Acceptability

of

Male

Circumcision

for

Prevention

of

HIV/AIDS

in

Sub-Saharan

Africa

A

Review

Based

on

epidemiological

clinical

and

experimental

evidence

male

circumcision

-LRB-

MC

-RRB-

could

have

a

significant

impact

on

the

HIV

epidemic

in

selected

areas

We

reviewed

studies

of

the

acceptability

of

MC

in

sub-Saharan

Africa

to

assess

factors

that

will

influence

uptake

of

circumcision

in

traditionally

non-circumcising

populations

Thirteen

studies

from

nine

countries

were

identified

Across

studies

the

median

proportion

of

uncircumcised

men

willing

to

become

circumcised

was

-LRB-

range

-RRB-

Sixty

nine

percent

-LRB-

-RRB-

of

women

favored

circumcision

for

their

partners

and

-LRB-

-RRB-

of

men

and

-LRB-

-RRB-

of

women

were

willing

to

circumcise

their

sons

Because

the

level

of

acceptability

across

the

nine

countries

was

quite

consistent

additional

acceptability

studies

that

pose

hypothetical

questions

to

participants

are

unnecessary

We

recommend

pilot

interventions

making

safe

circumcision

services

available

in

conjunction

with

current

HIV

prevention

strategies

and

evaluating

the

safety

and

acceptability

of

circumcision

Introduction

Numerous

observational

studies

have

reported

a

significant

protective

effect

of

male

circumcision

-LRB-

MC

-RRB-

against

HIV

and

other

sexually

transmitted

infections

-LRB-

STIs

-RRB-

in

men

-LRB-

Bailey

Plummer

Moses

Cameron

et

al.

Gray

et

al.

Lavreys

et

al.

Siegfried

et

al.

Urassa

Todd

Boerma

Hayes

Isingo

Weiss

Quigley

Hayes

-RRB-

Recently

a

randomized

controlled

trial

-LRB-

RCT

-RRB-

of

MC

to

reduce

HIV

incidence

in

Orange

Farm

South

Africa

was

stopped

prematurely

due

to

an

observed

protective

effect

of

MC

of

in

intention

to

treat

analysis

and

in

a

per

protocol

analysis

This

effect

was

consistent

with

the

protective

effect

found

in

cohort

studies

-LRB-

Auvert

et

al.

-RRB-

Ecological

studies

have

shown

that

the

countries

in

sub-Saharan

Africa

with

the

highest

HIV

prevalence

are

those

in

which

MC

is

little

practiced

-LRB-

Halperin

Bailey

Moses

et

al.

-RRB-

Based

on

the

epidemiological

and

experimental

evidence

to

date

MC

could

have

a

significant

impact

on

the

HIV

epidemic

in

these

most

highly

affected

countries

However

the

effectiveness

of

the

intervention

will

depend

on

many

factors

not

the

least

of

which

is

the

extent

to

which

MC

is

accepted

and

taken

up

by

males

in

these

populations

If

sufficient

numbers

of

males

are

circumcised

there

could

be

an

effect

similar

to

herd

immunity

since

preventing

men

from

becoming

infected

will

also

protect

their

sex

partners

At

more

moderate

levels

of

uptake

the

effect

is

less

clear

In

addition

to

the

proportion

of

males

who

will

become

circumcised

the

age

at

circumcision

will

also

be

a

determinant

of

how

rapidly

the

intervention

results

in

reduction

of

HIV

prevalence

in

the

population

If

infant

circumcision

is

preferred

over

say

pubertal

circumcision

then

the

time

lag

from

introduction

of

a

large

scale

intervention

until

observable

reductions

in

HIV

prevalence

could

be

decades

Because

acceptance

of

MC

by

men

and

by

parents

of

males

in

traditionally

non-circumcising

communities

will

be

crucial

to

the

success

of

a

MC

intervention

for

reducing

HIV

prevalence

we

provide

a

review

of

the

extant

literature

on

acceptability

of

MC

in

sub-Saharan

Africa

Study

Collection

and

Search

Strategies

Criteria

for

inclusion

in

this

review

were

established

before

the

literature

searches

were

carried

out

and

included

studies

researching

acceptability

of

MC

as

an

HIV

prevention

method

formally

or

as

a

part

of

a

larger

study

conducted

in

sub-Saharan

Africa

and

published

in

a

peer-reviewed

journal

or

presented

at

an

international

conference

Electronic

searches

were

conducted

in

MEDLINE

using

the

following

strategy

term

circumcision

in

the

title

abstract

or

keywords

was

combined

with

acceptability

attitudes

or

beliefs

in

the

title

abstract

or

keywords

generating

articles

subset

by

HIV

or

STIs/STD

in

the

title

abstract

or

keywords

producing

articles

and

finally

limited

to

English

language

articles

published

from

through

resulting

in

publications

Electronic

search

conducted

in

Google

Scholar

using

phrase

acceptability

of

male

circumcision

in

Africa

as

HIV

prevention

resulted

in

publications

Nine

articles

were

directly

related

to

the

acceptability

of

circumcision

in

sub-Saharan

Africa

Four

additional

studies

were

identified

through

personal

communication

with

authors

A

map

of

study

sites

in

nine

countries

is

presented

in

Fig.

Key

characteristics

of

the

studies

included

in

this

review

are

shown

in

Table

Fig.

-LRB-

by

level

administrative

unit

-RRB-

where

male

circumcision

-LRB-

MC

-RRB-

acceptability

studies

were

conductedTable

of

male

circumcision

-LRB-

MC

-RRB-

acceptability

studies

-LRB-

N

-RRB-

of

the

studyStudy

populationEthnic

compositionCircumcision

status

of

participantsData

collection

methodsBotswana/Kebaabetswe

et

al.

-LRB-

-RRB-

Male

and

female

participants

age

in

urban

and

rural

settingsEthnically

heterogeneous

-LRB-

over

ethnicities

-RRB-

Both

circumcised

and

uncircumcised

men

Interviews

pre

and

post-educational

sessionKenya/Bailey

et

al.

-LRB-

-RRB-

of

Nyanza

Province

age

men

and

women

focus

groups

each

people

urban

and

rural

population

farmers

business

people

teachers

sex

workers

barmaids

and

touts.Ethnically

homogenous

-LRB-

Luo

-RRB-

Not

recorded

nearly

all

likely

uncircumcisedFocus

groups

interviews

with

healthcare

providersKenya/Bailey

-LRB-

Unpublished

report

to

AIDSMARK

-RRB-

Clinicians

were

interviewed

to

assess

their

knowledge

and

practice

of

MC

records

of

MC

performed

in

the

area

were

reviewed

circumcised

men

and

their

wives

were

interviewedEthnically

homogenous

-LRB-

Luo

-RRB-

Both

circumcised

and

uncircumcisedInterviews

KAB

questionnaires

record

reviewKenya/Mattson

et

al.

-LRB-

-RRB-

Men

and

women

years

of

age

and

older

of

Luo

ethnicity

in

urban

and

rural

settingsEthnically

homogenous

-LRB-

Luo

-RRB-

Both

circumcised

and

uncircumcised

menStructured

interviewsMalawi/Ngalande

et

al.

-LRB-

-RRB-

Participants

focus

groups

with

men

and

women

years

oldEthnically

diverse

-LRB-

Chewa

Tonga

Yao

Ngoni

Lomwe

and

Nyanja

-RRB-

Both

circumcised

and

uncircumcised

menFocus

groupsSouth

Africa/Lagarde

et

al.

