Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations: web annex 2.3 part 2. synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country

WEB ANNEX 2.3 PART 2 SYNTHESIS OF LITERATURE ON VOLUNTARY MEDICAL MALE CIRCUMCISION: FACILITATORS AND BARRIERS, BY COUNTRY 2.3 PART 2 PREVENTING HIV THROUGH SAFE VOLUNTARY MEDICAL MALE CIRCUMCISION FOR ADOLESCENT BOYS AND MEN IN GENERALIZED HIV EPIDEMICS Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations. Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country ISBN 978-92-4-000930-1 (electronic version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC- SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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In: Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. This publication forms part of the WHO guideline entitled Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations. It is being made publicly available for transparency purposes and information, in accordance with the WHO handbook for guideline development, 2nd edition (2014). 3Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country WEB ANNEX 2.3 PART 2 SYNTHESIS OF LITERATURE ON VOLUNTARY MEDICAL MALE CIRCUMCISION: FACILITATORS AND BARRIERS, BY COUNTRY Drawn from the 2018 Systematic Review Solutions literature review (see Annex 2.3, Part 1) Organized according to the dimensions of effective service coverage by T. Mwaturura To inform WHO guidelines development, in 2018 a review was undertaken of literature on enhancing uptake of VMMC among adolescent boys and men. The following table organizes reported barriers and facilitators to VMMC uptake extracted from studies, identified in this review,1 in 16 countries. The study location, VMMC knowledge among participants and other comments are included. The facilitators of and barriers to VMMC are organized by the dimensions of the prevention cascade: 1. awareness, knowledge and intent 2. availability 3. accessibility 4. acceptability and quality. 1 Systematic Review Solutions. WHO guidance on VMMC for HIV prevention amongst adolescent boys and men: literature reviews for PICOs 1, 2 & 3, full report, unpublished, 2018; available from WHO/UCN/Global HIV, Hepatitis and STIs Programmes (hiv-aids@who.int) and as Web Annex 2.1, Part 1. 4 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Botswana Jayeoba 2012 2009 Awareness–knowledge– intent • protection from HIV Awareness–knowledge– intent Not indicated Molepolole and Mochudi 80% of adolescent boys correctly described male circumcision Availability Not indicated Availability Not indicated Accessibility • cost (free of charges) Accessibility Not indicated Acceptability and quality • protection from other illnesses Acceptability and quality • pain • complications during/after procedure Wirth 2016 2013 Awareness–knowledge– intent • protection against HIV and other infections Awareness–knowledge– intent Not indicated Two communities with high uptake (Gaborone, Palapye) and two communities with low uptake (Molepolole, Maun) Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • increased cleanliness • increased sexual pleasure and perceived attractiveness • fashionable desire to fit in • influence of female partners Acceptability and quality Not indicated Tapera 2017 2016 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent • lack of knowledge of how male circumcision reduces HIV infection University of Botswana Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • health/hygiene benefits • sexual satisfaction • traditional/cultural values • how information about MC was received; media and friends were common sources Acceptability and quality Not indicated China Jiang 2013 2009 Awareness–knowledge– intent • protection against HIV and STIs Awareness–knowledge– intent Not indicated Western provinces in China: Guangxi Chongqing Xinjiang In group willing to be circumcised, 80.4% had heard about MC. In group not willing to be circumcised group, 64% had heard about MC. Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • concern about cost of surgery Acceptability and quality • improve partners’ hygiene • redundant foreskin • enhance sexual pleasure • prevention of penile cancer • better penile appearance • traditional or religious reason Acceptability and quality • not necessary or not effective • concern about potential danger associated with surgery • concern about reduced sexual ability Table A2.3(2).1. Facilitators and barriers to VMMC for adolescent and adult men from identified studies in systematic review, 2018 5Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Huang 2013 2009– 2010 Awareness–knowledge– intent • protection against HIV and STIs Awareness–knowledge– intent • no idea of benefits of VMMC Western provinces in China: Guangxi Chongqing Xinjiang In group willing to be circumcised, 88.5% had heard about MC. In group not willing to be circumcised, 83.1% had heard about MC. Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • concern about cost of surgery Acceptability and quality • having phimosis • prevention of penile cancer • improve partners’ hygiene • enhance sexual pleasure • better penile appearance • traditional or religious reason Acceptability and quality • not necessary or not effective • concern about potential danger associated with surgery • concern about reducing sexual ability Jiang 2015 2009– 2010 Awareness–knowledge– intent • HIV/STI prevention Awareness–knowledge– intent Not indicated Guangxi Medical University; Chongqing Medical University; Xinjiang Medical University 81.5% had heard about MC. Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • concern about cost of surgery Acceptability and quality • improve partners’ hygiene • remove redundant foreskin • enhance sexual pleasure • prevention of penile cancer • better penile appearance • traditional or religious reason Acceptability and quality • not necessary or not effective • concern about potential danger associated with surgery • concern about reducing sexual ability Yang 2012 2009– 2010 Awareness–knowledge– intent • HIV/STI prevention Awareness–knowledge– intent Not indicated Western provinces in China: Guangxi Chongqing Xinjiang Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improve partners’ hygiene • remove redundant foreskin • prevention of penile cancer • traditional or religious reason Acceptability and quality • not necessary or not effective • concern about potential danger associated with surgery • concern about reducing sexual ability Wang 2016 2011– 2012 Awareness–knowledge– intent • reduced risk of HIV/STIs Awareness–knowledge– intent Not indicated Shenzhen Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • expensive Acceptability and quality • reduced female sex partner’s risk of gynaecological diseases Acceptability and quality • pain • severe surgical complications • erectile dysfunction • perceived as strange by peers or by female sex partners • embarrassment Sullivan 2009 Not indicated Awareness–knowledge– intent • protection from HIV infection Awareness–knowledge– intent Not indicated Xinjiang Uyghur Autonomous Region; Yunnan Province Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality Not indicated Acceptability and quality Not indicated 6 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Dominican Republic Brito 2010 2007– 2008 Awareness–knowledge– intent Nearly all health care providers knew of health benefits (hygiene, reduced STIs); two thirds knew about reduced risk of HIV Awareness–knowledge– intent • lack of information and knowledge about MC and benefits in the community Altagracia Province Not indicated Study was done to evaluate the feasibility of introducing MC services in the Dominican Republic and to assess qualitatively men’s, women’s and health care providers’ acceptability, knowledge and attitudes toward MC. Availability Not indicated Availability (potential) • lack of trained personnel to perform the procedures • lack of surgical equipment • lack of continuous electricity or running water in some of the clinics • lack of physical space for surgery Accessibility Not indicated Accessibility • cost of the procedure Acceptability and quality • cultural tradition • increase in sexual pleasure and performance including fewer problems in retracting foreskin and easier to use condoms • improves hygiene Acceptability and quality • uncircumcised penis more natural • equated removal of the foreskin to losing a part of the body • most men believed that women prefer their partners uncircumcised • fewer than half considered the foreskin a barrier against lacerations of the glans and, hence, protective against HIV Brito 2009 2008 Awareness–knowledge– intent • reduces STI/HIV Awareness–knowledge– intent • lack of knowledge of MC benefits 19 communities in Altagracia Province Not indicated Acceptability improved from 29% to 67% after an information session explaining the benefits of the procedure. Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improves hygiene • reduces STIs and penile cancer Acceptability and quality • decreases sexual pleasure eSwatini Gurman 2015 2010 Awareness–knowledge– intent • knowledge about circumcision Awareness–knowledge– intent Not indicated Not indicated 95.94% of respondents had heard of VMMC. Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • importance of ploughing season to daily schedule • getting circumcised will raise man’s status in his community • man will enjoy sex more if circumcised • erections last longer for circumcised men • women prefer sex with a circumcised man • been tested for HIV in last 12 months Acceptability and quality • sex is more painful for a circumcised man • Christian man should not get circumcised • circumcision makes penetration more painful • circumcision will leave a wound that will never heal • getting circumcised takes too much time away from work • time required to abstain after circumcision is too long 7Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Adams 2015 2013 Awareness–knowledge– intent • difficult to get HIV and STIs (adolescents’ perception) Awareness–knowledge– intent Not indicated Kwaluseni community, central eSwatini Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • perceived enhancement of sexual performance Acceptability and quality • fear of pain was only a minor barrier • threat to masculinity: circumcision was perceived as a threat to a man’s ability to function sexually, thereby indirectly threatening his ability to maintain his family and, consequently, his manhood • concerns about loss of sexual pleasure • fear of botched surgeries • the futility of VMMC: some men could not see the value of circumcision because VMMC is only partially protective and circumcised men still must use condoms for HIV protection. • fear of the unknown and irreversibility of circumcision • suspicion about the origins of HIV and Western health interventions India Sahay 2014 2009– 2011 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Meerut (Uttar Pradesh state, Northern India); Kolkata (West Bengal state, Eastern India); Belgaum (Karnataka state, Southern India); Mumbai (Maharashtra state, Western India) Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • cost of operation Acceptability and quality • religious faith • beliefs regarding hygienic