Circumcision preference among women and uncircumcised men prior to scale-up of male circumcision for HIV prevention in Kisumu, Kenya

Following the endorsement by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) of male circumcision as an additional strategy to HIV prevention, initiatives to introduce safe, voluntary medical male circumcision (VMMC) services commenced in 2008 in several sub-Saharan African communities. Information regarding perceptions of circumcision as a method of HIV prevention, however, is largely limited to data collected before this important endorsement and the associated increase in the availability of VMMC services. To address this, we completed a community-based survey of male circumcision (MC) perceptions in the major non-circumcising community in Kenya, which is the current focus of VMMC programs in the country. Data was collected between November 2008 and April 2009, immediately before VMMC program scale-up commenced. Here we present results limited to women (n = 1088) and uncircumcised males (n = 460) to provide insight into factors contributing to the acceptability and preference for MC in those targeted by VMMC programs. Separate multivariable models examining preference for circumcision were defined for married men, unmarried men, and women. Belief in the protective effect of circumcision on HIV risk was strongly associated with preference for MC in all models. Other important factors included education, perceived improvement in sexual pleasure, and perceptions of impact on condom utilization. Identified barriers to circumcision were the belief that circumcision was not part of the local culture, the perception of a long healing period following the procedure, the lack of a specific impetus to seek out services, and the general fear of pain associated with becoming circumcised. A minority of participants expressed beliefs suggesting that behavioral risk compensation with increased MC prevalence and awareness is a possibility. This work describes the early impact of a large-scale VMMC program on beliefs and behaviors regarding MC and HIV risk. It is hoped that our findings may offer guidance into anticipating potential impacts that similar programs may observe in populations throughout Eastern Africa.     

Traditional male circumcision practices among the Kurya of North-eastern Tanzania and implications for national programmes

The World Health Organisation and the Joint United Nations Programme on AIDS recommend male circumcision (MC) as an additional intervention against HIV infection. Various sub-Saharan African countries are at different stages of rolling out MC programmes. Despite initial fears, studies conducted among traditionally non-circumcising communities in Africa have shown that MC is widely accepted as a biomedical intervention. However, little is known on how traditionally circumcising communities where MC carries considerable social meaning and significance would respond to such programmes. This study was conducted among a traditionally circumcising community in Tarime district in Tanzania as part of a national situation analysis prior to initiating a national MC programme. It employed key informant interviews and focus group discussions for data collection. Results show that the Kurya ethnic group practice MC as a rite of passage from childhood to adulthood. Each clan organises its own circumcision ceremony, which takes place every even numbered years. Clan leaders and traditional circumcisers are central to its organisation. Among the Kurya, there is high regard for traditional MC as it is perceived as upholding cultural practice and identity. It also embodies notions of bravery since anaesthetics are not used. On the other hand, medical MC is not viewed as prestigious since anaesthetics are used to suppress pain. Social pressure for traditional MC is applied through ridiculing of those uncircumcised or circumcised at health facilities. In general, there are positive attitudes towards MC as it is perceived as enhancing personal hygiene and having a protective effect against sexually transmitted infections. For the success of nation-wide MC programmes, there is need to develop programmes that incorporate both clinical and sociocultural interests.     

Male circumcision for HIV prevention: female risk compensatory behaviour in South Africa

