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Elizabeth William Mauya Master of Public Health (MPH) Dissertation University of Dar es Salaam November 2018 THE PERCEPTION AND ACCEPTABILITY OF MALE CIRCUMCISION AS AN HIV PREVENTIVE MEASURE IN NJOMBE TOWN COUNCIL, NJOMBE REGION By Elizabeth William Mauya The Dissertation is submitted in Partial Fulfillment of the Requirements for Degree of Masters in Public Health of the University of Dar es salaam. University of Dar es Salaam. November 2018.CERTIFICATION This is to certify that the undersigned read and that I do hereby recommend for acceptance by the University of Dar es Salaam a dissertation entitled The perception and acceptability of male circumcision as an HIV preventive measure in Njombe Town Council in fulfillment of the requirements for the degree of Masters in Public Health of the University of Dar es Salaam Dr. Gasto Frumence (Supervisor) Date. DECLARATION AND COPYRIGHT I, Elizabeth William Mauya, do hereby declare that this Dissertation is my own original work and that it has not been presented and will not be presented to any other University for a similar or any other degree award. Signature This Dissertation is copyright material presented under the Berne Convention, the Copyright Act 1999 and other International and national enactments, on that behalf on Intellectual property. It may not be reproduced by any means, in full or in part, except for short extracts in fair dealings, for research or private study, critical scholarly review or discourse with an acknowledgment, without the written permission of the School of Graduate Studies on behalf of both the author and the University of Dar es Salaam. ACKNOWLEDGEMENT Above all, my appreciations are towards Almighty God. His strength, power, protection and support enabled me to me reach the goal of this study. My beloved brother Nicholaus Mauya also deserves a vote of thanks for his moral support from the beginning of my studies to the very end. I would like to express my heartfelt appreciation to my supervisor Dr, Gasto Frumence, for his guidance and support for making sure this work successful. With genuine humility and much respect, I would like extend my wholehearted appreciation to the University of Dar es Salaam particularly the College of Social Science department of Sociology for introducing Masters of Public health. In particular, I would like to extend my sincere gratitude to Jhpiego Male Circumcision team particularly Dr. Augustino Hellar, Flora Hezwa, Thomas Maokola, Mustapha Njozi,Frank Phiri, for shring their practical and theoretical knowledge wth me during the entire process of data collection, analysis and dissertation write up. My gratitude would never be fully extended if the Regional Health Management Team (RHMT) of Njombe region, Council Health Management Team (CHMT) of Njombe town council were left out. In particular, I thank Dr, Eusebi Kessy (Njombe Regional Aids Coordinator) together with Male Circumcision providers, community health promoters for giving me useful information for my research. Last but far from the least, I thank my classmates for the wholehearted cooperation, support, constant reminders and encouragements that fueled my self-esteem and confidence in carrying out this study. I will ceaselessly remember them in my carrier life. DEDICATION I am dedicating this dissertation to my lovely late father Mr. William Mauya, who would always be proud of my academic achievement, may his soul rest in an eternal peace, Amen. Also to my mother Mrs. Christina Mauya and to all my brothers and sisters, who have tirelessly supported and encouraged me. ABSTRACT Voluntary Medical Male Circumcision (VMMC) has been proved as a biomedical intervention that would be potential to save millions of lives and significant resources if it can be scaled up in high HIV prevalence regions where male circumcision is uncommon. While male circumcision is considered to be an effective new intervention in the fight against HIV and AIDS, it has raised social cultural debate and objection from different people in the community at large. The study aimed at examining the perception and acceptability of Voluntary Medical Male Circumcision as a strategy for HIV prevention in Njombe town council with the highest HIV prevalence. The study adopted a descriptive case study, data collection was done through the use of interviews, questionnaires and literature review. The study population included community members and some officials who work in different organizations dealing with VMMC. The findings show that various factors influence community participation on male circumcision such as costs of service, wound healing time, awareness of the existence of male circumcision services and importance of male circumcision towards prevention of HIV. The study indicated that respondents are aware of the existing link between male circumcisions and prevention of HIV/AIDS. It was found out that factors that influenced the circumcision of males in the region were due to the ongoing campaign conducted by government and non-government organizations. The study also found out that many stakeholders participate in male circumcision including the government of Tanzania, WHO/UNAIDS, USAID and others. The study recommends that male circumcision should be integrated on the daily routine of health services that are provided in the facilities. ABBREVIATIONS AND ACRONYMS AIDSAcquired Immune Deficiency SyndromeCHMTCouncil Health Management TeamCSO Community Sensitization OrganizationEIMCEarly Infant Male CircumcisionHIVHuman Immune deficiency VirusHPVHuman Papilloma VirusMCMale CircumcisionMCHIP Maternal and Child Integrated ProgramMoHCDGEC Ministry of Health, Community Development, Gender, Elderly and ChildrenNACP National AIDS Control ProgrammeNGONon-Governmental OrganizationPEPFARPresidents Emergency Plan for AIDS ReliefRHMT Regional Health management TeamSTISexually Transmitted InfectionTACAIDSTanzania Commission for AIDSTHIS Tanzania Health Information SystemTHMISTanzania Health Management System UNAIDSUnited Nations Joint Programme on HIV/AIDSUSAIDUnited States Agency for International DevelopmentVMMC Voluntary Medical Male CircumcisionWHOWorld Health Organization TABLE OF CONTENTS TOC o 1-3 u CERTIFICATION PAGEREF _Toc522541757 h i DECLARATION AND COPYRIGHT PAGEREF _Toc522541758 h ii ACKNOWLEDGEMENT PAGEREF _Toc522541761 h iii ABBREVIATIONS AND ACRONYMS PAGEREF _Toc522541762 h vi TABLE OF CONTENTS PAGEREF _Toc522541763 h vii LIST OF FIGURES PAGEREF _Toc522541764 h xi LIST OF TABLES PAGEREF _Toc522541765 h xii CHAPTER ONE PAGEREF _Toc522541766 h 1 INTRODUCTION PAGEREF _Toc522541767 h 1 1.1 Background to the problem PAGEREF _Toc522541768 h 1 1.2 Statement of the Problem PAGEREF _Toc522541769 h 3 1.3 Main Objective of the study PAGEREF _Toc522541770 h 4 1.4 Specific Objectives PAGEREF _Toc522541771 h 5 1.5 Research Questions PAGEREF _Toc522541772 h 5 1.6 Significance of the Study PAGEREF _Toc522541773 h 5 CHAPTER TWO PAGEREF _Toc522541774 h 6 REVIEW OF THE LITERATURE PAGEREF _Toc522541775 h 6 2.1 Introduction PAGEREF _Toc522541776 h 6 2.2 HIV epidemic in Njombe Town Council PAGEREF _Toc522541777 h 6 2.3 Male Circumcision as a HIV preventive measure PAGEREF _Toc522541778 h 7 2.4 Perception and acceptability of male circumcision among people. PAGEREF _Toc522541779 h 8 2.5 Stakeholders Involvement in scaling up for VMMC services. PAGEREF _Toc522541780 h 11 2.6 Theoretical Framework. PAGEREF _Toc522541781 h 12 CHAPTER THREE PAGEREF _Toc522541783 h 15 RESEARCH METHODOLOGY PAGEREF _Toc522541784 h 15 3.0. Introduction PAGEREF _Toc522541785 h 15 3.1 Research Design PAGEREF _Toc522541786 h 15 3.2 Study Area PAGEREF _Toc522541787 h 15 3.3 Study Population PAGEREF _Toc522541788 h 16 3.4. Sampling Procedure PAGEREF _Toc522541791 h 17 3.4.1 Selecting the Study participants for Quantitative interview PAGEREF _Toc522541792 h 17 3.4.1 Selecting the Study participants for Qualitative interview PAGEREF _Toc522541793 h 18 3.5.1. Collection of Primary Data PAGEREF _Toc522541794 h 18 3.5.2. Collection of Secondary Data PAGEREF _Toc522541795 h 19 3.6. Data collection Instruments PAGEREF _Toc522541796 h 19 3.6.1. Questionnaire PAGEREF _Toc522541797 h 19 3.6.2. Key informant interviews PAGEREF _Toc522541798 h 20 3.7. Ethical Consideration PAGEREF _Toc522541799 h 20 3.8. Validation of Research Instruments PAGEREF _Toc522541800 h 21 3.9. Data management and analysis PAGEREF _Toc522541801 h 21 CHAPTER FOUR PAGEREF _Toc522541802 h 22 FINDINGS AND DISCUSSION PAGEREF _Toc522541803 h 22 4.0 Introduction PAGEREF _Toc522541804 h 22 4.1 Social Demographic Characteristics of the Respondents PAGEREF _Toc522541805 h 22 4.2 Source of information about VMMC services PAGEREF _Toc522541807 h 24 4.3 Factors influencing acceptability of VMMC services PAGEREF _Toc522541809 h 24 4.3.1 Individual awareness of VMMC services as HIV preventive strategy PAGEREF _Toc522541810 h 25 4.3.2 Level of community participation on VMMC services PAGEREF _Toc522541811 h 25 4.3.3 Factors that might influence uptake of VMMC services PAGEREF _Toc522541813 h 26 4.4 Peoples perception about VMMC services as HIV preventive measure PAGEREF _Toc522541815 h 27 4.4.1 VMMC reduces the risks of getting HIV/AIDS PAGEREF _Toc522541816 h 28 4.4.2 Circumcised men do not have to use condom every time they have sex PAGEREF _Toc522541818 h 29 4.5 Stakeholders involved in VMMC and the role they play PAGEREF _Toc522541819 h 30 4.6 Factors that hinders VMMC services uptake for men aged 20 years and above PAGEREF _Toc522541821 h 35 CHAPTER FIVE PAGEREF _Toc522541823 h 41 SUMMARY, CONCLUSION AND RECOMMENDATION PAGEREF _Toc522541824 h 41 5.1 Summary of the Findings PAGEREF _Toc522541825 h 41 5.2 Conclusion PAGEREF _Toc522541826 h 43 5.3 Recommendations PAGEREF _Toc522541827 h 44 REFERENCES PAGEREF _Toc522541828 h 46 APPENDICIES PAGEREF _Toc522541829 h 53 APPENDIX 2 KEY INFORMANT INTERVIEW FORM PAGEREF _Toc522541830 h 58 LIST OF FIGURES Figure 1 Individual Perceptions Modifying Factors Likelihood of Action from Health Belief Model (Glanz et al, 2002). PAGEREF _Toc522541782 h 14 Figure 2 source of information about VMMC services PAGEREF _Toc522541808 h 24 Figure 3 Individual awareness and community participation on VMMC services PAGEREF _Toc522541812 h 26 Figure 4 VMMC uptake by age category from 2011 – 2016 PAGEREF _Toc522541822 h 36 LIST OF TABLES Table 1 Population Distribution by Age groups and by Sex in Njombe Town Council PAGEREF _Toc522541789 h 16 Table 2 socio demographic factors of respondents PAGEREF _Toc522541806 h 23 Table 3 Showing factor influencing male circumsion uptake in Njombe, 2016 PAGEREF _Toc522541814 h 27 Table 4 Peoples perception about VMMC services PAGEREF _Toc522541817 h 28 Table 5 A Summary of Stakeholders involvement in male circumsicion and the role played PAGEREF _Toc522541820 h 34 CHAPTER ONE INTRODUCTION 1.1 Background to the problem Male circumcision involves the complete removal of the entire foreskin that covers the head of the penis. Male circumcision is considered to be an old practice and common surgical procedure that has been conducted by a lot of societies for health, cultural or religious reasons ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1186/1471-2458-12-1067, ISSN 1471-2458, PMID 23227923, abstract BACKGROUND To investigate the changing circumcision rate in South Korea in the last decade and to propose underlying causes for this change, in the context of the present fluctuating world-wide trends in circumcision.nnMETHODS From 2009 to 2011, 3,296 South Korean males (or their parents) aged 0-64 years were asked about their circumcision status, their age at circumcision, and their information level regarding circumcision. We employed non-probability sampling considering the sensitive questions on the study theme.nnRESULTS Currently the age-standardized circumcision rate for South Korean males aged 14-29 is found to be 75.8. In an earlier study performed in 2002, the rate for the same age group was 86.3. Of particular interest, males aged 14-16 show a circumcision rate of 56.4, while the same age group 10 years ago displayed a much higher percentage, at 88.4. In addition, the extraordinarily high circumcision rate of 95.2 found 10 years ago for the 17-19 age group is now reduced to 74.4. Interestingly, of the circumcised males, the percentage circumcised in the last decade was only 25.2 i.e., the majority of the currently circumcised males had undergone the operation prior to 2002, indicating that the actual change in the last decade is far greater. Consistent with this conjecture, the 2002 survey showed that the majority of circumcised males (75.7) had undergone the operation in the decade prior to that point. Focusing on the flagship age group of 14-16, this drop suggests that, considering the population structure of Korean males, approximately one million fewer circumcision operations have been performed in the last decade relative to the case of non-decline. This decline is strongly correlated with the information available through internet, newspapers, lectures, books, and television within the circumcised population, both the patients and their parents had less prior knowledge regarding circumcision, other than information obtained from person to person by oral communication. Within the uncircumcised population, the prior knowledge was far greater, suggesting that information discouraging circumcision played an important role.nnCONCLUSION South Korean male circumcision is likely to be undergoing a steep decline. The cause for this decline seems to be the increase in information available on the pros and cons of circumcision., author dropping-particle , family Kim, given DaiSik, non-dropping-particle , parse-names false, suffix , dropping-particle , family Koo, given Sung-Ae, non-dropping-particle , parse-names false, suffix , dropping-particle , family Pang, given Myung-Geol, non-dropping-particle , parse-names false, suffix , container-title BMC public health, id ITEM-1, issued date-parts 2012 , page 1067, title Decline in male circumcision in South Korea., type article-journal, volume 12 , uris http//www.mendeley.com/documents/uuidf1cbec1c-2420-4cc7-9a1b-d00dadba138d , mendeley formattedCitation (Kim et al. 2012), plainTextFormattedCitation (Kim et al. 2012), previouslyFormattedCitation (Kim et al. 2012) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Kim et al. 2012). Epidemiological evidence has proved that male circumcision can prevent female to male HIV transmission in the following ways The fore skin creates a moist delicate part of the penis and the inner surface of the fore skin contains cells that are especially vulnerable to infection by HIV. If the fore skin is removed, the skin on the head of the penis tends to become tougher and more resistant to infection. In addition, any small tears in the fore skin that occur during sex make it much easier for the virus to enter the body ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.2471/BLT.08.051482, ISBN 1564-0604 (Electronic)n0042-9686 (Linking), ISSN 00429686, PMID 18797642, abstract OBJECTIVE Male circumcision reduces the risk of HIV acquisition by approximately 60. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries.nnMETHODS This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions.nnFINDINGS Of 443 males circumcised traditionally, 156 (35.2) experienced an adverse event compared with 99 of 559 (17.7) circumcised clinically (odds ratio 2.53 95 confidence interval 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities.nnCONCLUSION Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored., author dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , dropping-particle , family Egesah, given Omar, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Stephanie, non-dropping-particle , parse-names false, suffix , container-title Bulletin of the World Health Organization, id ITEM-1, issue 9, issued date-parts 2008 , page 669-677, title Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya, type article-journal, volume 86 , uris http//www.mendeley.com/documents/uuidd4bb5646-8ef0-480e-a304-99948e43a96b , mendeley formattedCitation (Bailey et al. 2008), plainTextFormattedCitation (Bailey et al. 2008), previouslyFormattedCitation (Bailey et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Bailey et al. 2008). Voluntary Medical Male Circumcision (VMMC) has been proved as a biomedical intervention that would be potential to save millions of lives and significant resources if it can be scaled up in high HIV prevalence regions where male circumcision is uncommon ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family PEPFAR, given , non-dropping-particle , parse-names false, suffix , id ITEM-1, issue June, issued date-parts 2013 , title PEPFAR Annual Report, type report , uris http//www.mendeley.com/documents/uuide0dc5c0d-f6d5-45ad-8124-269fca8a7af9 , mendeley formattedCitation (PEPFAR 2013), plainTextFormattedCitation (PEPFAR 2013), previouslyFormattedCitation (PEPFAR 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (PEPFAR 2013). Observational and epidemiological studies conducted suggest that male circumcision reduces the risk of HIV prevalence. Three randomized controlled trials conducted in South Africa, Kenya and Uganda showed that voluntary medical male circumcision reduces female to male HIV transmission by at least 60 ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pmed.0020298, ISBN 10.1371/journal.pmed.0020298, ISSN 15491277, PMID 16231970, abstract BACKGROUND Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted in a general population of South Africa to test this hypothesis.nnMETHODS AND FINDINGS A total of 3,274 uncircumcised men, aged 18-24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95 CI. Protection against HIV infection was calculated as 1 – RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0-21.0) when the data were analyzed. There were 20 HIV infections (incidence rate 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95 CI 0.24-0.68 p 0.001). This RR corresponds to a protection of 60 (95 CI 32-76). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61 (95 CI 34-77).nnCONCLUSION Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.)., author dropping-particle , family Auvert, given Bertran, non-dropping-particle , parse-names false, suffix , dropping-particle , family Taljaard, given Dirk, non-dropping-particle , parse-names false, suffix , dropping-particle , family Lagarde, given Emmanuel, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sobngwi-Tambekou, given Jolle, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sitta, given Rmi, non-dropping-particle , parse-names false, suffix , dropping-particle , family Puren, given Adrian, non-dropping-particle , parse-names false, suffix , container-title PLoS Medicine, id ITEM-1, issue 11, issued date-parts 2005 , page 1112-1122, title Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk The ANRS 1265 trial, type article-journal, volume 2 , uris http//www.mendeley.com/documents/uuid040baa59-9d72-4b32-84fe-7ea00ddb8000 , id ITEM-2, itemData DOI 10.2471/BLT.08.051482, ISBN 1564-0604 (Electronic)n0042-9686 (Linking), ISSN 00429686, PMID 18797642, abstract OBJECTIVE Male circumcision reduces the risk of HIV acquisition by approximately 60. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries.nnMETHODS This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions.nnFINDINGS Of 443 males circumcised traditionally, 156 (35.2) experienced an adverse event compared with 99 of 559 (17.7) circumcised clinically (odds ratio 2.53 95 confidence interval 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities.nnCONCLUSION Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored., author dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , dropping-particle , family Egesah, given Omar, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Stephanie, non-dropping-particle , parse-names false, suffix , container-title Bulletin of the World Health Organization, id ITEM-2, issue 9, issued date-parts 2008 , page 669-677, title Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya, type article-journal, volume 86 , uris http//www.mendeley.com/documents/uuidd4bb5646-8ef0-480e-a304-99948e43a96b , mendeley formattedCitation (Auvert et al. 2005 Bailey et al. 2008), plainTextFormattedCitation (Auvert et al. 2005 Bailey et al. 2008), previouslyFormattedCitation (Auvert et al. 2005 Bailey et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Auvert et al. 2005 Bailey et al. 2008).This finding is supported by over 40 sociological and epidemiological studies which show a strong link between circumcision and reduced HIV prevalence. Furthermore, the ecological studies have shown that those countries with the highest HIV prevalence are the ones with little practices of Male Circumcision ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.2471/BLT.08.051482, ISBN 1564-0604 (Electronic)n0042-9686 (Linking), ISSN 00429686, PMID 18797642, abstract OBJECTIVE Male circumcision reduces the risk of HIV acquisition by approximately 60. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries.nnMETHODS This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions.nnFINDINGS Of 443 males circumcised traditionally, 156 (35.2) experienced an adverse event compared with 99 of 559 (17.7) circumcised clinically (odds ratio 2.53 95 confidence interval 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities.nnCONCLUSION Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored., author dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , dropping-particle , family Egesah, given Omar, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Stephanie, non-dropping-particle , parse-names false, suffix , container-title Bulletin of the World Health Organization, id ITEM-1, issue 9, issued date-parts 2008 , page 669-677, title Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya, type article-journal, volume 86 , uris http//www.mendeley.com/documents/uuidd4bb5646-8ef0-480e-a304-99948e43a96b , mendeley formattedCitation (Bailey et al. 2008), plainTextFormattedCitation (Bailey et al. 2008), previouslyFormattedCitation (Bailey et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Bailey et al. 2008). Also, male circumcision is believed to offer a value for money as it saves costs by averting new HIV infection and reducing the number of people needing HIV treatment and care ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISBN 978 92 4 159556 8, abstract Until recently, the primary model for providing HIV testing and counselling has been client-initiated HIV testing and counselling – also known as voluntary counselling and testing (VCT) – in which individuals must actively seek an HIV test at a health or community-based facility. But uptake of client-initiated HIV testing and counselling has been limited by low coverage of services, fear of stigma and discrimination, and the perception by many people – even in high prevalence areas – that they are not at risk. Current evidence also suggests many opportunities to diagnose HIV in clinical settings are being missed, even in places with serious HIV epidemics. While, therefore, expanded access to client-initiated HIV testing and counselling is still necessary, other approaches are also required if coverage of HIV testing and counselling is to increase and, ultimately, universal access to HIV prevention, treatment, care and support is to be achieved. The new WHO/UNAIDS guidance was prepared in light of increasing evidence that provider-initiated testing and counselling can increase uptake of HIV testing, improve access to health services for people living with HIV, and may create new opportunities for HIV prevention. Provider-initiated HIV testing and counselling involves the health care provider specifically recommending an HIV test to patients attending health facilities. In these circumstances, once specific pre-test information has been provided, the HIV test would ordinarily be performed unless the patient declines. Provider-initiated HIV testing and counselling has already been implemented in a range of clinical settings in several low- and middle-income countries, including Botswana, Kenya, Malawi, Uganda and Zambia, as well as in pre-natal settings in parts of Canada, Thailand, the United Kingdom, and the United States., author dropping-particle , family WHO, given , non-dropping-particle , parse-names false, suffix , id ITEM-1, issued date-parts 2007 , number-of-pages 1-60, title Guidance on provider-initiated HIV testing and counselling in health facilities, type book , uris http//www.mendeley.com/documents/uuid9c2cba14-e9bf-421a-a7b3-e0fd46f24078 , mendeley formattedCitation (WHO 2007b), plainTextFormattedCitation (WHO 2007b), previouslyFormattedCitation (WHO 2007b) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (WHO 2007b). In addition to the reduction risk of acquiring HIV infection among circumcised men, male circumcision provides other health benefits to men and to women as analyzed below Male Circumcision reduces the risk of acquiring some sexually transmitted infections (STIs) particularly ulcerative STIs, including herpes and syphilis ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1136/sti.2005.017442, ISBN 1368-4973 (Print)r1368-4973 (Linking), ISSN 1368-4973, PMID 16581731, abstract OBJECTIVES Male circumcision is associated with reduced risk of HIV infection. This may be partly because of a protective effect of circumcision on other sexually transmitted infections (STI), especially those causing genital ulcers, but evidence for such protection is unclear. Our objective was to conduct a systematic review and meta-analyses of the associations between male circumcision and infection with herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Haemophilus ducreyi. METHODS Electronic databases (1950-2004) were searched using keywords and text terms for herpes simplex, syphilis, chancroid, ulcerative sexually transmitted diseases, or their causative agents, in conjunction with terms to identify epidemiological studies. References of key articles were hand searched, and data were extracted using standardised forms. Random effects models were used to summarise relative risk (RR) where appropriate. RESULTS 26 articles met the inclusion criteria. Most syphilis studies reported a substantially reduced risk among circumcised men (summary RR 0.67, 95 confidence interval (CI) 0.54 to 0.83), although there was significant between study heterogeneity (p 0.01). The reduced risk of HSV-2 infection was of borderline statistical significance (summary RR 0.88, 95 CI 0.77 to 1.01). Circumcised men were at lower risk of chancroid in six of seven studies (individual study RRs 0.12 to 1.11). CONCLUSIONS This first systematic review of male circumcision and ulcerative STI strongly indicates that circumcised men are at lower risk of chancroid and syphilis. There is less association with HSV-2. Potential male circumcision interventions to reduce HIV in high risk populations may provide additional benefit by protecting against other STI., author dropping-particle , family Weiss, given Ha a, non-dropping-particle , parse-names false, suffix , dropping-particle , family Thomas, given Sl L, non-dropping-particle , parse-names false, suffix , dropping-particle , family Munabi, given Sk K, non-dropping-particle , parse-names false, suffix , dropping-particle , family Hayes, given Rj J, non-dropping-particle , parse-names false, suffix , container-title Sexually transmitted infections, id ITEM-1, issue 2, issued date-parts 2006 , page 101-9 discussion 110, title Male circumcision and risk of syphilis, chancroid, and genital herpes a systematic review and meta-analysis., type article-journal, volume 82 , uris http//www.mendeley.com/documents/uuiddc72fc1a-0878-48c1-9fd5-7678ab6dea9e , mendeley formattedCitation (Weiss et al. 2006), plainTextFormattedCitation (Weiss et al. 2006), previouslyFormattedCitation (Weiss et al. 2006) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Weiss et al. 2006). Scientifically it has being proven that men who are circumcised has got a lower