Search

Background: Telehealth is growing, especially in areas where access to health facilities is difficult. We previously used 2-way texting (2wT) via SMS to improve the quality of postoperative care after voluntary medical male circumcision in South Africa. In this study, we offered males aged 15 years and older WhatsApp or SMS as their message delivery and interaction platform to explore user preferences and behaviors., Objective: The objectives of this process evaluation embedded within a larger 2wT expansion trial were to (1) explore 2wT client preferences, including client satisfaction, with WhatsApp or SMS; (2) examine response rates (participation) by SMS and WhatsApp; and (3) gather feedback from the 2wT implementation team on the WhatsApp approach., Methods: Males aged 15 years and older undergoing voluntary medical male circumcision in program sites could choose their follow-up approach, selecting 2wT via SMS or WhatsApp or routine care (in-person postoperative visits). The 2wT system provided 1-way educational messages and an open 2-way communication channel between providers and clients. We analyzed quantitative data from the 2wT database on message delivery platforms (WhatsApp vs SMS), response rates, and user behaviors using chi-square tests, z tests, and t tests. The team conducted short phone calls with WhatsApp and SMS clients about their perceptions of this 2wT platform using a short, structured interview guide. We consider informal reflections from the technical team members on the use of WhatsApp. We applied an implementation science lens using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to focus results on practice and policy improvement., Results: Over a 2-month period-from August to October, 2023-337 males enrolled in 2wT and were offered WhatsApp or SMS and were included in the analysis. For 2wT reach, 177 (53%) participants chose WhatsApp as their platform (P=.38). Mean client age was 30 years, and 253 (75%) participants chose English for automated messages. From quality assurance calls, almost all respondents (87/89, 98%) were happy with the way they were followed up. For effectiveness, on average for the days on which responses were requested, 58 (33%) WhatsApp clients and 44 (28%) SMS clients responded (P=.50). All 2wT team members believed WhatsApp limited the automated message content, language choices, and inclusivity as compared with the SMS-based 2wT approach., Conclusions: When presented with a choice of 2wT communication platform, clients appear evenly split between SMS and WhatsApp. However, WhatsApp requires a smartphone and data plan, potentially reducing reach at scale. Clients using both platforms responded to 2wT interactive prompts, demonstrating similar effectiveness in engaging clients in follow-up. For telehealth interventions, digital health designers should maintain an SMS-based platform and carefully consider adding WhatsApp as an option for clients, using an implementation science approach to present evidence that guides the best implementation approach for their setting., (©Isabella Fabens, Calsile Makhele, Nelson Kibiribiri Igaba, Sizwe Hlongwane, Motshana Phohole, Evelyn Waweru, Femi Oni, Madalitso Khwepeya, Maria Sardini, Khumbulani Moyo, Hannock Tweya, Mourice Barasa Wafula, Jacqueline Pienaar, Felex Ndebele, Geoffrey Setswe, Tracy Qi Dong, Caryl Feldacker. Originally published in JMIR Formative Research (https://formative.jmir.org), 16.10.2024.)

Public health initiatives in Zambia encourage the uptake of early infant male circumcision (EIMC) as an HIV prevention strategy. This study assessed EIMC parental decision-making during perinatal care in Lusaka, Zambia, focusing on the influence of sociodemographic factors, family, and friends. A longitudinal pilot perinatal intervention, Like Father Like Son (LFLS), was implemented among 300 couples attending antenatal clinics in four urban community health centers. Participants were assessed postpartum regarding subsequent EIMC decisions. Partners, religion, and marital status were associated with the EIMC decision-making. Large scale EIMC promotion interventions that target both parents during perinatal care should be explored., (© 2024. The Author(s).)

Background: Paediatric circumcision is a standard surgical procedure that frequently induces anxiety, fear, and pain in young patients. Child-friendly nursing has shown potential in alleviating psychosocial distress in paediatric care settings. However, its specific impact on patients undergoing circumcision remains underexplored. This study aimed to evaluate the effectiveness of child-friendly nursing in reducing patients' anxiety, fear and pain in patients undergoing paediatric circumcision., Methods: Clinical data of paediatric patients who underwent circumcision at Taizhou Hospital of Zhejiang Province from January 2022 to November 2023 were retrospectively analysed. Patients were divided into the traditional nursing (January 2022 to December 2022) and child-friendly nursing (January 2023 to November 2023) groups. Psychosocial parameters, including anxiety, depression, pain, and fear, were assessed using the Children's Anxiety Meter-State (CAM-S), Children's Depression Inventory (CDI), Wong-Baker FACES Pain Rating Scale (WBFPRS), and Children's Fear Scale (CFS), respectively., Results: No significant differences were found in CAM-S, CDI, WBFPRS, and CFS scores between the two groups before intervention ( p > 0.05). However, post-intervention scores for all parameters in the child-friendly nursing group were significantly lower than those in the traditional nursing group ( p < 0.001). The results suggest that child-friendly nursing effectively reduces anxiety, depression, fear and pain in children undergoing circumcision., Conclusions: This study provides compelling evidence supporting the effectiveness of child-friendly nursing in enhancing surgical experiences and improving psychosocial outcomes for paediatric patients undergoing circumcision., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s).)

Despite voluntary medical male circumcision (VMMC) being a cost-effective intervention for preventing HIV transmission, its scale-up has faced challenges. Several interventions to address these challenges in priority countries, including Uganda, have not yielded the desired results. This cross-sectional qualitative study aimed to explore the factors that affect the demand for VMMC and identify possible solutions. Semi-structured phone interviews were conducted with 29 males aged at least 18 and not more than 65 drawn randomly from a database representative of the general population maintained by an independent research organisation. Reflexive thematic analysis was conducted, and data analysis was done using NVivo version 12. The results were presented in narrative format with supporting quotes. The study received ethical and regulatory clearance to be conducted in Uganda. The average age of the respondents was 28 years. Almost all respondents had some education, and most lived in rural areas. Two themes were generated, namely, 1) deficits and opportunities for VMMC, which are issues that currently hinder the uptake of VMMC but, if addressed, would lead to better demand, and 2) pivots and shifts for VMMC, which are changes that need to be made to improve the uptake of VMMC. We found that several challenges, including myths, misconceptions, health system gaps, and uncertainties about the postoperative period, hindered the uptake of VMMC. Pivots and shifts for improving the uptake of VMMC include intensifying VMMC campaigns, addressing inequities, and addressing access barriers. We concluded that several challenges, including myths and misconceptions, health system-related gaps, and uncertainties in the post-circumcision period, persist and negatively impact the scale-up of VMMC in Uganda. VMMC beneficiaries have plausible proposals for addressing challenges. The Uganda Ministry of Health should address the myths, misconceptions, health system-related gaps, and uncertainties about the postoperative period and should involve VMMC beneficiaries in reviewing interventions to address gaps., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Primary healthcare facilities are central to the implementation of voluntary medical male circumcision (VMMC) as points of access to integrated health services in line with the Kenya AIDS Strategic Framework II (2020/21-2024/25). Knowledge of factors that explain men's uptake of VMMC and sexual health services at these facilities and preferences of where to get the services remain poorly understood. Using qualitative methodologies, we examined factors that determined facility choice for VMMC services and reasons for preferring the facility among men aged 25-39 years who previously underwent VMMC. The current study draws from focus group discussion interviews with circumcised men and their partners conducted as part of a randomized controlled trial to assess impact of two demand creation interventions in western Kenya. This involved 12 focus group discussions (FGD) with 6-10 participants each. Six FGDs were conducted with circumcised men, and 6 with their sex partners. Thematic issues relevant to a predetermined framework were identified. The themes were organized as follows: service availability, accessibility, affordability, appropriateness and, acceptability. Facility location, physical layout, organization of patient flow, infrastructure, and service provider skills were the outstanding factors affecting the choice of VMMC service outlets by men aged 25-39 years. Additionally, preferences were influenced by individual's disposition, attitudes, knowledge of VMMC services and tacit balance between their own recognized health needs versus desire to conform to social-cultural norms. Facility choice and individual preference are intricate issues, simultaneously involving multiple but largely intra-personal and facility-level factors. The intrapersonal dimensions elicited may also reflect differential responses to strategic communications and demand creation messages with promotion and prevention frames., (© 2024. The Author(s).)

