For the past 10 years voluntary medical male circumcision has been recommended as a way of reducing female-to-male transmission of HIV. Estimates show that it could reduce infections by 60%. Several sub-Saharan African countries with high rates of HIV prevalence but low rates of male circumcision have rolled out the procedure as part of their HIV prevention initiatives.
Since 2007 more than 9 million circumcisions have been performed in eastern and southern Africa. But to cover more than 80% of men on the continent by 2025, about 20 million more men need to be circumcised. If this happens about 3.4 million new HIV infections could be averted, reducing the number of people who would need HIV treatment and care.
While circumcision has been encouraged there are many places where it has faced challenges. This is linked to misconceptions about the purpose of circumcision as well as religious and cultural concerns which prevent men from getting circumcised.
Uganda is a case in point. By the end of 2015 the country’s health ministry aimed to circumcise 80% – or 4.2 million – men aged between 15 and 49. But between 2008 to 2013 the country only managed to circumcise 50% of this population. Most of these were young boys.
Our research found that religious and cultural beliefs compete with the messages about the purpose of circumcision. We found that this got in the way of men deciding whether or not to be circumcised medically and also affected the way they behaved afterwards.
When medical circumcision is introduced in settings where there are high rates of HIV, it must take into account local beliefs about circumcision. And local religious and social group leaders and women must be involved in the roll-out.
Conflicts of belief
Several studies have compared uptake of circumcision in societies where there is a tradition of circumcision and those where there are not.
When circumcision is not part of religious or cultural practices, introducing voluntary male circumcision can be problematic because it is associated with ethnic and religious identities. This is the case in Zimbabwe, Kenya, and parts of South Africa where there are both social and cultural barriers to circumcision.
In Uganda, only 20% of men practice traditional male circumcision for cultural and religious reasons. This is considerably lower than Kenya (80%) or Tanzania (70%) but similar to many other southern African countries.
We conducted a study of the beliefs and perceptions about circumcision in fishing villages on the shores of Lake Victoria, Uganda. The villages were part of an HIV combination prevention pilot study.
The overall aim of the trial was to investigate factors limiting access to HIV prevention interventions and to determine the feasibility of conducting an HIV combination prevention effectiveness trial to reduce HIV incidence among fishing communities in Uganda.
HIV combination prevention packages would include male circumcision along with access to antiretrovirals, prevention of mother to child transmission, condom promotion, counselling and testing, and health education.
We looked at the influence that different understandings and beliefs about male circumcision may have on voluntary male circumcision in the fishing communities, which are ethnically mixed and have high HIV prevalence.
In Uganda just over 7% of the population is living with HIV.
How the men felt
We found that even when men opted for voluntary medical male circumcision, they followed practices afterwards that were informed by traditional beliefs. This at times involved engaging in unsafe sexual behaviour. While men understood the health benefits of medical circumcision, these messages were sometimes mixed with beliefs drawn from traditional circumcision practices.
For example, several respondents believed that vaginal fluids helped them heal after being circumcised. Some also believed that vaginal fluids could heal wounds from cuts and snake bites as a form of first aid. In these villages it was reported that women also used vaginal fluids to treat themselves and their children’s injuries.
They also believed that having sex with a non-regular partner could chase away spirits and that circumcision offered them protection from sexually transmitted infections. These encouraged unsafe sexual practices.
Changing the mindset
Both personal and community-wide misconceptions need to be improved if the uptake of male circumcision is going to be improved, and if post-procedure behaviour is going to be changed. This can only be done if local knowledge systems in the community are engaged.
Engagements must include local religious and community leaders and must involve both men and women. And this must happen during the roll out of the circumcision procedures but also afterwards.
Key local actors such as traditional and religious leaders from different ethnic groups could help provide support for an approach that takes into account local beliefs about circumcision.