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 influence of male circumcision for HIV prevention on sexual behaviour among traditionally circumcised men in Cape Town, South Africa

We examined the relationship between HIV prevention beliefs related to male circumcision and sexual behaviour/sexually transmitted infection (STI) acquisition among traditionally circumcised men in Cape Town, South Africa. HIV-negative men (n = 304), circumcised for cultural/religious reasons, attending a health clinic in Cape Town, South Africa, completed cross-sectional surveys. Generalized linear models were used to analyse the relationships between unprotected vaginal sex acts, number of female sexual partners, STI diagnoses and male circumcision-related beliefs and risk perceptions. Men who were aware that circumcision offers protection against HIV (relative risk [RR] = 1.19, 95% confidence interval [CI] = 1.06-1.32, P < 0.01), endorsed risk compensation related to male circumcision (RR = 1.15, 95% CI = 1.11-1.12, P < 0.01) and perceived lower risk of HIV infection when circumcised (RR = 1.08, 95% CI = 1.04-1.12, P < 0.01) were more likely to report unprotected vaginal sex acts. Similar patterns were also identified when predicting number of female sexual partners. Men who were more likely to endorse risk compensation related to male circumcision were also more likely to be diagnosed with a chronic STI (odds ratio [OR] = 1.64, 95% CI = 1.06-2.53, P < 0.05). Our findings suggest that we must not overlook the effects of beliefs towards male circumcision for HIV prevention among men traditionally circumcised; doing so may undermine current efforts to reduce HIV transmission through male circumcision.     

Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa

Background  

Recent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-to-male transmission risk by 60% or more. However, the public health impact of large-scale male circumcision programs for HIV prevention is unclear.     

Voluntary medical male circumcision for HIV prevention and early resumption of sexual activity: a literature review

A number of programs have focused on scale-up and implementation research regarding voluntary medical male circumcision; however, there is limited research with regard to factors and strategies related to abstinence compliance and the effects of resuming sex during the wound healing period (42-day post-circumcision). We searched the literature for peer-reviewed articles examining early resumption of sex during this period. This review identifies factors that may predispose a client to engage in sex during the 42-day postoperative period, examines how early resumption of sex can inhibit wound healing and increase seroconversion, and reviews strategies that may increase adherence to abstinence during the wound healing period. We found that the most common factor that may predispose a client to engage in sex before the end of the postoperative period is marriage or cohabitation with a sexual partner. With regard to the effect of sex during the postoperative period on wound healing and seroconversion, we found that adverse events incurred were mild, and there was an increased risk of seroconversion. The only strategy studied to increase compliance to abstinence during the postoperative period utilized text messaging, and the trial results indicate that text messaging did not increase abstinence compliance.     

Voluntary medical male circumcision for HIV prevention in fishing communities in Uganda: the influence of local beliefs and practice

Local beliefs and practices about voluntary medical male circumcision (VMMC) may influence uptake and effectiveness. Data were gathered through interviews with 40 people from four ethnically mixed fishing communities in Uganda. Some men believed that wound healing could be promoted by contact with vaginal fluids while sex with non-regular partners could chase away spirits – practices which encouraged unsafe sexual practices. Information given by providers stressed that VMMC did not afford complete protection from sexually-transmitted infections, however, a number of male community members held the view that they were fully protected once circumcised. Both men and women said that VMMC was good not just for HIV prevention but also as a way of maintaining hygiene among the men. The implementation of VMMC in high-HIV prevalence settings needs to take account of local beliefs about circumcision, working with local religious/social group leaders, women and peers in the roll-out of the intervention.     

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.     

Medical male circumcision for HIV/AIDS prevention in Uganda - the cost of disposable versus re-usable circumcision kits

We evaluated the cost implications of medical male circumcisions for HIV prevention when performed using re-usable equipment that is sterilized after each use versus using single-use disposal kits. In Uganda, a re-usable circumcision kit results in a net saving of US$7.14-US$12.34 or 46-59%. In resource-limited settings seeking to expand access to medical male circumcision for HIV prevention, substantial cost reductions may be achieved by adopting re-usable circumcision kits.     

Acceptability of male circumcision for prevention of HIV infection among men and women in Uganda

In the last decade, three randomized controlled trials in Kenya, South Africa, and Uganda have shown that medical male circumcision (MMC) reduces the sexual transmission of HIV from women to men. Objectives of this assessment were to measure acceptability of adult MMC and circumcision of children to inform policies regarding whether and how to promote MMC as an HIV prevention strategy. This mixed-method study, conducted across four Ugandan districts, included a two-stage household survey of 833 adult males and 842 adult females, focus group discussions, and a health provider survey. Respondents' acceptability of MMC was positive and substantial after being informed about the results of recent randomized trials. In uncircumcised men, between 40% and 62% across the districts would consider getting circumcised. Across the four districts between 60% and 86% of fathers and 49% and 95% of mothers were supportive of MMC for sons. Widespread support exists among men and women in this study for promoting MMC as part of Uganda's current 'ABC + ' HIV prevention strategy.     