South Africa promotes male circumcision (MC) as an HIV prevention method and implemented a national plan to scale-up MC in the country from 2012 to 2016. Literature has suggested that female risk compensatory behaviours (RCBs) are occurring in countries where these programmes have been implemented. Behaviours such as decreased condom use, concurrent sexual partners and sexual activity during the circumcision wound-healing period have the potential to jeopardise the campaigns’ objectives. Literature has shown that directly providing women with MC information results in correct knowledge however, previous studies have not directly sought women’s views and ideas on engagement with the information. This study aims to identify and explore female RCBs in relation to MC campaigns in South Africa, and to identify interventions that would result in greater female involvement in the campaigns. Snowball sampling was used to conduct twelve qualitative vignette-facilitated semi-structured interviews with women residing in a municipal housing estate in Durban, Kwa-Zulu Natal, South Africa. Interviews were audio-recorded, verbatim transcribed and analysed using framework analysis. MC knowledge and understanding varied, with some participants mistaking MC as direct HIV protection for females. Despite a lack in knowledge, the majority of women did not report signs of RCBs. Even with a lack of evidence of RCBs, misinterpretation of the MC protective effect has the potential to lead to RCBs; a concept acknowledged in the literature. Several women expressed that MC campaigns are directed to males only and expressed a keenness to be more involved. Suggested interventions include couple counselling and female information sessions in community clinics. Exploring women’s attitude towards involvement in MC campaigns fills in a research knowledge gap that is important to international health, as women have a vital role to play in reducing the transmission of HIV.     

The acceptability of male circumcision as an HIV intervention among a rural Zulu population, Kwazulu-Natal, South Africa

Epidemiological and biological studies provide compelling evidence for the protective effect of male circumcision against the acquisition of HIV. Three randomized controlled trials are currently underway to assess the impact of male circumcision as an HIV intervention in traditionally non-circumcising areas with high levels of heterosexually-transmitted infection. This study explores the acceptability of male circumcision among the rural Zulu around Hlabisa and Mtubatuba, KwaZulu-Natal, South Africa. A cross-sectional convenience sample of 100 men and 44 women was surveyed, and two male focus groups held, to ascertain circumcision preferences within the population. Four in-depth interviews with service providers assessed the feasibility of promoting male circumcision. Fifty-one per cent of uncircumcised men and 68% of women favoured male circumcision of themselves or their partners; while 50% of men and 73% of women would circumcise their sons. For men, the main predictors of circumcision preference pertained to beliefs surrounding sexual pain and pleasure; for women, knowledge about the relationship between male circumcision status and STI acquisition was the key indicator for circumcision preference. Among both sexes the main barrier to circumcision was fear of pain and death. The greatest logistical barrier was that circumcision can presently only be carried out by trained hospital doctors.     

How Informed are Clients Who Consent? A Mixed-Method Evaluation of Comprehension Among Clients of Male Circumcision Services in Zambia and Swaziland

Comprehension is fundamental for informed consent—an individual’s right to choose a medical procedure, such as male circumcision (MC). Because optimal benefits depend on post-surgical behaviors, comprehension is particularly critical for MC programs. We evaluated clients’ comprehension of MC’s risks and benefits, wound care instructions, and risk reduction post-MC using a true/false test (n = 1181) and 92 semi-structured interviews (SSIs) in Zambia and Swaziland. Most participants (89 % Zambia, 93 % Swaziland) passed the true/false test, although adolescents scored lower (significantly so in Swaziland) than adults and one-third (including nearly half of adolescents in Zambia) said MC has no risks. SSIs indicated confusion between “risk” of adverse surgical outcomes and reduced “risk” of HIV; most respondents acknowledged the 6 week abstinence period post-MC, yet few said resuming sex early increases HIV risk. Providers should distinguish between surgical “risks” and reduced HIV “risk,” and emphasize that HIV risk increases with sex before complete healing.     

A typology of penile cutting in Papua New Guinea: results of a modified Delphi study among sexual health specialists

Male circumcision (MC) significantly reduces the risk of HIV acquisition in men. The geographical, linguistic and cultural diversity of Papua New Guinea (PNG) makes issues of acceptability and implementation complex, and culturally appropriate HIV and Sexually Transmissible Infection (STI) prevention strategies are crucial in this setting. A modified Delphi approach was conducted with sexual health specialists to document and classify variants of penile cutting as part of a programme of research being carried out to investigate the acceptability and potential epidemiological impact of MC for HIV prevention in PNG, and options for future roll-out. Three broad categories were identified: circumcision, longitudinal incisions (including dorsal slit procedures) and incisions that did not alter the profile of penis or foreskin. The typology provides a universal language for health practitioners and policy makers that will inform future sexual health deliberations. The popularity of dorsal slit procedures in PNG has significant implications due to its procedural simplicity and limited resource requirements, making it an attractive provider option compared to medical circumcision. Further research is urgently required to examine the effectiveness of dorsal slit procedures for HIV prevention in PNG, the prevalence of various forms of penile cutting and the extent to which health staff are currently engaged in dorsal slit procedures.     

