary Medical Male Circumcision Programs in Africa? Mathematical Modeling Analysis.

BackgroundThe epidemiological and programmatic implications of inclusivity of HIV-positive males in voluntary medical male circumcision (VMMC) programs are uncertain. We modeled these implications using Zambia as an illustrative example.Methods and FindingsWe used the Age-Structured Mathematical (ASM) model to evaluate, over an intermediate horizon (2010–2025), the effectiveness (number of VMMCs needed to avert one HIV infection) of VMMC scale-up scenarios with varying proportions of HIV-positive males. The model was calibrated by fitting to HIV prevalence time trend data from 1990 to 2014. We assumed that inclusivity of HIV positive males may benefit VMMC programs by increasing VMMC uptake among higher risk males, or by circumcision reducing HIV male-to-female transmission risk. All analyses were generated assuming no further antiretroviral therapy (ART) scale-up.The number of VMMCs needed to avert one HIV infection was projected to increase from 12.2 VMMCs per HIV infection averted, in a program that circumcises only HIV-negative males, to 14.0, in a program that includes HIV-positive males. The proportion of HIV-positive males was based on their representation in the population (e.g. 12.6% of those circumcised in 2010 would be HIV-positive based on HIV prevalence among males of 12.6% in 2010). However, if a program that only reaches out to HIV-negative males is associated with 20% lower uptake among higher-risk males, the effectiveness would be 13.2 VMMCs per infection averted. If improved inclusivity of HIV-positive males is associated with 20% higher uptake among higher-risk males, the effectiveness would be 12.4. As the assumed VMMC efficacy against male-to-female HIV transmission was increased from 0% to 20% and 46%, the effectiveness of circumcising regardless of HIV status improved from 14.0 to 11.5 and 9.1, respectively. The reduction in the HIV incidence rate among females increased accordingly, from 24.7% to 34.8% and 50.4%, respectively.ConclusionImproving inclusivity of males in VMMC programs regardless of HIV status increases VMMC effectiveness, if there is moderate increase in VMMC uptake among higher-risk males and/or if there is moderate efficacy for VMMC against male-to-female transmission. In these circumstances, VMMC programs can reduce the HIV incidence rate in males by nearly as much as expected by some ART programs, and additionally, females can benefit from the intervention nearly as much as males.

Overcoming Barriers to Uptake of Voluntary Medical Male Circumcision in a Traditionally Circumcising Community in Machinga District, Malawi

Introduction: Voluntary medical male circumcision (VMMC) reduces chances of contracting HIV during heterosexual intercourse in males, and risk of cervical cancer in their female sexual partners. However, its uptake among traditionally circumcising communities, where male circumcision carries a cultural significance, has not been studied. Previous research has focused on barriers to uptake of VMMC in non-circumcising communities. This study was conducted to determine socio-cultural barriers to VMMC uptake in order to identify culture-sensitive and evidence-based interventions to increase its uptake. Methodology: This exploratory mixed methods cross-sectional study generated quantitative data from 262 randomly sampled sexually active men; and qualitative data through four focus-group discussions with 58 purposely selected male participants and 10 key informants. Results: The study established that only 6.3% (n = 15) of those circumcised (90.8%, n = 238) were circumcised in clinical setting. Limited access to VMMC services, cost, pain, being attended to by female providers and cultural influences were the major hindrances to uptake of VMMC. Conclusion: Although there is a paradigm shift of preference from traditional male circumcision to VMMC in this community, its uptake is low. The study recommends that besides introducing mobile VMMC services, the Ministry of Health should collaborate with traditional circumcisers and local leaders to provide gender-and-culture-sensitive safer medical male circumcision services.

The communication channel which generates the most demand for Voluntary Medical Male Circumcision at Ndola Central Hospital

