title: "Man, what took you so long?" Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania.
abstract: BACKGROUND
  In 2009, the Government of Tanzania embarked on scaling up voluntary medical male circumcision (VMMC) services for HIV prevention in 8 priority regions, with the aim of serving 2.8 million boys and men ages 10-34 years by 2013. By mid-2012, more than 110,000 boys and men in Iringa and Njombe regions had received VMMC. The majority (85%) of these VMMC clients were under 19 years old (average age, 16 years). This study aimed to identify potential barriers and facilitators to VMMC among older men.
  
  
  METHODS
  We conducted 16 focus group discussions, stratified by sex and age, with 142 purposefully selected participants in 3 districts of Iringa and Njombe regions.
  
  
  RESULTS
  Both men and women generally had positive attitudes toward VMMC. Social and personal barriers to obtaining VMMC among adult men included shame associated with seeking services co-located with younger boys and perceived inappropriateness of VMMC after puberty, particularly after marriage and after having children. Additional barriers included concerns about partner infidelity during the post-surgical abstinence period, loss of income, and fear of pain associated with post-surgical erections. Facilitators included awareness of the HIV-prevention benefit and perceptions of cleanliness and enhanced attractiveness to women.
  
  
  CONCLUSIONS
  While men and women in Iringa and Njombe regions in Tanzania generally view VMMC as a desirable procedure, program implementers need to address barriers to VMMC services among adult men. Selected service delivery sites in the Iringa and Njombe regions will be segregated by age to provide services that are "friendly" to adult men. Services will be complemented with behavior change communication initiatives to address concerns of older men, encourage women's support for circumcision and adherence to the post-surgical abstinence period, and change social norms that inhibit older men from seeking circumcision.
authors.affiliation: Jhpiego Tanzania, Dar es Salaam , Tanzania.
authors.forename: Marya
authors.initials: M
authors.lastname: Plotkin
authors.affiliation: U.S. Agency for International Development , Washington, DC , USA.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: Jhpiego Tanzania, Dar es Salaam , Tanzania.
authors.forename: Hawa
authors.initials: H
authors.lastname: Mziray
authors.affiliation: Department of Cultural Anthropology and Tourism, Tumaini University , Iringa , Tanzania.
authors.forename: Jan
authors.initials: J
authors.lastname: Küver
authors.affiliation: Regional Medical Office, Ministry of Health and Social Welfare , Iringa , Tanzania.
authors.forename: Ezekiel
authors.initials: E
authors.lastname: Mpuya
authors.affiliation: Department of Cultural Anthropology and Tourism, Tumaini University , Iringa , Tanzania.
authors.forename: Paul James
authors.initials: PJ
authors.lastname: Luvanda
authors.affiliation: Jhpiego Tanzania, Dar es Salaam , Tanzania.
authors.forename: Augustino
authors.initials: A
authors.lastname: Hellar
authors.affiliation: Jhpiego , Baltimore, Maryland , USA ; Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland , USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Curran
authors.affiliation: Jhpiego , Baltimore, Maryland , USA.
authors.forename: Mainza
authors.initials: M
authors.lastname: Lukobo-Durell
authors.affiliation: Jhpiego , Baltimore, Maryland , USA ; Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland , USA.
authors.forename: Tigistu Adamu
authors.initials: TA
authors.lastname: Ashengo
authors.affiliation: Jhpiego Tanzania, Dar es Salaam , Tanzania.
authors.forename: Hally
authors.initials: H
authors.lastname: Mahler