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Perceptions and knowledge of voluntary medical male circumcision for HIV prevention in traditionally noncircumcising communities in South Africa a
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Jacob Robin Hoffman , Kirsten D. Arendse , Carl Larbi , Naomi a
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Johnson & Lauraine M.H. Vivian
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Department of Public Health, University of Cape Town, Cape Town, South Africa Published online: 02 Mar 2015.
To cite this article: Jacob Robin Hoffman, Kirsten D. Arendse, Carl Larbi, Naomi Johnson & Lauraine M.H. Vivian (2015) Perceptions and knowledge of voluntary medical male circumcision for HIV prevention in traditionally non-circumcising communities in South Africa, Global Public Health: An International Journal for Research, Policy and Practice, 10:5-6, 692-707, DOI: 10.1080/17441692.2015.1014825 To link to this article: http://dx.doi.org/10.1080/17441692.2015.1014825
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Global Public Health, 2015 Vol. 10, Nos. 5–6, 692–707, http://dx.doi.org/10.1080/17441692.2015.1014825
Perceptions and knowledge of voluntary medical male circumcision for HIV prevention in traditionally non-circumcising communities in South Africa Jacob Robin Hoffman*, Kirsten D. Arendse, Carl Larbi, Naomi Johnson and Lauraine M.H. Vivian
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Department of Public Health, University of Cape Town, Cape Town, South Africa (Received 17 April 2014; accepted 17 November 2014) Voluntary medical male circumcision (VMMC) has been recommended for the prevention of HIV transmission, particularly in sub-Saharan Africa. Uptake of the campaign has been relatively poor, particularly in traditionally non-circumcising regions. This study evaluates the knowledge, attitudes and practices of medical male circumcision (MC) of 104 community members exposed to promotional campaigns for VMMC for five years. Results show that 93% of participants have heard of circumcision and 72% have heard of some health benefit from the practice. However, detailed knowledge of the relationship with HIV infection is lacking: 12.2% mistakenly believed you could not get HIV after being circumcised, while 75.5% believe that a circumcised man is still susceptible and another 12.2% do not know of any relationship between HIV and MC. There are significant barriers to the uptake of the practice, including misperceptions and fear of complications commonly attributed to traditional, non-medical circumcision. However, 88.8% of participants believe circumcision is an acceptable practice, and community-specific promotional campaigns may increase uptake of the service. Keywords: circumcision; HIV; prevention; South Africa
Introduction In South Africa, voluntary medical male circumcision (VMMC) forms part of the National Strategic Plan for HIV, sexually transmitted infections and TB 2012–2016, which aims to reduce the 12.2% national prevalence of HIV infection (South African National AIDS Council, 2012; Shisana et al., 2014). The promotion of VMMC in South Africa is linked to a broader intervention by the World Health Organization (WHO) and the Joint United Nations Programme for HIV/AIDS (UNAIDS) to encourage medical male circumcision (MC) for HIV prevention in 14 priority countries with high HIV prevalence and low MC rates (WHO, 2012). The intervention was launched in the wake of evidence from three large randomised-controlled trials (RCTs) involving over 11,000 participants, which suggested the procedure may reduce female-to-male transmission of HIV by up to 60% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Much of the burden of disease is in those aged 25–49 years of age, with an incidence of 25%–30% in these age groups in South Africa (Shisana et al., 2014). VMMC may
*Corresponding author. Email: [email protected] © 2015 Taylor & Francis
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be a complementary tool for addressing high incidence of HIV infection rates in this age bracket. Feasibility and cost-effectiveness studies conducted prior to the WHO campaign suggest that 80% coverage of MC would be necessary to significantly impact HIV incidence and may decrease incidence by up to 35% (Hallett et al., 2008; Njeuhmeli et al., 2011; Westercamp & Bailey, 2007). However, little data exist, which evaluate the impact of the intervention on targeted communities, particularly those that are noncircumcising, where penetration of public health services has been notably poor. This study was conducted in two neighbouring, non-circumcising communities of Saldanha Bay in the Vredenberg District in the the Western Cape province of South Africa, where local health services have been promoting and undertaking VMMC services for the last five years. Prevalence of HIV infection in the Western Cape province is 5.0%, below the national prevalence of 12.2%. Uptake of the service has been poor and this study was conducted to identify potential facilitating or inhibiting factors. It is not yet understood what motivates members of traditionally non-circumcising communities to seek VMMC services. However, knowledge of the procedure and its benefits, associated risks and sociocultural aspects likely influence the decision to become circumcised (Westercamp & Bailey, 2007). Establishing motivating factors within this target population was thus a key objective of the study. It was anticipated that knowledge of MC among the study population would be derived from both medical and non-medical sources. Given that multiple factors influence uptake of VMMC, it is imperative to identify local barriers within a broader sociopolitical context. Furthermore, concerns surrounding the scaling up of VMMC services such as risk compensation, questionable external validity of the RCTs on which the intervention is based and issues related to cost-effectiveness raise ethical concerns about the appropriateness of the WHO-driven intervention compared to the controlled trials (de Lange, 2013; Green et al., 2010; McAllister, Travis, Bollinger, Rutiser, & Sundar, 2008). Other bioethical concerns surrounding the function of the male foreskin in sexual health should also be considered in the promotion of VMMC campaigns. A study conducted in Denmark found that rates of sexual dysfunction are greater for circumcised men and women with circumcised spouses (Frisch, Lindholm, & Grønbæk, 2011). Men reported more orgasm difficulties while women reported orgasm difficulties, dyspareunia and incomplete sexual needs fulfilment. These increased sexual difficulties were robust when adjusting for religious differences and suggest that both men and women may have increased sexual dysfunction following circumcision. Biological evidence supports concerns that MC may lead to sexual difficulties. Sensory testing examining fine-touch pressure thresholds of the circumcised and uncircumcised penis found that MC ablates some of the more sensitive areas of the adult penis (Sorrells et al., 2007). While some researchers have found decreased sexual needs fulfilment, other studies of recently circumcised men have shown positive results regarding how the practice is taken up in traditionally non-circumcising communities (Lundsby, Dræbel, & Wolf Meyrowitsch, 2012). However, there is still a gap between the perceived acceptability of the practice and the rate of uptake (Lundsby et al., 2012). Our study is the first to investigate the knowledge, attitudes and practices surrounding MC in an area where VMMC services have been promoted for HIV prevention over a five-year period. As such, it has the potential to elucidate barriers facing health promoters in this region. Furthermore, these insights may be extrapolated to the evaluation of similar campaigns elsewhere.
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Methodology An analytical cross-sectional study design was employed, encompassing both quantitative and qualitative components. A questionnaire was used to obtain the necessary data and was designed based on the requirements of stakeholders, from reviewing current relevant literature and the adaptation of a few previously used questionnaires (Ngodji, 2010). The questionnaire, which encompassed a mixture of open- and closed-ended questions, was initially written in English and then translated into Afrikaans. To ensure validity of our study, bias and chance association was minimised. The questionnaire was designed to elicit prior knowledge or assumptions about MC before divulging any information on the existence of health benefits or risks, or alluding to the campaign that had been carried out in the area. This was done to avoid confounding results when reporting on prior knowledge and preferences. Questions related to the medical practice of circumcision were posed before asking about worries related to the procedure or knowledge of risks related to circumcision. Following the initial questions, prompts were given later in the interview so that perceptions surrounding health benefits, risks and motivating factors could be explored in more detail. The questionnaires may be found in the Supplementary material. Data collection was conducted in the town of Saldanha, specifically in the communities of Diazville and White City. Saldanha Bay is located in the West Coast Region of the Western Cape, South Africa. Residents of this area are predominantly Christian, Coloured (a South African term for people of mixed descent) and Afrikaansspeaking. Both males and females of age 18 years and older were included in the study. The communities of White City and Diazville are located in the Saldanha Bay municipality. An outline of Saldanha Bay Municipality’s Integrated Development Plan indicates that White City has a population of 6205 (Saldanha Bay Municipality, 2013). Of the community members, 52% are Coloured, 34% Black African, 12% White and 1.5% Asian/Indian. Of the individuals, 28.6% have no monthly income and another 21.7% of individuals earn between R1 and R3200 per month. 29.4% of households have an annual income less than R38,200 per annum. Diazville has a population of 8591. The community is 85% Coloured, 14% Black African and the remaining 1% Asian, Indian and White. 46% of individuals have no monthly income and another 42% of individuals earn between R1 and R3200 per month. 45% of households have an annual income less than R38,200 per annum. In both communities, more than 90% of individuals live in a house or formal structure and over 95% have access to basic amenities. Most relevant economic activities include employment at local fishing, agriculture, mining and tourism industries and other skill-based labour. The study required that participants: . Be permanent residents of Diazville or White City . Have lived in the area for at least five years (i.e. before 2008) . Consented to partake in the study A sample size of 100 was agreed upon prior to data collection. In total, 126 households were visited, and a final sample population of 104 individuals was obtained. There were 67 men aged 18–78 and 37 women aged 20–86 that made up the sample of 104 participants. The sample size was comparable to similar studies conducted on this topic and consisted only of individuals from traditionally non-circumcising backgrounds (Lagarde, Dirk, Puren, Reathe, & Bertran, 2003; Lundsby et al., 2012; Mattson, Bailey, Muga, & Poulussen, 2005; Vambe, 2013).
