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A Trends Analysis of Medical Male Circumcision for HIV Prevention

In Eastern and Southern Africa


Keywords:
Medical, male circumcision, trends, Eastern, Southern, Africa.
ABSTRACT:

Medical male circumcision is now a part of the strategy for HIV prevention in
Eastern and Southern Africa. This paper analyses the status of research and recent
trends in male circumcision for HIV prevention in thirteen priority countries. A search
for the words male, circumcision, HIV/AIDS, Africa was done in the free online
PubMed Central database of the United States National Library of Medicine (National
Institutes of Health). In all the primary studies published over the past two years, the
major trends in VMMC include: mathematical confirmation of the protective role of
male circumcision in HIV prevention, awareness of and demand for male
circumcision, acceptability of male circumcision, male circumcision versus sexual risk
compensation, roll-out of male circumcision, and policy environment for adoption
and scale-up of male circumcision. The study revealed the need to conduct more
studies on male circumcision for HIV prevention especially in countries like Namibia,
Malawi, Lesotho, Mozambique, and Zambia. These studies should especially focus on
increasing the acceptability and roll-out of voluntary medical male circumcision as
well as implementing robust policies and allocating more local resources to this latest
strategy of HIV prevention. Uptake of voluntary medical male circumcision should be
scaled-up if the benefits of HIV prevention are to be realized.
020-029 | JRPH | 2012 | Vol 1 | No 2
This article is governed by the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/2.0), which gives permission for unrestricted use, non-commercial, distribution and
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www.jhealth.info
Journal of Research in
Public Health
An International
Scientific Research Journal
Author:
Kazhila C. Chinsembu.




Institution:
University of Namibia,
Faculty of Science,
Department of Biological
Sciences, P/Bag 13301,
Windhoek, Namibia.




Corresponding author:
Kazhila C. Chinsembu.





Email:
kchinsembu@unam.na








Phone No:
+264-61-2063426.


Fax:
+264-61-2063791.


Web Address:
http://www.jhealth.info/
documents/PH0009.pdf.


Dates:
Received: 23 Jul 2012 Accepted: 10 Aug 2012 Published: 18 Sep 2012
Article Citation:
Kazhila C. Chinsembu.
A Trends Analysis of Medical Male Circumcision for HIV Prevention In Eastern and
Southern Africa.
Journal of Research in Public Health (2012) 1(2): 020-029
Original Research
Journal of Research in Public Health
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INTRODUCTION
Male circumcision (MC), the surgical removal of
the foreskin of the penis, is practiced all over the world
for medical, religious, and cultural reasons. About
30% of men are circumcised globally (Wilcken et al.,
2010). Research has shown that MC can prevent HIV/
AIDS infection (Mwandi et al., 2011). Three randomized
controlled trials revealed that MC reduces HIV
acquisition from infected women by almost 60%
(Auvert et al., 2005; Bailey et al., 2007; Gray et al.,
2007). Further to these empirical data, the World Health
Organization (WHO) and the Joint United Nations
Programme on HIV/AIDS (UNAIDS) in 2007
recommended that countries should include medical
MC in the suite of services for HIV prevention
(Mwandi et al., 2011).
Thirteen countries in Eastern and Southern
Africa (Botswana, Lesotho, Malawi, Mozambique,
Namibia, Rwanda, South Africa, Swaziland, Tanzania,
Uganda, Zambia, Zimbabwe, and Kenya) were prioritized
for scale-up of Voluntary Medical Male Circumcision
(VMMC). The objective of this study was to analyze the
research status and trends in MC for HIV prevention in
Eastern and Southern Africa.

METHODOLOGY
The search words male, circumcision,
HIV/AIDS, Africa were entered into the free online
PubMed Central (PMC) database of the United States
National Library of Medicine (National Institutes of
Health). The search was performed on March 28, 2012,
and was limited to research and review articles
published in the two-year period between 2010 and
2012. A total of 157 publications were displayed after
the search. Of these, 30 publications were deemed
relevant to this systematic review based on the
following exclusion and inclusion criteria.
Publications that reported studies from outside
Africa and those that did not specifically deal with
HIV/AIDS and male circumcision were excluded. Review
articles and conference abstracts were not included.
Only original research articles were incorporated into
this study. These were categorised according to the year
of publication, country or countries where research was
conducted, type of research, and the main focus area of
the study (Table 1).

