WEPDC0104 Barriers to and facilitators of VMMC uptake among older men aged 25-39 years in Nyanza Region, Western Kenya (the TASCO study) Kawango Agot1, Jonathan Grund2, Edward Mboya1, Paul Musingila3, Eunice Omanga1, Donath Emusu3, Elijah Odoyo-June3, Spala Ohaga1, Boaz Otieno-Nyunya3 1 Impact Research and Development Organization, Kisumu, Kenya, 2 Centers for Disease Control and Prevention, Atlanta, GA USA, 3 Centers for Disease Control and Prevention, Kisumu, Kenya Center for Global Health Division of Global HIV/AIDS

Background VMMC reduces HIV risk by ~60% in men Kenya introduced VMMC in 2008 with a goal of circumcising 80% of males aged 15- 49 years; 1.2m VMMCs done through 2015 VMMC uptake is low among men aged ≥25 years globally (~8%), and in Kenya (~6%) Modeling has suggested that circumcising “older” clients will increase the immediacy of VMMC’s impact on HIV incidence The TASCO study assessed interventions to increase VMMC uptake among men aged 25-39 years in Nyanza Region, Kenya Study was conducted in a random sample of 45 Locations (SNUs) within 11 districts (4 counties) in Nyanza Region, Kenya 11 study districts While 1.2m MCs have been done up through the end of 2015, Kenya’s VMMC program has primarily attracted younger clients; approximately 94% of clients are ≤25 years from the biggest implementing partner Modeling has suggested that circumcising “older” clients will increase the immediacy of the impact on HIV incidence In Western Kenya, regional HIV prev of 15.1% vs 5.6 nationally

Methods Study aim is to describe primary barriers and facilitators for VMMC among men aged 25-39 years All households in study villages were visited; study staff interviewed consenting male household residents aged 25-39 years (n=5,639) Circumcision status was verified by trained, male study staff Participants were asked an open-ended question on primary reasons for getting circumcised (facilitators) or not getting circumcised (barriers) Uncircumcised men were offered enrollment in the TASCO study Demand creation interventions were conducted in accordance with the study arms, and all participants were offered VMMC Follow-up interview included open-ended question on reasons for getting circumcised for men who accepted VMMC during the study (facilitators) In interviews, participants were asked to list all of the barriers or facilitators and then rank the importance of each reason Prior to analysis, responses were reviewed and categorized We calculated the frequencies of the most important (primary) barriers and facilitators overall and by demographic category While 1.2m MCs have been done up through the end of 2015, Kenya’s VMMC program has primarily attracted younger clients; approximately 94% of clients are ≤25 years from the biggest implementing partner Modeling has suggested that circumcising “older” clients will increase the immediacy of the impact on HIV incidence In Western Kenya, regional HIV prev of 15.1% vs 5.6 nationally

Results: Barriers Primary reason for not being circumcised prior to the intervention (n= 2,784) Most common primary barriers to VMMC were concern about Lost wages from time spent getting MC and during recovery (34%) and concerns of Pain or fear (32%) Dislike of VMMC facility or providers (13%) (including queuing with younger clients, facilities with female service providers, inconvenient site location/hours) and Culture/Religion (7%) were less common primary barriers Additional barriers included in Other category: long waits at clinic; 6 weeks of sexual abstinence; VMMC is perceived to be for younger boys, lack of VMMC information or knowledge, and being HIV+ Similar responses by age, educational attainment, marital status, and county The two most prominent primary barriers were lost wages and pain/fear of the procedure or pain, each reported by 1/3 of participants. Dislike of the facility and/or providers, included responses queuing with younger clients, female providers, and inconvenient site location/hours did not feature as prominently. Interestingly, concerns about the recommended 6 weeks of sexual abstinence was not a common primary barrier for these men aged 25-39 years. Only 1.5% of men reported this as their primary barrier. “Other” includes recommended 6 weeks of sexual abstinence, VMMC perceived to be for younger boys, lack of information about VMMC, and already being HIV positive.

Results: Facilitators Primary reason for circumcision prior to the intervention (n= 2,849) and during the intervention period (n=363) Most common primary facilitators to VMMC were Reduction in HIV risk for men circumcised before the study (43%), and those circumcised during the study (50%) For men circumcised prior to study, Culture/Religion was also a primary facilitator (19%), but not for those circumcised during the study (1%) Additional facilitators included in Other health category: Reduced STI risk; Reduced cervical cancer risk in partners; reduced penile cancer risk Other non-health categories included Improved sexual performance; peer pressure Similar responses by age, educational attainment, marital status, and county Purple is clients who were circumcised before the study began, while the green is men who were circumcised during the study. Reduction in HIV risk was the primary reason for both groups of men For men getting circumcised before the study, culture/religion (which includes opposition by family, friends, sexual partners, as well as VMMC being viewed as going against culture) was a strong facilitator. In conclusion, Concern about lost wages and pain/fear are the most common reasons uncircumcised men aged 25- 39 years were not circumcised Dislike of the VMMC facility or providers is also an important barrier to uptake Reduction of HIV risk is the primary reason why men aged 25-39 years get circumcised Innovative demand creation strategies are needed to address structural and financial barriers among uncircumcised men aged 25- 39 years in Nyanza Region, Kenya

Conclusions Concern about lost wages and pain/fear are the most common reasons why uncircumcised men aged 25-39 years were not circumcised prior to the study Dislike of the VMMC facility or providers is also an important barrier to uptake for these men Concerns about the recommended 6 weeks of sexual abstinence was not a common primary barrier Reduction of HIV risk is the primary reason why men aged 25-39 years get circumcised Innovative demand creation strategies are needed to address structural and financial barriers among uncircumcised men aged 25-39 years in Nyanza Region, Kenya While 1.2m MCs have been done up through the end of 2015, Kenya’s VMMC program has primarily attracted younger clients; approximately 94% of clients are ≤25 years from the biggest implementing partner Modeling has suggested that circumcising “older” clients will increase the immediacy of the impact on HIV incidence In Western Kenya, regional HIV prev of 15.1% vs 5.6 nationally

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

Thank you! Jonathan Grund jgrund@cdc.gov