risk of getting a penile cancer ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Castellsaguu00e9, given Xavier, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bosch, given Xavier, non-dropping-particle , parse-names false, suffix , dropping-particle , family Muu00f1oz, given Nubia, non-dropping-particle , parse-names false, suffix , dropping-particle , family Meijer, given Chris, non-dropping-particle , parse-names false, suffix , dropping-particle V., family Shah, given Keerti, non-dropping-particle , parse-names false, suffix , dropping-particle De, family Sanjosu00e9, given Silvia, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ranceschi, given Silvia F, non-dropping-particle , parse-names false, suffix , container-title The New England journal of medicine, id ITEM-1, issue 15, issued date-parts 2002 , page 69-75, title Male Circumcision, Penile Human Papillomavirus Infection, and Cervical Cancer In Female Partners, type article-journal, volume 346 , uris http//www.mendeley.com/documents/uuid1392d2b7-f2bb-47bc-b03d-947382cb795e , mendeley formattedCitation (Castellsaguu00e9 et al. 2002), plainTextFormattedCitation (Castellsaguu00e9 et al. 2002), previouslyFormattedCitation (Castellsaguu00e9 et al. 2002) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Castellsagu et al. 2002). Male circumcision is also associated with the lower rate of urinary tract infection among male infants. The results from meta-analysis reported that male infants who were circumcised were found to have lower rate of urinary tract infection compared to uncircumcised male infants ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Morris, given Brian J., non-dropping-particle , parse-names false, suffix , dropping-particle , family Wiswell, given Thomas E., non-dropping-particle , parse-names false, suffix , container-title The Journal of Urology, id ITEM-1, issue 6, issued date-parts 2013 , page 2118, title Circumcision and Lifetime Risk of Urinary Tract Infection A Systematic Review and Meta-Analysis, type article-journal, volume 189 , uris http//www.mendeley.com/documents/uuid3ab977d7-d7bb-46c4-8695-629f748f6977 , id ITEM-2, itemData DOI 10.1136/adc.2004.049353, ISBN 1468-2044 (Electronic)r0003-9888 (Linking), ISSN 1468-2044, PMID 15890696, abstract Objective To undertake a meta-analysis of published data on the effect of circumcision on the risk of urinary tract infection (UTI) in boys. Data sources Randomised controlled trials and observational studies comparing the frequency of UTI in circumcised and uncircumcised boys were identified from the Cochrane controlled trials register, MEDLINE, EMBASE, reference lists of retrieved articles, and contact with known investigators. Methods Two of the authors independently assessed study quality using the guidelines provided by the MOOSE statement for quality of observational studies. A random effects model was used to estimate a summary odds ratio (OR) with 95 confidence intervals (CI). Results Data on 402 908 children were identified from 12 studies (one randomised controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with a significantly reduced risk of UTI (OR 0.13 95 CI, 0.08 to 0.20 p0.001) with the same odds ratio (0.13) for all three types of study design. Conclusions Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1, the number-needed-to-treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of UTI recurrence is 10 and 30 and the numbers-needed-to-treat are 11 and 4, respectively. Haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2. Assuming equal utility of benefits and harms, net clinical benefit is likely only in boys at high risk of UTI., author dropping-particle , family Singh-Grewal, given D, non-dropping-particle , parse-names false, suffix , dropping-particle , family Macdessi, given J, non-dropping-particle , parse-names false, suffix , dropping-particle , family Craig, given J, non-dropping-particle , parse-names false, suffix , container-title Arch Dis Child, id ITEM-2, issued date-parts 2005 , page 853-858, title Circumcision for the prevention of urinary tract infection in boys a systematic review of randomised trials and observational studies, type article-journal, volume 90 , uris http//www.mendeley.com/documents/uuid446fb63c-eec8-4737-8c92-15e539e80d6e , mendeley formattedCitation (Morris Wiswell 2013 Singh-Grewal et al. 2005), plainTextFormattedCitation (Morris Wiswell 2013 Singh-Grewal et al. 2005), previouslyFormattedCitation (Morris Wiswell 2013 Singh-Grewal et al. 2005) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Morris Wiswell 2013 Singh-Grewal et al. 2005) Male circumcision has been proved to protect women from getting human papilloma virus (HPV) which ultimately leads to cervical cancer. Scientific evidence has shown that a man who is circumcised has a less likely chance of transmitting HPV to a woman as well as other sexual transmitted infection ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1097/OLQ.0b013e31822e60cb, ISBN 0148-5717, ISSN 0148-5717, PMID 20371490, abstract Backgroundu2014The role of circumcision in male HPV acquisition is not clear. Methodsu2014Male university students (18u201320 years of age) were recruited from 2003u20132009 and followed tri-annually. Shaft/scrotum, glans, and urine samples were tested for 37 alpha HPV genotypes. Cox proportional hazards methods were used to evaluate the association between circumcision and HPV acquisition. Logistic regression was used to assess whether number of genital sites infected at incident HPV detection or site of incident detection varied by circumcision status. Resultsu2014In 477 men, rates of acquiring clinically-relevant HPV types (high-risk types plus types 6 and 11) did not differ significantly by circumcision status (hazard ratio HR for uncircumcised relative to circumcised subjects 0.995CI0.7u20131.2). However, compared to circumcised men, uncircumcised men were 10.1 (95CI2.9u201335.6) times more likely to have the same HPV type detected in all 3 genital specimens than in a single genital specimen and were 2.7 (95CI1.6u20134.5) times more likely to have an HPV-positive urine or glans specimen at first detection. Conclusionsu2014While the likelihood of HPV acquisition did not differ by circumcision status, uncircumcised men were more likely than circumcised men to have infections detected at multiple genital sites, which may have implications for HPV transmission., author dropping-particle , family VanBuskirk, given Kelley, non-dropping-particle , parse-names false, suffix , dropping-particle , family Winer, given Rachel L., non-dropping-particle , parse-names false, suffix , dropping-particle , family Hughes, given James P., non-dropping-particle , parse-names false, suffix , dropping-particle , family Feng, given Qinghua, non-dropping-particle , parse-names false, suffix , dropping-particle , family Arima, given Yuzo, non-dropping-particle , parse-names false, suffix , dropping-particle , family Lee, given Shu-Kuang, non-dropping-particle , parse-names false, suffix , dropping-particle , family Stern, given Michael E., non-dropping-particle , parse-names false, suffix , dropping-particle , family Ou02bcReilly, given Sandra F., non-dropping-particle , parse-names false, suffix , dropping-particle , family Koutsky, given Laura A., non-dropping-particle , parse-names false, suffix , container-title Sexually Transmitted Diseases, id ITEM-1, issue 11, issued date-parts 2011 , page 1074-1081, title Circumcision and Acquisition of Human Papillomavirus Infection in Young Men, type article-journal, volume 38 , uris http//www.mendeley.com/documents/uuid3043e1ce-2f5f-490d-91ba-746c36676327 , id ITEM-2, itemData DOI 10.1086/528379, ISBN 0022-1899, ISSN 0022-1899, PMID 18284369, abstract Background. Lack of circumcision has been identified as a risk factor for male genital human papillomavirus (HPV) infection, although this association has not been consistently supported. Methods. Specimens for HPV testing were collected from a cohort of 379 (primarily heterosexual) adult males. HPV prevalence in the glans penis and coronal sulcus, penile shaft, scrotum, semen, and urine was compared by circumcision status. Results. Overall, HPV DNA prevalence ranged from 6 in semen to 52 in the penile shaft. The prevalence of anyHPVinfection in the glans/corona was significantly higher in uncircumcisedmen(46) than in circumcisedmen (29) (odds ratio OR, 1.96 95 confidence interval CI, 1.02u20133.75, adjusted for demographic characteristics and sexual history). Uncircumcised men also had an increased risk of oncogenic HPV infection (adjusted OR, 2.51 95 CI, 1.11-5.69) and infection with multiple HPV types (adjusted OR, 3.56 95 CI, 1.50u20138.50). Among uncircum- cised men, HPV prevalence in the foreskin (44) was comparable to that in the glans/corona, and type-specific positivity was observed between the 2 sites ( 0.52). Conclusions. Uncircumcised men have an increased risk of HPV infection, including with oncogenic HPV, specifically localized to the glans/corona, possibly because of its proximity to the foreskin, which may be particularly vulnerable to infection., author dropping-particle , family Hernandez, given B. Y., non-dropping-particle , parse-names false, suffix , dropping-particle , family Wilkens, given L. R., non-dropping-particle , parse-names false, suffix , dropping-particle , family Zhu, given X., non-dropping-particle , parse-names false, suffix , dropping-particle , family McDuffie, given K., non-dropping-particle , parse-names false, suffix , dropping-particle , family Thompson, given P., non-dropping-particle , parse-names false, suffix , dropping-particle , family Shvetsov, given Y. B., non-dropping-particle , parse-names false, suffix , dropping-particle , family Ning, given L., non-dropping-particle , parse-names false, suffix , dropping-particle , family Goodman, given M. T., non-dropping-particle , parse-names false, suffix , container-title The Journal of Infectious Diseases, id ITEM-2, issue 6, issued date-parts 2008 , page 787-794, title Circumcision and Human Papillomavirus Infection in Men A Site-Specific Comparison, type article-journal, volume 197 , uris http//www.mendeley.com/documents/uuid2cd0c073-f6a7-49be-8ebd-240294766722 , mendeley formattedCitation (VanBuskirk et al. 2011 Hernandez et al. 2008), plainTextFormattedCitation (VanBuskirk et al. 2011 Hernandez et al. 2008), previouslyFormattedCitation (VanBuskirk et al. 2011 Hernandez et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (VanBuskirk et al. 2011 Hernandez et al. 2008). Moreover, desire in sexual desire and sexual un-inhabitation can be increased through male circumcision ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Morris, given Brian J., non-dropping-particle , parse-names false, suffix , dropping-particle , family Krieger, given John N., non-dropping-particle , parse-names false, suffix , container-title The Journal of Sexual Medicine, id ITEM-1, issue 11, issued date-parts 2013 , page 2644, title Does Male Circumcision Affect Sexual Function, Sensitivity, or Satisfactionu2014A Systematic Review, type article-journal, volume 10 , uris http//www.mendeley.com/documents/uuidf92b9186-7a0e-48b3-bdfc-fb30de5d2db2 , mendeley formattedCitation (Morris Krieger 2013), plainTextFormattedCitation (Morris Krieger 2013), previouslyFormattedCitation (Morris Krieger 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Morris Krieger 2013). Based on the results from the studies conducted by the World Health Organization (WHO) and joint United Nations Programme on HIV/AIDS, it was recommended that different countries in Sub-Saharan Africa should introduce and scale up male circumcision services as an important intervention for HIV prevention ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISBN 978 92 4 159556 8, abstract Until recently, the primary model for providing HIV testing and counselling has been client-initiated HIV testing and counselling – also known as voluntary counselling and testing (VCT) – in which individuals must actively seek an HIV test at a health or community-based facility. But uptake of client-initiated HIV testing and counselling has been limited by low coverage of services, fear of stigma and discrimination, and the perception by many people – even in high prevalence areas – that they are not at risk. Current evidence also suggests many opportunities to diagnose HIV in clinical settings are being missed, even in places with serious HIV epidemics. While, therefore, expanded access to client-initiated HIV testing and counselling is still necessary, other approaches are also required if coverage of HIV testing and counselling is to increase and, ultimately, universal access to HIV prevention, treatment, care and support is to be achieved. The new WHO/UNAIDS guidance was prepared in light of increasing evidence that provider-initiated testing and counselling can increase uptake of HIV testing, improve access to health services for people living with HIV, and may create new opportunities for HIV prevention. Provider-initiated HIV testing and counselling involves the health care provider specifically recommending an HIV test to patients attending health facilities. In these circumstances, once specific pre-test information has been provided, the HIV test would ordinarily be performed unless the patient declines. Provider-initiated HIV testing and counselling has already been implemented in a range of clinical settings in several low- and middle-income countries, including Botswana, Kenya, Malawi, Uganda and Zambia, as well as in pre-natal settings in parts of Canada, Thailand, the United Kingdom, and the United States., author dropping-particle , family WHO, given , non-dropping-particle , parse-names false, suffix , id ITEM-1, issued date-parts 2007 , number-of-pages 1-60, title Guidance on provider-initiated HIV testing and counselling in health facilities, type book , uris http//www.mendeley.com/documents/uuid9c2cba14-e9bf-421a-a7b3-e0fd46f24078 , mendeley formattedCitation (WHO 2007b), plainTextFormattedCitation (WHO 2007b), previouslyFormattedCitation (WHO 2007b) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (WHO 2007b). In Tanzania the National AIDS Control Programme (NACP) of the Ministry of Health Community Development, Gender, Elderly and Children (MoHCDGEC) introduced the scale up strategy for Voluntary Medical Male Circumcision in 2009, targeting male aged 11-34 years, particularly in 12 regions where male circumcision prevalence is low. The National Health Survey conducted in Tanzania identified Njombe region as one among the regions with the highest HIV prevalence estimated at 15 and low male circumcision prevalence of 49 ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1159/000362780.Interpretation, ISSN 09697330, abstract Tanzania Commission for AIDS (TACAIDS)HIV/AIDS and Malaria Indicator Survey 2011-12, author dropping-particle , family Tanzania Commission for AIDS (TACAIDS), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family Zanzibar AIDS Commission (ZAC), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family National Bureau of Statistics (NBS) Tanzania and Macro International Inc., given , non-dropping-particle , parse-names false, suffix , container-title Dar es Salaam, Tanzania, id ITEM-1, issued date-parts 2013 , number-of-pages 103-110, publisher-place Dar es Salaam, title HIV/AIDS and Malaria Indicator Survey 2011u201312, type report , uris http//www.mendeley.com/documents/uuid6d99d5fb-e0c2-479a-b554-c04537d7a790 , mendeley formattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), plainTextFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), previouslyFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Tanzania Commission for AIDS (TACAIDS) et al. 2013). Njombe region is among 12 regions in Tanzania providing VMMC as one of methods for HIV prevention since 2011. From 2011 to 2016 Njombe Region has being receiving technical and financial support from United States Presidents Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID). The VMMC intervention was being implemented under the Maternal and Child Integrated Program (MCHIP), which was led by Jhpiego (an affiliate of John Hopkins University) together with MoHCDGEC. The program have managed to provide VMMC service to 141,794 clients and HIV Counseling and testing ,91 of those males were circumcised ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family PEPFAR, given , non-dropping-particle , parse-names false, suffix , id ITEM-1, issue June, issued date-parts 2013 , title PEPFAR Annual Report, type report , uris http//www.mendeley.com/documents/uuide0dc5c0d-f6d5-45ad-8124-269fca8a7af9 , mendeley formattedCitation (PEPFAR 2013), plainTextFormattedCitation (PEPFAR 2013), previouslyFormattedCitation (PEPFAR 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (PEPFAR, 2013) 1.2 Statement of the Problem Following evidence from both observational and epidemiological studies, WHO recommended that member states should consider Male Circumcision (MC) as one of the new strategies for HIV prevention, and called for all countries including Tanzania to ensure that the national comprehensive HIV intervention packages contain male circumcision interventions ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISBN 978 92 4 159556 8, abstract Until recently, the primary model for providing HIV testing and counselling has been client-initiated HIV testing and counselling – also known as voluntary counselling and testing (VCT) – in which individuals must actively seek an HIV test at a health or community-based facility. But uptake of client-initiated HIV testing and counselling has been limited by low coverage of services, fear of stigma and discrimination, and the perception by many people – even in high prevalence areas – that they are not at risk. Current evidence also suggests many opportunities to diagnose HIV in clinical settings are being missed, even in places with serious HIV epidemics. While, therefore, expanded access to client-initiated HIV testing and counselling is still necessary, other approaches are also required if coverage of HIV testing and counselling is to increase and, ultimately, universal access to HIV prevention, treatment, care and support is to be achieved. The new WHO/UNAIDS guidance was prepared in light of increasing evidence that provider-initiated testing and counselling can increase uptake of HIV testing, improve access to health services for people living with HIV, and may create new opportunities for HIV prevention. Provider-initiated HIV testing and counselling involves the health care provider specifically recommending an HIV test to patients attending health facilities. In these circumstances, once specific pre-test information has been provided, the HIV test would ordinarily be performed unless the patient declines. Provider-initiated HIV testing and counselling has already been implemented in a range of clinical settings in several low- and middle-income countries, including Botswana, Kenya, Malawi, Uganda and Zambia, as well as in pre-natal settings in parts of Canada, Thailand, the United Kingdom, and the United States., author dropping-particle , family WHO, given , non-dropping-particle , parse-names false, suffix , id ITEM-1, issued date-parts 2007 , number-of-pages 1-60, title Guidance on provider-initiated HIV testing and counselling in health facilities, type book , uris http//www.mendeley.com/documents/uuid9c2cba14-e9bf-421a-a7b3-e0fd46f24078 , mendeley formattedCitation (WHO 2007b), plainTextFormattedCitation (WHO 2007b), previouslyFormattedCitation (WHO 2007b) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (WHO 2007). While male circumcision is considered to be an effective new intervention in the fight against HIV and AIDS, it has raised social cultural debate and objection from different people in the community at large. Despite all the efforts done to advocate for Voluntary Medical Male Circumcisions through community sensitization, peer promoters, magazine and radio advertisements, there is insufficient knowledge on how prevention of HIV can be archived through male circumcision. Study by ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.2471/BLT.08.051482, ISBN 1564-0604 (Electronic)n0042-9686 (Linking), ISSN 00429686, PMID 18797642, abstract OBJECTIVE Male circumcision reduces the risk of HIV acquisition by approximately 60. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries.nnMETHODS This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions.nnFINDINGS Of 443 males circumcised traditionally, 156 (35.2) experienced an adverse event compared with 99 of 559 (17.7) circumcised clinically (odds ratio 2.53 95 confidence interval 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities.nnCONCLUSION Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored., author dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , dropping-particle , family Egesah, given Omar, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Stephanie, non-dropping-particle , parse-names false, suffix , container-title Bulletin of the World Health Organization, id ITEM-1, issue 9, issued date-parts 2008 , page 669-677, title Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya, type article-journal, volume 86 , uris http//www.mendeley.com/documents/uuidd4bb5646-8ef0-480e-a304-99948e43a96b , mendeley formattedCitation (Bailey et al. 2008), plainTextFormattedCitation (Bailey et al. 2008), previouslyFormattedCitation (Bailey et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json Bailey et al. (2008) reported that the effectiveness of MC depends on its acceptability, particularly in African context where traditionally some communities do not practice Voluntary Medical Male Circumcision. Despite different initiatives conducted to promote Voluntary Medical Male Circumcision in Tanzania with particular focus in the regions and districts where HIV prevalence is high including Njombe town council, there is a limited research that has been carried out to examine the perception and acceptability of Male circumcision as HIV prevention strategy. Therefore this study is an attempt to address this knowledge gap by understanding and exploring the perception and acceptability of male circumcision as an HIV preventive measure. 1.3 Main Objective of the study The overall objective was to examine the perception and acceptability of Voluntary Medical Male Circumcision (VMMC) as a strategy for HIV prevention in Njombe Town Council. 1.4 Specific Objectives To assess the peoples perception about VMMC services as HIV preventive measure. To determine factors influencing acceptability of VMMC services. To describe various stakeholders involved in VMMC services and the role they play in creating demand for VMMC services at the community level. 1.5 Research Questions What are the peoples perceptions about VMMC services as a HIV prevention strategy What are the factors influencing acceptability of the VMMC services What are the role and contribution of various stakeholders in advocating for VMMC services 1.6 Significance of the Study The study serves primarily the significance at researchers level, being a fundamental requirement for the accomplishment of masters degree award at the University of Dar es Salaam. Findings of the study may help VMMC implementers to improve interventions to adults so as to increase number of adults accessing VMMC services. The study will as well provide a learning reference for other researchers around Tanzania and the world at large who are interested in conducting their studies in similar field hence addressing the knowledge gap on the issues relating to male circumcision and HIV/AIDS prevalence. CHAPTER TWO REVIEW OF THE LITERATURE 2.1 Introduction This chapter presents a review of literature on what other studies have reported on HIV epidemic. It focuses on Voluntary Medical Male Circumcision as a HIV preventive measure, perception and acceptability of Voluntary Medical Male Circumcision, stakeholders involvement in creating awareness and demand for Voluntary Medical Male Circumcision services in sub Saharan African as well as across the world. 2.2 HIV epidemic in Njombe Town Council The national HIV prevalence rate has shown a declining trend among adults aged 15-49.The prevalence has declined from 7.0 in 2003/04 to 5.7 in 2007/08 to 5.1 in 2011/12 ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1159/000362780.Interpretation, ISSN 09697330, abstract Tanzania Commission for AIDS (TACAIDS)HIV/AIDS and Malaria Indicator Survey 2011-12, author dropping-particle , family Tanzania Commission for AIDS (TACAIDS), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family Zanzibar AIDS Commission (ZAC), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family National Bureau of Statistics (NBS) Tanzania and Macro International Inc., given , non-dropping-particle , parse-names false, suffix , container-title Dar es Salaam, Tanzania, id ITEM-1, issued date-parts 2013 , number-of-pages 103-110, publisher-place Dar es Salaam, title HIV/AIDS and Malaria Indicator Survey 2011u201312, type report , uris http//www.mendeley.com/documents/uuid6d99d5fb-e0c2-479a-b554-c04537d7a790 , mendeley formattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), plainTextFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), previouslyFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Tanzania Commission for AIDS (TACAIDS) et al. 2013). Njombe Town Council has been reported to be the highest council with HIV prevalence in Njombe region of 14.2 which is considered to be three times over the national average. The lowest prevalence is recorded in Manyara region at 1.5 ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1159/000362780.Interpretation, ISSN 09697330, abstract Tanzania Commission for AIDS (TACAIDS)HIV/AIDS and Malaria Indicator Survey 2011-12, author dropping-particle , family Tanzania Commission for AIDS (TACAIDS), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family Zanzibar AIDS Commission (ZAC), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family National Bureau of Statistics (NBS) Tanzania and Macro International Inc., given , non-dropping-particle , parse-names false, suffix , container-title Dar es Salaam, Tanzania, id ITEM-1, issued date-parts 2013 , number-of-pages 103-110, publisher-place Dar es Salaam, title HIV/AIDS and Malaria Indicator Survey 2011u201312, type report , uris http//www.mendeley.com/documents/uuid6d99d5fb-e0c2-479a-b554-c04537d7a790 , mendeley formattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), plainTextFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), previouslyFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Tanzania Commission for AIDS (TACAIDS) et al. 2013).Lack of Voluntary Medical Male Circumcision is considered to be one of the factors responsible for the spread of HIV infection in Njombe Town Council, as Njombe Town Council is reported to have low prevalence of male circumcision which is at 49,ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1159/000362780.Interpretation, ISSN 09697330, abstract Tanzania Commission for AIDS (TACAIDS)HIV/AIDS and Malaria Indicator Survey 2011-12, author dropping-particle , family Tanzania Commission for AIDS (TACAIDS), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family Zanzibar AIDS Commission (ZAC), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family National Bureau of Statistics (NBS) Tanzania and Macro International Inc., given , non-dropping-particle , parse-names false, suffix , container-title Dar es Salaam, Tanzania, id ITEM-1, issued date-parts 2013 , number-of-pages 103-110, publisher-place Dar es Salaam, title HIV/AIDS and Malaria Indicator Survey 2011u201312, type report , uris http//www.mendeley.com/documents/uuid6d99d5fb-e0c2-479a-b554-c04537d7a790 , mendeley formattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), plainTextFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), previouslyFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Tanzania Commission for AIDS (TACAIDS) et al. 2013). 