RESULTS
Protective effect of male circumcision on HIV
acquisition and transmission
Fiamma et al. (2010) used a longitudinal dataset
obtained during the first male circumcision randomized
controlled trial (Orange farm male circumcision trial,
ANRS-1265) and demonstrated for the first time that
the effect of the intervention could have been
approximately estimated by HIV incidence testing
applied to blood samples collected at the final follow-up
visit. Using rigorous theoretical and statistical formulae
(intention-to-treat effect, 95% confidence intervals, and
bootstrap resampling), the results of Fiamma et al.
(2010) verified the previously reported (in survival
analysis) HIV protective effect of 60% conferred by male
circumcision.
Also, using data from Kenya and Zimbabwe,
Hallett et al. (2011) mathematically modeled that
circumcision may confer a 46% reduction in the rate of
HIV transmission from circumcised men to their female
partners. They projected that the protective impact of
circumcision on the spread of HIV is substantially
increased for women, and that an increase in the risk of
acquisition and transmission of HIV during circumcision
wound healing is unlikely to have a major effect on the
population-level impact of circumcision interventions.

Chinsembu,2012
021 Journal of Research in Public Health (2012) 1(2): 020-029
Although it was previously expected that women
would benefit modestly from male circumcision
implementation (as fewer of their sexual partners would
be infected), the projections of Hallett et al. (2011)
showed that women could also receive a direct benefit
from male circumcision. These authors posited that if
their estimate about the long-term effect of
circumcision on male-to-female HIV transmission was
correct, then women in stable partnerships with
infected men would receive a degree of protection from
circumcision similar to that received by men in
partnerships with infected women.
Awareness of and demand for male circumcision
In Uganda, adults were more aware of male
circumcision than youth (Wilcken et al., 2010).
Awareness increased with educational level. Marital
status, religion, geographical location, ethnicity,
employment status, and circumcision status were not
determinants of awareness of male circumcision for HIV
prevention in youth (Wilcken et al., 2010). Preference
for circumcision in a traditionally non-circumcising
Luo community in Kisumu, Kenya, was increased by the
knowledge that circumcised men are less likely to
become infected with HIV (Westercamp et al., 2010).
In order to enhance demand for voluntary
medical male circumcision, key informants in Eastern
and Southern Africa stated that effective
communication channels for demand creation should
include the mass media, print materials (small media),
and outreach/mobilization (Bertrand et al. 2011).
However, there were variations in the cost of demand
creation activities by the country and the programme,
decisions about the quality and comprehensiveness of
programming, and the lack of data on critical elements
needed to trigger the decision to voluntarily seek
medical circumcision services among eligible men. Thus,
Bertrand et al. (2011) cautioned that a standard package
of core demand creation elements would not be
universally applicable to all countries. This finding
underscored the importance of tailoring demand
creation strategies and cost estimates to specific
country contexts.
Acceptability of male circumcision
Among Rwandan men, half of the study
participants were willing to be circumcised and 79%
accepted circumcision for their sons (Gasasira et al.,
2012). The main drivers of male circumcision were
benefits in HIV prevention and improved hygiene. Men
who were old did not favour male circumcision.
Acceptability of male circumcision increased with
younger age (adolescents and young adults were more
willing to be circumcised), living in the Eastern Province
and with the factors marriage, and knowledge of the
protective role of circumcision (Gasasira et al., 2012).
Mugwanya and co-workers, working in Uganda,
found that circumcision for male children was favoured
as a future risk reduction strategy for HIV infection. Men
preferred 6 months while women preferred 2 months as
the preferred ages for circumcision of their infant sons
(Mugwanya et al., 2011).
Among Tanzanian parents, medical pre-pubertal
circumcision was accepted along ethnic lines
(Wambura et al., 2011). Preference for pre-pubertal
male circumcision was associated with the non-Kurya
ethnic group.
In Kenya, Herman-Roloff et al. (2011)
documented that male circumcision uptake was
facilitated by the need for hygiene, social pressure,
protection from HIV infection, and increased sexual
performance and satisfaction. They also found several
barriers to male circumcision: culture, religion, fear of
adverse events, and post-surgical abstinence.
Chinsembu,2012
Journal of Research in Public Health (2012) 1(2): 020-029 022


