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Creating demand for voluntary medical male circumcision (VMMC) amongst adolescents in South Africa
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Creating demand for voluntary medical male circumcision (VMMC) amongst adolescents in South Africa


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HEARD senior researcher Gavin George highlighted the factors that influence demand for voluntary medical male circumcision in a presentation at the XI International AIDS Impact Conference in …

HEARD senior researcher Gavin George highlighted the factors that influence demand for voluntary medical male circumcision in a presentation at the XI International AIDS Impact Conference in Barcelona, Spain

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  • 1. Creating demand for voluntary medical male circumcision (VMMC) amongst adolescents in South Africa Presentation to AIDS Impact 2013, Barcelona, Spain Gavin George with Kaymarlin Govender, Janet Frohlich & Petronella Chirawu Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
  • 2. Introduction • Voluntary medical male circumcision (VMMC) has been identified as an essential prevention mechanism in high HIV prevalence, primarily heterosexual, epidemic settings • In KwaZulu-Natal (KZN), a province of South Africa, the aim is to scale up VMMC services to 80% of males aged 0-49 by 2016, a total of over 1.25 million people. By 2012 a little over 200 000 circumcisions had been done • In a context of high levels of HIV, increasing demand of VMMC services is imperative if provincial and national targets are to be met. A clear understanding of the barriers and facilitators of VMMC is vital for cost-effective and rapid scale-up.
  • 3. Purpose and Method Purpose: This study aimed to assess young people’s perceptions and experience of barriers and facilitators of VMMC as well as perceptions about education and counselling on VMMC in schools. Specifically, this study unpacks the factors that influence demand for VMMC among high school learners in Vulindlela, KZN. Method: The qualitative study was conducted between September and October 2012 as part of a prospective cohort study.
  • 4. Methods continued… A VMMC programme run by the Centre for the Aids Programme of Research in South Africa (CAPRISA) in the Vulindlela sub-district of KZN had circumcised 2971 boys between January 2010 and July 2012. Twelve out of the 42 schools where the male circumcision programme was run were randomly selected to participate in the study. Data was collected using focus group discussions in the local Zulu language by three trained interviewers. Twelve focus group discussions (FGDs) were conducted with boys who had undergone VMMC and seven FGDs with boys who had chosen not to undergo circumcision.
  • 5. Methods continued… Focus group discussions with boys who had undergone VMMC focused on motivations for undergoing VMMC, VMMC counselling and sexual behaviour after undergoing VMMC. The focus group discussions with uncircumcised boys asked questions around their perceptions about VMMC, why they and their peers would want or not want to get tested for HIV. Each focus group had approximately 6-8 participants aged 16 years and older from grades 10, 11 and 12. An additional five FGDs were held with boys who were randomly selected from the participating schools to augment the data. Two of the FGDS were done after boys attended circumcision camps organized and run by CAPRISA during the school holidays.
  • 6. Results • The results are presented according to the issues raised by the participants. • Boys expressed concern about a range of issues from a personal and community perspective. • Understanding these reasons for circumcision provided a useful counterpoint to understand why someone might want to be circumcised or had to date avoided it. • Results are distilled down to an individual, inter personal and community wide facilitators and barriers as provided by the Social Cognitive Theory (SCT) framework.
  • 7. Results o Key Motivators • One of the key motivations and indeed a typical starting point offered by participants included the need to prevent themselves from STIs and HIV and also to maintain hygiene and cleanliness. • Sexual performance and perception that circumcision made them more attractive to their sexual partners. “One of my girlfriends from Sweetwater felt a difference when I had sex after circumcision and she even asked me what I did. I told her that this thing that was problematic has been removed. She asked to come for a second visit since I’m circumcised.”
  • 8. Results o Role of culture Much of this influence is linked to masculinity and that circumcision represents accepted norms of masculinity. Boys often spoke of these influences together, including those from their peers. Where circumcision is seen as a cultural necessity, its modern medical version is generally well preferred because it was done in a sterile environment under anaesthetic ‘I prefer medical male circumcision. There’s traditional and the other is performed by a religion called Shembe, they cut without giving you an injection, whereas a hospital injects you to alleviate the pain. I can’t stand to be cut with a razor or knife.’