-LRB-

-RRB-

Men

aged

years

and

women

aged

yearsEthically

heterogeneous

-LRB-

Sotho

Tswana

Xhosa

and

other

ethnicities

-RRB-

of

men

years

old

were

circumcisedInterviews

using

standardized

questionnaireSouth

Africa/Scott

et

al.

-LRB-

-RRB-

Adult

men

and

adult

women

in

rural

Zulu

land

and

service

providersEthnically

homogenous

-LRB-

Zulu

-RRB-

Both

circumcised

and

uncircumcised

menInterviews

focus

groupsSouth

Africa/Rain-Taljaard

et

al.

-LRB-

-RRB-

of

year

old

males

interviewed

in

August

and

year

old

males

interviewed

in

August

diverse

-LRB-

Sotho

Xhosa

Zulu

Tswana

Shangaan

and

Venda

-RRB-

of

men

years

old

were

circumcisedInterviews

and

focus

groupsSwaziland/Tsela

and

Halperin

-LRB-

-RRB-

Men

aged

were

interviewed

in

urban

and

rural

settingNot

reported

but

likely

majority

were

of

men

were

circumcisedInterviewsTanzania/Nnko

et

al.

-LRB-

-RRB-

Sukuma

men

from

a

cohort

of

factory

workers

in

Mwanza

town

focus

groups

from

mostly

rural

area

and

population

based

surveysEthnically

homogenous

-LRB-

Sukuma

-RRB-

of

men

in

the

sample

were

circumcisedInterviews

and

cohort

data

analysisUganda/Bailey

et

al.

-LRB-

-RRB-

Circumcised

and

uncircumcised

men

to

years

old

from

the

Industrial

Borough

Mbale

Ethnically

diverse

-LRB-

tribal

groups

including

Gisu

-RRB-

of

men

were

circumcisedStructured

interviewsZambia/Lukobo

and

Bailey

-LRB-

submitted

-RRB-

Men

and

women

in

the

focus

groups

in

rural

and

urban

settingsEthnically

diverse

-LRB-

Lunda

Luvale

Chewa

Tonga

-RRB-

Both

circumcised

and

uncircumcised

menFocus

groupsZimbabwe/Halperin

et

al.

-LRB-

-RRB-

Men

attending

beer

halls

in

HarareNot

reported

but

likely

majority

were

ShonaBoth

circumcised

and

uncircumcised

menInterviews

focus

group

Diversity

of

the

Study

Sample

All

studies

employed

some

variation

of

a

convenience

sample

Out

of

studies

reviewed

eight

were

designed

specifically

to

study

acceptability

of

MC

-LRB-

Bailey

Muga

Poulussen

Abicht

Kebaabetswe

et

al.

Lagarde

Dirk

Puren

Reathe

Bertran

Lukobo

Bailey

Submitted

Mattson

Bailey

Muga

Poulussen

Onyango

Ngalande

Levy

Kapondo

Bailey

Scott

Weiss

Viljoen

Tsela

Halperin

-RRB-

two

included

questions

on

MC

acceptability

in

the

context

of

a

larger

study

-LRB-

Bailey

Neema

Othieno

Halperin

Fritz

McFarland

Woelk

-RRB-

and

three

included

formal

MC

acceptability

data

collection

as

well

as

previously

collected

data

as

part

of

a

larger

scope

of

research

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Nnko

Washija

Urassa

Boerma

Rain-Taljaard

et

al.

-RRB-

Seven

of

the

studies

were

performed

in

largely

ethnically

homogenous

populations

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Bailey

et

al.

Halperin

et

al.

Mattson

et

al.

Nnko

et

al.

Scott

et

al.

Tsela

Halperin

-RRB-

while

the

remaining

studies

implemented

specific

strategies

to

ensure

an

ethnically

mixed

sample

-LRB-

Bailey

et

al.

Kebaabetswe

et

al.

Lagarde

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Rain-Taljaard

et

al.

-RRB-

Ten

of

studies

included

both

male

and

female

participants

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Bailey

et

al.

Kebaabetswe

et

al.

Lagarde

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

Nnko

et

al.

Rain-Taljaard

et

al.

Scott

et

al.

-RRB-

The

remaining

three

studies

were

restricted

to

males

-LRB-

Bailey

et

al.

Halperin

et

al.

Tsela

Halperin

-RRB-

Only

two

studies

addressed

acceptability

in

adolescent

populations

separately

from

adults

-LRB-

Nnko

et

al.

Rain-Taljaard

et

al.

-RRB-

Three

studies

purposely

included

the

participation

of

female

sex

workers

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

and

four

studies

included

the

opinions

of

MC

providers

in

the

assessment

of

circumcision

acceptability/promotion

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Bailey

et

al.

Rain-Taljaard

et

al.

Scott

et

al.

-RRB-

Nine

studies

included

both

rural

and

urban

populations

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Bailey

et

al.

Kebaabetswe

et

al.

Lagarde

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

Nnko

et

al.

Tsela

Halperin

-RRB-

one

study

limited

participation

to

rural

groups

only

-LRB-

Scott

et

al.

-RRB-

and

three

studies

were

restricted

to

urban

groups

-LRB-

Bailey

et

al.

Halperin

et

al.

Rain-Taljaard

et

al.

-RRB-

All

the

studies

were

conducted

in

areas

where

circumcision

is

not

traditionally

practiced

Two

purposely

also

included

at

least

one

area

where

most

men

are

circumcised

-LRB-

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Ten

studies

assessed

the

circumcision

status

of

male

participants

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Bailey

et

al.

Halperin

et

al.

Kebaabetswe

et

al.

Lagarde

et

al.

Mattson

et

al.

Nnko

et

al.

Rain-Taljaard

et

al.

Scott

et

al.

Tsela

Halperin

-RRB-

and

all

studies

allowed

participation

regardless

of

circumcision

status

Summary

of

Quantitative

Results

of

Acceptability

Eight

of

the

studies

reviewed

included

quantitative

assessments

of

the

acceptability

of

MC

in

six

countries

using

interview

questionnaires

Results

are

summarized

in

Fig.

and

Table

Four

of

the

eight

studies

included

women

respondents

Willingness

of

uncircumcised

men

to

become

circumcised

varied

from

in

Uganda

to

in

Swaziland

The

variation

depended

in

part

on

how

the

question

was

posed

and

the

context

of

the

study

For

example

one

of

the

highest

acceptability

levels

-LRB-

-RRB-

was

recorded

in

Botswana

after

an

informational

session

in

which

participants

were

told

about

the

health

benefits

and

risks

associated

with

the

procedure

-LRB-

Kebaabetswe

et

al.

-RRB-

In

some

studies

adults

were

asked

if

they

would

be

circumcised

or

prefer

their

partner

to

be

circumcised

if

MC

were

proven

to

be

protective

against

HIV

and

STIs

-LRB-

Halperin

et

al.

Lagarde

et

al.

Rain-Taljaard

et

al.

Tsela

Halperin

-RRB-

In

others

participants

were

asked

if

they

would

accept

MC

if

it

were

safe

and

affordable

-LRB-

Bailey

et

al.

Kebaabetswe

et

al.

Mattson

et

al.

Scott

et

al.

-RRB-

Fig.

of

male

circumcision

-LRB-

MC

-RRB-

acceptability

from

eight

quantitative

studies

in

six

sub-Saharan

African

countriesTable

preference

and

conditions

for

acceptability

reported

in

eight

studies

from

six

sub-Saharan

African

countriesAuthors/year/country

Of

uncircumcised

men

willing

to

be

circumcised

Of

women

favoring

circumcision

of

their

partners

Of

men

willing

to

circumcise

their

sons

Of

women

willing

to

circumcise

their

sonsKebaabetswe

et

al.