To investigate the prevalence of male circumcision and the willingness to undergo male circumcision and influencing factors among MSM in Maanshan City, we conducted a cross-sectional study from June 2016 to December 2019. Respondent-driven sampling (RDS) was used to recruit participants. Influential factors of willingness to accept circumcision were identified by a multivariable logistic regression model. The multivariable logistic regression model revealed that five variables were independent influential factors for willingness to participate. The factors include that used condoms during last anal intercourse ( OR = 1.87, 95% CI :1.03-3.41, P = 0.04), sex with female sex partners ( OR = 0.499, 95% CI :0.298-0.860, P = 0.012, level of education (junior college: OR = 0.413, 95% CI :0.200-0.854, P = 0.017; bachelor's degree or higher: OR = 0.442, 95% CI :0.208-0.938, P = 0.033), condom use during oral sex in the last six months ( OR = 4.20, 95% CI :1.47-12.0, P = 0.007) and level of knowledge of PrEP ( OR = 5.09, 95% CI :1.39-18.7, P = 0.014). Given the willingness of MSM to accept circumcision was low in China, establishing a proper understanding of circumcision is essential if it is to be used as a strategy to prevent HIV infection among MSM. Therefore, publicity and education on the operation should be strengthened to increase the willingness to undergo male circumcision.

Despite increasing interest in Early-Infant and Early-Adolescent Medical Circumcision (EIMC and EAMC, respectively) in Zambia, parental willingness to have their sons undergo the procedure has not been explored. This study describes Zambian parents' perspectives on EIMC and EAMC. A total of N = 600 men and women (n = 300 couples) were recruited. Most parents, 89% and 83%, planned to have their newborn or adolescent sons circumcised, respectively, and 70% and 57% had plans for EIMC and EAMC, respectively. Most (91% for infants and 86% for adolescents) reported they were considering the pros and cons of circumcision. Parents' age (OR 1.05), having children living in one's home (OR 3.58), and lower education (OR 0.63) were associated with sons' circumcision. The minimal risks associated with circumcision and the lifetime benefits conferred underscore its contribution to public health in high HIV prevalence areas., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Policy statements on penile circumcision have focused primarily on disease, dysfunction, or sensation, with relatively little consideration of psychological and psychosocial implications of the procedure. There has also been minimal consideration of potential qualitative changes in the subjective experience of sexual activity following changes in penile anatomy (foreskin removal) or associated sexual biomechanics. We present a critical overview of literature on the psychological, psychosocial, and psychosexual implications of penile circumcision. We give consideration to differences among circumcisions performed in infancy, childhood, or adulthood. We also discuss potential psychosocial effects on parents electing, or failing to elect, circumcision for their children. We propose a framework for policy considerations and future research, recognizing that cultural context is particularly salient for the narratives individuals construct around penile circumcision, including both affected individuals and medical professionals who perform the surgeries. We argue that additional attention should be paid to the potential for long-term effects of the procedure that may not be properly considered when the patient is an infant or child., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose of Review: Evidence from clinical trials identified the effectiveness of voluntary medical male circumcision (VMMC) as an additional strategy to reduce the risk of HIV transmission from women to men. However, concerns about post-circumcision sexual risk compensation may hinder the scale-up of VMMC programs. We reviewed the evidence of changes in risky sexual behaviors after circumcision, including condomless sex, multiple sex partners, and early resumption of sex after surgery., Recent Findings: Most clinical trial data indicate that condomless sex and multiple partners did not increase for men after circumcision, and early resumption of sex is rare. Only one post-trial surveillance reports that some circumcised men had more sex partners after surgery, but this did not offset the effect of VMMC. Conversely, qualitative studies report that a small number of circumcised men had increased risky sexual behaviors, and community-based research reports that more men resumed sex early after surgery. With the large-scale promotion and expansion of VMMC services, it may be challenging to maintain effective sexual health educations due to various restrictions. Misunderstandings of the effect of VMMC in preventing HIV infection are the main reason for increasing risky sexual behaviors after surgery. Systematic and practical sexual health counseling services should be in place on an ongoing basis to maximize the effect of VMMC., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To conduct the first systematic review critically examining evidence on whether early male circumcision has short- and long-term adverse psychological effects., Methods: We searched PubMed, EMBASE, SCOPUS, Cochrane Library, and Google Scholar., Results: Twenty-four studies with original data met the inclusion criteria. These comprised 11,173 total males, 4340 circumcised in infancy and 6908 uncircumcised. Nineteen were rated 1+, 2++ or 2+, and 5 were rated 2- by SIGN criteria. Neonatal circumcision, particularly without anesthetic, increased vaccination pain response, but had little effect on breastfeeding or cognitive ability. Studies reporting associations with sudden infant death syndrome, autism, alexithymia and impaired sexual function and pleasure had design flaws and were rated 2-. Sexual arousal, touch, pain, and warmth thresholds measured by quantitative sensory testing were not diminished in neonatally circumcised men. Neonatal circumcision was not associated with empathy in men, contradicting the hypothesis that procedural pain causes central nervous system changes. After correcting all associations with socioaffective processing parameters for multiple testing only higher sociosexual desire, dyadic sexual libido/drive, and stress remained significant. The relatively greater sexual activity found in circumcised men might reflect reduced sexual activity in uncircumcised men overall owing to pain and psychological aversion in those with foreskin-related medical conditions (reverse causality). Most studies employed case-control designs with limited follow-up. Studies beyond childhood were prone to confounding., Conclusion: The highest quality evidence suggest that neonatal and later circumcision has limited or no short-term or long-term adverse psychological effects., (© 2022 Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd.)