2.3 Male Circumcision as a HIV preventive measure Male circumcision is believed to protect male from infection with HIV because the mucosal tissue of the foreskin is more susceptible to HIV and can be an entry portal of the virus. Male circumcision together with other protective intervention could play an important role in HIV prevention ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISBN 978 92 4 159556 8, abstract Until recently, the primary model for providing HIV testing and counselling has been client-initiated HIV testing and counselling – also known as voluntary counselling and testing (VCT) – in which individuals must actively seek an HIV test at a health or community-based facility. But uptake of client-initiated HIV testing and counselling has been limited by low coverage of services, fear of stigma and discrimination, and the perception by many people – even in high prevalence areas – that they are not at risk. Current evidence also suggests many opportunities to diagnose HIV in clinical settings are being missed, even in places with serious HIV epidemics. While, therefore, expanded access to client-initiated HIV testing and counselling is still necessary, other approaches are also required if coverage of HIV testing and counselling is to increase and, ultimately, universal access to HIV prevention, treatment, care and support is to be achieved. The new WHO/UNAIDS guidance was prepared in light of increasing evidence that provider-initiated testing and counselling can increase uptake of HIV testing, improve access to health services for people living with HIV, and may create new opportunities for HIV prevention. Provider-initiated HIV testing and counselling involves the health care provider specifically recommending an HIV test to patients attending health facilities. In these circumstances, once specific pre-test information has been provided, the HIV test would ordinarily be performed unless the patient declines. Provider-initiated HIV testing and counselling has already been implemented in a range of clinical settings in several low- and middle-income countries, including Botswana, Kenya, Malawi, Uganda and Zambia, as well as in pre-natal settings in parts of Canada, Thailand, the United Kingdom, and the United States., author dropping-particle , family WHO, given , non-dropping-particle , parse-names false, suffix , id ITEM-1, issued date-parts 2007 , number-of-pages 1-60, title Guidance on provider-initiated HIV testing and counselling in health facilities, type book , uris http//www.mendeley.com/documents/uuid9c2cba14-e9bf-421a-a7b3-e0fd46f24078 , mendeley formattedCitation (WHO 2007b), plainTextFormattedCitation (WHO 2007b), previouslyFormattedCitation (WHO 2007b) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (WHO,2007b). The three randomized clinical trials that were conducted in Kenya, Uganda and South Africa proved that Male Circumcision is considered to be safe and effective method of reducing female to male HIV transmission by about 60 ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pmed.0020298, ISBN 10.1371/journal.pmed.0020298, ISSN 15491277, PMID 16231970, abstract BACKGROUND Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted in a general population of South Africa to test this hypothesis.nnMETHODS AND FINDINGS A total of 3,274 uncircumcised men, aged 18-24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95 CI. Protection against HIV infection was calculated as 1 – RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0-21.0) when the data were analyzed. There were 20 HIV infections (incidence rate 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95 CI 0.24-0.68 p 0.001). This RR corresponds to a protection of 60 (95 CI 32-76). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61 (95 CI 34-77).nnCONCLUSION Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.)., author dropping-particle , family Auvert, given Bertran, non-dropping-particle , parse-names false, suffix , dropping-particle , family Taljaard, given Dirk, non-dropping-particle , parse-names false, suffix , dropping-particle , family Lagarde, given Emmanuel, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sobngwi-Tambekou, given Jolle, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sitta, given Rmi, non-dropping-particle , parse-names false, suffix , dropping-particle , family Puren, given Adrian, non-dropping-particle , parse-names false, suffix , container-title PLoS Medicine, id ITEM-1, issue 11, issued date-parts 2005 , page 1112-1122, title Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk The ANRS 1265 trial, type article-journal, volume 2 , uris http//www.mendeley.com/documents/uuid040baa59-9d72-4b32-84fe-7ea00ddb8000 , id ITEM-2, itemData DOI 10.2471/BLT.08.051482, ISBN 1564-0604 (Electronic)n0042-9686 (Linking), ISSN 00429686, PMID 18797642, abstract OBJECTIVE Male circumcision reduces the risk of HIV acquisition by approximately 60. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries.nnMETHODS This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions.nnFINDINGS Of 443 males circumcised traditionally, 156 (35.2) experienced an adverse event compared with 99 of 559 (17.7) circumcised clinically (odds ratio 2.53 95 confidence interval 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities.nnCONCLUSION Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored., author dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , dropping-particle , family Egesah, given Omar, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Stephanie, non-dropping-particle , parse-names false, suffix , container-title Bulletin of the World Health Organization, id ITEM-2, issue 9, issued date-parts 2008 , page 669-677, title Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya, type article-journal, volume 86 , uris http//www.mendeley.com/documents/uuidd4bb5646-8ef0-480e-a304-99948e43a96b , mendeley formattedCitation (Auvert et al. 2005 Bailey et al. 2008), plainTextFormattedCitation (Auvert et al. 2005 Bailey et al. 2008), previouslyFormattedCitation (Auvert et al. 2005 Bailey et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Auvert et al. 2005 Bailey et al. 2008). The study found a statistically significant reduction in male participants risk for HIV infection from medical circumcision. In these studies, men who had been randomly assigned to the circumcision group had a 60 (South Africa), 53 (Kenya), and 51 (Uganda) lower incidence of HIV infection compared with men assigned to the wait-list group to be circumcised at the end of the study. Given results from the studies WHO recommended countries with the highest HIV prevalence and low prevalence of male circumcision practices to implement male circumcision as a potential intervention as a HIV prevention strategy ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISBN 978 92 4 159556 8, abstract Until recently, the primary model for providing HIV testing and counselling has been client-initiated HIV testing and counselling – also known as voluntary counselling and testing (VCT) – in which individuals must actively seek an HIV test at a health or community-based facility. But uptake of client-initiated HIV testing and counselling has been limited by low coverage of services, fear of stigma and discrimination, and the perception by many people – even in high prevalence areas – that they are not at risk. Current evidence also suggests many opportunities to diagnose HIV in clinical settings are being missed, even in places with serious HIV epidemics. While, therefore, expanded access to client-initiated HIV testing and counselling is still necessary, other approaches are also required if coverage of HIV testing and counselling is to increase and, ultimately, universal access to HIV prevention, treatment, care and support is to be achieved. The new WHO/UNAIDS guidance was prepared in light of increasing evidence that provider-initiated testing and counselling can increase uptake of HIV testing, improve access to health services for people living with HIV, and may create new opportunities for HIV prevention. Provider-initiated HIV testing and counselling involves the health care provider specifically recommending an HIV test to patients attending health facilities. In these circumstances, once specific pre-test information has been provided, the HIV test would ordinarily be performed unless the patient declines. Provider-initiated HIV testing and counselling has already been implemented in a range of clinical settings in several low- and middle-income countries, including Botswana, Kenya, Malawi, Uganda and Zambia, as well as in pre-natal settings in parts of Canada, Thailand, the United Kingdom, and the United States., author dropping-particle , family WHO, given , non-dropping-particle , parse-names false, suffix , id ITEM-1, issued date-parts 2007 , number-of-pages 1-60, title Guidance on provider-initiated HIV testing and counselling in health facilities, type book , uris http//www.mendeley.com/documents/uuid9c2cba14-e9bf-421a-a7b3-e0fd46f24078 , mendeley formattedCitation (WHO 2007b), plainTextFormattedCitation (WHO 2007b), previouslyFormattedCitation (WHO 2007b) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (WHO 2007b).The ecological studies have also shown that the countries in sub Saharan Africa with the highest HIV prevalence are those in which there is little male circumcision practice ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.2471/BLT.08.051482, ISBN 1564-0604 (Electronic)n0042-9686 (Linking), ISSN 00429686, PMID 18797642, abstract OBJECTIVE Male circumcision reduces the risk of HIV acquisition by approximately 60. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries.nnMETHODS This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions.nnFINDINGS Of 443 males circumcised traditionally, 156 (35.2) experienced an adverse event compared with 99 of 559 (17.7) circumcised clinically (odds ratio 2.53 95 confidence interval 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities.nnCONCLUSION Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored., author dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , dropping-particle , family Egesah, given Omar, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Stephanie, non-dropping-particle , parse-names false, suffix , container-title Bulletin of the World Health Organization, id ITEM-1, issue 9, issued date-parts 2008 , page 669-677, title Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya, type article-journal, volume 86 , uris http//www.mendeley.com/documents/uuidd4bb5646-8ef0-480e-a304-99948e43a96b , mendeley formattedCitation (Bailey et al. 2008), plainTextFormattedCitation (Bailey et al. 2008), previouslyFormattedCitation (Bailey et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Bailey et al. 2008). A study on the association between male circumcision and HIV infection was conducted in urban district of Bukoba and reported, that male circumcision has a significant protective effect against HIV infection. The study found that men who were uncircumcised were almost two times more likely to be HIV positive compared to those who were circumcised (OR1.9, 95 CI1.3-2.9). Furthermore, the study reported that male circumcision which was introduced as in intervention to HIV prevention in Kagera region where Bukoba urban district is situated, might have contributed to the decrease of HIV prevalence from 24 in 1987 to 4.7 in 2009 ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1186/2049-3258-72-38, ISSN 2049-3258, abstract Kagera is one of the 22 regions of Tanzania mainland, which has witnessed a decline in HIV prevalence during the past two decades decreasing from 24 in 1987 to 4.7 in 2009 in the urban district of Bukoba. Access to social capital, both structural and cognitive, might have played a role in this development. The aim was to examine the association between individual structural and cognitive social capital and socio-economic characteristics and the likelihood of being HIV infected. We conducted a population-based cross-sectional study of 3586 participants, of which 3423 (95) agreed to test for HIV following pre-test counseling. The HIV testing was performed using enzyme-linked immunosorbent assay (ELISA) antibody detection tests. Multiple logistic regression analysis was applied to estimate the impact of socio-economic factors, individual structural and cognitive social capital and HIV sero-status. Individuals who had access to low levels of both structural and cognitive individual social capital were four and three times more likely to be HIV positive compared to individuals who had access to high levels. The associations remained statistically significant for both individual structural and cognitive social capital after adjusting for potential confounding factors such as age, sex, marital status, occupation, level of education and wealth index (OR 8.6, CI 5.7-13.0 and OR 2.4, CI 1.6-3.5 for individual structural and cognitive social capital respectively). For both women and men access to high levels of individual structural and cognitive social capital decreased the risk of being HIV infected. This study confirms previous qualitative studies indicating that access to structural and cognitive social capital is protective to HIV infection. We suggest that policy makers and programme managers of HIV interventions may consider strengthening and facilitating access to social capital as a way of promoting HIV preventive information and interventions in order to reduce new HIV infections in Tanzania., author dropping-particle , family Frumence, given Gasto, non-dropping-particle , parse-names false, suffix , dropping-particle , family Emmelin, given Maria, non-dropping-particle , parse-names false, suffix , dropping-particle , family Eriksson, given Malin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kwesigabo, given Gideon, non-dropping-particle , parse-names false, suffix , dropping-particle , family Killewo, given Japhet, non-dropping-particle , parse-names false, suffix , dropping-particle , family Moyo, given Sabrina, non-dropping-particle , parse-names false, suffix , dropping-particle , family Nystrom, given Lennarth, non-dropping-particle , parse-names false, suffix , container-title Archives of Public Health, id ITEM-1, issue 1, issued date-parts 2014 , page 38, title Access to social capital and risk of HIV infection in Bukoba urban district, Kagera region, Tanzania, type article-journal, volume 72 , uris http//www.mendeley.com/documents/uuida8a940dc-e0cb-47cf-93b7-1736907c2346 , mendeley formattedCitation (Frumence et al. 2014), plainTextFormattedCitation (Frumence et al. 2014), previouslyFormattedCitation (Frumence et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Frumence et al. 2014). The data of Tanzania Health Management Information System (THMIS) of 2011-2012 has shown the relationship between HIV prevalence and male circumcision among men aged 15-49.The data reported that men who were circumcised had a lower infection of HIV compared to uncircumcised by 3 and 5 respectively ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1159/000362780.Interpretation, ISSN 09697330, abstract Tanzania Commission for AIDS (TACAIDS)HIV/AIDS and Malaria Indicator Survey 2011-12, author dropping-particle , family Tanzania Commission for AIDS (TACAIDS), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family Zanzibar AIDS Commission (ZAC), given , non-dropping-particle , parse-names false, suffix , dropping-particle , family National Bureau of Statistics (NBS) Tanzania and Macro International Inc., given , non-dropping-particle , parse-names false, suffix , container-title Dar es Salaam, Tanzania, id ITEM-1, issued date-parts 2013 , number-of-pages 103-110, publisher-place Dar es Salaam, title HIV/AIDS and Malaria Indicator Survey 2011u201312, type report , uris http//www.mendeley.com/documents/uuid6d99d5fb-e0c2-479a-b554-c04537d7a790 , mendeley formattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), plainTextFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013), previouslyFormattedCitation (Tanzania Commission for AIDS (TACAIDS) et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Tanzania Commission for AIDS (TACAIDS) et al. 2013). A situational analysis conducted in Tanzania recommended that circumcision should be rolled out for males of all ages in a culturally sensitive way and in a clinically safe setting, also priority should be in those areas where the prevalence of circumcision is low and the prevalence of HIV infection is high ADDIN CSL_CITATION citationItems id ITEM-1, itemData abstract HIV and AIDS remains the most important public health problem in Tanzania and sub- Saharan Africa. Promoting effective interventions that prevent new infections and controls the epidemic is a priority. Circumcision is an effective intervention for HIV prevention in men. This report describes the results of the situation analysis study conducted in rural and urban areas of Mara, Kagera and Mbeya Regions of Tanzania. The main objective of the study was to investigate the context, extent and pattern of male circumcision practices in selected areas of Tanzania and to provide recommendations to the government of Tanzania on the effective roll-out of male circumcision services in the country., author dropping-particle , family Wambura, given M, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mwanga, given J, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mosha, given J, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mshana, given G, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mosha, given F, non-dropping-particle , parse-names false, suffix , dropping-particle , family Changalucha, given J, non-dropping-particle , parse-names false, suffix , id ITEM-1, issue September, issued date-parts 2009 , number-of-pages 30-33, title Situation Analysis for Male Circumcision in Tanzania, type report , uris http//www.mendeley.com/documents/uuiddd20fa7e-5a5b-44e9-878e-08b04bd15faa , mendeley formattedCitation (Wambura et al. 2009), plainTextFormattedCitation (Wambura et al. 2009), previouslyFormattedCitation (Wambura et al. 2009) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Wambura et al. 2009). 2.4 Perception and acceptability of male circumcision among people. In most of Sub Saharan African Countries acceptability of male circumcision is likely to be perpetuated by various factors including socio-cultural beliefs, religion and perceived inappropriateness of the services after puberty ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISSN 2071-2936 (Electronic), PMID 27380850, abstract BACKGROUND Medical male circumcision (MMC) has become a significant dimension of HIV prevention interventions, after the results of three randomised controlled trials in Uganda, South Africa and Kenya demonstrated that circumcision has a protective effect against contracting HIV of up to 60. Following recommendations by the World Health Organization, Zimbabwe in 2009 adopted voluntary MMC as an additional HIV prevention strategy to the existing ABC behaviour change model. PURPOSE The purpose of this study is thus to investigate the factors contributing to the low uptake of MMC. METHODS The study was a quantitative cross-sectional survey conducted in Mutare rural district, Zimbabwe. Questionnaires with open- and closed-ended questions were administered to the eligible respondents. The target population were male participants aged 15-29 who met the inclusion criteria. The households were systematically selected with a sample size of 234. Statistical Package for the Social Sciences was used to analyse the data. RESULTS Socioculturally, circumcised men are viewed as worthless (37), shameful (30) and are tainted as promiscuous (20), psychological factors reported were infection and delayed healing (39), being ashamed and dehumanised (58), stigmatised and discriminated (40.2) and fear of having an erection during treatment period (89.7) whilst socio-economic factors were not having time, as it will take their time from work (58) and complications may arise leading to spending money on treatment (84). CONCLUSION Knowledge deficits regarding male medical circumcision lead to low uptake, education on male medical circumcision and its benefits. Comprehensive sexual health education should target men and dispel negative attitudes related to the use of health services., author dropping-particle , family Chiringa, given Irene O, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ramathuba, given Dorah U, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mashau, given Ntsieni S, non-dropping-particle , parse-names false, suffix , container-title African journal of primary health care family medicine, id ITEM-1, issue 2, issued date-parts 2016 , page e1-6, title Factors contributing to the low uptake of medical male circumcision in Mutare Rural District, Zimbabwe., type article-journal, volume 8 , uris http//www.mendeley.com/documents/uuid98dc1c0c-21f6-4432-a901-12cc6cdb874e , id ITEM-2, itemData DOI 10.1371/journal.pone.0083998, ISBN 1932-6203, ISSN 19326203, PMID 24802112, abstract BACKGROUND In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high.nnMETHODS AND FINDINGS Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their protection by marriage, cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men.nnCONCLUSIONS Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy., author dropping-particle , family Macintyre, given Kate, non-dropping-particle , parse-names false, suffix , dropping-particle , family Andrinopoulos, given Katherine, non-dropping-particle , parse-names false, suffix , dropping-particle , family Moses, given Natome, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bornstein, given Marta, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ochieng, given Athanasius, non-dropping-particle , parse-names false, suffix , dropping-particle , family Peacock, given Erin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bertrand, given Jane, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-2, issue 5, issued date-parts 2014 , page 1-7, title Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuidccb93f6d-21d5-4d6e-a5d9-13a905d0f76a , id ITEM-3, itemData DOI 10.1371/journal.pone.0085051, ISBN 10.1371/journal.pone.0085051, ISSN 19326203, PMID 24802746, abstract BACKGROUND We conducted quantitative and qualitative studies to explore barriers and motivating factors to VMMC for HIV prevention, and to assess utilization of existing VMMC communication channels.nnMETHODS AND FINDINGS A population-based survey was conducted with 2350 respondents aged 15-49. Analysis consisted of descriptive statistics and bivariate analysis between circumcision and selected demographics. Logistic regression was used to determine predictors of male circumcision uptake compared to intention to circumcise. Focus group discussions (FGDs) were held with men purposively selected to represent a range of ethnicities. 68 and 53 of female/male respondents, respectively, had heard about VMMC for HIV prevention, mostly through the radio (71). Among male respondents, 11.3 reported being circumcised and 49 reported willingness to undergo VMMC. Factors which men reported motivated them to undergo VMMC included HIV/STI prevention (44), improved hygiene (26), enhanced sexual performance (6) and cervical cancer prevention for partner (6). Factors that deterred men from undergoing VMMC included fear of pain (40), not believing that they were at risk of HIV (18), lack of partner support (6). Additionally, there were differences in motivators and barriers by age. FGDs suggested additional barriers including fear of HIV testing, partner refusal, reluctance to abstain from sex and myths and misconceptions.nnCONCLUSIONS VMMC demand-creation messages need to be specifically tailored for different ages and should emphasize non-HIV prevention benefits, such as improved hygiene and sexual appeal, and need to address mens fear of pain. Promoting VMMC among women is crucial as they appear to have considerable influence over mens decision to get circumcised., author dropping-particle , family Hatzold, given Karin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mavhu, given Webster, non-dropping-particle , parse-names false, suffix , dropping-particle , family Jasi, given Phineas, non-dropping-particle , parse-names false, suffix , dropping-particle , family Chatora, given Kumbirai, non-dropping-particle , parse-names false, suffix , dropping-particle , family Cowan, given Frances M., non-dropping-particle , parse-names false, suffix , dropping-particle , family Taruberekera, given Noah, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mugurungi, given Owen, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ahanda, given Kim, non-dropping-particle , parse-names false, suffix , dropping-particle , family Njeuhmeli, given Emmanuel, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-3, issue 5, issued date-parts 2014 , page 1-7, title Barriers and motivators to voluntary medical male circumcision uptake among different age groups of men in Zimbabwe Results from a mixed methods study, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuidc9b69880-9b9e-4855-bfdd-b820a05b7542 , mendeley formattedCitation (Chiringa et al. 2016 Macintyre et al. 2014 Hatzold et al. 2014), plainTextFormattedCitation (Chiringa et al. 2016 Macintyre et al. 2014 Hatzold et al. 2014), previouslyFormattedCitation (Chiringa et al. 2016 Macintyre et al. 2014 Hatzold et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Chiringa et al. 2016 Macintyre et al. 2014 Hatzold et al. 2014). An acceptability study that was done in Botswana, Kenya, Swaziland and South Africa discovered that more adults, both men and women will accept for their sons to be circumcised than their spouse or themselves. The studies have showed that 75 of the parents would accept circumcision to be done to their sons if it is safe, affordable and proven to protect against transmission of HIV/AIDS ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.2471/BLT.08.051482, ISBN 1564-0604 (Electronic)n0042-9686 (Linking), ISSN 00429686, PMID 18797642, abstract OBJECTIVE Male circumcision reduces the risk of HIV acquisition by approximately 60. Male circumcision services are now being introduced in selected populations in sub-Saharan Africa and further interventions are being planned. A serious concern is whether male circumcision can be provided safely to large numbers of adult males in developing countries.nnMETHODS This prospective study was conducted in the Bungoma district, Kenya, where male circumcision is universally practised. Young males intending to undergo traditional or clinical circumcision were identified by a two-stage cluster sampling method. During the July-August 2004 circumcision season, 1007 males were interviewed 30-89 days post- circumcision. Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-circumcision, and 298 men underwent clinical exams 45-89 days post-procedure. Twenty-one traditional and 20 clinical practitioners were interviewed to assess their experience and training. Inventories of health facilities were taken to assess the condition of instruments and supplies necessary for performing safe circumcisions.nnFINDINGS Of 443 males circumcised traditionally, 156 (35.2) experienced an adverse event compared with 99 of 559 (17.7) circumcised clinically (odds ratio 2.53 95 confidence interval 1.89-3.38). Bleeding and infection were the most common adverse effects, with excessive pain, lacerations, torsion and erectile dysfunction also observed. Participants were aged 5 to 21 years and half were sexually active before circumcision. Practitioners lacked knowledge and training. Proper instruments and supplies were lacking at most health facilities.nnCONCLUSION Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention. Two-thirds of African men are circumcised, most by traditional or unqualified practitioners in informal settings. Safety of circumcision in communities where it is already widely practised must not be ignored., author dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , dropping-particle , family Egesah, given Omar, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Stephanie, non-dropping-particle , parse-names false, suffix , container-title Bulletin of the World Health Organization, id ITEM-1, issue 9, issued date-parts 2008 , page 669-677, title Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya, type article-journal, volume 86 , uris http//www.mendeley.com/documents/uuidd4bb5646-8ef0-480e-a304-99948e43a96b , mendeley formattedCitation (Bailey et al. 2008), plainTextFormattedCitation (Bailey et al. 2008), previouslyFormattedCitation (Bailey et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Bailey et al. 2008). A study conducted in Tanzania has shown that both men and women supported male circumcision but they associated it with cultural values. For instance such procedure is most appropriate before adolescence as they consider it shameful for older men of 20 years and above to seek male circumcision services ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.9745/GHSP-D-12-00037, ISSN 2169-575X, PMID 25276521, abstract BACKGROUND In 2009, the Government of Tanzania embarked on scaling up voluntary medical male circumcision (VMMC) services for HIV prevention in 8 priority regions, with the aim of serving 2.8 million boys and men ages 10-34 years by 2013. By mid-2012, more than 110,000 boys and men in Iringa and Njombe regions had received VMMC. The majority (85) of these VMMC clients were under 19 years old (average age, 16 years). This study aimed to identify potential barriers and facilitators to VMMC among older men.nnMETHODS We conducted 16 focus group discussions, stratified by sex and age, with 142 purposefully selected participants in 3 districts of Iringa and Njombe regions.nnRESULTS Both men and women generally had positive attitudes toward VMMC. Social and personal barriers to obtaining VMMC among adult men included shame associated with seeking services co-located with younger boys and perceived inappropriateness of VMMC after puberty, particularly after marriage and after having children. Additional barriers included concerns about partner infidelity during the post-surgical abstinence period, loss of income, and fear of pain associated with post-surgical erections. Facilitators included awareness of the HIV-prevention benefit and perceptions of cleanliness and enhanced attractiveness to women.nnCONCLUSIONS While men and women in Iringa and Njombe regions in Tanzania generally view VMMC as a desirable procedure, program implementers need to address barriers to VMMC services among adult men. Selected service delivery sites in the Iringa and Njombe regions will be segregated by age to provide services that are friendly to adult men. Services will be complemented with behavior change communication initiatives to address concerns of older men, encourage womens support for circumcision and adherence to the post-surgical abstinence period, and change social norms that inhibit older men from seeking circumcision., author dropping-particle , family Plotkin, given Marya, non-dropping-particle , parse-names false, suffix , dropping-particle , family Castor, given Delivette, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mziray, given Hawa, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ku00fcver, given Jan, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mpuya, given Ezekiel, non-dropping-particle , parse-names false, suffix , dropping-particle , family Luvanda, given Paul James, non-dropping-particle , parse-names false, suffix , dropping-particle , family Hellar, given Augustino, non-dropping-particle , parse-names false, suffix , dropping-particle , family Curran, given Kelly, non-dropping-particle , parse-names false, suffix , dropping-particle , family Lukobo-Durell, given Mainza, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ashengo, given Tigistu Adamu, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mahler, given Hally, non-dropping-particle , parse-names false, suffix , container-title Global health, science and practice, id ITEM-1, issue 1, issued date-parts 2013 , page 108-16, title Man, what took you so long Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania., type article-journal, volume 1 , uris http//www.mendeley.com/documents/uuid713a3ff8-f117-45b2-adc5-a1ea69ebccde , mendeley formattedCitation (Plotkin et al. 2013), plainTextFormattedCitation (Plotkin et al. 2013), previouslyFormattedCitation (Plotkin et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Plotkin et al. 2013). Moreover, a study that was conducted in Northwest Tanzania on assessing the determinants of male circumcision status in traditionally non-circumcising ethnic group and the respondent reported that the reasons for accepting male circumcision is because it enhances penile hygiene, reduces sexually transmitted disease incidence, and improves sexually transmitted disease cure rates ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Nnko, given S, non-dropping-particle , parse-names false, suffix , dropping-particle , family R, given Washija, non-dropping-particle , parse-names false, suffix , dropping-particle , family M, given Urassa, non-dropping-particle , parse-names false, suffix , dropping-particle , family J, given Boerma, non-dropping-particle , parse-names false, suffix , container-title Sex Transm Dis, id ITEM-1, issue 4, issued date-parts 2001 , title Dynamics of male circumcision practices in northwest Tanzania, type article-journal, volume 28 , uris http//www.mendeley.com/documents/uuidc1e3b46c-5b4c-4824-8f3c-3af7c82e5b71 , mendeley formattedCitation (Nnko et al. 2001), plainTextFormattedCitation (Nnko et al. 2001), previouslyFormattedCitation (Nnko et al. 2001) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Nnko et al. 2001). Another study conducted in Tanzania among police officers in Dar es Salaam has provided important evidence about the perceived benefits of circumcision. The study found that knowledge, beliefs, perceptions and attitudes towards male circumcision influence the acceptability of male circumcision among adults ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1186/1471-2458-12-529, ISBN 1471-2458 (Electronic)r1471-2458 (Linking), ISSN 1471-2458, PMID 22812484, abstract BACKGROUND In recent randomized controlled trials, male circumcision has been proven to complement the available biomedical interventions in decreasing HIV transmission from infected women to uninfected men. Consequently, Tanzania is striving to scale-up safe medical male circumcision to reduce HIV transmission. However, there is a need to investigate the perceptions of male circumcision in Tanzania using specific populations. The purpose of the present study was to assess the perceptions of male circumcision in a cohort of police officers that also served as a source of volunteers for a phase I/II HIV vaccine (HIVIS-03) trial in Dar es Salaam, Tanzania.nnMETHODS In-depth interviews with 24 men and 10 women were conducted. Content analysis informed by the socio-ecological model was used to analyze the data.nnRESULTS Informants perceived male circumcision as a health-promoting practice that may prevent HIV transmission and other sexually transmitted infections. They reported male circumcision promotes sexual pleasure, confidence and hygiene or sexual cleanliness. They added that it is a religious ritual and a cultural practice that enhances the recognition of manhood in the community. However, informants were concerned about the cost involved in male circumcision and cleanliness of instruments used in medical and traditional male circumcision. They also expressed confusion about the shame of undergoing circumcision at an advanced age and pain that could emanate after circumcision. The participants advocated for health policies that promote medical male circumcision at childhood, specifically along with the vaccination program.nnCONCLUSIONS The perceived benefit of male circumcision as a preventive strategy to HIV and other sexually transmitted infections is important. However, there is a need to ensure that male circumcision is conducted under hygienic conditions. Integrating male circumcision service in the routine childhood vaccination program may increase its coverage at early childhood. The findings from this investigation provide contextual understanding that may assist in scaling-up male circumcision in Tanzania., author dropping-particle , family Tarimo, given Edith Am, non-dropping-particle , parse-names false, suffix , dropping-particle , family Francis, given Joel M, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kakoko, given Deodatus, non-dropping-particle , parse-names false, suffix , dropping-particle , family Munseri, given Patricia, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bakari, given Muhammad, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sandstrom, given Eric, non-dropping-particle , parse-names false, suffix , container-title BMC Public Health, id ITEM-1, issue 1, issued date-parts 2012 , page 529, publisher , title The perceptions on male circumcision as a preventive measure against HIV infection and considerations in scaling up of the services a qualitative study among police officers in Dar es Salaam, Tanzania, type article-journal, volume 12 , uris http//www.mendeley.com/documents/uuid3f1911e1-99fb-43e6-831b-c69435d359c8 , id ITEM-2, itemData DOI 10.1371/journal.pone.0134667, ISSN 19326203, PMID 26237217, abstract BACKGROUND Haiti has the highest number of people living with HIV infection in the Caribbean/Latin America region. Medical male circumcision (MMC) has been recommended to help prevent the spread of HIV. We sought to assess knowledge, attitudes, practices and beliefs about MMC among a sample of health care providers in Haiti.nnMETHODS A convenience sample of 153 health care providers at the GHESKIO Centers in Haiti responded to an exploratory survey that collected information on several topics relevant to health providers about MMC. Descriptive statistics were calculated for the responses and multivariable logistic regression was conducted to determine opinions of health care providers about the best age to perform MMC on males. Bayesian network analysis and sensitivity analysis were done to identify the minimum level of change required to increase the acceptability of performing MMC at age less than 1 year.nnRESULTS The sample consisted of medical doctors (31.0), nurses (49.0), and other health care professionals (20.0). Approximately 76 showed willingness to offer MMC services if they received training. Seventy-six percent believed that their male patients would accept circumcision, and 59 believed infancy was the best age for MMC. More than 90 of participants said that MMC would reduce STIs. Physicians and nurses who were willing to offer MMC if provided with adequate training were 2.5 (1.15-5.71) times as likely to choose the best age to perform MMC as less than one year. Finally, if the joint probability of choosing the best age to perform MMC as one year or older and having the mistaken belief that MMC prevents HIV entirely is reduced by 63 then the probability of finding that performing MMC at less than one year acceptable to health care providers is increased by 35.nnCONCLUSION Participants demonstrated high levels of knowledge and positive attitudes towards MMC. Although this study suggests that circumcision is acceptable among certain health providers in Haiti, studies with larger and more representative samples are needed to confirm this finding., author dropping-particle , family Du00e9vieux, given Jessy G., non-dropping-particle , parse-names false, suffix , dropping-particle , family Saxena, given Anshul, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenberg, given Rhonda, non-dropping-particle , parse-names false, suffix , dropping-particle , family Klausner, given Jeffrey D., non-dropping-particle , parse-names false, suffix , dropping-particle , family Jean-Gilles, given Michu00e8le, non-dropping-particle , parse-names false, suffix , dropping-particle , family Madhivanan, given Purnima, non-dropping-particle , parse-names false, suffix , dropping-particle , family Gaston, given Stu00e9phanie, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rubens, given Muni, non-dropping-particle , parse-names false, suffix , dropping-particle , family Theodore, given Harry, non-dropping-particle , parse-names false, suffix , dropping-particle , family Deschamps, given Marie Marcelle, non-dropping-particle , parse-names false, suffix , dropping-particle , family Koenig, given Serena P., non-dropping-particle , parse-names false, suffix , dropping-particle , family William Pape, given Jean, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-2, issue 8, issued date-parts 2015 , page 1-12, title Knowledge, attitudes, practices and beliefs about Medical Male Circumcision (MMC) among a sample of health care providers in Haiti, type article-journal, volume 10 , uris http//www.mendeley.com/documents/uuid2009cb66-0db8-4d81-875d-9c9f02df3808 , mendeley formattedCitation (Tarimo et al. 2012 Du00e9vieux et al. 2015), plainTextFormattedCitation (Tarimo et al. 2012 Du00e9vieux et al. 2015), previouslyFormattedCitation (Tarimo et al. 2012 Du00e9vieux et al. 2015) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Tarimo et al. 2012 Dvieux et al. 2015). People have got different perceptions about male circumcision, whereby some people have associated male circumcision with improved hygiene, some believe that circumcision leads to reduced incidence of STIs ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISSN 2071-2936 (Electronic), PMID 27380850, abstract BACKGROUND Medical male circumcision (MMC) has become a significant dimension of HIV prevention interventions, after the results of three randomised controlled trials in Uganda, South Africa and Kenya demonstrated that circumcision has a protective effect against contracting HIV of up to 60. Following recommendations by the World Health Organization, Zimbabwe in 2009 adopted voluntary MMC as an additional HIV prevention strategy to the existing ABC behaviour change model. PURPOSE The purpose of this study is thus to investigate the factors contributing to the low uptake of MMC. METHODS The study was a quantitative cross-sectional survey conducted in Mutare rural district, Zimbabwe. Questionnaires with open- and closed-ended questions were administered to the eligible respondents. The target population were male participants aged 15-29 who met the inclusion criteria. The households were systematically selected with a sample size of 234. Statistical Package for the Social Sciences was used to analyse the data. RESULTS Socioculturally, circumcised men are viewed as worthless (37), shameful (30) and are tainted as promiscuous (20), psychological factors reported were infection and delayed healing (39), being ashamed and dehumanised (58), stigmatised and discriminated (40.2) and fear of having an erection during treatment period (89.7) whilst socio-economic factors were not having time, as it will take their time from work (58) and complications may arise leading to spending money on treatment (84). CONCLUSION Knowledge deficits regarding male medical circumcision lead to low uptake, education on male medical circumcision and its benefits. Comprehensive sexual health education should target men and dispel negative attitudes related to the use of health services., author dropping-particle , family Chiringa, given Irene O, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ramathuba, given Dorah U, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mashau, given Ntsieni S, non-dropping-particle , parse-names false, suffix , container-title African journal of primary health care family medicine, id ITEM-1, issue 2, issued date-parts 2016 , page e1-6, title Factors contributing to the low uptake of medical male circumcision in Mutare Rural District, Zimbabwe., type article-journal, volume 8 , uris http//www.mendeley.com/documents/uuid98dc1c0c-21f6-4432-a901-12cc6cdb874e , id ITEM-2, itemData DOI 10.1186/1471-2458-12-529, ISBN 1471-2458 (Electronic)r1471-2458 (Linking), ISSN 1471-2458, PMID 22812484, abstract BACKGROUND In recent randomized controlled trials, male circumcision has been proven to complement the available biomedical interventions in decreasing HIV transmission from infected women to uninfected men. Consequently, Tanzania is striving to scale-up safe medical male circumcision to reduce HIV transmission. However, there is a need to investigate the perceptions of male circumcision in Tanzania using specific populations. The purpose of the present study was to assess the perceptions of male circumcision in a cohort of police officers that also served as a source of volunteers for a phase I/II HIV vaccine (HIVIS-03) trial in Dar es Salaam, Tanzania.nnMETHODS In-depth interviews with 24 men and 10 women were conducted. Content analysis informed by the socio-ecological model was used to analyze the data.nnRESULTS Informants perceived male circumcision as a health-promoting practice that may prevent HIV transmission and other sexually transmitted infections. They reported male circumcision promotes sexual pleasure, confidence and hygiene or sexual cleanliness. They added that it is a religious ritual and a cultural practice that enhances the recognition of manhood in the community. However, informants were concerned about the cost involved in male circumcision and cleanliness of instruments used in medical and traditional male circumcision. They also expressed confusion about the shame of undergoing circumcision at an advanced age and pain that could emanate after circumcision. The participants advocated for health policies that promote medical male circumcision at childhood, specifically along with the vaccination program.nnCONCLUSIONS The perceived benefit of male circumcision as a preventive strategy to HIV and other sexually transmitted infections is important. However, there is a need to ensure that male circumcision is conducted under hygienic conditions. Integrating male circumcision service in the routine childhood vaccination program may increase its coverage at early childhood. The findings from this investigation provide contextual understanding that may assist in scaling-up male circumcision in Tanzania., author dropping-particle , family Tarimo, given Edith Am, non-dropping-particle , parse-names false, suffix , dropping-particle , family Francis, given Joel M, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kakoko, given Deodatus, non-dropping-particle , parse-names false, suffix , dropping-particle , family Munseri, given Patricia, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bakari, given Muhammad, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sandstrom, given Eric, non-dropping-particle , parse-names false, suffix , container-title BMC Public Health, id ITEM-2, issue 1, issued date-parts 2012 , page 529, publisher , title The perceptions on male circumcision as a preventive measure against HIV infection and considerations in scaling up of the services a qualitative study among police officers in Dar es Salaam, Tanzania, type article-journal, volume 12 , uris http//www.mendeley.com/documents/uuid3f1911e1-99fb-43e6-831b-c69435d359c8 , id ITEM-3, itemData DOI 10.1371/journal.pone.0083998, ISBN 1932-6203, ISSN 19326203, PMID 24802112, abstract BACKGROUND In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high.nnMETHODS AND FINDINGS Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their protection by marriage, cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men.nnCONCLUSIONS Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy., author dropping-particle , family Macintyre, given Kate, non-dropping-particle , parse-names false, suffix , dropping-particle , family Andrinopoulos, given Katherine, non-dropping-particle , parse-names false, suffix , dropping-particle , family Moses, given Natome, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bornstein, given Marta, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ochieng, given Athanasius, non-dropping-particle , parse-names false, suffix , dropping-particle , family Peacock, given Erin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bertrand, given Jane, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-3, issue 5, issued date-parts 2014 , page 1-7, title Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuidccb93f6d-21d5-4d6e-a5d9-13a905d0f76a , id ITEM-4, itemData ISBN http//hdl.handle.net/10019.1/80249, abstract Thesis (MPhil)–Stellenbosch University, 2013., author dropping-particle , family Mubekapi, given Constance, non-dropping-particle , parse-names false, suffix , id ITEM-4, issue March, issued date-parts 2013 , publisher Stellenbosch University, title Knowledge, attitudes and practices of male circumcision as an HIV prevention method among males in a Mine, Geita, Tanzania, type thesis , uris http//www.mendeley.com/documents/uuida8592281-cb53-46b5-9761-9b8dc80158e4 , mendeley formattedCitation (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014 Mubekapi 2013), plainTextFormattedCitation (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014 Mubekapi 2013), previouslyFormattedCitation (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014 Mubekapi 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014 Mubekapi 2013).Others have a misconceptions that male circumcision reduces sexual pleasure by reducing glans sensitivity ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0019814, ISBN 1932-6203 (Electronic)n1932-6203 (Linking), ISSN 19326203, PMID 21603622, abstract Numerous studies have demonstrated that male circumcision (MC) reduces the incidence of the Type-1 human immunodeficiency virus (HIV) among heterosexual men by at least half., author dropping-particle , family Herman-Roloff, given Amy, non-dropping-particle , parse-names false, suffix , dropping-particle , family Otieno, given Nixon, non-dropping-particle , parse-names false, suffix , dropping-particle , family Agot, given Kawango, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ndinya-Achola, given Jeckoniah, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 5, issued date-parts 2011 , page 3-8, title Acceptability of medical male circumcision among uncircumcised men in Kenya one year after the launch of the national male circumcision program, type article-journal, volume 6 , uris http//www.mendeley.com/documents/uuid7b624f1d-6c40-48ff-9030-a44853fd0058 , mendeley formattedCitation (Herman-Roloff et al. 2011), plainTextFormattedCitation (Herman-Roloff et al. 2011), previouslyFormattedCitation (Herman-Roloff et al. 2011) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Herman-Roloff et al. 2011). This may discourage a number of male adults from being circumcised. They feel they cannot fully enjoy sex with a circumcised penis. The results of the study conducted in eight provinces of South Africa on perception and acceptability found that traditional circumcision was more preferred in Pedi ethnic group as compared to other ethnic groups. Traditional circumcision is considered as the pride of the nation by the Pedi ethnic group. They consider traditional male circumcision not only about the removal of the fore skin, but also a place where one learns values on how to conduct himself in a community ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.5897/JPHE2014.0671, ISBN 2141-2316, ISSN 2141-2316, abstract In recent years safe voluntary male medical circumcision (VMMC) has been recommended by the World Health Organization (WHO) as one of the preventive strategies for human immunodeficiency virus (HIV)-infection for those countries with high HIV prevalence and low medical male circumcision rates. This study aimed to assess the level of knowledge, attitude, and acceptance of safe VMMC among male university students attending Botswana University. A survey instrument was used to collect descriptive data in this study. Out of the total number of faculties within the university (8), we purposively selected our sample from the faculty of science due to its predominant male student population of 1,045. A total of 437 students were recruited from the various departments within the faculty. A semi-structured questionnaire was used for data collection. Study results indicate that 95.4 of the participants had heard about VMMC and 64.8 of those who had heard about VMMC were uncircumcised. About 31.4 knew about the complications of VMMC. Participants having undergone VMMC were twice as likely to be aware that VMMC reduces the risk of penile cancer and that it improves penile hygiene. Participants who knew that VMMC reduces the risk of other STIs were found to be four times more likely to accept VMMC as a preventive method for HIV infection. Participants having been medically circumcised were four times more likely to disagree with the statement that VMMC decreases sexual satisfaction and ten times more likely to disagree with the statement that the tip of the penis has to be covered by the foreskin. Study findings suggest that in terms of knowledge and attitude, the most significant factor associated with mens acceptability of VMMC was their awareness that it reduces the risk of other STIs. It is therefore concluded that even though there exist a high-level of awareness and favourable attitude towards VMMC among the young male population such awareness does not seem to influence individuals to become medically circumcised., author dropping-particle , family Mndzebel, given S L, non-dropping-particle , parse-names false, suffix , dropping-particle , family Tegegn, given G A, non-dropping-particle , parse-names false, suffix , container-title Jounal of Public Health and Epidemiology, id ITEM-1, issue Medunsa Campus, (NSPH), University of Limpopo, Limpopo Province, South Africa., issued date-parts 2015 , page 6-14, title Knowledge, attitude and acceptance of voluntary male medical circumcision among male students attending Botswana University, type article-journal, volume 7 , uris http//www.mendeley.com/documents/uuidbdeecaa4-232b-4e77-ac94-be8db7c307ce , mendeley formattedCitation (Mndzebel Tegegn 2015), plainTextFormattedCitation (Mndzebel Tegegn 2015), previouslyFormattedCitation (Mndzebel Tegegn 2015) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Mndzebel Tegegn 2015) and also an initiation into manhood ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISSN 2071-2936 (Electronic), PMID 27380850, abstract BACKGROUND Medical male circumcision (MMC) has become a significant dimension of HIV prevention interventions, after the results of three randomised controlled trials in Uganda, South Africa and Kenya demonstrated that circumcision has a protective effect against contracting HIV of up to 60. Following recommendations by the World Health Organization, Zimbabwe in 2009 adopted voluntary MMC as an additional HIV prevention strategy to the existing ABC behaviour change model. PURPOSE The purpose of this study is thus to investigate the factors contributing to the low uptake of MMC. METHODS The study was a quantitative cross-sectional survey conducted in Mutare rural district, Zimbabwe. Questionnaires with open- and closed-ended questions were administered to the eligible respondents. The target population were male participants aged 15-29 who met the inclusion criteria. The households were systematically selected with a sample size of 234. Statistical Package for the Social Sciences was used to analyse the data. RESULTS Socioculturally, circumcised men are viewed as worthless (37), shameful (30) and are tainted as promiscuous (20), psychological factors reported were infection and delayed healing (39), being ashamed and dehumanised (58), stigmatised and discriminated (40.2) and fear of having an erection during treatment period (89.7) whilst socio-economic factors were not having time, as it will take their time from work (58) and complications may arise leading to spending money on treatment (84). CONCLUSION Knowledge deficits regarding male medical circumcision lead to low uptake, education on male medical circumcision and its benefits. Comprehensive sexual health education should target