Programme science research on medical male circumcision scale-up in sub-Saharan Africa

Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
Sexually transmitted infections (Impact Factor: 3.4). 05/2013; 89(5). DOI: 10.1136/sextrans-2012-050595
Source: PubMed


Three randomised trials demonstrate that voluntary medical male circumcision (MMC) reduces male HIV acquisition by 50-60%, and post-trial surveillance has shown that the effects are long lasting. Scale-up of services has been initiated in 14 high-priority sub-Saharan African countries with high rates of HIV and low prevalence of MMC. However, circumcision coverage in the region remains low. Challenges to MMC rollout include suboptimal demand among higher-risk men, the need to expand access and reduce costs of MMC through personnel task shifting and task sharing, assuring and maintaining a high quality of service provision, and the testing and introduction of non-surgical devices. In addition, early infant male circumcision has not been adequately evaluated in Africa. Here, we describe challenges to implementation and discuss the ongoing and future role of implementation and programme science in addressing such challenges.

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    • "The lower-than-desired uptake of VMMC among adult men is motivating the GoK and implementing partners to develop new strategies to increase the numbers of men seeking VMMC services. National and provincial VMMC task forces and implementing partners are piloting new approaches to recruit men over the age of 25 for services [5], [9], but while the need for programmes to target older men has been identified, evidence-based strategies to accomplish this have not been fully developed or tested [11]. Additionally, input from key groups such as female partners, employers, and community and religious leaders, who may influence men’s perceptions of barriers to VMMC uptake and their ability to overcome these barriers, has not been widely gathered. "
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    ABSTRACT: Background: Uptake of VMMC among adult men has been lower than desired in Nyanza, Kenya. Previous research has identified several barriers to uptake but qualitative exploration of barriers is limited and evidence-informed interventions have not been fully developed. This study was conducted in 2012 to 1) increase understanding of barriers to VMMC and 2) to inform VMMC rollout through the identification of evidence-informed interventions among adult men at high risk of HIV in Nyanza Province, Kenya. Methods: Focus groups (n=8) and interviews were conducted with circumcised (n=8) and uncircumcised men (n=14) from the two districts in Nyanza, Kenya. Additional interviews were conducted with female partners (n=20), health providers (n=12), community leaders (n=12) and employers (n=12). Interview and focus group guides included questions about individual, interpersonal and societal barriers to VMMC uptake and ways to overcome them. Inductive thematic coding and analysis were conducted through a standard iterative process. Results: Two primary concerns with VMMC emerged 1) financial issues including missing work, losing income during the procedure and healing and family survival during the recovery period and 2) fear of pain during and after the procedure. Key interventions to address financial concerns included: a food or cash transfer, education on saving and employer-based benefits. Interventions to address concerns about pain included refining the content of demand creation and counseling messages about pain and improving the ways these messages are delivered. Conclusions: Men need accurate and detailed information on what to expect during and after VMMC regarding both pain and time away from work. This information should be incorporated into demand creation activities for men considering circumcision. Media content should frankly and correctly address these concerns. Study findings support scale up and/or further improvement of these ongoing educational programs and specifically targeting the demand creation period.
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