Circumcision: current practice and acceptability



Cultural acceptance of circumcision will be vital, if this practice is to be an important complementary intervention for prevention of HIV infection.

Around 20% of men globally and 35% in developing countries are circumcised for religious, cultural, medical and other reasons. Male circumcision practices vary throughout Africa. Countries in West Africa, where male circumcision is common, have HIV prevalence levels well below those of countries in eastern and southern Africa despite the presence of other risk factors. In countries of southern and eastern Africa with the highest HIV prevalence, male circumcision rates are generally under 20%.

Men in Muslim countries are circumcised, as in North Africa and a large part of West Africa. But elsewhere it depends on other cultural factors, including changes that occurred under colonization. For example in Cameroon and the Democratic Republic of the Congo, which are predominantly non-Muslim, most men are circumcised. In Kenya, around 85% of adult men are circumcised, mainly as a rite of passage to manhood.

Only one major ethnic group in Kenya, the Luo, who make up around 13% of the Kenyan population, do not traditionally practice male circumcision. It is among this group that the current trial in Kenya is taking place. Study leader, Robert Bailey, told the Bulletin that acceptability studies have shown that approximately 60% of Luo men would prefer to be circumcised if it could be done safely and at minimal cost.

Circumcision rates tend to be low in South Africa, apart from the Eastern Cape where as many as 80–90% of men are circumcised. The Xhosa men in this region undergo circumcision as part of a traditional right of passage, between 18 and 20 years of age (see photo on p. 509. Dr Adrian Puren, co-author of the Orange Farm study and deputy director of the National Institute for Communicable Disease in Johannesburg, says: "Culture is not necessarily a barrier to circumcision. In our trial we found that even Zulus, who traditionally have a low rate of circumcision, they were willing to be circumcised."

Acceptability studies in Kenya, Uganda, South Africa, Swaziland, the United Republic of Tanzania and Zimbabwe have shown that around 60% of men would like to be circumcised. A large Harvard AIDS Institute survey in Botswana found that over 80% of uncircumcised men said they would like to be circumcised if it were performed safely and affordably (Sex Transm Infect 2003;79:214-19). Several of the countries that are most severely affected by HIV — Swaziland, Botswana, Lesotho and South Africa — practised male circumcision widely in the past, but the practice waned with urbanization and Westernisation. Promoting it now would be returning to traditional culture, not introducing an unfamiliar practice.

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