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Feasibility and Acceptability of Early Infant Male Circumcision As an HIV Prevention Intervention in Zimbabwe

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Feasibility and Acceptability of Early Infant Male Circumcision As an HIV Prevention Intervention in Zimbabwe Feasibility and acceptability of early infant male circumcision as an HIV prevention intervention in Zimbabwe Thesis submitted in fulfilment of the requirements of the University College London degree of Doctor of Philosophy (PhD) in Social Science Webster Mavhu 2014 Author’s Declaration I, Webster Mavhu, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. i Abstract The overall aim of the research outlined in this PhD thesis is to assess the feasibility and acceptability of early infant male circumcision (EIMC) as an HIV prevention intervention in Zimbabwe in order to inform roll out. Mathematical modelling estimates that circumcising 1.9 million Zimbabwean men aged 15-49 by 2015 could avert 42% of new HIV infections that would have otherwise occurred by 2025. Since 2009, Zimbabwe has provided voluntary medical male circumcision (VMMC) to over 300,000 adult and adolescent men. In order to ensure that the protective effect of male circumcision is sustained in the longer-term, Zimbabwe intends to roll out EIMC alongside adult MC, starting 2015. Although EIMC’s effects on HIV will take longer to realise, infant circumcision is easier, safer and cheaper than adult MC. Further, EIMC may more effectively prevent HIV acquisition as the procedure is carried out before the individual becomes sexually active, negating the risk associated with acquisition or transmission of HIV during the healing period. Since large-scale EIMC for HIV prevention, or indeed for other reasons, has never been practised in Zimbabwe or more widely in Southern Africa, there are concerns around its feasibility and acceptability. Clearly, acceptability of infant MC will have a bearing on uptake, roll out and subsequent effectiveness in preventing HIV. In Zimbabwe, there are also concerns about the feasibility of rolling out EIMC for HIV prevention within the context of existing health services, many of which are already overburdened and understaffed. The PhD research is in two phases. The first phase describes a systematic review and thematic synthesis I conducted to explore parental reasons for non-adoption of infant MC for HIV prevention in sub-Saharan Africa. Additionally, this phase qualitatively explored hypothetical acceptability of EIMC among parents and wider family as well as hypothetical feasibility and acceptability of EIMC among health-care workers. Findings from the first phase informed the design of a study to pilot EIMC roll out. The second phase was nested within a trial that assessed the feasibility, safety, acceptability and cost of rolling out EIMC using devices in Zimbabwe. It explored actual acceptability of EIMC among parents and wider family as well as actual feasibility and acceptability of EIMC among health-care workers. Findings from both phases informed recommendations for a demand generation intervention for EIMC which is currently being developed and will subsequently be tested for impact. Given that EIMC has been identified as a key HIV prevention intervention for sustaining the prevention gains anticipated through VMMC across sub-Saharan Africa, the findings of this research are likely to have broad implications for HIV prevention across the region. ii Table of Contents Abstract ........................................................................................................................................... ii List of Tables ................................................................................................................................ vii List of Figures .............................................................................................................................. viii List of Abbreviations ..................................................................................................................... ix Acknowledgements ...................................................................................................................... xi CHAPTER 1: INTRODUCTION ................................................................................................... 1 1.1 Overview ............................................................................................................................... 1 1.2 Background: Zimbabwe HIV/AIDS epidemic .................................................................. 1 1.3 National response to the HIV/AIDS epidemic ................................................................. 3 1.4 Background to the PhD Project......................................................................................... 3 1.5 Aim and objectives .............................................................................................................. 5 1.5.1 The aim of the PhD research ........................................................................................... 5 1.5.2 The specific objectives of the PhD research .................................................................... 5 1.6 Organisation of the thesis .................................................................................................. 5 1.7 Role of the candidate .......................................................................................................... 6 CHAPTER 2: MALE CIRCUMCISION – HISTORY AND POTENTIAL HIV BENEFITS .... 7 2.1 Overview ............................................................................................................................... 7 2.2 Male circumcision: historical perspective ........................................................................ 7 2.3 Estimated global prevalence of male circumcision ........................................................ 8 2.4 Social and cultural significance of male circumcision in Southern Africa ................... 9 2.5 Male circumcision and prevention of HIV acquisition .................................................. 10 2.6 Comparison of male circumcision with other biomedical interventions .................... 12 2.7 WHO/UNAIDS recommendations for male circumcision scale-up ............................ 12 2.8 Adult voluntary medical male circumcision for HIV prevention .................................. 14 2.9 Zimbabwe: history and prevalence of male circumcision ........................................... 16 2.10 Potential impact of rolling out male circumcision in Zimbabwe ............................... 18 2.11 Reasons for non-adoption of VMMC for HIV prevention in Zimbabwe ................... 18 2.12 General and HIV-related advantages of infant male circumcision .......................... 19 2.13 Disadvantages of infant male circumcision for HIV prevention ............................... 20 2.14 Concerns around acceptability and feasibility of EIMC in Zimbabwe ..................... 22 CHAPTER 3: SYSTEMATIC REVIEW AND THEMATIC SYNTHESIS .............................. 23 3.1 Overview ............................................................................................................................. 23 3.2 Background to the systematic review and thematic synthesis ................................... 23 3.3 Debate surrounding qualitative synthesis ..................................................................... 24 3.4 A brief description of qualitative synthesis approaches .............................................. 24 3.5 Methods for the systematic review ................................................................................. 25 3.5.1 Inclusion criteria for publications .................................................................................. 25 iii 3.5.2 Exclusion criteria............................................................................................................ 25 3.5.3 Search strategy .............................................................................................................. 25 3.5.4 Selection of eligible papers ........................................................................................... 26 3.5.5 Assessment of quality of included studies .................................................................... 26 3.6 Results of systematic review ........................................................................................... 27 3.6.1 Identified and selected papers ...................................................................................... 27 3.6.2 Characteristics of included studies ................................................................................ 28 3.7 Methods for the thematic synthesis ................................................................................ 34 3.7.1 Stage one: line-by-line coding of study findings............................................................ 34 3.7.2 Stage two: developing descriptive themes ................................................................... 35 3.7.3 Stage three: generating analytical themes .................................................................... 38 3.8 Results and discussion of the thematic synthesis........................................................ 38 3.9 Strengths and limitations of the study ............................................................................ 39 3.10 Conclusion ....................................................................................................................... 40 CHAPTER 4: METHODS ........................................................................................................... 41 4.1 Overview
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