"Nothing new": responses to the introduction of antiretroviral drugs in South Africa

Interviews conducted in South Africa found that awareness of antiretroviral therapy was generally poor. Antiretroviral drugs were not perceived as new, but one of many alternative therapies for HIV/AIDS. Respondents had more detailed knowledge of indications, effects and how to access alternative treatments, which is bolstered by the active promotion and legitimization of alternative treatments. Many expressed a lack of excitement about the introduction of antiretroviral therapy, and little change in their attitudes concerning the epidemic.     

Constructions of sexuality and HIV risk among young people in Venda,South Africa: implications for HIV prevention

The study explored constructions of sexuality among young people of Venda in Limpopo, South Africa, and cultural practices that can be used to develop context-specific HIV prevention programmes. HIV prevention can be promoted by including some cultural practices in prevention programmes and changing some aspects of culture that may contribute negatively to health. Six focus group discussions were held with school-going young people (Grades 10 to 12) in urban and rural areas to explore their constructions of sexuality and HIV risk. Four focus group discussions were held with community leaders in the same areas to explore their constructions of young people’s sexuality and cultural practices relevant to HIV prevention. Through discourse analysis, the following dominant discourses that influence young people’s sexual risk behaviour were identified: rite of passage, the male sexual drive discourse (sex is natural and unavoidable); discourse of hegemonic masculinity (sex to prove masculinity); sex as a commodity; non-adherence to cultural practices; and HIV is normalised (AIDS is like flu). Some alternative constructions and shifts in gender norms were noticed, especially among female participants. The constructions of young people were not culture-specific but similar to those identified in other South African cultures. Community leaders identified a few cultural practices that could be considered in HIV prevention, for example, reinstating the rite of passage to provide age-appropriate sex and HIV education (behavioural intervention), and promoting traditional male circumcision (biological intervention). Cultural practices that contribute negatively to health should be challenged such as current constructions of gender roles (masculinity and femininity) and the practice that parents do not talk to young people about sex (both structural interventions).     

Potential for an intervention based on male circumcision in a South African town with high levels of HIV infection

The study aims to investigate the potential for an intervention based on male circumcision in a South African town with a high level of HIV infection. It draws on two cross-sectional studies conducted in August 2000 among a sample of 606 male adults aged 13-59 years, and in August 1999 among a sample of 723 male youth aged 14-24 years. A qualitative study was further conducted on perceptions and attitudes towards male circumcision using focus group discussions and in-depth interview. Among men aged 25-59 years, 36% reported being circumcised The median reported age at circumcision was 20. A total of 42% of 14-24-year-old circumcised men reported having been circumcised in a medical setting. Circumcised and uncircumcised men did not differ in their sexual behaviour or in sociodemographic characteristics, apart from their age and ethnic group. Among 467 uncircumcised adult men, 59% said that they would be circumcised if circumcision reduced the chances of getting HIV and STDs. Focus group discussions showed that circumcision is still important to many people, and is seen as an essential part of the transition into adulthood Reluctance to be circumcised was mainly related to the possibility of adverse outcomes of circumcision performed in non-medical settings, although initiation schools remain attractive for education and transmission of cultural values. Some misconceptions remain, however, especially about the preventative nature of circumcision for STD transmission. The cultural importance of male circumcision has weakened over the last century and when it is done it is often by a medical practitioner. An intervention that would include male circumcision seems feasible in communities such as the one where this study was conducted but needs to be carefully planned in order to ensure that participants understand that circumcision probably reduces, but certainly does not eliminate, the risk of HIV infection.     

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.     

An mHealth HIV prevention programme for youth: lessons learned from the iloveLife.mobi programme in South Africa

ABSTRACT

A mobile-based behavioural change program iloveLive.mobi was implemented to prevent HIV among young people (12–24 years) in South Africa. The mobile site offered access to sexual and reproductive health and psychosocial information through interactive learning. The site provided incentives for positive behaviour (such as HIV testing). The research aimed to evaluate the effectiveness of the iloveLife.mobi site in promoting protective behaviour of users. A mixed-methods approach was used, including document review, KAPB survey (n = 1882), group discussions (n = 68) and telephonic interviews (n = 175) with users and interviews with 46 project and community stakeholders. The SRH and psychosocial information on the site was age-appropriate and useful to young people (82.2%). The site reached young men who are generally difficult to reach with SRH information. High-frequency users reported more confidence related to condom use and HIV testing and more protective behaviour (condom use, VMMC) compared to low-frequency users. Users also reported more protective behaviour (HIV testing, VMMC, condom use) than a comparable national sample. iloveLife.mobi became a repository for learning to reach young people with health information. The research highlights key issues to consider when implementing an mHealth platform in a low- or middle-income country, where literacy levels and technical infrastructure may cause challenges.     

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

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

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

Abstract

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.