-LRB-

-RRB-

Before

and

after

information

session

if

procedure

is

done

in

safe

hospital

settings

and

is

Before

and

after

information

Before

and

after

information

session

if

procedure

is

done

in

safe

hospital

settings

and

is

free

Before

and

after

information

session

if

procedure

is

done

in

safe

hospital

settings

and

is

freeMattson

et

al.

-LRB-

-RRB-

If

procedure

involved

minimal

cost

and

little

If

procedure

was

safe

and

affordable

-LRB-

Bailey

Muga

Poulussen

-RRB-

If

little

pain

was

involvedLagarde

et

al.

-LRB-

-RRB-

South

If

MC

protected

from

Thought

most

women

preferred

circumcised

Of

non-circumcised

men

and

of

circumcised

men

if

MC

protected

from

If

MC

protected

from

STIs/HIVScott

et

al.

-LRB-

-RRB-

South

If

performed

safely

and

at

low

Rain-Taljaard

et

al.

-LRB-

-RRB-

South

If

MC

reduced

chances

of

STIs

and

HIVN/aN/aN

aTsela

and

Halperin

-LRB-

-RRB-

If

MC

protected

against

N/aBailey

et

al.

-LRB-

-RRB-

If

cost

was

minimalN/aN/aN

aHalperin

et

al.

-LRB-

-RRB-

If

MC

protected

against

HIV/STIs

and

was

safe

and

affordableN/aN/aN

a

In

general

approximately

the

same

proportion

of

women

would

prefer

circumcision

for

their

partners

or

their

sons

as

men

would

prefer

circumcision

for

themselves

or

their

sons

In

Botswana

Kenya

South

Africa

and

Swaziland

where

men

or

women

were

asked

about

circumcision

for

their

sons

more

adults

would

agree

to

the

procedure

for

their

child

than

for

their

spouse

or

themselves

Approximately

of

parents

would

seek

circumcision

for

their

son

if

it

was

safe

affordable

and

shown

to

be

protective

against

HIV

and

STIs

Across

studies

the

median

proportion

of

uncircumcised

men

willing

to

become

circumcised

was

-LRB-

range

-RRB-

Sixty

nine

percent

-LRB-

range

-RRB-

of

women

favored

circumcision

for

their

partners

and

-LRB-

-RRB-

of

men

and

-LRB-

-RRB-

of

women

were

willing

to

circumcise

their

sons

The

study

restricted

to

rural

population

found

that

of

men

were

willing

to

become

circumcised

while

median

proportion

in

the

same

category

was

-LRB-

range

-RRB-

in

three

urban

studies

and

-LRB-

-RRB-

in

studies

that

included

both

rural

and

urban

population

Barriers

to

the

Acceptability

of

MC

Pain

Apprehension

about

pain

during

and

after

the

procedure

was

reported

to

be

the

major

barrier

to

MC

acceptability

in

most

studies

-LRB-

Bailey

et

al.

Kebaabetswe

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

Scott

et

al.

-RRB-

Participants

belonging

to

non-circumcising

ethnic

groups

were

familiar

with

the

circumcision

practices

in

neighboring

circumcising

tribes

where

pain

was

a

key

characteristic

of

the

procedure

As

a

rite

of

passage

to

becoming

a

man

the

endurance

of

the

pain

from

circumcision

is

often

an

integral

aspect

of

the

ceremony

For

example

of

circumcised

participants

in

South

Africa

described

the

traditional

procedure

as

very

painful

as

mildly

painful

and

as

not

painful

-LRB-

Lagarde

et

al.

-RRB-

Culture

and

Religion

Lack

of

circumcision

was

mentioned

as

an

element

of

the

ethnic

identity

of

those

who

do

not

circumcise

traditionally

However

remaining

with

one

's

foreskin

is

not

considered

crucial

to

one

's

own

ethnic

identity

It

serves

as

an

ethnic

marker

primarily

used

by

others

In

both

Botswana

and

Swaziland

studies

only

of

participants

for

example

felt

that

circumcision

would

lead

to

disapproval

by

their

community

-LRB-

Kebaabetswe

et

al.

Tsela

Halperin

-RRB-

although

in

Botswana

cited

cultural

reasons

as

a

factor

in

their

decision

not

to

circumcise

their

male

child

-LRB-

Kebaabetswe

et

al.

-RRB-

It

is

fundamentally

different

from

belonging

to

an

ethnic

group

that

does

practice

traditional

circumcision

For

the

Yao

in

Malawi

for

example

or

the

Lunda

and

Luvale

tribes

in

Zambia

or

the

Bagisu

in

Uganda

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Nnko

et

al.

-RRB-

it

is

unacceptable

to

remain

uncircumcised

to

the

extent

that

forced

circumcisions

of

older

boys

are

not

uncommon

In

some

ethnic

groups

in

which

circumcision

is

not

commonly

practiced

disapproval

of

circumcision

is

evident

in

the

existence

of

a

derogatory

term

for

a

circumcised

man

or

a

man

with

a

congenitally

shortened

prepuce

These

terms

include

rayuom

in

DhoLuo

-LRB-

Bailey

et

al.

-RRB-

and

njilwa

in

the

Sukuma

language

-LRB-

Nnko

et

al.

-RRB-

In

ethnically

homogenous

areas

circumcision

could

lead

to

rejection

by

local

women

and

serve

as

a

barrier

to

marriage

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

-RRB-

In

more

ethnically

diverse

areas

however

circumcision

among

traditionally

non-circumcising

peoples

could

be

held

as

a

positive

increasing

a

man

's

chances

of

being

accepted

by

the

women

of

the

surrounding

circumcising

groups

Religion

is

a

major

determinant

of

circumcision

acceptability

MC

is

universally

associated

with

Islam

It

is

also

considered

fundamental

to

some

minority

Christian

and

animist

sects

There

was

no

clear

consensus

on

compatibility

of

MC

with

Christian

beliefs

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Nnko

et

al.

Rain-Taljaard

et

al.

Scott

et

al.

-RRB-

Great

variability

in

perceptions

of

Christian

churches

positions

on

MC

was

described

by

different

study

populations

ranging

from

condemning

MC

as

a

pagan

practice

-LRB-

Rain-Taljaard

et

al.

-RRB-

to

viewing

MC

as

consistent

with

Christian

tradition

according

to

the

Bible

and

Jesus

circumcision

status

-LRB-

Lukobo

Bailey

Submitted

-RRB-

In

South

Africa

of

circumcised

and

of

uncircumcised

study

participants

described

circumcision

as

forbidden

by

their

religion

-LRB-

Lagarde

et

al.

-RRB-

Sukuma

study

participants

in

Tanzania

felt

that

the

Christian

religion

did

not

theologically

promote

MC

while

circumcision

services

were

known

to

be

available

in

church-run

hospitals

-LRB-

Nnko

et

al.

-RRB-

Lukobo

and

Bailey

describe

the

prevalent

Zambian

perception

of

circumcision

being

linked

with

Muslim

or

animist

Chawa

heritage

with

several

participants

also

reporting

the

belief

that

Christians

should

practice

MC

since

Jesus

was

circumcised

and

the

Bible

teaches

the

practice

-LRB-

Lukobo

Bailey

Submitted

-RRB-

Similar

findings

were

reported

by

Ngalande

et

al.

in

Malawi

-LRB-

Ngalande

et

al.

-RRB-

In

Kenya

the

Nomiya

Church

and

a

few

other

small

Christian

sects

require

circumcision

for

church

membership

-LRB-

Mattson

et

al.

