Surveys

A cross-sectional biomedical survey (ANRS-12285) was conducted among a random sample of men between August and September 2015. A first random sample of 34 clusters was obtained among the 346 clusters obtained from Statistics South Africa Enumerator Area aerial photographs. In each of the 34 clusters, a systematic sample of 1 in 5 of the households was selected [9]. Voluntary, written informed consent was obtained from men aged 18–49 years. All men who stayed at least 2 nights in the household in the past 7 days and who spoke English or one of the 2 main local languages (Sesotho and IsiZulu) were eligible. Each participant was interviewed at home using an anonymous, structured and standardized questionnaire. Interviews were followed by individual and confidential HIV and STI counselling and testing. Participants underwent a clinical examination performed by a trained male nurse to assess their clinical MC status (presence or absence of foreskin). Participants with symptomatic STIs were treated free of charge at the study site or at local health facilities according to the national STI syndromic management treatment guidelines. Individuals who tested positive for HIV were referred for appropriate care and treatment. Among 981 eligible households, 870 accepted to participate in the study, which corresponds to a response rate of 88.5%. In these 870 households, 696 men were eligible and 522 men accepted to participate in the study, which corresponds to a response rate of 75.0%.

During the survey, the following background characteristics were collected; age group, ethnic group, religion, alcohol consumption, education level, occupation, current and previous marital status, parenthood status, monthly income and length of stay in Orange Farm. Other collected factors were HIV testing history and self-assessment of HIV infection risk level. Factors related to knowledge and attitude regarding MC were also collected. For men reporting themselves as uncircumcised, willingness to become circumcised and the main reason for not being circumcised were collected. For circumcised men, we collected the main reason for being circumcised and the date of circumcision. We observed that some men made false claims of being circumcised. As a result and because the collection of data preceded the genital examination, these men were excluded from the data collected specifically from uncircumcised men (willingness to become circumcised and main reason for being uncircumcised).

The Human Research Ethics Committee (Medical) of the University of the Witwatersand, Johannesburg, South Africa, granted ethical clearance for the study on January 19^th 2015 (M140946).

MC prevalence rate over time

Fig 1 represents the variation with time of the MC prevalence rate among adults aged 18 to 49 years. This prevalence rate increased only very slightly between 2010–2011 and 2015, from 55.4 to 56.7% (p = 0.60). However, when controlling for age group, we found an aPRR of 1.15 (95%CI: 1.05 to 1.25) p = 0.002. Knowing that the time since the 2010–2011 survey was 4.5 years, this aPRR corresponds to an average increase per year of 3.1% (95%CI: 1.2% to 8.6%).

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Fig 1

Male circumcision (MC) prevalence rate among men aged 18–49 years obtained in three independent cross-sectional surveys conducted in Orange Farm in the years 2007–2008, 2010–2011 and 2015.

Fig 2 represents the variation with time of the MC prevalence rate among adults aged 18 to 19 years. This prevalence rate increased from 9.5% in 2007–2008 to 87.5% (42/48; 95%CI: 76.0% to 94.6%) in 2015, a value not significantly different from 80% (p = 0.28).

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Fig 2

Male circumcision (MC) prevalence rate among men aged 18–19 years obtained in three independent cross-sectional surveys conducted in Orange Farm in the years 2007–2008, 2010–2011 and 2015.

Among adults aged 20 to 29 years the MC prevalence increased from 56.9% (1146/2013) to 61.8% (144/233) between 2010–2011 and 2015, which corresponds to an aPRR adjusted on age group of 1.10 (0.98–1.23) p = 0.10.

Among the circumcised men, 11 reported to have been circumcised in the past 12 months. The proportion of circumcised men among those who were uncircumcised 12 months ago was estimated as 11/(226+11), corresponding to an uptake rate of 4.6% (95%CI: 2.5% to 7.9%) per year.

Reported MC status

Among the 337 men who reported to be circumcised, 41 (12.2%; 95%CI: 9.0% to 16.0%) were in fact uncircumcised. Among the 185 men who reported to be uncircumcised 0 (95%CI: 0.0% to 1.3%) were in fact circumcised. To report having attended an initiation school was not a good marker of the MC status as 88/131 (67.2%; (95%CI: 58.8% to 74.8%) were circumcised, while the number of circumcised men among those reporting to not have attended an initiation school was 208/391 or 53.2% (95%CI: 48.2% to 58.1%).