“Now that PrEP is reducing the risk of transmission of HIV,why then do you still insist that we use condoms?” the condom quandary among PrEP users and health care providers in Kenya

ABSTRACT

Communication around condom use in the context of PrEP services presents a potential conundrum for patients and providers. Within the Partners Scale-Up Project, which supports integration of PrEP delivery in HIV care clinics, we interviewed 41 providers and 61 PrEP users and identified themes relating to condom messaging and use. Most providers counselled PrEP initiators to always use both PrEP and condoms, except when trying to conceive. However, others reported contexts and rationales for not emphasizing condom use. Providers reported that PrEP users were sometimes confused, even frustrated, with their insistence on using condoms in addition to PrEP. PrEP users generally regarded PrEP as a more feasible and desirable HIV prevention method than condoms, enabling increased sexual pleasure and conception, and reducing the conflict and stigma associated with condom use. Innovative approaches to condom counselling in PrEP programs are needed.     

Acceptability of male circumcision for prevention of HIV infection in Zambia

Numerous observational studies and three clinical trials have shown male circumcision (MC) to be partially protective against HIV acquisition in heterosexual men. This has led to consideration of introducing circumcision as an HIV prevention strategy in parts of sub-Saharan Africa. This study assesses the acceptability of male circumcision as an intervention to improve male genital hygiene and reduce sexually transmitted infections, including HIV-1 in Zambia. Thirty-four focus group discussions were conducted - 17 with men and 17 with women - in four districts chosen to represent urban and rural communities where circumcision is and is not traditionally practiced. In communities where circumcision is little practiced, the main facilitators for acceptance were improved genital hygiene, HIV/STI prevention, and low cost. The main barriers were cultural tradition, high cost, pain, and concerns for safety. If MC is proven to reduce risk for HIV and STIs, most participants reported that they would seek circumcision for themselves or their partners or their sons if it was free or at a minimal cost. Acceptability of male circumcision for STI and HIV prevention appears to be high in Zambia.     

A qualitative study of sexual behavior change and risk compensation following adult male circumcision in urban Swaziland

Male circumcision has been shown to reduce the risk of heterosexual transmission of HIV infection in men by up to 60% in three randomized controlled trials. Less is known, however, about sexual behavior change in men who have been circumcised and whether male circumcision's protective effect leads to riskier sexual behaviors. This study used qualitative in-depth interviews to understand men's sexual behavior after circumcision and to determine whether and how men participated in riskier sexual behaviors following male circumcision. Men in urban Swaziland, circumcised in the previous 12 months, were recruited and asked about their perceptions of sexual risk and sexual behavior post-circumcision. Results showed that following circumcision, men experience changes in both their sexual attitudes and behavior, which can be considered both protective and risky for HIV transmission. Most of them described protective changes (e.g., more responsible attitudes towards safe sex, reducing sexual temptation and partners, easier condom use). A minority, however, experienced increased sexual risk-taking, typically during a brief period of sexual experimentation shortly after circumcision. HIV counseling and counseling throughout the circumcision process is shown to be critical in influencing protective behaviors. Findings in this study confirm the existence of risk compensation following circumcision; however, this study adds important contextual insight about precisely when and why such risk-taking occurs. Nevertheless this study suggests that male circumcision scale-up as an HIV prevention strategy is likely to foster protective behavior change among men. The integration of HIV counseling with circumcision provision remains critical for effectively mitigating HIV risk behavior as male circumcision gains momentum as a viable HIV prevention tool.     

