Effectiveness of an "Exclusive Intervention Strategy" to increase medical male circumcision uptake among men aged 25-49 years in South Africa

Barriers and Facilitators to, and Experience of, Voluntary Medical Male Circumcision Among Men Who Have Sex with Men in China: A Mixed-Methods Study

Voluntary medical male circumcision (VMMC) may be incorporated into HIV prevention services for men who have sex with men (MSM). We conducted a mixed-methods study to elucidate barriers and facilitators to, and experience of, VMMC among MSM. Participants were MSM aged 18 years and older who were enrolled in an ongoing multicenter randomized controlled trial (RCT) to evaluate VMMC to prevent HIV among MSM in China. RCT participants completed a questionnaire before and after VMMC to assess perceptions of and complications after the procedure. A subset of RCT participants were selected for in-depth interviews. Interviewees answered open-ended questions about barriers and facilitators to and experience of undergoing VMMC. Six-step thematic analysis incorporating inductive and deductive approaches was used to interpret interview responses. A total of 457 MSM completed the pre-VMMC survey, 115 circumcised MSM completed post-VMMC surveys, and 30 MSM completed an interview. Main barriers to VMMC uptake were concerns about pain, length of wound healing, cost, lack of knowledge about or misconceptions of VMMC, and stigma related to surgery. Facilitators to VMMC could be categorized as internal factors (foreskin) and external factors (motivation and follow-up care). Interestingly, the VMMC experiences of others could be transformed from a barrier into a facilitator to VMMC in some circumstances. After VMMC participants transitioned from a negative state of pain, remorse, difficulty sleeping, and discomfort to a positive state of symptom alleviation and personal hygiene improvement. Optimizing facilitators and addressing barriers may encourage VMMC among MSM. Joint efforts should be made by relevant stakeholders to improve the awareness and uptake of VMMC among MSM.

Factors Influencing the Uptake of Voluntary Medical Male Circumcision Among Boda-Boda Riders Aged 18–49 Years in Hoima, Western Uganda

Introduction

Methods

Results

Conclusion

An economic evaluation of an intervention to increase demand for medical male circumcision among men aged 25-49 years in South Africa

BACKGROUND

Studies estimate that circumcising men between the ages of 20-30 years who have exhibited previous risky sexual behaviour could reduce overall HIV prevalence. Demand creation strategies for medical male circumcision (MMC) targeting men in this age group may significantly impact these prevalence rates.

OBJECTIVES

The objective of this study is to evaluate the cost-effectiveness and cost-benefit of an implementation science, pre-post study designed to increase the uptake of male circumcision for ages 25-49 at a fixed MMC clinic located in Gauteng Province, South Africa.

METHODS

A health care provider perspective was utilised to collect all costs. Costs were compared between the standard care scenario of routine outreach strategies and a full intervention strategy. Cost-effectiveness was measured as cost per mature man enrolled and cost per mature man circumcised. A cost-benefit analysis was employed by using the Bernoulli model to estimate the cases of HIV averted due to medical male circumcision (MMC), and subsequently translated to averted medical costs.

RESULTS

In the 2015 intervention, the cost of the intervention was $9445 for 722 men. The total HIV treatment costs averted due to the intervention were $542,491 from a public care model and $378,073 from a private care model. The benefit-cost ratio was 57.44 for the public care model and 40.03 for the private care model. The net savings of the intervention were $533,046 or $368,628 - depending on treatment in a public or private setting.

CONCLUSIONS

The intervention was cost-effective compared to similar MMC demand interventions and led to statistically significant cost savings per individual enrolled.

High risk sexual behaviours associated with traditional beliefs about gender roles among men interested in medical male circumcision in South Africa

BACKGROUND

Beliefs about gender roles and high-risk sexual behaviours underlie the human immunodeficiency virus (HIV) epidemic in South Africa. Yet, there is limited information on the relationships between beliefs about gender roles and risky sexual behaviours. Few studies have explored the association between beliefs about gender roles, high risk sexual behaviour, and health-seeking behaviour among men.

METHODS

We investigated associations between gender beliefs (dichotomised as traditional or progressive) and high-risk sexual behaviour among South African men presenting for medical male circumcision (Apr 2014 to Nov 2015).