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Data collection, in the form of face-to-face, interviewer-facilitated completion of a questionnaire took place over a period of three days from 29 to 31 July 2013 (two days in Diazville and one day in White City). The interviews were conducted in Afrikaans (and/or English where possible) by one of four Bachelor of Medicine and Bachelor of Surgery students from the University of Cape Town in their fourth year of study. A local community health worker who worked in the area at the time of the study accompanied each student and assisted with communicating and translating. Community health workers also helped to identify households suitable for interview. Opportunistic sampling was also employed, whereby residents encountered on the street were approached and recruited. Following presentation and explanation of the study and the consent form, all eligible participants were required to provide written, signed informed consent. Interviews lasted 10–15 minutes on average and took place primarily in the vicinity of participants’ homes or on the street. Before completion of the interview, questionnaires were checked for completeness. Following data collection, questionnaires were coded and results entered into an Excel spreadsheet. A health benefits knowledge score was calculated for each participant. This score is an indicator of the general awareness of circumcision practice, real and perceived health benefits of MC, as well as the relationship between circumcision status and risk of HIV infection. The score reflected a summation of points awarded for answers to certain questions through the questionnaire. One point was awarded if the participant had heard of circumcision (Question B1). Up to six points were awarded for knowledge of any or specific health benefits (Questions C2 and C3). Up to four points were awarded for knowledge of the correct relationship between MC and HIV infection (Questions C4, C5, C6 and C7). The questions and points awarded in formulating the health benefits knowledge score were as follows and relate to the questionnaire in the supplementary material (S1): Question B1, yes = 1 point, no = 0 points; Question C2, yes = 1 point, no = 0 points; Question C3, 1 point awarded for each health benefit listed. Question C4, yes = 1 point, no = 0 points; Question C5, 1 point awarded for ‘lowers risk of HIV’. No points for any other answer; Question C6, yes = 1 point, no = 0 points; Question C7, yes = 1 point, no = 0 points. The final score was a sum of the points awarded with a maximum total of 11 points. Participants were then stratified into high and low health benefit knowledge score groups, with six points or more defined as having a high score. This was chosen as 54.8% of participants had knowledge scores of five or lower, thus obtaining two groups of proportional size, an upper and lower half of those interviewed. These two groups were used for further analysis as a categorical variable in place of the raw health benefits knowledge scores obtained. Prism 5 and Stata were used for statistical analysis and the generation of appropriate figures and tables. Significant differences and associations between demographic and outcome data, or between two or more outcomes, were investigated. Chi-squared and Fisher exact tests were employed to test the association of categorical variables. The level of significance for all statistical tests was set at p = .05.
Results Results describe the social demographics of the population, the practice of circumcision in the communities, the knowledge and sources of information for MC, motivating factors and finally barriers to the uptake of VMMC in these communities.
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Socio-demographic description of the study population Participants’ ages ranged from 18 to 86 years, spanning the target population for the intervention as well as the parents of those in target populations. The highest prevalence age group (28.8%) was between 35 and 44 years old. Relationship status was fairly equally distributed between married participants (31.7%), those in a relationship (30.8%) and single (37.5%). Most participants (69.2%) had some secondary-level education, whereas 14% received primary-level education and 16% completed matric. Participants were predominantly unemployed (61.5%) and two-thirds (70.2%) had a total monthly household income of less than R3000 ($288), whereas a quarter (23.1%) received more than R3000 ($288). Afrikaans was the most common home language (96.2%) with only one individual speaking English at home and 2.9% other languages. Of the 79% who considered themselves religious, 94.2% were Christian with other religious groups making up the remainder, including Islam and Rastafarianism. MC in the communities In total, 16 (23.9%) men interviewed were circumcised, which was not delineated by age. The highest prevalence was in the 25- to 34-years age bracket with a circumcision rate of 27.8%. The lowest prevalence was in the 35- to 44-years age bracket with a prevalence rate of 14.3%. There were no significant differences with regard to circumcision status and employment, relationship status, level of education or religion. Over half of the circumcised respondents had been circumcised as adults (56.2%), a quarter had been circumcised as babies (25.0%) and the remainder as pre-adolescents (18.8%). Half of the men were circumcised in a hospital. Others had been to a private doctor, traditional circumcision camps or were circumcised at home, representing a range of underlying medical and non-medical motivating factors. Men were circumcised for beliefs in improved hygiene and health benefits (26%) or for cultural or religious reasons (37%). Others did not provide a reason for their circumcision (26%) or did not know why their parents made the decision for them when they were children (11%). Two men who had traditional circumcisions were from Sotho families and thus from a traditionally circumcising background, while another was Zulu, which is a non-circumcising culture. The other traditional circumcisions were for men of amaXhosa heritage, although they did not identify isiXhosa as their language and culture. Traditional circumcision was often framed as a rite of passage and part of ‘becoming a man’. These reasons are displayed in Figure 1.
Figure 1.
Reasons for circumcision among circumcised participants.
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Although there were few men who were circumcised, most participants (93.3%) had heard about MC. The majority (64.4%) knew of someone in their community who was circumcised and many had heard of family members who had been circumcised (46.2%). Information about circumcision was obtained largely from family and community members, with under a third (28.8%) having been exposed to the government campaigns and less than one-fifth through formal contact with the health system, whether directly from a medical professional or from print media. Of those who indicated exposure to the campaign through any form of media, those interventions run by local government shared an almost equal proportion with TV coverage via news, documentaries or advertisements. General knowledge of MC, explanation of circumcision practice and perceived health benefits knowledge score Participants’ ability to explain circumcision was rated as poor, average or good when answering Question B3. This distinction was made primarily based on the ability to describe the procedure and was considered good if the participant added information related to anatomy removed or insight into reasons for getting circumcised, including perceived health benefits and religious or cultural reasons. The overall ability to explain circumcision was neither comprehensive, inclusive of perceived health benefits and risks, nor poor. Of those interviewed, 29.1% explained circumcision poorly and 47.6% indicated that they knew the procedure involves removal of tissue from the penis, but did not offer knowledge of anatomy or function of the foreskin. Of the respondents, 23.3% could explain circumcision well, had good knowledge of the tissue removed and mentioned perceived health benefits as a result of circumcision. The median score for the health benefits knowledge scores was 6 (18.3%) with scores 4, 5, 6, and 7 out of 11 accounting for more than 65% of respondents. 26% had a health benefits knowledge score of 3 or less, whereas 9% had a score of 8 or more. When evaluating associations with the health benefits knowledge score, there were roughly equal numbers who had a good health benefits knowledge score as those with poor ones. There was no significant difference in high or low health benefits knowledge score when delineated by socio-demographic characteristics. Knowledge of MC and health benefits When asked about health benefits, 71.8% of participants knew of at least one health benefit, whereas 28.2% of participants knew of none. The participants were asked for specific health benefits, determining prior knowledge without prompts. The most commonly reported health benefit of MC was the perception of improved genital hygiene (52.0%). Nearly a third (31.7%) of the participants identified reduced risk of STIs as a health benefit, but few (15.4%) explicitly mentioned any link between circumcision and HIV. Knowledge around MC and HIV Although few people mentioned the reduced risk of HIV when unprompted, 26.9% said that they understand there is a relationship between MC and HIV when asked directly. However, only 18.3% understood the correct relationship without direct questioning, while 12.2% believed that a man who is circumcised could not get HIV (Table 1). There was no difference in this knowledge based on circumcision status.
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Table 1. Knowledge about the relationship between MC and HIV. Yes (%)
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Knowledge that relationship exists Knows correct relationship Believes circumcision can reduce risk of HIV Believes one can still get HIV after circumcision
28 19 67 74
(26.9) (18.3) (68.4) (75.5)
No (%) 76 85 23 12
(73.1) (81.7) (23.5) (12.2)
I don’t know (%)
Total (n)
8 (8.2) 12 (12.2)
104 104 98 98
Motivating factors for VMMC The vast majority (88.8%) of participants believe circumcision is an acceptable practice, which showed no difference across socio-demographic characteristics or gender. Acceptability is shown in Figure 2 and relation to socio-demographics in Figure 3. The majority of men (57.7%), women (60.2%) and mothers (70.4%) are seen to prefer circumcision for themselves, their partners or their sons, respectively (Table 2). The reasons given for preferences include cleanliness, health, safety, protection, cultural and religious reasons, as well as sex-related benefits. Reasons given for people not preferring circumcision are fear of pain or complications, circumcision not forming part of their culture or religion or that the decision should belong to the individual and is not for one’s family to decide (Table 2). Among the uncircumcised men, there was an overall significant correlation between higher health benefits knowledge scores and willingness to consider going for circumcision (n = 49, χ2 = 4.69, p = .03). The knowledge of any health benefit was significantly associated with a greater likelihood of considering circumcision (n = 49, χ2 = 4.31, p = .038), with the perception of improved genital hygiene being the most significant association with willingness to consider circumcision (n = 49, χ2 = 5.22, p = .022). Men willing to consider circumcision (83.3%) reported the belief of improved hygiene as being an encouraging factor. However, at the end of the interview, after providing participants with accurate information regarding medical MC, prevention of HIV infection was the most frequently given motivator for uncircumcised men considering circumcision (91%) (Tables 3 and 4).
Figure 2.
Overall acceptability of MC.
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Figure 3.
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Acceptability of circumcision by socio-demographic characteristics.
