Date Published: May 3, 2018
Author(s): Hannah N. Gilbert, Monique A. Wyatt, Stephen Asiimwe, Bosco Turyamureeba, Elioda Tumwesigye, Heidi Van Rooyen, Ruanne V. Barnabas, Connie L. Celum, Norma C. Ware.
Voluntary medical male circumcision (MMC) reduces risk of HIV infection, but uptake remains suboptimal among certain age groups and locations in sub-Saharan Africa. We analysed qualitative data as part of the Linkages Study, a randomized controlled trial to evaluate community-based HIV testing and follow-up as interventions promoting linkage to HIV treatment and prevention in Uganda and South Africa. Fifty-two HIV-negative uncircumcised men participated in the qualitative study. They participated in semistructured individual interviews exploring (a) home HTC experience; (b) responses to test results; (c) efforts to access circumcision services; (d) outcomes of efforts; (e) experiences of follow-up support; and (f) local HIV education and support. Interviews were audio-recorded, translated, transcribed, and summarized into “linkage summaries.” Summaries were analysed inductively to identify the following three thematic experiences shaping men’s circumcision choices: (1) intense relief upon receipt of an unanticipated seronegative diagnosis, (2) the role of peer support in overcoming fear, and (3) anticipation of missed economic productivity. Increased attention to the timing of demand creation activities, to who delivers information about the HIV prevention benefits of MMC, and to the importance of missed income during recovery as a barrier to uptake promises to strengthen and sharpen future MMC demand creation strategies.
Linkage to antiretroviral treatment and effective prevention following widespread testing promises to reduce HIV incidence in Africa. A number of strategies to increase linkage are being evaluated, including integration and “streamlining” of services, point of care CD4 and viral load testing, economic incentives, and community-based testing with counselling and follow-up support [1–6]. Active linking to prevention services, such as voluntary medical male circumcision (MMC) is an important component of this comprehensive approach.
Many men in this study entered the home testing encounter expecting a positive diagnosis; the unanticipated news that they were HIV-negative created a strong motivation to preserve health. Some men then simply went on to be circumcised. For others, initial motivation was stymied by fears about the procedure. Circumcision success stories, a set of informal communications in which circumcised men described positive experiences of the procedure, helped some men overcome their fear. Others, while motivated to circumcise, were unable to act because of the economic challenges posed by missed work. These men were unable to reconcile the long-term health benefits of circumcision with the short-term imperatives of providing for their families in an economy based on agricultural labour. These men saw missed productivity during the MMC recovery period as an insurmountable barrier.
In addition to the content of MMC demand creation interventions, attention to their circumstances—the “when” and “who” of intervention delivery—may improve effectiveness. The need to sustain income during recovery from circumcision for many men living in settings of economic scarcity must be addressed in order for circumcision targets to be met.