men and dispel negative attitudes related to the use of health services., author dropping-particle , family Chiringa, given Irene O, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ramathuba, given Dorah U, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mashau, given Ntsieni S, non-dropping-particle , parse-names false, suffix , container-title African journal of primary health care family medicine, id ITEM-1, issue 2, issued date-parts 2016 , page e1-6, title Factors contributing to the low uptake of medical male circumcision in Mutare Rural District, Zimbabwe., type article-journal, volume 8 , uris http//www.mendeley.com/documents/uuid98dc1c0c-21f6-4432-a901-12cc6cdb874e , id ITEM-2, itemData DOI 10.1186/1471-2458-12-529, ISBN 1471-2458 (Electronic)r1471-2458 (Linking), ISSN 1471-2458, PMID 22812484, abstract BACKGROUND In recent randomized controlled trials, male circumcision has been proven to complement the available biomedical interventions in decreasing HIV transmission from infected women to uninfected men. Consequently, Tanzania is striving to scale-up safe medical male circumcision to reduce HIV transmission. However, there is a need to investigate the perceptions of male circumcision in Tanzania using specific populations. The purpose of the present study was to assess the perceptions of male circumcision in a cohort of police officers that also served as a source of volunteers for a phase I/II HIV vaccine (HIVIS-03) trial in Dar es Salaam, Tanzania.nnMETHODS In-depth interviews with 24 men and 10 women were conducted. Content analysis informed by the socio-ecological model was used to analyze the data.nnRESULTS Informants perceived male circumcision as a health-promoting practice that may prevent HIV transmission and other sexually transmitted infections. They reported male circumcision promotes sexual pleasure, confidence and hygiene or sexual cleanliness. They added that it is a religious ritual and a cultural practice that enhances the recognition of manhood in the community. However, informants were concerned about the cost involved in male circumcision and cleanliness of instruments used in medical and traditional male circumcision. They also expressed confusion about the shame of undergoing circumcision at an advanced age and pain that could emanate after circumcision. The participants advocated for health policies that promote medical male circumcision at childhood, specifically along with the vaccination program.nnCONCLUSIONS The perceived benefit of male circumcision as a preventive strategy to HIV and other sexually transmitted infections is important. However, there is a need to ensure that male circumcision is conducted under hygienic conditions. Integrating male circumcision service in the routine childhood vaccination program may increase its coverage at early childhood. The findings from this investigation provide contextual understanding that may assist in scaling-up male circumcision in Tanzania., author dropping-particle , family Tarimo, given Edith Am, non-dropping-particle , parse-names false, suffix , dropping-particle , family Francis, given Joel M, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kakoko, given Deodatus, non-dropping-particle , parse-names false, suffix , dropping-particle , family Munseri, given Patricia, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bakari, given Muhammad, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sandstrom, given Eric, non-dropping-particle , parse-names false, suffix , container-title BMC Public Health, id ITEM-2, issue 1, issued date-parts 2012 , page 529, publisher , title The perceptions on male circumcision as a preventive measure against HIV infection and considerations in scaling up of the services a qualitative study among police officers in Dar es Salaam, Tanzania, type article-journal, volume 12 , uris http//www.mendeley.com/documents/uuid3f1911e1-99fb-43e6-831b-c69435d359c8 , id ITEM-3, itemData DOI 10.1371/journal.pone.0083998, ISBN 1932-6203, ISSN 19326203, PMID 24802112, abstract BACKGROUND In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high.nnMETHODS AND FINDINGS Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their protection by marriage, cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men.nnCONCLUSIONS Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy., author dropping-particle , family Macintyre, given Kate, non-dropping-particle , parse-names false, suffix , dropping-particle , family Andrinopoulos, given Katherine, non-dropping-particle , parse-names false, suffix , dropping-particle , family Moses, given Natome, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bornstein, given Marta, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ochieng, given Athanasius, non-dropping-particle , parse-names false, suffix , dropping-particle , family Peacock, given Erin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bertrand, given Jane, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-3, issue 5, issued date-parts 2014 , page 1-7, title Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuidccb93f6d-21d5-4d6e-a5d9-13a905d0f76a , mendeley formattedCitation (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014), plainTextFormattedCitation (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014), previouslyFormattedCitation (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Chiringa et al. 2016 Tarimo et al. 2012 Macintyre et al. 2014).Another study by ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Urassa, given M, non-dropping-particle , parse-names false, suffix , dropping-particle , family Todd, given J, non-dropping-particle , parse-names false, suffix , dropping-particle , family Boerama, given J, non-dropping-particle , parse-names false, suffix , dropping-particle , family Hayes, given R, non-dropping-particle , parse-names false, suffix , dropping-particle , family Isingo, given R, non-dropping-particle , parse-names false, suffix , container-title AIDS, id ITEM-1, issue 3, issued date-parts 1997 , title Male circumcision and susceptibility to HIV infection among men in Tanzania, type article-journal, volume 11 , uris http//www.mendeley.com/documents/uuid7c158605-3999-4112-8769-8219da0aca6a , mendeley formattedCitation (Urassa et al. 1997), plainTextFormattedCitation (Urassa et al. 1997), previouslyFormattedCitation (Urassa et al. 1997) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json Urassa et al. (1997) argued that previously the acceptability of male circumcision was dominant among Muslims and specific ethnic groups, but things have changed where by circumcision status is related to many other demographic, socio-cultural and behavioral variables that have an influence. Furthermore, male circumcision in some of the societies is viewed as a milestone for manhood, protection from disease and an enhancement for womens sexual pleasure as circumcised men are thought to be able to perform longer, hence increasing their female partners satisfaction ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Lukobo, given M.D., non-dropping-particle , parse-names false, suffix , dropping-particle , family Bailey, given R.C., non-dropping-particle , parse-names false, suffix , container-title AIDS care, id ITEM-1, issue 4, issued date-parts 2007 , title Acceptability of male circumcision for prevention of HIV infection in Zambia, type article-journal, volume 19 , uris http//www.mendeley.com/documents/uuidfa056a3c-8582-4efa-956d-c03e7d7ad482 , mendeley formattedCitation (Lukobo Bailey 2007), plainTextFormattedCitation (Lukobo Bailey 2007), previouslyFormattedCitation (Lukobo Bailey 2007) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Lukobo Bailey 2007). A study by ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Dowsett, given Gary W, non-dropping-particle , parse-names false, suffix , dropping-particle , family Couch, given Murray, non-dropping-particle , parse-names false, suffix , container-title REPRODUCTIVE HEALTH MATTERS, id ITEM-1, issue 29, issued date-parts 2007 , title Male Circumcision and HIV Prevention Is There Really Enough of the Right Kind of Evidence, type article-journal, volume 15 , uris http//www.mendeley.com/documents/uuide7fb0ddd-bfa8-4a71-a519-98e22923abe8 , mendeley formattedCitation (Dowsett Couch 2007), plainTextFormattedCitation (Dowsett Couch 2007), previouslyFormattedCitation (Dowsett Couch 2007) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Dowsett Couch 2007) explained that the question of acceptability of male circumcision is more complex than has been assessed so far. Although acceptability of male circumcision has been reported at promisingly high levels in many settings, coverage seem implausible. It has been noted that male circumcision alone will not be the silver bullet that will stop the HIV epidemic. There is need for it to be implemented along with other strategies ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0002212, ISBN 1932-6203 (Electronic)n1932-6203 (Linking), ISSN 19326203, PMID 18493593, abstract BACKGROUND Three randomised controlled trials have clearly shown that circumcision of adult men reduces the chance that they acquire HIV infection. However, the potential impact of circumcision programmes–either alone or in combination with other established approaches–is not known and no further field trials are planned. We have used a mathematical model, parameterised using existing trial findings, to understand and predict the impact of circumcision programmes at the population level. FINDINGS Our results indicate that circumcision will lead to reductions in incidence for women and uncircumcised men, as well as those circumcised, but that even the most effective intervention is unlikely to completely stem the spread of the virus. Without additional interventions, HIV incidence could eventually be reduced by 25-35, depending on the level of coverage achieved and whether onward transmission from circumcised men is also reduced. However, circumcision interventions can act synergistically with other types of prevention programmes, and if efforts to change behaviour are increased in parallel with the scale-up of circumcision services, then dramatic reductions in HIV incidence could be achieved. In the long-term, this could lead to reduced AIDS deaths and less need for anti-retroviral therapy. Any increases in risk behaviours following circumcision, i.e. risk compensation, could offset some of the potential benefit of the intervention, especially for women, but only very large increases would lead to more infections overall. CONCLUSIONS Circumcision will not be the silver bullet to prevent HIV transmission, but interventions could help to substantially protect men and women from infection, especially in combination with other approaches., author dropping-particle , family Hallett, given Timothy B., non-dropping-particle , parse-names false, suffix , dropping-particle , family Singh, given Kanwarjit, non-dropping-particle , parse-names false, suffix , dropping-particle , family Smith, given Jennifer A., non-dropping-particle , parse-names false, suffix , dropping-particle , family White, given Richard G., non-dropping-particle , parse-names false, suffix , dropping-particle , family Abu-Raddad, given Laith J., non-dropping-particle , parse-names false, suffix , dropping-particle , family Garnett, given Geoff P., non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 5, issued date-parts 2008 , page 1-9, title Understanding the impact of male circumcision interventions on the spread of HIV in southern Africa, type article-journal, volume 3 , uris http//www.mendeley.com/documents/uuidd4ecc094-43d1-43a2-aaaa-56f34ce5f24a , mendeley formattedCitation (Hallett et al. 2008), plainTextFormattedCitation (Hallett et al. 2008), previouslyFormattedCitation (Hallett et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Hallett et al. 2008). 2.5 Stakeholders Involvement in scaling up for VMMC services. A well-defined leadership and partnerships are considered to contribute to a successful programme, particularly one involving many different sectors of the community and players. Identifying leadership, developing partnerships and recognizing champions facilitate the development and implementation of a national male circumcision programme ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family WHO, given , non-dropping-particle , parse-names false, suffix , container-title Male circumcision Global trends and determinants of prevalence, safety and acceptability, id ITEM-1, issued date-parts 2007 , page 7, title Global prevalence of male circumcision, type article-journal , uris http//www.mendeley.com/documents/uuida1f3250a-dbf5-47eb-9f3c-a46d9fe392bc , mendeley formattedCitation (WHO 2007a), plainTextFormattedCitation (WHO 2007a), previouslyFormattedCitation (WHO 2007a) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (WHO 2007a). A situational analysis that was conducted in Tanzania suggested that for successful implementation of male circumcision programme, it should have a favorable policy at different levels of authority and the meaningful involvement of all stakeholders in the whole process ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1186/1471-2458-11-506, abstract Background Male circumcision (MC) has been shown to be effective against heterosexual acquisition of HIV infection and is being scaled up as an additional strategy against HIV in several countries of Africa. However, the policy environment (whether to formulate new specific policy on MC or adapts the existing ones) and the role of various stakeholders in the MC scale up process in Tanzania was unclear. We conducted this study as part of a situation analysis to understand the attitudes of policy makers and other key community and health authority decision makers towards MC, policy and regulatory environment, and the readiness of a health system to accommodate scaling up of MC services. Methods We conducted 36 key informants interviews with a broad range of informants including civil servants, religious leaders, cultural and traditional gatekeepers and other potential informants. Study informants were selected at the national level, regional, district and community levels to represent both traditionally circumcising and non-circumcising communities. Results Study informants had positive attitudes and strong beliefs towards MC. Key informants in traditionally non-circumcising districts were willing to take their sons for medically performed MC. Religious leaders and traditional gatekeepers supported MC as it has been enshrined in their holy scripts and traditional customs respectively. Civil servants highlighted the need for existence of enabling policy and regulatory environment in the form of laws, regulations and guidelines that will ensure voluntary accessibility, acceptability, quality and safety for those in need of MC services. Majority of informants urged the government to make improvements in the health system at all levels to ensure availability of adequate trained personnel, infrastructure, equipment, and supplies for MC scale up, and insisted on the involvement of different MC stakeholders as key components in effective roll out of medically performed MC programme in the country. Conclusions Findings from the situation analysis in Tanzania have shown that despite the absence of a specific policy on MC, basic elements of enabling policy environment at national, regional, district and community levels are in place for the implementation of MC scale up programme., author dropping-particle , family Mwanga, given Joseph R, non-dropping-particle , parse-names false, suffix , dropping-particle , family Wambura, given Mwita, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mosha, given Jacklin F, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mshana, given Gerry, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mosha, given Frank, non-dropping-particle , parse-names false, suffix , dropping-particle , family Changalucha, given John, non-dropping-particle , parse-names false, suffix , container-title BMC Public Health, id ITEM-1, issued date-parts 2011 , title Policy environment and male circumcision for HIV prevention Findings from a situation analysis study in Tanzania, type article-journal , uris http//www.mendeley.com/documents/uuide30d947b-6e56-46ac-b088-25b231f5d160 , mendeley formattedCitation (Mwanga et al. 2011), plainTextFormattedCitation (Mwanga et al. 2011), previouslyFormattedCitation (Mwanga et al. 2011) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Mwanga et al. 2011). Women also have been playing a crucial role in creating demand for male circumcision services. In Uriri district of Nyanza province in Kenya women involvement in advocating for male circumcision has helped to increase the uptake of men older than 18 years in male circumcision services. Before it was reported that men older than 18 years have been slow to access male circumcision services but with the championship of women in advocating for circumcision services 30 to 50 men were reported being circumcised within a month (MCC News, 2012).Several studies have reported that pressure from women influences men to go for circumcision ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0074391, ISBN 1932-6203, ISSN 19326203, PMID 24009771, abstract While male circumcision reduces the risk of female-to-male HIV transmission and certain sexually transmitted infections (STIs), there is little evidence that circumcision provides women with direct protection against HIV. This study used qualitative methods to assess womens perceptions of male circumcision in Iringa, Tanzania. Women in this study had strong preferences for circumcised men because of the low risk perception of HIV with circumcised men, social norms favoring circumcised men, and perceived increased sexual desirability of circumcised men. The health benefits of male circumcision were generally overstated many respondents falsely believed that women are also directly protected against HIV and that the risk of all STIs is greatly reduced or eliminated in circumcised men. Efforts to engage women about the risks and limitations of male circumcision, in addition to the benefits, should be expanded so that women can accurately assess their risk of HIV or STIs during sexual intercourse with circumcised men., author dropping-particle , family Layer, given Erica H., non-dropping-particle , parse-names false, suffix , dropping-particle , family Beckham, given Sarah W., non-dropping-particle , parse-names false, suffix , dropping-particle , family Mgeni, given Lilian, non-dropping-particle , parse-names false, suffix , dropping-particle , family Shembilu, given Catherine, non-dropping-particle , parse-names false, suffix , dropping-particle , family Momburi, given Romani B., non-dropping-particle , parse-names false, suffix , dropping-particle , family Kennedy, given Caitlin E., non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 8, issued date-parts 2013 , page 1-8, title After my husbands circumcision, I know that I am safe from diseases Womens Attitudes and Risk Perceptions Towards Male Circumcision in Iringa, Tanzania, type article-journal, volume 8 , uris http//www.mendeley.com/documents/uuidd30d21a3-ca78-4519-8587-621ed8f55637 , mendeley formattedCitation (Layer et al. 2013), plainTextFormattedCitation (Layer et al. 2013), previouslyFormattedCitation (Layer et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Layer et al. 2013). Finding from a study conducted to assess the role of women in promoting the uptake of medical male circumcision in Tanzania has revealed that women have an important role to play in an uncircumcised mans decision of whether or not to get circumcised ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0139009, ISBN 9789170634376, ISSN 19326203, PMID 24801882, abstract OBJECTIVES To estimate the prevalence of circumcision among young men in rural Mwanza, North-Western Tanzania, and document trends in circumcision prevalence over time. To investigate associations of circumcision with socio-demographic characteristics, reported sexual behaviours and sexually transmitted infections (STIs).nnDESIGN A cross-sectional survey in communities which had previously participated in a cluster-randomized trial of an adolescent sexual health intervention that did not include male circumcision in 20 rural communities.nnMETHODS In 2007/08, 7300 young men (age 16-23 years) were interviewed and examined by a clinician. The prevalence of circumcision by age was compared with data collected during the trial in 1998-2002. Odds ratios (OR) and 95 confidence intervals (CI) for the association of circumcision with socio-demographic characteristics, reported sexual behaviours and with HIV and other STIs were estimated using multivariable conditional logistic regression.nnRESULTS The prevalence of male circumcision was 40.6, and age-specific prevalence had more than doubled since 2001/2002. Circumcised men reported less risky sexual behaviours, being more likely to report having ever used a condom (adjusted ORu200au200a2.62, 95CI2.32-2.95). Men circumcised before sexual debut were at reduced risk of being HIV seropositive compared with non-circumcised men (adjusted ORu200au200a0.50, 95CI0.25-0.97), and also had reduced risks of HSV-2 infection and genital ulcer syndrome in the past 12 months compared with non-circumcised men.nnCONCLUSIONS There was a steep increase in circumcision prevalence between 2001/02 and 2007/08 in the absence of a promotional campaign. Circumcised men reported safer sexual practices than non-circumcised men and had lower prevalence of HIV and HSV-2 infection., author dropping-particle , family Osaki, given Haika, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mshana, given Gerry, non-dropping-particle , parse-names false, suffix , dropping-particle , family Wambura, given Mwita, non-dropping-particle , parse-names false, suffix , dropping-particle , family Grund, given Jonathan, non-dropping-particle , parse-names false, suffix , dropping-particle , family Neke, given Nyasule, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kuringe, given Evodius, non-dropping-particle , parse-names false, suffix , dropping-particle , family Plotkin, given Marya, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mahler, given Hally, non-dropping-particle , parse-names false, suffix , dropping-particle , family Terris-Prestholt, given Fern, non-dropping-particle , parse-names false, suffix , dropping-particle , family Weiss, given Helen, non-dropping-particle , parse-names false, suffix , dropping-particle , family Changalucha, given John, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 9, issued date-parts 2015 , page 1-11, title If You Are Not Circumcised, i Cannot Say Yes The role of women in promoting the uptake of voluntary medical male circumcision in Tanzania, type article-journal, volume 10 , uris http//www.mendeley.com/documents/uuidb37166c7-b373-465f-a904-e4506b71f938 , mendeley formattedCitation (Osaki et al. 2015), plainTextFormattedCitation (Osaki et al. 2015), previouslyFormattedCitation (Osaki et al. 2015) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Osaki et al. 2015). Reviewed literature show that most of the studies focused their attention on Male Circumcision as an HIV prevention strategy however, few studies have looked the issues of perception and acceptability of Male Circumcision as a HIV preventive measure particularly from the areas with high HIV prevalence. Similarly, from the reviewed literature little is known about the stakeholders roles and contribution in creating demands for Male Circumcision services. 2.6 Theoretical Framework. This study was guided by the Health Belief Model (HBM) which was developed in the 1950s, by the group of social psychologists working for public health services at the United States. The Health Belief Model (HBM) attempts to explain why individuals may accept or reject preventive health services or adopt health behavior. It also argues that health behavior is determined by personal beliefs or perception about a disease and the strategies available to decrease its occurrence ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1111/j.1365-2648.2010.05450.x, ISBN 9780763743833, ISSN 1365-2648, PMID 20946564, abstract After reading this chapter the student will be able to 1. Explain the original concept of the Health Belief Model. 2. Discuss how the constructs of perceived seriousness, susceptibility, benefits, and barriers might predict health behavior. 3. Analyze the impact of the modifying variables on health behavior. 4. Identify cues to action and how they motivate behavior. 5. Use the theory to explain at least one behavior. THEORETICAL CONCEPT The Health Belief Model (HBM) is by far the most comm, author dropping-particle , family Stretcher, given V, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rosenstock, given I M, non-dropping-particle , parse-names false, suffix , container-title Health Behavior and Health Education Theory, Research and Practice, id ITEM-1, issued date-parts 1997 , page 31-36, title The Health Belief Model, type chapter , uris http//www.mendeley.com/documents/uuid2f85ae8c-41ab-4cbf-a44d-f350afe12a48 , mendeley formattedCitation (Stretcher Rosenstock 1997), plainTextFormattedCitation (Stretcher Rosenstock 1997), previouslyFormattedCitation (Stretcher Rosenstock 1997) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Stretcher Rosenstock,1997). The HBM is based on the assumption that a person is considered being rational and will take a health related action if, one must feel that a negative health condition can be avoided by taking a recommended action and the person must also believe that he/she is capable of taking the recommended action. The HBM is analyzed by six main theoretical precepts as follows. Perceived Susceptibility. Ones subjective perception of the possibility of getting a health condition/disease. For example, HIV infection. Perceived severity. Assessing the feeling/belief about how serious or severe the disease is. The perception of seriousness is often based on the medical information or knowledge an individual has in relation to certain disease and personal evaluation on the possible social consequence. Perceived benefits. A persons opinion of the value or usefulness of the new behavior in decreasing the risk of developing a disease by adopting a healthier behavior. Perceived barriers. Individuals own evaluation of the negative consequences that may result from adopting a particular health action including financial cost as well as physical and psychological demand. Cues to action. Including events, people or things that motivate people to change their behavior or take action toward a healthier behavior. Self-efficacy. Self-efficacy is the belief in ones own ability to do something. Thus in HBM self-efficacy is considered to be persons evaluation on his/her ability to execute the recommended behavior so as to produce the desired outcomes. The conceptual framework on figure 1 has been used to demonstrate the Health Belief Model The HBM interrelate with the background factors, knowledge and attitudes that influence the perception and acceptability of Voluntary Medical Male Circumcision as an HIV prevention strategy. With the reference to the framework, improving the involvement of stakeholders on advocating for male circumcision services is likely to influence a positive perception and hence lead into acceptability of male circumcision for HIV prevention especially among men aged 20 years and above. This study considered three perceptions of HBM, namely perceived susceptibility and severity, perceived benefits and perceived barriers theoretical precepts, meaning that individuals have different views on how uncircumcised person is susceptible to getting HIV infection and severity of HIV and benefits of VMMC, such as reduced risk of acquiring HIV, reduced risk of cervical cancer in female partners and improved hygiene. Fear of pain, cultural and religious beliefs, risk of medical complication, and social shame of being circumcised at the age of 20 years and above have being identified as perceived barriers that hinder the acceptance of VMMC services in Njombe Town Council. Health Belief Model on Perceptions and Acceptability of VMMC services Figure SEQ Figure ARABIC 1 Individual Perceptions Modifying Factors Likelihood of Action from Health Belief Model (Glanz et al, 2002). CHAPTER THREE RESEARCH METHODOLOGY 3.0. Introduction This chapter briefly describes the methods employed in the study to realize the research objectives. Specifically provides a description of the study area, study design, sample size and sampling techniques. It also elaborates on the data sources and tools that were used for data collection. 