Background and Purpose: It has been demonstrated that male circumcision has numerous health benefits. Various channels of communication are used to disseminate information about male circumcision. The objective of this study was to identify the communication channels which generate the most demand for voluntary medical male circumcision (VMMC) at Ndola Central Hospital (NCH). Methods: All clients aged16 years or older who came for VMMC at NCH in a period of 3 months (01/02/15 to 01/05/15) were captured in the study. A structured questionnaire was used to collect data. Data entry and analysis were conducted using Epi Data version 3.1 and SPSS version 16.0, respectively. The Pearson’s Chi-square and the Fisher’s exact tests were used to establish associations. The cut off point for statistical significance was set at the 5% level. Results: A total of 94 individuals participated in this study. Participants who were 16-24 years were motivated by Community leaders (22.3%), Television (22.3%) and Friends (20.2%). The 25+ age group cited Television (18.1%), Radio (18.1%) and Friends (18.1%) as the channels that generated most of their interest for VMMC. Overall, the highest demand to undergo VMMC was generated by Television (40.4%). 66% of participants believed that women are better promoters of VMMC. About 3 in 4 (78%) of the participants had to seek second opinion before undergoing VMMC. Conclusions: Television as a channel that generated most of the interest for VMMC should be used in order to increase uptake of VMMC.

Low Uptake of Voluntary Medical Male Circumcision Among High Risk Men in Malawi.

Malawi is one of 14 priority countries for voluntary medical male circumcision (VMMC) initiatives with the lowest VMMC uptake. Using data from a study of 269 men accessing VMMC in southern Malawi and latent class analysis, men were classified based on four risk factors: ever tested for HIV, condom use at last sex, having casual/concurrent sexual partners, and using alcohol before sex. Two distinct classes were identified: 8% of men were classified as high risk, while 92% were classified as low/medium risk. Poisson regression modeling indicated that men who had lower education (risk ratio [RR] 1.07, p<0.05) and were ages 19-26 (RR 1.07, p<0.05) were more likely to be in the high risk group. The low numbers of men in the high risk category seeking services suggests the need to implement targeted strategies to increase VMMC uptake among such high risk men.

Strength of Evidence on Demand Creation for Voluntary Medical Male Circumcision From 7 Impact Evaluations in Southern and Eastern Africa.

Background:Seven new impact evaluations of pilot programs for increasing the demand for voluntary medical male circumcision (VMMC) provide evidence of what works and what does not. The study findings suggest that financial compensation designed to relieve the opportunity or transportation costs from undergoing the procedure can increase the uptake of VMMC. There is also evidence that programs using peer influence can be effective, although so far only sports-based programs demonstrate a strong effect. We explore the strength of evidence in each of these 7 studies to better interpret the findings for policy making.Methods:We perform a risk of bias assessment and conduct power calculations using actual values for each of the 7 studies.Results:Three of the 7 studies have a medium risk of bias, whereas the other 4 have a low risk of bias. All but 2 of the studies have adequate power to detect meaningful effects. In the 2 with insufficient power, the estimated effects are large but statistically insignificant.Conclusion:The positive evidence that financial incentives presented as compensation for opportunity costs to men seeking and obtaining VMMC can increase uptake comes from strong studies, which have high power and low to medium risk of bias. The positive evidence that a comprehensive sports-based program for young men can increase uptake also comes from a strong study. The strength of the studies further validates these findings.

The Impact of SMS-Based Interventions on VMMC Uptake in Lusaka Province, Zambia: A Randomized Controlled Trial.

Introduction:Zambia has high HIV prevalence and low voluntary medical male circumcision (VMMC) rates, heightening the need for effective VMMC demand generation strategies for HIV prevention.Methods:A 3-arm randomized controlled trial measured the impact of 2 short message service (SMS) campaigns on self-reported and verified VMMC uptake over 6 months in Lusaka Province. The study enrolled 2312 uncircumcised males aged 15–30 previously subscribed on Zambia U-Report, an existing SMS platform providing confidential, free counseling services relevant to HIV and other sexually transmitted infections. Participants in the “Conventional” campaign group received a standard package of messages promoting VMMC. Messages sent to the “Tailored” campaign group were targeted at participants' intention level to get circumcised. The control group had routine counselor access through SMS. Data were collected using SMS surveys, and verification of self-reported VMMC uptake used health facility client data.Results:Six-month self-reported VMMC uptake was 11.6%, 12.6%, and 10.4% in the Conventional, Tailored, and control arms, respectively; verified uptake was 1.8%, 1.1%, and 1.5%. Using multivariate logistic regression, the adjusted odds ratio of self-reported VMMC uptake was 1.17 (95% CI: 0.80 to 1.72) in the Conventional campaign arm compared with the control arm and 1.24 (95% CI: 0.84 to 1.81) in the Tailored campaign arm. The adjusted odds ratios of verified VMMC uptake in the Conventional and Tailored campaign arms were 1.34 (95% CI: 0.45 to 4.02) and 0.67 (95% CI: 0.20 to 2.23), respectively.Conclusions:Neither SMS campaign had statistically significant impact on VMMC uptake compared with routine SMS counseling. Future research is necessary to fully understand the potential of SMS-based tools for VMMC demand creation.