benefits Acceptability and quality • pain associated with the procedure Jamaica Walcott 2013 2011 Awareness–knowledge– intent • protection from STIs • knowledge of VMMC Awareness–knowledge– intent • limited knowledge about MC Western Jamaica 72.2% of men reported having heard of MC Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • penile hygiene • enhancement of sexual pleasure Acceptability and quality • “should not change the way God made the penis” • “surgery may damage the penis” 8 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Kenya Westercamp 2012 2008– 2009 Awareness–knowledge– intent • HIV prevention Awareness–knowledge– intent Not indicated Kisimu Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • cost • lack of transportation Acceptability and quality • condom use less necessary • increase in sexual pleasure Acceptability and quality • belief that VMMC is not part of their culture • length of recovery • pain • perceived risks of the procedure • opposition by friends and family Evens 2014 2012 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Urban Kisumu East and rural Rachuonyo in Nyaza Province Not indicated Interventions to increase uptake of circumcision suggested by participants: • improving messaging regarding expected pain and pain management • improving mechanisms for delivering the messages Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • access to VMMC services Acceptability and quality Not indicated Acceptability and quality Primary: • financial issues, including missing work, losing income during the procedure and healing period • fear of pain during and after the procedure Secondary: • the abstinence period • female partners’ opinions of circumcision • sexual function after VMMC • potential adverse events • cultural concerns • concerns about adverse events Macintyre 2014 2012 Awareness–knowledge– intent • protection against disease including HIV Awareness–knowledge– intent Not indicated Urban, peri-urban and rural sites in Turkana Not indicated Availability Not indicated Availability • absence of service delivery • lack of drugs or equipment Accessibility Not indicated Accessibility • excessive distance to service delivery sites Acceptability and quality • stigma against not being circumcised (most likely to prevail in urban areas) • cleanliness Acceptability and quality • fears related to service delivery: low quality of care and disrespectful or even unqualified clinicians • not aligned with Turkana culture • old age (less sexually active) • no sexual activity (“no need to undergo circumcision because no longer having sex”) • social influences (family and community relationships) • stigma from being circumcised (most likely to prevail in rural areas) 9Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Herman- Roloff 2011 Not indicated Awareness–knowledge– intent • HIV/STI protection Awareness–knowledge– intent Not indicated Urban Kisumu East, rural Nyando and rural Kisumu West in Nyanza Province Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • long distance to the health facility Acceptability and quality • improved hygiene • sexual performance and satisfaction • social pressure Acceptability and quality • too much time away from work • cultural and religious values • the possibility of adverse effects • the post-surgical abstinence period • a desire to maintain the status quo: “The protection against HIV and STIs is not 100%, and if a man is already HIV-positive, has good hygiene, or is already practicing other HIV prevention methods, he will not benefit from the procedure”. • increased promiscuity • decrease in male and female sexual satisfaction Lanham 2012 Not indicated Awareness–knowledge– intent • reduced HIV risk Awareness–knowledge– intent Not indicated Urban district of Kisumu East and rural District of Siaya in Nyanza Province Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improved hygiene • fewer penile problems Acceptability and quality Not indicated Lesotho Skolnik 2014 2013 Awareness–knowledge– intent • HIV and STI protection (self and partner) Awareness–knowledge– intent Not indicated Urban (Carewell and Apex clinics); peri- urban (Ntsekhe Hospital) and rural (Mokhotlong Hospital) Not indicated Availability Not indicated Availability • not knowing where to go Accessibility Not indicated Accessibility • long wait time • lack of transport • cost Acceptability and quality • penile hygiene • improved sexual pleasure (self and partner) • gaining social prestige Acceptability and quality • female staff • poor service, staff attitude • lack of full coverage against HIV • mixing young and old clients • HIV testing • fear of pain and injection • long healing time or abstinence • safety concerns • preference for traditional circumcision 10 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Malawi Rennie 2015 2008 Awareness–knowledge– intent • effectiveness of male circumcision for HIV prevention Awareness–knowledge– intent Not indicated Blantyre District Not indicated Availability Not indicated Availability Not indicated Accessibility • less time and expense would be involved in clinic- based circumcisions than in those done traditionally in the village, which often involve elaborate, expensive ceremonies and community celebrations Accessibility Not indicated Acceptability and quality • clinic-based circumcision has better access to proper anaesthetics and procedures than traditional male circumcision and will allow the wound to heal faster • religion Acceptability and quality • fear/expect that the procedure will involve a great deal of pain • the wound will be a hindrance to sexual activity • do