-RRB-

Rain-Taljaard

and

colleagues

report

the

South

African

belief

that

circumcision

is

fundamentally

an

African

tradition

and

that

Western

ideas

concerning

the

practice

should

not

be

taken

seriously

Further

participants

stated

that

many

Christian

churches

opposed

circumcision

as

a

pagan

tradition

-LRB-

Rain-Taljaard

et

al.

-RRB-

However

it

was

unclear

whether

this

opposition

was

directed

at

circumcision

itself

or

at

rites

and

ceremonies

with

which

it

was

associated

Before

MC

is

promoted

in

a

country

it

would

be

prudent

to

consult

and

collaborate

with

religious

leaders

to

learn

the

stance

of

the

various

churches

regarding

MC

In

many

cases

churches

can

act

as

helpful

advocates

or

obstructive

opponents

and

may

have

significant

influence

on

acceptability

of

MC

Cost

The

cost

of

the

procedure

was

a

significant

barrier

to

MC

acceptability

by

participants

in

many

studies

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Bailey

et

al.

Lagarde

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

-RRB-

Some

participants

expressed

the

opinion

that

if

circumcision

were

promoted

by

the

government

it

should

be

provided

at

health

clinics

and

hospitals

for

free

or

at

reduced

cost

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Others

recognized

the

need

to

pay

for

services

because

a

free

circumcision

was

viewed

as

being

of

potentially

poor

quality

-LRB-

Ngalande

et

al.

-RRB-

Male

and

female

participants

in

Zambia

believed

that

if

the

MC

procedure

were

free

or

extremely

inexpensive

more

men

would

be

willing

to

get

circumcised

-LRB-

Lukobo

Bailey

Submitted

-RRB-

In

one

study

as

many

as

of

participants

who

initially

stated

that

their

preference

was

to

remain

uncircumcised

changed

their

minds

when

the

proposed

cost

of

the

procedure

was

set

at

US$

-LRB-

Mattson

et

al.

-RRB-

Cost

of

traditional

circumcision

was

considered

to

be

high

in

many

areas

and

there

is

a

gradual

shift

from

traditional

to

medical

circumcision

in

part

for

this

reason

-LRB-

Bailey

Egesah

Lukobo

Bailey

Submitted

Ngalande

et

al.

Rain-Taljaard

et

al.

-RRB-

Traditional

circumcision

is

often

expensive

due

to

the

costs

of

food

drink

special

clothing

and

other

items

required

during

a

sometimes

prolonged

celebration

Complications

and

Adverse

Effects

If

men

and

parents

believe

that

circumcision

leads

to

high

rates

of

complications

then

uptake

of

MC

is

likely

to

be

slow

Concerns

for

safety

were

universal

in

the

studies

examined

Mothers

were

vocal

in

their

concerns

especially

in

cases

of

infant

and

early

childhood

circumcision

Excessive

bleeding

was

a

major

concern

and

this

fear

was

heightened

if

the

procedure

was

to

be

performed

by

a

traditional

circumciser

outside

the

hospital

setting

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Infection

and

difficulty

in

healing

were

expressed

as

concerns

as

well

but

were

generally

believed

to

be

minimized

in

clinical

settings

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Using

the

same

knife

for

several

boys

was

believed

to

be

common

in

traditional

settings

and

a

source

of

infections

including

HIV

-LRB-

Bailey

et

al.

Halperin

et

al.

Lagarde

et

al.

Ngalande

et

al.

Rain-Taljaard

et

al.

-RRB-

Women

were

especially

opposed

to

circumcision

at

the

traditional

initiation

schools

as

they

feared

that

their

children

may

be

injured

or

die

during

the

process

-LRB-

Rain-Taljaard

et

al.

-RRB-

Overall

there

seemed

to

be

a

great

deal

of

trust

in

medical

practitioners

and

a

strong

preference

for

circumcision

services

to

be

made

available

in

public

health

facilities

by

trained

health

professionals

Potential

for

Behavioral

Disinhibition

If

men

and

their

partners

believe

that

circumcision

offers

protection

from

HIV

infection

they

may

be

less

inhibited

-LRB-

disinhibited

-RRB-

in

their

sexual

activities

and

engage

in

higher

HIV

risk

behaviors

thereby

mitigating

a

partially

protective

effect

of

MC

Fortunately

the

perception

that

MC

provides

full

protection

against

HIV

and

STIs

was

found

to

be

generally

rare

but

it

was

expressed

by

a

few

study

participants

in

South

Africa

and

in

Nyanza

Province

Kenya

-LRB-

Bailey

et

al.

Rain-Taljaard

et

al.

-RRB-

In

focus

groups

in

Kenya

Malawi

and

Zambia

a

concern

about

the

possibility

of

behavioral

disinhibition

was

inevitably

expressed

Most

participants

did

seem

to

appreciate

the

concept

of

risk

reduction

opposed

to

risk

elimination

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Similarly

in

Swaziland

of

study

participants

advocated

having

only

one

partner

and

promoted

condom

use

for

circumcised

men

-LRB-

Tsela

Halperin

-RRB-

There

is

some

evidence

of

behavioral

disinhibition

among

circumcised

men

A

study

in

South

Africa

found

a

significant

association

between

circumcision

status

and

the

higher

reported

number

of

non-spousal

lifetime

partners

-LRB-

Lagarde

et

al.

-RRB-

Circumcised

men

in

Uganda

were

found

to

engage

in

more

HIV

risk

behaviors

than

uncircumcised

men

-LRB-

Bailey

et

al.

-RRB-

In

addition

to

reporting

more

extramarital

partners

in

the

previous

year

-LRB-

vs.

P

-RRB-

circumcised

men

had

an

overall

higher

risk

profile

A

few

respondents

in

another

South

African

study

expressed

the

belief

that

MC

potentially

encouraged

adultery

as

newly

circumcised

men

were

curious

to

test

the

new

shape

of

the

penis

-LRB-

Rain-Taljaard

et

al.

-RRB-

One

study

in

Botswana

found

that

participants

felt

that

circumcision

before

the

age

of

six

years

may

help

to

avoid

a

change

in

sexual

behavior

associated

with

sense

of

increased

protection

due

to

circumcision

-LRB-

Kebaabetswe

et

al.

-RRB-

Men

attending

beer

halls

in

Harare

Zimbabwe

were

aware

of

the

partial

protection

against

HIV

provided

by

MC

and

had

a

good

understanding

of

the

limitations

and

the

concept

of

risk

reduction

-LRB-

Halperin

et

al.

-RRB-

Other

Reasons

Not

to

Circumcise

Other

barriers

to

circumcision

mentioned

by

participants

were

lack

of

access

to

health

care

required

time

away

from

work

the

loss

of

penile

sensitivity

reduction

in

penis

size

decreased

ability

to

satisfy

women

excessive

sexual

desire

increased

promiscuity

-LRB-

Bailey

et

al.

Rain-Taljaard

et

al.

-RRB-

and

the

perception

of

circumcision

as

old-fashioned

-LRB-

Lagarde

et

al.

Rain-Taljaard

et

al.

-RRB-

Facilitators

of

MC

Acceptability

Hygiene

Penile

hygiene

was

universally

recognized

as

being

extremely

important

and

was

viewed

as

a

major

benefit

of

circumcision

-LRB-

Bailey

et

al.

Halperin

et

al.

Kebaabetswe

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

Nnko

et

al.

-RRB-

A

great

majority

of

participants

both

male

and

female

from

multiple

studies

agreed

that

it

was

much

easier

for

a

circumcised

man

to

maintain

cleanliness

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

Nnko

et

al.

Rain-Taljaard

et

al.

