Increasing Availability and Acceptability of Circumcision in Zambia

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DESCRIPTION (provided by applicant): Male circumcision (MC) has been proven to be a potent HIV prevention strategy in Southern and Eastern Africa, reducing risk of HIV acquisition in men by 50-60%. In response to WHO recommendations to establish national programs to promote MC, the Zambian Ministry of Health has created the National Male Circumcision Strategy and Implementation Plan (2010-2020), with the goal of performing 2.5 million circumcisions by 2020, or 250,000 circumcisions per year. However, recent evidence from the population-based Zambia Sexual Behaviour Survey (2010) indicates that of the 88% of the Zambian male population who are uncircumcised, over 80% express no interest in undergoing male circumcision as an HIV prevention strategy.[NB: only 25,000 circumcisions were performed over the past 12 months]. Reaching the national goal will require significantly increasing the available pool of qualified health care providers (from 400 to 1500) to perform circumcisions (supply), as well as developing effective community-level behavioral change interventions promoting circumcision among the population as an acceptable means of reducing risk of HIV infection (demand). This application proposes to test a "biobehavioral partnership" to simultaneously improve both circumcision acceptability and availability at the community health center level. Study hypotheses will test whether circumcision programs which combine an evidence-based sexual risk reduction/MC promotion intervention with competent biomedical MC services at the community level will 1) be more likely to achieve the rates of circumcision necessary to reach the goals of the Zambian National Circumcision Plan than those programs offering biomedical MC services alone while 2) preventing risk compensation/behavioral disinhibition among those undergoing MC. Successful outcomes from this innovative study will have major policy implications for HIV prevention across Southern and Eastern Africa over the next ten years.