Introduction

Randomised trials suggest that male circumcision (MC) reduces a man's risk of acquiring HIV through heterosexual sex by 51–60% over an 18–24 months period [1], [2], [3]. Longer-term follow up suggests that this protective effect persists beyond 24 months [4], [5]. WHO/UNAIDS has recommended rapid scale-up of MC in high HIV prevalence countries to maximise intervention effectiveness at a population level [6]. In order to ensure that this protective effect is sustained in the longer-term, WHO/UNAIDS and UNICEF also recommend early infant male circumcision (EIMC) be implemented in parallel [6], [7].

Although EIMC's effects on HIV will take longer to realize, infant circumcision is likely to ultimately be more effective at preventing HIV acquisition than adult MC as the procedure is carried out long before the individual becomes sexually active, negating the risk associated with sex during the healing period [8]. Additionally, the procedure is quicker and easier to perform than adult circumcision [9]. Moreover, various surgical devices can be used to perform EIMC more simply, and these can be used by health-care cadres other than doctors, making infant circumcision potentially more accessible than adult MC. Compared to adult MC, EIMC results in fewer surgical adverse events and post-operative complications [10], [11], [12]. Furthermore, EIMC is much cheaper, with recent studies estimating that it is likely to be a cost-saving HIV prevention intervention [13], [14].

Since 2009, Zimbabwe has provided circumcision to adult and adolescent men through a collaborative effort between the government and technical agencies. The programme aims to reach 1.2 million 15–29 year-olds by 2015 [15]. Starting in mid 2012, a pilot roll-out of EIMC will be conducted. Since large-scale EIMC for HIV prevention is not yet widely available in Zimbabwe or throughout Southern Africa, there are concerns around its acceptability [8]. Clearly, acceptability will have a bearing on uptake, roll-out and subsequent effectiveness in preventing HIV.

In a 2009 representative household survey of 2,746 rural Zimbabweans (aged 18–44), 60% of women and 58% of men reported willingness to have their son circumcised; willingness was associated with increased HIV and MC knowledge [16]. Here we report on a qualitative study designed to explore these issues in more depth. Findings will inform communication strategies to promote EIMC in Zimbabwe, to plan appropriately for service delivery and to provide guidance for EIMC policy development.

Methods

Results

A total of 240 participants took part in FGDs; an additional three key informants were interviewed. EIMC knowledge was generally poor. Despite low knowledge, EIMC acceptability was high among participants from most ethnic groups. Older men from one traditionally circumcising population, who circumcise during adolescence, were strongly opposed to EIMC. Paediatricians reported a recent increase in parents requesting EIMC. Participants raised several concerns that have implications for circumcision roll-out. We present these themes in more depth below.

Discussion

Data from this qualitative study corroborate some of the quantitative findings from our population-based survey, namely that EIMC was seen as widely acceptable. However, given the very low levels of knowledge or experience of EIMC, it is not clear whether this hypothetical acceptability will translate into actual acceptability once EIMC roll-out begins. It is clear though that participants were very interested in the intervention as described, that is, one that could protect their sons against future HIV.

This qualitative study additionally identified new issues which have implications for EIMC implementation. Firstly, given the low levels of knowledge about the procedure, it will be important to provide information at a community level to enhance the procedure's acceptability. These qualitative findings reinforce the need for multi-faceted awareness campaigns (e.g. community mobilisation, road shows) to ensure that everyone in the community is reached and not just those in contact with clinical services [16].

Education needs to include both women and men; it should also target multiple generations. While reinforcing the crucial role fathers play in EIMC decision-making shown elsewhere [19], [20], our data suggest that fathers need to be provided with information directly not just through their wives. As caretakers of their family's health, women often receive information from health-care centres during routine visits. Yet men are notoriously hard to reach via health services [21], [22], [23]. Other venues should therefore be considered. Workplaces and beer halls have been successfully used to increase knowledge of health-related matters [24], [25].

Participants raised concerns around the safety of EIMC. Similar concerns have also been observed in other studies across the region [8], [16], [26], [27]. Study participants generally thought a newborn's penis is ‘too fragile’ to undergo circumcision. Overall, the level of anxiety observed suggested that these concerns need to be addressed head-on to improve EIMC uptake. Awareness campaigns need to adequately communicate that it is not only possible but also preferable for circumcision to be done soon after birth. In practice, however, acceptability and uptake will depend on perceptions of procedure's safety [28]. Provision of EIMC will therefore need to be carefully supervised and monitored to ensure i) a good cosmetic result and ii) that adverse effects are prevented.

Participants strongly felt that safe EIMC can only be provided by highly-trained doctors. However, in practice, it is likely that EIMC will largely be performed by midwives/nurses since it is an uncomplicated procedure [8], [9]. Communication materials/models should focus on the fact that nurses and midwives have the relevant skill/expertise to perform the procedure and that including them in EIMC delivery will make the procedure accessible through more remote health-care facilities, which are only served by nursing cadres.

Study findings support the now well-recognised notion that cultural beliefs are integral to successful MC provision [6], [8], [12], [29]. In this study, several ethnic groups were concerned about handling and disposal of the removed foreskin. Secondly, some participants preferred circumcision to be performed by individuals of either the same tribe or religion. Thirdly, older Shangaan men strongly opposed EIMC as they felt that it undermines their tradition by separating circumcision from adolescent initiation, in addition to allowing women (mothers) to nurse the wound, considered taboo.

These findings have at least three implications for rolling-out circumcision, in general and EIMC, specifically. Firstly, implementers will need to recognise and understand cultural and religious beliefs attached to MC among certain groups [12]. It will be important to engage key traditional and religious leaders in efforts to mobilise a wider understanding and acceptance of circumcision for HIV prevention. Secondly, MC providers need to be drawn from diverse ethnic/religious circles. Lastly, EIMC communication materials/models should specifically address concerns around safety, timing and tissue disposal.

This study has several strengths. Firstly, this research was conducted with participants representing the majority of ethnic groups, and in half of Zimbabwe's ten provinces. Secondly, our sample size was large for a qualitative study. The sample was purposively selected to ensure a wide range of views were heard from a diverse population. Thirdly, we managed to achieve theme saturation, an important component of qualitative research.

There were some limitations to this study. Firstly, although EIMC was defined prior to group discussions, some participants still discussed neonatal circumcision and had to be reminded that they needed to focus on infant circumcision. Secondly, we explored EIMC acceptability in the absence of widely-available services or any communication campaign that specifically provides information about infant circumcision. Hypothetical acceptability may be quite different from actual acceptance when EIMC is eventually rolled-out [8]. It will be crucial to assess EIMC acceptability within the context of actual roll-out. Lastly, while religious beliefs might be expected to affect attitudes/beliefs related to EIMC, neither our qualitative nor quantitative data found any indication of this. Nonetheless, it may be worth exploring this issue in more depth with religious groups that are specifically known to resist biomedical interventions and who make up a significant minority of the population in Zimbabwe and sub-Saharan Africa more widely.

In conclusion, this study found that EIMC is a potentially acceptable HIV prevention intervention in Zimbabwe and provided a framework for addressing likely barriers to uptake. Specifically, awareness campaigns that increase knowledge will be crucial to translating hypothetical acceptability into actual uptake. These data suggest that barriers are not insurmountable - which bodes well for achieving high EIMC targets in sub-Saharan Africa, in general and Zimbabwe, specifically.

Acknowledgments

We thank study participants, without whom this study would not have been possible. We would also like to thank Sibusisiwe Sibanda, Nqabutho Nyathi and Sekai Mukaro for assisting with data collection.