-RRB-

The

majority

of

participants

including

women

believed

that

it

was

worrisome

that

men

do

not

maintain

proper

hygiene

Because

women

were

the

primary

providers

of

water

poor

penile

hygiene

was

often

seen

as

a

woman

's

failing

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

-RRB-

In

both

Zambia

and

Malawi

women

were

considered

responsible

for

cleaning

their

partners

penises

after

sexual

intercourse

Additionally

women

in

these

populations

linked

their

own

risk

of

STIs

to

their

partners

genital

hygiene

-LRB-

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Ease

of

maintaining

proper

penile

hygiene

proved

a

major

factor

in

women

's

acceptability

of

circumcision

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

-RRB-

Protection

from

STIs

and

HIV

Hygiene

as

a

mechanism

of

protection

from

STIs

was

mentioned

by

a

great

number

of

participants

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

It

was

held

that

germs

dirt

bacteria

and

viruses

had

a

greater

opportunity

to

proliferate

in

the

warm

moist

environment

beneath

the

foreskin

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Nnko

et

al.

Rain-Taljaard

et

al.

-RRB-

Participants

also

expressed

a

belief

that

it

would

be

easier

to

detect

rashes

and/or

ulcerations

with

the

foreskin

removed

allowing

for

earlier

treatment

-LRB-

Bailey

et

al.

Ngalande

et

al.

-RRB-

The

foreskin

was

also

perceived

as

a

portal

of

entry

for

sexually

transmitted

infection

as

the

tissue

is

considered

prone

to

traumatic

injury

during

sexual

intercourse

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Rain-Taljaard

et

al.

-RRB-

MC

was

recognized

as

a

medical

procedure

to

reduce

or

eliminate

penile

ulcerations

and

diseases

of

the

penis

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Nnko

et

al.

-RRB-

Conversely

a

minority

of

respondents

in

Zambia

reported

that

the

circumcised

penis

was

always

dry

susceptible

to

cracking

and

that

this

state

provided

a

portal

of

entry

for

bacteria

and

viruses

-LRB-

Lukobo

Bailey

Submitted

-RRB-

Seventy

percent

of

Botswana

study

participants

willing

to

circumcise

their

male

child

listed

protection

from

STIs

or

HIV

among

their

reasons

for

doing

so

-LRB-

Kebaabetswe

et

al.

-RRB-

In

Nyanza

Province

Kenya

of

uncircumcised

men

and

of

women

believed

that

it

was

easier

for

uncircumcised

men

to

acquire

STIs

compared

to

circumcised

men

This

belief

dropped

to

and

respectively

concerning

the

acquisition

of

AIDS

-LRB-

Mattson

et

al.

-RRB-

In

Swaziland

of

participants

stated

that

MC

reduced

risk

of

STIs

and

believed

that

MC

reduced

risk

of

HIV

-LRB-

Tsela

Halperin

-RRB-

In

Tanzania

STIs

were

considered

more

severe

and

more

infective

in

uncircumcised

men

with

ulcers

healing

faster

in

those

who

are

circumcised

-LRB-

Nnko

et

al.

-RRB-

Nearly

all

commercial

sex

workers

believed

that

there

exists

a

strong

association

between

lack

of

circumcision

and

STIs

including

HIV

-LRB-

Ngalande

et

al.

-RRB-

In

South

Africa

-LRB-

Scott

et

al.

-RRB-

no

association

was

found

between

willingness

to

be

circumcised

and

perceived

health

benefits

It

was

belief

about

sexual

pleasure

that

was

the

strongest

predictor

of

being

willing

to

undergo

circumcision

Acceptability

by

Other

Ethnic

Groups

Common

reasons

given

for

favoring

MC

were

the

social

political

and

sexual

benefits

that

could

accrue

when

interacting

with

those

in

predominantly

circumcising

groups

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

The

Luo

believed

that

they

were

often

discriminated

against

by

other

Kenyans

due

to

their

circumcision

status

which

led

to

political

exclusion

and

even

security

concerns

in

times

of

social

upheaval

-LRB-

Bailey

et

al.

-RRB-

Many

younger

men

from

traditionally

non-circumcising

groups

cited

being

accepted

as

a

sexual

or

marriage

partner

by

women

from

other

ethnic

groups

as

an

important

reason

to

be

circumcised

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Nnko

et

al.

-RRB-

Sexual

Pleasure

Among

Circumcised

versus

Uncircumcised

How

circumcision

is

perceived

to

influence

sexual

drive

sexual

performance

and

sexual

pleasure

for

the

man

himself

or

for

his

partner

is

likely

to

influence

decision

making

around

MC

Participants

in

many

studies

believed

that

circumcision

enhances

sexual

pleasure

-LRB-

Bailey

Unpublished

Bailey

et

al.

Lagarde

et

al.

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

Nnko

et

al.

Rain-Taljaard

et

al.

-RRB-

Most

studies

assessed

three

factors

associated

with

sexual

activity

based

on

circumcision

status

sexual

performance

sexual

pleasure

for

men

and

sexual

pleasure

for

women

Fifty

percent

of

circumcised

and

of

uncircumcised

participants

in

South

Africa

believed

that

MC

increased

sexual

performance

while

only

and

respectively

believed

that

MC

decreased

sexual

pleasure

-LRB-

Lagarde

et

al.

-RRB-

Other

studies

found

that

a

high

proportion

of

men

and

a

majority

of

women

believed

that

circumcised

men

enjoyed

sex

more

than

uncircumcised

men

-LRB-

Mattson

et

al.

Rain-Taljaard

et

al.

-RRB-

About

half

of

female

participants

reported

preference

for

circumcised

men

-LRB-

Lagarde

et

al.

Mattson

et

al.

-RRB-

Many

had

no

preference

A

study

in

South

Africa

found

that

men

were

times

more

likely

to

prefer

circumcision

if

they

believed

that

circumcised

men

enjoyed

sex

more

and

times

more

likely

to

prefer

circumcision

if

they

believed

that

women

enjoy

sex

more

with

circumcised

men

-LRB-

Scott

et

al.

-RRB-

Other

studies

did

not

find

a

consensus

about

circumcision

status

and

sexual

pleasure

on

the

part

of

the

man

or

the

woman

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

For

some

circumcision

was

irrelevant

to

pleasure

as

pleasure

was

more

related

to

emotional

attachment

and

past

sexual

experience

-LRB-

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Attitudes

about

circumcision

and

pleasure

may

be

different

in

areas

where

dry

sex

is

practiced

-LRB-

Lukobo

Bailey

Submitted

-RRB-

Other

Reasons

to

Circumcise

Other

reasons

to

be

circumcised

reported

by

participants

included

the

belief

that

it

was

easier

for

circumcised

men

to

use

condoms

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

Bailey

et

al.

Kebaabetswe

et

al.

-RRB-

that

MC

proved

manhood

that

aim

during

urination

was

improved

and

that

not

being

circumcised

brought

bad

luck

-LRB-

Rain-Taljaard

et

al.

-RRB-

Time

and

Setting

of

Circumcision

Procedure

Preferred

Age

at

Circumcision

The

ages

at

which

males

become

circumcised

will

have

an

effect

on

how

rapidly

MC

interventions

may

impact

the

HIV

epidemic

in

any

given

area

Preferred

age

at

circumcision

varied

both

between

and

within

studies

There

appeared

to

be

two

leading

directions

exhibited

by

many

studies

either

circumcise

males

as

babies

due

to

a

simpler

procedure

less

fear

easier

care

and

faster

healing

or

circumcise

males

around

puberty

and

adolescence

when

boys

can

decide

and

take

care

of

the

wound

for

themselves

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Rain-Taljaard

et

al.

