Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Females’ Peer Influence and Support for Adolescent Males Receiving Voluntary Medical Male Circumcision Services

Females’ Peer Influence and Support for Adolescent Males Receiving Voluntary Medical Male... Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 Clinical Infectious Diseases SUPPLEMENT ARTICLE Females’ Peer Influence and Support for Adolescent Males Receiving Voluntary Medical Male Circumcision Services 1 2 1 2 3 4 5 Michelle R. Kaufman, Kim H. Dam, Kriti Sharma, Lynn M. Van Lith, Karin Hatzold, Arik V. Marcell, Webster Mavhu, 6 7 8 9 9 10 XX Catherine Kahabuka, Lusanda Mahlasela, Eshan U. Patel, Emmanuel Njeuhmeli, Kim Seifert Ahanda, Getrude Ncube, 11 12 8 Gissenge Lija, Collen Bonnecwe, and Aaron A. R. Tobian 1 2 3 XXXX Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Center for Communication Programs, Baltimore, Maryland; Population Services International, Harare, Zimbabwe; 4 5 6 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe; CSK Research Solutions, 7 8 9 Ltd, Dar es Salaam, Tanzania; Centre for Communication Impact, Pretoria, South Africa; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and Office 10 11 of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia; Ministry of Health and Child Care, Harare, Zimbabwe; Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania; and National Department of Health, Pretoria, South Africa Background. While female involvement in voluntary medical male circumcision (VMMC) has been studied among adults, little is known about the influence of adolescent females on their male counterparts. This study explored adolescent females’ involvement in VMMC decision making and the postoperative wound healing process in South Africa, Tanzania, and Zimbabwe. Methods. Across 3 countries, 12 focus group discussions were conducted with a total of 90 adolescent females (aged 16–19 years). Individual in-depth interviews were conducted 6–10 weeks post-VMMC with 92 adolescent males (aged 10–19 years). Transcribed and translated qualitative data were coded into categories and subcategories by 2 independent coders. Results. Adolescent female participants reported being supportive of male peers’ decisions to seek VMMC, with the caveat that some thought VMMC gives males a chance to be promiscuous. Regardless, females from all countries expressed preference for circumcised over uncircumcised sexual partners. Adolescent females believed VMMC to be beneficial for the sexual health of both partners, viewed males with a circumcised penis as more attractive than uncircumcised males, used their romantic relationships with males or the potential for sex as leveraging points to convince males to become circumcised, and demonstrated supportive attitudes in the wound-healing period. Interviews with males confirmed that encouragement from females was a motivating factor in seeking VMMC. Conclusions. Adolescent female participants played a role in convincing young males to seek VMMC and remained supportive of the decision postprocedure. Programs aiming to increase uptake of VMMC and other health-related initiatives for adolescent males should consider the perspective and influence of adolescent females. Keywords. adolescents; voluntary medical male circumcision; HIV prevention; females; sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk 30% lower likelihood of having HIV and were less likely to have OA-CC-BY of acquiring human immunodeficiency virus (HIV), human pap - herpes simplex virus type 2 [16]. illomavirus, and herpes simplex virus type 2 among men [1–10], While female involvement in VMMC decision making has been and Trichomonas vaginalis, bacterial vaginosis, and human pap- studied among adults [17–19], little is known regarding the influ - illomavirus among female partners [11–13]. Women also benefit ence of female peers on adolescent VMMC clients. Research on indirectly from the expansion of VMMC services because the adolescents in sub-Saharan Africa shows that peers have a large probability of encountering an HIV-infected male partner grad- impact on adolescent sexual and reproductive health behaviors ually declines with programmatic scale-up [14]. Mathematical [20–26]. Understanding adolescent females’ level of influence on models have also shown a 46% long-term reduction in male-to- adolescent VMMC uptake may be important for programmatic female HIV transmission due to reduced male susceptibility fol- scale-up and sustainability. This study utilized focus groups with lowing VMMC [15]. A recent study of women in KwaZulu Natal, female adolescents aged 16–19 years and in-depth interviews South Africa, showed that those with circumcised partners had a (IDIs) with male adolescents aged 10–19 years to explore the influ - ence and support of adolescent females in the decision-making and healing process for male peers and sexual partners receiving Correspondence: M.  R. Kaufman, Johns Hopkins Bloomberg School of Public Health, VMMC across 3 countries: South Africa, Tanzania, and Zimbabwe. Department of Health, Behavior and Society, 624  N Broadway, Baltimore, MD 21205 (michellekaufman@jhu.edu). Clinical Infectious Diseases 2018;66(S3):S183–8 METHODS © The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America.  This is an Open Access article distributed under the terms of the Creative Commons Female Participants Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted Focus group discussions (FGDs; 6–10 participants in each) were reuse, distribution, and reproduction in any medium, provided the original work is properly cited. conducted with 90 female adolescents aged 16–19 years in South DOI: 10.1093/cid/cix1057 Female Support for Male Circumcision • CID 2018:66 (Suppl 3) • S183 Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 Africa, Tanzania, and Zimbabwe (4 FGDs per country). Female all transcripts, and when further content analysis arose, cod- adolescent participants were recruited from the communities in ers generated themes and subthemes within predetermined which VMMC clinics were located, and male adolescent partic- areas of inquiry in the semistructured interview guides. Coders ipants were recruited from 4 VMMC sites per country, as pre- compared all applied codes and discussed discrepancies until viously described [27]. VMMC community mobilizers (who an agreement was reached. In the rare event that an individ- encouraged male adolescents to be circumcised and were familiar ual code resulted in no agreement between coders, the primary with adolescents in the area) and/or trained research coordinators investigator made a final determination. recruited female participants at youth groups, youth-gathering locations, and schools. Female participants were not necessarily RESULTS sexual partners of VMMC clients. Table  1 shows the participant demographics overall and by FGDs with female adolescents focused on their opinions country. Table 2 displays the themes and subthemes that arose and perceptions of VMMC and examples of how female ado- from the adolescent female and male client perspectives. lescents try to convince their boyfriends to seek VMMC. They were asked about their knowledge of VMMC’s impact on HIV Female Adolescents’ Acceptance of VMMC and on hygiene, as well as their views about VMMC’s influence Female Beliefs Regarding VMMC Benets fi on relationships in general and on sexual behaviors. Male ado- Female participants believed VMMC is mutually benefi- lescents were asked about their experiences in disclosing their cial for healthier sexual relations and considered it a modern VMMC status and/or discussing the procedure experience and prerequisite to date a male. When female participants were perceptions with their female adolescent peers. prompted regarding the benefits of VMMC, most mentioned the protection against HIV infection, sexually transmitted Male Participants infections, and cervical cancer in the female sexual partners of IDIs were conducted with 92 male adolescents (aged circumcised males. 