Introduction: In Sweden, the law treats female genital cutting (FGC) differently from male genital cutting (MGC). However, the comparability of the medical, ethical, and legal aspects of genital cutting of girls and boys are increasingly discussed by scholars, although little is known about how practicing communities view these aspects. This study aimed to explore attitudes towards comparison of genital cutting of girls and boys among Swedish Somalis, and to investigate factors associated with considering the two practices to be comparable., Material and Methods: In a cross-sectional questionnaire with 648 Swedish Somali men and women from four Swedish cities, descriptive statistics and logistic regression were used for the analysis., Results: Among the Swedish Somalis, 10% considered FGC and MGC to be comparable practices. A majority (98%) of the participants thought FGC could cause long-term health complications, but only 1% considered the physical health disadvantage of MGC would outweigh the physical health benefits. FGC was perceived to be a violation of children's rights by 60%, whereas this proportion for MGC was 3%. Individuals who had a dominant bridging social capital and those who expressed that performing FGC follows religion were more likely to think that FGC and MGC were comparable practices., Conclusions: The increased global attention and emphasis on the comparability of genital cutting of boys and girls was not reflected in this study among Swedish Somalis. Rather, attitudes reflected the common description of the two practices in global public health campaigns, portraying FGC as a harmful practice violating children's rights, while describing MGC as a public health measure. Social interactions and separation of FGC from religion could explain why FGC and MGC were not considered comparable., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Botswana is one of the countries in Eastern and Southern Africa significantly impacted by the Human Immunodeficiency Virus (HIV). To control the spread of HIV, the government in 2009 rolled out the voluntary medical male circumcision (VMMC) programme as an additional HIV prevention strategy with the goal of circumcising 80% of HIV negative men by 2016. However, the country failed to achieve this goal as less than 30% of the targeted men were circumcised by 2016. A study was therefore conducted to explore and describe the factors that are perceived by men in Botswana to influence the uptake of VMMC in order to inform future policymaking and programming on VMMC. An exploratory descriptive, qualitative design was utilised to investigate perceived factors influencing the uptake of VMMC among men. Data were collected from 38 men, aged 18-49 years in Kweneng East, Botswana using semi-structured individual interviews and focus group discussions (FGDs). Tesch's method of qualitative data analysis was used to code and categorise transcribed data into meaningful themes. Upon analysis, three themes emerged as influencing the uptake of VMMC: (a) the influence of value systems associated with stakeholder consultation in the community; (b) the influence of value systems associated with cultural beliefs and (c) the influence of value systems associated with religious beliefs. The influence of value systems associated with stakeholder consultation in the community was found to manifest in the form of the lack of consultation with men at the inception of the VMMC; the lack of involvement of village elders during the service delivery process and the lack of involvement of women in VMMC. In addition, the influence of value systems associated with cultural beliefs was found to manifest in the form of the lack of openness between parents and children on sexual matters and the lack of traditional leadership support in VMMC. Lastly, the influence of value systems associated with religious beliefs was found to manifest in the form of religious views not in support of the VMMC and religious views in support of the VMMC. It is concluded that value systems associated with stakeholder consultation, cultural beliefs and religious beliefs were the factors influencing the uptake of VMMC among men in Kweneng East, Botswana, and these factors to a larger extent deterred men from using VMMC services. Based on these findings, it is therefore concluded that government and other providers of VMMC should consider the influence of value systems on the uptake of VMMC in order to provide culturally congruent VMMC services and boost of the uptake of VMMC among men in Kweneng East, Botswana.

Introduction: Voluntary medical male circumcision (VMMC) is a scientifically proven HIV prevention intervention. Uganda, like many countries has been implementing VMMC for over 10 years but uptake is still low especially in northern Uganda. To attain 80% needed for public health impact, scale-up was recommended with many innovations implemented with sub-optimal results. This study therefore wanted to find out some of the correlates of VMMC uptake in Gulu district, northern Uganda., Methods: Two studies were conducted separately but data was analyzed for this study. For the quantitative study, proportions and frequencies were used to measure perception of increased risk of HIV infection using age, gender, occupation, marital and circumcision status. Qualitative study provided data from FGDs, IDIs and KIIs were first transcribed in Acholi and then translated in English. Transcripts were uploaded in MAXDQA software for data management. A code book for emerging themes was developed., Results: A total of 548 respondents were interviewed for the quantitative study, where two thirds (66%) of the participants perceived themselves to be at increased risk of HIV infection. For the qualitative study, 149 participants from 19 FGDs, 11 KIIs and 9 IDIs were interviewed. Data were analyzed thematically using both inductive and deductive approaches. Devices were preferred to conventional surgery while mobile services were preferred to static services. However, there were divergent views regarding circumcision service providers' socio-demographics and these were influenced mainly by age, level of education and location., Conclusion: People in Northern Uganda perceived themselves to be at an increased risk of HIV infection. They preferred devices to conventional surgery, mobile services to static services but had varying views about the socio-demographics of the service providers., (© 2020 Nanteza BM et al.)

Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda.

This article presents a case study of Simon, a 25-year old Black South African male. According to his Pedi customs, Simon underwent traditional male circumcision (TMC) as a 12-year-old adolescent. He tells of his fears relative to this experience and how, over time, he transitioned from a belief in TMC to a strong preference for medical male circumcision (MMC). Using a single-case study design, the aim of the research was to explore the value of the exercise of choice in TMC, which may influence cultural perceptions of gender and masculinity. The study unpacks the way in which the meaning and experience of TMC is shaped by the social and cultural contexts of South Africa. This qualitative exploration complements conventional medical accounts of circumcision, which are often focused on the medical procedure while ignoring cultural and social factors. Issues of gender, particularly the construction of hegemonic masculinity and how it positions men, women, and young boys in relation to each other and their communities, are discussed. Simon's case study provides new insights and perspectives on personally and culturally sensitive issues which are not easily accessed nor commonly understood. Data collected via in-depth interviews were transcribed and analyzed thematically. Analysis applied information from the literature and key concepts from the theoretical standpoint of social constructivism. Case study analysis allowed space for unexpected, emergent themes to arise from the data. Four main themes were identified, notably language, silence, patriarchy, and masculinity.

