Male circumcision: An acceptable strategy for HIV prevention in Botswana

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Male circumcision An acceptable strategy for HIV
prevention in Botswana

• Roger Shapiro
• Poloko Kebaabetswe
• Shahin Lockman
• Serara Mogwe
• Rose Mandevu
• Ibou Thior
• Max Essex
• The Botswana-Harvard AIDS Institute Partnership /
  The Botswana Ministry of Health / The Harvard
  School of Public Health / The University of
  Botswana

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Abstract
Background Male circumcision is known to reduce
the risk of acquiring HIV, but few studies have
been performed to assess its acceptability among
either children or adults in sub-Saharan
Africa.Methods We conducted a cross-sectional
survey in nine geographically representative
locations in Botswana to determine the
acceptability of male circumcision in the
country, as well as the preferred age and setting
for male circumcision. Interviews were conducted
using standardized questionnaires both before and
after an informational session outlining the
risks and benefits of male circumcision.Results
Among 605 persons surveyed, the median age was
29 years (range 18 74 years), 52 were male,
and 15 tribal groups were represented. Before
the informational session, 408 (68) responded
that they would definitely or probably circumcise
a male child if circumcision was offered free of
charge in a hospital setting this number
increased to 542 (89) after the informational
session. Among 238 uncircumcised men, 145 (61)
stated that they would definitely or probably get
circumcised themselves if it were offered free of
charge in a hospital setting this increased to
192 (81) after the informational session. In a
multivariate analysis of all participants,
persons with children were more likely to favor
circumcision than persons without children
(Adjusted Odds Ratio 1.8, 95 CI 1.0, 3.4).
Most participants (55) felt that the ideal age
for circumcision is before 6 years, and 90 of
participants felt that circumcision should be
performed in the hospital setting.Conclusions
We conclude that male circumcision is highly
acceptable in Botswana. The option for safe
circumcision should be made available to parents
in Botswana for their male children. Circumcision
might also be an acceptable option for adults and
adolescents, if its efficacy as an HIV prevention
strategy is supported by clinical trials.
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Background

• Male circumcision is known to reduce the risk of
  acquiring HIV, but few studies have been
  performed to assess its acceptability among
  either children or adults in sub-Saharan Africa
• Male circumcision was traditionally practiced in
  almost all Bantu-speaking regions of subSaharan
  Africa, and remains a cultural practice
  throughout much of the region today
• However, circumcision has become less common in
  some regions of Africa where it was traditionally
  practiced. Non-circumcising areas now include
  almost all of Uganda, Rwanda, Burundi, Zambia,
  Malawi, Zimbabwe and Botswana, and parts of
  western Kenya, western Tanzania, the Democratic
  Republic of Congo, Namibia, Mozambique, and South
  Africa
• Male circumcision is no longer a cultural
  practice in Botswana, nor is it offered for male
  infants at government hospitals

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Methods Survey Administration

• Between March 17 and June 17, 2001, 605
  interviews were conducted at 9 locations
  throughout Botswana
• Sites were geographically and ethnically
  representative
• 2 cities (Gaborone and Francistown), 1 town
  (Lobatse), 6 villages (Maun, Ghansi, Serowe,
  Kanye, Ramotswa, and Bobonong)
• Interviews were conducted in Setswana by a team
  of 3 trained bilingual health educators
• Interviewers approached potential participants at
  meeting places and public markets
• Participants were eligible if they were age 18 or
  older
• Informed consent was signed by all participants

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Methods Survey Design

• Survey was administered in 2 parts
• Part 1 was administered before any information
  about male circumcision was provided to the
  participant by the health educator
• Part 2 was administered after the health educator
  read a short informational pamphlet regarding the
  potential risks and benefits of male circumcision
  to the participant

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Results Response Rate, Demographics, and
Baseline Knowledge

• 57 of those approached agreed to participate
• 29 different tribal groups from throughout the
  country were represented 
• Male circumcision was correctly described by 74
  of participants
• interviewers described circumcision to all
  participants who defined it incorrectly (4) or
  who were unsure (22) before proceeding with the
  interview

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Characteristics of Study Participants
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Acceptability of Male Circumcision, by Sex and
Circumcision Status
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of Participants Who Would Choose to Circumcise
a Male Child, if Offered in a Safe Hospital
Setting, Free of Charge(data shown only for
responses following informational session)

N238
N605
N78
N289
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of Uncircumcised Men Who Would Choose to Be
Circumcised, if Offered in a Safe Hospital
Setting, Free of Charge (N238) (data shown only
for responses following informational session)

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Acceptability of Male Circumcision (continued)
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Differences in Acceptability of Male Circumcision
by Participant Characteristics

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Conclusions

• Safe circumcision services in Botswana could
  provide an effective, available, permanent, and
  affordable means to reduce the incidence of HIV
  in the next generation of children
• Our study demonstrates that circumcision services
  for male children in Botswana would be highly
  acceptable
• After an informational session, 89 of all
  participants stated that they would definitely or
  probably circumcise their male child if this
  service were offered in a hospital setting
• 50 felt that the best age for circumcision is
  
• 90 felt that circumcision should be performed in
  a hospital setting
• If randomized, clinical trials support the
  effectiveness and safety of circumcision among
  adolescents or adults, our study also indicates a
  high level of acceptability for such programs in
  Botswana

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Recommendations

• Parents in Botswana should be offered the option
  of hospital-based circumcision for their male
  children to protect them from the acquisition of
  HIV
• The majority of births in Botswana occur at the
  district hospitals, and circumcision services
  could be implemented with existing resources by
  training physicians and nurses at these
  locations
• Based on the results of this study, the Botswana
  Ministry of Health has established a committee to
  discuss the implementation of infant circumcision
  services at district hospitals throughout the
  country