Introduction: Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men. Methods: We conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women thought was the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men. Results: Overall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors. Conclusions: Across eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.

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Perceived norms about male circumcision and personal circumcision status: a cross-sectional, population-based study in rural Uganda

Introduction Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa (SA). However, up to 98% of VMMC clients heal without adverse events (AEs). With demonstrated VMMC safety across global programs, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications per year. As part of a randomized controlled trial (RCT) to test two-way texting (2wT) follow-up as compared to routine, in-person visits for adult VMMC clients, the objective of this study was to compare costs of 2wT-based telehealth to routine post-VMMC care in both rural and urban SA settings. Methods We used an activity-based costing (ABC) approach to estimate the costs in post-VMMC care, including counselling, follow-ups, and tracing activities. All costs were estimated in $US dollars for both 2wT and routine care to test the hypotheses that 2wT follow-up would result in per-client cost savings. Data were collected from routine National Department of Health VMMC forms, the RCT database, and time-and-motion surveys. Sensitivity analysis presents different scale-up scenarios. Results We included 1,084 clients: 537 in routine care and 547 in 2wT. Average client follow-up cost is $6.48 for routine care and $4.25 for 2wT. 2wT saved costs in both rural and urban locations. Average savings of $2.23 was greater in rural ($1.61) than urban areas ($0.62). 2wT would save $0.88, $2.23, and $4.93, respectively, if: men attended one visit; men attended visits in similar proportions to that observed in the RCT; and men attended both visits. Conclusion 2wT reduces post-VMMC care costs by supporting most men to heal at home while using telehealth to triage clients with potential AEs to timely, in-person care. 2wT savings are higher in rural areas. Scale-up of 2wT-based follow-up could significantly reduce overall VMMC costs while maintaining service quality.

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Cost savings in male circumcision post-operative care continuum in rural and urban South Africa: Evidence on the importance of initial counselling and daily SMS

Voluntary Medical Male Circumcision to Reduce HIV Acquisition and Transmission.

Abstract Purpose of Review Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations. Recent Findings Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Summary Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels. 

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Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges

Wiza N Mwanza

Papers

Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges