Women s knowledge, a0tudes, prac6ce and experience regarding VMMC and EIMC in priority countries: what do we know? Kelly Curran Jhpiego Bal6more, Maryland, USA
Outline VMMC Knowledge Common sources of informa6on Knowledge on protec6on against HIV, par6al protec6on, male- to- female transmission, other issues A0tudes Approval and disapproval of VMMC in general and for partners Concerns and specific a0tudes Prac6ce: Risk compensa6on Role in partner decisions EIMC/VMMC for sons A0tudes Approval and disapproval of EIMC/VMMC for sons
VMMC: Knowledge
Where do women get their knowledge and opinions about VMMC? 5 studies (4 with <60 women, one with 494) in Kenya, Zimbabwe, Zambia, Botswana, South Africa, Uganda Mass media, posters, school, friends, church all commonly cited Health care workers less important sources than these in most countries Mahvu, 2012; Riess, 2014; Abbo^, 2013; Plank, 2010, WHiPT 2010
Women s knowledge: MC protects men from HIV 6 quan6ta6ve and 1 qualita6ve study enrolling 30-292 women in Uganda, Botswana, Kenya, South Africa, Namibia, Swaziland Wide varia6on: 32-100% aware of or heard that MC protects men from HIV Lowest in South Africa and Malawi In one rural area, men more likely to know; in nearby urban area, women Wilcken, 2010; Plank, 2010; Mugwanya, 2010; Lanham, 2012; Mantell, 2013
Women s knowledge: par6al protec6on 7 studies (all quan6ta6ve) of 60-7464 women in South Africa, Botswana, Namibia, Swaziland, Kenya, Uganda Wide varia6on: 36-100% of women aware protec6on for men is only par6al, including wide varia6on within countries (but also wide varia6on in ques6on format) Auvert, 2014 (CROI); Andersson, 2012; Lanham, 2012; Mugwanya, 2010
Women s knowledge: Other issues 3 quan6ta6ve and 2 qualita6ve studies on 20-7618 women in Kenya, Namibia, Swaziland, South Africa, Uganda, Zambia, Tanzania Very poor knowledge on MC protec6on against STI s (existence of protec6on, protec6on against some STIs only) Wide varia6on (23-70%) in knowledge about abstaining 6 weeks post- procedure 61-85% aware men s6ll need to use condom KAIS, 2014; Abbott, 2013; Layer, 2013 (PLoS); Layer, 2013 (AIDS Care), WHiPT 2010
Women s knowledge about VMMC: preven6on of male- to- female transmission 6 quan6ta6ve and 2 qualita6ve studies of 30-5561 women in South Africa, Kenya, Botswana, Namibia, Swaziland, Uganda, Malawi, Tanzania Across countries, 61-97% aware that women not protected by MC if man is HIV+ Auvert, 2014 (CROI); Riess, 2014; Andersson, 2012; Mugwanya, 2010; Maughan Brown, 2014; Layer, 2013 (PLoS)
Summary: Women s knowledge on VMMC Friends, rela6ves and mass media important sources of women s knowledge on VMMC Majority of women in most studies aware MC protects men from HIV, protec6on is par6al, and protec6on against male- to- female transmission has not been demonstrated But pockets of lack of knowledge exist Less awareness of: Par6al protec6on against some STIs 6 weeks post- procedure abs6nence Need for con6nued condom use
VMMC: Approval and Disapproval
Women s a0tudes: approval or preference Before 2007: high acceptability in 8 sub- Saharan African countries 9 studies (4 qualita6ve, 5 quan6ta6ve) with 20-7474 women in Kenya, Zambia, Tanzania, Zimbabwe, Botswana, Namibia, Swaziland, South Africa, Uganda 58-77% approved of/preferred circumcision, including many female sex workers Inten6ons: In one study, 41-50% of women with uncircumcised partners plan to ask partner for MC (vs. 35-56% men planned to get MC) Importance of educa6on: In one rural area, 58% approved IF it could prevent HIV Westercamp, 2007; Riess, 2014; Lanham, 2012; Layer, 2013 (PLoS); Hatzold, 2014; Westercamp, 2011; Andersson, 2012; Mahvu, 2011; WHiPT 2010
VMMC: Concerns and Specific A0tudes
Women s concerns about VMMC: increased risk behavior among men 6 studies (2 qualita6ve, 4 quan6ta6ve) with 20-1088 women throughout sub- Saharan Africa Will VMMC increase men s risk behavior? the majority of female ter6ary students in one study said yes 35% and 45% of respondents in two countries stated MC could not be introduced for this reason Sex comparison: In one study, 28% of women vs. 10% of men thought MC would increase promiscuity Mantell, 2013; Abbott, 2013; Westercamp, 2013; Shacham, 2013; Westercamp, 2007; WHiPT 2010
Women s a0tudes about VMMC: Other issues Barriers to MC Women: pain, cultural issues, and religion important Men: disagreed, ci6ng cost, lack of 6me, fear of complica6ons Reasons for approval some6mes focused more on sexual benefits to women than on health Auvert, 2014 (CROI); Shacham, 2013; Jones, 2014; Obure, 2011