Male circumcision, attitudes to HIV prevention and HIV status: a cross-sectional study in Botswana, Namibia and Swaziland

In efficacy trials male circumcision (MC) protected men against HIV infection. Planners need information relevant to MC programmes in practice. In 2008, we interviewed 2915 men and 4549 women aged 15-29 years in representative cluster samples in Botswana, Namibia and Swaziland, asking about socio-economic characteristics, knowledge and attitudes about HIV and MC and MC history. We tested finger prick blood samples for HIV. We calculated weighted frequencies of MC knowledge and attitudes, and MC history and HIV status. Multivariate analysis examined associations between MC and other variables and HIV status. In Botswana, 11% of young men reported MC, 28% in Namibia and 8% in Swaziland; mostly (75% in Botswana, 94% - mostly Herero - in Namibia and 68% in Swaziland) as infants or children. Overall, 6.5% were HIV positive (8.3% Botswana, 2.6% Namibia and 9.1% Swaziland). Taking other variables into account, circumcised men were as likely as uncircumcised men to be HIV positive. Nearly half of the uncircumcised young men planned to be circumcised; two-thirds of young men and women planned to have their sons circumcised. Some respondents had inaccurate beliefs and unhelpful views about MC and HIV, with variation between countries. Between 9 and 15% believed a circumcised man is fully protected against HIV; 20-26% believed men need not be tested for HIV before MC; 14-26% believed HIV-positive men who are circumcised cannot transmit the virus; and 8-34% thought it was "okay for a circumcised man to expect sex without a condom". Inaccurate perceptions about protection from MC could lead to risk compensation and reduce women's ability to negotiate safer sex. More efforts are needed to raise awareness about the limitations of MC protection, especially for women, and to study the interactions between MC roll out programmes and primary HIV prevention programmes.     

Risk of HIV infection but not other sexually transmitted diseases is lower among homeless Muslim men in Kolkata

OBJECTIVE: To compare the risk of HIV and sexually transmitted diseases (STD) among homeless Muslim (circumcised) and Hindu (uncircumcised) men in Kolkata, India. BACKGROUND: Many observational studies and clinical trials in Africa have demonstrated that male circumcision provides protection against HIV acquisition, but there are sparse data on circumcision and HIV in India, which has the largest number of HIV cases in the world. METHODS: Using a two-stage probability proportionate to size cluster design among homeless men aged 18-49 years in Kolkata, India, data were obtained on religion, behavioral risk factors, and HIV/STD prevalence, by administering an anonymous questionnaire. Rapid HIV tests and testing for syphilis were performed on blood, and urine samples were obtained to test for gonorrhea. RESULTS: The odds ratio for HIV among Muslims (circumcised) compared to Hindus (uncircumcised) was 0.43 (95% confidence interval 0.29-0.67). Despite Muslims having more partners and visits to commercial sex workers, the rates of syphilis and gonorrhea were similar. The results suggest that a biological effect of circumcision protects against HIV infection. CONCLUSION: The beneficial effect of circumcision should be communicated to high-risk groups, as well as to the general population.     

Acceptability of Circumcision Among Clients of Female Sex Worker in Hong Kong

Clients of female sex workers (CFSW) are at high risk of HIV transmission. Circumcision reduces the risk of heterosexual transmission of HIV. A total of 353 CFSW were interviewed using a combined interviewer-computer-assisted method. Amongst the participants, 28.0% were circumcised, whilst 63.8% of the uncircumcised participants were willing to take up circumcision (conditioned on being briefed about a 50% potential risk reduction effect). In a stepwise logistic regression model, frequency of patronizing female sex workers and factors related to the Health Belief Model were significantly associated with conditional willingness. Amongst uncircumcised participants, 20.9% anticipated risk compensation (i.e. would use condoms less frequently after being circumcised). Adjusting for background variables, inconsistent condom use during commercial sex and self-reported STD history in the last 6?months were significantly associated with anticipated risk compensation. It is feasible to promote circumcision among CFSW but such programs also need to promote condom use.     