Objectives: To determine caregiver-reported reasons for delay of desired neonatal circumcision., Methods: Caregivers requesting elective outpatient circumcision at two urban tertiary care hospitals were surveyed from 1/2017 to 12/2018. Boys >3 years and those with abnormal penile anatomy were excluded. Patient/parent demographics, insurance status, comorbidities, birth history, family history, reasons circumcision was desired, and reasons for circumcision delay were obtained., Results: Surveys were completed by 206/229 caregivers (90% response rate). Respondents were primarily mothers (74%) who identified as African-American (62%). Eligible boys presented at a median 7.5 months [0.3-35.6] and were predominantly African-American (63%), publicly-insured at birth (83%), and publicly-insured at present (86%). 80% were full-term. 83% had no comorbidities. Most caregivers (84%) requested inpatient circumcision, primarily for penile cleanliness (75%) and infection prevention (72%). Common reasons for delay included neonatal circumcision not being performed by the birth physician/hospital (26%) and prematurity (16%). Publicly-insured boys were more likely to encounter delays related birth physician/hospital not performing circumcisions (P = .02). Non-Caucasian/mixed race boys were less likely to be eligible for circumcision without general anesthesia (P = .004). In 108 cases (52%), circumcision was requested for full-term boys without comorbidities. Of these, 72 (35% of the cohort) now require general anesthesia to undergo circumcision., Conclusion: Among 206 boys experiencing circumcision delay, most were full-term, African-American, and publicly-insured. Common reasons for delay included neonatal circumcision not being performed by the birth hospital/physician and prematurity. General anesthesia could have been avoided in >35% of boys if circumcision was performed at birth., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Voluntary Medical Male Circumcision (VMMC) is an effective HIV prevention strategy prioritized by the World Health Organisation (WHO) for regions of high HIV prevalence, South Africa (SA) and in particular KwaZulu-Natal (KZN) is one of such regions. Since the roll out of VMMC in 2010 there has been little research conducted on the implementation of this service. Existing studies on the uptake of VMMC have mainly focused on service users resulting in a paucity of data on health care workers perspectives on the intervention., Aim: To analyse health care workers' perceptions and experiences of implementing voluntary medical male circumcision in KZN, SA., Setting: The study took place at six different health districts and their six respective rural clinics in the KZN province of SA., Methods: A qualitative approach using a phenomenographic design was employed. Data were collected from a sample of 18 participants comprising of health care providers (n = 12) and health policy makers (n = 6). Individual, face-to-face interviews were conducted using a semi-structured interview guide. An audiotape was used to record the data, which were transcribed verbatim and then analysed using a step-wise phenomenographic data analysis procedure., Results: Participants reported that VMMC was implemented by the department of health with support from non-governmental organisations and private general practitioners. Negative perceptions and negative experiences regarding VMMC and implementation were reported., Conclusion: The implementation of VMMC is compromised due to poor preparation and training of healthcare workers for implementing the service. Addressing health care workers' needs for training and preparation is crucial for successful implementation of VMMC.

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.

Background: Voluntary medical male circumcision (VMMC) is a key component of combination HIV-prevention programmes. Several high-HIV-prevalence countries in sub-Saharan Africa, including Zimbabwe, are looking to scale up VMMC activities. There is limited evidence on how a combination of social learning from peer education by a role model with different behavioural incentives influences demand for VMMC in such settings., Methods/design: This matched-cluster randomised controlled trial with 1740 participants will compare two behavioural incentives against a control with no intervention. In the intervention clusters, participants will participate in an education session delivered by a circumcised young male ("role model") on the risks of HIV infection and the benefits from medical male circumcision. All participants will receive contributions towards transport costs to access medical male circumcision at participating clinics. Via blocked randomisation, in the intervention clusters participants will be randomly assigned to receive one of two types of incentives - fixed cash payment or lottery payment - both conditional on undergoing surgical VMMC. In two sites, a community-led intervention will also be implemented to address social obstacles and to increase support from peers, families and social structures. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at 6 months will include self-reported uptake of VMMC triangulated with clinic data., Discussion: This is the first trial to pilot-test social learning to improve risk perception and self-efficacy and to address the fear of pain associated with VMMC and possible present-biased preferences with front-loaded compensations as well as fixed or lottery-based cash payments. This study will generate important knowledge to inform HIV-prevention policies about the effectiveness of behavioural interventions and incentives, which could be easily scaled-up., Trial Registration: This trial has been registered on ClinicalTrials.gov (identifier: NCT03565588). Registered on 21 June 2018.

In priority sub-Saharan African countries, on the ground observations suggest that the success of voluntary medical male circumcision (VMMC) programs should not be based solely on numbers of males circumcised. We identify gaps in the consent process and poor psychosocial outcomes among a key target group: male adolescents. We assessed compliance with consent and assent requirements for VMMC in western Kenya among males aged 15-19 (N = 1939). We also examined differences in quality of life, depression, and anticipated HIV stigma between uncircumcised and circumcised adolescents. A substantial proportion reported receiving VMMC services as minors without parent/guardian consent. In addition, uncircumcised males were significantly more likely than their circumcised peers to have poor quality of life and symptoms of depression. Careful monitoring of male adolescents' well-being is needed in large-scale VMMC programs. There is also urgent need for research to identify effective strategies to address gaps in the delivery of VMMC services.

Objective: To systematically evaluate evidence against male circumcision (MC)., Methods: We searched PubMed, Google Scholar, EMBASE and Cochrane databases., Results: Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems., Conclusions: Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence., (© 2019 The Authors. Journal of Evidence-Based Medicine published by Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd.)

Voluntary medical male circumcision (VMMC) is an evidence-based biomedical HIV prevention but under-utilized by male sexually transmitted diseases patients (MSTDP) in China. A parallel-group, non-blinded randomized controlled trial was conducted. Participants were uncircumcised heterosexual MSTDP attending four sexually transmitted diseases (STD) clinics in three Chinese cities. A total of 244 MSTDP were randomized 1:1 into the intervention group (n = 108) and the control group (n = 136). In addition to the education booklet received by the control group, the intervention group watched a 10-min video clip and received a brief counseling delivered by clinicians in the STD clinics. The interventions were developed based on the Health Belief Model and the Theory of Planned Behavior. At Month 6, participants in the intervention group reported significantly higher uptake of VMMC (14.8% versus 2.9%; RR 5.03, 95% CI 1.73, 14.62, p = 0.001). The brief STD clinic-based intervention was effective in increasing VMMC uptake among MSTDP in China.Trial registry: This study is registered at ClinicalTrials.gov, number NCT03414710. https://clinicaltrials.gov/ct2/show/NCT03414710 .