Risks, barriers and complications Participants were asked to identify general and specific risks related to MC, but 65.4% were not aware of any risks regarding the medical procedure or in relation to traditional practice. There was no significant difference in risk perception by socio-demographic characteristics or circumcision status. Infection was the most frequently identified risk (45.9%), if a risk was identified at all. Other commonly reported risks were death (21.6%), bleeding (13.5%) and pain (5.4%) (Table 5). Six participants reported that risks were specifically associated with traditional circumcisions, citing media coverage of traditional practices in the Eastern Cape, which highlights the risk of infection and death. One man believed there was an increased risk of getting HIV if circumcised, based on similar media coverage. When asked about personal worries or barriers to them considering the procedure or encouraging their partners or sons to be circumcised, the majority of respondents mentioned at least one factor that would discourage or prevent them from undergoing circumcision. The most commonly cited reason was fear of infection (41.8%), followed by pain (38.8%), religion, loss of performance, time off work and reaction of peers. Infection and pain were feared for both medical and traditional circumcisions. Some respondents expressed desire for clinics to provide more information about the procedure, pain management and the healing process. Table 2. Reasons for perceived positive and negative preferences for men, partners and sons being circumcised.
Positive reason Cleanliness/health Safety/protection/fewer illnesses Cultural/religious/personal reasons Sex-related benefit Negative reason Fear (pain, complications) Cultural or religious reasons It is the child’s decision
Men prefer
Women prefer
Mothers prefer
19 15 7 2
13 16 2 2
17 20 4 0
5 4 0
3 1 0
0 1 1
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Table 3. factors.
Male participants’ willingness to consider circumcision by health benefits knowledge
Knowledge score Low knowledge score High knowledge score Heard of health benefits No Yes Benefit – hygiene No Yes Benefit – HIV No Yes Benefit – STIs No Yes Benefit – penile cancer No Yes Benefit – cervical cancer No Yes Total
Not willing to consider circumcision (n = 25)
Willing to consider circumcision (n = 24)
Total (%) (n = 49)
19 (76.0) 6 (24.0)
11 (45.8) 13 (54.2)
30 (61.2) 19 (38.8)
.030
11 (44.0) 14 (56.0)
4 (16.7) 20 (83.3)
15 (30.6) 34 (69.4)
.038
19 (76.0) 6 (24.0)
9 (37.5) 15 (62.5)
28 (57.1) 21 (42.9)
.022
22 (88.0) 3 (12.0)
21 (87.5) 3 (12.5)
43 (87.8) 6 (12.2)
19 (76.0) 6 (24.0)
14 (58.3) 10 (41.7)
33 (67.3) 16 (32.7)
24 (96.0) 1 (4.0)
24 (100) 0 (0)
48 (98.0) 1 (2.0)
24 (96.0) 1 (4.0) 25 (51.0)
24 (100) 0 (0) 24 (49.0)
48 (98.0) 1 (2.0) 49 (100)
p value
Note: Significance displayed for χ2: p < .05, p value stated in table.
Financial barriers to VMMC were also raised. The majority of respondents (76.9%) did not know that the service is offered for free at the local clinic or hospital. There were no significant differences in this knowledge between male and females, circumcised and uncircumcised men or those willing and not willing to consider circumcision. Table 6 considers the barriers and preventative factors given by participants related to willingness to consider the procedure. Unsurprisingly, those not willing to consider circumcision were more likely to have heard of risks related to the procedure (n = 49, χ2 = 3.99, p = .046); a similar pattern emerged for those willing to encourage children or partners to undergo circumcision. However, there was no single particular worry or preventative factor. Over half (54%) of participants responded that proper explanation of the procedure would make them feel more comfortable, and 43% believed that better understanding of the pain management process would encourage them to undergo circumcision.
Discussion This study is the first to examine knowledge, attitudes and practice of VMMC in traditionally non-circumcising communities that have been exposed to a promotional campaign for five years.
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Table 4. Male participants’ willingness to consider circumcision by encouraging factors. Not willing to consider circumcision (n = 25)
Willing to consider circumcision (n = 24)
Total (%), n = 49
1 (4.0) 24 (96.0)
1 (4.2) 23 (95.8)
16 (32.7) 33 (67.3)
11 (44.0) 14 (56.0)
4 (16.7) 20 (83.3)
15 (30.6) 34 (69.4)
7 (28.0) 18 (72.0)
2 (8.3) 22 (91.7)
9 (18.4) 40 (81.6)
8 (32.0) 17 (68.0)
7 (29.2) 17 (70.8)
15 (30.6) 34 (69.4)
9 (36.0) 16 (64.0)
14 (58.3) 10 (41.7)
23 (46.9) 26 (53.1)
10 (40.0) 15 (60.0)
18 (75.0) 6 (25.0)
28 (57.1) 21 (42.9)
Any encouraging factor No Yes Encourage – hygiene No Yes Encourage – HIV No Yes Encourage – STIs No Yes Encourage – UTI No Yes Encourage – religion No Yes
p value
0.038
0.018
Note: Significance displayed for χ2: p < .05, p value stated in table.
Knowledge of circumcision: sources, health benefits and acceptability It was found that prevalence of circumcision in these traditionally non-circumcising communities was expectantly low, but knowledge of circumcision was notably high despite minimal exposure to the campaign. Circumcision is a sensitive topic, yet the majority of participants had heard about it through family and friends and not through formal health-care campaigns. Information was shared between male work colleagues and was gathered through family and friends for the majority of the women. Women were commonly supportive of the practice and believed in some benefit to their sexual health, such as reduced risk of infection for themselves and their partners and believed it improved genital hygiene. MC was a highly acceptable practice, with many men willing to consider it despite low knowledge of HIV-related benefits. Overall knowledge of circumcision health benefits was average, with few displaying poor or no knowledge of circumcision, similar to results obtained by Ngodji (2010). Three-fourths (75.5%) of participants were aware of some health benefit; however, most Table 5.
Knowledge of circumcision complications.
Complication Infection Death Bleeding Pain
Frequency, N = 37 (%) 17 8 5 2
(45.9) (21.6) (13.5) (5.4)
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Table 6. Male participants’ willingness to consider circumcision by preventing factors, risks and worries.
Any preventing factor No Yes Prevent – risk of infection No Yes Prevent – peers No Yes Prevent – loss of performance No Yes Prevent – pain No Yes Prevent – work No Yes Any perceived risks No Yes Any worries surrounding the procedure No Yes Worry – pain No Yes Worry – infection No Yes Worry – performance No Yes Worry – inexperience No Yes Worry – other No Yes
Not willing to consider circumcision (n = 25)
Willing to consider circumcision (n = 24)
Total (%), n = 49
3 (12.0) 22 (88.0)
12 (50.0) 12 (50.0)
15 (30.6) 34 (69.4)
11 (44.0) 14 (56.0)
17 (70.8) 7 (29.2)
28 (57.1) 21 (42.9)
20 (80.0) 5 (20.0)
19 (79.2) 5 (20.8)
39 (79.6) 10 (20.4)
15 (60.0) 10 (40.0)
20 (83.3) 4 (16.7)
35 (71.4) 14 (28.6)
11 (44.0) 14 (56.0)
16 (66.7) 8 (33.3)
27 (55.1) 22 (44.9)
20 (80.0) 5 (20.0)
17 (70.8) 7 (29.2)
37 (75.5) 12 (24.5)
13 (52.0) 12 (48.0)
19 (79.2) 5 (20.8)
32 (65.3) 17 (34.7)
11 (44.0) 14 (56.0)
14 (58.3) 10 (41.7)
25 (51.0) 24 (49.0)
20 (80.0) 5 (20.0)
19 (79.2) 5 (20.8)
39 (79.6) 10 (20.4)
23 (92.0) 2 (8.0)
23 (95.8) 1 (4.2)
46 (93.9) 3 (6.1)
25 (100) 0 (0)
24 (100) 0 (0)
49 (100) 0 (0)
22 (88.0) 3 (12.0)
23 (95.8) 1 (4.2)
45 (91.8) 4 (8.2)
18 (72.0) 7 (28.0)
19 (79.2) 5 (20.8)
37 (75.5) 12 (24.5)
p value **
0.046
Note: Significance displayed for χ2: p < .05, p values stated in table; **p < .01.
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(52.0%) identified only the perception of improved hygiene. Only 15.4% mentioned, without prompt, that circumcision reduced one’s risk of HIV, though 68.8% stated that this was true when asked directly. The highly prevalent perception of basic health benefits from MC may underlie high acceptability of circumcision, as perception of hygienic benefits has a strong association with acceptability (Halperin, Fritz, McFarland, & Woelk, 2005; Westercamp & Bailey, 2007).