3.1 Research Design In order to discover the perception and the acceptability of male circumcision as an HIV preventive measure in Njombe Town Council, a cross-sectional descriptive research design employing both quantitative and qualitative methods of data collection has been used for this study. . 3.2 Study Area This study was conducted in Njombe Town Council which is located in the Southern Highlands of Tanzania in the Njombe Region. It was established in July 2007 under the Local Government Act no.8 of 1982.Njombe Town Council boarders Ludewa District and Ruvuma Region the South, Morogoro Region on the east, Makete District and Njombe District on the western and northern parts. Administratively, the council is divided into two divisions, 7 wards and total of 44 villages and 232 sub-villages. 3.3 Study Population The study involved men and women of 18 years and above from Njombe Town Council. This was due to the fact that the selected population is sexually active and has previous shown low uptake of VMMC from previous data. Based on the 2012 National Population Census, the council has a population of 130,223 people with a growth rate of 2.1 per annum and total fertility rate is estimated to be 4. Out of 130,223 people, 69,111 were females and 61,112 were males ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family National Bureau of Statistics (NBS) and Office of Chief Government Statistician (OCGS), given Zanzibar, non-dropping-particle , parse-names false, suffix , id ITEM-1, issued date-parts 2013 , publisher-place Dar es Salaam, title Population Distribution by Age and Sex, 2013, type report , uris http//www.mendeley.com/documents/uuide963ecf1-43fe-42c9-bb07-269d6edf9e12 , mendeley formattedCitation (National Bureau of Statistics (NBS) and Office of Chief Government Statistician (OCGS) 2013), plainTextFormattedCitation (National Bureau of Statistics (NBS) and Office of Chief Government Statistician (OCGS) 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (National Bureau of Statistics (NBS) and Office of Chief Government Statistician (OCGS), 2013). Table SEQ Table ARABIC 1 Population Distribution by Age groups and by Sex in Njombe Town Council Age GroupSexTotalMaleFemaleLess than 18 years25,28125,93251,21318 – 29 years18,30221,5313883330 – 44 years10,07311,6222169545 – 60 years4,6545,85910,51361 and above years2,8024,1676,969Total61,11269,111130,223Source 2012 Population and housing census 3.4. Sampling Procedure The objective of sampling procedure is to secure a sample, which will reproduce the characteristics of the population. Both random and purposive sampling methods were employed in data collection. 3.4.1 Selecting the Study participants for Quantitative interview Multi-stage sampling was applied in the selection of respondents to participate in the quantitative interview Stage 1 Selection of the study district Njombe Town Council was purposively selected as was easily accessible by the researcher Stage 2 Selection of the wards Out of thirteen wards of the Njombe Town Council, two wards were randomly selected to be used as representative wards for the study. The selected wards were Njombe Mji and Ramadhani based on their predominantly mixture of urban and rural characteristics. Stage 3 Selection of the respondent Random sampling has been used to obtain sample size by using the following formula Sample size EMBED Equation.3 , where (2 is the chi-square value for 1 degree of freedom at some desired probability level (3.841), EMBED Equation.3 is the population size (140641), EMBED Equation.3 is the population parameter of a variable (0.5) and EMBED Equation.3 2 is the confidence interval (0.01) (Bernard1995). Hence sample size was 95.96 which was approximated to 96 respondents. 3.4.1 Selecting the Study participants for Qualitative interview Purposive sampling was used for the qualitative part of the study, in selection of study participants. The method was preferred as individuals were supposed to respond basing on their knowledge and experience on VMMC uptake and their perception on the barriers on uptake of VMMC services. A total of 16 key informants (KIs) who included 6 MC peer promoters, 5 MC health providers (i.e. surgeons and counselors), 5 individuals who have been involved in planning, coordination and implementation of VMMC services. These were purposively selected because they had experience about advocating male circumcision as an HIV prevention measure as well as the most involved group in male circumcision intervention and people who has created demand for male circumcision services in Njombe Town Council. Hence total sample for the qualitative study was 16 key informants. Data Collection Methods Data were collected between June and August 2016.The study relied on both secondary and primary data for accomplishing the study. Primary data were collected by the researcher directly from original sources (respondents) and assembled specifically for the research problem at hand while secondary data were data which already exist and which were collected for some other purposes but which were used in the current research project. 3.5.1. Collection of Primary Data Primary data for quantitative part were collected through administered questionnaire that contained questions pertaining factors influencing acceptability of MC services in Njombe Town Council. For the qualitative survey, key informant interview guide was used for the interview that was used to gather information, views and opinion on peoples perceptions about Male Circumcision as a HIV prevention strategy as well as reasons on why men aged 20 years and above have being reported to have a low turnout in demanding Voluntary Medical Male Circumcision services. 3.5.2. Collection of Secondary Data The secondary data has been obtained from Jhpiego Voluntary Medical Male Circumcision dataset, the data contain the cumulative number of men that has being circumcised in Njombe Town Council since 2011 up to 2015 and age strata of males who have received the services. Secondary data were mainly collected to provide a better understanding of the research problem on the acceptability of male circumcision services according to age group. In additional review of documents such as journals, thesis, reports and strategic plans were used to review the contribution of stakeholders in scaling up, advocating and implementation of male circumcision. 3.6. Data collection Instruments The data collection instruments used in this study include a questionnaire for collecting quantitative data (Appendix 1) and key informant interview guide for collecting qualitative data (Appendix 2). 3.6.1. Questionnaire A questionnaire with both close-ended and open-ended questions was administered to respondents in face-to-face interviews. Closed-ended questions consisted of dichotomous questions that required the respondents to choose one out of the two or more responses. To include all the possible responses that might be expected, some of the closed questions included an open-ended option that is please explain. Questionnaire were circulated to men and women of Njombe Town Council, male circumcision health providers, male circumcision peer promoters, RHMT and CHMT members, CSO members and NGOs that work on coordinating and implementing male circumcision services. 3.6.2. Key informant interviews Key informant interviews were guided by a set of questions and were intended to capture the detailed view of the subject. Key informant interview guide was used for the interview that used to gather information, about the role of stakeholders in coordinating male circumcision activities and the reason why men aged 20 years and above have being reported to have a low turnout in demanding MC services. 3.7. Ethical Consideration This research was conducted after observing all logical procedure that includes obtaining an introductory letter from the University of Dar es salaam. The researcher explained clearly to the respondents the intention of the study in order to inspire their involvement in the study. Each participant was asked for their written consent to participate in the study. They were also assured that the information that has been obtained will be confidentially, privacy, anonymity and used for intended purpose only. 3.8. Validation of Research Instruments Pre-testing of tool was done to check for validity. Questions used was checked, by initially discussing them with the research supervisor as well as other experts in the department of Sociology to obtain the opinions. 3.9. Data management and analysis The data from questionnaires were entered using epidata 3.1. Double data entry was done to minimize errors in the entry of data. After entry, data were coded and analyzed using the Statistical Package for Social Sciences (SPSS) window version 22. Descriptive statistics were captured and the results have been presented using tables, figures and percentage as well as frequency tables. CHAPTER FOUR FINDINGS AND DISCUSSION TC CHAPTER FOUR f C l 1 4.0 Introduction This chapter presents study findings followed by discussion of the findings. The purpose of the study was to examine the perception and acceptability of voluntary medical male circumcision as a strategy for HIV prevention in Njombe Region. 4.1 Social Demographic Characteristics of the Respondents A total of 96 respondents participated in this study. Results in REF _Ref463950806 h MERGEFORMAT Table 2 shows that, 60 (62.5) were male while 31 (37.5) were female. Majority of the respondents (45.8) were aged between 18-29 years, while 38.5 of respondent were aged 30-39 and 15.6 were aged 40-49. Marital status was categorized into two main categories, of those never married representing single and the rest were put in the ever married group. Results from REF _Ref463950806 h MERGEFORMAT Table 2, showed that those ever married were relatively many as compared to those never married with 54.2 and 45.8 respectively. REF _Ref463950806 h MERGEFORMAT Table 2 shows out of 96 respondents, 46.9 had completed secondary school education followed by 25 who have completed primary education,19.8 were diploma holder and 8.3 were degree holder. In the employment status, majority 34.4 of respondents were employed in the informal sector, where as 12.5 were unemployed. Table SEQ Table ARABIC 2 Socio demographic factors of respondents Socio-demographic factorFrequencyPercentAge group18-294445.830-393738.540-491515.6GenderMale6062.5Female3637.5Marital statusNever Married4445.8Ever Married5254.2Education levelPrimary education2425.0Secondary / Certificates 4546.9Diploma1919.8Degree 88.3EmploymentFormal employment 2728.1Informal employment 3334.4Self employed 2425.0Unemployed 1212.5Total96100.04.2 Source of information about VMMC services Respondents were asked to mention their source of information about VMMC services. The main source of information was media (TV, radio and print media) with more than half of respondents acknowledging this as their main source of information (See REF _Ref464048412 h MERGEFORMAT Figure 2). Second main source of information about VMMC services was others category which included, relatives, friends and health care providers and that was reported by 33 of respondents. The least reported was the VMMC campaign, again this was tricks as the campaign had to be advertised and majority get to know about VMMC campaign through media. However, about 16 of respondents reported VMMC campaign as their direct main source of information on VMMC services. See Figure 2. Figure SEQ Figure ARABIC 2 source of information about VMMC services 4.3 Factors influencing acceptability of VMMC services The study wanted to determine factors influencing acceptability of VMMC services. The generated findings indicate that there are several factors that might influence the acceptability of VMMC services as a measure to protect from HIV/AIDS. These included individuals awareness, community participation and individual factors that influence uptake of VMMC services. 4.3.1 Individual awareness of VMMC services as HIV preventive strategy The aim was to determine the level of awareness of individuals about VMMC services as an HIV prevention strategy in the district. Among the respondents, 81.3 agreed that they were aware of the existence of VMMC services in their communities and health facilities that were providing the respective services. However, 19 of respondents were not aware of the existence of VMMC services in their communities (see Figure 3). The study observed higher awareness of VMMC services among men and the community around irrespective of low uptake of VMMC services by adults. The high awareness and acceptability of VMMC services is also reported by a study done in Zimbabwe ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.11564/29-1-722, ISSN 08505780, abstract Background Medical male circumcision was introduced in Zimbabwe in 2009 as an additional HIV prevention method. This study sought to investigate support for the roll-out of voluntary medical male circumcision (VMMC) and menu2019s willingness to get circumcised for HIV prevention. Data and Methods Data for this study was collected from a randomly selected sample of 681 men and women in the age group 18-49 years in Harare, Zimbabwe. The obtained data was analysed using descriptive statistics, bivariate and regression analysis. Results and Conclusion The results of the study suggest that knowledge and acceptability of VMMC is high. However, despite the relatively high knowledge and acceptability of VMMC, less than half of the male participants were willing to undergo circumcision for HIV prevention. The study concluded that there is an apparent gap between knowledge and acceptability of VMMC and menu2019s willingness to undergo circumcision for HIV prevention., author dropping-particle , family Chikutsa, given Antony, non-dropping-particle , parse-names false, suffix , dropping-particle , family Maharaj, given Pranitha, non-dropping-particle , parse-names false, suffix , container-title African Population Studies, id ITEM-1, issue 1, issued date-parts 2015 , page 1587-1596, title Support for Voluntary Medical Male Circumcision (VMMC) for HIV prevention among men and women in Zimbabwe, type article-journal, volume 29 , uris http//www.mendeley.com/documents/uuid0daa3204-0139-4745-85d8-4f1110ac83a2 , mendeley formattedCitation (Chikutsa Maharaj 2015), plainTextFormattedCitation (Chikutsa Maharaj 2015), previouslyFormattedCitation (Chikutsa Maharaj 2015) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Chikutsa Maharaj 2015). High rates of awareness and acceptability of VMMC services was also reported by ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.4314/ajtcam.v11i4.19, ISBN 0189-6016, ISSN 01896016, PMID 25392591, abstract BACKGROUND The objectives of the current national study were to determine the rates of self-reported circumcision among South African men and, more importantly, evaluate the acceptability of male circumcision in South Africa by uncircumcised adult men and all adult women.nnMATERIALS AND METHODS The study based on a population-based survey included a nationally representative subgroup of 6654 men aged 15 years and older who where included in the analysis on male circumcision prevalence, and a subgroup of 6796 women aged 15 to 49 years who were included in the analysis on male circumcision acceptance.nnRESULTS An overall prevalence of self-reported male circumcision of 42.8 was found. Among the Black African population group the prevalence of male circumcision was 48.2, 32.1 were traditionally and 13.4 were medically circumcised. Among males not circumcised 45.7 of 15-24 years olds indicated that they would consider being circumcised compared to 28.3 among 25-49 years olds. In multivariate analysis among non-circumcised men Black African and Coloured population groups and having heard of the HIV protective effect of male circumcision were significant predictors for male circumcision acceptability, and among women with a non-circumcised sexual partner, Black African and Coloured population groups and higher education were predictors for male circumcision acceptability.nnCONCLUSION The study found high rates and high acceptability of male circumcision. Findings associated with the acceptability of male circumcision can be used to increase awareness of the benefits of male circumcision for HIV prevention., author dropping-particle , family Peltzer, given Karl, non-dropping-particle , parse-names false, suffix , dropping-particle , family Onoya, given Dorina, non-dropping-particle , parse-names false, suffix , dropping-particle , family Makonko, given Elias, non-dropping-particle , parse-names false, suffix , dropping-particle , family Simbayi, given Leickness, non-dropping-particle , parse-names false, suffix , container-title African Journal of Traditional, Complementary and Alternative Medicines, id ITEM-1, issue 4, issued date-parts 2014 , page 126-130, title Prevalence and acceptability of male circumcision in South Africa, type article-journal, volume 11 , uris http//www.mendeley.com/documents/uuidcb4ffa3c-fe49-4c9f-a20a-a8d82b12ff48 , mendeley formattedCitation (Peltzer et al. 2014), plainTextFormattedCitation (Peltzer et al. 2014), previouslyFormattedCitation (Peltzer et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json Peltzer et al. (2014). In another study, researchers went further to conclude that both men and women are supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services is the challengeADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0083998, ISBN 1932-6203, ISSN 19326203, PMID 24802112, abstract BACKGROUND In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high.nnMETHODS AND FINDINGS Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their protection by marriage, cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men.nnCONCLUSIONS Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy., author dropping-particle , family Macintyre, given Kate, non-dropping-particle , parse-names false, suffix , dropping-particle , family Andrinopoulos, given Katherine, non-dropping-particle , parse-names false, suffix , dropping-particle , family Moses, given Natome, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bornstein, given Marta, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ochieng, given Athanasius, non-dropping-particle , parse-names false, suffix , dropping-particle , family Peacock, given Erin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bertrand, given Jane, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 5, issued date-parts 2014 , page 1-7, title Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuidccb93f6d-21d5-4d6e-a5d9-13a905d0f76a , mendeley formattedCitation (Macintyre et al. 2014), plainTextFormattedCitation (Macintyre et al. 2014), previouslyFormattedCitation (Macintyre et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Macintyre et al. 2014). 4.3.2 Level of community participation on VMMC services The study found out that 84.6 of respondents indicated that either themselves or their family members have been circumcised, it was found out that 15.4 of respondents were not circumcised, or their partners or sons were not circumcised. However, majority of respondents according to the research findings were circumcised and their boys or male children or partners were circumcised. This shows that the VMMC services were accepted by the majority of the community (See Figure 3). Figure SEQ Figure ARABIC 3 Individual awareness and community participation on VMMC services 4.3.3 Factors that might influence uptake of VMMC services The study assessed the factors that might influence the uptake of VMMC services. The study findings indicate that about 17 of all respondents who participated in the study reported that their participation in male circumcision services are being influenced by several factors as shown on REF _Ref463954332 h MERGEFORMAT Table 3. Table SEQ Table ARABIC 3 Showing factor influencing male circumsion uptake in Njombe, 2016 Factors influencing Male circumcision uptakeFrequencyPercentAwareness of health benefits such as reducing sexual transmitted diseases 1616.7Influence from Friends, family (such as parents, partner etc)1717.7HIV MC campaign 3334.4Media influence (such as Radio magazine)1818.7Religion and cultural practices1212.5Total96100.0 Also, 17.7 of all respondents said that they participated in the male medical circumcision due to the support and encouragement from friends and family members such as wife, parents, fiance and brothers/sisters. Likewise, the study found out that some of the respondents (34.4) indicated that factors that influenced male circumcision in Njombe Town Council were due to the ongoing campaign conducted by government and non-government organizations. The study found out that to a large extent HIV campaign was the major leading factor towards the increased awareness of VMMC in Njombe Town Council. 4.4 Peoples perception about VMMC services as HIV preventive measure The first research question of the study was to examine peoples perception about voluntary medical male circumcision services as HIV preventive measure in Njombe town council. The findings from this study indicate that there are various peoples perception about VMMC as an HIV preventive measure, such perception include circumcised men take too long to ejaculate, VMMC inhibits sexual satisfaction, VMMC reduces risk of HIV / AIDS, VMMC circumcision reduces risk of STIs, VMMC reduces sexual pleasure and circumcised men do need to use condom. The following section present and discuss these perceptions in detail. 4.4.1 VMMC reduces the risks of getting HIV/AIDS The study examined the extent to which male circumcision reduced the risks of getting HIV/AIDS among male in Njombe Town Council, shown in Table 4 are the results. Table 4 Peoples perception about VMMC services PerceptionResponse, n ()AgreeDisagreeDont knowCircumcised men take too long to ejaculate23 (24.0)39 (40.6)34 (35.4)Women enjoy sex with circumcised men 60 (62.5)16 (16.7)20 (20.8)VMMC reduces risk of HIV / AIDS transmission41 (42.7)37 (38.5)18 (18.8)VMMC reduces risk of STIs75 (78.1)11 (11.5)10 (10.4)VMMC reduces sexual pleasure13 (13.5)71 (74.0)12 (12.5)Circumcised men do not need to use condom14 (14.6)73 (76.0)9 (9.4) The study findings show that 42.7 of respondents who participated in this study agreed that voluntary male circumcision was useful in reducing the spread or prevent male from contacting HIV/AIDS. At the same time 38.5 of all respondents disagreed which means that according to them male circumcision did not prevent the spread of HIV/AIDS. They argue that even circumcised men are at the risk of getting HIV/AIDS as uncircumcised men. Also, 18.8 of all respondents remained silent which may mean that they were not sure as to whether male circumcision could prevent the spread of HIV. In this study, it was reported that individuals were influenced to take VMMC services as a measure that might prevent them from HIV infection. ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0085051, ISBN 10.1371/journal.pone.0085051, ISSN 19326203, PMID 24802746, abstract BACKGROUND We conducted quantitative and qualitative studies to explore barriers and motivating factors to VMMC for HIV prevention, and to assess utilization of existing VMMC communication channels.nnMETHODS AND FINDINGS A population-based survey was conducted with 2350 respondents aged 15-49. Analysis consisted of descriptive statistics and bivariate analysis between circumcision and selected demographics. Logistic regression was used to determine predictors of male circumcision uptake compared to intention to circumcise. Focus group discussions (FGDs) were held with men purposively selected to represent a range of ethnicities. 