Background:  Medical male circumcision (MMC) and traditional male circumcision (TMC) are reportedly having negative and positive outcomes in the Eastern Cape province. Researchers show contradictory remedies; some advocate for abolishment of TMC and others call for the integration of both methods., Aim:  This study aimed to explore factors influencing the integration of TMC and MMC at different socio-ecological levels., Setting:  The study was conducted at Ingquza Hill Local Municipality in the Eastern Cape province., Methods:  An explorative qualitative study design, using in-depth interviews (IDIs) and focus group discussions (FGDs), was employed in this study. Purposive sampling was used to select the participants. A framework analysis approach was used to analyse the data, and the themes were developed in line with the socio-ecological model., Results:  Four main themes emerged from the data as important in influencing the integration of TMC and MMC methods. These included: (1) individual factors, related to circumcision age eligibility and post-circumcision behaviour; (2) microsystem factors, related to alcohol and drug abuse, peer pressure, abuse of initiates, and family influence; (3) exosystem factors, related to financial gains associated with circumcision and the role of community forums; and (4) macrosystem factors, related to stigma and discrimination, and male youth dominance in circumcision practices., Conclusion:  Male circumcision in this area is influenced by complex factors at multiple social levels. Interventions directed at all of these levels are urgently needed to facilitate integration of the TMC and MMC methods.

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.

Voluntary medical male circumcision (VMMC) is effective in reducing the risk of human immunodeficiency virus (HIV). However, countries like Tanzania have high HIV prevalence but low uptake of VMMC. We conducted a discrete-choice experiment to evaluate the preferences for VMMC service attributes in a random sample of 325 men aged 18 years or older from the general population in 2 Tanzanian districts, Njombe and Tabora. We examined the preference for financial incentives in the form of a lottery ticket or receiving a guaranteed transport voucher for attendance at a VMMC service. We created a random-parameters logit model to account for individual preference heterogeneity and a latent class analysis model for identifying groups of men with similar preferences to test the hypothesis that men who reported sexually risky behaviors (i.e., multiple partners and any condomless sex in the past 12 months) may have a preference for participation in a lottery-based incentive. Most men preferred a transport voucher (84%) over a lottery ticket. We also found that offering a lottery-based financial incentive may not differentially attract those with greater sexual risk. Our study highlights the importance of gathering local data to understand preference heterogeneity, particularly regarding assumptions around risk behaviors.

Randomized trials have shown that voluntary medical male circumcision (VMMC) significantly reduces HIV acquisition risk in men. We sought to identify subpopulations of Botswanan men with high levels of VMMC uptake by comparing an observational cohort of men presenting for circumcision services at two high-volume clinics in Botswana's capital city, Gabo-rone, with a matched, population-based random sample of uncircumcised men. Among these high uptake VMMC subpopulations, we then examined the immediate factors that play a role in men's decision to seek VMMC services. As compared to their population-based controls, men choosing to undergo circumcision were more likely to be ages 24-34, more highly educated, to have a religious affiliation, and in a serious relationship. Our results suggest that married men and highly educated men were more likely to pursue circumcision for personal hygiene reasons. These findings have direct implications for targeted demand creation and mobilization activities to increase VMMC uptake in Botswana.

Medical male circumcision (MMC) has expanded in sub-Saharan Africa, yet uptake remains sub-optimal. We sought to understand women's perceptions of and influence on MMC in Rakai, Uganda. We conducted in-depth interviews with 27 women in fishing and trading communities, including women married to circumcised and uncircumcised men, single women, and sex workers. Data analysis followed a team-based framework approach. All female participants preferred circumcised men because of perceived reduced HIV and sexually transmitted infection (STI) risk, improved penile hygiene, and increased sexual pleasure. Perceived negative aspects included abstinence during wound healing, potentially increased male sexual risk behaviors, fear of being blamed for HIV acquisition, and economic insecurity due to time off work. Participants felt women could persuade their partners to be circumcised, accompany them to the clinic, refuse sex with uncircumcised men, and participate in community MMC activities. Findings support women's important role in MMC acceptance.

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., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Street-connected youth (SCY) in Kenya and elsewhere in sub-Saharan Africa are at high risk of HIV. Voluntary Male Medical Circumcision (VMMC) reduces the risk of female-to-male HIV transmission. Circumcision is also a traditional coming-of-age process in many Kenyan ethnic groups. This paper describes the acceptability of VMMC delivered as part of a ten-day healing, educational, and 'coming-of-age' retreat implemented as a pilot with SCY., Methods: Male SCY aged between 12 and 24 living on the street for more than 3 months were eligible to participate. The study took place over 10 days. After medical circumcision, youth participated in education modules. Data collected included qualitative semi-structured exit interviews featuring structured and open-ended questions about factors relevant to this intervention's acceptability., Results: There were 116 SCY (median age 14, IQR 13-15) who participated in the study. All were circumcised successfully, with no major complications. The majority of participants (81%) agreed that the circumcision procedure was uncomplicated, and 99% agreed the education was an important part of the initiation process. Thematic analysis of interview data highlighted four factors important to the program's acceptability: providing food, shelter, security; providing a safe place to heal; including traditional elements; and being with peers., Conclusions: This novel implementation of VMMC was found to be acceptable to SCY participants and could likely be adapted and scaled for HIV prevention and education with SCY elsewhere in Kenya and sub-Saharan Africa where circumcision is part of traditional coming-of-age processes., (Copyright © 2018. Published by Elsevier Inc.)

Patient race/ethnicity affects health care utilization, provider trust, and treatment choice. It is uncertain how these influences affect pediatric care. We performed a systematic review (PubMed, Scopus, Web of Science, PsycINFO, Cochrane, and Embase) for articles examining race/ethnicity and parental treatment decision-making, adhering to PRISMA methodology. A total of 9200 studies were identified, and 17 met inclusion criteria. Studies focused on treatment decisions concerning end-of-life care, human papillomavirus vaccination, urological surgery, medication regimens, and dental care. Findings were not uniform between studies; however, pooled results showed (1) racial/ethnic minorities tended to prefer more aggressive end-of-life care; (2) familial tradition of neonatal circumcision influenced the decision to circumcise; and (3) non-Hispanic Whites were less likely to pursue human papillomavirus vaccination but more likely to complete the vaccine series if initiated. The paucity of studies precluded overarching findings regarding the influence of race/ethnicity on parental treatment decisions. Further investigation may improve family-centered communication, parent engagement, and shared decision-making.

Traditional male circumcision (TMC) is a cultural ritual that involves the removal of the penile foreskin of a male person undertaken as part of a rite of passage from childhood into adulthood. The aim of the study was to determine the notions of manhood in TMC by African adolescent boys in Ngove Village, Limpopo Province. This was a qualitative study that sampled a total of 20 adolescent boys through purposive sampling. Data were collected using semistructured interviews and analyzed through interpretive phenomenological analysis (IPA). Five main themes emerged from this study, namely: (a) TMC as a passage to manhood, (b) the role of TMC in role modeling, (C) fearlessness and aggressiveness as qualities of manhood in TMC, (d) TMC as indicating readiness for heterosexual relationships, and (e) the decline in the practice of TMC. The study concludes with discussion and recommendation of integration of both traditional male circumcision and medical male circumcision (MMC) with specific tactfulness and respect of the notion of manhood value embedment in the process to gain cooperation of the local community members affected.