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Motivators of MC: contextual and community-specific In the sub-Saharan setting, consistent motivators identified comprise of hygienic benefit, protection from HIV and STIs and the perceived increase in sexual pleasure (Westercamp & Bailey, 2007). Motivators were put forth predominantly by females, particularly beliefs concerning improved hygiene and reduced risk of infection (Mattson et al., 2005). However, it was interesting to note that other studies in South Africa found no association between willingness to be circumcised and perceived health benefits (Westercamp & Bailey, 2007). The strongest predictor in this setting for voluntary MC is the perception of increased sexual pleasure (Westercamp & Bailey, 2007). In our study, sex-related reasons were the least commonly given for respondents regarding perceived preferences for circumcision and did not emerge as strong motivators for MC. Instead, the biomedical rationale came through strongly, supporting circumcision for safety from infection or perceived hygienic benefit. Women and mothers were seen to prefer circumcision for their partners and sons (60% and 70%, respectively). Their predominant motivators were that MC could provide protection from infection, although interestingly, protection from HIV was not explicitly stated as a motivating factor for MC, only becoming a significant motivator once informed of the potential health benefits from being circumcised. Behavioural adaptation and the potential for risk compensation Concerns with the promotion of MC to lower a man’s risk of HIV and other STIs include questionable validity of the RCTs on which the intervention is based, risk compensation, condom avoidance, sexual dysfunction and false perceptions of immunity from HIV and STI’s following circumcision, which may increase male-to-female transmission (Auvert et al., 2005; Bridges, Selck, Gray, McIntyre, & Martinson, 2011; Frisch et al., 2011; Green et al., 2010). There is a chance of increased risky sexual behaviour following VMMC due to misconceptions around the extent to which circumcision protects against HIV (Auvert et al., 2005). If men have sexual intercourse before the circumcision wound is fully healed, they are also likely to be at greater risk of HIV acquisition (Auvert et al., 2005). A meta-analysis that looked at changes in sexual behaviour as secondary outcomes of the three RCTs found no statistically significant changes in sexual behaviour or risk compensation (Siegfried, Muller, Deeks, & Volmink, 2013). However, in South Africa circumcised men had a significantly higher number of sexual partners compared to their uncircumcised counterparts (Siegfried et al., 2013). In the Kenyan study, there was an overall decrease in risky sexual behaviour in both circumcised and uncircumcised groups; however, the intervention group had significantly higher levels of unprotected sex and lower consistent condom use (Bailey et al., 2007). In our study, 12.2% mistakenly believe that men who are circumcised cannot get HIV, while 75.5% believe that a circumcised man is still susceptible. A study in
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Namibia found that 7.6% of men believed that a circumcised man does not need to wear a condom (Ngodji, 2010), whereas a study conducted in Swaziland indicated that only 1.6% of participants believed that circumcision provides 100% protection from HIV (Vambe, 2013). Our result of 12.2% is notably larger than in these other studies, highlighting the need for adequate pre- and post-procedure counselling as well as health promotion to inform men and women that a circumcised man and all his potential partners are still susceptible to HIV and other STIs, and that safe sex practices are still advisable. This in itself may affect willingness to become circumcised and willingness to encourage a partner or child to become circumcised, as continued protection would still require safe sexual practices. Although MC significantly decreases an individual’s risk of contracting HIV, it is yet to be seen how this, when scaled up to national levels, may impact the HIV epidemic and whether the decrease in incidence will be as substantial as predicted (Garenne, 2008). In another study, Hallett et al. (2008) used a deterministic model to estimate the impact of such an intervention. They predict that if effectively implemented with 90% population coverage, addition of VMMC to current efforts could decrease HIV prevalence by 25%– 35%, assuming no risk compensation occurs. Indeed, the cost-effectiveness of the intervention has been under question, which would be further hampered by risk compensation (McAllister et al., 2008). Unforeseen complications when scaling up to the national level may be detrimental to expanding the intervention, including ethical concern about broadening the practice to minors, who are unable to consent or dissent independently. Furthermore, findings that relate to sexual dysfunction after circumcision are of concern and raise bioethical issues around the promotion of MC campaigns (Frisch et al., 2011; Sorrells et al., 2007). Informed consent would require knowledge of the foreskin’s functional relevance and possibility of sexual dysfunction. Additional concerns regarding proxy consent and substitute decision-making emerge when applied to minors. Promoters of MC should have an understanding of the level of knowledge within the population concerning these findings and their implications for sexual health. Knowledge of these aspects of MC should be sought and addressed in future studies looking at population knowledge of MC, especially in those areas where promotional campaigns are already underway. While further investigation of differences in sexual experience and sexual difficulties should be examined in the future, it is beyond the scope of this study. Feasibility for the future: perceived risks and the future of the campaign Of the men who were uncircumcised, roughly half would consider going for circumcision. Men were more likely to consider circumcision if they had a high knowledge score or were aware of hygienic benefits of circumcision. Knowing a family member was similarly significant and likely represents a trustworthy source of information for the potential patient. Hygienic benefit was the most common encouraging factor given by women, whereas prevention of HIV was the strongest encourager for men willing to consider circumcision (91%). This is encouraging for future campaigns as it suggests a strong underlying motivating factor for MC. However, it is of concern that this has not translated into increased uptake of the service. Inhibiting factors must be considered if the campaign is to achieve the 80% coverage it seeks. When asked about risks of circumcision, 35.6% of the participants said that they knew of some. Of the respondents, infection was identified as the most common (45.9%), with death coming second (21.6%). The complications and risks of VMMC in a clinic
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setting were fear of pain and infection. No respondents mentioned fear of sexual dissatisfaction nor indicated that they were aware of this potential risk. Many of these participants had mentioned their exposure to media surrounding traditional circumcision practices among African populations, particularly in the Eastern Cape and Limpopo, which resulted in infection and death. This indicates a lack of distinction between VMMC and traditional practices in these communities and has an effect on uptake of the service. The majority who would consider going were less likely to believe that there are risks such as those associated with traditional practices. In many studies about the acceptability of MC in traditionally non-circumcising communities, a recurring barrier is the cost of the procedure as well as additional costs such as transport to the clinic and absence from work (Westercamp & Bailey, 2007). In the Vredenburg district, circumcision at the state hospital is free; however, this study found that only 16% of respondents knew that the service was free and 77% did not know the cost, suggesting that informing communities that circumcision is free may increase circumcision uptake.
Implications and limitations of this study for future campaign evaluation The results of our study cast doubt on whether targets of 80% coverage within five years (Njeuhmeli et al., 2011) can feasibly be met without addressing community-specific barriers and developing a combination approach to underpin the campaign in different areas. The information currently circulating in these communities is not sufficient to stimulate high uptake of an intervention promoting MC for the prevention of HIV transmission. Prevention of HIV was the most encouraging motivator across all groups of men, yet the role of VMMC in HIV prevention was not well known. The scope of the information available to the communities regarding MC is limited and this superficial knowledge is vulnerable to influence from media coverage of traditional circumcision in other parts of South Africa. This was evidenced in a high number of perceived risks surrounding traditional circumcision including infection and death, as opposed to more intuitive fears such as pain and bleeding in the post-operative period (Westercamp & Bailey, 2007). In conclusion, if the WHO-backed intervention is to be successful, and the target of 80% coverage is to be reached, more research needs to be done to identify regionalspecific barriers to the uptake of VMMC for HIV prevention. In these communities, barriers may be addressed by educating around misperceptions regarding traditional versus medical circumcision, addressing risk compensation and stimulating the dissemination of high-quality information regarding the biological and social relevance of circumcision in HIV prevention and the availability of subsidised local services. In this study, 12.2% interviewed believed a man can no longer become infected with HIV once circumcised. This is of concern and must be addressed if risk compensation is to be minimised. This relatively small study conducted in traditionally non-circumcising communities has shown that many social and political influences play a role in motivating or discouraging someone to consider circumcision. By addressing the causes of the concern and providing good quality, detailed biomedical information on the topic to all involved, the intervention stands to be more successful.
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Acknowledgements The authors thank all those who made this research possible, including the University of Cape Town Department of Public Health and Primary Healthcare Directorate. The authors also thank the people and organisations who worked with them in the communities of Vredenberg District, including Western Cape Government, Vital Connection and Mfesane.
Disclosure statement No potential conflict of interest was reported by the authors. Supplemental data
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Supplemental data for this article can be accessed here.
References Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R., & Puren, A. (2005). Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine, 2, 1112–1122. doi:10.1371/journal.pmed0020298 Bailey, R. C., Moses, S., Parker, C. B., Agot, K., Maclean, I., Krieger, J. N., … Ndinya-Achola, J. O. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet, 369, 643–656. doi:10.1016/S0140-6736(07)60312-2 Bridges, J. F. P., Selck, F. W., Gray, G. E., McIntyre, J. A., & Martinson, N. A. (2011). Condom avoidance and determinants of demand for male circumcision in Johannesburg, South Africa. Health Policy and Planning, 26, 298–306. doi:10.1093/heapol/czq064 De Lange, C. (2013). AIDS prevention: Africa’s circumcision challenge. Nature, 503, 182–185. doi:10.1038/503182a Frisch, M., Lindholm, M., & Grønbæk, M. (2011). Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. International Journal of Epidemiology, 40, 1367–1381. doi:10.1093/ije/dyr104 Garenne, M. (2008). Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research, 7(1), 1–8. doi:10.2989/ AJAR.2008.7.1.1.429 Gray, R. H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., … Wawer, M. J. (2007). Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet, 369, 657–666. doi:10.1016/S0140-6736(07)60313-4 Green, L., Travis, J., McAllister, R., Peterson, K., Vardanyan, A., & Craig, A. (2010). Male circumcision and HIV prevention: Insufficient evidence and neglected external validity. American Journal of Preventive Medicine, 39, 479–482. doi:10.1016/j.amepre.2010.07.010 Hallett, T. B., Singh, K., Smith, J. A., White, R. G., Abu-raddad, L. J., & Garnett, G. P. (2008). Understanding the impact of male circumcision interventions on the spread of HIV in Southern Africa. PLoS ONE, 3(5), 1–9. doi:10.1371/journal.pone.0002212 Halperin, D.T., Fritz, K., McFarland, W., & Woelk, G. (2005). Acceptability of adult male circumcision for sexually transmitted disease and HIV prevention in Zimbabwe. Sexually Transmitted Diseases, 32, 238–239. doi:10.1097/01.olq.0000149782.47456.5b Lagarde, E., Dirk, T., Puren, A., Reathe, R., & Bertran, A. (2003). Acceptability of male circumcision as a tool for preventing HIV infection in a highly infected community in South Africa. AIDS, 17(1), 89–95. doi:10.1097/01.aids.0000042594.93174.ed Lundsby, K., Dræbel, T., & Wolf Meyrowitsch, D. (2012). “It brought joy in my home as in the area of my wife.” How recently circumcised adult men ascribe value to and make sense of male circumcision. Global Public Health, 7, 352–366. doi:10.1080/17441692.2011.632638 Mattson, C. L., Bailey, R. C., Muga, R., & Poulussen, R. (2005). Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya. AIDS Care: Psychological and Socio-Medical Aspects of AIDS/HIV, 17, 182– 194. doi:10.1080/09540120512331325671 McAllister, R., Travis, J., Bollinger, D., Rutiser, C., & Sundar, V. (2008). The cost to circumcise Africa. Journal of Men’s Health, 7, 307–316.