Scott

et

al.

-RRB-

Among

the

nine

countries

where

acceptability

studies

have

been

undertaken

only

in

Botswana

were

most

participants

in

favor

of

circumcision

in

infancy

and

early

childhood

Fifty-five

percent

of

respondents

were

in

favor

of

circumcising

children

under

years

old

with

half

of

those

preferring

neonatal

circumcision

-LRB-

Kebaabetswe

et

al.

-RRB-

In

all

other

areas

a

significant

minority

were

in

favor

of

infant

or

early

childhood

MC

but

most

favored

circumcision

between

ages

years

with

very

few

saying

that

over

years

was

best

Those

who

advocated

for

infant

circumcision

did

so

for

reasons

relating

to

decreased

pain

during

the

procedure

and

faster

healing

times

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

-RRB-

although

babies

under

year

of

age

were

thought

to

experience

excessive

pain

leading

to

crying

and

fevers

-LRB-

Lukobo

Bailey

Submitted

-RRB-

Participants

from

Malawi

viewed

infants

especially

vulnerable

to

potential

complications

of

MC

due

to

lack

of

maturity

and

difficulty

of

timely

detection

of

bleeding

due

to

babies

being

carried

on

the

mothers

backs

-LRB-

Ngalande

et

al.

-RRB-

Many

studies

reported

strong

beliefs

among

participants

that

circumcision

should

take

place

before

the

onset

of

sexual

activity

-LRB-

Lukobo

Bailey

Submitted

Ngalande

et

al.

Rain-Taljaard

et

al.

-RRB-

Ages

years

were

thought

to

be

best

since

the

boy

could

make

the

decision

for

himself

understand

the

significance

of

the

event

take

care

of

the

wound

himself

heal

faster

than

if

done

post-pubertally

and

has

likely

not

begun

sexual

activity

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

Rain-Taljaard

et

al.

-RRB-

Circumcision

as

an

adult

or

post-pubertally

was

reported

by

many

to

be

undesirable

due

to

higher

risk

of

complications

pain

during

the

procedure

-LRB-

Ngalande

et

al.

Rain-Taljaard

et

al.

-RRB-

and

painful

erections

after

MC

leading

to

complications

and

delays

in

healing

-LRB-

Bailey

et

al.

Lukobo

Bailey

Submitted

Ngalande

et

al.

-RRB-

Many

people

from

traditionally

non-circumcising

communities

felt

that

they

had

insufficient

knowledge

to

make

a

decision

about

when

best

to

circumcise

They

preferred

to

consult

clinical

professionals

to

get

their

advice

-LRB-

Bailey

et

al.

Ngalande

et

al.

-RRB-

Practitioners

interviewed

in

Kenya

and

Malawi

preferred

not

to

perform

neonatal

circumcision

due

to

the

small

size

of

the

penis

and

foreskin

potentially

leading

to

higher

rates

of

errors

and

complications

These

providers

preferred

to

perform

the

operation

at

ages

years

-LRB-

Bailey

et

al.

-RRB-

Preferred

Circumcisers

In

areas

where

traditional

circumcision

is

uncommon

the

preference

is

overwhelmingly

for

a

medical

practitioner

to

be

the

provider

All

studies

reported

fear

of

infection

bleeding

excessive

pain

and

possible

mutilation

at

the

hands

of

traditional

circumcisers

-LRB-

Kebaabetswe

et

al.

Lagarde

et

al.

Lukobo

Bailey

Submitted

-RRB-

In

Zambia

-LRB-

Lukobo

Bailey

Submitted

-RRB-

even

in

the

traditionally

circumcising

area

of

Zambezi

District

the

majority

believed

medical

doctors

to

be

experienced

more

apt

to

use

sterile

equipment

able

to

minimize

pain

through

anesthesia

and

capable

of

dealing

with

complications

The

few

participants

who

preferred

traditional

surgeons

viewed

these

practitioners

as

more

experienced

and

more

willing

to

maintain

confidentiality

-LRB-

Lukobo

Bailey

Submitted

-RRB-

Scott

et

al.

found

that

of

male

Zulu

preferred

MC

by

a

doctor

or

medical

surgeon

by

a

nurse

by

traditional

circumciser

and

by

other

providers

-LRB-

Scott

et

al.

-RRB-

Another

study

based

in

South

Africa

observed

that

MC

was

commonly

performed

in

both

initiation

schools

and

by

clinical

providers

The

more

common

circumcision

was

in

an

ethnic

group

the

less

likely

it

was

done

in

medical

settings

-LRB-

Rain-Taljaard

et

al.

-RRB-

Acceptability

in

Certain

Populations

Women

's

Beliefs

and

their

Influence

The

influence

of

women

on

the

decision

to

circumcise

is

likely

to

be

highly

variable

across

cultures

and

across

families

within

communities

However

in

many

settings

women

as

mothers

and

as

partners

are

likely

to

have

considerable

influence

even

if

it

is

not

overt

Any

effort

to

promote

MC

will

be

more

successful

if

it

appeals

to

women

as

well

as

men

Bailey

et

al.

-LRB-

-RRB-

found

that

women

's

beliefs

may

have

a

strong

influence

on

male

acceptability

of

circumcision

in

western

Kenya

This

influence

may

stem

from

women

's

strong

emphasis

on

penile

hygiene

for

their

partners

and

the

wish

to

protect

their

young

sons

from

acquisition

of

infections

as

they

become

sexually

active

Scott

et

al.

-LRB-

-RRB-

on

the

other

hand

suggested

that

in

South

Africa

women

are

likely

to

have

only

an

indirect

influence

through

the

male

perception

that

women

enjoy

sex

more

with

circumcised

men

A

different

study

from

South

Africa

found

that

women

had

a

strong

influence

on

men

's

decision

to

circumcise

often

scheduling

the

appointment

for

their

boyfriends

or

husbands

Single

mothers

however

were

believed

to

have

no

influence

over

their

teenage

sons

decisions

to

circumcise

-LRB-

Rain-Taljaard

et

al.

-RRB-

Thirteen

percent

of

circumcised

participants

in

yet

another

South

African

study

-LRB-

Lagarde

et

al.

-RRB-

reported

undergoing

circumcision

because

their

partner

expressly

requested

it

Acceptability

in

Youth

Two

out

of

thirteen

studies

assessed

acceptability

of

MC

among

adolescents

In

Tanzania

school

aged

boys

and

girls

believed

that

it

was

easier

for

an

uncircumcised

man

to

acquire

STIs

that

it

was

easier

for

a

circumcised

man

to

maintain

proper

genital

hygiene

and

that

circumcision

enhanced

sexual

pleasure

for

both

partners

-LRB-

Nnko

et

al.

-RRB-

As

in

most

areas

adolescent

boys

linked

circumcision

with

modernity

and

good

hygiene

Overall

adolescent

males

and

females

proved

to

be

knowledgeable

about

potential

benefits

of

MC

-LRB-

Nnko

et

al.

Rain-Taljaard

et

al.

-RRB-

Nnko

et

al.

-LRB-

-RRB-

observed

that

knowledge

and

a

positive

attitude

about

MC

became

most

obvious

in

secondary

schools

due

to

the

effects

of

increased

ethnic

mixing

Many

studies

found

that

younger

participants

were

more

likely

to

view

circumcision

favorably

than

their

elders

-LRB-

Lukobo

Bailey

Submitted

Mattson

et

al.

Ngalande

et

al.

Nnko

et

al.

-RRB-

In

Botswana

only

of

men

ages

years

were

willing

to

be

circumcised

compared

to

of

year-olds

-LRB-

Kebaabetswe

et

al.