RESULTS

Of 2792 enrolled men, 47.4% reported traditional gender beliefs. Participant ages ranged between 18-46 years (median age 26 years; interquartile range, 21-31 years). Most participants had at least one sex partner over the last 12 months (68.2%). Younger men (18-24 years old vs. 25-46 years old) (odds ratio [OR], 1.5 [95% confidence interval (CI) 1.0-2.0]), those with multiple partners ([OR], 1.5 (CI) 1.3-1.8]) and participants unsure of their last partner's HIV status (OR, 1.4 [95% CI 1.1-1.7]) were more likely to have traditional beliefs on gender roles.

CONCLUSION

Young men with traditional beliefs on gender roles may be more likely to engage in high-risk sexual behaviour and could be good candidates for HIV prevention programmes. N = 206 (max 350) Trial registration Name of registry: Clinicaltrials.gov; Trial registration number: NCT02352961; Date of registration: 30 January 2015 "Retrospectively registered"; URL of trial registry record: https://www.clinicaltrials.gov/.

'PrEP should be for men only': Young heterosexual men's views on PrEP in rural South Africa

BACKGROUND

Gaps persist in HIV testing, treatment, and prevention services for men, leading to higher attributable mortality compared to women. We sought to characterise HIV prevention knowledge, risk behaviours, and interest in pre-exposure prophylaxis (PrEP) among young men in rural South Africa.

METHODS

We conducted interviews with HIV-negative heterosexual men which were thematically analysed to identify key themes.

RESULTS

Among 31 participants, median age was 26 (IQR23-31), 77% were unemployed, 52% reported previous STI, 84% reported casual sexual partners. Men acknowledged inconsistent condom use with multiple partners, reporting high-risk sexual behaviour despite recognised risk. Mistrust between partners was common. Respondents reported willingness to take PrEP to protect themselves and their partner, though anticipated stigma and structural barriers. Men worried that if their female partner had PrEP, she would become sexually active with others.

CONCLUSIONS

In rural South Africa, young heterosexual men acknowledged high HIV-risk behaviour, expressed concern about acquiring HIV, and recognised the value of PrEP. Men were often not supportive of their female partners taking PrEP. Implementing HIV prevention services needs to incorporate young men's perspectives and may require gender-specific interventions, including addressing stigma, differentiated service delivery models such as community-based services or adapting facility services to target men.

Predicting the long-term impact of voluntary medical male circumcision on HIV incidence among men who have sex with men in Beijing, China

Using a deterministic compartmental modeling procedure to fit prevalence from 2005-2015, we projected new HIV cases during 2016-2026 under different coverage rates ranging from 0.0001 (at baseline) to 0.15 (an optimistic assumption) with simulations on varying transmission rates, model calibration to match historical data, and sensitivity analyses for different assumptions. Compared with the baseline (λ = 0.0001), we found the new HIV cases would reduce with the increase of coverage rates of the voluntary medical male circumcision (VMMC) among men who have sex wtih men (MSM). The higher the coverage rate, the lower the new HIV incidence would be. As one of the first studies to model the potential impact of VMMC among MSM in China, our model suggested a modest to the significant public health impact of VMMC. Even at just 15% VMMC annual uptake rate, the reduction in new infections is substantial. Therefore, there is a strong need to determine the efficacy of VMMC among MSM, to improve the evidence base for its potential use among MSM in low circumcision settings. Only then can policymakers decide whether to incorporate VMMC into a package of HIV prevention interventions targeting MSM.

Voluntary medical male circumcision and HIV infection among men who have sex with men: Implications from a systematic review

Background:

With the rapidly-increased HIV epidemic among men who have sex with men worldwide, the effectiveness of voluntary medical male circumcision as the tool of HIV prevention still remains undetermined.

Purpose:

In the current study, we conducted a systematic review and meta-analysis to assess the association between voluntary medical male circumcision and HIV risk among men who have sex with men.

Methods and Conclusion:

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, we conducted a comprehensive literature search through multiple databases. A total of 37 articles/abstracts were included in the analysis. We employed random-effects models and subgroup analyses based upon key study characteristics derived from empirical studies. A total of 117,293 men who have sex with men were included in the meta-analysis, and no randomized control trials have been identified. The odds of being HIV positive were 7% lower among men who have sex with men who were circumcised than among men who have sex with men who were uncircumcised (adjusted odds ratio, 0.93; 95% confidence interval, 0.88–0.99). The evidence for the potential protective effect of voluntary medical male circumcision was stronger among men who have sex with men in Asia and Africa (adjusted odds ratio, 0.62; 95% confidence interval, 0.53–0.73). Our meta-analyses may suggest a protective effect of voluntary medical male circumcision against HIV infection among men who have sex with men, especially in settings like Asia/Africa.