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Ngodji, T. K. (2010). Knowledge, attitudes and practices of male circumcision for HIV prevention among voluntary counseling and testing clients in Onandjokwe District Hospital, Namibia. Cape Town: University of Western Cape. Njeuhmeli, E., Forsythe, S., Reed, J., Opuni, M., Bollinger, L., Heard, N., … Hankins, C. (2011). Voluntary medical male circumcision: Modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Medicine, 8(11), e1001132. doi:10.1371/journal.pmed.1001132 Saldanha Bay Municipality. (2013). IDP 2012-2017 revision 1 (pp. 145–149). Saldanha Bay: Author. Shisana, O., Rehle, T., Simbayi, L., Zuma, K., Jooste, S., Zungu, N., … Al, E. (2014). South African national HIV prevalence, incidence and behaviour study, 2012. Cape Town: Human Sciences Research Council. Siegfried, N., Muller, M., Deeks, J., & Volmink, J. (2013). Male circumcision for prevention of heterosexual acquisition of HIV in men. The Cochrane Collaboration, 5, 1–39. Sorrells, M. L., Snyder, J. L., Reiss, M. D., Eden, C., Milos, M. F., Wilcox, N., & Van Howe, R. S. (2007). Fine-touch pressure thresholds in the adult penis. BJU International, 99, 864–869. doi:10.1111/j.1464-410X.2006.06685.x South African National AIDS Council. (2012). National Strategic Plan on HIV, STIs and TB. Pretoria: Author. p. 32. Vambe, D. (2013). A study of KAP of circumcised men towards safe sex in Manakayane district in Swaziland. Stellenbosch: Stellenbosch University. Westercamp, N., & Bailey, R. (2007). Acceptability of male circumcision for prevention of HIV/ AIDS in Sub-Saharan Africa: A review. AIDS and Behavior, 11, 341–355. doi:10.1007/s10461006-9169-4 WHO. (2012). Voluntary medical male circumcision for HIV prevention. Geneva: Author.
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Perceptions and knowledge of voluntary medical male circumcision for HIV prevention in traditionally noncircumcising communities in South Africa a
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Jacob Robin Hoffman , Kirsten D. Arendse , Carl Larbi , Naomi a
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Department of Public Health, University of Cape Town, Cape Town, South Africa Published online: 02 Mar 2015.
To cite this article: Jacob Robin Hoffman, Kirsten D. Arendse, Carl Larbi, Naomi Johnson & Lauraine M.H. Vivian (2015) Perceptions and knowledge of voluntary medical male circumcision for HIV prevention in traditionally non-circumcising communities in South Africa, Global Public Health: An International Journal for Research, Policy and Practice, 10:5-6, 692-707, DOI: 10.1080/17441692.2015.1014825 To link to this article: http://dx.doi.org/10.1080/17441692.2015.1014825
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Global Public Health, 2015 Vol. 10, Nos. 5–6, 692–707, http://dx.doi.org/10.1080/17441692.2015.1014825
Perceptions and knowledge of voluntary medical male circumcision for HIV prevention in traditionally non-circumcising communities in South Africa Jacob Robin Hoffman*, Kirsten D. Arendse, Carl Larbi, Naomi Johnson and Lauraine M.H. Vivian
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Department of Public Health, University of Cape Town, Cape Town, South Africa (Received 17 April 2014; accepted 17 November 2014) Voluntary medical male circumcision (VMMC) has been recommended for the prevention of HIV transmission, particularly in sub-Saharan Africa. Uptake of the campaign has been relatively poor, particularly in traditionally non-circumcising regions. This study evaluates the knowledge, attitudes and practices of medical male circumcision (MC) of 104 community members exposed to promotional campaigns for VMMC for five years. Results show that 93% of participants have heard of circumcision and 72% have heard of some health benefit from the practice. However, detailed knowledge of the relationship with HIV infection is lacking: 12.2% mistakenly believed you could not get HIV after being circumcised, while 75.5% believe that a circumcised man is still susceptible and another 12.2% do not know of any relationship between HIV and MC. There are significant barriers to the uptake of the practice, including misperceptions and fear of complications commonly attributed to traditional, non-medical circumcision. However, 88.8% of participants believe circumcision is an acceptable practice, and community-specific promotional campaigns may increase uptake of the service. Keywords: circumcision; HIV; prevention; South Africa
Introduction In South Africa, voluntary medical male circumcision (VMMC) forms part of the National Strategic Plan for HIV, sexually transmitted infections and TB 2012–2016, which aims to reduce the 12.2% national prevalence of HIV infection (South African National AIDS Council, 2012; Shisana et al., 2014). The promotion of VMMC in South Africa is linked to a broader intervention by the World Health Organization (WHO) and the Joint United Nations Programme for HIV/AIDS (UNAIDS) to encourage medical male circumcision (MC) for HIV prevention in 14 priority countries with high HIV prevalence and low MC rates (WHO, 2012). The intervention was launched in the wake of evidence from three large randomised-controlled trials (RCTs) involving over 11,000 participants, which suggested the procedure may reduce female-to-male transmission of HIV by up to 60% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Much of the burden of disease is in those aged 25–49 years of age, with an incidence of 25%–30% in these age groups in South Africa (Shisana et al., 2014). VMMC may
*Corresponding author. Email: [email protected] © 2015 Taylor & Francis
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be a complementary tool for addressing high incidence of HIV infection rates in this age bracket. Feasibility and cost-effectiveness studies conducted prior to the WHO campaign suggest that 80% coverage of MC would be necessary to significantly impact HIV incidence and may decrease incidence by up to 35% (Hallett et al., 2008; Njeuhmeli et al., 2011; Westercamp & Bailey, 2007). However, little data exist, which evaluate the impact of the intervention on targeted communities, particularly those that are noncircumcising, where penetration of public health services has been notably poor. This study was conducted in two neighbouring, non-circumcising communities of Saldanha Bay in the Vredenberg District in the the Western Cape province of South Africa, where local health services have been promoting and undertaking VMMC services for the last five years. Prevalence of HIV infection in the Western Cape province is 5.0%, below the national prevalence of 12.2%. Uptake of the service has been poor and this study was conducted to identify potential facilitating or inhibiting factors. It is not yet understood what motivates members of traditionally non-circumcising communities to seek VMMC services. However, knowledge of the procedure and its benefits, associated risks and sociocultural aspects likely influence the decision to become circumcised (Westercamp & Bailey, 2007). Establishing motivating factors within this target population was thus a key objective of the study. It was anticipated that knowledge of MC among the study population would be derived from both medical and non-medical sources. Given that multiple factors influence uptake of VMMC, it is imperative to identify local barriers within a broader sociopolitical context. Furthermore, concerns surrounding the scaling up of VMMC services such as risk compensation, questionable external validity of the RCTs on which the intervention is based and issues related to cost-effectiveness raise ethical concerns about the appropriateness of the WHO-driven intervention compared to the controlled trials (de Lange, 2013; Green et al., 2010; McAllister, Travis, Bollinger, Rutiser, & Sundar, 2008). Other bioethical concerns surrounding the function of the male foreskin in sexual health should also be considered in the promotion of VMMC campaigns. A study conducted in Denmark found that rates of sexual dysfunction are greater for circumcised men and women with circumcised spouses (Frisch, Lindholm, & Grønbæk, 2011). Men reported more orgasm difficulties while women reported orgasm difficulties, dyspareunia and incomplete sexual needs fulfilment. These increased sexual difficulties were robust when adjusting for religious differences and suggest that both men and women may have increased sexual dysfunction following circumcision. Biological evidence supports concerns that MC may lead to sexual difficulties. Sensory testing examining fine-touch pressure thresholds of the circumcised and uncircumcised penis found that MC ablates some of the more sensitive areas of the adult penis (Sorrells et al., 2007). While some researchers have found decreased sexual needs fulfilment, other studies of recently circumcised men have shown positive results regarding how the practice is taken up in traditionally non-circumcising communities (Lundsby, Dræbel, & Wolf Meyrowitsch, 2012). However, there is still a gap between the perceived acceptability of the practice and the rate of uptake (Lundsby et al., 2012). Our study is the first to investigate the knowledge, attitudes and practices surrounding MC in an area where VMMC services have been promoted for HIV prevention over a five-year period. As such, it has the potential to elucidate barriers facing health promoters in this region. Furthermore, these insights may be extrapolated to the evaluation of similar campaigns elsewhere.