A Sport-Based Intervention to Increase Uptake of Voluntary Medical Male Circumcision Among Adolescent Male Students: Results From the MCUTS 2 Cluster-Randomized Trial in Bulawayo, Zimbabwe.

Mathematical models suggest that 570,000 HIV infections could be averted between 2011 and 2025 in Zimbabwe if the country reaches 80% voluntary medical male circumcision (VMMC) coverage among 15- to 49-year-old male subjects. Yet national coverage remains well below this target, and there is a need to evaluate interventions to increase the uptake. A cluster-randomized trial was conducted to assess the effectiveness of Make-The-Cut-Plus (MTC+), a single, 60-minute, sport-based intervention to increase VMMC uptake targeting secondary school boys (14-20 years). Twenty-six schools in Bulawayo, Zimbabwe, were randomized to either receive MTC+ at the start (intervention) or end (control) of a 4-month period (March to June 2014). VMMC uptake over these 4 months was measured via probabilistic matching of participants in the trial database (n = 1226 male participants; age, 14-20 years; median age, 16.2 years) and the registers in Bulawayo's 2 free VMMC clinics (n = 5713), using 8 identifying variables. There was strong evidence that the MTC+ intervention increased the odds of VMMC uptake by approximately 2.5 fold (odds ratio = 2.53; 95% confidence interval, 1.21 to 5.30). Restricting to participants who did not report being already circumcised at baseline, MTC+ increased VMMC uptake by 7.6% (12.2% vs 4.6%, odds ratio = 2.65; 95% confidence interval, 1.19 to 5.86). Sensitivity analyses related to the probabilistic matching did not change these findings substantively. The number of participants who would need to be exposed to the demand creation intervention to yield one additional VMMC client was 22.7 (or 13.2 reporting not already being circumcised). This translated to approximately US dollar 49 per additional VMMC client. The MTC+ intervention was an effective and cost-effective strategy for increasing VMMC uptake among school-going adolescent male subjects in Bulawayo.

Innovative Demand Creation for Voluntary Medical Male Circumcision Targeting a High Impact Male Population: A Pilot Study Engaging Pregnant Women at Antenatal Clinics in Kampala, Uganda.

Background:Circumcision has been shown to be an effective method of HIV prevention; however, only 28% of Ugandan men aged 15–49 years are circumcised. There is a paucity of data on the role of intimate partners in generating demand for voluntary medical male circumcision (VMMC). We conducted a pilot study to assess the feasibility of a partner-focused intervention targeting males >25 years.Methods:Among pregnant women in their third trimester attending antenatal care we evaluated the impact of a pilot behavior change intervention on VMMC through a quasi-experimental approach. We observed VMMC numbers among spouses of women as per standard practice (comparison phase), and after introducing a behavioral change communication package (intervention phase). Logistic regression was used to compare the odds of VMMC uptake between comparison and intervention phases. We used qualitative methods to evaluate the casual chain using a thematic approach.Results:Of the 601 women studied, 90% articulated the health benefits of VMMC and 99% expressed interest in their spouse getting circumcised. Women's knowledge was not increased by the intervention. Four men were circumcised in the comparison and 7 in the intervention phase. The intervention was not associated with higher odds of circumcision (odds ratio 1.5, 95% CI: 0.3 to 6.0, P = 0.65). We interviewed 117 individuals overall with the main enablers for VMMC being: free VMMC, transport reimbursement, and health benefits. Deterrents included misconceptions, lost wages and fear of pain. Most of the uncircumcised men interviewed reported interest in VMMC.Conclusions:Our pilot intervention had no significant impact on increasing VMMC demand. The study demonstrated the feasibility of pregnant women engaging their spouses to discuss VMMC.

A Randomized Evaluation of a Demand Creation Lottery for Voluntary Medical Male Circumcision Among Adults in Tanzania.

