Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets

Abstract

IntroductionVoluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya.Methods and resultsThe study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care.ConclusionOur findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.

Communication-related factors influencing the uptake of voluntary medical male circumcision among men in Lilongwe Urban, Malawi

“…In trying to mobilise others to uptake VMMC, some mobilisers make use of peer pressure including use of abusive and/or stigmatizing language (Gilbertson et al, 2019) which is the case in the example given above. An uncircumcised man is considered not man enough to discuss the advantages and disadvantages of circumcision as that topic is preserved of circumcised men only.…”

“…Studies of the uptake of VMMC in Tanzania and Zimbabwe (Chiringa et al, 2016;Plotkin et al, 2013) respectively, as well as in Malawi (NAC, 2015) established that social and cultural factors, as well as physical pain, were barriers to the uptake of VMMC while the perceived benefits (including improved sex life, hygiene and protection from HIV) were facilitators. A study conducted in Kenya and other countries such as South Africa, Tanzania, and Zimbabwe found that barriers to VMMC uptake included increased burden on clinics, long waits for care, misleading mobilisation, low client follow-up rates, and inconsistent messaging among others (Gilbertson et al, 2019). Most VMMC studies have focused on analysing the barriers and facilitators of VMMC uptake and have contributed towards the knowledge in designing communication strategies, but few have been undertaken to get a deep understanding of communication-related factors that influence the uptake of VMMC from an individual's perspective.…”

Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe

“…In a quantitative study from South Africa [15], notable challenges in VMMC program quality such as poor monitoring of AEs, lack of adequate provider training in expansion sites, and sub-optimal supervision were likely related to donor-driven and Ministry-required VMMC program expansion within a short timeframe. Similarly, a qualitative study of the unintended consequences of VMMC target achievement on the quality of VMMC care received by adolescents in Kenya found misleading demand creation strategies, long wait times for clients, exhausted clinic workers, and lack of adherence to VMMC best practices [41]. They also suggest more input from local VMMC providers, mobilizers, and implementing partners should be considered for target setting and call for strengthened adherence to standards for responsible conduct of VMMC.…”

A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa

“…To avoid or mitigate adverse events in VMMC programs, researchers have pointed out the need to improve the quality of VMMC services. Their suggestions include increasing parental engagement among adolescent clients [ 35 , 36 ], managing targets to ensure service providers are not overwhelmed by demand [ 36 , 37 ], enhancing preoperative screening [ 36 , 38 ], ensuring consistent and thorough counseling to ensure patients know how to care for themselves [ 39 ], and improving patient access to post-operative medical care [ 40 ].…”

“…Social and cultural impacts ranging from the individual level to that of community and society are important, yet less widely considered potential unintended consequences of VMMC campaigns. For males who remain non-circumcised but live within contexts where VMMC campaigns have been successful, social impacts may include stigmatization and/or discrimination [ 35 , 36 ]. Importantly, VMMC programs target traditionally non-circumcising communities, within which some people oppose circumcision for cultural reasons.…”