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Methodology An analytical cross-sectional study design was employed, encompassing both quantitative and qualitative components. A questionnaire was used to obtain the necessary data and was designed based on the requirements of stakeholders, from reviewing current relevant literature and the adaptation of a few previously used questionnaires (Ngodji, 2010). The questionnaire, which encompassed a mixture of open- and closed-ended questions, was initially written in English and then translated into Afrikaans. To ensure validity of our study, bias and chance association was minimised. The questionnaire was designed to elicit prior knowledge or assumptions about MC before divulging any information on the existence of health benefits or risks, or alluding to the campaign that had been carried out in the area. This was done to avoid confounding results when reporting on prior knowledge and preferences. Questions related to the medical practice of circumcision were posed before asking about worries related to the procedure or knowledge of risks related to circumcision. Following the initial questions, prompts were given later in the interview so that perceptions surrounding health benefits, risks and motivating factors could be explored in more detail. The questionnaires may be found in the Supplementary material. Data collection was conducted in the town of Saldanha, specifically in the communities of Diazville and White City. Saldanha Bay is located in the West Coast Region of the Western Cape, South Africa. Residents of this area are predominantly Christian, Coloured (a South African term for people of mixed descent) and Afrikaansspeaking. Both males and females of age 18 years and older were included in the study. The communities of White City and Diazville are located in the Saldanha Bay municipality. An outline of Saldanha Bay Municipality’s Integrated Development Plan indicates that White City has a population of 6205 (Saldanha Bay Municipality, 2013). Of the community members, 52% are Coloured, 34% Black African, 12% White and 1.5% Asian/Indian. Of the individuals, 28.6% have no monthly income and another 21.7% of individuals earn between R1 and R3200 per month. 29.4% of households have an annual income less than R38,200 per annum. Diazville has a population of 8591. The community is 85% Coloured, 14% Black African and the remaining 1% Asian, Indian and White. 46% of individuals have no monthly income and another 42% of individuals earn between R1 and R3200 per month. 45% of households have an annual income less than R38,200 per annum. In both communities, more than 90% of individuals live in a house or formal structure and over 95% have access to basic amenities. Most relevant economic activities include employment at local fishing, agriculture, mining and tourism industries and other skill-based labour. The study required that participants: . Be permanent residents of Diazville or White City . Have lived in the area for at least five years (i.e. before 2008) . Consented to partake in the study A sample size of 100 was agreed upon prior to data collection. In total, 126 households were visited, and a final sample population of 104 individuals was obtained. There were 67 men aged 18–78 and 37 women aged 20–86 that made up the sample of 104 participants. The sample size was comparable to similar studies conducted on this topic and consisted only of individuals from traditionally non-circumcising backgrounds (Lagarde, Dirk, Puren, Reathe, & Bertran, 2003; Lundsby et al., 2012; Mattson, Bailey, Muga, & Poulussen, 2005; Vambe, 2013).
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Data collection, in the form of face-to-face, interviewer-facilitated completion of a questionnaire took place over a period of three days from 29 to 31 July 2013 (two days in Diazville and one day in White City). The interviews were conducted in Afrikaans (and/or English where possible) by one of four Bachelor of Medicine and Bachelor of Surgery students from the University of Cape Town in their fourth year of study. A local community health worker who worked in the area at the time of the study accompanied each student and assisted with communicating and translating. Community health workers also helped to identify households suitable for interview. Opportunistic sampling was also employed, whereby residents encountered on the street were approached and recruited. Following presentation and explanation of the study and the consent form, all eligible participants were required to provide written, signed informed consent. Interviews lasted 10–15 minutes on average and took place primarily in the vicinity of participants’ homes or on the street. Before completion of the interview, questionnaires were checked for completeness. Following data collection, questionnaires were coded and results entered into an Excel spreadsheet. A health benefits knowledge score was calculated for each participant. This score is an indicator of the general awareness of circumcision practice, real and perceived health benefits of MC, as well as the relationship between circumcision status and risk of HIV infection. The score reflected a summation of points awarded for answers to certain questions through the questionnaire. One point was awarded if the participant had heard of circumcision (Question B1). Up to six points were awarded for knowledge of any or specific health benefits (Questions C2 and C3). Up to four points were awarded for knowledge of the correct relationship between MC and HIV infection (Questions C4, C5, C6 and C7). The questions and points awarded in formulating the health benefits knowledge score were as follows and relate to the questionnaire in the supplementary material (S1): Question B1, yes = 1 point, no = 0 points; Question C2, yes = 1 point, no = 0 points; Question C3, 1 point awarded for each health benefit listed. Question C4, yes = 1 point, no = 0 points; Question C5, 1 point awarded for ‘lowers risk of HIV’. No points for any other answer; Question C6, yes = 1 point, no = 0 points; Question C7, yes = 1 point, no = 0 points. The final score was a sum of the points awarded with a maximum total of 11 points. Participants were then stratified into high and low health benefit knowledge score groups, with six points or more defined as having a high score. This was chosen as 54.8% of participants had knowledge scores of five or lower, thus obtaining two groups of proportional size, an upper and lower half of those interviewed. These two groups were used for further analysis as a categorical variable in place of the raw health benefits knowledge scores obtained. Prism 5 and Stata were used for statistical analysis and the generation of appropriate figures and tables. Significant differences and associations between demographic and outcome data, or between two or more outcomes, were investigated. Chi-squared and Fisher exact tests were employed to test the association of categorical variables. The level of significance for all statistical tests was set at p = .05.
Results Results describe the social demographics of the population, the practice of circumcision in the communities, the knowledge and sources of information for MC, motivating factors and finally barriers to the uptake of VMMC in these communities.
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Socio-demographic description of the study population Participants’ ages ranged from 18 to 86 years, spanning the target population for the intervention as well as the parents of those in target populations. The highest prevalence age group (28.8%) was between 35 and 44 years old. Relationship status was fairly equally distributed between married participants (31.7%), those in a relationship (30.8%) and single (37.5%). Most participants (69.2%) had some secondary-level education, whereas 14% received primary-level education and 16% completed matric. Participants were predominantly unemployed (61.5%) and two-thirds (70.2%) had a total monthly household income of less than R3000 ($288), whereas a quarter (23.1%) received more than R3000 ($288). Afrikaans was the most common home language (96.2%) with only one individual speaking English at home and 2.9% other languages. Of the 79% who considered themselves religious, 94.2% were Christian with other religious groups making up the remainder, including Islam and Rastafarianism. MC in the communities In total, 16 (23.9%) men interviewed were circumcised, which was not delineated by age. The highest prevalence was in the 25- to 34-years age bracket with a circumcision rate of 27.8%. The lowest prevalence was in the 35- to 44-years age bracket with a prevalence rate of 14.3%. There were no significant differences with regard to circumcision status and employment, relationship status, level of education or religion. Over half of the circumcised respondents had been circumcised as adults (56.2%), a quarter had been circumcised as babies (25.0%) and the remainder as pre-adolescents (18.8%). Half of the men were circumcised in a hospital. Others had been to a private doctor, traditional circumcision camps or were circumcised at home, representing a range of underlying medical and non-medical motivating factors. Men were circumcised for beliefs in improved hygiene and health benefits (26%) or for cultural or religious reasons (37%). Others did not provide a reason for their circumcision (26%) or did not know why their parents made the decision for them when they were children (11%). Two men who had traditional circumcisions were from Sotho families and thus from a traditionally circumcising background, while another was Zulu, which is a non-circumcising culture. The other traditional circumcisions were for men of amaXhosa heritage, although they did not identify isiXhosa as their language and culture. Traditional circumcision was often framed as a rite of passage and part of ‘becoming a man’. These reasons are displayed in Figure 1.
Figure 1.
Reasons for circumcision among circumcised participants.
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Although there were few men who were circumcised, most participants (93.3%) had heard about MC. The majority (64.4%) knew of someone in their community who was circumcised and many had heard of family members who had been circumcised (46.2%). Information about circumcision was obtained largely from family and community members, with under a third (28.8%) having been exposed to the government campaigns and less than one-fifth through formal contact with the health system, whether directly from a medical professional or from print media. Of those who indicated exposure to the campaign through any form of media, those interventions run by local government shared an almost equal proportion with TV coverage via news, documentaries or advertisements. General knowledge of MC, explanation of circumcision practice and perceived health benefits knowledge score Participants’ ability to explain circumcision was rated as poor, average or good when answering Question B3. This distinction was made primarily based on the ability to describe the procedure and was considered good if the participant added information related to anatomy removed or insight into reasons for getting circumcised, including perceived health benefits and religious or cultural reasons. The overall ability to explain circumcision was neither comprehensive, inclusive of perceived health benefits and risks, nor poor. Of those interviewed, 29.1% explained circumcision poorly and 47.6% indicated that they knew the procedure involves removal of tissue from the penis, but did not offer knowledge of anatomy or function of the foreskin. Of the respondents, 23.3% could explain circumcision well, had good knowledge of the tissue removed and mentioned perceived health benefits as a result of circumcision. The median score for the health benefits knowledge scores was 6 (18.3%) with scores 4, 5, 6, and 7 out of 11 accounting for more than 65% of respondents. 26% had a health benefits knowledge score of 3 or less, whereas 9% had a score of 8 or more. When evaluating associations with the health benefits knowledge score, there were roughly equal numbers who had a good health benefits knowledge score as those with poor ones. There was no significant difference in high or low health benefits knowledge score when delineated by socio-demographic characteristics. Knowledge of MC and health benefits When asked about health benefits, 71.8% of participants knew of at least one health benefit, whereas 28.2% of participants knew of none. The participants were asked for specific health benefits, determining prior knowledge without prompts. The most commonly reported health benefit of MC was the perception of improved genital hygiene (52.0%). Nearly a third (31.7%) of the participants identified reduced risk of STIs as a health benefit, but few (15.4%) explicitly mentioned any link between circumcision and HIV. Knowledge around MC and HIV Although few people mentioned the reduced risk of HIV when unprompted, 26.9% said that they understand there is a relationship between MC and HIV when asked directly. However, only 18.3% understood the correct relationship without direct questioning, while 12.2% believed that a man who is circumcised could not get HIV (Table 1). There was no difference in this knowledge based on circumcision status.