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.

Medical adult male circumcision has been shown to offer men significant protection against HIV infection during peno-vaginal sex. This has resulted in calls for a national roll-out of medical adult male circumcision in South Africa, a rights-based constitutional democracy. This article explores the ways that the potential tensions between this call to circumcise as a practice of good health citizenship and the guaranteed right to bodily integrity are negotiated in interviews with 30 urban-based men in Johannesburg. The results suggest that despite its demonstrable biological efficacy, these tensions may paralyse decision- and policy-makers in grappling with the potential scaling up of medical adult male circumcision for HIV prevention in South Africa.

Background: Neonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure., Methods: In-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes., Results: Six themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented., Conclusions: Thai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.

Background: Experience with providers shapes the quality of adolescent health services, including voluntary medical male circumcision (VMMC). This study examined the perceived quality of in-service communication and counseling during adolescent VMMC services., Methods: A postprocedure quantitative survey measuring overall satisfaction, comfort, perceived quality of in-service communication and counseling, and perceived quality of facility-level factors was administered across 14 VMMC sites in South Africa, Tanzania, and Zimbabwe. Participants were adolescent male clients aged 10-14 years (n = 836) and 15-19 years (n = 457) and completed the survey 7 to 10 days following VMMC. Adjusted prevalence ratios (aPRs) were estimated by multivariable modified Poisson regression with generalized estimating equations and robust variance estimation to account for site-level clustering., Results: Of 10- to 14-year-olds and 15- to 19-year-olds, 97.7% and 98.7%, respectively, reported they were either satisfied or very satisfied with their VMMC counseling experience. Most were also very likely or somewhat likely (93.6% of 10- to 14-year olds and 94.7% of 15- to 19-year olds) to recommend VMMC to their peers. On a 9-point scale, the median perceived quality of in-service (counselor) communication was 9 (interquartile range [IQR], 8-9) among 15- to 19-year-olds and 8 (IQR, 7-9) among 10- to 14-year-olds. The 10- to 14-year-olds were more likely than 15- to 19-year-olds to perceive a lower quality of in-service (counselor) communication (score <7; 21.5% vs. 8.2%; aPR, 1.61 [95% confidence interval, 1.33-1.95]). Most adolescents were more comfortable with a male rather than female counselor and provider. Adolescents of all ages wanted more discussion about pain, wound care, and healing time., Conclusions: Adolescents perceive the quality of in-service communication as high and recommend VMMC to their peers; however, many adolescents desire more discussion about key topics outlined in World Health Organization guidance.

Background: Voluntary medical male circumcision (VMMC) is one of few opportunities in sub-Saharan Africa to engage male adolescents in the healthcare system. Limited data are available on the level of parental communication, engagement, and support adolescents receive during the VMMC experience., Methods: We conducted 24 focus group discussions with parents/guardians of adolescents (N = 192) who agreed to be circumcised or were recently circumcised in South Africa, Tanzania, and Zimbabwe. In addition, male adolescents (N = 1293) in South Africa (n = 299), Tanzania (n = 498), and Zimbabwe (n = 496) were interviewed about their VMMC experience within 7-10 days postprocedure. We estimated adjusted prevalence ratios (aPRs) using multivariable Poisson regression with generalized estimating equations and robust standard errors., Results: Parents/guardians noted challenges and gaps in communicating with their sons about VMMC, especially when they did not accompany them to the clinic. Adolescents aged 10-14 years were significantly more likely than 15- to 19-year-olds to report that their parent accompanied them to a preprocedure counseling session (56.5% vs 12.5%; P < .001). Among adolescents, younger age (aPR, 0.86; 95% confidence interval [CI], .76-.99) and rural setting (aPR, 0.34; 95% CI, .13-.89) were less likely to be associated with parental-adolescent communication barriers, while lower socioeconomic status (aPR, 1.37; 95% CI, 1.00-1.87), being agnostic (or of a nondominant religion; aPR, 2.87; 95% CI, 2.21-3.72), and living in South Africa (aPR, 2.63; 95% CI, 1.29-4.73) were associated with greater perceived barriers to parental-adolescent communication about VMMC. Parents/guardians found it more difficult to be involved in wound care for older adolescents than for adolescents <15 years of age., Conclusions: Parents play a vital role in the VMMC experience, especially for younger male adolescents. Strategies are needed to inform parents completely throughout the VMMC adolescent experience, whether or not they accompany their sons to clinics.

Background: The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have set a Fast-Track goal to achieve 90% coverage of voluntary medical male circumcision (VMMC) among boys and men aged 10-29 years in priority settings by 2021. We aimed to identify age-specific facilitators of VMMC uptake among adolescents., Methods: Younger (aged 10-14 years; n = 967) and older (aged 15-19 years; n = 559) male adolescents completed structured interviews about perceptions of and motivations for VMMC before receiving VMMC counseling at 14 service provision sites across South Africa, Tanzania, and Zimbabwe. Adjusted prevalence ratios (aPRs) were estimated using multivariable modified Poisson regression models with generalized estimating equations and robust standard errors., Results: The majority of adolescents reported a strong desire for VMMC. Compared with older adolescents, younger adolescents were less likely to cite protection against human immunodeficiency virus (HIV) or other sexually transmitted infections (aPR, 0.77; 95% confidence interval [CI], .66-.91) and hygienic reasons (aPR, 0.55; 95% CI, .39-.77) as their motivation to undergo VMMC but were more likely to report being motivated by advice from others (aPR, 1.88; 95% CI, 1.54-2.29). Although most adolescents believed that undergoing VMMC was a normative behavior, younger adolescents were less likely to perceive higher descriptive norms (aPR, 0.79; .71-.89), injunctive norms (aPR, 0.86; 95% CI, .73-1.00), or anticipated stigma for being uncircumcised (aPR, 0.79; 95% CI, .68-.90). Younger adolescents were also less likely than older adolescents to correctly cite that VMMC offers men and boys partial HIV protection (aPR, 0.73; 95% CI, .65-.82). Irrespective of age, adolescents' main concern about undergoing VMMC was pain (aPR, 0.95; 95% CI, .87-1.04). Among younger adolescents, fear of pain was negatively associated with desire for VMMC (aPR, 0.89; 95% CI, .83-.96)., Conclusions: Age-specific strategies are important to consider to generate sustainable demand for VMMC. Programmatic efforts should consider building on the social norms surrounding VMMC and aim to alleviate fears about pain.

