WEPDC 0104 Barriers to and facilitators of VMMC

WEPDC 0104 Barriers to and facilitators of VMMC uptake among older men aged 25 -39 years in Nyanza Region, Western Kenya (the TASCO study) Kawango Agot 1, Jonathan Grund 2, Edward Mboya 1, Paul Musingila 3, Eunice Omanga 1, Donath Emusu 3, Elijah Odoyo-June 3, Spala Ohaga 1, Boaz Otieno-Nyunya 3 1 Impact Research and Development Organization, Kisumu, Kenya, 2 Centers for Disease Control and Prevention, Atlanta, GA USA, 3 Centers for Disease Control and Prevention, Kisumu, Kenya Center for Global Health Division of Global HIV/AIDS

Background • VMMC reduces HIV risk by ~60% in men • Kenya introduced VMMC in 2008 with a goal of circumcising 80% of males aged 1549 years; 1. 2 m VMMCs done through 2015 • VMMC uptake is low among men aged ≥ 25 years globally (~8%), and in Kenya (~6%) • Modeling has suggested that circumcising “older” clients will increase the immediacy of VMMC’s impact on HIV incidence • The TASCO study assessed interventions to increase VMMC uptake among men aged 25 -39 years in Nyanza Region, Kenya • Study was conducted in a random sample of 45 Locations (SNUs) within 11 districts (4 counties) in Nyanza Region, Kenya 11 study districts

Methods • Study aim is to describe primary barriers and facilitators for VMMC among men aged 25 -39 years • All households in study villages were visited; study staff interviewed consenting male household residents aged 25 -39 years (n=5, 639) • • – Circumcision status was verified by trained, male study staff – Participants were asked an open-ended question on primary reasons for getting circumcised (facilitators) or not getting circumcised (barriers) Uncircumcised men were offered enrollment in the TASCO study – Demand creation interventions were conducted in accordance with the study arms, and all participants were offered VMMC – Follow-up interview included open-ended question on reasons for getting circumcised for men who accepted VMMC during the study (facilitators) In interviews, participants were asked to list all of the barriers or facilitators and then rank the importance of each reason Prior to analysis, responses were reviewed and categorized We calculated the frequencies of the most important (primary) barriers and facilitators overall and by demographic category

Results: Barriers Primary reason for not being circumcised prior to the intervention (n= 2, 784) 50% 40% 34% 32% 30% 20% 13% 10% 7% 7% 7% Di sli k e VM M Lo s he r Ot tw ag es No C fa Pa cil i ti ity n/F nt er / p ear es r te d/ ovid Lo er w s HI Cu V ltu ris re k /R el ig io n 0% • Most common primary barriers to VMMC were concern about Lost wages from time spent getting MC and during recovery (34%) and concerns of Pain or fear (32%) • Dislike of VMMC facility or providers (13%) (including queuing with younger clients, facilities with female service providers, inconvenient site location/hours) and Culture/Religion (7%) were less common primary barriers • Additional barriers included in Other category: long waits at clinic; 6 weeks of sexual abstinence; VMMC is perceived to be for younger boys, lack of VMMC information or knowledge, and being HIV+ • Similar responses by age, educational attainment, marital status, and county

Results: Facilitators Primary reason for circumcision prior to the intervention (n= 2, 849) and during the intervention period (n=363) 60% 50% Circumcised prior to study 50% 43% 40% Circumcised during study 30% 19% 20% 17% 14% 16% 9% 10% 7% 9% 7% 8% 1% 0% du Re ce IV d. H ris e n Re / re u lt Cu k io lig hy a ur E o nc lt ea rh e th d ge ds n e ri h O o pr Im d ve n gie b am yf il r yo f er h Ot no n a he lth • Most common primary facilitators to VMMC were Reduction in HIV risk for men circumcised before the study (43%), and those circumcised during the study (50%) • For men circumcised prior to study, Culture/Religion was also a primary facilitator (19%), but not for those circumcised during the study (1%) • Additional facilitators included in Other health category: Reduced STI risk; Reduced cervical cancer risk in partners; reduced penile cancer risk • Other non-health categories included Improved sexual performance; peer pressure • Similar responses by age, educational attainment, marital status, and county

Conclusions • Concern about lost wages and pain/fear are the most common reasons why uncircumcised men aged 25 -39 years were not circumcised prior to the study • Dislike of the VMMC facility or providers is also an important barrier to uptake for these men • Concerns about the recommended 6 weeks of sexual abstinence was not a common primary barrier • Reduction of HIV risk is the primary reason why men aged 25 -39 years get circumcised • Innovative demand creation strategies are needed to address structural and financial barriers among uncircumcised men aged 25 -39 years in Nyanza Region, Kenya

Acknowledgments Impact Research and Development Organization CDC Atlanta Kawango Agot Benard Ayieko Edward Mboya Duncan Odera Spala Ohaga Eunice Omanga Jacob Onyango Walter Otieno Leonard Soo CDC Kenya Naomi Bock Jonathan Grund Sarah Porter Carlos Toledo Ojwang’ Lusi Donath Emusu Paul Musingila Samuel Mwalili Elijah Odoyo-June Frankline Onchiri Boaz Otieno-Nyunya Emily Zielinski-Gutierrez Ministry of Health-Kenya University of North Carolina Inter-County VMMC Taskforce Athanasius Ochieng Harsha Thirumurthy

Thank you! Jonathan Grund jgrund@cdc. gov