Psychosocial Factors Influencing Promotion of Male Circumcision for HIV Prevention in a Non-Circumcising Community in Rural Western Kenya

Introduction Sub-Saharan Africa (SSA), home to 10% of the world's population, remains more heavily affected by HIV and AIDS than any other region of the world (UNAIDS/WHO, 2006). Although availability of antiretroviral therapy for individuals infected with HIV is increasing, many more new infections occur for every additional person started on such treatment (Global HIV Prevention Working Group [GHPWG], 2006). Preventing new infections is the only realistic hope for stemming the HIV pandemic, yet currently available prevention measures have often been unsuccessful in restricting the spread of HIV (GHPWG, 2006; Muula, 2007). HIV testing and counseling, promotion of condom use, reduction in sexual partners, and treatment for other sexually transmitted infections (STI) are some of the main intervention strategies currently employed by national AIDS control programs. Research evidence from over 40 observational studies (see Weiss, Quigley, & Hayes, 2000) and three randomized control trials (Auvert, Taljaard, Lagarde, Sobngwi-Tambekou, Sitta & Puren, 2005; Bailey, Moses, Parker, Agot, Maclean, Krieger, et al., 2007; Gray, Kigozi, Serwadda, Makumbi, Watya, Nalugoda, et al., 2007) indicates that male circumcision (MC) is an efficacious, partially protective strategy in reducing heterosexual transmission of HIV from women to men. Accordingly, MC is now recommended as an additional HIV preventive strategy (WHO/UNAIDS, 2007). Consequently, several SSA countries are preparing to roll-out projects promoting and providing medicalized MC services. The prerequisite to any public health promotion process is collecting data and learning about community perceptions of factors that may facilitate or inhibit adoption of the new intervention (Green & Kreuter, 2005). Although acceptability of MC has been studied previously (see Westercamp & Bailey, 2007), most of these studies were conducted before the procedure was included as an additional HIV preventive strategy. These perceptions could have changed with more information and socio-cultural transformations (Rollnick, Mason, & Butler, 2002). There is need for more detailed understanding of factors that may influence promotion of MC in communities that are traditionally non-circumcising, now that it is recommended as an additional HIV preventive measure. The country's HIV prevalence is 7.8% as shown by estimates from the 2007 Kenya Aids Indicator Survey (KAIS). The Nyanza region in western Kenya, mostly inhabited by the Luo, one of the largest ethnic groups in the country, leads other regions with a 15.3% HIV prevalence (Government of Kenya [GOK], 2008). There are around 40 indigenous ethnic groups in Kenya; the five most populous ones are the Luo, Kikuyu, Kalenjin, Luhya, and Akamba. Unlike the great majority of other ethnic groups in Kenya, the Luo do not traditionally circumcise their males; approximately 90% of Luo men are uncircumcised (Agot, Ndinya-Achola, Kreiss, & Weiss, 2004; Caldwell & Caldwell, 1994). KAIS reports indicated higher HIV prevalence (13.9%) among uncircumcised men compared to 4.1% of circumcised men (GOK). The 2003 Kenya demographic health surveillance provided estimates of HIV prevalence in those aged between 15 and 49 years who identified themselves as Luo at 18% for males and 26% for females (Central Bureau of Statistics [CBS], Ministry of Health [MOH], & ORC Macro, 2003). From new evidence, lack of circumcision is one factor that explains high HIV prevalence among Luos, as compared to other ethnic groups in Kenya. Since preventing HIV infection among men equally protects their sex partners (Agot et al.), high HIV prevalence and low MC levels makes the Luo an ideal community in Kenya for promoting and providing medicalised MC interventions. Kenya's MOH recently added MC to its HIV/AIDS preventive strategies after a series of consultations with various stakeholders and approved the MC policy in October 2007. …