Title

Predictors of male circumcision uptake during the Botswana Combination Prevention Project (BCPP) mobilization

Presenter

Tafireyi Marukutira

Authors

T. Marukutira^1,2,3, L. Block⁴, L.A. Mills⁵, J. Moore⁴, P. Bachanas⁴, T. Schissler⁶, R. Mosha⁶, N. Bock⁴, O. Komotere⁶, K. Mukokomani⁷, T. Diswai⁶, S.M. Davies⁴

Institutions

¹US Centers for Disease Control and Prevention, Botswana Combination Prevention Project, Gaborone, Botswana, ²Burnet Institute, Public Health, Melbourne, Australia, ³Monash University, Epidemiology and Preventive Medicine, Melbourne, Australia, ⁴US Centers for Disease Control and Prevention, Atlanta, United States, ⁵US Centers for Disease Control and Prevention, Gaborone, Botswana, ⁶Jhpiego, Gaborone, Botswana, ⁷Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana

Background: Male circumcision (MC) is a proven HIV prevention intervention in sub-Saharan Africa, but uptake has been low in some countries, including Botswana. Better characterization of men who accept versus reject MC could inform demand creation efforts, but information on men who reject MC is rarely available. The Botswana Combination Prevention Project (BCPP) collected population-level data on demographics and HIV risk factors and offered free MC, allowing comparison of those who did and did not accept MC.
Methods: BCPP, a community-randomized trial, enrolled 16-49 year old citizen residents of 30 communities randomized to receive either intensified standard-of-care services or HIV prevention interventions including mobile HIV testing and MC, between October 2013 and February 2016. During the 6-8 week MC surge in the 15 intervention communities, MC was offered in tents or a mobile clinic. All male participants with an HIV-negative test or unknown status who reported being uncircumcised were offered linkage to MC by peer escort, phone-based and in-person mobilization, appointments, reminder calls, and transport. Demographic and risk factors were compared between those who did and did not undergo MC using chi-squared testing.
Results: Of the 15,970 eligible men, 8,534 (53%) reported being uncircumcised. Of these, 577 (7%) underwent MC during the surge. Men who did not get MC were substantially older and more likely to be employed and ever married (Table 1). They had a statistically higher but essentially identical likelihood of reporting two or more sex partners in the past year. They were substantially more likely to believe their recent partner was HIV-positive (15% vs. 5%).

Demographic and risk factors	Underwent MC (n=577)	Did not undergo MC (n=7957)	Chi-sq	p value
Mean age in years (standard deviation)	25 (8)	29 (9)	N/A	<0.001
Completed secondary school	473 (82%)	6252 (79%)	2.83	0.09
Never married	534 (93%)	6521 (83%)	39.68	<0.001
Employed	183 (32%)	3231 (45%)	32.86	<0.001
Reported last sexual partner HIV-positive*	17/354 (5%)	816/5250 (16%)	36.89	<0.001
>1 sexual partner in past 12 months	45 (8%)	469 (7%)	37.38	<0.001
*Among those with at least one sexual partner in the past 12 months

[Table 1: Demographic and risk factors of men undergoing or not undergoing male circumcision (MC)]

Conclusions: Older age, ever having married, employment, and an HIV-positive partner were factors associated with not seeking MC. Male circumcision programs could improve outreach to men with HIV-positive partners due to their high risk, while also reaching out to the general population. Characterizing and addressing unique barriers to MC for employed and older men may also improve general uptake.

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