Introduction 2001 1989 2000 1999 2003 1997 2000 2005 1999 1990 In addition to the proportion of males who will become circumcised, the age at circumcision will also be a determinant of how rapidly the intervention results in reduction of HIV prevalence in the population. If infant circumcision is preferred over, say, pubertal circumcision, then the time lag from introduction of a large scale intervention until observable reductions in HIV prevalence could be decades. Because acceptance of MC by men and by parents of males in traditionally non-circumcising communities will be crucial to the success of a MC intervention for reducing HIV prevalence, we provide a review of the extant literature on acceptability of MC in sub-Saharan Africa. Study Collection and Search Strategies 1 1 Fig. 1 Locations (by level 3 administrative unit) where male circumcision (MC) acceptability studies were conducted  Table 1 N Country/Authors/Year Time of the study Study population Ethnic composition Circumcision status of participants Data collection methods 2003 2001 316 Male and 289 female participants, age 18–74, in urban and rural settings Ethnically heterogeneous (over 15 ethnicities) Both circumcised and uncircumcised men  Interviews, pre- and post-educational session 2002 1998 Residents of Nyanza Province, age 16–80, men and women, 30 focus groups, each 6–14 people, urban and rural population, farmers, business people, teachers, sex workers, barmaids, and touts. Ethnically homogenous (Luo) Not recorded; nearly all likely uncircumcised Focus groups; interviews with healthcare providers Kenya/Bailey (Unpublished report to AIDSMARK, 2002) 1999 32 Clinicians were interviewed to assess their knowledge and practice of MC, records of MC performed in the area were reviewed, 7 circumcised men and their wives were interviewed Ethnically homogenous (Luo) Both circumcised and uncircumcised Interviews, KAB questionnaires, record review 2005 1999 107 Men and 110 women, 16 years of age and older of Luo ethnicity, in urban and rural settings Ethnically homogenous (Luo) Both circumcised and uncircumcised men Structured interviews 2006 2003 318 Participants, 32 focus groups with men and women 16–80 years old Ethnically diverse (Chewa, Tonga, Yao, Ngoni, Lomwe, and Nyanja)  Both circumcised and uncircumcised men Focus groups 2003 2001 482 Men aged 19–29 years and 302 women aged 14–25 years Ethically heterogeneous (Sotho, Tswana, Xhosa and other ethnicities) 22% of men 19–29 years old were circumcised Interviews using standardized questionnaire 2005 2002 100 Adult men and 44 adult women in rural Zulu land and 4 service providers Ethnically homogenous (Zulu) Both circumcised and uncircumcised men Interviews, focus groups 2003 1999–2000 Sample of 606 13–59 year old males interviewed in August 2000 and 723 14–24 year old males interviewed in August 1999 Ethnically diverse (Sotho, Xhosa, Zulu, Tswana, Shangaan, and Venda) 36% of men 25–59 years old were circumcised Interviews and focus groups 2006 2006 409 Men aged 15–49 were interviewed in urban and rural setting Not reported, but likely majority were Swazi 14% of men were circumcised Interviews 2001 1991–1997 998 Sukuma men from a cohort of factory workers in Mwanza town, 13 focus groups from mostly rural area, and population based surveys Ethnically homogenous (Sukuma) 21% of men in the sample were circumcised Interviews and cohort data analysis 1999 1997 188 Circumcised and 177 uncircumcised men 18 to 67 years old from the Industrial Borough, Mbale.  Ethnically diverse (17 tribal groups, including Gisu) 52% of men were circumcised Structured interviews Zambia/Lukobo and Bailey (submitted) 2003 160 Men and 162 women in the 34 focus groups in rural and urban settings Ethnically diverse (Lunda, Luvale, Chewa, Tonga) Both circumcised and uncircumcised men Focus groups 2005 2000 200 Men attending beer halls in Harare Not reported, but likely majority were Shona Both circumcised and uncircumcised men Interviews, focus group Diversity of the Study Sample 2002 2003 2003 2005 2006 2005 2006 1999 2005 2001 2003 2002 2005 2005 2001 2005 2006 1999 2003 2003 2006 2003 2002 2003 2003 2005 2006 2001 2003 2005 1999 2005 2006 2001 2003 2002 2006 2002 2003 2005 2002 2003 2003 2005 2006 2001 2006 2005 1999 2005 2003 2006 1999 2005 2003 2003 2005 2001 2003 2005 2006 Summary of Quantitative Results of Acceptability 2 2 2003 2005 2003 2003 2006 1999 2003 2005 2005 Fig. 2 Levels of male circumcision (MC) acceptability from eight quantitative studies in six sub-Saharan African countries  Table 2 Circumcision preference and conditions for acceptability reported in eight studies from six sub-Saharan African countries Authors/year/country % Of uncircumcised men willing to