68 and 53 of female/male respondents, respectively, had heard about VMMC for HIV prevention, mostly through the radio (71). Among male respondents, 11.3 reported being circumcised and 49 reported willingness to undergo VMMC. Factors which men reported motivated them to undergo VMMC included HIV/STI prevention (44), improved hygiene (26), enhanced sexual performance (6) and cervical cancer prevention for partner (6). Factors that deterred men from undergoing VMMC included fear of pain (40), not believing that they were at risk of HIV (18), lack of partner support (6). Additionally, there were differences in motivators and barriers by age. FGDs suggested additional barriers including fear of HIV testing, partner refusal, reluctance to abstain from sex and myths and misconceptions.nnCONCLUSIONS VMMC demand-creation messages need to be specifically tailored for different ages and should emphasize non-HIV prevention benefits, such as improved hygiene and sexual appeal, and need to address mens fear of pain. Promoting VMMC among women is crucial as they appear to have considerable influence over mens decision to get circumcised., author dropping-particle , family Hatzold, given Karin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mavhu, given Webster, non-dropping-particle , parse-names false, suffix , dropping-particle , family Jasi, given Phineas, non-dropping-particle , parse-names false, suffix , dropping-particle , family Chatora, given Kumbirai, non-dropping-particle , parse-names false, suffix , dropping-particle , family Cowan, given Frances M., non-dropping-particle , parse-names false, suffix , dropping-particle , family Taruberekera, given Noah, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mugurungi, given Owen, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ahanda, given Kim, non-dropping-particle , parse-names false, suffix , dropping-particle , family Njeuhmeli, given Emmanuel, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 5, issued date-parts 2014 , page 1-7, title Barriers and motivators to voluntary medical male circumcision uptake among different age groups of men in Zimbabwe Results from a mixed methods study, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuidc9b69880-9b9e-4855-bfdd-b820a05b7542 , mendeley formattedCitation (Hatzold et al. 2014), plainTextFormattedCitation (Hatzold et al. 2014), previouslyFormattedCitation (Hatzold et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json Hatzold et al.,( 2014) reported similar findings indicating that protection for HIV/AIDS, improved hygiene and sexual appeal were factors that encouraged men to go for VMMC service. Also in other studies it was observed that there was clear potential for men to go for circumcision in reducing HIV transmission and the associated human and economic costs ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1186/1471-2458-14-1119, ISBN 1471-2458, ISSN 1471-2458, PMID 25359662, abstract BACKGROUND In February 2012, the Lesotho Ministry of Health launched a national voluntary medical male circumcision (VMMC) program. To assess the motivations for seeking VMMC, a cross-sectional mixed methods study was conducted among clients aged 18 years and older at four sites.nnMETHODS A total of 161 men participated in individual survey interviews and 35 participated in four focus group discussions.nnRESULTS Men sought medical circumcision for the following main reasons protection against HIV (73), protection from other sexually transmitted infections (62), and improved penile hygiene (47). Forty percent learned about VMMC through friends who had already accessed services. According to these men, perceived concerns hindering service uptake include fear of pain (57), a female provider (18), and compulsory HIV testing (15).nnCONCLUSIONS The study provides important insights into the motivations of clients seeking VMMC services. Findings can be used by the national VMMC program to attract more clients and address barriers to uptake., author dropping-particle , family Skolnik, given Laura, non-dropping-particle , parse-names false, suffix , dropping-particle , family Tsui, given Sharon, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ashengo, given Tigistu Adamu, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kikaya, given Virgile, non-dropping-particle , parse-names false, suffix , dropping-particle , family Lukobo-Durrell, given Mainza, non-dropping-particle , parse-names false, suffix , container-title BMC public health, id ITEM-1, issue 1, issued date-parts 2014 , page 1119, title A cross-sectional study describing motivations and barriers to voluntary medical male circumcision in Lesotho., type article-journal, volume 14 , uris http//www.mendeley.com/documents/uuid56551690-86f3-46ed-ad5f-b819e57b5779 , id ITEM-2, itemData DOI 10.1136/sti.2005.017442, ISBN 1368-4973 (Print)r1368-4973 (Linking), ISSN 1368-4973, PMID 16581731, abstract OBJECTIVES Male circumcision is associated with reduced risk of HIV infection. This may be partly because of a protective effect of circumcision on other sexually transmitted infections (STI), especially those causing genital ulcers, but evidence for such protection is unclear. Our objective was to conduct a systematic review and meta-analyses of the associations between male circumcision and infection with herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Haemophilus ducreyi. METHODS Electronic databases (1950-2004) were searched using keywords and text terms for herpes simplex, syphilis, chancroid, ulcerative sexually transmitted diseases, or their causative agents, in conjunction with terms to identify epidemiological studies. References of key articles were hand searched, and data were extracted using standardised forms. Random effects models were used to summarise relative risk (RR) where appropriate. RESULTS 26 articles met the inclusion criteria. Most syphilis studies reported a substantially reduced risk among circumcised men (summary RR 0.67, 95 confidence interval (CI) 0.54 to 0.83), although there was significant between study heterogeneity (p 0.01). The reduced risk of HSV-2 infection was of borderline statistical significance (summary RR 0.88, 95 CI 0.77 to 1.01). Circumcised men were at lower risk of chancroid in six of seven studies (individual study RRs 0.12 to 1.11). CONCLUSIONS This first systematic review of male circumcision and ulcerative STI strongly indicates that circumcised men are at lower risk of chancroid and syphilis. There is less association with HSV-2. Potential male circumcision interventions to reduce HIV in high risk populations may provide additional benefit by protecting against other STI., author dropping-particle , family Weiss, given Ha a, non-dropping-particle , parse-names false, suffix , dropping-particle , family Thomas, given Sl L, non-dropping-particle , parse-names false, suffix , dropping-particle , family Munabi, given Sk K, non-dropping-particle , parse-names false, suffix , dropping-particle , family Hayes, given Rj J, non-dropping-particle , parse-names false, suffix , container-title Sexually transmitted infections, id ITEM-2, issue 2, issued date-parts 2006 , page 101-9 discussion 110, title Male circumcision and risk of syphilis, chancroid, and genital herpes a systematic review and meta-analysis., type article-journal, volume 82 , uris http//www.mendeley.com/documents/uuiddc72fc1a-0878-48c1-9fd5-7678ab6dea9e , mendeley formattedCitation (Skolnik et al. 2014 Weiss et al. 2006), plainTextFormattedCitation (Skolnik et al. 2014 Weiss et al. 2006), previouslyFormattedCitation (Skolnik et al. 2014 Weiss et al. 2006) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Skolnik et al. 2014 Weiss et al. 2006) 4.4.2 Circumcised men do not have to use condom every time they have sex The finding shows that 76 of respondents disagree that circumcised men do not have to use condoms every time they have sex with their partners. This shows that majority of the community are aware that male circumcision is only partial means of HIV prevention. At the same time 13.5 of all respondents agreed which means that according to them circumcised men do not have to use condoms every time they have sex. Also, 12.5 of all respondents remained silent which may mean that they were not sure as to whether circumcised men do not have to use condom or use whenever they have sex 4.5 Stakeholders involved in VMMC and the role they play This was the third research question whereby the study sought to examine the stakeholders involved in Voluntary Medical Male Circumcision and the role they play in creating demand for VMMC services at the community level in Njombe Town Council. Questionnaires, interviews and literature reviews were used as means of data collection. The study was able to collect information from five types of stakeholders who are involved in male circumcision in the study areas. These include Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), USAID, Community Sensitization Organization, male circumcision health providers and peer promoters/voluntary community advocates and more details are narrated as follows. Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) RHMT and CHMT have being working on behalf of the ministry of health to plan and coordinate VMMC services as narrated by one of the RHMT. Our main obligation in male circumcision activities involved in planning and coordination, advocacy meetings, sensitization through local radio like Uplands radio where we are being invited to conduct a radio magazine session. Also we are obliged to conduct quality assurance activities so as to make sure that services are provided according to the standards of ministry of health as well as to ensure that providers are well trained and following procedures and that the VMMC sites are appropriately stocked (RHMT Member).In every male circumcision activity that is conducted within our council we are obliged to work closely with the NGO to identify a health facilities that services should be offered as well as giving permission for them to use the trained health providers(CHMT Member) USAID Through her organization such as Jhpiego in collaboration with MoHCDGEC they work hand in hand to make sure that male circumcision activities are implemented as planned as explained by one of the study respondents, The organization has been responsible for free services delivery and demand creation of VMMC services in Njombe region since 2011.We have been implementing high-volume campaigns, outreach and mobile services, as well as operating on fixed sites. The organization has been implementing several demand creation activities, using radio, cultural performances, public events, and other tactics to reach men who have not yet been circumcised (USAID, Njombe regional representative). Community sensitization organization (CSO) SUMASESU is the main community sensitization organization that is working closely with Njombe Town Council community to bring awareness of male circumcision services. As narrated by one of the organizations leaders, we work from the grass root level with local leaders, religious leaders, schools and youth organization. Our main focus is to make sure that local communities are well informed on the importance of male circumcision services as an HIV prevention strategy. Dissemination of leaflets, posters, brochures to the community members has helped the VMMC messages to be well spread Egnatio Mtawa (Executive Director). Male circumcision health providers this include two type of health provider namely surgeons and counselors. All of them are well trained according to Ministry of Health standards. One of the respondents in this study stated that, By the guidance of the counseling flip chart we provide group education and an individual counseling where as in group education we make sure that the VMMC clients is well informed of the important issues such as HIV/AIDS and risk reduction, HIV testing services (HTS), VMMC service package and its associated benefits, What to expect during the VMMC procedure, including risks as well as demonstrating correct and consistence use of condom (VMMC counselor). Respondents reported further that when it comes to individual counseling focus is on delivering the key information about the association between male circumcision and HIV/AIDS reduction. The emphasis is to ensure that individuals are aware that male circumcision reduces the risk of acquiring HIV infection. One of the interviewed counselor had the following remarks,VMMC reduces the risk of acquiring HIV through heterosexual intercourse (by approximately 60 percent), providing only partial protection therefore, condoms must be used consistently and correctly after VMMC (VMMC Counselor).When explaining the role of a surgeon in VMMC,one study participated reported that Im obliged to make a physical examination on the client before operating him to make sure that hes physical fit to undergo surgery. Community peer promoters/voluntary community advocates. This has been the main group that has played a vital role in advocating male circumcision as HIV prevention in Njombe Town Council. The study respondents reported that peer promoters are well trained and equipped with communication materials that they are supposed to use as their guidance in delivering a message to the community about VMMC.One of the peer promoters expressed the following, We pass around the community where we live to educate men and women, and adolescents both male and female about the benefits of male circumcision for HIV risk reduction, we are naturally networkers where as we usually connect VMMC clients with the nearby health center where they can go and access the services for free(VMMC peer promoter) Table 5 A Summary of Stakeholders involvement in male circumsicion and the role played Name of stake holderRole played Ministry of HealthPlanning, implementing, coordinating and monitoring the provision of male circumcision services in health facilities of Njombe region.USAID / JhpiegoFinancing projects geared towards prevention of HIV such as VMMC in Njombe Region. This is done through channeling resources to non-governmental organizations such as Jhpiego under AIDSFREE program.Community Sensitization OrganizationsWho sensitize and mobilize male to seek male circumcision services as means of HIV prevention strategy.Male Circumcision Health ProvidersProvide a package of services that include, HIV testing, screening for sexually transmitted infections, physical exam, medical circumcision, provision of condoms, and HIV risk-reduction counselingCommunity Peer Promoters / Voluntary Community Advocates These groups of people are responsible for sensitization and advocacy of VMMC services by interpersonal communication skills and experiential media. From the literature review, it was found out that the government of Tanzania participates in male circumcision as means towards prevention of HIV as it has introduced polices and strategies. The major emphasis of The National HIV Prevention Strategy is to bring to full scale proven and prioritized HIV prevention interventions that address the drivers of the epidemic, while ensuring that disproportionately affected population groups are provided with appropriate HIV prevention efforts. The strategy is designed to provide stakeholders involved in a wide range of HIV prevention, care, treatment, and support programs with guided reference for the prevention of new HIV infections. The study found out that the government works together with different stakeholders who play a critical role in HIV prevention. They include policy makers, community leaders, government ministries community based organizations, local governments, faith-based organizations, the private sector, and development partners ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1186/1471-2458-11-506, abstract Background Male circumcision (MC) has been shown to be effective against heterosexual acquisition of HIV infection and is being scaled up as an additional strategy against HIV in several countries of Africa. However, the policy environment (whether to formulate new specific policy on MC or adapts the existing ones) and the role of various stakeholders in the MC scale up process in Tanzania was unclear. We conducted this study as part of a situation analysis to understand the attitudes of policy makers and other key community and health authority decision makers towards MC, policy and regulatory environment, and the readiness of a health system to accommodate scaling up of MC services. Methods We conducted 36 key informants interviews with a broad range of informants including civil servants, religious leaders, cultural and traditional gatekeepers and other potential informants. Study informants were selected at the national level, regional, district and community levels to represent both traditionally circumcising and non-circumcising communities. Results Study informants had positive attitudes and strong beliefs towards MC. Key informants in traditionally non-circumcising districts were willing to take their sons for medically performed MC. Religious leaders and traditional gatekeepers supported MC as it has been enshrined in their holy scripts and traditional customs respectively. Civil servants highlighted the need for existence of enabling policy and regulatory environment in the form of laws, regulations and guidelines that will ensure voluntary accessibility, acceptability, quality and safety for those in need of MC services. Majority of informants urged the government to make improvements in the health system at all levels to ensure availability of adequate trained personnel, infrastructure, equipment, and supplies for MC scale up, and insisted on the involvement of different MC stakeholders as key components in effective roll out of medically performed MC programme in the country. Conclusions Findings from the situation analysis in Tanzania have shown that despite the absence of a specific policy on MC, basic elements of enabling policy environment at national, regional, district and community levels are in place for the implementation of MC scale up programme., author dropping-particle , family Mwanga, given Joseph R, non-dropping-particle , parse-names false, suffix , dropping-particle , family Wambura, given Mwita, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mosha, given Jacklin F, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mshana, given Gerry, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mosha, given Frank, non-dropping-particle , parse-names false, suffix , dropping-particle , family Changalucha, given John, non-dropping-particle , parse-names false, suffix , container-title BMC Public Health, id ITEM-1, issued date-parts 2011 , title Policy environment and male circumcision for HIV prevention Findings from a situation analysis study in Tanzania, type article-journal , uris http//www.mendeley.com/documents/uuide30d947b-6e56-46ac-b088-25b231f5d160 , mendeley formattedCitation (Mwanga et al. 2011), plainTextFormattedCitation (Mwanga et al. 2011), previouslyFormattedCitation (Mwanga et al. 2011) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Mwanga et al. 2011). 4.6 Factors that hinders VMMC services uptake for men aged 20 years and above The study findings indicate that there were fewer men aged 20 years and above who attended health facilities to get VMMC services. REF _Ref464111770 h MERGEFORMAT Figure shows that the rate of men aged 20 years and above to go for VMMC services has been low. The percentage has always been less than 20, with only 2013 when the percentage of men aged 20 and above going for VMMC services was 25. The data shows that since 2011-2016 only 18 of men aged 20 years and above have being circumcised compared to 82 of 10-19 years as shown in REF _Ref464111770 h MERGEFORMAT Figure. Figure 4 VMMC uptake by age category from 2011 2016 The qualitative data collected from key stakeholders (Ministry of Health, USAID, CSO, male circumcision health providers, peer promoters /voluntary community advocates) a number of factors were mentioned to explain why there is low turnout of men of 20 years and above in seeking for VMMC services in Njombe Town Council. These, which will be explained in detail in the following section include culture barriers, misconception, lack of friendly services, fear of pain, and financial concerns Culture barriers. The study respondents reported that men aged 20 and above resist the VMMC services due the fact that MC is not part of their culture. One of respondents said that As we know that majority of Njombe community are Christians hence they relate it with Islamic culture they believe that MC was meant for the Muslims (CHMT member). Misconception. The study respondent reported that, there have been a huge demand creations activities advocating VMMC services in Njombe, hence men of 20 years and above have got a negative concept about the services to the extent that they relate it with freemason only because it is provided free of charge. For instance, one respondent said, They question why the organization is using a lot of resources for the service if its not from those believers of freemason (VMMC peer promoter). Respondent reported further that, some think that the foreskins are being exported to the foreign countries for being used in making cosmetics, while others think the foreskin are being used for witchcraft. They question, We are so suspicious of the services because why are you collecting the foreskin in the plastic bags if theyre not transported for making cosmetics (VMMC health provider). Also as part of misconception, some adults are scared of not being able to get children after VMMC Service, as they fear the injection, which is done on the penis that it might cause impotency. One of study respondent narrated that they overhead that the injections they are using in VMMC procedure are meant to cause impotency among men as the main intention those who provide the funds is to control birth among Africans (CSO, representative). In addition, the perception that male circumcision may lead to sexual impotency was reported as one of the barriers for adult men to go for VMMC services in this study. In other studies, it was found that individual factors that hindered men from attending VMMC services were lack of partner support, fear of sexual impotency and encouragement from relative or close friend ADDIN CSL_CITATION citationItems id ITEM-1, itemData author dropping-particle , family Ssekubugu, given Robert, non-dropping-particle , parse-names false, suffix , dropping-particle , family Leontsini, given Elli, non-dropping-particle , parse-names false, suffix , dropping-particle , family Wawer, given Maria J., non-dropping-particle , parse-names false, suffix , dropping-particle , family Serwadda, given David, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kigozi, given Godfrey, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kennedy, given Caitlin E., non-dropping-particle , parse-names false, suffix , dropping-particle , family Nalugoda, given Fred, non-dropping-particle , parse-names false, suffix , dropping-particle , family Sekamwa, given Richard, non-dropping-particle , parse-names false, suffix , dropping-particle , family Wagman, given Jennifer, non-dropping-particle , parse-names false, suffix , dropping-particle , family Gray, given Ronald H., non-dropping-particle , parse-names false, suffix , container-title Qualitative health research, id ITEM-1, issue 6, issued date-parts 2013 , page 795 – 804, title Contextual Barriers and Motivators to Adult Male Medical Circumcision in Rakai, Uganda, type article-journal, volume 23 , uris http//www.mendeley.com/documents/uuid85f53b53-09ce-4728-a0e4-87792ddfd5cd , id ITEM-2, itemData DOI 10.11604/pamj.2014.19.337.5245, ISBN 1937-8688, ISSN 19378688, PMID 25918577, abstract INTRODUCTION Voluntary Medical Male Circumcision (VMMC) is the surgical removal of the foreskin by a trained health worker. VMMC was introduced in Zimbabwe in 2009. It is of concern that the programme performance has been below expectations nationally and in Mazowe district. Zimbabwe is unlikely to meet its 2015 target of circumcising 1 200 000 men aged between 15 and 29 years and unlikely to enjoy maximum benefits of VMMC which include prevention of HIV, sexually transmitted infections and cervical cancer. We therefore broadly aimed at identifying factors influencing the level of VMMC uptake in Mazowe district. METHODS An analytic cross-sectional study was carried out in Mazowe district. A multi-stage probability sampling strategy was used to select 300 men aged between 18 and 49 years. Pretested interviewer administered questionnaires, key informant interviews and focus group discussions were used to collect data. Quantitative data was analysed using Epi info where odds ratios and p-values were calculated. Qualitative data was analysed thematically. RESULTS Being of Shona origin (AOR 7.69 (95CI 1.78-33.20)), fear of pain (AOR 7.09 (95CI 2.58-19.47)) and fear of poor wound healing (AOR 2.68 (95CI 1.01-7.08)) were independently associated with being uncircumcised while having a circumcised friend and encouragement by a friend or relative were independently associated with being circumcised. CONCLUSION Fear of pain, fear of poor wound healing and encouragement by a friend or relative were associated with circumcision status. Widening use of surgical devices and third part referrals may assist in scaling up the programme., author dropping-particle , family Rupfutse, given Maxwell, non-dropping-particle , parse-names false, suffix , dropping-particle , family Tshuma, given Cremence, non-dropping-particle , parse-names false, suffix , dropping-particle , family Tshimanga, given Mufuta, non-dropping-particle , parse-names false, suffix , dropping-particle , family Gombe, given Notion, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bangure, given Donewell, non-dropping-particle , parse-names false, suffix , dropping-particle , family Wellington, given Maureen, non-dropping-particle , parse-names false, suffix , container-title Pan African Medical Journal, id ITEM-2, issued date-parts 2014 , page 1-8, title Factors associated with uptake of voluntary medical male circumcision, Mazowe District, Zimbabwe, 2014, type article-journal, volume 19 , uris http//www.mendeley.com/documents/uuid0c53cf4e-771d-4956-a169-416d1b702e11 , mendeley formattedCitation (Ssekubugu et al. 2013 Rupfutse et al. 2014), plainTextFormattedCitation (Ssekubugu et al. 2013 Rupfutse et al. 2014), previouslyFormattedCitation (Ssekubugu et al. 2013 Rupfutse et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Ssekubugu et al. 2013 Rupfutse et al. 2014). Lack of age specific friendly services During the provision of the VMMC services, the rooms are not separated according to age group. This arrangement has demoralized older men to seek the services because of shame of being identified as uncircumcised by the youth who would be with them on the same room. The respondent narrate that the older men claim Its shame, we feel shame to go for male circumcision because there is no privacy for adults. We cannot stay in queue with our children and our grandchildren as they will know that we were not yet circumcised (VMMC health provider). Lack of age specific friendly services for adults was reported to influence the uptake of VMMC services in the study area. Similar results were reported by another study done in Tanzania and Zimbabwe showing that service delivery modalities and intensities affect client profiles in conjunction with other contextual factors such as implementing campaigns during school holidays in Zimbabwe and cultural preference for circumcision at a young age in Tanzania ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0083642, ISSN 19326203, PMID 24801882, abstract BACKGROUND Scaling up voluntary medical male circumcision (VMMC) to 80 of men aged 15-49 within five years could avert 3.4 million new HIV infections in Eastern and Southern Africa by 2025. Since 2009, Tanzania and Zimbabwe have rapidly expanded VMMC services through different delivery (fixed, outreach or mobile) and intensity (routine services, campaign) models. This review describes the modality and intensity of VMMC services and its influence on the number and age of clients.nnMETHODS AND FINDINGS Program reviews were conducted using data from implementing partners in Tanzania (MCHIP) and Zimbabwe (PSI). Key informant interviews (N 13 Tanzania N 8 Zimbabwe) were conducted transcripts were analyzed using Nvivo. Routine VMMC service data for May 2009-December 2012 were analyzed and presented in frequency tables. A descriptive analysis and association was performed using the z-ratio for the significance of the difference. Key informants in both Tanzania and Zimbabwe believe VMMC scale-up can be achieved by using a mix of service delivery modality and intensity approaches. In Tanzania, the majority of clients served during campaigns (59) were aged 10-14 years while the majority during routine service delivery (64) were above 15 (p0.0001). In Zimbabwe, significantly more VMMCs were done during campaigns (64) than during routine service delivery (36) (p0.00001) the difference in the age of clients accessing services in campaign versus non-campaign settings was significant for age groups 10-24 (p0.05), but not for older groups.nnCONCLUSIONS In Tanzania and Zimbabwe, service delivery modalities and intensities affect client profiles in conjunction with other contextual factors such as implementing campaigns during school holidays in Zimbabwe and cultural preference for circumcision at a young age in Tanzania. Formative research needs to be an integral part of VMMC programs to guide the design of service delivery modalities in the face of, or lack of, strong social norms., author dropping-particle , family Ashengo, given Tigistu Adamu, non-dropping-particle , parse-names false, suffix , dropping-particle , family Hatzold, given Karin, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mahler, given Hally, non-dropping-particle , parse-names false, suffix , dropping-particle , family Rock, given Amelia, non-dropping-particle , parse-names false, suffix , dropping-particle , family Kanagat, given Natasha, non-dropping-particle , parse-names false, suffix , dropping-particle , family Magalona, given Sophia, non-dropping-particle , parse-names false, suffix , dropping-particle , family Curran, given Kelly, non-dropping-particle , parse-names false, suffix , dropping-particle , family Christensen, given Alice, non-dropping-particle , parse-names false, suffix , dropping-particle , family Castor, given Delivette, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mugurungi, given Owen, non-dropping-particle , parse-names false, suffix , dropping-particle , family Dhlamini, given Roy, non-dropping-particle , parse-names false, suffix , dropping-particle , family Xaba, given Sinokuthemba, non-dropping-particle , parse-names false, suffix , dropping-particle , family Njeuhmeli, given Emmanuel, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 5, issued date-parts 2014 , page 1-8, title Voluntary Medical Male Circumcision (VMMC) in Tanzania and Zimbabwe Service delivery intensity and modality and their influence on the age of clients, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuidbbb2c8ac-57f4-4169-b7fc-a6e0aefb29a4 , mendeley formattedCitation (Ashengo et al. 2014), plainTextFormattedCitation (Ashengo et al. 2014), previouslyFormattedCitation (Ashengo et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Ashengo et al. 2014). Also demand-creation messages need to be specifically tailored for different ages and should emphasize on some activities which might increase VMMC uptake including dispelling VMMC misconceptions increasing involvement of