Herman-Roloff et al. (2011) recommended that
the activities which may increase male circumcision
uptake should dispel misconceptions around male
circumcision; increase the involvement of religious
leaders, womens groups, and peer educators; and
enhance the significance of male circumcision among
men who are already using an HIV/AIDS prevention
strategy.
Chinsembu,2012
023 Journal of Research in Public Health (2012) 1(2): 020-029
Year of
Publication
Country Research type Research Problem Reference
2010 Uganda Cross-sectional Awareness of MC Wilcken et al., (2010)
2010 South Africa Cross-sectional/
qualitative studies
Feasibility of roll-out of AMC Lissouba et al.,(2010)
2010 South Africa Secondary analysis
of longitudinal data/
laboratory analyses
Effect of MC on HIV
acquisition
Fiamma et al. (2010)
2010 Kenya Randomized
controlled trial
Risks for self-reported penile
injuries versus MC
Mehta et al., (2010)
2010 Kenya Qualitative:
Interviews/ FGDs
Examining sexual risk
compensation in circumcised
men
Riess et al. (2010)
2010 Kenya Population-based
survey
Beliefs about male
circumcision in a traditionally
non-circumcising community
Westercamp et al., (2010)
2010 Botswana Cross-sectional study Acceptability of EIMC Plank et al., (2010)
2011 Uganda Cross-sectional Acceptability of EIMC Mugwanya et al., (2011)
2011 Tanzania Cross-sectional Acceptability of MC Wambura et al., (2011)
2011 Swaziland Situation analysis Logistics, commodities, and
waste management
Edgil et al. (2011)
2011 Tanzania Qualitative:
Interviews
Acceptability/policy
environment
Mwanga et al., (2011)
2011 Eastern and
Southern
Africa
Modelling Impact and cost of scale-up of
adult VMMC
Njeuhmeli et al. (2011)
2011 Kenya/
Zimbabwe
Modelling Population impacts of MC on
HIV transmission
Hallett et al. (2011)
2011 Kenya Situation analysis of
secondary and
primary data
Challenges, responses, and
lessons from national VMMC
Herman-Roloff et al. (2011)
2011 Eastern/
Southern
Africa
Secondary analysis
of data based on DOI
and Expand Net
frameworks
Progress towards scale-up of
VMMC: factors/ policies for
adoption and implementation
Dickson et al. (2011)
2011 Lesotho Cross-sectional study Concordance of MC self-
reported status with physical
examination status
Thomas et al., (2011)
2011 Kenya Qualitative: FGDs Acceptability of MC among
uncircumcised men
Herman-Roloff et al., (2011)
2011 Eastern/
Southern
Africa
Qualitative:
Interviews of 7 key
informants
Challenges of demand
creation for VMMC
Bertrand et al. (2011)
2012 Rwanda Cross-sectional Perception and determinants
of MC
Gasasira et al., (2012)
2012 Zimbabwe Qualitative: FGDs Acceptability of EIMC Mavhu et al., (2012)
EIMC = Early Infant Male Circumcision; DOI= Diffusion of Innovation; MC= Male Circumcision;
VMMC = Voluntary Medical Male Circumcision
Table 1: Summary of primary studies used in the trends analysis
In Botswana, medical male infant circumcision
was acceptable especially within the first 6 weeks to
1 year after birth (Plank et al., 2010). Many respondents
(92%) stated they would accept infant circumcision if
the procedure was available in a clinical setting,
primarily to prevent future HIV infection, and 85%
stated the infant's father must participate in the
decision (Plank et al., 2010).
Among Zimbabweans, despite their poor
knowledge of male circumcision, acceptance of infant
male circumcision was high regardless of ethnicity
(Mavhu et al., 2012). However, many expressed cultural
concerns about the motive for mass male circumcision,
and the disposal of the foreskin. Older Zimbabweans
spoke against early infant male circumcision because it
depreciated adolescent initiation ceremonies and
allowed mothers to nurse the wound; the latter is
considered taboo.
Sexual risk compensation
Riess et al. (2010) examined sexual risk
compensation in circumcised Kenyan men. Their results
showed that a minority of circumcised men reported
higher risk behaviours by either not using condoms or
increasing the number of casual sexual partners. The
increased risky sexual behavior may be attributed to the
fact that circumcised respondents described being able
to perform more rounds of sex and experienced less
penile coital trauma (cuts on the penis during sex). The
risk of coital injury (soreness, scratches, abrasions,
bleeding) is lower for circumcised than uncircumcised
men (Mehta et al., 2010).
On the other hand, a majority of circumcised
Kenyan men did not report any increased changes in
risky sexual behaviours after circumcision. The results of
this study by Riess et al. (2010) illustrated that male
circumcision does not necessarily lead to risk
compensation as long as one is aware of sexual risky
behaviours, undergoes HIV/male circumcision
counseling and education, takes HIV testing, and
maintains a desire to remain HIV negative.
Roll-out of male circumcision
Within a South African poor setting, the
feasibility to roll-out high quality adult male
circumcision according to UNAIDS/WHO operational
guidelines was confirmed by Lissouba et al. (2010).
Using an innovative surgical organization, Lissouba and
colleagues documented that 150 adult male
circumcisions were performed per day under local
anaesthesia by one medical circumciser and 5 nurses.
Using the Decision Makers Programme Planning
Tool (DMPPT), researchers modeled the impact and cost
of scaling up adult voluntary medical male circumcision
in Botswana, Lesotho, Malawi, Mozambique, Namibia,
Rwanda, South Africa, Swaziland, Tanzania, Uganda,
Zambia, Zimbabwe, and Nyanza Province in Kenya.
According to Njeuhmeli et al. (2011), the cost of one
voluntary medical male circumcision ranged from
US$65.85 to US$95.15.
Njeuhmeli et al. (2011) estimated that scaling up
voluntary medical adult male circumcision to reach 80%
coverage in the 13 countries by 2015 entailed
performing 20.34 million circumcisions between 2011
and 2015 and an additional 8.42 million between 2016
and 2025 (to maintain the 80% coverage). This scale-up
was expected to avert 3.36 million new HIV infections
through 2025.
The same authors calculated that the scale-up
programme would cost a total of US$2 billion between
2011 and 2025. However, they maintained that
voluntary medical male circumcision would also rake in
net savings amounting to US$16.51billion due to
averted HIV/AIDS treatment and care costs. Their
Chinsembu,2012
Journal of Research in Public Health (2012) 1(2): 020-029 024
findings corroborate that rapid medical male
circumcision scale-up in Eastern and Southern Africa is
justified given its likely impact on the regions HIV
epidemics and the resultant cost savings.
Further to the cost estimates derived by
Njeuhmeli et al. (2011), a situational cost analysis to
inform the planning of voluntary medical male
circumcision services was carried out in Swaziland.
Edgil et al. (2011) found that an additional per cost of
US$60 is required for supply chain and waste
management, HIV counselling and testing, and
treatment of sexually transmitted infections. This
additional US$60 is required over and above the
US$65.85 to US$95.15 needed to perform one medical
male circumcision. Therefore, the overall cost of one
voluntary medical male circumcision would likely range
between US$125.85 and US$155.15 in Eastern and
Southern Africa.
Policy environment for adoption and scale-up of male
circumcision
Using the diffusion of innovation model, Dickson
et al. (2011) studied the adoption of voluntary medical
male circumcision in Eastern and Southern Africa. Their
findings reveal that the innovators (Kenya) started
performing voluntary medical male circumcisions in or
before 2008 and reached a cumulative total of 232,287
voluntary medical male circumcisions by 2010.
South Africa, Zambia, and Swaziland (early
adopters) started in or before 2008, but by 2010 had
cumulative totals of 145,475, 81,849, and 24,315
voluntary medical male circumcisions, respectively
(Dickson et al. 2011). Countries in the category of early
majority started in 2009 and achieved the following
voluntary medical male circumcisions by 2010:
Botswana (11,197), Zimbabwe (13,977), Tanzania
(29,443), Namibia (1,987), and Mozambique (7,733).