Background:Uptake of voluntary medical male circumcision (VMMC) among adult men has fallen short of targets in Tanzania. We evaluated a smartphone raffle intervention designed to increase VMMC uptake in three regions.Methods:Among 7 matched pairs of health facilities, 1 in each pair was randomly assigned to the intervention, consisting of a weekly smartphone raffle for clients returning for follow-up and monthly raffle for peer promoters and providers. VMMC records of clients aged 20 and older were analyzed over three months, with the number performed compared with the same months in the previous year. In multivariable models, the intervention's effect on number of VMMCs was adjusted for client factors and clustering. Focus groups with clients and peer promoters explored preferences for VMMC incentives.Results:VMMCs increased 47% and 8% in the intervention and control groups, respectively; however, the changes were not significantly different from one another. In the Iringa region subanalysis, VMMCs in the intervention group increased 336% (exponentiated coefficient of 3.36, 95% CI: 1.14 to 9.90; P = 0.028), after controlling for facility pair, percentage of clients ≥ age 30, and percentage testing HIV positive; the control group had a more modest 63% increase (exponentiated coefficient 1.63, 95% CI: 1.18 to 2.26; P = 0.003). The changes were not significantly different. Focus group respondents expressed mixed opinions about smartphone raffles; some favored smaller cash incentive or transportation reimbursement.Implications:A smartphone raffle might increase VMMC uptake in some settings by helping late adopters move from intention to action; however, this study did not find strong evidence to support its implementation broadly.

Sequential Cross-Sectional Surveys in Orange Farm, a Township of South Africa, Revealed a Constant Low Voluntary Medical Male Circumcision Uptake among Adults despite Demand Creation Campaigns and High Acceptability.

BackgroundWHO recommends a male circumcision (MC) prevalence rate higher than 80% to have a substantial impact on the HIV-AIDS epidemic in Eastern and Southern Africa. Orange Farm, a township in South Africa, has a free-for-service voluntary medical male circumcision (VMMC) clinic in operation since 2008. Following an intense campaign from 2008 to 2010, MC prevalence rate increased to 55.4% (ANRS-12126). Ongoing and past VMMC campaigns focused on youths, through school talks, and adults at a community level. The main objective of the study was to assess the change in MC prevalence rate among adults aged 18–19 and 18–49 years in the past 5 years.MethodsA cross-sectional survey (ANRS-12285) was conducted among a random sample of 522 adult men in 2015. MC status and characteristics of participants were collected through a genital examination and a face-to-face questionnaire.ResultsMC prevalence rate among young adult men aged 18–19 years increased markedly from 61.2% (95%CI: 57.4% to 65.0%) in 2010 to 87.5% (76.0% to 94.6%) in 2015 (p<0.001). In the same period, among men aged 18–49 years, MC prevalence rate varied slightly from 55.4% (53.6% to 57.1%) to 56.7% (52.4% to 60.9%). In 2015, 84.9% (79.2% to 89.5%) of uncircumcised adult men reported that they were willing to be circumcised. However, we estimated that only 4.6% (11/237; 2.5% to 7.9%) of the uncircumcised men underwent circumcision in 2015, despite 117/185 (63.2%; 95%CI: 56.1% to 69.9%) who reported that they were definitely willing to become circumcised.ConclusionsIn Orange Farm, VMMC campaigns were successful among the youth and led to a sufficiently high MC prevalence rate to have a substantial impact in the future on the HIV-AIDS epidemic. However, despite high acceptability and a free VMMC service, VMMC campaigns since 2010 have failed to increase MC prevalence rate among adults to above 80%. These campaigns should be revisited.

Triggering the decision to undergo medical male circumcision: a qualitative study of adult men in Botswana

ABSTRACTIn 2007, the World Health Organization endorsed voluntary medical male circumcision (VMMC) as part of comprehensive HIV-prevention strategies. A major challenge facing VMMC programs in sub-Saharan Africa remains demand creation; there is urgent need for data on key elements needed to trigger the decision among eligible men to seek VMMC. Using qualitative methods, we sought to better understand the circumcision decision-making process in Botswana related to VMMC. From July to November 2013, we conducted 27 focus group discussions in four purposively selected communities in Botswana with men (stratified by circumcision status and age), women (stratified by age) and community leaders. All discussions were facilitated by a trained same-sex interviewer, audio recorded, transcribed and translated to English, and analyzed for key themes using an inductive content analytic approach. Improved hygiene was frequently cited as a major benefit of circumcision and many participants believed that cleanliness was directly responsible for the protective effect of VMMC on HIV infection. While protection against HIV was frequently noted as a benefit of VMMC, the data indicate that increased sexual pleasure and perceived attractiveness, not fear of HIV infection, was an underlying reason why men sought VMMC. Data from this qualitative study suggest that more immediate benefits of VMMC, such as improved hygiene and sexual pleasure, play a larger role in the circumcision decision compared with protection from potential HIV infection. These findings have immediate implications for targeted demand creation and mobilization activities for increasing uptake of VMMC among adult men in Botswana.