not believe that male circumcision can reduce a man’s risk of contracting HIV • VMMC may result in greater infection because it would encourage reduced condom use and increased sexual risk- taking • would promote promiscuity, and men choosing to be circumcised would be stigmatized as immoral • fear that VMMC would promote premarital sex and sexual immorality • too invasive and the health benefits not sufficient to warrant adoption Shacham 2014 2008– 2009 Awareness–knowledge– intent • reduced risk of STIs/HIV Awareness–knowledge– intent Not indicated 70 villages in Zomba District Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • cost Acceptability and quality • enhanced sexual pleasure for female partners • religion/culture • improve men’s health/ cleanliness Acceptability and quality • pain • increased risk of HIV • encouragement of premarital sex • religion/culture Papua New Guinea Kelly 2013 2009 Awareness–knowledge– intent • prevention of HIV and STIs Awareness–knowledge– intent Not indicated National Capital District; Eastern Highlands Province; East Sepik Province; West New Britain Province Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • cultural acceptability • penile hygiene and health Acceptability and quality • sexual risk compensation (false sense of security) • risk of men becoming promiscuous • religion: goes against Christian faith • cultural: new practice that is culturally inappropriate 11Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Tyan 2013 2009– 2011 Awareness–knowledge– intent • prevention of STI (HIV) and cervical cancer • reduction of STI/HIV cases • awareness of MC in the community Awareness–knowledge– intent • lack of information National Capital District; Eastern Highlands Province; East Sepik Province; West New Britain Province Not indicated Availability Not indicated Availability • scarce human resources Accessibility • referrals made to access proper medical services Accessibility • costs: young men would not have cash to access services due to poor employment options Acceptability and quality • entry point to voluntary counselling and testing Acceptability and quality Not indicated MacLaren 2013 2011– 2012 Awareness–knowledge– intent • reduced risk of HIV Awareness–knowledge– intent Not indicated National Capital District; Madang Province; Oro Province; Enga Province Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • proves manhood (sociocultural practice) • have more sexual partners • sexual pleasure • makes a man’s body grow strong and penis grow bigger (sociocultural beliefs) • overall health benefit Acceptability and quality • not a part of their cultural practice/tradition • decreases sexual pleasure South Africa Ikwegbue 2015 2012 Awareness–knowledge– intent • protection against HIV Awareness–knowledge– intent • low level of knowledge about the potential benefits of VMMC Northern KwaZulu-Natal 64% reported knowing the meaning of VMMC Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality Not indicated Acceptability and quality • sexual problems • increase in promiscuity George 2014 2012– 2013 Awareness–knowledge– intent • reduced risk of HIV acquisition Awareness–knowledge– intent Not indicated Vulindlela sub-district of KwaZulu-Natal Not indicated Availability • availability of mobile VMMC camps • “Boys felt a positive and safe environment was created.” Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improved hygiene • increase in sexual pleasure • availability of better pain management procedures • cultural necessity • preferences of sexual partners • influence of peers and family Acceptability and quality Individual barriers: • pain associated with the procedure and adverse events • low perception of HIV risk • fears about the procedure Social barriers: • fear of HIV testing (subsequent results and stigma) • the need to abstain from sex during the six-week healing period • family disapproval of the procedure • experience of peers 12 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments George 2017 2012– 2013 Awareness–knowledge– intent • reduced risk of STIs Awareness–knowledge– intent Not indicated Vulindlela, rural sub-district of KwaZulu-Natal Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improved hygiene Acceptability and quality • self-efficacy to use condoms Hoffman 2015 2013 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Saldanha Bay, Western Cape Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improved hygiene • health benefits • cultural or religious reasons Acceptability and quality • fear of infection, pain and loss of performance • religion • time off work • reaction of peers Marshall 2016 2015 Awareness–knowledge– intent • reduced risk of HIV Awareness–knowledge– intent Not indicated Orange Farm Township, Gauteng Province Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • tradition/religion • hygiene • peer pressure Acceptability and quality • culture • fear of the procedure, pain or injury • time constraints United Republic of Tanzania Francis 2012 2010 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent • lack of awareness Dar es Salaam Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • cost Acceptability and quality Not indicated Acceptability and quality • anticipation of pain during circumcision • fear of losing part of the body Plotkin 2013 2011 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Iringa Municipal Council, Mufindi and Njombe District Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • increased virility and a more attractive penis • VMMC within marriage as a favourable option for reducing risk of HIV acquisition • cleanliness • higher social status Acceptability and quality • cultural reasons/pressure from parents • fear of penile injury from erections during the recovery period • concern about loss of income in the recovery period • best performed before puberty • perceived as shameful 13Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Osaki 2015 2014 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Tabora and Njombe regions Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • denial of sex: woman may refuse to have sexual intercourse with uncircumcised man • avoid embarrassment with female sexual partners • mothers as decision-makers Acceptability and quality • multiple concurrent partnerships (infidelity) Thailand Tieu 2010 2008 Awareness–knowledge– intent • knowledge of VMMC (informational pamphlet containing description of the procedure, costs, risks and benefits, recent circumcision trial results) Awareness–knowledge– intent • lack of knowledge about male circumcision and its role in HIV prevention Not indicated Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality Not indicated Acceptability and quality • fear of pain and other risks of surgery • having no time for surgery because of work constraints • beliefs that they were not at risk for contracting HIV and other STIs • time required away from work for the surgery and postoperative healing • already had good genital hygiene by cleaning penis regularly (referring to association of circumcision with good genital hygiene) Uganda Ssekubugu 2013 2004– 2006 Awareness–knowledge– intent • prevention and healing of STIs Awareness–knowledge– intent • lack of awareness Rakai, southwestern Uganda Not indicated Factors considered as both barriers and facilitators of VMMC: • HIV testing and counselling • opportunity to access HTS and HIV care and treatment, but some fear of knowing status Partner’s influence: • women’s perception that partners would be more sexually active with other women or that the man’s partner would be promiscuous during the wound healing and abstinence period • female partner’s preference for circumcised penis Sexual potency: • VMMC perceived to override the perceived effect of syphilis in Buganda by restoring or improving sexual potency • VMMC and/or the anaesthesia for VMMC is associated with loss of sexual potency Availability Not indicated Availability Not indicated Accessibility • access to HIV and other ancillary care Accessibility Not indicated Acceptability and quality • penile hygiene • peer influence Acceptability and quality • pain • medical complications • infertility • lack of empirical efficacy, based on knowledge of people in the village who had died or considered to be HIV-infected, yet presumed to be circumcised • waiting time before resumption of sex and work • religion 14 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Albert 2011 2008 Awareness–knowledge– intent • reduction in STIs and HIV/ AIDS transmission Awareness–knowledge– intent Not indicated Kampala district (capital); Gulu district (North Central) Kumi district (Northeast) Rukungiri (Southwest) Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • increased hygiene • increase in men’s sex drive and/or women’s sexual pleasure Acceptability and quality • concerns about the medical procedure • religious or cultural identity • influence on post-procedure risk behaviours – that is, promiscuity among men due to the safety that VMMC provides • financial assistance during recovery period Wilcken 2010 2008 Awareness–knowledge– intent • prevention of HIV/STDs Awareness–knowledge– intent Not indicated Rural areas of Mpigi, Kayunga and Kaliro districts, Central and Eastern Uganda Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • accessibility of services • costs Acceptability and quality • religious reasons • improved hygiene • cultural reasons • enhanced sexual pleasure • social acceptability Acceptability and quality • cultural reasons • fear of complications • religious reasons • opposition of the partner or parents Kong 2014 2010– 2011 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Rakai District Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • receiving voluntary HIV counselling and testing Acceptability and quality • low self-perceived HIV infection risk: did not think they were at risk of HIV infection • fear of pain or injury • against their traditional or religious beliefs • circumcised men may still get HIV • their partner objected to VMMC • concern of reduced libido or sexual satisfaction • men were too busy for surgery • already HIV infected Kibira 2015 2011 Awareness–knowledge– intent • protective against HIV Awareness–knowledge– intent • not knowing VMMC is protective against HIV Central, Kampala, Eastern, Northern and Western regions Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • higher perceived risk of HIV Acceptability and quality Not indicated 15Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Mati 2016 2011 Awareness–knowledge– intent • knowledge of reduced HIV risk Awareness–knowledge– intent Not indicated Not indicated Not indicated Study among married women. “Younger, wealthier, more educated and Muslim women were more likely to support MC.” Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • religion (Muslim > Catholics) • ethnicity (Baganda) • ability to negotiate condom use • ability to refuse sex Acceptability and quality • ethnicity and religious group (Itesa) Lilleston 2017 2012 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Rakai district Not indicated “Quality of MMC services was influenced by the setting in which the procedure was performed, the safety of procedure, and the gender of the provider.” Availability Not indicated Availability • distance from the clinic Accessibility Not indicated Accessibility • direct financial costs (that is, private clinicians’ charge for the procedure and transportation costs to get to the clinic) • limited VMMC appointment slots Acceptability and quality • sharing experiences with friends • improves sexual performance • cleanliness of sex Acceptability and quality • pain • negative effect on fertility • healing period • religion (among Christians) • fears of infection after surgery related to poorly executed circumcisions • lack of access to post- procedure treatment and follow-up • provider’s (female) gender • connotes infidelity • parental objections due to the belief that VMMC would encourage sexual promiscuity • indirect opportunity costs (for example, time away from work) Nevin 2015 2013 Awareness–knowledge– intent • increased protection from HIV and other STIs Awareness–knowledge– intent Not indicated Four fishing communities in Kalanga district: Bumanji, Kalanga Town Council, Kasenyi and Mweena Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • cleaner and more hygienic: – VMMC improves general hygiene of the penis, including the reduction of foul odours – VMMC reduces the transmission of STIs via improved cleanliness due to the removal of the foreskin • improved sexual performance and desirability Acceptability and quality • increases a recipient’s libido: “no longer satisfied by one partner” • loss of income due to missed employment and subsequent failure to fulfil familial obligations • fisher folk require longer recovery periods after circumcision due to strenuous activity and submersion in potentially unsanitary water • both men and women reported concerns about spousal infidelity, post- circumcision abstinence and early resumption of sexual activity 16 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Gilbert 2018 2013– 2015 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Rural southwest Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • receiving a negative HIV test result • hearing circumcision success stories from peers Acceptability and quality • fear of physical pain, compromise of sexual health • long healing time • economic impact Kibira 2017 2015 Awareness–knowledge– intent • personal need to reduce HIV/ STI risk • protect sexual partners from risk of cervical cancer • health education about surgical procedure and healing Awareness–knowledge– intent Not indicated Wakiso district, central Uganda [Study participants interviewed after receiving VMMC services] Inconsistency in delivering information about VMMC: “One man said the session was rushed and that he had no opportunity to ask questions. ‘They did not tell us anything.’” Availability Not indicated Availability • limited availability of counsellors or staff time to provide information about VMMC Accessibility Not indicated Accessibility Not indicated Acceptability and quality • influence of sexual partners in circumcision decision • personal hygiene • positive community perception of male circumcision • enhance sexual performance • mistrust in partners’ sexual behaviour Acceptability and quality • not convinced that circumcision reduces HIV infection risk Nakyanjo 2018 2015 Awareness–knowledge– intent • reduced risk of HIV and STIs Awareness–knowledge– intent Not indicated Rakai District Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improved penile hygiene • improved sexual desire and pleasure Acceptability and quality • behavioural: – riskier sexual behaviours – increased sexual desire, leading men to seek extra- marital relationships if they thought they had lower risk of HIV infection • wound healing period and sexual abstinence • time off work and loss of income • “blame game”: if an HIV-negative man gets circumcised but acquires HIV, results in domestic violence or separation 17Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Zambia Lukobo 2007 2003 Awareness–knowledge– intent • education on the advantages and disadvantages of VMMC Awareness–knowledge– intent Not indicated Lusaka District (capital city); Zambezi District (North West); Luanshya District (North Central); Monze (Southern Province) Not indicated Availability Not indicated Availability Not indicated Accessibility • offered at no or minimal costs Accessibility • cost Acceptability and quality • reduced risk of STI/HIV • good hygiene Acceptability and quality • cultural tradition does not include MC • pain associated with the procedure and the healing process • length of time for healing • before puberty is preferred age for circumcision because less painful, and child would heal quickly Jones 2013 2012 Awareness–knowledge– intent • HIV prevention Awareness–knowledge– intent • knowledge that condom use would still be required for HIV prevention Lusaka Not indicated “Public health initiatives should continue to clarify the limits of risk reduction associated with MMC, as well as risk associated with early resumption of sex in the immediate post-MMC period.” Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • increased endorsement by female partner • cultural acceptability Acceptability and quality Not indicated Price 2014 2012 Awareness–knowledge– intent • HIV/STI prevention Awareness–knowledge– intent Not indicated Lusaka Not indicated Participant’s comment: “When I asked who could help me, the first person told me, “I don’t know. Ask somebody else.” The next person I asked told me they offer it every day, but somebody else said they did it only on certain days.” “The supply side problems identified in this study are reflective of broader health system weaknesses, rather than VMMC specific issues.” “Male participant explained how fear resulted in having a 10-year period between the time he decided to become circumcised and the date he was interviewed. Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • service issues include difficulty accessing information from health professionals due to long queues, incomplete counselling and inconsistencies in information received Acceptability and quality • hygiene, being clean • prevents cervical cancer • female pleasure/male sexual performance • prevents cracks, bruises and abrasions • encouragement from friends • female partner’s support Acceptability and quality • wound care and healing • pain and injections • adverse events and outcomes • fear of the surgery Zulu 2015 2012– 2014 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Lusaka Qualitative study with clients after VMMC “Early resumption of sexual activities is an important contributor to unfavourable outcomes, particularly for those with high risk histories.” Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • improved penile hygiene • sexual satisfaction • women’s perceptions, attitudes and opinions Acceptability and quality • prolonged abstinence from sexual activity • post-surgical complications 18 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Cook 2015 Not indicated Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Lusaka Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • women’s attitudes and women’s increased acceptance Acceptability and quality Not indicated Zimbabwe Mavhu 2011 2009 Awareness–knowledge– intent • knowledge of VMMC and its health benefits Awareness–knowledge– intent Not indicated Rural (two unspecified provinces) Level of knowledge based on eight MC items: High – 12% Medium – 32% Low – 56% Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • men more willing to undergo MC and women more favourable towards MC when aware of its benefits Acceptability and quality • disbelief that VMMC protects against HIV • cultural issues • fear of pain and/or adverse effect Khumako- Sakutukwa 2013 Not indicated Awareness–knowledge– intent Not indicated Awareness–knowledge– intent • limited knowledge of both traditional and medical circumcision • reluctance to defer sexual contact during the healing period post-circumcision • older men (age not specified) highlighted the need for more education about the long-term benefits of medical circumcision and the need to abstain during healing period • older men prefer MC promotion addressed to younger men, who are perceived to be more sexually active and at higher HIV risk Mutoko rural district in Mashonaland East province of Zimbabwe; Vulindlela, rural district in KwaZulu-Natal province of South Africa Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • HIV protection: willingness to accept VMMC if the procedure would prevent them from getting HIV • health and sexual benefits Acceptability and quality • cultural and local barriers: VMMC regarded as an outsider’s practice indicating lower social status or status as a foreigner • health risks with procedure • stigma and shame: emasculated because they did not have a foreskin • reduction of penis size 19Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Hatzold 2014 2013 Among those who were willing to undergo VMMC: Awareness–knowledge– intent • prevention of HIV • self-efficacy • social support Among males who were not willing to be circumcised: Awareness–knowledge– intent • myths/incorrect information, including that MC can lead to infertility • partner has not asked (lack of partner’s support was a significant barrier among 4% of men ages 25–49) National population-based survey February 2013 in 60 rural and 40 urban areas Qualitative study conducted in June–Oct 2010 in Bulawayo, Harare, Mashonaland West, Masvingo and Matabeleland North 61% (both males and females) had heard of VMMC as an HIV prevention method Quote: “She [wife] asked ‘Why, when you are already married? They say it offers prevention from HIV. Where do you think the HIV will come from?’” Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility • worried about cost Acceptability and quality Major reasons: • hygienic purposes Minor reasons: • prevent cervical cancer in partner • to set a good example for their community or children • to please their female partners • followed my friends • my partner told me to Acceptability and quality Major reasons: • fear of HIV test • pain Minor reasons: • not perceived to be at risk of HIV due to monogamy • fear of complications • length of healing period Montano 2014 Not indicated Awareness–knowledge– intent Not indicated Awareness–knowledge– intent • lack of knowledge on how VMMC prevents HIV Urban: Harare and Bulawayo Rural: Mutoko and Matobo districts Not indicated Availability • in local (including rural) clinics Availability • shortage of equipment and materials Accessibility Not indicated Accessibility • VMMC is not free Acceptability and quality • will give you peace of mind • will enhance sexual pleasure/ enjoyment for you Acceptability and quality • cause women to shun you and say your penis is different • might not heal properly, cause disfigurement • culture is against VMMC • VMMC is new, not offered before in community • wife/girlfriend is against VMMC • people describe VMMC as painful Rupfutse 2014 April– September 2013 Awareness–knowledge– intent • village heads: prevention of HIV, STIs and cervical cancer in female partners Awareness–knowledge– intent • procrastination Mazowe District: Shona people (92%) and Nyanja (8%) Not indicated Availability