Background: The minimum package of voluntary medical male circumcision (VMMC) services, as defined by the World Health Organization, includes human immunodeficiency virus (HIV) testing, HIV prevention counseling, screening/treatment for sexually transmitted infections, condom promotion, and the VMMC procedure. The current study aimed to assess whether adolescents received these key elements., Methods: Quantitative surveys were conducted among male adolescents aged 10-19 years (n = 1293) seeking VMMC in South Africa, Tanzania, and Zimbabwe. We used a summative index score of 8 self-reported binary items to measure receipt of important elements of the World Health Organization-recommended HIV minimum package and the US President's Emergency Plan for AIDS Relief VMMC recommendations. Counseling sessions were observed for a subset of adolescents (n = 44). To evaluate factors associated with counseling content, we used Poisson regression models with generalized estimating equations and robust variance estimation., Results: Although counseling included VMMC benefits, little attention was paid to risks, including how to identify complications, what to do if they arise, and why avoiding sex and masturbation could prevent complications. Overall, older adolescents (aged 15-19 years) reported receiving more items in the recommended minimum package than younger adolescents (aged 10-14 years; adjusted β, 0.17; 95% confidence interval [CI], .12-.21; P < .001). Older adolescents were also more likely to report receiving HIV test education and promotion (42.7% vs 29.5%; adjusted prevalence ratio [aPR], 1.53; 95% CI, 1.16-2.02) and a condom demonstration with condoms to take home (16.8% vs 4.4%; aPR, 2.44; 95% CI, 1.30-4.58). No significant age differences appeared in reports of explanations of VMMC risks and benefits or uptake of HIV testing. These self-reported findings were confirmed during counseling observations., Conclusions: Moving toward age-equitable HIV prevention services during adolescent VMMC likely requires standardizing counseling content, as there are significant age differences in HIV prevention content received by adolescents.

Background: Adolescent boys (aged 10-19 years) constitute the majority of voluntary medical male circumcision (VMMC) clients in sub-Saharan Africa. They are at higher risk of postoperative infections compared to adults. We explored adolescents' wound-care knowledge, self-efficacy, and practices after VMMC to inform strategies for reducing the risks of infectious complications postoperatively., Methods: Quantitative and qualitative data were collected in South Africa, Tanzania, and Zimbabwe between June 2015 to September 2016. A postprocedure survey was conducted approximately 7-10 days after VMMC among male adolescents (n = 1293) who had completed a preprocedure survey; the postprocedure survey assessed knowledge of proper wound care and wound-care self-efficacy. We also conducted in-depth interviews (n = 92) with male adolescents 6-10 weeks after the VMMC procedure to further explore comprehension of providers' wound-care instructions as well as wound-care practices, and we held 24 focus group discussions with randomly selected parents/guardians of the adolescents., Results: Adolescent VMMC clients face multiple challenges with postcircumcision wound care owing to factors such as forgetting, misinterpreting, and disregarding provider instructions. Although younger adolescents stated that parental intervention helped them overcome potential hindrances to wound care, parents and guardians lacked crucial information on wound care because most had not attended counseling sessions. Some older adolescents reported ignoring symptoms of infection and not returning to the clinic for review when an adverse event had occurred., Conclusions: Increased involvement of parents/guardians in wound-care counseling for younger adolescents and in wound-care supervision, alongside the development of age-appropriate materials on wound care, are needed to minimize postoperative complications after VMMC.

Background: Little is known regarding the impact of counseling delivered during voluntary medical male circumcision (VMMC) services on adolescents' human immunodeficiency virus (HIV) knowledge, VMMC knowledge, or post-VMMC preventive sexual intentions. This study assessed the effect of counseling on knowledge and intentions., Methods: Surveys were conducted with 1293 adolescent clients in 3 countries (South Africa, n = 299; Tanzania, n = 498; Zimbabwe, n = 496). Adolescents were assessed on HIV and VMMC knowledge-based items before receiving VMMC preprocedure counseling and at a follow-up survey approximately 10 days postprocedure. Sexually active adolescents were asked about their sexual intentions in the follow-up survey. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated by modified Poisson regression models with generalized estimating equations and robust variance estimators., Results: Regarding post-VMMC HIV prevention knowledge, older adolescents were significantly more likely than younger adolescents to know that a male should use condoms (age 10-14 years, 41.1%; 15-19 years, 84.2%; aPR, 1.38 [95% CI, 1.19-1.60]), have fewer sex partners (age 10-14 years, 8.1%; age 15-19 years, 24.5%; aPR, 2.10 [95% CI, 1.30-3.39]), and be faithful to one partner (age 10-14 years, 5.7%; age 15-19 years, 23.2%; aPR, 2.79 [95% CI, 1.97-3.97]) to further protect himself from HIV. Older adolescents demonstrated greater improvement in knowledge in most categories, differences that were significant for questions regarding number of sex partners (aPR, 2.01 [95% CI, 1.18-3.44]) and faithfulness to one partner post-VMMC (aPR, 3.28 [95% CI, 2.22-4.86]). However, prevention knowledge levels overall and HIV risk reduction sexual intentions among sexually active adolescents were notably low, especially given that adolescents had been counseled only 7-10 days prior., Conclusions: Adolescent VMMC counseling needs to be improved to increase knowledge and postprocedure preventive sexual intentions.

Background: While female involvement in voluntary medical male circumcision (VMMC) has been studied among adults, little is known about the influence of adolescent females on their male counterparts. This study explored adolescent females' involvement in VMMC decision making and the postoperative wound healing process in South Africa, Tanzania, and Zimbabwe., Methods: Across 3 countries, 12 focus group discussions were conducted with a total of 90 adolescent females (aged 16-19 years). Individual in-depth interviews were conducted 6-10 weeks post-VMMC with 92 adolescent males (aged 10-19 years). Transcribed and translated qualitative data were coded into categories and subcategories by 2 independent coders., Results: Adolescent female participants reported being supportive of male peers' decisions to seek VMMC, with the caveat that some thought VMMC gives males a chance to be promiscuous. Regardless, females from all countries expressed preference for circumcised over uncircumcised sexual partners. Adolescent females believed VMMC to be beneficial for the sexual health of both partners, viewed males with a circumcised penis as more attractive than uncircumcised males, used their romantic relationships with males or the potential for sex as leveraging points to convince males to become circumcised, and demonstrated supportive attitudes in the wound-healing period. Interviews with males confirmed that encouragement from females was a motivating factor in seeking VMMC., Conclusions: Adolescent female participants played a role in convincing young males to seek VMMC and remained supportive of the decision postprocedure. Programs aiming to increase uptake of VMMC and other health-related initiatives for adolescent males should consider the perspective and influence of adolescent females.