be circumcised % Of women favoring circumcision of their partners % Of men willing to circumcise their sons % Of women willing to circumcise their sons 2003 61% Before and 81% after information session, if procedure is done in safe hospital settings and is free 50% Before and 79% after information session 67% Before and 90% after information session, if procedure is done in safe hospital settings and is free  62% Before and 90% after information session, if procedure is done in safe hospital settings and is free 2005 70%, If procedure involved minimal cost and little pain 69%  2000 89%, If little pain was involved 2003 73%, If MC protected from STIs/HIV 47% Thought most women preferred circumcised men 71% Of non-circumcised men and 82% of circumcised men, if MC protected from STIs/HIV 70%, If MC protected from STIs/HIV 2005 51%, If performed safely and at low cost 68%  50%  73%  2003 59%, If MC reduced chances of STIs and HIV N/a N/a N/a 2006 54%; 87%, If MC protected against HIV/STIs N/a 71%  N/a 1999 29%, If cost was minimal N/a N/a N/a 2005 45% If MC protected against HIV/STIs, and was safe and affordable N/a N/a N/a In general, approximately the same proportion of women would prefer circumcision for their partners or their sons as men would prefer circumcision for themselves or their sons. In Botswana, Kenya, South Africa and Swaziland, where men or women were asked about circumcision for their sons, more adults would agree to the procedure for their child than for their spouse or themselves. Approximately 75% of parents would seek circumcision for their son if it was safe, affordable and shown to be protective against HIV and STIs. Across studies, the median proportion of uncircumcised men willing to become circumcised was 65% (range 29–87%). Sixty nine percent (range 47–79%) of women favored circumcision for their partners, and 71% (50–90%) of men and 81% (70–90%) of women were willing to circumcise their sons. The study restricted to rural population found that 51% of men were willing to become circumcised, while median proportion in the same category was 45% (range 29–59%) in three urban studies and 77% (70–87%) in studies that included both rural and urban population. Barriers to the Acceptability of MC Pain 2002 2003 2005 2006 2005 2003 Culture and Religion 2003 2006 2003 1999 2001 rayuom 2002 njilwa 2001 2002 1999 2006 2001 2003 2005 2003 2003 2001 2006 2005 2003 Before MC is promoted in a country, it would be prudent to consult and collaborate with religious leaders to learn the stance of the various churches regarding MC. In many cases, churches can act as helpful advocates or obstructive opponents and may have significant influence on acceptability of MC. Cost 2002 2003 2005 2002 2006 2006 2005 2006 2006 2003 Complications and Adverse Effects 2002 2006 2002 2006 2002 2005 2003 2006 2003 2003 Overall, there seemed to be a great deal of trust in medical practitioners and a strong preference for circumcision services to be made available in public health facilities by trained health professionals. Potential for Behavioral Disinhibition 2002 2003 2002 2006 2006 2003 1999 P 2003 2003 2005 Other Reasons Not to Circumcise 2002 2003 2003 2003 Facilitators of MC Acceptability Hygiene 2002 2005 2003 2005 2006 2001 2002 2005 2006 2001 2003 2002 2006 2002 2005 2006 Protection from STIs and HIV 2002 2006 2002 2006 2001 2003 2002 2006 2002 2006 2003 2002 2006 2001 2003 2005 2006 2001 2006 2005 Acceptability by Other Ethnic Groups 2002 2006 2002 2002 2006 2001 Sexual Pleasure Among Circumcised versus Uncircumcised 2002 2003 2005 2006 2001 2003 2003 2005 2003 2003 2005 2005 2002 2006 2006 Other Reasons to Circumcise 2002 2003 2003 Time and Setting of Circumcision Procedure Preferred Age at Circumcision 2002 2006 2003 2005 2003 2002 2006 2006 2003 2002 2006 2003 2006 2003 2002 2006 2002 2006 2002 Preferred Circumcisers 2003 2003 2005 2003 Acceptability in Certain Populations Women’s Beliefs and their Influence The influence of women on the decision to circumcise is likely to be highly variable across cultures and across families within communities. However, in many settings, women, as mothers and as partners, are likely to have considerable influence, even if it is not overt. Any effort to promote MC will be more successful if it appeals to women as well as men. 2002 2005 2003 2003 Acceptability in Youth 2001 2001 2003 2001 2005 2006 2001 2003 2001 2006 2001 Hypothetical versus Actual Acceptability Asking people whether they might prefer to be circumcised under various hypothetical scenarios (e.g., if it is found to reduce risk of HIV acquisition; or if it is at minimal cost and safe) is one means of assessing acceptability. A more realistic means is to discover