Systematic Review of the Barriers and Facilitators to Voluntary Male Medical Circumcision (VMMC) Uptake in Priority Countries and Recommendations for a Way Forward

Background: In 2007, the WHO called for scaling-up VMMC as an effective HIV prevention strategy, particularly in 14 priority countries with generalized HIV epidemics and low male circumcision prevalence. While millions have accessed VMMC since scale-up, demand has been lower than expected, compromising VMMC’s HIV/STI prevention benefits at population level.  The purpose of this study is to systematically analyze the literature to understand barriers and facilitators to VMMC uptake across settings and offer recommendations.  

Methods: We conducted a systematic review that included 23 qualitative, quantitative, and mixed methods studies published in peer reviewed journals (2007 through 2015).  Data was extracted in a study summary table, and tables and conceptual maps summarizing VMMC barriers and facilitators.  

Results: The data revealed 17 barriers and 16 facilitators at community, individual, interpersonal, and service provision levels.  Key barriers were MC perceived as being practiced by other or foreign cultures and religions; fear of pain caused by the procedure; and futility of VMMC because of low HIV risk behavior and still needing to use condoms.  The main facilitators were improved hygiene, family and peer support (especially for boys and young men), and enhanced sexual pleasure and sex appeal.  VMMC was strongly preferred for younger than older men.  Lost wages, cost associated with circumcision, and inconveniences around having to take time off for healing were not prominent barriers across settings. 

Conclusions: Programs should address barriers to VMMC uptake at various levels, particularly community level where they appear neglected.  Additionally, they should continue to offer VMMC to boys among whom MC has become normative across settings.  In the case of adults, offering VMMC information through individually-tailored counseling sessions may help to overcome stigma and determine its appropriateness given individual circumstances.  Given that lost wages were not a prominent barrier, monetary incentives may not be justified across settings.