A Study Assessing the Implementation of Male Circumcision as an HIV Prevention Strategy in Kenya

A Study Assessing the Implementation of Male Circumcision as an HIV Prevention Strategy in Kenya Amy Kate Noel Herman-Roloff B.A., Bethel University, 2000 M.P.H., University of Minnesota, 2003 Dissertation Chairperson: Dr. Robert C. Bailey Research has demonstrated that male circumcision (MC) reduces the incidence of HIV acquisition in heterosexual men by at least half. In 2008, Kenya launched the national Voluntary Medical Male Circumcision (VMMC) program for HIV prevention, and plans to circumcise 860,000 males by 2013. Despite the protective effect of MC, there are concerns about the acceptability and safety of the procedure. This study was implemented in Nyanza Province, Kenya, and used a mixed method approach to assess components of the VMMC program. The quantitative component of this study used both passive (N = 3,705) and active (N = 1,449) surveillance methods to monitor study participants. The qualitative component of this study included 12 focus group discussions among uncircumcised men. The primary barriers to VMMC uptake included time away from work; culture and religion; possible adverse events (AEs); and the post-surgical abstinence period. The primary facilitators to VMMC uptake included hygiene; social pressure; protection against HIV and other sexually transmitted infections; and improved sexual performance and satisfaction. Among the participants who underwent circumcision, the post-MC AE rate was 2.1% in the passive system and 7.5% in the active system. Experienced VMMC providers, who had performed more than 100 procedures, were less likely to provide an MC that resulted in an AE compared to inexperienced providers. Approximately one-third of participants reported engaging in sexual activity during the recommended 42-day abstinence period. In a multivariable analysis, being married was the strongest predictor of engaging in early sexual activity. To increase VMMC uptake it is important to dispel misconceptions and increase the relevance of MC among men who are already practicing an HIV prevention method. As large-scale MC programs continue to be implemented throughout Africa, robust surveillance is crucial to identify factors that may improve the safety and efficacy of the program. The most important factor to reduce the AE rate is to ensure that providers achieve clinical expertise before they perform unsupervised procedures. Strategies to reduce engaging in early sexual activity should be implemented such as including female partners in counseling, mass education campaigns, and targeted programs for VMMC clients.