Neonatal circumcision in Zimbabwe

1. Neonatal circumcision in Zimbabwe Frances Cowan Webster Mavhu ZAPP-UZ

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 PLoS Med 2010 Binagwaho et al

4. Acceptability and intentions related to neonatal circumcision Map depicting Zimbabwean provinces • 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

5. Survey results: Knowledge about male circumcision by sex (%) 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

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)

10. Results of qualitative data 3 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 • 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

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