Increasing early infant male circumcision uptake in Zambia: Like Father, Like Son

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Abstract. Despite compelling research supporting Voluntary Medical Male Circumcision (VMMC) as conveying life-time HIV risk reduction by 60-75%, most Zambian men have been reluctant to undergo VMMC. The Government of the Republic of Zambia, as well as several other Sub-Saharan countries, has identified Early Infant Male Circumcision (EIMC) as an important component of the overall program to increase male circumcision at the population level. However, though the hypothetical acceptability of the procedure appears high among pregnant Zambian women (97%), pilot studies indicate extremely low uptake of EIMC (11%). Although there is widespread agreement that EIMC would convey both short- and long-term health advantages, the uptake of EIMC by Zambian parents has been significantly lower than originally targeted by the Government of the Republic of Zambia. The “Spear and Shield 1” (S&S1) comprehensive adult HIV risk reduction program conducted by this research team significantly increased VMMC rates among Zambian men who initially had no interest in undergoing the procedure. Currently, the Spear and Shield 2 (S&S2) dissemination and implementation program has expanded this Community Health Center (CHC)-based program to 96 CHCs in four Zambian Provinces with high rates of HIV and low prevalence of male circumcision. To date, ~20,000 men and women have attended the S&S2 program. This R34 application, “Like Father, Like Son(s)” (LFLS), proposes to develop the foundation for a randomized clinical trial to test a culturally tailored EIMC intervention to significantly increase the uptake of male circumcision. This innovative strategy for increasing the acceptability and uptake of both EIMC and VMMC will utilize a family-oriented approach, using pregnancy as the pivot to encourage couples (n = 300 couples) to consider EIMC for their male neonates and VMMC for all eligible family members. The proposed three-year feasibility study will build on the successful S&S model and develop and pilot test key intervention components among couples attending antenatal clinics in CHCs; CHC health care providers will be trained to perform VMMC and EIMC, and HIV Counseling and Testing staff will be trained to conduct S&S+LFLS. This planning grant application proposes to 1) utilize collaborative community and expert input to develop the study protocol, content of the LFLS component, and assessment instruments; 2) integrate the LFLS couple sessions into the S&S program; 3) evaluate the influence of the intervention on acceptability and uptake of VMMC and EIMC within the family; and 4) evaluate the feasibility and acceptability of conducting the integrated intervention within the Zambian CHC context. This feasibility study would provide the foundation (protocol, intervention, assessment instruments) for a randomized clinical trial of S&S+LFLS to significantly improve MC uptake among Zambian men and their sons. If successful, the combination of S&S and LFLS could have a synergistic effect on the nation-wide uptake of VMMC and EIMC.