-RRB-

In

Kenya

younger

men

were

more

likely

to

accept

circumcision

Among

those

years

old

said

that

they

would

prefer

to

be

circumcised

whereas

only

of

those

over

years

preferred

to

be

circumcised

-LRB-

Bailey

-RRB-

Results

from

more

qualitative

studies

entailing

focus

group

discussions

were

consistent

with

these

quantitative

results

Younger

men

in

Zambia

Malawi

and

Tanzania

were

more

likely

to

express

a

desire

to

be

circumcised

-LRB-

Lukobo

Bailey

Submitted

Ngalande

et

al.

Nnko

et

al.

-RRB-

Hypothetical

versus

Actual

Acceptability

Asking

people

whether

they

might

prefer

to

be

circumcised

under

various

hypothetical

scenarios

-LRB-

e.g.

if

it

is

found

to

reduce

risk

of

HIV

acquisition

or

if

it

is

at

minimal

cost

and

safe

-RRB-

is

one

means

of

assessing

acceptability

A

more

realistic

means

is

to

discover

where

MC

services

are

available

and

see

who

takes

advantage

of

the

services

Alternatively

one

can

offer

the

services

in

non-circumcising

communities

and

see

the

response

This

approach

permits

assessment

of

not

just

numbers

seeking

the

services

but

also

the

ages

and

population

segments

that

respond

as

well

as

factors

that

inhibit

or

facilitate

uptake

of

the

services

A

trial

intervention

in

Siaya

District

Kenya

an

area

where

circumcision

is

not

traditionally

practiced

was

introduced

in

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

-RRB-

During

a

month

period

circumcisions

were

performed

in

health

facilities

where

only

procedures

had

been

done

in

the

previous

year

In

a

comparison

district

where

no

intervention

was

available

just

circumcisions

were

preformed

over

the

same

period

Demand

for

MC

services

was

judged

to

be

high

but

was

highly

dependent

on

cost

When

the

price

charged

for

a

circumcision

was

reduced

from

US

to

US

demand

surged

and

of

all

circumcisions

occurred

during

the

months

when

the

price

was

reduced

The

median

age

of

those

circumcised

was

years

were

below

age

years

and

an

estimated

were

circumcised

before

their

sexual

debut

The

researchers

felt

that

a

greater

number

of

younger

males

would

have

been

circumcised

had

parental

permission

not

been

required

for

those

under

age

years

and

if

the

cost

were

reduced

permanently

since

older

males

tended

to

have

more

financial

support

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

-RRB-

The

results

from

this

trial

intervention

are

consistent

with

results

from

studies

of

hypothetical

acceptability

indicating

that

cost

is

consistently

found

to

be

a

major

barrier

to

uptake

of

circumcision

in

traditionally

non-circumcising

communities

Further

evidence

of

acceptability

comes

from

the

one

RCT

completed

in

Orange

Farm

South

Africa

and

the

two

ongoing

trials

in

Kisumu

Kenya

and

Rakai

Uganda

both

of

which

have

completed

enrollment

Because

every

participant

in

these

three

trials

stands

a

chance

of

being

circumcised

immediately

upon

randomization

all

of

them

must

prefer

to

be

circumcised

in

order

to

enroll

in

the

study

The

Orange

Farm

trial

screened

young

men

ages

years

We

do

not

know

what

proportion

of

the

total

population

of

year

olds

these

men

represent

However

that

all

but

-LRB-

-RRB-

of

the

men

consented

to

enroll

indicates

that

acceptability

was

high

-LRB-

Auvert

et

al.

-RRB-

In

Kisumu

Kenya

a

community

in

which

of

adult

men

are

uncircumcised

of

the

-LRB-

-RRB-

uncircumcised

men

in

the

population

ages

years

came

to

the

study

clinic

seeking

to

enroll

in

the

study

Of

these

-LRB-

-RRB-

were

eligible

to

enroll

and

of

those

eligible

accepted

to

be

randomized

-LRB-

Bailey

-RRB-

This

acceptability

rate

agrees

very

closely

with

the

figure

found

in

the

sample

by

Mattson

et

al.

-LRB-

-RRB-

from

the

same

area

In

Rakai

Uganda

a

rural

community

in

which

of

adult

men

are

uncircumcised

approximately

of

all

eligible

HIV

uninfected

men

in

the

community

enrolled

in

the

trial

before

enrollment

was

closed

-LRB-

R.

Gray

personal

communication

-RRB-

That

such

large

numbers

of

men

are

willing

to

join

these

trials

suggests

that

circumcision

acceptability

is

high

and

that

uptake

of

MC

in

these

communities

could

be

rapid

if

sufficient

resources

are

available

to

accommodate

large

numbers

of

procedures

Discussion

Through

searching

electronic

databases

and

contacting

authors

we

identified

studies

from

nine

countries

that

include

investigation

of

the

acceptability

of

MC

in

traditionally

non-circumcising

regions

in

sub-Saharan

Africa

We

found

one

additional

report

of

a

pilot

intervention

introducing

MC

services

into

health

facilities

where

circumcision

was

little

practiced

The

level

of

acceptability

across

the

nine

countries

appears

greater

than

might

be

expected

considering

that

all

thirteen

communities

where

the

studies

were

performed

were

all

traditionally

non-circumcising

The

lowest

level

of

acceptability

by

uncircumcised

men

-LRB-

-RRB-

was

reported

from

eastern

Uganda

in

a

study

conducted

in

before

MC

became

well

recognized

as

possibly

being

associated

with

STIs

and

HIV

-LRB-

Bailey

et

al.

-RRB-

More

than

half

of

men

in

the

regions

studied

appear

to

be

receptive

if

not

eager

to

become

circumcised

Cost

fear

of

pain

and

concern

for

safety

were

the

three

most

consistent

barriers

to

acceptability

of

MC

In

communities

where

circumcision

is

the

norm

families

expect

to

incur

the

obligatory

circumcision

expenses

negating

the

importance

of

cost

In

non-circumcising

communities

circumcision

is

regarded

as

a

voluntary

procedure

that

may

be

unlikely

to

take

precedence

over

competing

needs

Cost

is

viewed

as

including

not

only

the

payment

for

the

procedure

but

also

the

opportunity

costs

of

time

away

from

work

and

other

income

generating

activities

Cost

as

a

primary

consideration

was

shown

dramatically

by

the

pilot

intervention

in

Siaya

Kenya

where

men

came

in

large

numbers

when

the

charges

were

lowered

to

US

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

-RRB-

These

results

indicate

that

the

true

cost

of

the

procedure

will

have

to

be

supplemented

to

achieve

significant

uptake

of

MC

The

concerns

for

safety

and

pain

are

based

partially

on

the

perception

of

circumcision

as

a

surgical

procedure

with

inherent

risks

and

partially

on

the

occasional

press

releases

publicizing

mutilations

and

deaths

Personal

knowledge

of

neighboring

communities

where

traditional

initiates

withstand

excruciating

pain

also

likely

plays

a

role

Sustained

uptake

of

MC

will

require

performance

of

the

procedure

with

minimal

adverse

events

This

can

be

achieved

through

proper

training

and

supervision

of

practitioners

proper

instrumentation

and

sterilization

complete

instructions

to

patients

follow-up

with

patients

and

over

all

attention

to

quality

control

-LRB-

Krieger

et

al.