Not indicated Availability Not indicated Accessibility • VMMC offered for free Accessibility • long queues or long waiting time at clinics or hospitals • shortage of medicines at health facilities Acceptability and quality • having a circumcised relative/ friend • encouragement by a friend or relative • discussing circumcision with female partner Acceptability and quality Primary/major reasons: • fear of pain • long abstinence period (30.3%) • rude nurses Secondary/minor reasons: • too old for VMMC • partner infidelity during abstinence • being HIV-positive • fear of reduced sexual performance • reports of death due to traditional MC • cultural barriers • perceived excessive pain, excessive swelling, disfigurement 20 Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Moyo 2015 July– August 2012 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent • lack of reliable and adequate information on VMMC • misconceptions and myths about the health effects: – injection to control pain perceived to cause male infertility – cultural belief in witchcraft results in scepticism about the safety and disposal of removed foreskin Rural Mhondoro- Ngezi in Mashonaland West Province Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality Not indicated Acceptability and quality • perceived challenge to masculinity • fear of HIV testing associated with VMMC • fear of possibility of irreversible accidents and mistakes during operation • in case of adverse event, lack of insurance to cover costs • post-circumcision stigma • recuperation period unwanted • operation by a female health worker • belief that VMMC is a strategy to control African men’s sexuality Chikutsa 2015a 2013 Awareness–knowledge– intent Not indicated Awareness–knowledge– intent • use of condoms after circumcision: some respondents questioned the efficacy of male circumcision, given that one must use condoms for HIV prevention even after getting circumcised High density suburbs of Harare: participants in a mixed-sex focus group discussion from a local shopping area Not indicated Improves sexual performance Note: There is no evidence of change in sexual performance with MC. Author’s remark: “It is not clear where belief on increased promiscuity emanates from, but it appears to be strong among men.” Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • cleanliness: widely understood as emphasized in the promotion of VMMC, where MC was defined as “getting men cleaned”, while others viewed MC as a removal of a body part that keeps dirt, making it difficult for men to remain clean; “reduces the breeding of bacteria” • protective effect against STIs and HIV • women satisfied with circumcised penis • belief that it improves sexual performance Acceptability and quality • perceived to cause loss of sexual desire • leads to marriage breakdown due to prolonged healing period before resumption of intercourse • fear of HIV test before circumcision • cultural belief: fears that the removed foreskin may be used in satanic rituals • stigma among peers • VMMC associated with disability and illness • may lead to ridicule in a society where the practice is still relatively new • circumcising men at hospitals gives impression that you are already ill and, therefore, need medical attention • perceived boost in men’s sexual appetite; women perceive increase risk of promiscuity 21Web Annex 2.3 Part 2. Synthesis of literature on voluntary medical male circumcision: facilitators and barriers, by country Author, publication date Year data collected Facilitators Barriers Location VMMC knowledge Comments Chikutsa 2015b Not indicated Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Harare 97% of men and 96.7% of women had heard about VMMCAvailability • knowledge of a place offering VMMC services Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • HIV/STI prevention • improves genital cleanliness Acceptability and quality • time off work • painful procedure Chiringa 2016 Not indicated Awareness–knowledge– intent Not indicated Awareness–knowledge– intent Not indicated Four sections in Bambazonke Not indicated Availability Not indicated Availability Not indicated Accessibility Not indicated Accessibility Not indicated Acceptability and quality • reduced risk of STIs and HIV infection • sexual pleasure • religious purposes (religious affiliation has influence on decision to undergo circumcision or not) • reverse stigma: men and boys undergo circumcision for fear of being stigmatized, especially if the majorities are circumcised Acceptability and quality • fear of pain • fear of the unknown • ancestors’ permission and being shunned by the community • sociocultural factors: being viewed as worthless and shameful • religious beliefs that it is a sin to change the way one was created • psychological factors: – infection and delayed healing, being ashamed and dehumanized, stigmatized and discriminated against – fear of having an erection during treatment period – fear regarding sexual performance, penis size – fear of losing partner due to perceived reduction of sexual pleasure – fear of HIV testing – fear of injections • economic factors: – will take time from work – complications may arise, leading to spending money on treatment HIV = human immunodeficiency virus; HTS = HIV testing services; MC = male circumcision; MMC = medical male circumcision; STIs = sexually transmitted infections; VMMC = voluntary medical male circumcision. For more information, contact: World Health Organization Global HIV, Hepatitis and STIs Programmes 20, Avenue Appia 1211 Geneva 27 Switzerland E-mail: hiv-aids@who.int https://www.who.int/hiv/pub/malecircumcision/en/