religious leaders, womens groups, and peer promoters for VMMC promotion and increasing the relevance of VMMC among men who are already practicing it as an HIV prevention method ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0019814, ISBN 1932-6203 (Electronic)n1932-6203 (Linking), ISSN 19326203, PMID 21603622, abstract Numerous studies have demonstrated that male circumcision (MC) reduces the incidence of the Type-1 human immunodeficiency virus (HIV) among heterosexual men by at least half., author dropping-particle , family Herman-Roloff, given Amy, non-dropping-particle , parse-names false, suffix , dropping-particle , family Otieno, given Nixon, non-dropping-particle , parse-names false, suffix , dropping-particle , family Agot, given Kawango, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ndinya-Achola, given Jeckoniah, non-dropping-particle , parse-names false, suffix , dropping-particle , family Bailey, given Robert C., non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 5, issued date-parts 2011 , page 3-8, title Acceptability of medical male circumcision among uncircumcised men in Kenya one year after the launch of the national male circumcision program, type article-journal, volume 6 , uris http//www.mendeley.com/documents/uuid7b624f1d-6c40-48ff-9030-a44853fd0058 , mendeley formattedCitation (Herman-Roloff et al. 2011), plainTextFormattedCitation (Herman-Roloff et al. 2011), previouslyFormattedCitation (Herman-Roloff et al. 2011) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Herman-Roloff et al. 2011) Financial concerns Includes missing out of work during the procedure and on healing period, of which requires them to stay away from their economic activities of which they consider it a barrier towards attaining the service. One of the study respondent narrated that As you know in their economic systems, the father is the head of household and financial provider, so its difficult for a father to stay at home for two or more weeks waiting for a wound to heal and be out of economic activities (RHMT member). This study revealed that fear to remain economically inactive for one or more weeks was a barrier for utilization of VMMC services. This is because most male adults are economically active and other family members depend on them. Men were afraid that VMMC services would lead them to stay away from work during wound healing period. Similar observation was witnessed in a study done in Kenya where adults demanded for detailed information about pain and how long they will stay away from work so that they can decide to go for VMMC services ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1371/journal.pone.0098221, ISBN 1932-6203, ISSN 19326203, PMID 24901226, abstract BACKGROUND Uptake of VMMC among adult men has been lower than desired in Nyanza, Kenya. Previous research has identified several barriers to uptake but qualitative exploration of barriers is limited and evidence-informed interventions have not been fully developed. This study was conducted in 2012 to 1) increase understanding of barriers to VMMC and 2) to inform VMMC rollout through the identification of evidence-informed interventions among adult men at high risk of HIV in Nyanza Province, Kenya.nnMETHODS Focus groups (n 8) and interviews were conducted with circumcised (n 8) and uncircumcised men (n 14) from the two districts in Nyanza, Kenya. Additional interviews were conducted with female partners (n 20), health providers (n 12), community leaders (n 12) and employers (n 12). Interview and focus group guides included questions about individual, interpersonal and societal barriers to VMMC uptake and ways to overcome them. Inductive thematic coding and analysis were conducted through a standard iterative process.nnRESULTS Two primary concerns with VMMC emerged 1) financial issues including missing work, losing income during the procedure and healing and family survival during the recovery period and 2) fear of pain during and after the procedure. Key interventions to address financial concerns included a food or cash transfer, education on saving and employer-based benefits. Interventions to address concerns about pain included refining the content of demand creation and counseling messages about pain and improving the ways these messages are delivered.nnCONCLUSIONS Men need accurate and detailed information on what to expect during and after VMMC regarding both pain and time away from work. This information should be incorporated into demand creation activities for men considering circumcision. Media content should frankly and correctly address these concerns. Study findings support scale up and/or further improvement of these ongoing educational programs and specifically targeting the demand creation period., author dropping-particle , family Evens, given Emily, non-dropping-particle , parse-names false, suffix , dropping-particle , family Lanham, given Michele, non-dropping-particle , parse-names false, suffix , dropping-particle , family Hart, given Catherine, non-dropping-particle , parse-names false, suffix , dropping-particle , family Loolpapit, given Mores, non-dropping-particle , parse-names false, suffix , dropping-particle , family Oguma, given Isaac, non-dropping-particle , parse-names false, suffix , dropping-particle , family Obiero, given Walter, non-dropping-particle , parse-names false, suffix , container-title PLoS ONE, id ITEM-1, issue 6, issued date-parts 2014 , title Identifying and addressing barriers to uptake of voluntary medical male circumcision in Nyanza, Kenya among men 18-35 A qualitative study, type article-journal, volume 9 , uris http//www.mendeley.com/documents/uuida8eba4ea-4026-4043-b572-2462734f8593 , mendeley formattedCitation (Evens et al. 2014), plainTextFormattedCitation (Evens et al. 2014), previouslyFormattedCitation (Evens et al. 2014) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Evens et al. 2014). A study done in Zimbabwe reported delayed in wound healing a as barrier for adult men to go for VMMC services ADDIN CSL_CITATION citationItems id ITEM-1, itemData ISSN 2071-2936 (Electronic), PMID 27380850, abstract BACKGROUND Medical male circumcision (MMC) has become a significant dimension of HIV prevention interventions, after the results of three randomised controlled trials in Uganda, South Africa and Kenya demonstrated that circumcision has a protective effect against contracting HIV of up to 60. Following recommendations by the World Health Organization, Zimbabwe in 2009 adopted voluntary MMC as an additional HIV prevention strategy to the existing ABC behaviour change model. PURPOSE The purpose of this study is thus to investigate the factors contributing to the low uptake of MMC. METHODS The study was a quantitative cross-sectional survey conducted in Mutare rural district, Zimbabwe. Questionnaires with open- and closed-ended questions were administered to the eligible respondents. The target population were male participants aged 15-29 who met the inclusion criteria. The households were systematically selected with a sample size of 234. Statistical Package for the Social Sciences was used to analyse the data. RESULTS Socioculturally, circumcised men are viewed as worthless (37), shameful (30) and are tainted as promiscuous (20), psychological factors reported were infection and delayed healing (39), being ashamed and dehumanised (58), stigmatised and discriminated (40.2) and fear of having an erection during treatment period (89.7) whilst socio-economic factors were not having time, as it will take their time from work (58) and complications may arise leading to spending money on treatment (84). CONCLUSION Knowledge deficits regarding male medical circumcision lead to low uptake, education on male medical circumcision and its benefits. Comprehensive sexual health education should target men and dispel negative attitudes related to the use of health services., author dropping-particle , family Chiringa, given Irene O, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ramathuba, given Dorah U, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mashau, given Ntsieni S, non-dropping-particle , parse-names false, suffix , container-title African journal of primary health care family medicine, id ITEM-1, issue 2, issued date-parts 2016 , page e1-6, title Factors contributing to the low uptake of medical male circumcision in Mutare Rural District, Zimbabwe., type article-journal, volume 8 , uris http//www.mendeley.com/documents/uuid98dc1c0c-21f6-4432-a901-12cc6cdb874e , mendeley formattedCitation (Chiringa et al. 2016), plainTextFormattedCitation (Chiringa et al. 2016), previouslyFormattedCitation (Chiringa et al. 2016) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Chiringa et al. 2016). Fear of pain Adults aged 20 years and above had a fear of pain, and that hindered them to go for MC services. The respondent narrates that older men says, They hear that soon after the end of anesthesia, you feel strong pain. So they are afraid to go for medical male circumcision (VMMC health provider). Fear of pain was also reported by a study done in Botswana ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.1038/jid.2014.371, ISBN 6176321972, ISSN 15378276, PMID 1000000221, author dropping-particle , family Malterer, given Melanie B, non-dropping-particle , parse-names false, suffix , dropping-particle , family Glass, given Samantha J, non-dropping-particle , parse-names false, suffix , dropping-particle , family Newman, given Joseph P, non-dropping-particle , parse-names false, suffix , container-title NIH Public Access, id ITEM-1, issue 3, issued date-parts 2008 , page 735-745, title Acceptability of Male Circumcision Among Adolescent Boys and their Parents, Botswana, type article-journal, volume 44 , uris http//www.mendeley.com/documents/uuid599ad3e7-d822-46a1-8b6a-8e7c8e1e16a3 , mendeley formattedCitation (Malterer et al. 2008), plainTextFormattedCitation (Malterer et al. 2008), previouslyFormattedCitation (Malterer et al. 2008) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Malterer et al. 2008), which reported that VMMC uptake might be high if procedure done safely, for free and with adequate pain control in a hospital setting. Another study done in Njombe in previous years outlined that partner infidelity during the post-surgical abstinence period, loss of income, and fear of pain associated with post- surgical erections were factors associated with low uptake of male circumcision ADDIN CSL_CITATION citationItems id ITEM-1, itemData DOI 10.9745/GHSP-D-12-00037, ISSN 2169-575X, PMID 25276521, abstract BACKGROUND In 2009, the Government of Tanzania embarked on scaling up voluntary medical male circumcision (VMMC) services for HIV prevention in 8 priority regions, with the aim of serving 2.8 million boys and men ages 10-34 years by 2013. By mid-2012, more than 110,000 boys and men in Iringa and Njombe regions had received VMMC. The majority (85) of these VMMC clients were under 19 years old (average age, 16 years). This study aimed to identify potential barriers and facilitators to VMMC among older men.nnMETHODS We conducted 16 focus group discussions, stratified by sex and age, with 142 purposefully selected participants in 3 districts of Iringa and Njombe regions.nnRESULTS Both men and women generally had positive attitudes toward VMMC. Social and personal barriers to obtaining VMMC among adult men included shame associated with seeking services co-located with younger boys and perceived inappropriateness of VMMC after puberty, particularly after marriage and after having children. Additional barriers included concerns about partner infidelity during the post-surgical abstinence period, loss of income, and fear of pain associated with post-surgical erections. Facilitators included awareness of the HIV-prevention benefit and perceptions of cleanliness and enhanced attractiveness to women.nnCONCLUSIONS While men and women in Iringa and Njombe regions in Tanzania generally view VMMC as a desirable procedure, program implementers need to address barriers to VMMC services among adult men. Selected service delivery sites in the Iringa and Njombe regions will be segregated by age to provide services that are friendly to adult men. Services will be complemented with behavior change communication initiatives to address concerns of older men, encourage womens support for circumcision and adherence to the post-surgical abstinence period, and change social norms that inhibit older men from seeking circumcision., author dropping-particle , family Plotkin, given Marya, non-dropping-particle , parse-names false, suffix , dropping-particle , family Castor, given Delivette, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mziray, given Hawa, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ku00fcver, given Jan, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mpuya, given Ezekiel, non-dropping-particle , parse-names false, suffix , dropping-particle , family Luvanda, given Paul James, non-dropping-particle , parse-names false, suffix , dropping-particle , family Hellar, given Augustino, non-dropping-particle , parse-names false, suffix , dropping-particle , family Curran, given Kelly, non-dropping-particle , parse-names false, suffix , dropping-particle , family Lukobo-Durell, given Mainza, non-dropping-particle , parse-names false, suffix , dropping-particle , family Ashengo, given Tigistu Adamu, non-dropping-particle , parse-names false, suffix , dropping-particle , family Mahler, given Hally, non-dropping-particle , parse-names false, suffix , container-title Global health, science and practice, id ITEM-1, issue 1, issued date-parts 2013 , page 108-16, title Man, what took you so long Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania., type article-journal, volume 1 , uris http//www.mendeley.com/documents/uuid713a3ff8-f117-45b2-adc5-a1ea69ebccde , mendeley formattedCitation (Plotkin et al. 2013), plainTextFormattedCitation (Plotkin et al. 2013), previouslyFormattedCitation (Plotkin et al. 2013) , properties noteIndex 0 , schema https//github.com/citation-style-language/schema/raw/master/csl-citation.json (Plotkin et al. 2013) CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATION 5.1 Summary of the Findings The purpose of the study was to examine the perception and acceptability of Voluntary Medical Male Circumcision (VMMC) as a strategy for HIV prevention in Njombe Town Council. Data collection was done using questionnaires and interviews as well as through literature review. The findings of the study indicate that majority of respondents who participated in this study stated that awareness of the existence and importance of Voluntary Medical Male Circumcision towards prevention of HIV was among the major reasons that made them to participate in the medical circumcision in Njombe Town Council. The study found out that community members were aware of the role of male circumcision in prevention of HIV infection.However, few respondents said that they were not aware that there is close link between male circumcision and HIV transmission. Respondents said that they participated in the voluntary medical male circumcision due to the support and encouragement from family members such as wife, parents, fiance and brothers/sisters. However, the study also found out that some men did not participate in the circumcision practices because of restriction from family members. Furthermore, the study found out that most of the respondents indicated that factors that influenced the circumcision of male in the study area were due to the ongoing campaign conducted by government and non-government organizations. The study found out that to a large extent VMMC campaign was the major leading factor towards the increased awareness of VMMC in Njombe Town Council and beyond. In addition, the study found out that the government of Tanzania participates in advocating male circumcision as a means towards prevention of HIV through introduction of polices and strategies that promote Voluntary medical Male Circumcision. The major emphasis of The National HIV Prevention Strategy is to bring to full scale proven and prioritized HIV prevention interventions that address the drivers of the epidemic, while ensuring that disproportionately affected population groups are provided with appropriate HIV prevention efforts. It is designed to provide stakeholders involved in a wide range of HIV prevention, care, treatment, and support programs with guided reference for the prevention of new HIV infections. Furthermore, the study found out that the government works together with different stakeholders who play a critical role in HIV prevention. They include policy makers, community leaders, government ministries community based organizations, local governments, non-governmental organization, faith-based organizations, the private sector, and development partners. The findings for this study showed that most of the respondents agreed that voluntary medical male circumcision services were useful in reducing the spread or prevent male from contacting HIV/AIDS. While at the same time some respondents perception showed disagreement that male circumcision prevents the spread of HIV/AIDS. It was also found that although male circumcision is perceived to prevent the spread of HIV/AIDS but it was supposed to be done scientifically and professionally in the hospitals. 5.2 Conclusion Male circumcision is facing a number of social cultural and economic barriers that prevent some of the men aged 20 years and above to undergo it. Such barriers include fears of pains during circumcision, becoming economically inactive during circumcision period and fear that circumcised men may become impotent. Despite these few barriers this study found that most of the interviewed study participants showed that they are aware that uncircumcised men may contract STIs including HIV compared to circumcised men. Furthermore, most of the community members perceived as the appropriate strategy in preventing males against sexually transmitted infections. Generally, the community members had a positive perception that Voluntary Medical Male Circumcision can be used as one of the strategies in reducing the spread of HIV infection. The practice should then be used in line with other strongly dedicated protective gears such as condoms, remain faithful with one partner and/or abstinence. It was revealed that to a certain extent the community members in Njombe Town Council do accept male circumcision as an HIV/AIDS prevention strategy. Therefore, it can be concluded that according to community members perception, male circumcision can be used as one of the strategies for reducing the spread of HIV infection. 5.3 Recommendations The following recommendations are proposed based on the study findings to make the VMMC services sustainable in Njombe Town Council Based on these findings, we recommend that information, education and communication strategies of VMMC should be advocated from the grassroots level placing on the public health benefits of Voluntary Medical Male Circumcision like improvement in genital hygiene and prevention of sexually transmitted illnesses, acceptability should be increased by increasing the advocacy in all levels of the community. In order to limit resistance to the acceptance of VMMC services among men of 20 years and above, community members should be well trained to educate their peers on the benefits of VMMC. For instance, people should be aware that, VMMC does not give a full protection from HIV infection. The community mobilization should also be used as an entry point for education about the traditional ABC – Abstinence, be faithful and use a Condom – prevention strategy, as well as an avenue for promoting voluntary counselling and testing. Community members in general and family members in particular should participate in health education campaigns on the importance of Voluntary Medical Male Circumcision at the health facility level and community sensitizations meetings so as to be able to participate fully in decision making process concerning male circumcision. Stakeholders who engage in male circumcision as preventive measure against HIV/AIDS in Tanzania such as Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDEC), NGOs, and donors/ implementing partners should increase the outreach to the whole community by providing more information concerning Voluntary Medical Male Circumcision. Such information should be made available in health care facilities to enhance community participation and decision on infant male circumcision. The sensitization campaigns on male circumcision should emphasize that parents and the general community should ensure that male children are sent to the health facilities such as hospitals and dispensaries at their young age so that they get Medical Male Circumcision. Likewise, the community should discourage some of the cultural traditions which affect the parent and community decision to participate in male circumcision. The health facilities involved in male circumcision should ensure privacy in services provision so as to motivate older men for the VMMC. Also the demand creation message should specifically emphasise the importance of the service to older men and their benefits to their partners. REFERENCES ADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY Ashengo, T.A. et al., 2014. Voluntary Medical Male Circumcision (VMMC) in Tanzania and Zimbabwe Service delivery intensity and modality and their influence on the age of clients. PLoS ONE, 9(5), pp.18. Auvert, B. et al., 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk The ANRS 1265 trial. PLoS Medicine, 2(11), pp.11121122. Bailey, R.C., Egesah, O. Rosenberg, S., 2008. Male circumcision for HIV prevention A prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bulletin of the World Health Organization, 86(9), pp.669677. Castellsagu, X. et al., 2002. 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Contextual Barriers and Motivators to Adult Male Medical Circumcision in Rakai, Uganda. Qualitative health research, 23(6), pp.795804. Stretcher, V. Rosenstock, I.M., 1997. The Health Belief Model. In Health Behavior and Health Education Theory, Research and Practice. pp. 3136. Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC) National Bureau of Statistics (NBS) Tanzania and Macro International Inc., 2013. HIV/AIDS and Malaria Indicator Survey 201112, Dar es Salaam. Available at http//scholar.google.com/scholarhlenbtnGSearchqintitleHIV/AIDSandMalariaIndicatorSurvey2011-1205Cnhttp//scholar.google.com/scholarhlenbtnGSearchqintitleTanzaniaHIV/AIDSandMalariaIndicatorSurvey2011125. Tarimo, E.A. et al., 2012. The perceptions on male circumcision as a preventive measure against HIV infection and considerations in scaling up of the services a qualitative study among police officers in Dar es Salaam, Tanzania. BMC Public Health, 12(1), p.529. Available at Urassa, M. et al., 1997. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS, 11(3). VanBuskirk, K. et al., 2011. Circumcision and Acquisition of Human Papillomavirus Infection in Young Men. Sexually Transmitted Diseases, 38(11), pp.10741081. Available at http//content.wkhealth.com/linkback/openurlsidWKPTLPlandingpagean00007435-201111000-00016. Wambura, M. et al., 2009. Situation Analysis for Male Circumcision in Tanzania, Weiss, H. a et al., 2006. Male circumcision and risk of syphilis, chancroid, and genital herpes a systematic review and meta-analysis. Sexually transmitted infections, 82(2), p.1019 discussion 110. Available at http//sti.bmj.com/content/82/2/101.short5Cnhttp//www.pubmedcentral.nih.gov/articlerender.fcgiartid2653870toolpmcentrezrendertypeabstract. Date of Interview _____/___/____ Name of Interviewer ______________________ Socio-economic and demographic characteristics How old are you 18-29————130-39————240-49————31.2 What is your gender Male————–1 Female————2 1.3 What is your marital status Married ————- 1 Divorced/single —– 2 What is your education level Primary Education ————–1 Secondary /certificate ————-2 Diploma —————————–3 Degree ————————–4 What is your employment status Formal employment ———————-1 Informal employment ——————– 2 Self-employed —————————–3 Unemployed ——————————- 4 SOURCE OF INFORMATION ABOUT MALE CIRCUMCISION Where have you heard about Male Circumcision_ Media (Radio,TV,news paper)———–1 VMMC campaign————————–2 Friends,family VMMC Peer promoters—-3 Factors influencing acceptability of the male circumcision services 2.0 Are you aware of the existence of VMMC services in your community and health facility that provide the respective services Yes —————— 1 No ——————- 2 2.1 Are you circumcised or is your partner or male child circumcised Yes —————— 1 No ——————- 2 2.2 What are the factors that influenced you to participate in male circumcision or to take your male child for circumcision Awareness of health benefits such as reducing sexual transmitted diseases Influence from Friends, family (such as parents, partner etc)HIV MC campaign Media influence (such as Radio magazine)Religion and cultural practices the peoples perceptions about Male Circumcision as a HIV prevention strategy Please Indicate Your Opinion on the Following Statements 3.0 Circumcised men take too long to ejaculate. Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 3.1 Women enjoy sex more with circumcised men than with men who are not circumcised Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 3.2 Male circumcision inhibits sexual satisfaction. Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 3.3 Male circumcision reduces the risks of getting HIV/AIDS. Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 3.4 Male circumcision reduces chances of transmitting HIV/AIDS to other people Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 3.5 Male circumcision reduces the risks of getting other sexually transmitted diseases ( STDs). Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 3.6 Male circumcision reduces sexual pleasure. Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 3.7 Circumcised men do not need to use a condom every time they have sex Agree ——————————— 1 Disagree —————————— 2 Do not know ————————- 3 APPENDIX 2 KEY INFORMANT INTERVIEW FORM Participant ID ___________________ Date of Interview _____/___/____ Name of Interviewer _____________________ 1.0 Type of Organization Non-Governmental Organization Government Faith Based Organization Community Sensitization Organization Other ______ The role and contribution of various stakeholders in advocating male circumcision services How long have you been working in this area/council 6 to 12 Month 1 year to 2 years 3 years to 4 years 5 years and above What interventions are you dealing with Explain What are the factors that hinder men of 20 years and above to go for VMMC services CONSENT FORM I am ELIZABETH MAUYA, a student from University of Dar es salaam UDSM pursuing a Master Degree of Public Health MPH. I am inviting you to participate in my research study entitled The Perception and Acceptability of Male Circumcision as an HIV Preventive Measure in Njombe Town Council, Njombe Region. I hope you will be able to assist me by completing the enclosed questionnaire. All information provided will be treated as private and confidential. It will be solely used for the purposes of my project paper. As is normally in academic research, I shall not disclose the Names of individuals who provided me with particular information. All data will be analyzed in a collective manner and not attributed to named individuals. The survey should take approximately 30 minutes to answer. Your assistance in facilitating the same will be highly appreciated. Thank you in advance for your time and cooperation. PAGE MERGEFORMAT 11 PAGE MERGEFORMAT 11 Age, sex, Ethnicity, Personality, Socioeconomic, Knowledge Perceived Benefits Minus Perceived barriers Perceived Susceptibility Perceived Severity Likelihood of Behavior Change (eg, Positive Perception and acceptability of VMMC services) Perceived Threat Cues of Action Education Media Community sensitization A29(eD/8 G
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