The effectiveness of voluntary medical male circumcision in lowering the risk of HIV infection for men in southern and eastern Africa by 51–60% was so compelling that three randomised clinical trials were halted prematurely as a result of positive preliminary results.1, 2 Follow-up studies of up to 5·5 years after circumcision have reported increased levels of protection (up to 67–73%), confirming the long-term protective effect of voluntary medical male circumcision.3, 4, 5 These findings support concurrent observations that behavioural disinhibition (eg, reduction in condom use, increase in multiple partners) did not occur in newly circumcised men.6, 7 Mathematical modelling suggests that widespread voluntary medical male circumcision in Africa could avert up to 3·4 million HIV infections and 300 000 deaths over the next 10 years, and an additional 3·7 million infections and 2·7 million deaths in the 10 years after that.8
Zambia has a population of over 14 million, a high prevalence of HIV (19·7% in urban areas), high incidence of HIV (4% per year in urban areas among those aged 15–49 years), and a low rate of male circumcision (12%).9 The WHO Global Programme on AIDS public health recommendations10 were initially codified by the Zambian Ministry of Health into a 5 year plan, the Zambian National Male Circumcision Strategy and Implementation Plan 2010–15, with the goal of doing 1·9 million male circumcisions (80% of the eligible male population) by 2015, or 400 000 circumcisions per year. The plan has since been extended until 2020, with a modified goal of 1·25 million male circumcisions by the end of 2015.
The initial enthusiasm for voluntary medical male circumcision led to long waiting lines of prospective patients at hospitals and community health centres, and as of October, 2014, over 700 000 circumcisions had been reported by the Government of the Republic of Zambia Ministry of Community Development, Mother and Child Health. However, this is about 37% of the national goal and the Zambia Sexual Behaviour Survey,9 and subsequent studies11 forecast a less optimistic portrait of the acceptability and uptake of voluntary medical male circumcision among the remaining population of uncircumcised Zambian men. Whereas studies done in several sub-Saharan African countries have found at least 65% of the men surveyed expressed willingness to be circumcised,11 the Zambia survey published in 2010 showed that over 80% of uncircumcised men interviewed had no interest in voluntary medical male circumcision. Among those surveyed, major impediments to circumcision as a risk-reduction strategy included fear of pain, concerns about sexual performance and satisfaction after surgery, cultural tradition, and partner preferences. These perceptions suggest the need for a more comprehensive strategy for increasing acceptability (demand) and availability (supply) of medical circumcision services in Zambia.
Research in context
Evidence before the study
We searched Scopus and PubMed between Jan 1, 2009, and Nov 30, 2014, with the terms “male circumcision”, “Africa”, and “intervention” for studies designed to increase voluntary medical male circumcision acceptability and uptake, and prevent behavioural disinhibition. Search results identified one behavioural intervention designed to reduce sexual risk behaviour after voluntary medical male circumcision that showed a decrease in sexual risk behaviour (ie, number of partners and unprotected vaginal sex in the experimental condition), suggesting the short-term effect of a brief counselling and HIV risk reduction session. Several previous studies have found no change in sexual risk behaviour after voluntary medical male circumcision. An additional intervention, providing monetary compensation to increase voluntary medical male circumcision uptake, showed a slight increase in uptake of the procedure as the level of compensation increased. However, in our study the compensation associated with voluntary medical male circumcision was less than half that associated with increasing rates in the monetary compensation intervention. A recent text messaging intervention did not affect risk behaviour, and all other recent studies primarily addressed the acceptability of voluntary medical male circumcision and barriers to uptake but have not addressed interventions to simultaneously increase uptake and decrease sexual risk behaviours.
Added value of the study
This study confirms the added value of nesting voluntary medical male circumcision within the context of a comprehensive sexual risk reduction intervention. Our study provides the first clinical trial evidence of the potential effect of a comprehensive behavioural intervention combined with increased voluntary medical male circumcision availability on the simultaneous increase in uptake and decrease in sexual risk behaviour.
Implications of all available evidence
Availability of the procedure might be necessary but not sufficient to encourage men to have voluntary medical male circumcision. These studies support combining educational and experiential interventions with targeted voluntary medical male circumcision promotion strategies to significantly increase uptake. The increase in the procedure is not associated with an increase in sexual risk behaviours; indeed, such comprehensive interventions also might increase condom use.
To optimise the potential benefits, innovative community-level interventions are needed to convince hard-to-reach uncircumcised Zambian men (ie, men who express no interest in the procedure) that voluntary medical male circumcision is a viable means of reducing their risk of HIV infection. In this cluster randomised controlled trial, we sought to measure the effect of increasing both the availability and the acceptability of voluntary medical male circumcision in men at high risk of HIV with little interest in the procedure, with a systematic and comprehensive sexual risk reduction and circumcision promotion intervention designed to scale up both supply of, and demand for, voluntary medical male circumcision services. Because health-care providers at all 13 study sites received training in the procedure before the study, changes in the likelihood of voluntary medical male circumcision would be due to the presence (or absence) of the experimental or control conditions relative to the observation-only condition. We hypothesised that the experimental intervention would significantly increase the likelihood of circumcision with no increase in sexual risk behaviours over the 12 month follow-up period as compared with the control condition.