-RRB-

The

studies

we

reviewed

revealed

that

it

is

virtually

universal

that

Africans

equate

circumcision

with

improved

hygiene

Also

widespread

is

the

belief

that

circumcision

leads

to

reduced

incidence

of

STIs

achieved

through

improved

hygiene

reduction

in

the

number

and

severity

of

scratches

tears

and

abrasions

to

which

the

foreskin

is

susceptible

and

through

earlier

detection

of

ulcers

leading

to

earlier

treatment

Although

not

as

frequent

a

significant

proportion

of

participants

in

the

studies

also

saw

circumcision

leading

to

reduced

risk

of

HIV

acquisition

through

the

same

route

If

MC

is

proven

in

the

remaining

two

clinical

trials

to

reduce

incidence

of

HIV

and

some

STIs

-LRB-

e.g.

HPV

chancroid

and

gonorrhea

-RRB-

this

information

will

be

consistent

with

the

already

existing

beliefs

of

most

sub-Saharan

Africans

Cultural

norms

ethnic

identity

and

religious

affiliation

were

viewed

as

central

factors

in

acceptability

of

circumcision

Circumcision

was

associated

with

specific

traditionally

circumcising

communities

and

with

Muslims

and

members

of

a

few

minority

Christian

and

animist

sects

It

will

likely

be

important

that

confidentiality

is

maintained

by

circumcision

practitioners

since

stigmatization

for

being

circumcised

is

a

possibility

in

non-circumcising

communities

An

important

conclusion

reached

by

several

studies

was

that

circumcision

was

increasingly

an

issue

of

personal

choice

rather

than

ethnic

identity

-LRB-

Rain-Taljaard

et

al.

Scott

et

al.

-RRB-

Urbanization

ethnic

mixing

and

exposure

to

other

cultures

and

religions

are

conducive

to

higher

acceptability

of

circumcision

in

traditionally

non-circumcising

ethnic

groups

In

East

and

Southern

Africa

most

MCs

are

done

between

ages

and

and

the

preferences

for

age

at

circumcision

found

in

studies

are

consistent

with

these

practices

However

a

large

enough

proportion

of

people

especially

mothers

preferred

infant

circumcision

to

consider

making

infant

circumcision

an

available

option

This

should

be

an

important

consideration

in

designing

MC

interventions

Information

campaigns

may

be

effective

in

increasing

acceptability

of

MC

This

was

found

to

be

true

in

Botswana

and

South

Africa

-LRB-

Kebaabetswe

et

al.

Scott

et

al.

-RRB-

However

many

studies

demonstrated

that

both

knowledge

and

acceptability

of

MC

varies

considerably

by

region

within

the

same

country

Therefore

informational

campaigns

may

be

more

effective

if

targeted

to

particular

communities

Just

as

the

international

health

community

is

concerned

about

the

possibility

that

promotion

of

circumcision

could

lead

to

increases

in

risky

sexual

behavior

-LRB-

World

Health

Organization

-RRB-

participants

in

many

of

the

studies

reviewed

were

similarly

concerned

Higher

risk

behaviors

have

been

found

to

be

associated

with

circumcision

status

previously

in

Uganda

Rwanda

and

Kenya

-LRB-

Bailey

et

al.

Seed

et

al.

Tyndall

et

al.

-RRB-

as

well

as

in

the

Orange

Farm

RCT

-LRB-

Auvert

et

al.

-RRB-

This

underlines

the

importance

of

the

counseling

and

education

that

must

be

provided

to

men

who

undergo

circumcision

reinforcing

the

idea

of

MC

reducing

not

eliminating

the

risk

of

HIV

and

other

STIs

There

are

several

limitations

to

the

studies

that

we

reviewed

All

used

convenience

sampling

to

recruit

participants

The

results

could

be

biased

if

recruits

were

more

likely

to

participate

if

they

had

a

favorable

view

of

MC

This

may

not

be

a

concern

since

most

studies

had

nearly

participation

by

those

who

were

asked

to

participate

Only

two

studies

verified

the

circumcision

status

of

the

participants

-LRB-

Lagarde

et

al.

Nnko

et

al.

-RRB-

and

of

the

studies

verified

MC

status

of

partners

of

interviewed

women

The

direction

in

which

this

may

have

biased

results

is

not

clear

There

were

differences

across

studies

in

design

some

were

more

qualitative

with

open

ended

questions

asked

in

a

group

discussion

setting

others

were

more

quantitative

using

closed-ended

questions

during

a

one-on-one

interview

There

was

variation

in

the

wording

of

questions

to

participants

about

the

conditions

under

which

they

would

accept

circumcision

Some

studies

were

geographically

restricted

and

as

a

result

may

have

limited

generalizability

and

lack

of

representiveness

of

populations

Geographical

coverage

was

spotty

within

study

countries

and

some

high

HIV

prevalence

countries

where

MC

is

little

practiced

-LRB-

e.g.

Mozambique

Lesotho

Namibia

-RRB-

were

not

included

Lastly

there

was

variation

in

the

time

when

the

studies

were

conducted

-LRB-

range

-RRB-

Attitudes

toward

circumcision

assessed

by

early

studies

-LRB-

Bailey

et

al.

Nnko

et

al.

-RRB-

may

have

changed

since

the

time

of

the

study

All

studies

attempted

to

assess

peoples

beliefs

and

attitudes

toward

circumcision

and

their

willingness

to

be

circumcised

under

some

hypothetical

conditions

sometime

in

the

future

We

can

not

know

from

these

studies

what

the

actual

uptake

of

circumcision

would

be

if

it

were

found

to

be

protective

in

three

clinical

trials

and

was

actively

promoted

We

have

only

one

example

of

an

introduction

of

MC

services

in

a

traditionally

non-circumcising

community

-LRB-

Bailey

Unpublished

report

to

AIDSMARK

-RRB-

and

this

was

at

a

time

when

circumcision

could

not

be

actively

promoted

but

could

only

be

made

available

Results

from

that

intervention

were

instructive

in

that

demand

for

safe

circumcision

was

robust

but

depended

very

much

upon

price

The

results

from

the

thirteen

available

studies

of

acceptability

of

MC

in

nine

countries

in

sub-Saharan

Africa

where

circumcision

is

little

practiced

are

very

consistent

Acceptability

of

MC

is

likely

to

be

high

enough

to

have

a

significant

impact

on

HIV

prevalence

in

these

communities

if

MC

is

proven

to

have

a

protective

effect

similar

to

that

found

in

observational

studies

and

in

the

Orange

Farm

RCT

It

is

doubtful

given

the

consistency

of

results

to

date

that

we

will

learn

a

great

deal

more

by

additional

acceptability

studies

that

pose

hypothetical

questions

to

participants

Instead

we

recommend

pilot

interventions

making

circumcision

services

available

in

health

facilities

after

training

of

clinicians

and

provision

of

proper

instruments

and

supplies

There

are

reports

that

demand

for

MC

services

is

already

high

in

many

traditionally

non-circumcising

communities

in

East

and

southern

Africa

-LRB-

Bangre

Nnko

et

al.

PlusNews

Timberg

-RRB-

There

is

a

danger

that

this

increasing

demand

will

be

filled

by

unqualified

practitioners

causing

unnecessary

adverse

events

Pilot

interventions

will

serve

simultaneously

to

test

whether

there

truly

is

a

growing

niche

and

if

so

to

gain

experience

in

filling

the

niche

with

safe

affordable

services

At

the

same

time

much

will

be

learned

about

the

operational

requirements

for

training

instrumentation

safety

counseling

and

follow-up

of

patients

supervision

of

staff

monitoring

of

behavioral

disinhibition

and

about

how

MC

services

can

be

integrated

with

HIV/STIs

prevention

services

including

VCT

STIs

diagnosis

and

treatment

behavioral

counseling

condom

promotion

and

anti-retroviral

therapies