Lukobo MD, Bailey RC. Acceptability of male circumcision for prevention of HIV infection in Zambia. AIDS Care 2007 Apr;19(4):471-7.
- To assess knowledge, attitudes and beliefs about male circumcision (MC) to reduce HIV infection in a broad range of Zambian adult men and women;
- To assess Zambian men's and women's acceptance of male circumcision if introduced to local health facilities.
Qualitative research study using 34 focus group discussions (17 with men and 17 with women).
Four districts selected to represent urban and rural areas and a diversity of ethnic groups and circumcision practices. They include:
- Lusaka district (eight focus groups), including the capital city, which is an urban district with a mixture of peoples who do and do not practice circumcision;
- Zambezi (eight focus groups) in northwestern Zambia, which is predominantly rural and contains the Lunda and Luvale ethnic groups, who both practice traditional MC;
- Luanshya (10 focus groups) in north central Zambia, which is ethnically diverse and where MC is not normally practiced; and
- Monze (eight focus groups) in the Southern Province, home to the Tonga, who do not traditionally practice MC. The focus groups were conducted from August 1 to September 5, 2003.
Men and women ages 17-73 years were eligible. No consenting person within that age range was excluded. Participants were recruited with assistance from Health Surveillance Assistants (unpaid community peer health workers who reside in the community and know all its residents) in each district. Potential participants were approached at markets, bus stops, bars, and other public places, and asked to participate in a group discussion on MC. Groups were formed to represent different genders, age groups, and HIV risk profiles. The six types of groups and median ages were, among men: young single (24.1 years); barmen and young vendors (24.3 years); married adults (49.8 years); and among women: young single (23.9 years); sex workers and bar maids (29.8); married adults (44.6 years). There were approximately 320 participants in total.
Focus group discussions were organized around the following topical areas: history of MC practices; reasons to circumcise; reasons not to circumcise; preferred ages for circumcision; preferred circumcisers; genital hygiene; genital inspection and touching; and sexual pleasure and sexual function among circumcised versus uncircumcised men.
Nearly all of the participants in non-circumcising districts reported that they would take their sons to a health facility to be circumcised, if they were educated on the advantages and disadvantages of MC and they determined that there were benefits. Even in Zambezi, where traditional circumcisers do most circumcisions, the majority of participants expressed a preference for the procedure to be done by a medically trained person in a health facility. Another condition was that the procedure should be free or should not cost more than K10,000.00 ($2.50US). A number of themes arose for possible reasons to circumcise and not to circumcise. Reasons not to circumcise included cultural tradition, pain, and safety, as well as other barriers, such as cost and the concern that men would engage in more sex if they perceived themselves to be fully protected by circumcision. Reasons to circumcise included prevention of sexually transmitted infections (STIs), and hygiene, as well as other facilitators, such as MC being a religious requirement or social norm. The preferred age for circumcision was before puberty, because it is less painful and children would heal more quickly; MC as an adult was not desirable. Regardless of community, there was great emphasis on the experience of the circumciser and the use of sterile instruments. Most women had no preference for a circumcised or uncircumcised partner.
The authors conclude that in Zambia there is no antipathy toward MC and that there is widespread belief that circumcision reduces risk of acquisition of STI, including HIV. Nearly all the participants in non-circumcising districts expressed willingness to be circumcised or have their son circumcised, if the benefits of MC were clear and the procedure were offered at no or minimal cost.
There is no quality rating system for qualitative studies. A main limitation was that the study was conducted in only four of the 72 districts of Zambia, and so may not be generalizable to Zambia as a whole. The districts, however, were chosen to represent a range of circumcision practices and religious communities, as well as a variety of men and women in urban, peri-urban and rural areas. Moreover, participants were not selected randomly. Rather, convenience sampling was employed, using recruited participants.
Other studies of acceptability of MC in other regions of east and southern Africa where circumcision is not traditionally performed have had similar results to the current study. In western Kenya, Zimbabwe, South Africa, and Tanzania, approximately 45-70% of uncircumcised men reported that they would like to be circumcised or would seriously consider circumcision if it were proven to be effective in reducing STI.(1,2,3,4) Since this study was conducted, three clinical trials have shown that MC is 51-60% protective against HIV. (5,6,7)
The results of this and other studies suggest that MC will be adopted by a sufficient proportion of young men and boys in east and southern Africa and may have an impact on HIV prevalence in these communities. However, safety and management of adverse events must be addressed in the rollout of MC. Another concern is risk compensation or disinhibition that may occur if circumcised men believe they are fully protected from acquiring HIV. Promotion of MC should be done in the context of the full spectrum of HIV prevention tools. This study also suggests that interventions designed to improve circumcision services should not be restricted to areas where circumcision is rarely practiced currently, but should be extended to traditionally circumcising areas as well.
- Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T. Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya. AIDS Care 2005 Feb;17(2):182-94.
- Scott BE, Weiss HA, Viljoen JI. The acceptability of male circumcision as an HIV intervention among a rural Zulu population, Kwa-Zulu Natal, South Africa. AIDS Care. 2005 Apr;17(3):304-13..
- Halperin DT, Fritz K, McFarland W, Woelk G. Acceptability of adult male circumcision for sexually transmitted disease and HIV prevention in Zimbabwe. Sex Transm Dis. 2005 Apr;32(4):238-9. (No abstract available.)
- Nnko S, Washija R, Urassa M, Boerma JT. Dynamics of male circumcision practices in northwest Tanzania. Sex Transm Dis 2001 Apr;28(4):214-8.
- Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007 Feb 24;369(9562):643-56.
- Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007 Feb 24;369(9562):657-66.
- Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005 Nov;2(11):e298.