The late majority (Uganda and Rwanda) started
in 2010 and did 9,052 and 1,694 voluntary medical male
circumcisions, respectively. By the end of 2010, the
laggards (Malawi and Lesotho) did 300 and 219
circumcisions, respectively. In Lesotho, there were
self-reports of false male circumcisions. Approximately
27% of adult males self-reported being circumcised but
only 50% of these men had complete male circumcision
as determined by a physical examination (Thomas et al.,
2011). Given this low male self-report accuracy,
countries scaling up voluntary medical male
circumcision should obtain physical-exam-based male
circumcision data to guide service delivery and cost
estimates (Thomas et al., 2011).
Overall, Dickson et al. (2011) found that at the
end of 2010, only 550,000 voluntary medical male
circumcisions had been performed, representing a
paltry 3% of the target coverage level in the 13 priority
Eastern and Southern African countries. The early
adopter countries developed national voluntary
medical male circumcision policies and implemented the
programme soon after the release of the WHO
recommendations in 2007.
However, based on modeling using the Decision
Makers Programme Planning Tool (DMPPT),
Dickson et al. (2011) contend that only Kenya will
achieve the DMPPT-estimated 80% coverage goal by
2015, having already achieved 61.5% of the DMPPT
target. None of the other countries appear to be on
track to achieve their targets.
According to Dickson and co-workers, potential
predicators of early adoption of male circumcision
programmes include having a voluntary medical male
circumcisions focal person, establishing a national
policy, having an operational strategy, and the
establishment of a pilot programme (Dickson et al.
2011).