where MC services are available and see who takes advantage of the services. Alternatively, one can offer the services in non-circumcising communities and see the response. This approach permits assessment of not just numbers seeking the services, but also the ages and population segments that respond as well as factors that inhibit or facilitate uptake of the services. A trial intervention in Siaya District, Kenya–an area where circumcision is not traditionally practiced—was introduced in 1999 (Bailey, Unpublished report to AIDSMARK, 2002). During a 25 month period, 433 circumcisions were performed in health facilities where only 6 procedures had been done in the previous year. In a comparison district, where no intervention was available, just 24 circumcisions were preformed over the same period. Demand for MC services was judged to be high but was highly dependent on cost. When the price charged for a circumcision was reduced from $3.62US to $1.45US, demand surged, and 50% of all circumcisions occurred during the 2 months when the price was reduced. The median age of those circumcised was 18 years; 25% were below age 12 years, and an estimated 35% were circumcised before their sexual debut. The researchers felt that a greater number of younger males would have been circumcised had parental permission not been required for those under age 18 years and if the cost were reduced permanently, since older males tended to have more financial support (Bailey, Unpublished report to AIDSMARK, 2002). The results from this trial intervention are consistent with results from studies of hypothetical acceptability indicating that cost is consistently found to be a major barrier to uptake of circumcision in traditionally non-circumcising communities. 2005 2006 2005 Discussion 1999 Cost, fear of pain, and concern for safety were the three most consistent barriers to acceptability of MC. In communities where circumcision is the norm families expect to incur the obligatory circumcision expenses negating the importance of cost. In non-circumcising communities circumcision is regarded as a voluntary procedure that may be unlikely to take precedence over competing needs. Cost is viewed as including not only the payment for the procedure, but also the opportunity costs of time away from work and other income generating activities. Cost as a primary consideration was shown dramatically by the pilot intervention in Siaya, Kenya, where men came in large numbers when the charges were lowered to $1.45US (Bailey, Unpublished report to AIDSMARK, 2002). These results indicate that the true cost of the procedure will have to be supplemented to achieve significant uptake of MC. 2005 The studies we reviewed revealed that it is virtually universal that Africans equate circumcision with improved hygiene. Also widespread is the belief that circumcision leads to reduced incidence of STIs achieved through improved hygiene, reduction in the number and severity of scratches, tears and abrasions to which the foreskin is susceptible and through earlier detection of ulcers, leading to earlier treatment. Although not as frequent, a significant proportion of participants in the studies also saw circumcision leading to reduced risk of HIV acquisition through the same route. If MC is proven in the remaining two clinical trials to reduce incidence of HIV and some STIs (e.g., HPV, HSV-2, chancroid and gonorrhea), this information will be consistent with the already existing beliefs of most sub-Saharan Africans. 2003 2005 In East and Southern Africa most MCs are done between ages 8 and 21 and the preferences for age at circumcision found in studies are consistent with these practices. However, a large enough proportion of people, especially mothers, preferred infant circumcision to consider making infant circumcision an available option. This should be an important consideration in designing MC interventions. 2003 2005 2005 1999 1995 1996 2005 2003 2001 1999 2001 All studies attempted to assess peoples’ beliefs and attitudes toward circumcision and their willingness to be circumcised under some hypothetical conditions sometime in the future. We cannot know from these studies what the actual uptake of circumcision would be if it were found to be protective in three clinical trials and was actively promoted. We have only one example of an introduction of MC services in a traditionally non-circumcising community (Bailey, Unpublished report to AIDSMARK, 2002), and this was at a time when circumcision could not be actively promoted, but could only be made available. Results from that intervention were instructive in that demand for safe circumcision was robust, but depended very much upon price. 2006 2001 2006 2005