P18.02 Circumcision of hiv positive males will not undermine the benefits of voluntary medical male circumcision programs in africa

Introduction The epidemiological and programmatic implications of inclusivity of HIV positive males in voluntary medical male circumcision (VMMC) programs are uncertain. We modelled these implications in Zambia as an illustrative example. Methods We used the Age-Structured Mathematical (ASM) model to evaluate the effectiveness (number of VMMCs needed to avert one HIV infection) of VMMC scale-up scenarios with varying proportions of HIV positive males. The range of proportions across the scenarios was derived from empirical data and programmatic considerations. Results The number of VMMCs needed to avert one HIV infection in Zambia was projected to increase from 12.2 VMMCs per HIV infection averted, in a program that circumcises only HIV negative males, to 14.0 in a program that includes HIV positive males, based on their prevalence in the population. However, if a program that only reaches out to negative males is associated with 20% lower uptake among higher-risk males, the effectiveness would be 13.2 VMMCs per infection averted. If improved inclusivity of positive males is associated with 20% higher uptake among higher-risk males, the effectiveness would be 12.4. As the assumed VMMC efficacy against male-to-female HIV transmission is increased from 0% to 20% and 46%, the effectiveness of circumcising regardless of HIV status improves from 14.0 to 11.5 and 9.1, respectively. HIV incidence rate reduction among females would increase accordingly from 24.7% to 34.8% and 50.4%, respectively. Conclusion Improving inclusivity of males in VMMC programs regardless of HIV status increases VMMC effectiveness, if there is moderate increase in VMMC uptake among higher-risk males and/or if there is moderate efficacy for VMMC against male-to-female transmission. In these circumstances, VMMC programs can reduce HIV incidence rate in males by nearly as much as expected by some anti-retroviral therapy programs, and additionally, females can benefit from the intervention by nearly as much as males. Disclosure of interest statement This publication is based on research funded by the Bill and Melinda Gates Foundation. Infrastructure support was provided by the Biostatistics, Epidemiology, and Biomathematics Research Core at the Weill Cornell Medical College in Qatar. The content of this manuscript is the sole responsibility of the authors. The information provided here is not official US Government information and does not necessarily represent the views or positions of United States Agency for International Development, the United States Government, or the Bill and Melinda Gates Foundation.

Stages of Change for Voluntary Medical Male Circumcision and Sexual Risk Behavior in Uncircumcised Zambian Men: The Spear and Shield Project

Dissemination and scale up of voluntary medical male circumcision (VMMC) programs is well supported by evidence that VMMC reduces HIV risk in populations with high HIV prevalence and low rates of circumcision, as is the case in Zambia. At both individual and population levels, it is important to understand what stages of change for VMMC are associated with, especially across cultures. This study evaluated VMMC knowledge, misinformation, and stages of change for VMMC of uncircumcised men and boys (over 18 years), as well as the concurrent relationship between VMMC stages of change and sexual risk behaviors. Uncircumcised (N = 800) adult men and boys (over 18) were screened and recruited from urban community health centers in Lusaka, Zambia, where they then completed baseline surveys assessing knowledge, attitudes, HIV risk behaviors, and stages of change for VMMC. A series of analyses explored cross-sectional relationships among these variables. VMMC was culturally acceptable in half of the sample; younger, unmarried, and more educated men were more ready to undergo VMMC. Stage of change for VMMC was also related to knowledge, and those at greater HIV risk reported greater readiness to undergo VMMC. Efforts to increase VMMC uptake should address the role of perceived HIV risk, risk behaviors, readiness, accurate knowledge, cultural acceptance, and understanding of the significant degree of HIV protection conferred as part of the VMMC decision making process. These results support incorporating comprehensive HIV risk reduction in VMMC promotion programs.