Scaling Up Circumcision Programs in Southern Africa: The Potential Impact of Gender Disparities and Changes in Condom Use Behaviors on Heterosexual HIV Transmission

Circumcision significantly reduces female-to-male transmission of HIV infection, but changes in behavior may influence the overall impact on transmission. We sought to explore these effects, particularly for societies where women have less power to negotiate safe sex. We developed a compartmental epidemic model to simulate the population-level impact of various circumcision programs on heterosexual HIV transmission in Soweto. We incorporated gender-specific negotiation of condom use in sexual partnerships and explored post-circumcision changes in condom use. A 5-year prevention program in which only an additional 10% of uncircumcised males undergo circumcision each year, for example, would prevent 13% of the expected new HIV infections over 20 years. Outcomes were sensitive to potential changes in behavior and differed by gender. For Southern Africa, even modest programs offering circumcision would result in significant benefits. Because decreases in male condom use could diminish these benefits, particularly for women, circumcision programs should emphasize risk-reduction counseling.     

Acceptability of male circumcision as a tool for preventing HIV infection in a highly infected community in South Africa

BACKGROUND: Because a growing body of evidence suggests that male circumcision (MC) is associated with a reduced risk of HIV infection in Africa, it is being considered as a potential prevention tool to reduce the spread of infection. Its feasibility must therefore be assessed. METHODS: A community-based cross-sectional study was conducted among a random sample of 482 men aged 19-29 years and 302 women aged 14-25 years, all living in the Westonaria district, South Africa. The prevalence of HIV infection was 11% among the men and 30% among the women. Trained personnel administered standardized questionnaires. RESULTS: Two-thirds of the 108 circumcised men (CM) were circumcised during a traditional ceremony and one-third in a clinical setting; the latter reported less pain and adverse outcomes. More than 70% of the non-circumcised men (NCM) stated that they would want to be circumcised if MC were proved to protect against sexually transmitted diseases (STD). Twenty-nine per cent of the CM and 22% of the NCM believed that MC protects against HIV and other STD. Moreover, 30% and 18%, respectively, believed that CM could safely have sex with multiple partners. Multivariate analysis showed that CM were more likely to report many lifetime partners. CONCLUSION: Although the level of MC in the area is relatively low, it is perceived positively. A significant proportion of the CM felt protected by their circumcision, a feeling unfortunately translated into unsafe practices. Our results strongly suggest that interventions including MC should carefully address the false sense of security that it may provide.     

Exploring the acceptability of Option B plus among HIV-positive Nigerian women engaged and not engaged in the prevention of mother-to-child transmission of HIV cascade: a qualitative study

The acceptability of lifelong antiretroviral therapy (ART) among HIV-positive women in high-burden Nigeria, is not well-known. We explored readiness of users and providers of prevention of mother-to-child transmission of HIV (PMTCT) services to accept lifelong ART -before Option B plus was implemented in Nigeria. We conducted 142 key informant interviews among 100 PMTCT users (25 pregnant-newly-diagnosed, 26 pregnant-in-care, 28 lost-to-follow-up (LTFU) and 21 postpartum women living with HIV) and 42 PMTCT providers in rural North-Central Nigeria. Qualitative data were manually analyzed via Grounded Theory. PMTCT users had mixed views about lifelong ART, strongly influenced by motivation to prevent infant HIV and by presence or absence of maternal illness. Newly-diagnosed women were most enthusiastic about lifelong ART, however postpartum and LTFU women expressed conditionalities for acceptance and adherence, including minimal ART side effects and potentially serious maternal illness. Providers corroborated user findings, identifying the postpartum period as problematic for lifelong ART acceptability/adherence. Option B plus scale-up in Nigeria will require proactively addressing PMTCT user fears about ART side effects, and continuous education on long-term maternal and infant benefits. Structural barriers such as the availability of trained providers, long clinic wait times and patient access to ART should also be addressed.     