10–19 years) 6–10 weeks post-VMMC procedure (South Africa, n = 36; Tanzania, n = 36; Zimbabwe, n = 20). This timeframe It reduces the chances of contracting diseases like HIV, was selected to allow for completion of the full post-VMMC cancer …especially HIV—that is the one we dread most as healing period and any follow-up appointments. Male partic- young people who are still growing up. If you have a cir- ipants were recruited at the health facility by trained research cumcised partner, you know that you are on the “safe side.” coordinators working with  VMMC mobilizers on the day of (Female, age 19, Harare, Zimbabwe) their procedure or VMMC providers during their follow-up appointment, as previously described [28]. Table 1. Study Participant Demographics by Country Ethics and General Procedures Characteristic Total South Africa Tanzania Zimbabwe The Human Sciences Research Council in South Africa, Tanzania National Institute for Medical Research, Medical Research Council Female adolescents (N = 90) (n = 28) (n = 28) (n = 34) (FGDs) of Zimbabwe, and Johns Hopkins Bloomberg School of Public Age, y Health Institutional Review Board approved the study prior to data 16–17 37 (41.1) 13 (46.4) 10 (35.7) 14 (41.2) collection. Parental permission was obtained for participants <18 18–19 53 (58.9) 15 (53.6) 18 (64.3) 20 (58.8) years of age, and assent/consent was obtained for all participants. Mean (SD) 17.6 (1.2) 17.5 (1.2) 17.7 (1.2) 17.5 (1.2) Setting Data were collected during June–September 2015 in Urban 54 (60.0) 8 (28.6) 20 (71.4) 26 (76.5) Tanzania, August–December 2015 in Zimbabwe, and February– Periurban 21 (23.3) 13 (46.4) 8 (28.6) 0 (0.0) June 2016 in South Africa. Interviews were conducted in private Rural 15 (16.7) 7 (25.0) 0 (0.0) 8 (23.5) settings by local, trained facilitators in English or local lan- Male adolescents (N = 92) (n = 36) (n = 36) (n = 20) guages: Sesotho, isiZulu, or isiSwati in South Africa; kiSwahili (IDIs) Age, y in Tanzania; Shona or Ndebele in Zimbabwe. Interviews were 10–14 49 (53.3) 28 (77.8) 15 (41.7) 6 (30.0) audio recorded, transcribed, and translated into English. 15–19 43 (46.7) 8 (22.2) 21 (58.3) 14 (70.0) Mean (SD) 14.5 (2.9) 13.4 (2.3) 15.1 (3.4) 15.5 (2.3) Analyses Setting Urban 55 (59.8) 9 (25.0) 31(86.1) 15 (75.0) Two coders independently coded transcripts using Atlas.ti soft- Periurban 14 (15.2) 9 (25.0) 5 (13.9) 0 (0.0) ware. The 2-step coding process included an initial independent Rural 23 (25.0) 18 (50.0) 0 (0.0) 5 (25.0) read-through of all transcripts by each coder to develop a cod- Data are presented as n (%) unless otherwise indicated. ing scheme. The coders then discussed any differences in the Abbreviations: FGDs, focus group discussions; IDIs, in-depth interviews; SD, standard scheme until a consensus was met. Research staff double-coded deviation. S184 • CID 2018:66 (Suppl 3) • Kaufman et al Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 Table 2. Themes by Participant Perspective and Subthemes Within Each So because circumcision helps in reducing the risk of dis- eases, I think it is a must for every male to be circumcised. Themes Participant Perspective Subthemes (Female, age 19, Makambako, Tanzania) Female adolescents’ acceptance of VMMC Females Many female peers supported, respected, While many females shared that they admired males who under- and preferred males who underwent went the procedure, some were skeptical and believed males would VMMC. Females Female participants found VMMC to be a use their circumcised status as an opportunity for promiscuity. positive step towards healthier sexual relations for both men and women. I don’t admire him [a circumcised male] at all. He is the Females Some female participants saw VMMC as a driver for promiscuous behavior. same as before even though he is circumcised. He will take Females’ role in VMMC decision making advantage now that he is safe and do crazy things. (Female, Females and males Male adolescents were reluctant to dis- age 16, Ermelo, South Africa) cuss VMMC with female peers and pla- tonic friends. Females and males Romantic and/or sexual partners influence Females’ Role in VMMC Decision Making the VMMC decision-making process for Discomfort Talking About VMMC With Female Peers males. Male adolescents reported that VMMC was a personal matter Females Many females leverage their relationship status to encourage males to seek not to be discussed with others. Most adolescent males across VMMC. all countries reported they rarely considered the opinions of Females and males Females’ preference for dating or having their female peers and platonic friends when deciding to seek sex with circumcised males is a factor in males’ decision to undergo VMMC. VMMC. Some males even reported not feeling comfortable Females and males Males were perceived as more attractive talking with female friends about their VMMC status, citing and confident following VMMC, which shyness and fear of being ridiculed or mocked. was viewed by females as a positive thing, unless they used that new confi- dence to be promiscuous. There aren’t any [girls my age that know I am circum- Female support after VMMC cised] because … it is actually embarrassing [laughs] … Males Adolescent males felt supported by female peers, partners, and family members because I am a boy and she is a girl. (Male, age 14, Mutare, after VMMC. Zimbabwe) Abbreviation: VMMC, voluntary medical male circumcision. This fear of potential embarrassment or ridicule from disclos- ing VMMC status was observed in all countries. Female ado- Adolescent females from all 3 countries expressed their overall lescents also explained that their male friends often did not feel preference for circumcised sexual partners. comfortable talking about VMMC with them. They [circumcised males] would have done a good Very few boys can talk about their circumcision experi- thing because they would have protected themselves from ence with girls; they talk about it among themselves. If they sexually transmitted diseases. He would have helped me ... talk about it with girls, then they must be very confident. He would have helped himself and me as well in terms of (Female, age 18, Makambako, Tanzania) preventing sexually transmitted diseases. So it is good to be circumcised. (Female, age 18, Mutare, Zimbabwe) Comfort Talking About VMMC With Female Partners In contrast to male adolescents’ reluctance to have direct con- Female Support of VMMC versations with their female peers, males admitted that if their In general, adolescent female participants were supportive of romantic and/or sexual partners had a strong preference regard- male peers’ decisions to seek VMMC. Many female partici- ing VMMC, this influenced their decision. Male adolescents in pants in Tanzania and Zimbabwe shared that they respected relationships appeared to include partners in the decision-mak- young men who underwent VMMC; they viewed it as a brave ing process. One adolescent reported that his girlfriend’s persis- decision to undergo the procedure to improve both partners’ tence in persuading him to get circumcised was a major reason he health. ultimately underwent VMMC. I think it is a must [to receive VMMC], not a matter of She [my girlfriend] used to nag me every day and told choice, of willingness. The world we live in today is dif- me that I  needed to get circumcised … she told me that ferent because there are so many diseases, unlike how the I have made the right decision, and our love has blossomed situation was back in the days when people could live with- even more. (Male, age 18, Mbeya, Tanzania) out being circumcised and still not risk getting diseases. Female Support for Male Circumcision • CID 2018:66 (Suppl 3) • S185 Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 While only a few males reported their girlfriends directly influ- to have sex, and the man comes just as he is getting in. enced their decision to undergo VMMC, others mentioned (Female, age 18, Mount Darwin, Zimbabwe) such encouragement as a motivating factor. Likewise, male adolescents believed VMMC would enable them Females Leveraging Relationship Status on VMMC to sexually satisfy their female partner. Young females admitted they both covertly and overtly tried to influence their partners’ decision to seek VMMC. Most female They [females] said it is not right as a man to have fore- participants in Tanzania and Zimbabwe disclosed they would skin …they state [it] clear; they said when you have sex they not initiate relationships or would readily discontinue them if don’t feel you right. (Male, age 18, Ermelo, South Africa) their partners refused VMMC. While a few female participants mentioned using the threat of infections, HIV, and cervical/ Confidence/Perceived Attractiveness as a Byproduct penile cancer as a means of persuasion, others believed that, According to both genders, males seemed more confident over- regardless of benefits for herself, if a female truly cares for her all following VMMC because they were more comfortable with partner, it is her duty to convince him to seek VMMC. their appearance. One young male reportedly hid the fact that he was not circumcised and felt scared a female would find out I would encourage [my boyfriend]. I would use different until he finally underwent VMMC: ways [to encourage him], ask him how he feels about circum- cision … then ask him if he thinks it’s better he goes [and gets To be sincere it was embarrassing [to not be circum- circumcised], so that once we decide to have sex, we know cised], and I was feeling bad, because even when you want that we are well protected, we don’t have stress, it’s just the to urinate you will have to go to a place where nobody will two of us. (Female, age 17, Orange Farm, South Africa) see