Introduction of Voluntary Medical Male Circumcision for HIV Prevention in Tanah Papua, Indonesia

Tanah Papua, comprising Papua and West Papua (Papua Barat), includes only 1.5% of Indonesia's total population but accounts for over 15% of the country's new human immunodeficiency virus (HIV) cases. Overall, adult HIV prevalence in Indonesia in 2018 was 0.26%; in Papua it was nearly ten times higher at 2.3%, and almost all new infections occurred through heterosexual transmission. Being a predominantly Muslim country, male circumcision (MC) is nearly universal in Indonesia except in Papua where MC is little practiced. The Indonesian government has turned attention to World Health Organization/UNAIDS 2007 recommendations to offer voluntary medical male circumcision (VMMC) in Tanah Papua as part of a comprehensive package of HIV services. Currently, there are no functioning VMMC programs designed specifically for Papua or with input by Papuans. Using a community-participatory approach, we developed and pilot-tested the Papua Indigenous Model (PIM) of VMMC for acceptability, feasibility, and safety as part of a comprehensive HIV prevention strategy to reduce HIV sexual transmission in Papua. The model of VMMC was developed based on numerous meetings with government officials, health providers, teachers, students, parents, and community leaders. In total, 88 adults and 31 adolescents provided input during focused group discussions. Thirty-two meetings were held with approximately 1050 community members. Staff at three community health facilities were trained in safe VMMC services according to WHO guidelines. While all males ages 15 and above were eligible for VMMC, recruitment by trained peer outreach workers focused especially on Papuan ethnic males ages 15-19 years. Based on other VMMC programs and our consultations with community members, we expected to screen 400 potential participants, but ultimately only 104 participants volunteered to be screened at the three facilities. Of the 104, 94 participants were eligible and accepted circumcision. The average pain score reported by participants was low: 3.4 at 30 min post-circumcision. Two participants (2.1%) experienced a moderate adverse event (AE); no severe AE occurred. Upon follow-up, 98% said that they were somewhat or very satisfied with the procedure; 98% agreed that "If I had a son, I would get him circumcised;" and all but three participants reported that if they had it to do again, they would get circumcised. Despite extensive consultation with local communities, VMMC uptake was lower than anticipated, while levels of satisfaction among those circumcised were high. Even with substantial community input into its promotion, achieving a successful scale-up of VMMC in Papua will be highly challenging, requiring significant support from local, national, and international stakeholders. Nevertheless, it should be made available, integrated with the numerous other evidence-based HIV prevention measures.