Association of Male Circumcision with Women's Knowledge of its Biomedical Effects and With Their Sexual Satisfaction and Function: A Systematic Review

Male circumcision (MC) is a key HIV prevention intervention for men in countries with high HIV prevalence. Women's understanding of MC is important but poorly understood. We conducted a systematic review including women's knowledge of MC's biomedical impacts and its association with female sexual satisfaction and function through October 2017. Thirty-eight articles were identified: thirty-two with knowledge outcomes, seven with sexual satisfaction, and four with sexual function (N = 38). Respondent proportions aware MC protects men from HIV were 9.84-91.8% (median 60.0%). Proportions aware MC protects men from STIs were 14.3-100% (72.6%). Proportions aware MC partially protects men from HIV were 37.5-82% (50.7%). Proportions aware MC is not proven to protect women from infection by an HIV-positive partner were 90.0-96.8% (93.0%). No increases over time were noted. Women's MC knowledge is variable. Education could help women support MC and make better-informed sexual decisions.

Modeling economic and epidemiological impact of voluntary medical male circumcision among men who have sex with men in Beijing, China

Voluntary medical male circumcision (VMMC) among men who have sex with men (MSM) may protect against HIV acquisition. We conducted a series of analyses to assess if expanded VMMC might reduce HIV incidence among MSM effectively and economically. We used a deterministic compartmental model to project new HIV cases (2016-2026) under annual VMMC coverage rates (λ) ranging from 0.0001 to 0.15. The 'number needed to avert' (NNA) is defined as the cumulative number of VMMCs conducted up to that year divided by the cumulative number of HIV cases averted in that specific year. Compared with the baseline circumcision coverage rate, we projected that new HIV cases would be reduced with increasing coverage. By 2026 (last year simulated), the model generated the lowest ratio (11.10) when the annual circumcision rate was the most optimistic (λ = 0.15). The breakeven point was observed at the year of 2019 with the annual VMMC coverage rate of 0.001. The total cost saved by averting HIV cases would range from 2.5 to 811 million US dollars by the end of 2026 with different hypothetical coverage rates. Our model suggests that acceleration in VMMC implementation among MSM could help stem the HIV/AIDS epidemic.

"To speak or not to speak": A qualitative analysis on the attitude and willingness of women to start conversations about voluntary medical male circumcision with their partners in a peri-urban area, South Africa

INTRODUCTION

Voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men and has long-term indirect protection for women, yet VMMC uptake in South Africa remains low (49.8%) in men (25-49 years). We explored the attitude and willingness of women to start conversations on VMMC with their sexual partners in a South African peri-urban setting to increase VMMC uptake.

METHODS

Thirty women with median age of 30 years (inter-quartile range 26-33 years) were interviewed in a language of their choice. Key questions included: types of approach to use, gender roles, benefits and barriers to introducing the topic of VMMC, and perceptions of VMMC. Interviews were digitally-recorded, transcribed, and translated. Through a standard iterative process, a codebook was developed (QSR NVIVO 10 software) and inductive thematic analysis applied.

RESULTS

Most women were willing talk to their sexual partners about circumcision, but indicated that the decision to circumcise remained that of their sexual partner. Women felt that they should encourage their partners, show more interest in circumcision, be patient, speak in a caring and respectful tone, choose a correct time when their partner was relaxed and talk in a private space about VMMC. Using magazine/newspaper articles, pamphlets or advertisements were identified as tools that could aid their discussion. Substantial barriers to initiating conversations on VMMC included accusations by partner on infidelity, fear of gender-based violence, cultural restrictions and hesitation to speak to a mature partner about circumcision.

CONCLUSIONS

Women need to ensure that before talking to their partner about circumcision, the environment and approach that they use are conducive. Female social network forums could be used to educate women on conversation techniques, skills to use when talking to their partners and how to address communication challenges about circumcision. Involvement of women in VMMC awareness campaigns could encourage circumcision uptake among men.