you. And also there was a certain feeling that makes you to be uncomfortable as a man. For instance, when you Some females disclosed they used the power of maintaining the approach a girl, you cannot be straight to her [about your relationship as leverage: circumcision status] … you become scared. She can agree [to have sex] but yet you are scared … you run away. (Male, age 19, Iringa, Tanzania) If a male knows his girlfriend loves him, and she tells him to do anything, he would listen to her. As for me, if he Gaining confidence when approaching partners for sexual does not accept to go and get circumcised, I  would leave encounters was a benefit reported by both males and females. him for the one who has. He must listen and accept to be circumcised if he wants to keep the relationship. (Female, They [circumcised males] become more confident, because age 19, Mbeya, Tanzania) even when they are with a female partner they are more com- Sexual Intimacy as an Incentive for VMMC fortable. A person cannot be comfortable with his partner if Overall, male adolescents noted that female preference for dat- he is not circumcised. He could even prefer to have sex when ing or having sex with circumcised males is a factor in their the lights are off. After he is circumcised, he becomes free and VMMC decision making. comfortable. (Female, age 19, Mbeya, Tanzania) I have heard some girls saying, ‘We now want guys who At the same time, some adolescent females did not approve of are circumcised, we no longer want the uncircumcised this gain in confidence, since they felt that males become more ones as they may have chirwere (HIV/AIDS).’ (Male, age promiscuous following the procedure. 16, Mount Darwin, Zimbabwe) I think what’s bad about circumcision is that those who Many female adolescents mentioned that having a circumcised have been circumcised tend to think they can’t be infected male partner not only means feeling protected from HIV trans- by any disease, and then such an individual will be forced to mission, but appears more hygienic and sexually appealing. do what? To have sex with different people because he will Females also mentioned that sex was more pleasurable with a be telling himself he won’t be infected because he is circum- circumcised as compared to an uncircumcised partner because cised. That’s not true. (Female, age 19, Bulawayo, Zimbabwe) of a belief that a circumcised male can prolong sex. Female Support After VMMC He will not come too early [when circumcised]; he will Males Feeling Supported by Females Ae ft r VMMC do so after some time has elapsed. It helps you to also enjoy After undergoing VMMC, male adolescents felt supported by [sex] as a woman. Because it is not nice when you agree female peers, romantic partners, and sisters. Males reported S186 • CID 2018:66 (Suppl 3) • Kaufman et al Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 females often approached them after the procedure, wanting Females’ overall positive support of VMMC is also reflected to know details about pain, the procedure itself, and how it in studies of the male perspective. For instance, a study of ado- changed the appearance of the penis. For instance, one male lescent and adult men seeking VMMC in Uganda found that talked about his sisters’ reaction: those who were in a relationship or were married had been influenced by their female partner to seek VMMC [ 29]. These My sisters know … they did not ask me a lot of ques- men expressed concern for their relationships throughout the tions about it because they know that I am a male and they decision process and emphasized the need to involve women are females, they just asked minor questions. They asked in awareness-raising activities. They viewed women as hold - if I cried, and I told them I didn’t … I just told them I was ing negotiating power when communicating with their male circumcised … they told me it is well and I have become partners and being likely to persuade men to get circumcised, clean now … They laughed at me at the beginning, but at making it a joint decision [17, 18]. One media campaign in the end my elder sister told me I had made a good deci- South Africa capitalized on adult women’s influence, with tel - sion. (Male, age 18, Mbeya, Tanzania) evision ads showing women in a salon talking about how they convinced their partners to seek VMMC and how sexy they find Males rarely reported being ridiculed or mocked by female the men once they do so [31]. Similar media campaigns may peers for their decision to be circumcised, despite having this also be effective among adolescents. fear prior to the procedure. In Zimbabwe, one male noted that Some female study participants expressed concern that females were more cautious around recently circumcised males. VMMC is a driver of promiscuous behavior. Research on risk compensation aer VMM ft C shows this concern is unfounded— They just see [recently circumcised boys] as … they seem VMMC is generally not associated with an increase in the num- reluctant to play with them. They sit very far from them. ber of sexual partners nor a reduction in future condom use They are afraid they might trigger something and you get [32–36]. Achieving greater buy-in from adolescent females for hurt. They don’t want to come near someone who has been VMMC and encouraging them to play a role in convincing their circumcised. (Male, age 14, Mount Darwin, Zimbabwe) male peers and romantic partners to seek VMMC services may require debunking this promiscuity myth. DISCUSSION This study has limitations. The findings are qualitative and This study demonstrates that adolescent female participants therefore not generalizable beyond the included participants. endorse and influence VMMC decision making by adoles- It is possible that participants did not fully disclose personal cent males. They reported leveraging their romantic rela- details such as experience with circumcised vs uncircumcised tionships—or the potential for a relationship—to convince males in the case of female participants, or male accounts of males to seek VMMC, and they remained supportive of the females ridiculing them for seeking or not seeking VMMC. To decision postprocedure. Adolescent males also viewed their mitigate this, we triangulated data from FGDs of female adoles- romantic relationships as playing a role in VMMC, and cents and IDIs conducted with adolescent VMMC clients look- they perceived females in their lives as supportive in their ing for corroborating and contradicting information. recovery. However, males reported being hesitant to dis- While the decision to undergo VMMC is ultimately that of the cuss VMMC with female peers with whom they were not in adolescent and/or his parent/guardian, it is evident that adoles- romantic relationships. In general, adolescent females could cent females in this study used their position as current or poten- be contributing to shaping social norms that encourage ado- tial partners, alongside the many benefits of VMMC (mutual lescent VMMC and that heighten stigma against those not partner health, attractiveness, sexual desire), as leveraging points seeking VMMC services [27]. for encouraging adolescent males to seek VMMC. Health pro- Female adolescents’ discussions about VMMC in this study grams should take the perspectives and influence of adolescent were consistent with research in Kenya, Uganda, Malawi, girls and young women into account as part of engaging adoles- and South Africa, which showed that adult female partners’ cent male clients in VMMC and other HIV-related initiatives. opinions can have an influence on men’s decision to undergo Notes VMMC [17, 18, 26, 29]. Women in Malawi and Uganda Acknowledgments. We are grateful to the adolescent participants in reported greater sexual satisfaction with circumcised part- this study for sharing their perspectives and experiences. The authors also ners as compared to uncircumcised partners, and women thank the VMMC facility managers, community mobilizers, and provid- perceived circumcised men as more hygienic and carrying ers for their support, and acknowledge the contributions of the Technical Advisory Group for the adolescent VMMC assessment and their guidance fewer diseases than uncircumcised men [19, 30]. A  study of throughout the study. We are privileged to work with this group of dedi- women in Kenya revealed that a man’s circumcision status was cated professionals from the US President’s Emergency Plan for AIDS Relief an important factor for determining whether to initiate sexual (PEPFAR), Centers for Disease Control and Prevention, Department of relations [18]. Defense, World Health Organization, United Nations Children’s Fund, and Female Support for Male Circumcision • CID 2018:66 (Suppl 3) • S187 Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 the Bill & Melinda Gates Foundation. Thanks go to the Human Sciences 14. UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention. Male circumcision for HIV prevention Research Council in South Africa, CSK Research Solutions in Tanzania, in high HIV prevalence settings: what can mathematical modeling contribute to PSI/Zimbabwe, and the Centre for Sexual Health and HIV/AIDS Research informed decision making? PLoS Med 2009; 6:e1000109. in Zimbabwe for their assistance with data collection. The authors also 15. Hallett TB, Alsallaq RA, Baeten JM, et al. Will circumcision provide even more appreciate the assistance of Meaghen Murphy with copy editing and Maria protection from HIV to women and men? New estimates of the population Elena Figueroa with project startup. impact of circumcision interventions. Sex Transm Infect 2011; 87:88–93. Disclaimer. e fin Th dings and conclusions in this report are those of the 16. Toledo C. Association between HIV and sexually transmitted infections and authors and do not necessarily represent the official position of the US gov - partner circumcision among women in uMgungundlovu District, South Africa: ernment, US Agency for International Development (USAID), PEPFAR, or a cross-sectional analysis of HIPSS baseline data. In: Ninth International AIDS any other affiliate organizations or institutions. Society Conference on HIV Science, Paris, France, 2017. 