Background: Young South Africans are at risk of HIV infection due to sexual risk behaviour in endemic HIV. While evidence suggests that scaled medical male circumcision (MMC) can help curb HIV infection rates in countries such as South Africa, evidence for MMC acceptability is needed. Both MMC and traditional circumcision are practised in South Africa, with certain cultural ethnicities preferring one over the other. Traditional circumcision may occur after sexual debut and foreskin removal may be incomplete. We investigated the acceptability of MMC versus traditional circumcision in Cape Town and Soweto, two culturally distinct settings in South Africa in the MACHO study.
Methods: MACHO was a mixed methods, longitudinal cohort study which investigated preferences for, attitudes, and uptake of elective MMC in 100 males (14-17 years), their guardians and other key informants in Cape Town and Soweto. Data were collected via researcher administered surveys, interviews, and focus groups and the dyads were followed up over a 24 month period.
Results: Results: 100 adolescent boys (Cape Town n=50;, Soweto n=50;) and their guardians were enrolled with a mean age of 15 (IQR: 14-16.)
Cultural ethnic composition (Table 1) was as follows:
Cape Town: 44 (88%) Xhosa, 1 (2%) Zulu, 3 (6%) Sotho/ Tswana, 2 (4%)Other
Soweto: 12 (26%) Xhosa, 25 (54%) Zulu, 9 (20%) Sotho/ Tswana, 0 Other
At baseline 27% had sexually debuted with a median age of 16 (IQR: 15-17). Prior to circumcision 0/50 boys in Cape Town preferred MMC, while in Soweto 42/50 preferred MMC. Each boy had on average 13,6 months (range 12-24 months) follow up, with 13 circumcisions done in 1361 months follow up time. Soweto participants were 11 times more likely to have been circumcised than those in Cape Town (p=0.001, HR 11,11 95% CI: 1,09 - 113,33).
Conclusions: Cultural beliefs and tradition strongly influenced MMC acceptability and uptake. Despite reasonable knowledge about the benefits of early MMC, many young males delay uptake, reducing the benefits of MMC before sexual debut. Programs to promote circumcision should take into consideration cultural and traditional mores and efforts should be made to ensure all circumcision is safe, effective and acceptable.