Background: The majority of individuals who seek voluntary medical male circumcision (VMMC) services in sub-Saharan Africa are adolescents (ages 10-19 years). However, adolescents who obtain VMMC services report receiving little information on human immunodeficiency virus (HIV) prevention and care. In this study, we assessed the perceptions of VMMC facility managers and providers about current training content and their perspectives on age-appropriate adolescent counseling., Methods: Semistructured in-depth interviews were conducted with 33 VMMC providers in Tanzania (n = 12), South Africa (n = 9), and Zimbabwe (n = 12) and with 4 key informant facility managers in each country (total 12). Two coders independently coded the data thematically using a 2-step process and Atlas.ti qualitative coding software., Results: Providers and facility managers discussed limitations with current VMMC training, noting the need for adolescent-specific guidelines and counseling skills. Providers expressed hesitation in communicating complete sexual health information-including HIV testing, HIV prevention, proper condom usage, the importance of knowing a partner's HIV status, and abstinence from sex or masturbation during wound healing-with younger males (aged <15 years) and/or those assumed to be sexually inexperienced. Many providers revealed that they did not assess adolescent clients' sexual experience and deemed sexual topics to be irrelevant or inappropriate. Providers preferred counseling younger adolescents with their parents or guardians present, typically focusing primarily on wound care and procedural information., Conclusions: Lack of training for working with adolescents influences the type of information communicated. Preconceptions hinder counseling that supports comprehensive HIV preventive behaviors and complete wound care information, particularly for younger adolescents.

Research exploring the impact of circumcision on the sexual lives of men has failed to consider men's attitudes toward their circumcision status, which may, in part, help to explain inconsistent findings in the literature. The current study explored the potential relationship between attitudinal factors toward one's circumcision status, timing of one's circumcision, and sexual correlates. A total of 811 men (367 circumcised as neonates, 107 circumcised in childhood, 47 circumcised in adulthood, and 290 intact) aged 19-84 years (M = 33.02, SD = 12.54) completed an online survey. We assessed attitudes toward one's circumcision status, three domains of body image (Male Genital Image Scale, Body Exposure during Sexual Activities Questionnaire, Body Image Satisfaction Scale), and self-reported sexual functioning (International Index of Erectile Function). Men who were circumcised as adults or intact men reported higher satisfaction with their circumcision status than those who were circumcised neonatally or in childhood. Lower satisfaction with one's circumcision status-but not men's actual circumcision status-was associated with worse body image and sexual functioning. These findings identify the need to control for attitudes toward circumcision status in the study of sexual outcomes related to circumcision. Future research is required to estimate the number of men who are dissatisfied with their circumcision status, to explore the antecedents of distress in this subpopulation, and to understand the extent of negative sexual outcomes associated with these attitudes.

Medical male circumcision has been recommended by the World Health Organization as part of a comprehensive approach to HIV prevention. Zimbabwe is one of the fourteen sub-Saharan countries that embarked on the Medical Male Circumcision (MMC) programme. However, the country has not yet met male circumcision targets. This paper examines the predictors of male circumcision in Zimbabwe. A cross-sectional survey was conducted on 784 men aged 15-35 years in Harare, Zimbabwe. Negative log-log logistic regression analysis was used to determine the predictors of male circumcision. The main predictors of circumcision were age, employment status, ever tested for HIV, approval of HIV testing prior to circumcision, knowledge about male circumcision and attitudes towards male circumcision. By and large, participants had good knowledge about male circumcision and viewed HIV prevention with a reasonably positive attitude. The identification of these predictors can be used to scale up the demand for male circumcision in Zimbabwe.

Slow adult male circumcision uptake is one factor leading some to recommend increased priority for infant male circumcision (IMC) in sub-Saharan African countries. This research, guided by the integrated behavioral model (IBM), was carried out to identify key beliefs that best explain Zimbabwean parents' motivation to have their infant sons circumcised. A quantitative survey, designed from qualitative elicitation study results, was administered to independent representative samples of 800 expectant mothers and 795 expectant fathers in two urban and two rural areas in Zimbabwe. Multiple regression analyses found IMC motivation among fathers was explained by instrumental attitude, descriptive norm and self-efficacy; while motivation among mothers was explained by instrumental attitude, injunctive norm, descriptive norm, self-efficacy, and perceived control. Regression analyses of beliefs underlying IBM constructs found some overlap but many differences in key beliefs explaining IMC motivation among mothers and fathers. We found differences in key beliefs among urban and rural parents. Urban fathers' IMC motivation was explained best by behavioral beliefs, while rural fathers' motivation was explained by both behavioral and efficacy beliefs. Urban mothers' IMC motivation was explained primarily by behavioral and normative beliefs, while rural mothers' motivation was explained mostly by behavioral beliefs. The key beliefs we identified should serve as targets for developing messages to improve demand and maximize parent uptake as IMC programs are rolled out. These targets need to be different among urban and rural expectant mothers and fathers.

Men are key decision makers for their son's circumcision, so understanding their beliefs is important for the uptake of early infant male circumcision in countries in sub-Saharan Africa that have high HIV prevalence. We analyzed men's preferences for circumcising their sons using data from a population-representative survey of 1501 uncircumcised men aged 25-49 years in western Kenya. Most men (59%) reported they would "definitely" want their son circumcised if a son was born to them within the next year. However, only 25% intended to become circumcised themselves. In multivariable Poisson regression models to estimate prevalence ratios, key predictors of the desire to circumcise their sons included knowledge that circumcision reduces HIV acquisition, having a supportive partner, discussing circumcision with the partner, altruism, and intention to be circumcised himself. Focusing on partner dynamics may have the greatest capacity to increase demand since 55% had not talked to their partner about circumcision.

Male circumcision (MC) significantly reduces HIV acquisition among men, leading WHO/UNAIDS to recommend high HIV and low MC prevalence countries circumcise 80% of adolescents and men age 15-49. Despite significant investment to increase MC capacity only 27% of the goal has been achieved in Zimbabwe. To increase adoption, research to create evidence-based messages is greatly needed. The Integrated Behavioral Model (IBM) was used to investigate factors affecting MC motivation among adolescents. Based on qualitative elicitation study results a survey was designed and administered to a representative sample of 802 adolescent boys aged 13-17 in two urban and two rural areas in Zimbabwe. Multiple regression analysis found all six IBM constructs (2 attitude, 2 social influence, 2 personal agency) significantly explained MC intention (R 2  = 0.55). Stepwise regression analysis of beliefs underlying each IBM belief-based construct found 9 behavioral, 6 injunctive norm, 2 descriptive norm, 5 efficacy, and 8 control beliefs significantly explained MC intention. A final stepwise regression of all the significant IBM construct beliefs identified 12 key beliefs best explaining intention. Similar analyses were carried out with subgroups of adolescents by urban-rural and age. Different sets of behavioral, normative, efficacy, and control beliefs were significant for each sub-group. This study demonstrates the application of theory-driven research to identify evidence-based targets for the design of effective MC messages for interventions to increase adolescents' motivation. Incorporating these findings into communication campaigns is likely to improve demand for MC.