17. Lanham M, L’Engle KL, Loolpapit M, Oguma IO. Women’s roles in voluntary Financial support. This work was supported by USAID with PEPFAR medical male circumcision in Nyanza Province, Kenya. PLoS One 2012; 7:e44825. funding (cooperative agreement number AID-OAA-A-12-00058) to the 18. Riess TH, Achieng MM, Bailey RC. Women’s beliefs about male circumcision, HIV Johns Hopkins Center for Communication Programs and was co-funded by prevention, and sexual behaviors in Kisumu, Kenya. PLoS One 2014; 9:e97748. the UK Department of International Development through the Integrated 19. Shacham E, Godlonton S, Thornton RL. Perceptions of male circumcision among Support Program in Zimbabwe. married couples in rural Malawi. J Int Assoc Provid AIDS Care 2014; 13:443–9. Supplement sponsorship. This article appears as part of the supplement 20. Bingenheimer JB, Asante E, Ahiadeke C. Peer influences on sexual activity among “Adolescent Voluntary Medical Male Circumcision: Vital Intervention Yet adolescents in Ghana. Stud Fam Plann 2015; 46:1–19. Improvements Needed,” sponsored by Johns Hopkins University. 21. Blum RW. Youth in sub-Saharan Africa. J Adolesc Health 2007; 41:230–8. Potential conifl cts of interest. All authors: No reported conflicts of 22. Fearon E, Wiggins RD, Pettifor AE, Hargreaves JR. Is the sexual behaviour of young people in sub-Saharan Africa influenced by their peers? A  systematic interest. All authors have submitted the ICMJE Form for Disclosure of review. Soc Sci Med 2015; 146:62–74. Potential Conflicts of Interest. Conflicts that the editors consider relevant to 23. Harrison A, Smit J, Hoffman S, et al. Gender, peer and partner influences on ado- the content of the manuscript have been disclosed. lescent HIV risk in rural South Africa. Sex Health 2012; 9:178–86. 24. Mmari K, Blum RW. Risk and protective factors that affect adolescent reproduc- References tive health in developing countries: a structured literature review. Glob Public 1. Auvert B, Sobngwi-Tambekou J, Cutler E, et  al. Effect of male circumcision on Health 2009; 4:350–66. the prevalence of high-risk human papillomavirus in young men: results of a ran- 25. Njau B, Mtweve S, Barongo L, et al. The influence of peers and other significant domized controlled trial conducted in Orange Farm, South Africa. J Infect Dis persons on sexuality and condom-use among young adults in northern Tanzania. 2009; 199:14–9. Afr J AIDS Res 2007; 6:33–40. 2. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. 26. George G, Strauss M, Chirawu P, et  al. Barriers and facilitators to the uptake Randomized, controlled intervention trial of male circumcision for reduction of of voluntary medical male circumcision (VMMC) among adolescent boys in HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2:e298. KwaZulu-Natal, South Africa. Afr J AIDS Res 2014; 13:179–87. 3. Bailey RC, Moses S, Parker CB, et  al. Male circumcision for HIV prevention 27. Patel EU, Kaufman MR, Dam KH, et al. Age differences in perceptions of and in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; motivations for voluntary medical male circumcision among adolescents in South 369:643–56. Africa, Tanzania, and Zimbabwe. Clin Infect Dis 2018; 66(Suppl 3):S173–82. 4. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in 28. Kaufman MR, Dam KH, Van Lith LM, et al. Voluntary medical male circumcision men in Rakai, Uganda: a randomised trial. Lancet 2007; 369:657–66. among adolescents: a missed opportunity for HIV behavioral interventions. AIDS 5. Gray RH, Serwadda D, Kong X, et al. Male circumcision decreases acquisition and 2017; 31:S233–41. increases clearance of high-risk human papillomavirus in HIV-negative men: a 29. Lunsford SS, Byabagambi J, Falconer-Stout Z, Karamagi E. Improving voluntary randomized trial in Rakai, Uganda. J Infect Dis 2010; 201:1455–62. medical male circumcision standards adherence and post-procedure follow-up in 6. Sobngwi-Tambekou J, Taljaard D, Lissouba P, et al. Effect of HSV-2 serostatus on Uganda: a mixed methods study. Afr J AIDS Res 2017; 16:39–46. acquisition of HIV by young men: results of a longitudinal study in Orange Farm, 30. Kigozi G, Lukabwe I, Kagaayi J, et  al. Sexual satisfaction of women partners of South Africa. J Infect Dis 2009; 199:958–64. circumcised men in a randomized trial of male circumcision in Rakai, Uganda. 7. Tobian AA, Charvat B, Ssempijja V, et al. Factors associated with the prevalence BJU Int 2009; 104:1698–701. and incidence of herpes simplex virus type 2 infection among men in Rakai, 31. Orr N, Hajiyiannis H, Matekane T, Ntlabati P. Post-broadcast evaluation of the Uganda. J Infect Dis 2009; 199:945–9. Brothers for Life medical male circumcision “Salon” campaign. Johannesburg, South 8. Tobian AA, Serwadda D, Quinn TC, et  al. Male circumcision for the pre- Africa: Centre for AIDS Development, Research and Evaluation (CADRE), 2016. vention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009; 32. Shi CF, Li M, Dushoff J. Evidence that promotion of male circumcision did not 360:1298–309. lead to sexual risk compensation in prioritized sub-Saharan countries. PLoS One 9. Wilson LE, Gravitt P, Tobian AA, et al. Male circumcision reduces penile high- 2017; 12:e0175928. risk human papillomavirus viral load in a randomised clinical trial in Rakai, 33. Balekang GB, Dintwa KF. A comparison of risky sexual behaviours between cir- Uganda. Sex Transm Infect 2013; 89:262–6. cumcised and uncircumcised men aged 30–44 years in Botswana. Afr Health Sci 10. Tobian AA, Gray RH. The medical benefits of male circumcision. JAMA 2011; 2016; 16:105–15. 306:1479–80. 34. Govender K, George G, Beckett S, Montague C, Frohlich J. Risk compensation 11. Davis MA, Gray RH, Grabowski MK, et al. Male circumcision decreases high-risk following medical male circumcision: results from a 1-year prospective cohort human papillomavirus viral load in female partners: a randomized trial in Rakai, study of young school-going men in KwaZulu-Natal, South Africa. Int J Behav Uganda. Int J Cancer 2013; 133:1247–52. Med 2017. doi:10.1007/s12529-017-9673-0. 12. Gray RH, Kigozi G, Serwadda D, et al. The effects of male circumcision on female 35. Westercamp M, Jaoko W, Mehta S, Abuor P, Siambe P, Bailey RC. Changes in male partners’ genital tract symptoms and vaginal infections in a randomized trial in circumcision prevalence and risk compensation in the Kisumu, Kenya popula- Rakai, Uganda. Am J Obstet Gynecol 2009; 200:42.e1–7. tion, 2008–2013. J Acquir Immune Defic Syndr 2017; 74:e30–7. 13. Wawer MJ, Tobian AA, Kigozi G, et  al. Effect of circumcision of HIV-negative 36. Gray R, Kigozi G, Kong X, et al. The effectiveness of male circumcision for HIV men on transmission of human papillomavirus to HIV-negative women: a ran- prevention and effects on risk behaviors in a posttrial follow-up study. AIDS domised trial in Rakai, Uganda. Lancet 2011; 377:209–18. 2012; 26:609–15. S188 • CID 2018:66 (Suppl 3) • Kaufman et al Please excuse the presence of this and the following test pages, which have been added to a small number of article PDFs for a limited time as part of our process of continual development and improvement. academic.oup.com/cid 1 of 4 academic.oup.com/cid Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do academic.oup.com/cid 2 of 4 eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. academic.oup.com/cid 3 of 4 Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. academic.oup.com/cid 4 of 4 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Clinical Infectious Diseases Oxford University Press

Loading next page...
