Reasons for the Low Uptake of Adult Male Circumcision for the Prevention of HIV Transmission in Swaziland

Saturday, 7 November 2015

Charles Maibvise, MPH, MPhiL, BSc (Hons)
Department of Health Studies, University of South Africa, Pretoria, South Africa
T. R. Mavundla, PhD
University of South Africa, Department of Health Studies, University of South Africa, Pretoria, South Africa

Background and introduction

Male circumcision (MC), the surgical removal of all or part of the foreskin of the penis in a male, has recently been proven to reduce heterosexual female-to-male transmission of HIV by about 60% (Auvert, Taljaard, Lagarde, Sobngwi-Tambekou, Sitta & Puren 2005). Against this background, efforts are being made to scale up MC uptake in thirteen priority East and Southern African countries that are worst affected by HIV and AIDS, one of which is Swaziland.

Swaziland is reported to have the highest prevalence of HIV worldwide, with 19% of the general population and 26.3% of the adult population infected (AVERT, 2013; USAID, 2010). As many as 4,500 people died of HIV/AIDS in 2013 alone (UNAIDS, 2014). As of 2013, Life expectancy at birth is estimated to be at 50 years, one of the lowest in the world (U.S. Central Intelligence Agency, 2013). The number of AIDS orphans was estimated at 73,000 as of 2013 (UNAIDS, 2014), with the result that 15% of the Swazi population consists of orphans and vulnerable children (UNDP, 2013).

In view of this, in 2007, Swaziland adopted mass MC for the prevention of HIV transmission as recommended by WHO and UNAIDS (WHO, 2007; WHO & UNAIDS, 2007a). Mathematical models have shown that if Swaziland could circumcise 50% of males aged 15 to 49 by the end of 2020, one HIV infection could be prevented for every four MCs performed (USAID, 2009; Grund, 2010). Despite intense campaigns to promote the mass MC,  uptake of the procedure is way below the set national targets of circumcising up to 80% of all men aged 15-24 over a five-year period (Ministry of Health [Swaziland] 2009b, Grund 2010).

The reasons for this low uptake of MC have not been sufficiently explored scientifically. The purpose of this study was to explore the reasons for the low uptake of MC in Swaziland despite the campaigns for the procedure. The following method was used.


A generic qualitative study was contacted, in which all men who were targeted by the mass MC campaign were eligible. However, in view of the age criteria for an informed consent, only those who were aged 18 years and above were considered. Ethical clearance was obtained from the Ministry of Health [Swaziland], Scientific and Ethics Committee. Participants were identified and selected by convenience sampling as they were coming for MC or other services, or accompanying their colleagues for such services, at Family Life Association of Swaziland (FLAS) Clinic, Mbabane. FLAS Clinic is one of the main providers of the MC services, among other sexual and reproductive health services in the country. Participants were fully informed about the study before being asked for their voluntary participation. Those who agreed to take part in the study were requested to sign the consent form before data collection. Data were collected through audiotaped individual in-depth face-to-face unstructured interviews. Sampling and data collection were done concurrently and continuously up to the point of data saturation. A total of 17 participants were interviewed. The manual process of qualitative data analysis was followed as described in Creswell (2003:191-195). The process involved transcription of the audiotapes and reading the transcript several times, identifying, coding and categorising similar segments. Main themes were identified, and each was described separately. Data were interpreted to come up with a comprehensive description of the reasons for the low uptake of MC as presented in the next section.


