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

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.

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.

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.

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.

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.

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.”

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.’

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.’

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.’

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.’

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.’

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.

•

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.

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.

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.