Community response To explore how men expect their community to react to recently circumcised men, we asked participants, ‘‘In the end, Onyango decided to get circumcised. What would his neighbors say about Onyango if they found out he was circumcised?’’ The range of expected community responses was wide, and participants attributed the variance to differences in age, education, and level of MC knowledge in the community. Older and/or less educated community members were expected to shun Onyango for abandoning his cultural traditions, while young and/ or more educated community members were expected to congratulate Onyango and to be curious about the procedure and his experience. P: ‘‘It will depend with the kind of the neighbors that Onyango has. If they have the knowledge about circumcision they will encourage him. But if they are not informed, they will laugh at him and even isolate him because he has gone against their customs.’’ Demand creation We asked participants, ‘‘The Government of Kenya now recommends male circumcision for HIV prevention. What would be some of the ways to sensitize men, like Onyango, about the benefits and risks of male circumcision?’’ Several sensitization approaches were discussed by participants. The following methods were proposed: radio broadcasts (in the local language so that people of all ages can understand them); women’s groups who can then mobilize their husbands, sex partners, and male children; church leaders who can then mobilize the members of their congregation and the community; peer educators (using them to promote MC would create job opportunities for recently circumcised youth), sports rallies, and school curricula/programs. Discussion While over 13 published studies indicated that MC was likely to be an acceptable HIV prevention strategy,[9] few studies have been published about revealed, non-hypothetical, preferences among uncircumcised men. Now that MC services are widely available at no cost, it is important to learn from uncircumcised men about the factors that influence MC uptake. To a large extent, our results are consistent with findings from studies conducted prior to the scale-up of MC;[9–11] however, some differences are notable. Previous studies explored the impact of cost on MC uptake, but MC services are being provided at no cost in Kenya. Additionally, one study in Malawi reported that free services were viewed as poor quality,[17] but no participant in our study mentioned this; conversely, some believed that males might be more likely to adopt MC because the service is free. While previous acceptability studies explored the impact of time away from work as part of the total ‘‘cost’’ of the procedure, in this study, time away from work was the most important barrier to MC acceptability, especially among men working in the informal sector (e.g., bicycle transporters) and older men. The WHO/UNAIDS recommends a six-week abstinence period following MC.[5] Participants in this study were aware that there is a recommended period of abstinence following MC; however, there was confusion about the duration of the period for abstinence, time away from work, and complete healing. National communication campaigns and couple’s counseling should clarify these periods to ensure realistic expectations for MC clients and Acceptability of Male Circumcision in Kenya their sex partners, and to promote wound healing among recently circumcised men. As noted in previous studies,[9] there was consensus that MC services should be offered in a medical setting, not in traditional settings, because a medical setting is believed to be more safe, and AEs can be handled by medical professionals. In this study, participants believed that medical male circumcision also clarifies the purpose of the national VMMC program – that is, VMMC is not trying to change, or dilute, any ethnic group’s culture; instead, it is promoting MC for medical and health purposes. This might be an important distinction to be made in other regions where MC is being promoted. When asked about HIV prevention methods, participants were most familiar with the ‘‘ABC’’ approach and frequently did not situate MC within their existing HIV prevention framework – this was especially true among young men. This trend was observed in Uganda where older men were significantly more aware of MC for HIV prevention than youths, and overall, only 38.2% of respondents mentioned MC as an HIV prevention strategy in an open-ended question.[18] In our study 7/12 groups reported MC as an HIV prevention strategy without prompting. While older men were more aware of MC for HIV prevention, they were less likely to believe that MC was necessary, especially if a man practiced other HIV prevention methods. This disparity between knowledge and beliefs is important, and should be explored in program implementation and future research. Several studies are on-going to assess the potential for risk compensation, or the increase in sexually risky behaviors, post- MC. Among the participants in this study, there was a wide range in estimates of the protective effect afforded by MC against HIV acquisition (range: 30%–100%). Similar to results reported by Reiss et al. and Wilcken et al., most participants did not know the exact magnitude of the protective effect,[14,18] but they knew that MC was not fully protective and that other HIV prevention methods would continue to be necessary. However, some participants believed that men might be motivated to seek MC services because they want to have sex without a condom and/or increase their number of sexual partners. Based on these beliefs, risk compensation remains a possibility, especially when services are provided with less counseling and less-or-no recurrent contact with MC clients than during the RCTs. It remains important for a national communication strategy to continue enforcing the general knowledge that MC is only partially protective against HIV acquisition and to clarify the magnitude of the protective effect. The possibility of discrimination was discussed by participants in this study; specifically, it was believed that some members of the community might shun recently circumcised men, especially when community members are older and/or less educated; this finding is consistent with findings from pervious studies.[9] While some participants in this study believed that men might seek MC services because Jesus was circumcised, others, especially young men, reported that it was a sin for men to change the way they were created. This ambiguity, and lack of consensus, has been observed in the literature.[9] Finally, Westercamp and Bailey recommended that it would be ‘‘prudent to consult and collaborate with religious leaders’’ before promoting MC in a country.[9] This remains an important recommendation in scaling-up MC services throughout Africa. Circumcision for adult men (over 18 years) was a barrier to MC adoption expressed by many in this study, and this is consistent with the findings of previous studies. Studies have reported that circumcision at 7–13 years of age is most preferable because a boy at this level of maturity can make the decision for himself, understand the significance of the event, take care of the wound PLoS ONE | www.plosone.org 5 May 2011 | Volume 6 | Issue 5 | e19814