The Papuan Indigenous Model of Voluntary Medical Male Circumcision (VMMC)

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ABSTRACT The number of people living with HIV continues to climb in Indonesia, especially in the province of Tanah Papua where prevention efforts based on abstinence or safer sex have shown only modest success, and PreP is not government approved for use. Voluntary medical male circumcision (VMMC) as a one-time procedure has been shown through clinical trials to reduce the risk of heterosexually acquired HIV infection in men by approximately 60%. Currently VMMC is not offered in Tanah Papua, where unlike the rest of Indonesia, the great majority of men are uncircumcised. This research will develop, implement, and assess the feasibility, acceptability, and safety of the Papuan Indigenous Model (PIM) of VMMC as a comprehensive, culturally and age-appropriate HIV intervention for Papuan males ages 12-18. Circumcision offers partial life-time HIV protection and a valuable opportunity to engage adolescent males with the health care system while instilling HIV preventive behaviors. The study’s 4 aims: AIM 1: To engage Papuan community members to explore acceptability, barriers and facilitators for introducing a school-based age and culturally appropriate, comprehensive VMMC intervention to reduce HIV incidence in the Papuan population. AIM 2: To assess the capacity of the community health system to meet international criteria for safe comprehensive VMMC services and to ensure the availability of resources and training necessary to meet these criteria in selected clinics. AIM 3: To design the PIM of school-based adolescent VMMC based on information collected in Aims 1 and 2 and in consultation with a community advisory board, the Ministry of Health and the Ministry of Education. AIM 4: To pilot-test the school-based PIM Intervention of VMMC with 400 boys ages 12-18 years at two HIV high-risk Papuan locations: the Nabire and Jayapura. Data will be collected through focus groups, in-depth interviews with key community stakeholders and adolescents, brief questionnaires administered to adolescent males pre- and 6 weeks post-surgery, a random subsampling of 30 boys interviewed 12 weeks post device-removal to detect changes in levels of satisfaction, onset of sexual activity, and possible compensatory sexual risk taking. Parent interviews will gauge their satisfaction. Primary outcomes are the proportion of adolescent males exposed to school-based PIM VMMC educational and informational sessions who get circumcised and surgical event safety. Secondary outcomes are satisfaction by adolescent males and parents, any sexual activity within 6 weeks after circumcision, changes in sexual risk behaviors between base-line and 12 weeks after circumcision, and perceptions of providers regarding MC training and implementation, ease of device use, and challenges encountered. The impact of the research lies in having developed and rigorously pilot-tested a culturally-appropriate, and age-tailored model of VMMC services for adolescent males ages 12-18 in Papua, where other HIV prevention services have been difficult to implement and the epidemic is proving intractable.