Background: In 2007, the WHO called for scaling-up voluntary maedical male circumcision (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 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 countries and offer recommendations.
Methods: PubMed, Embase, Web of Science, Scopus, and PsycINFO databases were searched for studies published in peer reviewed journals from 2007 through 2015. Reviewers assessed the eligibility of each study based on predefined inclusion criteria. Twenty three studies were selected: 16 qualitative, 4 quantitative, and 3 mixed methods studies. Data was extracted in a study summary table, and tables and conceptual maps summarizing VMMC barriers and facilitators across countries.
Results: The data revealed 17 barriers and 16 facilitators at community, individual, interpersonal, and service provision levels. Key barriers were: male circumcision 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 countries.
Conclusions: VMMC programs should address barriers to VMMC uptake at various levels, particularly community level where community involvement seems neglected. Additionally, VMMC services should continue to be made fully accessible to boys among whom MC is becoming normative across countries. In the case of adults, offering VMMC information through individually-tailored counseling sessions may help to overcome VMMC-related stigma among adults and determine its appropriateness based on individual circumstances. Given that lost wages were not a prominent barrier, monetary incentives for uptake may not be justified across countries and they should be assessed also considering their psychosocial impact.

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