Other Issues: sexual func6on and sa6sfac6on - Percep(on: - Across qualita6ve studies, female respondents generally believe circumcision increases or does not affect women s sexual pleasure - Women more likely than men to report circumcision increases female sexual pleasure, and majority report preferring circumcised men q - Experience q - Generally, either no change or improvement q - Kigozi 2009 Rakai RCT: among female partners of male par6cipants who received MC, 57.3% reported no change in sexual sa6sfac6on, 39.8% improvement, 2.9% worsening q - Female sex workers circumcised men sweeter Riess, 2014; Layer, 2013 (PLoS)
Other Issues: Blame- shiring and abuse - Early concern for VMMC leading to blaming women for HIV, domes(c violence/emo(onal abuse, etc. - Virtually no evidence on this issue, no indica(on this is happening - Publica6on bias? - Few anecdotal reports of nega6ve changes Layer, 2013 (PLoS)
Summary: women s a0tudes toward VMMC Support varies and may be higher in urban than rural areas, but is almost always 50% or higher Further acceptability studies probably not needed Great varia6on between se0ngs in concern for male risk compensa6on Evidence for disconnect between men and women on important barriers to MC
Prac6ce: Women s risk compensa6on with a circumcised male partner
Risk compensa6on with a circumcised male partner A0tude: 8-34% in one study agreed it was ok to have sex without condom if man circumcised (men vs. women similar) Educa6on, older age, sufficient food all associated with no answer 0-8% one study stated they would likely engage in more risky behavior now that MC available (men vs. women similar) Prac6ce: evidence for risk compensa6on in one study 39% of women aware of MC s protec6ve effec6veness always/usually used condoms, vs. 51% unaware (p<.01) 44% vs. 27% had riskier unprotected sex Andersson, 2013; Westercamp, 2011; Maughan Brown, 2014
VMMC: Influence on partners
Women s role in encouraging VMMC in partners Li^le quan6ta6ve data In qualita6ve data from Kenya, Zambia, Tanzania, women endorsed willingness to encourage partners Impact 14% of men in one country cited lack of partner support as a major barrier to MC Elsewhere, odds ra6o of 1.13 for willingness to get circumcised if partner was suppor6ve Riess, 2014; Lukobo, 2007; Hatzold, 2014; Jones, 2014; Layer, 2014; Obure, 2011
New data: path to MC research in Zambia Ipsos: global market research company Ongoing BMGF- funded explora6on of VMMC decision- making in Zimbabwe & Zambia to inform demand genera6on strategies Early findings in Zambia: Men do not recognize female partners as sources or influencers of their beliefs about VMMC, while women report themselves as influencers What s right? Further inves6ga6on ongoing Men do consider benefits to women late in their decision process, arer considering informa6on from healthcare workers and other men Will this generalize to Zimbabwe?
Obure, 2011 To women, men are very easy to deal with I think we can influence the men even more than their fellow men you just wait un6l you are relaxed on the pillow, then you just feed him slowly with words you don t scare him or make him feel that he is not sa6sfying you or that he is not man enough you just have him thinking about it over some 6me - Kenyan woman, 29 years old, interviewed on interpersonal influence in VMMC decisions by Obure et al, 2011
Summary: women s role in encouraging VMMC Not enough data yet Need impact assessments from programs reaching out to women But some evidence that female partners impact men s decisions
EIMC/VMMC for sons: Approval and Disapproval
Women s approval of EIMC/VMMC for sons 10 studies (3 qualita6ve, 7 quan6ta6ve) of 12-7464 women in Zimbabwe, Botswana, Namibia, Swaziland, Zambia, Uganda, Tanzania, South Africa 61-95% would obtain EIMC/VMMC for their sons typically higher than approval of VMMC for partners Except one study, in non- circumcising rural Uganda, 49% Majority preferred infant or pre- adolescent period to MC post- adolescence In several studies, acceptance depended on belief in benefits (e.g. approval increased 11-51% arer an educa6onal message) Uptake lower than willingness in one study (68% vs. 92%) Hatzold, 2014; Mahvu, 2012; Andresson, 2012; Lukobo, 2007; Jarrett, 2014; Mugwanya, 2010; Albert, 2014; Wambura; 2011; Plank, 2010; Plank, 2013; WHiPT 2010
Summary: What do we know about Women and VMMC? Most women in most se0ngs favor VMMC; reasons vary Evidence on areas with poor knowledge and risk compensa6on by women points to need for clear messaging on abs6nence during healing and con6nued self- protec6on Need to be^er understand role for female partners in encouraging VMMC