Introducing the female condom through the public health sector: experiences from South Africa

The successful implementation of new public health policy is influenced by provider preparedness and user acceptability of the new intervention. This paper describes the development and implementation of a participatory Training of Trainers (TOT) programme as a precursor to launch the South African government's female-initiated HIV prevention strategies in public health clinics. Three hundred peer-trainees from throughout South Africa were trained through a comprehensive, modular and interactive three-day workshop. The workshop content included: HIV/AIDS knowledge, beliefs and attitudes; values clarification regarding HIV infection and sexuality; sexual desensitization; 'hands-on' training in the use of and introduction of the female condom; and counselling, communication and programme planning skills. The TOT generated a cadre of knowledgeable health care workers for training others and provided a support structure at the service delivery level for ensuring potential users' access to the female condom within each province. Qualitative assessments of the training and trainer debriefing sessions suggest that the training was successful in increasing knowledge and promoting positive attitudes about female condoms. In addition, the expanded repertoire of problem-solving approaches left providers feeling confident about recommending this method to clients.     

Male Circumcision to Prevent HIV Transmission and Acquisition: What Else do We Need to Know?

There is growing interest and controversy regarding the promotion of male circumcision (MC) for the prevention of HIV transmission in Africa. Three randomized controlled studies has so far been stopped prematurely as evidence accumulated that showed that circumcision was superior to no circumcision in preventing HIV acquisition among sexually active men in Africa. To some people, the evidence is overwhelming and MC should be promoted aggressively. Others suggest cautious decision making. This paper attempts to review a continuum of perceptions and suggest that the decision to scale-up male circumcision cannot just bebased on randomized controlled trial results. ‘The findings suggest that circumcision should be advocated, just as we advocate condoms...We’ve got to do everything we can to decrease the rate of transmission of this disease.’ (Marx, 1989).     

Individual and Interpersonal Characteristics that Influence Male-Dominated Sexual Decision-Making and Inconsistent Condom Use Among Married HIV Serodiscordant Couples in Gujarat,India: Results from the Positive Jeevan Saathi Study

Approximately 40 % of new infections occur among married women. No studies have examined the factors that may contribute to HIV transmission among HIV-negative wives in HIV serodiscordant relationships in Gujarat, India. In 2010, a cross-sectional survey with 185 HIV serodiscordant, married couples (i.e. 185 HIV-positive husbands and their 185 HIV-negative wives) in Gujarat was conducted. Socio-demographic, individual, and interpersonal characteristics of HIV-positive husbands and their HIV negative wives were examined. The association of these characteristics with inconsistent condom use and male-dominated sexual decision-making, were examined using multivariate logistic regression analyses. Approximately 10 % of couples reported inconsistent condom use in the past 3 months and 20 % reported intimate partner violence (IPV). Reports of IPV were associated with a higher odds of inconsistent condom use among HIV-positive husbands (aOR = 6.281). Husbands who reported having received couples counseling had a lower odds of male-dominated decision making about condom use (aOR = 0.372). HIV-negative wives who reported sex communication had a lower odds of male-dominated decision making about condom use (aOR = 0.322) with their HIV-positive husbands. Although condom use is a traditional measure of risk behavior, other factors that facilitate risk, such as male-dominated sexual decision-making need to be considered in analyses of risk.     

A conceptual model of women's condom use intentions: Integrating intrapersonal and relationship factors

We developed and tested a multifaceted model of condom use intentions with cross-sectional data from 435 heterosexual women at risk for HIV/STIs. In addition to traditional intrapersonal variables drawn from established models of HIV prevention (e.g. attitudes, norms, self-efficacy), the present study examined the role of relationship factors and dynamics (i.e. relationship commitment, duration, condom use and pregnancy prevention decision-making) in shaping condom use intentions. In some cases, relationship variables were directly associated with condom use intentions. In other cases their effects on condom use intentions were mediated by intrapersonal constructs. The final model accounted for 66% of the variance in condom use intentions and confirmed the importance of integrating intrapersonal variables and relationship characteristics and dynamics in understanding women's intentions to use condoms. These results offer important insights for the design of interventions directed at promoting condom use among young women at risk for HIV/STIs and underscore the need to design prevention programs that address relationship characteristics and dynamics.