1. Beliefs about Male Circumcision among Men from a Traditionally Non- Circumcising Community in Rural Western Kenya, 2012-2014 Adega, A, Burmen, B, Mutai, K, Owuor, K, Odongo, F, Kwaro, D Kenya Medical Research Institute /Center for Disease Control Research and Public Health Collaboration

2. Introduction  Voluntary Medical Male circumcision is the removal of the foreskin - the retractable fold of tissue that covers the head of the penis  Male circumcision (MC), is associated with a reduction of the rate of heterosexual HIV acquisition in men by 60%  The correlation between circumcision and HIV prevalence is illustrated by the high HIV prevalence in regions where traditionally non- circumcising groups live  13 countries in sub-Saharan Africa targeted for scale up  Low prevalence of MC  High HIV prevalence  A large population at risk of heterosexually transmitted HIV WHO, UNAIDS, March 2007 Male Circumcision Consortium News October 2011

3. Introduction cont’  In Africa, 4 million HIV infections could be averted if 80% percent of the uncircumcised men underwent VMMC by 2015  For greatest impact, these men should undergo VMMC before the onset of sexual debut 15-17 years or if older, should be HIV-negative  In 2008, the prevalence of MC in Nyanza province, a traditionally non-circumcising community and (the region that bore the brunt of the HIV burden) was 46%  MC uptake among other communities is as high as over 90%

4. Current Kenya HIV Prevalence and Coverage of Male Circumcision RegionHIV prevalence in population (%) HIV prevalence in Males(%) Male circumcision coverage (%) Kenya5.1490 Nyanza Province15.11166.3 Nairobi Province73>90 N. E Province11>90 All other provinces3-52-3>90 Source (KAIS 2012)

5. Goal  We assessed beliefs on MC of men from a traditionally non- circumcising community in rural western Kenya, exposed to a Voluntary Male MC (VMMC) program roll-out, in order to furnish policy makes with information on expansion of VMMC services

6. Objectives  To describe the beliefs of sexually active men on VMMC from a traditionally non-circumcising community in rural Western Kenya  To compare recently circumcised men (underwent MC within the period of the scale up) to uncircumcised men

7. Study Area

8. Methodology  A large cross-sectional survey covering sexual behavior, HIV testing, HIV risk and MC was conducted among men 13 years and older in Gem, in Siaya County, Western Kenya between November 2012 and February 2014  This analysis included men who answered questions on MC  Respondents were grouped as uncircumcised, recently circumcised (within 2 years of interview date) or previously circumcised (more than 2 years prior to interview date)  Beliefs of recently circumcised men were compared to those of uncircumcised men using Chi-square statistics at a significance of p<0.05

9. Results 2066 (43%) answered questions on circumcision status 698 (34%) Circumcised 1368 (66%) Not circumcised 508 (37 %) Desired MC 266 (38%) Circumcised <2yrs 4837 males interviewed 860 (63%) Did not Desire MC 432 (62%) Circumcised >2yrs

10. Characteristics of male participants living in HDSA CharacteristicsTotal 1634 N(%)Recently circumcised 266 (16%)Uncircumcised 1368 (84%)P-value AGE GROUP 13-14 years178 (11)44 (17)134(10)<0.0001 15-24 years584 (36)189 (71)395(29) 25-34 years265(16)24 (9)241 (18) 35-44 years161(9)7 (3)154 (11) 45+ years446 (27)2 (0)444 (32) MARITAL STATUS Single799(49)234 (88)565(41)<0.0001 Married740(45)28(11)712(52) Previously married90(6)3(1)87 (6) INCOME None441(27)104(40)337(25)<0.0001 Work826(51)57(22)769(57) Family350(22)101(38)249(18) EDUCATION LEVEL None72 (4)1 (0)71 (5)<0.0001 Primary1175 (72)174 (67)1001(73) Above Primary384 (24)90(34)294 (22) EVER HAD SEX Yes1145(70)124 (45)1021(75)<0.0001 No489(30)142(55)347(25)

11. Beliefs about MC BeliefsRecently circumcised N=256 Uncircumcised N=1148 P-Value Believe MC has health benefits256 (100%)1079 (94%)<0.0001 MC reduces risk of HIV238/256 (93)980/1079 (91)0.2755 Perceive themselves to be at risk of HIV infection30/118 (25)260/881 (30)0.3582 believe that compared to uncircumcised men, circumcised men are: More likely to get HIV Less likely to get HIV 3 (1) 252 (99) 15 (1) 1152 (99) 0.8880 With MC is available, they are at lower risk of HIV: Agree Disagree 106 (43) 142 (57) 355 (32) 746 (68) 0.0016 Now that MC is available, condom use with partners of unknown HIV status is less necessary: Agree Disagree 4 (2) 249 (98) 13 (1) 1198 (99) 0.4931

12. Motivational factors for MC recently circumcised men n= 247/266

13. Hindering factors for MC among uncircumcised men n =1154

14. Limitations  Self reported circumcision was not clinically verified. Individuals may over- or under-report circumcision status versus physical exam  Potential for social desirability bias

15. Conclusions & Recommendations  Tradition was cited as a barrier to VMMC by nearly half of uncircumcised men  Need for a detailed understanding of cultural issues is needed to conceptualize and overcome these barriers  Programs to increase uptake of VMMC  Need to target men aged more than 24 years differently from younger cohorts and to address concerns about pain and costs

16. Acknowledgement  Participants of Gem Community  Staff of KEMRI/CDC  The Royal Society of Tropical Medicine and Hygiene  The ICASA 2015 Conference Secretariat ”This project was made possible by support from the President's Emergency Plan for AIDS Relief (PEPFAR) through cooperative agreement [No.5U19GH000041] from the U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV/AIDS (DGHA).“

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