How traditional and medical male circumcision services could work together

Voluntary medical male circumcision (VMMC) is a proven HIV prevention tool. Despite its health benefits, many young Malawian men who are willing to be circumcised are choosing to do so as part of a traditional ceremony. Understanding why this is could hold the key to improving VMMC uptake.

What is the research about?

Researchers surveyed and spoke with 260 men (42% were under 25) in Machinga District, Malawi to hear their views on VMMC, which evidence suggests reduces the risk of female-to-male HIV transmission by 60%.

Due to the nature in which traditional circumcision is performed, pain, bleeding and infection are common, and the foreskin is often not completely removed. Along with more risky behaviours such as ritual sexual practices after circumcision, and having more sexual partners because of the belief that HIV-positive circumcised men can’t transmit HIV, these factors mean that traditional circumcision does not provide the same HIV risk reduction as VMMC.

Machinga District is one of four areas in Malawi where traditional circumcisers (Angaliba) carry out male circumcision as part of a cultural rite-of-passage to mark boys’ journey into manhood. This remains the more popular male circumcision method, despite high rates of HIV.

Why is this research important?

Only one-third of Malawian men are circumscised (28%). And most of these circumcisions are traditional, with only 9% performed by a health professional.

Little research has been published on why men are continuing to choose traditional circumcision. Understanding this, and addressing any concerns that men have about VMMC, could help increase uptake of medical circumcision – and prevent more HIV infections.

What did they find out?

Most men in the study were circumcised (90%). Of these, 97% had been traditionally circumcised. Only 6% were medically circumcised.

Men in the study had these concerns relating to VMMC:

• fear of pain: 63% said this put men off VMMC. This perception could be due to the experience of traditional circumcision, which is done without anaesthetic. This may make many young men think VMMC will be as painful
• perceived surgical complications, such as bleeding: 31% said this put men off VMMC
• difficulties accessing VMMC clinics: 37% said this was a barrier, and 27% said the cost associated with medical circumcision (for example, having to pay for transport to a health facility) stopped men from doing it.
• older participants were concerned about the presence of female health providers. This was seen as disrespectful and a complete departure from male-only traditional circumcision camps, where older men care for younger men who have been circumcised until they recover
• missing out on the celebrations and feasting that happen in traditional circumcision ceremonies
• men in the study mentioned the financial advantages of traditional circumcision, especially for chiefs and Angaliba who profit from traditional circumcision so cannot afford to promote VMMC
• older, married men said women’s resistance to VMMC was a big influence on men’s decisions. Men said women often favoured traditional circumcision due to the financial benefits associated with it and would use their influence to ensure this is what happened
• peer pressure: many men described how young men are impatient for traditional circumcision to fit in with their peers because traditional circumcision takes place in large groups
• VMMC was seen as eroding cultural norms because traditional circumcision is a practice that has been passed down through the generations.

What does this mean for HIV services?

It means there are opportunities to increase the uptake of VMMC in communities that traditionally circumcise. But progress will only be made if these communities’ cultural beliefs and practices are taken into consideration.

One way to do this could be to bring local chiefs and healthcare workers together to work as a team. Once local leaders understand the HIV prevention benefits of medical circumcision, they may be willing to help healthcare workers carry out VMMC in traditional settings, particularly if there is financial compensation. The discomfort of being attended to by female health workers could be avoided by asking male health workers to carry out VMMC.

Traditional feasts and ceremonies could still take place after VMMC so this benefit is not lost. But if ceremonies include ritual sexual practices as some do (for example, newly circumcised men may receive ‘training’ by having sex with multiple partners), these aspects should be replaced by non-risky but culturally meaningful practices.

As fear of pain is a major concern, it could be useful to run a public awareness campaign to show that VMMC is a minor, safe procedure and not as painful as traditional circumcision because it is performed under anaesthetic. It may be useful to target women with messages about the importance of VMMC for reducing HIV infections, so they are aware of this benefit and will communicate it to their partners.