 
/lp/oxford-university-press/females-peer-influence-and-support-for-adolescent-males-receiving-Kn1Art1Hlw

References (38)

Publisher
Oxford University Press
Copyright
Copyright © 2022 Infectious Diseases Society of America
ISSN
1058-4838
eISSN
1537-6591
DOI
10.1093/cid/cix1057
Publisher site
See Article on Publisher Site

Abstract

Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 Clinical Infectious Diseases SUPPLEMENT ARTICLE Females’ Peer Influence and Support for Adolescent Males Receiving Voluntary Medical Male Circumcision Services 1 2 1 2 3 4 5 Michelle R. Kaufman, Kim H. Dam, Kriti Sharma, Lynn M. Van Lith, Karin Hatzold, Arik V. Marcell, Webster Mavhu, 6 7 8 9 9 10 XX Catherine Kahabuka, Lusanda Mahlasela, Eshan U. Patel, Emmanuel Njeuhmeli, Kim Seifert Ahanda, Getrude Ncube, 11 12 8 Gissenge Lija, Collen Bonnecwe, and Aaron A. R. Tobian 1 2 3 XXXX Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Center for Communication Programs, Baltimore, Maryland; Population Services International, Harare, Zimbabwe; 4 5 6 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe; CSK Research Solutions, 7 8 9 Ltd, Dar es Salaam, Tanzania; Centre for Communication Impact, Pretoria, South Africa; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, and Office 10 11 of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia; Ministry of Health and Child Care, Harare, Zimbabwe; Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania; and National Department of Health, Pretoria, South Africa Background. While female involvement in voluntary medical male circumcision (VMMC) has been studied among adults, little is known about the influence of adolescent females on their male counterparts. This study explored adolescent females’ involvement in VMMC decision making and the postoperative wound healing process in South Africa, Tanzania, and Zimbabwe. Methods. Across 3 countries, 12 focus group discussions were conducted with a total of 90 adolescent females (aged 16–19 years). Individual in-depth interviews were conducted 6–10 weeks post-VMMC with 92 adolescent males (aged 10–19 years). Transcribed and translated qualitative data were coded into categories and subcategories by 2 independent coders. Results. Adolescent female participants reported being supportive of male peers’ decisions to seek VMMC, with the caveat that some thought VMMC gives males a chance to be promiscuous. Regardless, females from all countries expressed preference for circumcised over uncircumcised sexual partners. Adolescent females believed VMMC to be beneficial for the sexual health of both partners, viewed males with a circumcised penis as more attractive than uncircumcised males, used their romantic relationships with males or the potential for sex as leveraging points to convince males to become circumcised, and demonstrated supportive attitudes in the wound-healing period. Interviews with males confirmed that encouragement from females was a motivating factor in seeking VMMC. Conclusions. Adolescent female participants played a role in convincing young males to seek VMMC and remained supportive of the decision postprocedure. Programs aiming to increase uptake of VMMC and other health-related initiatives for adolescent males should consider the perspective and influence of adolescent females. Keywords. adolescents; voluntary medical male circumcision; HIV prevention; females; sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk 30% lower likelihood of having HIV and were less likely to have OA-CC-BY of acquiring human immunodeficiency virus (HIV), human pap - herpes simplex virus type 2 [16]. illomavirus, and herpes simplex virus type 2 among men [1–10], While female involvement in VMMC decision making has been and Trichomonas vaginalis, bacterial vaginosis, and human pap- studied among adults [17–19], little is known regarding the influ - illomavirus among female partners [11–13]. Women also benefit ence of female peers on adolescent VMMC clients. Research on indirectly from the expansion of VMMC services because the adolescents in sub-Saharan Africa shows that peers have a large probability of encountering an HIV-infected male partner grad- impact on adolescent sexual and reproductive health behaviors ually declines with programmatic scale-up [14]. Mathematical [20–26]. Understanding adolescent females’ level of influence on models have also shown a 46% long-term reduction in male-to- adolescent VMMC uptake may be important for programmatic female HIV transmission due to reduced male susceptibility fol- scale-up and sustainability. This study utilized focus groups with lowing VMMC [15]. A recent study of women in KwaZulu Natal, female adolescents aged 16–19 years and in-depth interviews South Africa, showed that those with circumcised partners had a (IDIs) with male adolescents aged 10–19 years to explore the influ - ence and support of adolescent females in the decision-making and healing process for male peers and sexual partners receiving Correspondence: M.  R. Kaufman, Johns Hopkins Bloomberg School of Public Health, VMMC across 3 countries: South Africa, Tanzania, and Zimbabwe. Department of Health, Behavior and Society, 624  N Broadway, Baltimore, MD 21205 (michellekaufman@jhu.edu). Clinical Infectious Diseases 2018;66(S3):S183–8 METHODS © The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America.  This is an Open Access article distributed under the terms of the Creative Commons Female Participants Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted Focus group discussions (FGDs; 6–10 participants in each) were reuse, distribution, and reproduction in any medium, provided the original work is properly cited. conducted with 90 female adolescents aged 16–19 years in South DOI: 10.1093/cid/cix1057 Female Support for Male Circumcision • CID 2018:66 (Suppl 3) • S183 Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 Africa, Tanzania, and Zimbabwe (4 FGDs per country). Female all transcripts, and when further content analysis arose, cod- adolescent participants were recruited from the communities in ers generated themes and subthemes within predetermined which VMMC clinics were located, and male adolescent partic- areas of inquiry in the semistructured interview guides. Coders ipants were recruited from 4 VMMC sites per country, as pre- compared all applied codes and discussed discrepancies until viously described [27]. VMMC community mobilizers (who an agreement was reached. In the rare event that an individ- encouraged male adolescents to be circumcised and were familiar ual code resulted in no agreement between coders, the primary with adolescents in the area) and/or trained research coordinators investigator made a final determination. recruited female participants at youth groups, youth-gathering locations, and schools. Female participants were not necessarily RESULTS sexual partners of VMMC clients. Table  1 shows the participant demographics overall and by FGDs with female adolescents focused on their opinions country. Table 2 displays the themes and subthemes that arose and perceptions of VMMC and examples of how female ado- from the adolescent female and male client perspectives. lescents try to convince their boyfriends to seek VMMC. They were asked about their knowledge of VMMC’s impact on HIV Female Adolescents’ Acceptance of VMMC and on hygiene, as well as their views about VMMC’s influence Female Beliefs Regarding VMMC Benets fi on relationships in general and on sexual behaviors. Male ado- Female participants believed VMMC is mutually benefi- lescents were asked about their experiences in disclosing their cial for healthier sexual relations and considered it a modern VMMC status and/or discussing the procedure experience and prerequisite to date a male. When female participants were perceptions with their female adolescent peers. prompted regarding the benefits of VMMC, most mentioned the protection against HIV infection, sexually transmitted Male Participants infections, and cervical cancer in the female sexual partners of IDIs were conducted with 92 male adolescents (aged circumcised males. 