  • 9. Results o Role of family, partner and peers Boys also expressed the motivations that they had experienced from their sexual partners, again linked to manhood and sexual pleasure. ‘I was not willing from last year to get circumcised but telling my friends about this made them to encourage me to for it because, if I don’t go my girlfriend will get herself another guy who is circumcised then leave me. That is why I end up doing it.’ ‘My friend encouraged me. He told me about the procedure, and he was healing well. After that my brother went for circumcision I really believed it was not that painful when I saw him. The penis looks abnormal for a while and there’s slight pain. You have to be a real man to face that kind of pain.’
  • 10. Results o Information, timing and facilities Exposure to quality public information typically distributed by service providers who then provide those circumcision facilities was expressed by participants as a positive influence. “What people need is a lot of knowledge/information around what HIV is and why testing is important. I think that that would motivate them. Here at school there was a campaign and now I see there are more people being tested. Previously when we were tested, there used to only be a few people. In our class, all but 2 learners were tested today. Because when you have the knowledge, you are more likely to make informed decisions.’ Boys who were circumcised at the camp indicated their preference for VMMC at the camp. ‘Circumcising at the camp during holidays also gives you enough time for your wound to heal and no one interferes with the healing process and there are no sports because you are just at home.’
  • 11. Results o Barriers to VMMC Despite the wide availability of antiretroviral treatment for HIV provided for by the government, participants noted that the greatest barrier to VMMC is the HIV testing which precedes the procedure. Whilst some participants were fearful of the testing itself, others were worried about their results. ‘There is still a stereotype [stigma] here that if you have AIDS you should not mix with other people, that you should lead a solitary life because you might give it to other people. Some are scared of that. They are scared of being discriminated against.’ As the testing was sometimes done at school or near the school during school hours they felt that their reaction will give their results away. ‘I would love to test elsewhere because when we are tested here at school, it’s in the classroom. So now say you find out that you are positive, naturally you are in shock, so your schoolmates notice that you are upset when you come out. Then they start speculating that you are positive.’
  • 12. Results o Barriers to VMMC Some boys noted that they would not go through the circumcision procedure because of fear that it will be done incorrectly and also that the procedure will be painful. ‘The thing with circumcision is that once you have been incorrectly cut the vein on your private part will never get erected again.’ ‘I was nervous when I saw one of my school mates who were done, bleeding. As the result he had to return to the surgery to be re-stitched. That resulted in me being nervous at my turn.’ A few participants noted that some young people still had misconceptions about VMMC. ‘There are people that think that by being circumcised they have a “condom for life” and they will never contract any diseases.’
  • 13. Discussion - facilitators The results of this study showed boys believing circumcision to be important for reducing risk of STIs, especially HIV and for enhanced sexual pleasure and performance. Acknowledging and interpreting hygiene and sexual performance as individual facilitators for VMMC, shows consistency with extant literature Inter-personal and community level facilitators include the desire to imitate their peers and acknowledge the preferences of their sexual partners as well as following family and cultural rites of passage. •
  • 14. Discussion - barriers Individual barriers usually begin with fears of the procedure itself and the pain (including post- operative) associated with stitches. Other notable barriers included the fear of HIV testing which precedes medical circumcision. Tackling stigma and ensuring that young people are well informed of all the procedures at the community level is important and will reduce barriers to testing. HIV counseling and testing is a compulsory prerequisite if boys want to participate in the free VMMC programme.
  • 15. Conclusion The beliefs and attitudes of young men in the target age for VMMC, and of young women who are their potential partners, will affect the demand for VMMC programmes.
  • 16. Acknowledgements • Swedish Sida for funding this project • CAPRISA for allowing us to use their facilities • Learners for taking the time to share their thoughts and views.