Circumcision in Zambia

1. Circumcision in Zambia

2. Circumcision in Zambia • Traditional MC –NW Province and small Muslim communities in E. Province & elsewhere • NW Province (along with N. Province) has lowest HIV rates – but syphilis rate close to national average

3. SBS 2000 - % Circumcised • Urban 15.3% • Rural 17.8% • Total 16.9%

4. Preliminary Qualitative Work • 4 focus-group interviews with men • 2x2: • rural vs. urban • 18-24 unmarried vs. 25-39 married • conducted in Lusaka and Chongwe • Key informant interview with MC provider from Lusaka

5. Groups Traditionally doing MC • Not having MC is associated with uncleanliness, premature ejaculation and unfitness for marriage • Rationale: mark of attaining manhood, protection from ‘diseases’, capacity to please women sexually

6. Groups Not Doing MC • Traditional practice seen as done without the boy’s consent • Seen as reducing risk of STI (incl. HIV) • Limited demand for MC – some informants report wishing they’d been circumcised • Common belief that women prefer circumcised men

7. Age at Circumcision • Reported as usually between 8-15 • Concern that if done later in adulthood, healing is slower & complications more likely • Mixed views on infant MC (safety concerns)

8. Setting • Mixed views on traditional vs. medical • Tendency for those from MC-practicing groups to prefer camps; non-MC - hospital • Issues: safety, access, expense, associated teaching

9. STI/HIV Protection • Widely held view, even among non-MC ethnic groups, that MC reduces risk of STI/HIV transmission • Protection is attributed to harder, drier glans • A few informants consider MC as a ‘natural condom’ conferring 100% protection: most consider protection only partial • Some consider MC less effective in preventing HIV than other STIs

10. Effects on Sex • Seen to improve satisfaction for women • Male sexual satisfaction not seen to be threatened by MC; could be enhanced • View expressed that MC makes condom-use easier

11. Concerns • Fear of disease transmission with traditional practice, using the same knife on several boys (STIs, HIV) • Slow healing • Localized infection, blood loss • Risk of dying • Belief that MC is protective can encourage risky behavior

12. Supply • Expense is perceived as a barrier – both for traditional MC camps and medical MC • Few clinicians providing MC services • Informants reported trying unsuccessfully to access medical MC

13. Urban vs. Rural; Single vs. Married • Urban sample – less confident in safety of traditional MC • Little difference b/w singles and married – except married had more experience

14. Key Informant Interview • Lusaka-based MD from MC-practicing ethnic group • Reports widely held view on protection from infection • Reports considerable demand for medical MC, but mainly from MC-practicing groups and families having intermarried with MC-practicing groups • Sees slow increase in demand from other groups • Reports interest among medical colleagues in offering MC service

15. Conclusions • MC is relatively uncommon • Interest in MC even among ethnic groups not traditionally practicing MC • Widely held perception that MC reduces STI (and HIV) risk, although most consider HIV protection only partial • Demand for more information on MC

16. Next Steps • Government interest in a pilot as groundwork to expand access to quality MC • Implementing partners on the ground ready to participate (JHPIEGO, Horizons) • Need for assessment not only of feasibility but to better characterize potential demand • Explore policy/ regulatory issues

17. HIV Prevalence 1998 Sentinel Sites