Neonatal circumcision in Zimbabwe

1. Neonatal circumcision in Zimbabwe Frances Cowan Webster Mavhu

2. Background Mathematical modelling estimates that 750,000 HIV infections could be averted in Zimbabwe if 80% of adult men are circumcised within seven years Zimbabweans not traditionally circumcising (DHS 10%) Pilot adult circumcision programme has been completed (6,500 circumcised over 12 months) Intention is to circumcise 1.2 million over next 5-7 years – initially prioritising men aged 15-29 years Neonatal circumcision will be run in parallel at some sites with national scale up in 5 years time

3. Neonatal circumcision Technically easier to perform than adult circumcision, safer, lower complication rate, can be carried out by less qualified staff Cheaper to perform $15 c.v. $59 per procedure Likely to be much more cost effective than adult circumcision – cost saving even though benefits will take longer to realise

4. Acceptability and intentions related to neonatal circumcision October 2009 –a representative population-based survey was conducted in 2 provinces ( 6 districts) 2,746 adults (64% females) completed an interview using ACASI (87% of eligibles) Detailed results were presented in Posters 0350 and 0352 Map depicting Zimbabwean provinces

5. Male circumcision …… Protects against STI Protects against penile cancer Protects against uterine cancer Improves hygiene, Reduces fertility in men Reduces male sexual pleasure Reduces female sexual pleasure Does not benefit women

6. Survey results 60% (95% CI ) said that they would have their son circumcised if MC was effective in preventing HIV. Among those who would not, 39% did not believe it was effective, 19% said it was not culturally/religiously acceptable and 13% said their son should decide when older. Prior knowledge of circumcision was important 86% of men and 79% of women with high knowledge were willing 47% and 57% of those with low knowledge. Male willingness to have son circumcised was associated with MC knowledge (adjusted OR 1.32;95%CI:1.22-1.44) being HIV positive (AOR 2.00;95%CI:1.08-3.69). Female willingness to have son circumcised MC knowledge (AOR 1.11;95% CI:0.99-1.25), HIV knowledge (AOR 1.10;95% CI:1.02-1.19 being HIV negative (AOR 1.16;95% CI:1.00-1.35).

7. Qualitative data collection Expectant mothers and fathers (13 FGDs) ‘Expectant’ Grandmothers and Grandfathers (11 FGDs) HCWs involved in circumcision programme (8 IDIs) HCWs not working within circumcision programme (13 IDIs)

8. Results of qualitative data collection Father has ultimate decision, although female relatives likely to be influential and need knowledge too. ‘Important for men to be directly targeted with information – not just through women’. In general, all groups said if it will protect against HIV they would consent to the procedure People’s existing knowledge (including those of HCWs) is poor Concerns focused on safety of procedure (bleeding, keloid scarring, infection) baby may regret later what will happen to the discarded foreskin (‘swallow secrets’) suspicion about circumcision being widely promoted (‘why is it free’) stigma associated with ‘looking different’ which people believe leads to aggressive behaviour in adult men circumcised men more sexually active – circumcision believed to increase libido – not a concern just an observation ‘The man must make that decision because he is the one who knows whether or not that is practised in his clan; the woman cannot know anything about a clan to which she doesn’t belong’ (expectant father, fgd) ‘Even now as I speak, if I hear that they are now circumcising children at the hospital, I will carry my grandchild and go with him; we are now faced with the burden of looking after orphans due to AIDS’ (grandmother, fgd) ‘What if my child gets swollen like those people who have a large growth from ear piercing and girls run away from him. How will he be able to have children? (expectant father, fgd) ‘What if the child later asks me why I ever had him circumcised?' (expectant mother, fgd) ‘What will happen to the piece that gets removed?’ (grandfather, fgd)‘The man must make that decision because he is the one who knows whether or not that is practised in his clan; the woman cannot know anything about a clan to which she doesn’t belong’ (expectant father, fgd) ‘Even now as I speak, if I hear that they are now circumcising children at the hospital, I will carry my grandchild and go with him; we are now faced with the burden of looking after orphans due to AIDS’ (grandmother, fgd) ‘What if my child gets swollen like those people who have a large growth from ear piercing and girls run away from him. How will he be able to have children? (expectant father, fgd) ‘What if the child later asks me why I ever had him circumcised?' (expectant mother, fgd) ‘What will happen to the piece that gets removed?’ (grandfather, fgd)

9. Results of qualitative data 2 In Harare, private paediatricians reporting increasing number of Shona parents requesting boy child circumcision – but often when ‘too late’ –ie when child is a toddler rather than an infant Anecdotal increase in number of neonatal circumcisions being conducted privately Neonatal circumcision not currently covered by health insurance progamme (cosmetic procedure) and cost charged by most private providers is high (minimum of US$120) ‘The problem is that mothers are coming with babies who are 12 months old and are asking for circumcision’ (paediatrician, idi). ‘The problem is that mothers are coming with babies who are 12 months old and are asking for circumcision’ (paediatrician, idi).

10. Results of qualitative data 3 One traditionally circumcising population (Shanganis = 6% of population) strongly opposed to neonatal circumcision Circumcision is just one part of a comprehensive ‘rites of passage’ ritual Women would need to be involved in the process which is totally unacceptable Process highly secretive and the extent of procedure (full or partial) not known Other circumcising tribes in Zimbabwe including Xhosa, Chewa, Venda, Remba (x%), not opposed would prefer procedure to be performed by someone who was themselves circumcised Circumcision is just one part of a comprehensive ‘rites of passage’ ritual ‘There are “lectures” that we teach those that are circumcised and so we can not teach infants’ (grandfather, fgd) Women would need to be involved in the process which is totally unacceptable. ‘Infants would need to be nursed by their mothers (after circumcision) and so we don’t want the mothers to know what we do’ (chief, idi).Circumcision is just one part of a comprehensive ‘rites of passage’ ritual ‘There are “lectures” that we teach those that are circumcised and so we can not teach infants’ (grandfather, fgd) Women would need to be involved in the process which is totally unacceptable. ‘Infants would need to be nursed by their mothers (after circumcision) and so we don’t want the mothers to know what we do’ (chief, idi).

11. In summary Knowledge of circumcision is poor – procedure, benefits, timing, consequences Despite this there are high rates of willingness to have son circumcised during neonatal period in most ethnic groups Education needs to include both men and women Men need to be provided with information directly and not just through their wives

12. Acknowledgements Research Participants Webster Mavhu, Brenda Tengende UZ Dept Community Medicine Lisa Langhaug, Raluca Buzdugan University College London Godfrey Woelk RTI Karin Hatzold PSI Zimbabwe Clemens Benedickt UNFPA Zimbabwe Oscar Mundida Zimbabwe National AIDS Council Judith Sherman Sue Laver UNICEF Zimbabwe