The Male Circumcision Partnership identifies effective and affordable ways to deliver high-quality voluntary medical male circumcision services for HIV prevention.
Voluntary medical male circumcision has been shown to reduce female-to-male HIV infection by approximately 60% in high-prevalence areas. One study suggests that if male circumcision achieved full coverage in sub-Saharan Africa over the next ten years, nearly 6 million new HIV infections could be prevented in the region over the course of 20 years.
The Government of Zambia has set a goal of providing nearly 1.9 million men with circumcision services as an HIV prevention measure between 2009 and 2015. However, additional evidence is needed to guide successful large-scale implementation of the services.
The Population Council is evaluating service-delivery models, informed consent procedures, quality of care, adherence to recommendations regarding safe sex, and what women know and think about male circumcision in order to inform program scale-up in Zambia. Council studies have identified program components that require critical attention in order to be scaled up effectively.
For example, a year-long quantitative assessment of more than 750 men and adolescent boys revealed that while almost all had voluntarily chosen to be circumcised, many were confused about the significance and purpose of the informed consent form. Some participants thought the form they signed released the clinic from any liability. Others could not remember signing the form, even though they had. The assessment also found that consent procedures for adolescents were poorly understood and inconsistently implemented. Council researchers recommended providing information about informed consent during the community education process and reiterating the purpose of the form during initial counseling about the procedure.
Another study indicated that male circumcision could have unintended consequences if it is not accompanied by community-wide counseling and education. In-depth interviews of female sex workers revealed that circumcised men often tried to convince the women to forgo condoms, citing their circumcision status as adequate HIV protection. Council researchers recommended that male circumcision programs provide female sex workers with information explaining how male circumcision does and does not work as an HIV prevention measure.
Council researchers found that close to 25% of nearly 250 men who had been recently circumcised were resuming sexual activity before the recommended period of abstinence—six weeks—that allows for complete healing. Noting that sex before the circumcision site is fully healed increases the risk of HIV infection, researchers recommended providing additional counseling to men, and possibly to women, to encourage them not to have sex during the healing period.
The Council is also evaluating PrePex™, a potentially highly cost-effective non-surgical method for performing male circumcision, to determine whether it is acceptable to men.
Lessons learned in Zambia have the potential to influence programs and voluntary medical male circumcision service delivery in other high-prevalence countries in sub-Saharan Africa, thereby preventing millions of new HIV infections. Council research is also improving knowledge about the best ways to increase demand for male circumcision and promote safer post-circumcision sexual behavior.