10–19 years) 6–10 weeks post-VMMC procedure (South Africa, n = 36; Tanzania, n = 36; Zimbabwe, n = 20). This timeframe It reduces the chances of contracting diseases like HIV, was selected to allow for completion of the full post-VMMC cancer …especially HIV—that is the one we dread most as healing period and any follow-up appointments. Male partic- young people who are still growing up. If you have a cir- ipants were recruited at the health facility by trained research cumcised partner, you know that you are on the “safe side.” coordinators working with  VMMC mobilizers on the day of (Female, age 19, Harare, Zimbabwe) their procedure or VMMC providers during their follow-up appointment, as previously described [28]. Table 1. Study Participant Demographics by Country Ethics and General Procedures Characteristic Total South Africa Tanzania Zimbabwe The Human Sciences Research Council in South Africa, Tanzania National Institute for Medical Research, Medical Research Council Female adolescents (N = 90) (n = 28) (n = 28) (n = 34) (FGDs) of Zimbabwe, and Johns Hopkins Bloomberg School of Public Age, y Health Institutional Review Board approved the study prior to data 16–17 37 (41.1) 13 (46.4) 10 (35.7) 14 (41.2) collection. Parental permission was obtained for participants <18 18–19 53 (58.9) 15 (53.6) 18 (64.3) 20 (58.8) years of age, and assent/consent was obtained for all participants. Mean (SD) 17.6 (1.2) 17.5 (1.2) 17.7 (1.2) 17.5 (1.2) Setting Data were collected during June–September 2015 in Urban 54 (60.0) 8 (28.6) 20 (71.4) 26 (76.5) Tanzania, August–December 2015 in Zimbabwe, and February– Periurban 21 (23.3) 13 (46.4) 8 (28.6) 0 (0.0) June 2016 in South Africa. Interviews were conducted in private Rural 15 (16.7) 7 (25.0) 0 (0.0) 8 (23.5) settings by local, trained facilitators in English or local lan- Male adolescents (N = 92) (n = 36) (n = 36) (n = 20) guages: Sesotho, isiZulu, or isiSwati in South Africa; kiSwahili (IDIs) Age, y in Tanzania; Shona or Ndebele in Zimbabwe. Interviews were 10–14 49 (53.3) 28 (77.8) 15 (41.7) 6 (30.0) audio recorded, transcribed, and translated into English. 15–19 43 (46.7) 8 (22.2) 21 (58.3) 14 (70.0) Mean (SD) 14.5 (2.9) 13.4 (2.3) 15.1 (3.4) 15.5 (2.3) Analyses Setting Urban 55 (59.8) 9 (25.0) 31(86.1) 15 (75.0) Two coders independently coded transcripts using Atlas.ti soft- Periurban 14 (15.2) 9 (25.0) 5 (13.9) 0 (0.0) ware. The 2-step coding process included an initial independent Rural 23 (25.0) 18 (50.0) 0 (0.0) 5 (25.0) read-through of all transcripts by each coder to develop a cod- Data are presented as n (%) unless otherwise indicated. ing scheme. The coders then discussed any differences in the Abbreviations: FGDs, focus group discussions; IDIs, in-depth interviews; SD, standard scheme until a consensus was met. Research staff double-coded deviation. S184 • CID 2018:66 (Suppl 3) • Kaufman et al Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 Table 2. Themes by Participant Perspective and Subthemes Within Each So because circumcision helps in reducing the risk of dis- eases, I think it is a must for every male to be circumcised. Themes Participant Perspective Subthemes (Female, age 19, Makambako, Tanzania) Female adolescents’ acceptance of VMMC Females Many female peers supported, respected, While many females shared that they admired males who under- and preferred males who underwent went the procedure, some were skeptical and believed males would VMMC. Females Female participants found VMMC to be a use their circumcised status as an opportunity for promiscuity. positive step towards healthier sexual relations for both men and women. I don’t admire him [a circumcised male] at all. He is the Females Some female participants saw VMMC as a driver for promiscuous behavior. same as before even though he is circumcised. He will take Females’ role in VMMC decision making advantage now that he is safe and do crazy things. (Female, Females and males Male adolescents were reluctant to dis- age 16, Ermelo, South Africa) cuss VMMC with female peers and pla- tonic friends. Females and males Romantic and/or sexual partners influence Females’ Role in VMMC Decision Making the VMMC decision-making process for Discomfort Talking About VMMC With Female Peers males. Male adolescents reported that VMMC was a personal matter Females Many females leverage their relationship status to encourage males to seek not to be discussed with others. Most adolescent males across VMMC. all countries reported they rarely considered the opinions of Females and males Females’ preference for dating or having their female peers and platonic friends when deciding to seek sex with circumcised males is a factor in males’ decision to undergo VMMC. VMMC. Some males even reported not feeling comfortable Females and males Males were perceived as more attractive talking with female friends about their VMMC status, citing and confident following VMMC, which shyness and fear of being ridiculed or mocked. was viewed by females as a positive thing, unless they used that new confi- dence to be promiscuous. There aren’t any [girls my age that know I am circum- Female support after VMMC cised] because … it is actually embarrassing [laughs] … Males Adolescent males felt supported by female peers, partners, and family members because I am a boy and she is a girl. (Male, age 14, Mutare, after VMMC. Zimbabwe) Abbreviation: VMMC, voluntary medical male circumcision. This fear of potential embarrassment or ridicule from disclos- ing VMMC status was observed in all countries. Female ado- Adolescent females from all 3 countries expressed their overall lescents also explained that their male friends often did not feel preference for circumcised sexual partners. comfortable talking about VMMC with them. They [circumcised males] would have done a good Very few boys can talk about their circumcision experi- thing because they would have protected themselves from ence with girls; they talk about it among themselves. If they sexually transmitted diseases. He would have helped me ... talk about it with girls, then they must be very confident. He would have helped himself and me as well in terms of (Female, age 18, Makambako, Tanzania) preventing sexually transmitted diseases. So it is good to be circumcised. (Female, age 18, Mutare, Zimbabwe) Comfort Talking About VMMC With Female Partners In contrast to male adolescents’ reluctance to have direct con- Female Support of VMMC versations with their female peers, males admitted that if their In general, adolescent female participants were supportive of romantic and/or sexual partners had a strong preference regard- male peers’ decisions to seek VMMC. Many female partici- ing VMMC, this influenced their decision. Male adolescents in pants in Tanzania and Zimbabwe shared that they respected relationships appeared to include partners in the decision-mak- young men who underwent VMMC; they viewed it as a brave ing process. One adolescent reported that his girlfriend’s persis- decision to undergo the procedure to improve both partners’ tence in persuading him to get circumcised was a major reason he health. ultimately underwent VMMC. I think it is a must [to receive VMMC], not a matter of She [my girlfriend] used to nag me every day and told choice, of willingness. The world we live in today is dif- me that I  needed to get circumcised … she told me that ferent because there are so many diseases, unlike how the I have made the right decision, and our love has blossomed situation was back in the days when people could live with- even more. (Male, age 18, Mbeya, Tanzania) out being circumcised and still not risk getting diseases. Female Support for Male Circumcision • CID 2018:66 (Suppl 3) • S185 Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 While only a few males reported their girlfriends directly influ- to have sex, and the man comes just as he is getting in. enced their decision to undergo VMMC, others mentioned (Female, age 18, Mount Darwin, Zimbabwe) such encouragement as a motivating factor. Likewise, male adolescents believed VMMC would enable them Females Leveraging Relationship Status on VMMC to sexually satisfy their female partner. Young females admitted they both covertly and overtly tried to influence their partners’ decision to seek VMMC. Most female They [females] said it is not right as a man to have fore- participants in Tanzania and Zimbabwe disclosed they would skin …they state [it] clear; they said when you have sex they not initiate relationships or would readily discontinue them if don’t feel you right. (Male, age 18, Ermelo, South Africa) their partners refused VMMC. While a few female participants mentioned using the threat of infections, HIV, and cervical/ Confidence/Perceived Attractiveness as a Byproduct penile cancer as a means of persuasion, others believed that, According to both genders, males seemed more confident over- regardless of benefits for herself, if a female truly cares for her all following VMMC because they were more comfortable with partner, it is her duty to convince him to seek VMMC. their appearance. One young male reportedly hid the fact that he was not circumcised and felt scared a female would find out I would encourage [my boyfriend]. I would use different until he finally underwent VMMC: ways [to encourage him], ask him how he feels about circum- cision … then ask him if he thinks it’s better he goes [and gets To be sincere it was embarrassing [to not be circum- circumcised], so that once we decide to have sex, we know cised], and I was feeling bad, because even when you want that we are well protected, we don’t have stress, it’s just the to urinate you will have to go to a place where nobody will two of us. (Female, age 17, Orange Farm, South Africa) see you. And