Acceptability of Male Circumcision for Prevention of HIV/AIDS in Sub-Saharan Africa: A Review

N. Westercamp; R. C. Bailey


AIDS and Behavior. 2007;11(3):341-355. 

In This Article

Abstract and Introduction


Based on epidemiological, clinical and experimental evidence, male circumcision (MC) could have a significant impact on the HIV epidemic in selected areas. We reviewed studies of the acceptability of MC in sub-Saharan Africa to assess factors that will influence uptake of circumcision in traditionally non-circumcising populations. Thirteen studies from nine countries were identified. Across studies, the median proportion of uncircumcised men willing to become circumcised was 65% (range 29-87%). Sixty nine percent (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. Because the level of acceptability across the nine countries was quite consistent, additional acceptability studies that pose hypothetical questions to participants are unnecessary. We recommend pilot interventions making safe circumcision services available in conjunction with current HIV prevention strategies and evaluating the safety and acceptability of circumcision.


Numerous observational studies have reported a significant protective effect of male circumcision (MC) against HIV and other sexually transmitted infections (STIs) in men (Bailey, Plummer, & Moses, 2001; Cameron et al., 1989; Gray et al., 2000; Lavreys et al., 1999; Siegfried et al., 2003; Urassa, Todd, Boerma, Hayes, & Isingo, 1997; Weiss, Quigley, & Hayes, 2000). Recently, a randomized controlled trial (RCT) of MC to reduce HIV incidence in Orange Farm, South Africa was stopped prematurely due to an observed protective effect of MC of 60% in intention to treat analysis and 76% in a per protocol analysis. This effect was consistent with the protective effect found in cohort studies (Auvert et al., 2005).

Ecological studies have shown that the countries in sub-Saharan Africa with the highest HIV prevalence are those in which MC is little practiced (Halperin & Bailey, 1999; Moses et al., 1990). Based on the epidemiological and experimental evidence to date, MC could have a significant impact on the HIV epidemic in these most highly affected countries. However, the effectiveness of the intervention will depend on many factors, not the least of which is the extent to which MC is accepted and taken up by males in these populations. If sufficient numbers of males are circumcised, there could be an effect similar to herd immunity since preventing men from becoming infected will also protect their sex partners. At more moderate levels of uptake, the effect is less clear.

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.


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