A total of five themes emerged as reasons for the low uptake of MC, namely: perception of no significant benefit in preventing HIV transmission, fear of the procedure and the possible outcome, lack of patience, religious/cultural beliefs as well as worries about the fate of the foreskin

While participants agreed that circumcision reduces the chance of developing sexually transmitted infections (STI), they felt that HIV is an exceptional STI, whose transmission is independent of circumcision status. They were not convinced that MC offers a 60% chance of protection as reported in Auvert et al. (2005). Moreover, the mass MC activists still emphasise on the use of condoms among circumcised individuals, which participants interpreted as ineffectiveness of MC in preventing HIV transmission. Participants also expressed worries about the MC procedure itself and its possible adverse outcomes, mainly surgical pain and impaired sexual function. Those who were not prepared to know their HIV status were also concerned about the HIV testing and counselling which is attached to the medical MC procedure. Some participants also expressed impatience in queuing for the procedure at the expense of their economic productivity, while others were concerned about the time period needed to allow healing of the operation. According to the mass MC guidelines, a circumcised person should wait for 4 to 6 weeks to allow the operation to heal completely before engaging in sexual intercourse (WHO & UNAIDS, 2007b). Apparently this was reported to be too long a period for sexually active participants.

Religious and cultural beliefs also contributed to the low uptake of MC. Biblically, participants felt MC is a feature of the Old Testament, which is no longer supposed to be followed, while others felt it is an unjustifiable act of tempering with God’s temple, the human body. From an African Tradition Religion perspective, participants felt it is against their customs and values to remove any body part and dispose it anyhow, including incineration as is the case with medical MC, without following the proper rituals of traditional dissent burial. Moreover, some participants had a misconception that the foreskins were being used to make some Ben’s spices. According to one health care provider of the FLAS clinic, these spices were coincidentally introduced at the time when mass MC was launched. In addition, those who would have agreed to be circumcised were given these spices as incentives, hence the presumed association. 

Conclusion and recommendations

Results show that most of the reasons for not coming for MC were attributed to insufficient knowledge or misconceptions about some aspects of the procedure. Uncontrollable physiological forces and, to some extent, underutilisation of some potentially influential structures of the community were evident. Apparently some of these drawbacks are modifiable as follows, in an effort to improve MC uptake.

The findings that some Swazis still don’t believe that MC can reduce chances of heterosexual transmission of HIV implies that the current teaching is not sufficiently convincing. It is recommended that more precise and scientific or biomedical explanations be incorporated in the MC campaigns. Likewise, worries about the loss of sexual vigour post-operatively have not been explained clearly from a scientific perspective. Studies have shown that MC enhances sexual performance (Plotkin, Mziray, Küver, Prince, Curran & Mahler, 2011; Senol, Sen, Karademir, Sen & Saracoglu, 2008), and such information is necessary to allay people’s anxiety and convince them to undergo MC.

With a clear understanding of the mechanism of action of the procedure, the public is likely to appreciate the “partially protective” nature of the MC strategy. Participants did not reflect knowledge about the current concept of the comprehensive package for HIV prevention, of which MC is part. The relevant stakeholders, therefore, need to clarify and emphasise that MC is essentially meant to compliment other strategies aimed at reducing heterosexual transmission of HIV infection, and thus be a rescue measure in the event that those other strategies have failed, for whatever reason, deliberate or accidental.

Perioperative pain control measures associated with modern medical MC also need to be emphasised at the campaigns level, rather than only in the perioperative phase. Those who would have undergone the procedure may be engaged to attest to the effectiveness of this pain management which is characteristic of the procedure. Similarly, the HIV counselling and testing (HCT) which are attached to MC and currently discussed just before the procedure, may also need to be discussed at the campaigns level. The input of professional counsellors and the emphasis on clients’ rights in HTC needs to be considered.  

This study also revealed that some men are deterred from MC in preservation of their religious values. Apparently this is out of being misinformed or having misconceptions about the stance of their religions regarding MC, according to some scriptures (Galatians 5:6; Galatians 6:15; Corinthians 7:19). In this regard, the most influential and effective people in clarifying relationship between MC and each religion are the respective religious leaders. It is therefore recommended that these leaders be put aboard in the MC campaigns to assist mobilising their followers.

Over and above these modifiable factors, it is recommended that some efforts be directed towards strengthening neonatal MC. This will ensure that men undergo the procedure before they are sexually and economically active, as these factors have been proven to be challenges of adult MC.

These recommended interventions can be realised if there is collaborative efforts by clinicians, public health personnel, community or institutional.