also there was a certain feeling that makes you to be uncomfortable as a man. For instance, when you Some females disclosed they used the power of maintaining the approach a girl, you cannot be straight to her [about your relationship as leverage: circumcision status] … you become scared. She can agree [to have sex] but yet you are scared … you run away. (Male, age 19, Iringa, Tanzania) If a male knows his girlfriend loves him, and she tells him to do anything, he would listen to her. As for me, if he Gaining confidence when approaching partners for sexual does not accept to go and get circumcised, I  would leave encounters was a benefit reported by both males and females. him for the one who has. He must listen and accept to be circumcised if he wants to keep the relationship. (Female, They [circumcised males] become more confident, because age 19, Mbeya, Tanzania) even when they are with a female partner they are more com- Sexual Intimacy as an Incentive for VMMC fortable. A person cannot be comfortable with his partner if Overall, male adolescents noted that female preference for dat- he is not circumcised. He could even prefer to have sex when ing or having sex with circumcised males is a factor in their the lights are off. After he is circumcised, he becomes free and VMMC decision making. comfortable. (Female, age 19, Mbeya, Tanzania) I have heard some girls saying, ‘We now want guys who At the same time, some adolescent females did not approve of are circumcised, we no longer want the uncircumcised this gain in confidence, since they felt that males become more ones as they may have chirwere (HIV/AIDS).’ (Male, age promiscuous following the procedure. 16, Mount Darwin, Zimbabwe) I think what’s bad about circumcision is that those who Many female adolescents mentioned that having a circumcised have been circumcised tend to think they can’t be infected male partner not only means feeling protected from HIV trans- by any disease, and then such an individual will be forced to mission, but appears more hygienic and sexually appealing. do what? To have sex with different people because he will Females also mentioned that sex was more pleasurable with a be telling himself he won’t be infected because he is circum- circumcised as compared to an uncircumcised partner because cised. That’s not true. (Female, age 19, Bulawayo, Zimbabwe) of a belief that a circumcised male can prolong sex. Female Support After VMMC He will not come too early [when circumcised]; he will Males Feeling Supported by Females Ae ft r VMMC do so after some time has elapsed. It helps you to also enjoy After undergoing VMMC, male adolescents felt supported by [sex] as a woman. Because it is not nice when you agree female peers, romantic partners, and sisters. Males reported S186 • CID 2018:66 (Suppl 3) • Kaufman et al Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 females often approached them after the procedure, wanting Females’ overall positive support of VMMC is also reflected to know details about pain, the procedure itself, and how it in studies of the male perspective. For instance, a study of ado- changed the appearance of the penis. For instance, one male lescent and adult men seeking VMMC in Uganda found that talked about his sisters’ reaction: those who were in a relationship or were married had been influenced by their female partner to seek VMMC [ 29]. These My sisters know … they did not ask me a lot of ques- men expressed concern for their relationships throughout the tions about it because they know that I am a male and they decision process and emphasized the need to involve women are females, they just asked minor questions. They asked in awareness-raising activities. They viewed women as hold - if I cried, and I told them I didn’t … I just told them I was ing negotiating power when communicating with their male circumcised … they told me it is well and I have become partners and being likely to persuade men to get circumcised, clean now … They laughed at me at the beginning, but at making it a joint decision [17, 18]. One media campaign in the end my elder sister told me I had made a good deci- South Africa capitalized on adult women’s influence, with tel - sion. (Male, age 18, Mbeya, Tanzania) evision ads showing women in a salon talking about how they convinced their partners to seek VMMC and how sexy they find Males rarely reported being ridiculed or mocked by female the men once they do so [31]. Similar media campaigns may peers for their decision to be circumcised, despite having this also be effective among adolescents. fear prior to the procedure. In Zimbabwe, one male noted that Some female study participants expressed concern that females were more cautious around recently circumcised males. VMMC is a driver of promiscuous behavior. Research on risk compensation aer VMM ft C shows this concern is unfounded— They just see [recently circumcised boys] as … they seem VMMC is generally not associated with an increase in the num- reluctant to play with them. They sit very far from them. ber of sexual partners nor a reduction in future condom use They are afraid they might trigger something and you get [32–36]. Achieving greater buy-in from adolescent females for hurt. They don’t want to come near someone who has been VMMC and encouraging them to play a role in convincing their circumcised. (Male, age 14, Mount Darwin, Zimbabwe) male peers and romantic partners to seek VMMC services may require debunking this promiscuity myth. DISCUSSION This study has limitations. The findings are qualitative and This study demonstrates that adolescent female participants therefore not generalizable beyond the included participants. endorse and influence VMMC decision making by adoles- It is possible that participants did not fully disclose personal cent males. They reported leveraging their romantic rela- details such as experience with circumcised vs uncircumcised tionships—or the potential for a relationship—to convince males in the case of female participants, or male accounts of males to seek VMMC, and they remained supportive of the females ridiculing them for seeking or not seeking VMMC. To decision postprocedure. Adolescent males also viewed their mitigate this, we triangulated data from FGDs of female adoles- romantic relationships as playing a role in VMMC, and cents and IDIs conducted with adolescent VMMC clients look- they perceived females in their lives as supportive in their ing for corroborating and contradicting information. recovery. However, males reported being hesitant to dis- While the decision to undergo VMMC is ultimately that of the cuss VMMC with female peers with whom they were not in adolescent and/or his parent/guardian, it is evident that adoles- romantic relationships. In general, adolescent females could cent females in this study used their position as current or poten- be contributing to shaping social norms that encourage ado- tial partners, alongside the many benefits of VMMC (mutual lescent VMMC and that heighten stigma against those not partner health, attractiveness, sexual desire), as leveraging points seeking VMMC services [27]. for encouraging adolescent males to seek VMMC. Health pro- Female adolescents’ discussions about VMMC in this study grams should take the perspectives and influence of adolescent were consistent with research in Kenya, Uganda, Malawi, girls and young women into account as part of engaging adoles- and South Africa, which showed that adult female partners’ cent male clients in VMMC and other HIV-related initiatives. opinions can have an influence on men’s decision to undergo Notes VMMC [17, 18, 26, 29]. Women in Malawi and Uganda Acknowledgments. We are grateful to the adolescent participants in reported greater sexual satisfaction with circumcised part- this study for sharing their perspectives and experiences. The authors also ners as compared to uncircumcised partners, and women thank the VMMC facility managers, community mobilizers, and provid- perceived circumcised men as more hygienic and carrying ers for their support, and acknowledge the contributions of the Technical Advisory Group for the adolescent VMMC assessment and their guidance fewer diseases than uncircumcised men [19, 30]. A  study of throughout the study. We are privileged to work with this group of dedi- women in Kenya revealed that a man’s circumcision status was cated professionals from the US President’s Emergency Plan for AIDS Relief an important factor for determining whether to initiate sexual (PEPFAR), Centers for Disease Control and Prevention, Department of relations [18]. Defense, World Health Organization, United Nations Children’s Fund, and Female Support for Male Circumcision • CID 2018:66 (Suppl 3) • S187 Downloaded from https://academic.oup.com/cid/article/66/suppl_3/S183/4956264 by DeepDyve user on 18 July 2022 the Bill & Melinda Gates Foundation. Thanks go to the Human Sciences 14. UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention. Male circumcision for HIV prevention Research Council in South Africa, CSK Research Solutions in Tanzania, in high HIV prevalence settings: what can mathematical modeling contribute to PSI/Zimbabwe, and the Centre for Sexual Health and HIV/AIDS Research informed decision making? PLoS Med 2009; 6:e1000109. in Zimbabwe for their assistance with data collection. The authors also 15. Hallett TB, Alsallaq RA, Baeten JM, et al. Will circumcision provide even more appreciate the assistance of Meaghen Murphy with copy editing and Maria protection from HIV to women and men? New estimates of the population Elena Figueroa with project startup. impact of circumcision interventions. Sex Transm Infect 2011; 87:88–93. Disclaimer. e fin Th dings and conclusions in this report are those of the 16. Toledo C. Association between HIV and sexually transmitted infections and authors and do not necessarily represent the official position of the US gov - partner circumcision among women in uMgungundlovu District, South Africa: ernment, US Agency for International Development (USAID), PEPFAR, or a cross-sectional analysis of HIPSS baseline data. In: Ninth International AIDS any other affiliate organizations or institutions. Society Conference on HIV Science, Paris, France, 2017. 