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Male circumcision can reduce a man's risk of getting HIV by up to 60 percent, but men are often reluctant to get the cut
Seven years after WHO endorsed male circumcision as a way of preventing HIV infection in heterosexual men, there are still many reasons why men of a certain age in Kenya's southwestern Nyanza province have been reluctant to get the cut.
"Initially they say, 'What will my family eat when I'm recovering? I am the provider of my family'," Kenyan HIV specialist Dr Kawango Agot told me at an international conference on AIDS in Melbourne.
They are also worried their wives might suspect their motives and even accuse them of having an affair given that circumcision has been presented as a HIV prevention strategy.
For older men, it's embarrassment at the thought of being circumcised by a female health worker that puts them off or being made to line up with adolescent boys for the cut.
And then there's the fear of pain.
"It's a big thing for men, you know. They're not used to pain like women are," Agot said, with a burst of laughter.
In an attempt to overcome these barriers, Agot and her colleagues carried out a two-month experiment last year using food vouchers as an incentive to get men circumcised.
They targeted men aged 25-49 in Nyanza, which has the highest HIV rates and the lowest rates of circumcision in Kenya.
Research cited by the World Health Organization has shown that male circumcision - removing all or part of the foreskin - can reduce a man's risk of getting HIV by up to 60 percent.
“Getting men 25 years and above has been a big problem and yet we know that to have HIV impact we need to get sexually active men and high-risk men. This is the age group and they're not coming," said Agot, who presented her study at the conference on Monday.
The men were given a scratch card which revealed an amount of money - $2.50, $8.75, $15 or nothing at all - and told they would receive a food voucher for the same amount after they had been circumcised.
Agot said a food voucher rather than cash was offered because that's what the men had complained about - how to feed their family during the recovery period.
"At the same time, with cash you're not sure what they're going to do with it. You can give them cash and they go and buy sex or chang'aa (illegal brew) and that makes it worse than before," she said.
As a result, 72 men were circumcised and got their food vouchers - funded thanks to the Bill and Melinda Gates Foundation. About 9 percent of them had a food voucher worth $15, just over 6 percent had one worth $8.75 and the rest had vouchers worth either $2.50 or nothing at all.
Agot said the study was shared with Kenya's health ministry in the hope that officials would consider rolling out the scheme. She added that another study using a lottery system where the men didn't know what they might gain in exchange for being circumcised was underway.
She added that two sticking points might be cost and whether the participants in the study felt coerced into getting cut. Research done independently of her study, suggested they did not, she said.
"The median earnings for these people is $5 per day and if we wanted to compensate them for three days (for circumcision and recovery) we should have given them more than we gave - which means we are actually under-compensating … and they didn't think it was coercive," Agot said.
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