In national surveys examining providers’ practices and attitudes regarding the use of male circumcision for HIV prevention, many South African and Zimbabwean clinicians who provided STI or contraceptive services reported that they also performed male circumcisions (17%) or offered referrals (49%), and one in five (18%) said they usually or always counseled male patients about circumcision.1 Physicians were more likely than nurses to offer the procedure, and circumcision services were more common in urban than in rural areas, and at hospitals than at clinics. Six in 10 respondents were interested in receiving circumcision training.
The prevalence of HIV infection is high in both Zimbabwe (14%) and South Africa (18%). Circumcision reduces the risk of HIV transmission, but relatively few men have been circumcised (10% of adult males are circumcised in Zimbabwe, and 35% in South Africa). A major challenge in each country is training enough clinicians to perform circumcisions, which will require the involvement of nonphysician clinicians such as nurses and clinical officers. To help guide such efforts, researchers conducted national probability surveys in 2008–2009 of 1,444 clinicians (830 in Zimbabwe and 614 in South Africa) who were providing contraceptive, HIV and STI services at 75 hospitals and 166 clinics. Respondents were asked about their demographic, clinic and patient characteristics, and about their attitudes and practices regarding HIV, STI and contraceptive services. Researchers used ordered and multinomial logistic regression analyses to identify associations between characteristics and the provision of circumcision counseling, services or referrals, as well as the desire for training.
Seventy-two percent of respondents were advanced nurses (with at least three years of training), 20% were midlevel nurses and 8% were physicians; eight in 10 had been trained in HIV and STI prevention. Almost half of all respondents worked in urban locations, about a third in rural areas, and the remainder in small towns or periurban locales; 55% practiced in hospitals and 45% in clinics. More than eight in 10 clinicians provided voluntary counseling and testing services, and nearly all served HIV-positive patients, as well as those at risk for STI infection. Finally, 85% said they counseled most or all of their patients about condom use.
More than half of clinicians reported counseling male patients about how circumcision reduces the risk of HIV infection; 18% said they usually or always provided such counseling (25% in South Africa and 13% in Zimbabwe), and another 39% said they sometimes offered such counseling. In addition, nearly half talked with female patients about male circumcision. While 49% of respondents (66% in South Africa and 37% in Zimbabwe) offered referrals for circumcision, only 17% (22% and 14%, respectively) said they performed the procedure. Notably, physicians were more likely than nurses to perform circumcisions (56% vs. 14%); provision was twice as high in urban as in rural areas (23% vs. 11%), and it was more likely to be offered at hospitals than at clinics (30% vs. 2%). Six in 10 respondents were interested in receiving training for the procedure (62% of nurses and 49% of physicians); interest was similar in rural and urban areas.
When asked about patients’ attitudes toward circumcision, 31% of clinicians agreed that patients would be upset about having the procedure because of cultural beliefs, 44% believed they would worry about what their partner thinks and 35% said that men would not undergo the operation. Substantial minorities of clinicians believed that men would take more risks after having a circumcision (43%) and would not abstain from sex during the postoperation recovery period (27%). In general, clinicians’ perceptions of patients’ attitudes toward circumcision were more positive in South Africa than in Zimbabwe.
In multivariate analysis, professional training and practice-related characteristics were not associated with the frequency of patient counseling about circumcision for HIV prevention. However, a number of clinicians’ beliefs concerning patients’ attitudes were associated with less counseling: Respondents who said that patients would be upset about the procedure because of cultural beliefs, would not want the procedure, would increase risky behaviors as a result of the procedure or would not abstain from sex during recovery were less likely than their counterparts to frequently counsel patients (odds ratios, 0.5–0.7). In contrast, clinicians who provided condom counseling to most or all of their patients, as well as those who thought that abstinence counseling was highly effective, were more likely than others to frequently counsel patients about circumcision and HIV risk (1.5 and 2.0, respectively).
In other analyses, physicians were more likely than midlevel nurses to perform circumcisions rather than offer neither services nor referrals (odds ratio, 3.8), and clinicians in South Africa were more likely to do so than those in Zimbabwe (6.8). Respondents who thought patients would be upset about the procedure for cultural reasons or would engage in increased risky behaviors if they were circumcised, as well as those who believed that condom counseling was highly effective, had decreased odds of providing services (0.5–0.7). Not surprisingly, provision of circumcisions was far less likely at clinics than at hospitals (0.1).
The likelihood of providing referrals for circumcision services was much greater among clinicians in South Africa than in Zimbabwe (odds ratio, 7.5) and at clinics than at hospitals (2.0); the likelihood of referrals was also greater among respondents who provided voluntary counseling and testing services (1.7). Clinicians who believed patients would be upset about the procedure for cultural reasons or who thought patients would not abstain during postoperation recovery had reduced odds of offering referrals (0.7 for each).
Finally, South African clinicians were less likely than their Zimbabwean counterparts to desire circumcision training (odds ratio, 0.6); desire for such training was also lower among physicians than among midlevel nurses, and among respondents who thought that patients would be upset about receiving a circumcision because of cultural beliefs than among other clinicians (0.5–0.7).
Although a strength of the study was its use of national probability surveys, it had several limitations: a lower response rate in South Africa than in Zimbabwe, a lower response among physicians than among nurses in South Africa, and a focus on clinicians offering STI and HIV prevention services in low-resource settings. Yet the researchers believe that their findings “show great potential” for the diffusion of circumcision provision to nurses, especially those in clinics and in nonurban areas, and that nurses should be targeted for training to increase patients’ access to circumcision. Furthermore, the authors suggest that “training programs should help clinicians to address cultural and other patient-related concerns” regarding male circumcision.—J. Thomas
1. Sheldon WR et al., Male circumcision for HIV prevention: clinical practices and attitudes among healthcare providers in South Africa and Zimbabwe, Sexually Transmitted Diseases, 2012, 39(7):567–575.