Chinsembu,2012
025 Journal of Research in Public Health (2012) 1(2): 020-029
In Kenya, implementation of voluntary medical
male circumcision faced staff shortages, and
government had to endorse trained nurses to roll-out
the service (Herman-Roloff et al., 2011). Voluntary
counseling and testing (VCT) was also replaced with
provider-initiated testing and counseling (PITC) and
subsequently doubling the proportion of VMMC clients
tested for HIV.
A study in Tanzania (Mwanga et al., 2011) also
urged the government to make improvements in the
health system at all levels to ensure availability of
adequate trained personnel, infrastructure, equipment,
and supplies for male circumcision scale up, and insisted
on the involvement of different male circumcision
stakeholders as key components in effective roll out of
medically performed male circumcision.

DISCUSSION
This study analyzed key trends in VMMC in
Eastern and Southern Africa. Six key trends were
observed in all the studies published over the past two
years: mathematical confirmation of the protective role
of MC for HIV prevention, awareness of and demand for
MC, acceptability of MC, MC versus sexual risk
compensation, roll-out of MC, and policy environment
for adoption and scale-up of MC.
Recent data collection protocols, analyses, and
models have corroborated the efficacy of MC in
preventing HIV acquisition and transmission. Given the
strong evidence that exists, the role of MC in preventing
HIV infection is undoubtedly defensible. We therefore
foresee no further practical need for research in this
area, unless it is for academic purposes only.
This study did not find convincing evidence for
universal awareness of MC as a preventive strategy for
HIV/AIDS. This lack of awareness is quite prevalent in
culturally non-circumcising communities, and also
among older people. Several factors that hinder demand
for VMMC also exist. It is recommended that
locale-specific communicative programmes that should
trigger decisions towards MC should be increased
if universal awareness of MC as an HIV measure is to be
achieved. The cost of such awareness programmes will
also differ from country to country.
Despite the overwhelming evidence that MC
protects against HIV/AIDS, VMMC is not yet universally
accepted. Studies to ascertain the acceptability of
VMMC should be carried out in countries such as
Namibia, Malawi, Lesotho, Mozambique, South Africa,
and Zambia. Several barriers to MC should exist:
ethnicity, culture, religion, fear, misconceptions, and
gate-keepers such as older persons and fathers.
Increasing the roll-out of VMMC will have to overcome
these barriers. It is proposed that peer-educators can
help MC programme implementers secure the buy-in of
gate-keepers.
A key concern is that promoting MC may lead
circumcised men to develop a false sense of complete
protection against HIV and engage in risk compensation
by halting or decreasing previous protective behaviors
such as condom use or partner reduction, causing the
protective effects of MC to be reduced or negated. This
is a major concern especially that MC increases coital
activity and satisfaction. To reduce sexual risk
compensation, there is need to counsel circumcised
sexually active adolescents and adults that MC does not
totally protect an individual from HIV/AIDS infection.
There is evidence that roll-out of VMMC can be
achieved in poor settings. The total cost of VMMC was
estimated to be less than US$155.15. Although the
scale-up of VMMC in Eastern and Southern Africa was
estimated at US$2 billion, this cost is overshadowed by
Chinsembu,2012
Journal of Research in Public Health (2012) 1(2): 020-029 026


the savings that accrue from treatment and care of
HIV/AIDS patients. Therefore, in the long term, using
VMMC to prevent HIV infections will become a much
cheaper option than treatment and care.
One regrettable trend identified in this study is
that the adoption of VMMC been slow in countries with
high HIV/AIDS prevalence rates. There is also
mis-reporting of MC. Notwithstanding the progress
made by Kenya, the total coverage of MC in Eastern and
Southern Africa is still very low (3%). There is an urgent
need to devise national policies and implementation
programmes that promote VMMC in Eastern and
Southern Africa. Without a clear policy direction and
implementation agencies, the benefits of MC for
HIV prevention will not be realized in the near future.

CONCLUSIONS AND RECOMMENDATIONS
There is need to conduct more studies on MC
for HIV prevention especially in countries like Namibia,
Malawi, Lesotho, Mozambique, and Zambia. Throughout
Eastern and Southern Africa, VMMC is very low.
Therefore, uptake of VMMC should also be scaled-up if
the benefits of HIV prevention are to be realized.
Specifically, there is an urgent need to use
Information, Education and Communication (IEC) as well
as Behaviour Change Communication (BCC) strategies to
increase the uptake of VMMC. Such strategies should
centre around increasing the acceptability of VMMC by
breaking cultural barriers against VMMC. Governments
should also devise and implement robust policies to roll-
out VMMC. For example, governments must commit
more local resources to scale-up VMMC. This should
include robust programmes to train circumcisers and
bring VMMC services closer to the community.



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Chinsembu,2012
029 Journal of Research in Public Health (2012) 1(2): 020-029
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