1. Circumcision in Zambia

2. Traditional MC –NW Province and small Muslim communities in E. Province & elsewhere NW Province (along with N. Province) has lowest HIV rates – but syphilis rate close to national average

3. SBS 2000 - % Circumcised Urban15.3% Rural17.8% Total16.9%

4. Preliminary Qualitative Work 4 focus-group interviews with men 2x2: – rural vs. urban – 18-24 unmarried vs. 25-39 married conducted in Lusaka and Chongwe Key informant interview with MC provider from Lusaka

5. Groups Traditionally doing MC Not having MC is associated with uncleanliness, premature ejaculation and unfitness for marriage Rationale: mark of attaining manhood, protection from ‘diseases’, capacity to please women sexually

6. Groups Not Doing MC Traditional practice seen as done without the boy’s consent Seen as reducing risk of STI (incl. HIV) Limited demand for MC – some informants report wishing they’d been circumcised Common belief that women prefer circumcised men

7. Age at Circumcision Reported as usually between 8-15 Concern that if done later in adulthood, healing is slower & complications more likely Mixed views on infant MC (safety concerns)

8. Setting Mixed views on traditional vs. medical Tendency for those from MC-practicing groups to prefer camps; non-MC - hospital Issues: safety, access, expense, associated teaching

9. STI/HIV Protection Widely held view, even among non-MC ethnic groups, that MC reduces risk of STI/HIV transmission Protection is attributed to harder, drier glans A few informants consider MC as a ‘natural condom’ conferring 100% protection: most consider protection only partial Some consider MC less effective in preventing HIV than other STIs

10. Effects on Sex Seen to improve satisfaction for women Male sexual satisfaction not seen to be threatened by MC; could be enhanced View expressed that MC makes condom- use easier

11. Concerns Fear of disease transmission with traditional practice, using the same knife on several boys (STIs, HIV) Slow healing Localized infection, blood loss Risk of dying Belief that MC is protective can encourage risky behavior

12. Supply Expense is perceived as a barrier – both for traditional MC camps and medical MC Few clinicians providing MC services Informants reported trying unsuccessfully to access medical MC

13. Urban vs. Rural; Single vs. Married Urban sample – less confident in safety of traditional MC Little difference b/w singles and married – except married had more experience

14. Key Informant Interview Lusaka-based MD from MC-practicing ethnic group Reports widely held view on protection from infection Reports considerable demand for medical MC, but mainly from MC-practicing groups and families having intermarried with MC-practicing groups Sees slow increase in demand from other groups Reports interest among medical colleagues in offering MC service

15. Conclusions MC is relatively uncommon Interest in MC even among ethnic groups not traditionally practicing MC Widely held perception that MC reduces STI (and HIV) risk, although most consider HIV protection only partial Demand for more information on MC

16. Next Steps Government interest in a pilot as groundwork to expand access to quality MC Implementing partners on the ground ready to participate (JHPIEGO, Horizons) Need for assessment not only of feasibility but to better characterize potential demand Explore policy/ regulatory issues

17. HIV Prevalence 1998 Sentinel Sites