Adult male circumcision as an intervention against HIV: An operational study of uptake in a South African community (ANRS 12126)

The protective effect of adult male circumcision (AMC) on HIV acquisition has been reported in a review of epidemiological studies [1] and demonstrated by three randomized controlled trials conducted in Southern and Eastern Africa, which found that the risk of HIV acquisition among circumcised adult men was reduced by about 60% [2‐4]. As a health intervention, AMC is predicted to be significantly life- and cost-saving in terms of averted HIV infections and related medical costs [5‐8].

In 2007, WHO/UNAIDS recommended AMC as an important, additional intervention which should be delivered as part of a comprehensive HIV prevention package in communities with generalized HIV epidemics and low AMC prevalence [9]. Since this recommendation, efforts are being applied to roll-out safe and effective AMC services in several Eastern and Southern African countries [10‐12].

A review of studies investigating the acceptability of AMC as an intervention against HIV among Sub-Saharan African communities not practicing male circumcision was conducted in 2006 [13]. AMC acceptability among men was defined as their willingness to undergo the procedure. This review reported medium-high to high acceptability of AMC, if performed safely and at minimal cost, of 65% (95% confidence interval (CI): 29% to 87%) among men for themselves. As this review of acceptability studies was conducted before all AMC trials results were known, higher levels of acceptability may be expected following the WHO/UNAIDS recommendation [9].

Little is known however about the extent to which AMC as an intervention against HIV would be actually taken up in these communities. As demonstrated by modeling studies [6, 14, 15], the uptake of AMC is a key condition for a successful roll-out because it will condition the impact of the intervention on the spread of HIV. The most frequently reported barriers to AMC uptake in African communities, which are cost and surgical safety [13], are addressed when providing free medicalised AMC. Nonetheless, other factors may facilitate or inhibit intention to undergo AMC, and their identification is necessary to refine outreach and communication strategies, design effective AMC delivery models, and optimize the impact of AMC interventions on the HIV epidemic.

The overall aim of this study was to conduct an operational study of AMC uptake in a South African community. Specifically, the objectives were to a) evaluate community knowledge, attitudes and beliefs about male circumcision, b) assess male circumcision's association with HIV incidence and prevalence in the community, c) identify the demographic, biomedical, social, behavioral, and knowledge factors associated with intention to undergo AMC and d) estimate the uptake of free medicalised AMC as an intervention against HIV.

This operational study of AMC uptake in a South African community indicates that when offered free medicalised AMC, more than half of self-reported uncircumcised men choose to become circumcised. Furthermore, the study reveals that about half of self-reported circumcised men in the study had foreskins, and that when considering only men with foreskins, HIV prevalence did not differ between self-reported circumcised men and self-reported uncircumcised men. Conversely, the reported protective effect of clinical circumcision on HIV acquisition was higher than what was reported in the three male circumcision trials [2‐4]. The study also established that most men in the community had a fairly good knowledge of AMC and its association with HIV acquisition, despite some misconceptions, and suggested that intention to undergo AMC was associated with social factors. No association was found between self-reported circumcision status and risky sexual behavior. Furthermore, men willing to become circumcised were neither more nor less likely to be HIV-positive or at higher or lower risk of acquiring HIV than men who were not willing to undergo the procedure. Lastly, no evidence of a variation of the protective effect of AMC on HIV incidence with time since circumcision was found.

It is not possible to compare the uptake reported here with other findings since this is, to the best of our knowledge, the first study on AMC uptake conducted among a random sample representative of the general population. However, another South African study has reported an uptake of 33%, lower than the present estimate, in a non-random AMC study nested in an HIV efficacy trial [23].

This study has two main limitations. The first limitation is that it was only possible to determine the characteristics of participants who reported intention to undergo AMC, and not of those who actually underwent surgery, due to the way anonymous data were collected. However, more than 70% of the men who reported intention to undergo AMC were circumcised. A second limitation is that this study was conducted in the township where the first AMC trial was conducted, which may have influenced the decision to undergo AMC and could have enhanced community knowledge about the association between AMC and HIV acquisition. It is unlikely because a survey conducted in 2008 among a random sample of male residents found that only 2.1% knew the results of the AMC trial [20]. Nonetheless, even if Orange Farm is considered a typical South African township, some caution should be used when generalizing these results to other South African communities or to other countries.

One of the most interesting findings of this study is the fact that almost half of self-reported circumcised men had in fact an intact foreskin. This is most probably due to the initiation rituals which are customarily practiced in Southern and Eastern Africa. In South Africa, and this may also be true elsewhere, the initiation rituals may or may not involve the actual removal of the foreskin [24, 25]. Hence, men having undergone such initiation rituals, usually around puberty, may call themselves "circumcised", even if their foreskin is intact. This may also explain the apparent contradictions in knowledge, attitudes & beliefs about AMC and "circumcised" men found in this study.

The study findings, along with other examples of AMC roll-out interventions which are ongoing in Kenya, Botswana, Swaziland, Zambia and Zimbabwe [12], provide evidence that a satisfactory uptake can be expected from the AMC scale-up interventions that are on-going in other countries of Southern and Eastern Africa [10]. Furthermore, the findings indicate that such interventions are likely to reach men from the general population and not just those who are at higher or lower risk of HIV infection. Therefore, if a high uptake is obtained, the effect of AMC roll-out on HIV prevalence at population level may be substantial after some years, as predicted by modeling studies [6, 14, 26].

The study has some important implications for the planning of AMC roll-out. First, men who think that they are circumcised but who are not in reality must be reached. A possibility would be to include in the communication and information documentation photos and diagrams that illustrate what a circumcised penis looks like. A randomized trial aiming to assess methods to improve the self-reporting of male circumcision status among men and their partners was conducted in 2010 in Swaziland and Zambia [12]. The upcoming results of this trial will be helpful to identify the best approach. Secondly, it is likely that AMC roll-out interventions will require extensive communication campaigns to explain what clinical AMC is and its effect on HIV acquisition. Indeed, in Orange Farm, despite a high acceptability of male circumcision and the availability of clinical AMC in the community at a cost of about 40 Euros in most local medical practices, only about 15% of the men are clinically circumcised. In the present study, to achieve the reported uptake, free medicalised AMC was offered to each eligible man during individual counseling sessions. It is unknown whether such individual contacts will still be required once national AMC campaigns are launched. Thirdly, the AMC promotion campaigns should target both primary and secondary audiences. Indeed, the importance of family and partners support of AMC on intention to undergo clinical AMC is a noteworthy finding. Fourthly, the partial protective effect of AMC should be central to communication and counselling strategies. Although current knowledge about the effect of AMC on HIV acquisition is fairly good among men from the general population, there is still a sizeable proportion who think that circumcised men are not at risk of getting HIV and do not need to use condoms for protection against HIV and other STIs. Lastly, what AMC campaigns report about issues of sexual pleasure and partners' preference may have some implications on AMC uptake. In the present study, some men, in particular those who are self-reporting as circumcised, have the beliefs that AMC increases sexual pleasure and that women might prefer circumcised men. However, scientific evidence on this issue has not been established [27, 28].

This study demonstrates that AMC roll-out is a promising intervention against the HIV epidemic in Africa but that it will require careful design and comprehensive communication strategies to be successful.