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Table 1. Knowledge about the relationship between MC and HIV. Yes (%)
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Knowledge that relationship exists Knows correct relationship Believes circumcision can reduce risk of HIV Believes one can still get HIV after circumcision
28 19 67 74
(26.9) (18.3) (68.4) (75.5)
No (%) 76 85 23 12
(73.1) (81.7) (23.5) (12.2)
I don’t know (%)
Total (n)
8 (8.2) 12 (12.2)
104 104 98 98
Motivating factors for VMMC The vast majority (88.8%) of participants believe circumcision is an acceptable practice, which showed no difference across socio-demographic characteristics or gender. Acceptability is shown in Figure 2 and relation to socio-demographics in Figure 3. The majority of men (57.7%), women (60.2%) and mothers (70.4%) are seen to prefer circumcision for themselves, their partners or their sons, respectively (Table 2). The reasons given for preferences include cleanliness, health, safety, protection, cultural and religious reasons, as well as sex-related benefits. Reasons given for people not preferring circumcision are fear of pain or complications, circumcision not forming part of their culture or religion or that the decision should belong to the individual and is not for one’s family to decide (Table 2). Among the uncircumcised men, there was an overall significant correlation between higher health benefits knowledge scores and willingness to consider going for circumcision (n = 49, χ2 = 4.69, p = .03). The knowledge of any health benefit was significantly associated with a greater likelihood of considering circumcision (n = 49, χ2 = 4.31, p = .038), with the perception of improved genital hygiene being the most significant association with willingness to consider circumcision (n = 49, χ2 = 5.22, p = .022). Men willing to consider circumcision (83.3%) reported the belief of improved hygiene as being an encouraging factor. However, at the end of the interview, after providing participants with accurate information regarding medical MC, prevention of HIV infection was the most frequently given motivator for uncircumcised men considering circumcision (91%) (Tables 3 and 4).
Figure 2.
Overall acceptability of MC.
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Figure 3.
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Acceptability of circumcision by socio-demographic characteristics.
Risks, barriers and complications Participants were asked to identify general and specific risks related to MC, but 65.4% were not aware of any risks regarding the medical procedure or in relation to traditional practice. There was no significant difference in risk perception by socio-demographic characteristics or circumcision status. Infection was the most frequently identified risk (45.9%), if a risk was identified at all. Other commonly reported risks were death (21.6%), bleeding (13.5%) and pain (5.4%) (Table 5). Six participants reported that risks were specifically associated with traditional circumcisions, citing media coverage of traditional practices in the Eastern Cape, which highlights the risk of infection and death. One man believed there was an increased risk of getting HIV if circumcised, based on similar media coverage. When asked about personal worries or barriers to them considering the procedure or encouraging their partners or sons to be circumcised, the majority of respondents mentioned at least one factor that would discourage or prevent them from undergoing circumcision. The most commonly cited reason was fear of infection (41.8%), followed by pain (38.8%), religion, loss of performance, time off work and reaction of peers. Infection and pain were feared for both medical and traditional circumcisions. Some respondents expressed desire for clinics to provide more information about the procedure, pain management and the healing process. Table 2. Reasons for perceived positive and negative preferences for men, partners and sons being circumcised.
Positive reason Cleanliness/health Safety/protection/fewer illnesses Cultural/religious/personal reasons Sex-related benefit Negative reason Fear (pain, complications) Cultural or religious reasons It is the child’s decision
Men prefer
Women prefer
Mothers prefer
19 15 7 2
13 16 2 2
17 20 4 0
5 4 0
3 1 0
0 1 1
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Table 3. factors.
Male participants’ willingness to consider circumcision by health benefits knowledge
Knowledge score Low knowledge score High knowledge score Heard of health benefits No Yes Benefit – hygiene No Yes Benefit – HIV No Yes Benefit – STIs No Yes Benefit – penile cancer No Yes Benefit – cervical cancer No Yes Total
Not willing to consider circumcision (n = 25)
Willing to consider circumcision (n = 24)
Total (%) (n = 49)
19 (76.0) 6 (24.0)
11 (45.8) 13 (54.2)
30 (61.2) 19 (38.8)
.030
11 (44.0) 14 (56.0)
4 (16.7) 20 (83.3)
15 (30.6) 34 (69.4)
.038
19 (76.0) 6 (24.0)
9 (37.5) 15 (62.5)
28 (57.1) 21 (42.9)
.022
22 (88.0) 3 (12.0)
21 (87.5) 3 (12.5)
43 (87.8) 6 (12.2)
19 (76.0) 6 (24.0)
14 (58.3) 10 (41.7)
33 (67.3) 16 (32.7)
24 (96.0) 1 (4.0)
24 (100) 0 (0)
48 (98.0) 1 (2.0)
24 (96.0) 1 (4.0) 25 (51.0)
24 (100) 0 (0) 24 (49.0)
48 (98.0) 1 (2.0) 49 (100)
p value
Note: Significance displayed for χ2: p < .05, p value stated in table.
Financial barriers to VMMC were also raised. The majority of respondents (76.9%) did not know that the service is offered for free at the local clinic or hospital. There were no significant differences in this knowledge between male and females, circumcised and uncircumcised men or those willing and not willing to consider circumcision. Table 6 considers the barriers and preventative factors given by participants related to willingness to consider the procedure. Unsurprisingly, those not willing to consider circumcision were more likely to have heard of risks related to the procedure (n = 49, χ2 = 3.99, p = .046); a similar pattern emerged for those willing to encourage children or partners to undergo circumcision. However, there was no single particular worry or preventative factor. Over half (54%) of participants responded that proper explanation of the procedure would make them feel more comfortable, and 43% believed that better understanding of the pain management process would encourage them to undergo circumcision.
Discussion This study is the first to examine knowledge, attitudes and practice of VMMC in traditionally non-circumcising communities that have been exposed to a promotional campaign for five years.
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Table 4. Male participants’ willingness to consider circumcision by encouraging factors. Not willing to consider circumcision (n = 25)
Willing to consider circumcision (n = 24)
Total (%), n = 49
1 (4.0) 24 (96.0)
1 (4.2) 23 (95.8)
16 (32.7) 33 (67.3)
11 (44.0) 14 (56.0)
4 (16.7) 20 (83.3)
15 (30.6) 34 (69.4)
7 (28.0) 18 (72.0)
2 (8.3) 22 (91.7)
9 (18.4) 40 (81.6)
8 (32.0) 17 (68.0)
7 (29.2) 17 (70.8)
15 (30.6) 34 (69.4)
9 (36.0) 16 (64.0)
14 (58.3) 10 (41.7)
23 (46.9) 26 (53.1)
10 (40.0) 15 (60.0)
18 (75.0) 6 (25.0)
28 (57.1) 21 (42.9)
Any encouraging factor No Yes Encourage – hygiene No Yes Encourage – HIV No Yes Encourage – STIs No Yes Encourage – UTI No Yes Encourage – religion No Yes
p value
0.038
0.018
Note: Significance displayed for χ2: p < .05, p value stated in table.
Knowledge of circumcision: sources, health benefits and acceptability It was found that prevalence of circumcision in these traditionally non-circumcising communities was expectantly low, but knowledge of circumcision was notably high despite minimal exposure to the campaign. Circumcision is a sensitive topic, yet the majority of participants had heard about it through family and friends and not through formal health-care campaigns. Information was shared between male work colleagues and was gathered through family and friends for the majority of the women. Women were commonly supportive of the practice and believed in some benefit to their sexual health, such as reduced risk of infection for themselves and their partners and believed it improved genital hygiene. MC was a highly acceptable practice, with many men willing to consider it despite low knowledge of HIV-related benefits. Overall knowledge of circumcision health benefits was average, with few displaying poor or no knowledge of circumcision, similar to results obtained by Ngodji (2010). Three-fourths (75.5%) of participants were aware of some health benefit; however, most Table 5.
Knowledge of circumcision complications.
Complication Infection Death Bleeding Pain
Frequency, N = 37 (%) 17 8 5 2
(45.9) (21.6) (13.5) (5.4)
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Table 6. Male participants’ willingness to consider circumcision by preventing factors, risks and worries.
Any preventing factor No Yes Prevent – risk of infection No Yes Prevent – peers No Yes Prevent – loss of performance No Yes Prevent – pain No Yes Prevent – work No Yes Any perceived risks No Yes Any worries surrounding the procedure No Yes Worry – pain No Yes Worry – infection No Yes Worry – performance No Yes Worry – inexperience No Yes Worry – other No Yes
Not willing to consider circumcision (n = 25)
Willing to consider circumcision (n = 24)
Total (%), n = 49
3 (12.0) 22 (88.0)
12 (50.0) 12 (50.0)
15 (30.6) 34 (69.4)
11 (44.0) 14 (56.0)
17 (70.8) 7 (29.2)
28 (57.1) 21 (42.9)
20 (80.0) 5 (20.0)
19 (79.2) 5 (20.8)
39 (79.6) 10 (20.4)
15 (60.0) 10 (40.0)
20 (83.3) 4 (16.7)
35 (71.4) 14 (28.6)
11 (44.0) 14 (56.0)
16 (66.7) 8 (33.3)
27 (55.1) 22 (44.9)
20 (80.0) 5 (20.0)
17 (70.8) 7 (29.2)
37 (75.5) 12 (24.5)
13 (52.0) 12 (48.0)
19 (79.2) 5 (20.8)
32 (65.3) 17 (34.7)
11 (44.0) 14 (56.0)
14 (58.3) 10 (41.7)
25 (51.0) 24 (49.0)
20 (80.0) 5 (20.0)
19 (79.2) 5 (20.8)
39 (79.6) 10 (20.4)
23 (92.0) 2 (8.0)
23 (95.8) 1 (4.2)
46 (93.9) 3 (6.1)
25 (100) 0 (0)
24 (100) 0 (0)
49 (100) 0 (0)
22 (88.0) 3 (12.0)
23 (95.8) 1 (4.2)
45 (91.8) 4 (8.2)
18 (72.0) 7 (28.0)
19 (79.2) 5 (20.8)
37 (75.5) 12 (24.5)
p value **
0.046
Note: Significance displayed for χ2: p < .05, p values stated in table; **p < .01.