Characteristics of uncircumcised men

As shown in Table 1, in comparison with circumcised men, uncircumcised men were older, more often Zulu in ethnic origin, less educated and more often recently resident in Orange Farm. The multivariate analysis indicated in Table 2 shows that among uncircumcised men, in comparison with circumcised men, the proportion having ever been tested for HIV was 42% lower, the proportion reporting being at risk of HIV infection was 17% higher, the proportion reporting that MC increases pleasure during sex was 43% lower, the proportion reporting that circumcised men do not need to use condoms to protect them from HIV was also 36% lower, and the proportion reporting that circumcised men can become infected with HIV was 30% lower.

Table 3 summarizes the main reasons reported by uncircumcised men for not being circumcised. 65.4% of the reasons were accounted for by the following responses: "It is not my culture", "Fear of the procedure, fear of pain or injury", and "I do not have the time".

Among the 185 uncircumcised men, 117 (63.2%; 95%CI: 56.1% to 69.9%) reported that they were "Definitely" willing to become circumcised in the future, and 40 (21.6%; 95%CI: 16.2% to 28.0%) said "Maybe". As a result, a total of 157/185 84.9%; 95%CI: 79.2% to 89.5%) were not opposed to undergoing circumcision. Six uncircumcised men reported that they were "Unlikely" (3.2%; 95%CI: 1.4% to 6.6%) and 22 reported as being "Definitively not" (11.9%; 95%CI: 7.8% to 17.1%) willing to undergo circumcision in the future. Among those 28 men not willing to undergo circumcision, 15 reported that their culture or religion was the main reason for not being circumcised (53.6%; 95%CI: 35.5% to 70.9%).

Trends over time

In Orange Farm, an 80% MC coverage has already been achieved among young adults. This high coverage among young adults likely results from the intense campaigns among schools that was started with the Bophelo Pele project in 2008 [12] and repeated each year. The campaigns have led to a change of social norms regarding MC among the youth. To sustain the high coverage of MC among the youth, school talks and the free VMMC clinic in Orange Farm must be maintained. The reason for this success among the youth may be the fact that MC is now culturally and socially more acceptable for the youth than for adults [13,14].

A consequence of the high MC prevalence rate among the youth is that MC prevalence rate is expected to increase among adults with the replacement of generations. This increase will, however, take time. Our study showed that the increase among adults is unlikely to be expected from the current VMMC demand creation in Orange Farm, as the MC prevalence rate has remained relatively stable since 2011. The current demand creation is less intensive than the initial implementation during the 2008–2010 period. For example, between 2008 and 2010 thirty-six field workers were recruiting men for VMMC in Orange Farm. After 2010 this was reduced to two or three.

The results obtained in Orange Farm cannot be immediately extrapolated to other settings. Orange Farm is, however, considered as having similar characteristics to other townships in South Africa. The fact that MC prevalence rate is stable among adults despite the history of VMMC, some ongoing VMMC demand creation activities and the presence of a free-for-service VMMC clinic in the township is not reassuring. Coverage of 80% among adults may be difficult to obtain in South Africa.

In order to obtain MC coverage of 80% in the 14 priority countries, 20.8 million VMMCs will have to be performed [5]. To have reached the target mid-point of 10.4 million MCs is a remarkable success [15] obtained mainly thanks to PEPFAR funding but also due to political investment in these countries. 80% MC coverage has already been obtained in Ethiopia, Kenya and Tanzania. The experience in Orange Farm draws attention to the challenges in achieving the required coverage of 80% in some settings.

Barriers to MC program success

The important factors associated with being uncircumcised were age and ethnic group. Such factors have already been found to be important in other studies conducted in Eastern and Southern African countries where MC prevalence was low in the 2000s [16–20]. As also found in several other studies, the main reported reasons for not being circumcised were related to culture and fear of pain. Reasons that may be relatively easily addressed are fear of pain and lack of time, which represented almost 36% of the reasons mentioned by the participants [16,18,19,21].

The authors would like to thank Agenda Gumbo from Progressus (South Africa) for his contribution to this study.