17. Lanham M, L’Engle KL, Loolpapit M, Oguma IO. Women’s roles in voluntary Financial support. This work was supported by USAID with PEPFAR medical male circumcision in Nyanza Province, Kenya. PLoS One 2012; 7:e44825. funding (cooperative agreement number AID-OAA-A-12-00058) to the 18. Riess TH, Achieng MM, Bailey RC. Women’s beliefs about male circumcision, HIV Johns Hopkins Center for Communication Programs and was co-funded by prevention, and sexual behaviors in Kisumu, Kenya. PLoS One 2014; 9:e97748. the UK Department of International Development through the Integrated 19. Shacham E, Godlonton S, Thornton RL. Perceptions of male circumcision among Support Program in Zimbabwe. married couples in rural Malawi. J Int Assoc Provid AIDS Care 2014; 13:443–9. Supplement sponsorship. This article appears as part of the supplement 20. Bingenheimer JB, Asante E, Ahiadeke C. Peer influences on sexual activity among “Adolescent Voluntary Medical Male Circumcision: Vital Intervention Yet adolescents in Ghana. Stud Fam Plann 2015; 46:1–19. Improvements Needed,” sponsored by Johns Hopkins University. 21. Blum RW. Youth in sub-Saharan Africa. J Adolesc Health 2007; 41:230–8. Potential conifl cts of interest. All authors: No reported conflicts of 22. Fearon E, Wiggins RD, Pettifor AE, Hargreaves JR. Is the sexual behaviour of young people in sub-Saharan Africa influenced by their peers? A  systematic interest. All authors have submitted the ICMJE Form for Disclosure of review. Soc Sci Med 2015; 146:62–74. Potential Conflicts of Interest. Conflicts that the editors consider relevant to 23. Harrison A, Smit J, Hoffman S, et al. Gender, peer and partner influences on ado- the content of the manuscript have been disclosed. lescent HIV risk in rural South Africa. Sex Health 2012; 9:178–86. 24. Mmari K, Blum RW. Risk and protective factors that affect adolescent reproduc- References tive health in developing countries: a structured literature review. Glob Public 1. Auvert B, Sobngwi-Tambekou J, Cutler E, et  al. Effect of male circumcision on Health 2009; 4:350–66. the prevalence of high-risk human papillomavirus in young men: results of a ran- 25. Njau B, Mtweve S, Barongo L, et al. The influence of peers and other significant domized controlled trial conducted in Orange Farm, South Africa. J Infect Dis persons on sexuality and condom-use among young adults in northern Tanzania. 2009; 199:14–9. Afr J AIDS Res 2007; 6:33–40. 2. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. 26. George G, Strauss M, Chirawu P, et  al. Barriers and facilitators to the uptake Randomized, controlled intervention trial of male circumcision for reduction of of voluntary medical male circumcision (VMMC) among adolescent boys in HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2:e298. KwaZulu-Natal, South Africa. Afr J AIDS Res 2014; 13:179–87. 3. Bailey RC, Moses S, Parker CB, et  al. Male circumcision for HIV prevention 27. Patel EU, Kaufman MR, Dam KH, et al. Age differences in perceptions of and in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; motivations for voluntary medical male circumcision among adolescents in South 369:643–56. Africa, Tanzania, and Zimbabwe. Clin Infect Dis 2018; 66(Suppl 3):S173–82. 4. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in 28. Kaufman MR, Dam KH, Van Lith LM, et al. Voluntary medical male circumcision men in Rakai, Uganda: a randomised trial. Lancet 2007; 369:657–66. among adolescents: a missed opportunity for HIV behavioral interventions. AIDS 5. Gray RH, Serwadda D, Kong X, et al. Male circumcision decreases acquisition and 2017; 31:S233–41. increases clearance of high-risk human papillomavirus in HIV-negative men: a 29. Lunsford SS, Byabagambi J, Falconer-Stout Z, Karamagi E. Improving voluntary randomized trial in Rakai, Uganda. J Infect Dis 2010; 201:1455–62. medical male circumcision standards adherence and post-procedure follow-up in 6. Sobngwi-Tambekou J, Taljaard D, Lissouba P, et al. Effect of HSV-2 serostatus on Uganda: a mixed methods study. Afr J AIDS Res 2017; 16:39–46. acquisition of HIV by young men: results of a longitudinal study in Orange Farm, 30. Kigozi G, Lukabwe I, Kagaayi J, et  al. Sexual satisfaction of women partners of South Africa. J Infect Dis 2009; 199:958–64. circumcised men in a randomized trial of male circumcision in Rakai, Uganda. 7. Tobian AA, Charvat B, Ssempijja V, et al. Factors associated with the prevalence BJU Int 2009; 104:1698–701. and incidence of herpes simplex virus type 2 infection among men in Rakai, 31. Orr N, Hajiyiannis H, Matekane T, Ntlabati P. Post-broadcast evaluation of the Uganda. J Infect Dis 2009; 199:945–9. Brothers for Life medical male circumcision “Salon” campaign. Johannesburg, South 8. Tobian AA, Serwadda D, Quinn TC, et  al. Male circumcision for the pre- Africa: Centre for AIDS Development, Research and Evaluation (CADRE), 2016. vention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009; 32. Shi CF, Li M, Dushoff J. Evidence that promotion of male circumcision did not 360:1298–309. lead to sexual risk compensation in prioritized sub-Saharan countries. PLoS One 9. Wilson LE, Gravitt P, Tobian AA, et al. Male circumcision reduces penile high- 2017; 12:e0175928. risk human papillomavirus viral load in a randomised clinical trial in Rakai, 33. Balekang GB, Dintwa KF. A comparison of risky sexual behaviours between cir- Uganda. Sex Transm Infect 2013; 89:262–6. cumcised and uncircumcised men aged 30–44 years in Botswana. Afr Health Sci 10. Tobian AA, Gray RH. The medical benefits of male circumcision. JAMA 2011; 2016; 16:105–15. 306:1479–80. 34. Govender K, George G, Beckett S, Montague C, Frohlich J. Risk compensation 11. Davis MA, Gray RH, Grabowski MK, et al. Male circumcision decreases high-risk following medical male circumcision: results from a 1-year prospective cohort human papillomavirus viral load in female partners: a randomized trial in Rakai, study of young school-going men in KwaZulu-Natal, South Africa. Int J Behav Uganda. Int J Cancer 2013; 133:1247–52. Med 2017. doi:10.1007/s12529-017-9673-0. 12. Gray RH, Kigozi G, Serwadda D, et al. The effects of male circumcision on female 35. Westercamp M, Jaoko W, Mehta S, Abuor P, Siambe P, Bailey RC. Changes in male partners’ genital tract symptoms and vaginal infections in a randomized trial in circumcision prevalence and risk compensation in the Kisumu, Kenya popula- Rakai, Uganda. Am J Obstet Gynecol 2009; 200:42.e1–7. tion, 2008–2013. J Acquir Immune Defic Syndr 2017; 74:e30–7. 13. Wawer MJ, Tobian AA, Kigozi G, et  al. Effect of circumcision of HIV-negative 36. Gray R, Kigozi G, Kong X, et al. The effectiveness of male circumcision for HIV men on transmission of human papillomavirus to HIV-negative women: a ran- prevention and effects on risk behaviors in a posttrial follow-up study. AIDS domised trial in Rakai, Uganda. Lancet 2011; 377:209–18. 2012; 26:609–15. S188 • CID 2018:66 (Suppl 3) • Kaufman et al Please excuse the presence of this and the following test pages, which have been added to a small number of article PDFs for a limited time as part of our process of continual development and improvement. academic.oup.com/cid 1 of 4 academic.oup.com/cid Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do academic.oup.com/cid 2 of 4 eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. academic.oup.com/cid 3 of 4 Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum. academic.oup.com/cid 4 of 4

Journal

Clinical Infectious DiseasesOxford University Press

Published: Apr 3, 2018

Keywords: adolescent; tanzania; south africa

There are no references for this article.