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(52.0%) identified only the perception of improved hygiene. Only 15.4% mentioned, without prompt, that circumcision reduced one’s risk of HIV, though 68.8% stated that this was true when asked directly. The highly prevalent perception of basic health benefits from MC may underlie high acceptability of circumcision, as perception of hygienic benefits has a strong association with acceptability (Halperin, Fritz, McFarland, & Woelk, 2005; Westercamp & Bailey, 2007).
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Motivators of MC: contextual and community-specific In the sub-Saharan setting, consistent motivators identified comprise of hygienic benefit, protection from HIV and STIs and the perceived increase in sexual pleasure (Westercamp & Bailey, 2007). Motivators were put forth predominantly by females, particularly beliefs concerning improved hygiene and reduced risk of infection (Mattson et al., 2005). However, it was interesting to note that other studies in South Africa found no association between willingness to be circumcised and perceived health benefits (Westercamp & Bailey, 2007). The strongest predictor in this setting for voluntary MC is the perception of increased sexual pleasure (Westercamp & Bailey, 2007). In our study, sex-related reasons were the least commonly given for respondents regarding perceived preferences for circumcision and did not emerge as strong motivators for MC. Instead, the biomedical rationale came through strongly, supporting circumcision for safety from infection or perceived hygienic benefit. Women and mothers were seen to prefer circumcision for their partners and sons (60% and 70%, respectively). Their predominant motivators were that MC could provide protection from infection, although interestingly, protection from HIV was not explicitly stated as a motivating factor for MC, only becoming a significant motivator once informed of the potential health benefits from being circumcised. Behavioural adaptation and the potential for risk compensation Concerns with the promotion of MC to lower a man’s risk of HIV and other STIs include questionable validity of the RCTs on which the intervention is based, risk compensation, condom avoidance, sexual dysfunction and false perceptions of immunity from HIV and STI’s following circumcision, which may increase male-to-female transmission (Auvert et al., 2005; Bridges, Selck, Gray, McIntyre, & Martinson, 2011; Frisch et al., 2011; Green et al., 2010). There is a chance of increased risky sexual behaviour following VMMC due to misconceptions around the extent to which circumcision protects against HIV (Auvert et al., 2005). If men have sexual intercourse before the circumcision wound is fully healed, they are also likely to be at greater risk of HIV acquisition (Auvert et al., 2005). A meta-analysis that looked at changes in sexual behaviour as secondary outcomes of the three RCTs found no statistically significant changes in sexual behaviour or risk compensation (Siegfried, Muller, Deeks, & Volmink, 2013). However, in South Africa circumcised men had a significantly higher number of sexual partners compared to their uncircumcised counterparts (Siegfried et al., 2013). In the Kenyan study, there was an overall decrease in risky sexual behaviour in both circumcised and uncircumcised groups; however, the intervention group had significantly higher levels of unprotected sex and lower consistent condom use (Bailey et al., 2007). In our study, 12.2% mistakenly believe that men who are circumcised cannot get HIV, while 75.5% believe that a circumcised man is still susceptible. A study in
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Namibia found that 7.6% of men believed that a circumcised man does not need to wear a condom (Ngodji, 2010), whereas a study conducted in Swaziland indicated that only 1.6% of participants believed that circumcision provides 100% protection from HIV (Vambe, 2013). Our result of 12.2% is notably larger than in these other studies, highlighting the need for adequate pre- and post-procedure counselling as well as health promotion to inform men and women that a circumcised man and all his potential partners are still susceptible to HIV and other STIs, and that safe sex practices are still advisable. This in itself may affect willingness to become circumcised and willingness to encourage a partner or child to become circumcised, as continued protection would still require safe sexual practices. Although MC significantly decreases an individual’s risk of contracting HIV, it is yet to be seen how this, when scaled up to national levels, may impact the HIV epidemic and whether the decrease in incidence will be as substantial as predicted (Garenne, 2008). In another study, Hallett et al. (2008) used a deterministic model to estimate the impact of such an intervention. They predict that if effectively implemented with 90% population coverage, addition of VMMC to current efforts could decrease HIV prevalence by 25%– 35%, assuming no risk compensation occurs. Indeed, the cost-effectiveness of the intervention has been under question, which would be further hampered by risk compensation (McAllister et al., 2008). Unforeseen complications when scaling up to the national level may be detrimental to expanding the intervention, including ethical concern about broadening the practice to minors, who are unable to consent or dissent independently. Furthermore, findings that relate to sexual dysfunction after circumcision are of concern and raise bioethical issues around the promotion of MC campaigns (Frisch et al., 2011; Sorrells et al., 2007). Informed consent would require knowledge of the foreskin’s functional relevance and possibility of sexual dysfunction. Additional concerns regarding proxy consent and substitute decision-making emerge when applied to minors. Promoters of MC should have an understanding of the level of knowledge within the population concerning these findings and their implications for sexual health. Knowledge of these aspects of MC should be sought and addressed in future studies looking at population knowledge of MC, especially in those areas where promotional campaigns are already underway. While further investigation of differences in sexual experience and sexual difficulties should be examined in the future, it is beyond the scope of this study. Feasibility for the future: perceived risks and the future of the campaign Of the men who were uncircumcised, roughly half would consider going for circumcision. Men were more likely to consider circumcision if they had a high knowledge score or were aware of hygienic benefits of circumcision. Knowing a family member was similarly significant and likely represents a trustworthy source of information for the potential patient. Hygienic benefit was the most common encouraging factor given by women, whereas prevention of HIV was the strongest encourager for men willing to consider circumcision (91%). This is encouraging for future campaigns as it suggests a strong underlying motivating factor for MC. However, it is of concern that this has not translated into increased uptake of the service. Inhibiting factors must be considered if the campaign is to achieve the 80% coverage it seeks. When asked about risks of circumcision, 35.6% of the participants said that they knew of some. Of the respondents, infection was identified as the most common (45.9%), with death coming second (21.6%). The complications and risks of VMMC in a clinic
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setting were fear of pain and infection. No respondents mentioned fear of sexual dissatisfaction nor indicated that they were aware of this potential risk. Many of these participants had mentioned their exposure to media surrounding traditional circumcision practices among African populations, particularly in the Eastern Cape and Limpopo, which resulted in infection and death. This indicates a lack of distinction between VMMC and traditional practices in these communities and has an effect on uptake of the service. The majority who would consider going were less likely to believe that there are risks such as those associated with traditional practices. In many studies about the acceptability of MC in traditionally non-circumcising communities, a recurring barrier is the cost of the procedure as well as additional costs such as transport to the clinic and absence from work (Westercamp & Bailey, 2007). In the Vredenburg district, circumcision at the state hospital is free; however, this study found that only 16% of respondents knew that the service was free and 77% did not know the cost, suggesting that informing communities that circumcision is free may increase circumcision uptake.
Implications and limitations of this study for future campaign evaluation The results of our study cast doubt on whether targets of 80% coverage within five years (Njeuhmeli et al., 2011) can feasibly be met without addressing community-specific barriers and developing a combination approach to underpin the campaign in different areas. The information currently circulating in these communities is not sufficient to stimulate high uptake of an intervention promoting MC for the prevention of HIV transmission. Prevention of HIV was the most encouraging motivator across all groups of men, yet the role of VMMC in HIV prevention was not well known. The scope of the information available to the communities regarding MC is limited and this superficial knowledge is vulnerable to influence from media coverage of traditional circumcision in other parts of South Africa. This was evidenced in a high number of perceived risks surrounding traditional circumcision including infection and death, as opposed to more intuitive fears such as pain and bleeding in the post-operative period (Westercamp & Bailey, 2007). In conclusion, if the WHO-backed intervention is to be successful, and the target of 80% coverage is to be reached, more research needs to be done to identify regionalspecific barriers to the uptake of VMMC for HIV prevention. In these communities, barriers may be addressed by educating around misperceptions regarding traditional versus medical circumcision, addressing risk compensation and stimulating the dissemination of high-quality information regarding the biological and social relevance of circumcision in HIV prevention and the availability of subsidised local services. In this study, 12.2% interviewed believed a man can no longer become infected with HIV once circumcised. This is of concern and must be addressed if risk compensation is to be minimised. This relatively small study conducted in traditionally non-circumcising communities has shown that many social and political influences play a role in motivating or discouraging someone to consider circumcision. By addressing the causes of the concern and providing good quality, detailed biomedical information on the topic to all involved, the intervention stands to be more successful.
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Acknowledgements The authors thank all those who made this research possible, including the University of Cape Town Department of Public Health and Primary Healthcare Directorate. The authors also thank the people and organisations who worked with them in the communities of Vredenberg District, including Western Cape Government, Vital Connection and Mfesane.
Disclosure statement No potential conflict of interest was reported by the authors. Supplemental data
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Supplemental data for this article can be accessed here.
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