Male circumcision: An acceptable strategy for HIV prevention in Botswana

1. 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

2. 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.

3. 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 sub–Saharan 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

4. 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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6. 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

7. 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

8. Characteristic No. (%) Median age 29 years (range 18 – 74 years) Male sex 316 (52) Marital status Single Cohabitating Married Separated, divorced, widowed 343 (57) 88 (15) 128 (21) 46 (7) Number of children 0 1 2 3 4 or more 221 (36) 114 (19) 107 (18) 66 (11) 97 (16) Education completed None Primary school Secondary school Tertiary / university 34 (5) 185 (31) 321 (53) 65 (11) Occupation Salaried (government) Salaried (private) Domestic work / manual labor Self-employed Student Unemployed 134 (22) 105 (17) 64 (11) 103 (17) 36 (6) 163 (27) Religion Christian Muslim No religion / other 404 (67) 9 (2) 192 (31) Characteristics of Study Participants

9. No. (%) before informational session No. (%) after informational session P value for change in responses Circumcising a male child in a safe hospital setting, free of charge: All participants (N=605): Would definitely / would probably circumcise Would definitely not / would probably not circumcise Unsure Uncircumcised men only (N=238): Would definitely / would probably circumcise Would definitely not / would probably not circumcise Unsure Circumcised men only (N=78 ): Would definitely / would probably circumcise Would definitely not / would probably not circumcise Unsure Women only (N=289): Would definitely / would probably circumcise Would definitely not / would probably not circumcise Unsure 408 (68) 86 (14) 111 (18) 159 (67) 38 (16) 41 (17) 73 (94) 1 (1) 4 (5) 178 (62) 45 (16) 66 (23) 542 (89) 34 (6) 29 (5) 208 (87) 15 (6) 15 (6) 76 (97) 1 (1) 1 (1) 260 (90) 17 (6) 12 (4) < 0.0001 < 0.0001 NS < 0.001 Uncircumcised men only (N=238): Circumcising yourself in a safe hospital setting, free of charge: Would definitely / would probably circumcise Would definitely not / would probably not circumcise Unsure 145 (61) 46 (19) 47 (20) 192 (81) 22 (9) 24 (10) < 0.0001 Acceptability of Male Circumcision, by Sex and Circumcision Status

10. % 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) % N=238 N=78 N=289 N=605

11. % of Uncircumcised Men Who Would Choose to Be Circumcised, if Offered in a Safe Hospital Setting, Free of Charge (N=238) (data shown only for responses following informational session) %

12. Women only (N=289): Prefer a circumcised or an uncircumcised partner: Circumcised Uncircumcised No preference Unsure 146 (50) 20 (7) 61 (21) 63 (22) No. (%) before informational session 227 (79) 7 (2) 32 (11) 23 (8) No. (%) after informational session P value for change in responses < 0.0001 Cultural acceptability of circumcision: Circumcision is culturally acceptable Circumcision is not culturally acceptable Unsure 298 (50) 98 (16) 209 (34) -- -- -- Best age for male circumcision: Birth to 1 month 1 month to 1 year 2 years to 5 years 6 years to 10 years 11 years to 15 years Older than 15 years Never Unsure / other -- -- -- -- -- -- -- 152 (25) 52 (9) 129 (21) 95 (16) 88 (14) 49 (8) 18 (3) 22 (4) Best place for male circumcision: Hospital Traditional setting / other No place(circumcision not acceptable) Unsure / other -- -- -- 542 (90) 37 (6) 8 (1) 15 (3) Acceptability of Male Circumcision (continued)

13. Characteristic Proportion (%) favoring circumcision* among those with characteristic Proportion (%) favoring circumcision* among those without characteristic Univariate analysis P-value Multivariate analysis Adjusted Odds Ratio (95% CI) Male sex 230/271 (85) 178/223 (80) 0.14 N/S Married 111/127 (87) 297/367 (81) 0.10 N/S Has children 286/331 (86) 122/163 (75) 0.001 1.8 (1.0, 3.4) Secondary school education or higher 257/320 (80) 151/174 (87) 0.07 N/S Christian religion 269/321 (84) 139/173 (80) 0.33 -- Employed 310/373 (83) 98/121 (81) 0.59 -- Ethnic group† -- -- 0.28 N/S Location (all sites) -- -- 0.0002 0.03 Age (median) Favor circumcision: 30 yrs Do not favor circumcision: 26 yrs 0.002 N/S Differences in Acceptability of Male Circumcision by Participant Characteristics

14. 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 < 6 years • 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

15. 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