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randomised trials 15,16 assessed prevalence of sexual function available at 3-month post-VMMC. This may bias our
dysfunctional components (erectile dysfunction, ease of overall estimates of satisfaction and sexual function. We
ejaculation, etc.) up to 24 months post-VMMC and found a detected minimal baseline differences between men with and
decrease in dysfunction over time. In our programmatic without 3-month data available, and no characteristics were
evaluation, we asked participants to retrospectively report predictive of worsening sexual function. Men who did not
changes in sexual functioning, if any, at the 3-month follow- return for follow-up visits could potentially be more or less
up visit (as opposed to conducting a separate assessment of satisfied with their VMMC experience, which could bias our
sexual functioning at baseline). Men who were less satisfied results. We intentionally conducted an implementation
with the VMMC procedure were also more likely to report evaluation without intensive follow-up tracing to align with
worsening of sexual function. Men currently experiencing programmatic settings. The future evaluations could include
sexual dysfunction may be more likely to report that their more research procedures such as at-home follow-up tracing
status had worsened after VMMC because of recall bias. It is to collect data that are more complete.
also possible that men enrolled in our evaluation could
experience better sexual function at later time points. We also Conclusion
found modestly lower, although still very high, satisfaction
with the VMMC procedure at 3 months (84%), compared to To date, demand-creation messaging for VMMC in Botswana
7-day (90%) post-VMMC. To our knowledge, no other has primarily focussed on HIV prevention. However, as
programmatic evaluations amongst African men have VMMC uptake remains modest amongst Batswana men,
evaluated satisfaction with VMMC over time. The future there is a need to effectively promote VMMC to men at-risk
programmatic evaluations could identify areas for improving of HIV infection for whom protection against HIV may not
the VMMC procedure, counselling and follow-up care to be a motivator to undergo VMMC. Similar to prior studies
prevent potential negative effects on sexual function and from research settings in other African countries, our
satisfaction with the procedure. programmatic data show that the majority of the men report
improved sexual function across multiple categories and
Over a decade after initiation, uptake of VMMC in high overall satisfaction after VMMC. As VMMC continues
Botswana’s national programme remains modest. A recent to roll out in Botswana, incorporating evidence of other non-
10
systematic review from July 2019 by Ensor et al. has found HIV-related benefits of VMMC into demand-creation
that the most effective VMMC demand-creation interventions messaging may support maximising VMMC uptake.
are financial incentives and education or counselling
programmes delivered by community opinion leaders or Acknowledgements
27
individuals with personal experience of VMMC. To date, The authors are grateful to all the participants for their
no VMMC demand-creation intervention studies have been participation in the study.
conducted in Botswana and ongoing mass media campaigns
focus on protection against HIV associated with VMMC. The
future demand-creation messages in Botswana could be Competing interests
tailored to the values and preferences of the men at risk of The authors have declared that no competing interest exists.
HIV infection whilst extending beyond HIV prevention. 28,29
Integrating evidence for improved sexual function and Authors’ contributions
satisfaction following VMMC into mainstream messaging
could potentially motivate Batswana men, who may not All authors contributed equally to this work.
perceive their own HIV risk or for whom HIV prevention is
not a motivator for VMMC, to seek VMMC. Our evaluation Funding information
found high frequency of improved sexual function and
overall satisfaction with VMMC within programmatic This work was supported by the President’s Emergency Plan
settings, which could be helpful for framing the holistic for AIDS Relief (PEPFAR) through grant No. U91HA06801
benefits of VMMC in future messaging. from the US Department of Health and Human Services,
Health Resources and Services Administration (HRSA),
Our study has limitations. We only ascertained sexual function HIV/AIDS Bureau’s Global Health Systems Branch.
information at 3-month post-VMMC and retrospectively
asked men to compare aspects of sexual function with their Data availability statement
pre-VMMC experiences. This approach was intended to Data sharing is not applicable to this article as no new data
capture how VMMC impacts sexual function, although a were created or analysed in this study.
baseline assessment of sexual function would have improved
the rigour of our findings. Recall bias is possible with over-
reporting of worsening sexual function amongst dissatisfied Disclaimer
men or potentially choice-supportive bias of improved The views and opinions expressed in this article are those of
function to rationalise the decision to undergo VMMC. Not all the authors and do not necessarily reflect the official policy or
men returned for follow-up and/or had data on sexual position of any affiliated agency of the authors.

http://www.sajhivmed.org.za 144 Open Access