# Barriers and enablers to the utilisation of prison-based voluntary medical male circumcision (VMMC) among incarcerated men: a qualitative study from Maula Prison, Malawi

## TL;DR

This study explores why incarcerated men in Malawi use or avoid prison-based HIV prevention surgery, finding that factors like peer support and prison conditions play a big role.

## Contribution

The study identifies multilevel barriers and enablers to VMMC use in prisons using a social ecological model.

## Key findings

- Enablers include peer motivation, hygiene improvements, and post-surgery exemptions from labor.
- Barriers include fear of pain, stigma, misinformation, and lack of healthcare resources.
- VMMC acceptance is high, but utilisation depends on individual, interpersonal, and organisational factors.

## Abstract

The prevalence of HIV in Malawi is 7.1% among the general population and 16% among men who are incarcerated, indicating a widespread epidemic. To enhance HIV prevention in the nation, the Ministry of Health has made efforts to offer voluntary medical male circumcision (VMMC) services in prisons as an intervention to strengthen HIV prevention in the country. However, little is known about the barriers and enablers to the utilisation of VMMC among men who are incarcerated.

This phenomenological qualitative study aimed to explore the experiences of men who were incarcerated while utilising prison-based VMMC services at Maula Prison in Lilongwe. Data were collected through interviews with 7 men who are incarcerated and 7 prison staff, resulting in a sample of 14 participants. A thematic content analysis approach was used to analyse data from both men who were incarcerated and prison staff, guided by the social ecological model, to identify individual, interpersonal, and organisational factors influencing VMMC utilisation.

Both enablers and barriers to VMMC utilisation were identified. Key enablers included improved hygiene, motivation from peers and prison staff, availability of peer educators in the prison, exemption from hard labour during recovery and the availability of VMMC services within the prison. Major barriers consisted of fear of post-operative pain and complications, stigma and mockery from peers, spread of misconceptions about VMMC, shortages of healthcare personnel, limited VMMC-specific training among healthcare workers, overcrowded prison cells, and inadequate post-operative support resources such as soap, water, and nutritious food.

The study concluded that while VMMC is generally acceptable among men who are incarcerated, utilisation is shaped by a combination of individual knowledge, interpersonal influences, and organisational conditions within the prison environment. Addressing these multilevel barriers is essential to enhancing VMMC utilisation among men who are incarcerated.