Recent scientific studies have demonstrated that medically circumcised males have a significant degree of protection from HIV incidence (Baxter & Abdool Karim, 2016; Hatzold et al., 2014). According to randomised control trials (RCTs) conducted in Kenya, South Africa and Uganda, there is substantial evidence that VMMC decreases the risk of HIV transmission in heterosexual men practising vaginal penetrative sex by an estimated 60% (Bailey et al., 2007; Gruskin, 2007). This section examines the various studies conducted in Zimbabwe that
40
focused on VMMC for HIV prevention since the strategy was added to the HIV prevention tool box (Hatzold et al., 2014; Montague et al., 2014).
To date, no study, to the knowledge of the researcher has focused on the perspectives of youth in-school regarding the prevention of HIV incidence through a combination strategy of VMMC and condom use. The voices of in-school adolescents are sorely missing, and this area remains under researched. In-school youths continue to be marginalised from what Dutta (2008) describes as, ‘dominant discursive spaces’. VMMC was incepted in 2007 following WHO and UNAID’s formal incorporation of medicalised circumcision into the broad HIV prevention armoury (Gruskin, 2007; WHO/UNAIDS, 2007). Several studies have been conducted since then, but none known to the researcher has focused on this topic.
The following are examples of studies relevant to the topic of VMMC conducted in Zimbabwe. A note of caution must be raised that these studies are not the only ones done because some may be unknown to the researcher. Furthermore, it is vital to indicate that a review of all the literature on the topic, VMMC and condoms for HIV prevention among in- school youth in relation to the Zimbabwean context is beyond the scope of this literature review.
VMMC was incorporated in the comprehensive approach to HIV prevention, which Tatoud (2011) refers to as the ‘HIV prevention buffet’, in 2007 (Bailey et al., 2007;
WHO/UNAIDS, 2007). Several studies have focused on exploring knowledge and acceptability of this prevention intervention (Chamuka, 2014; Mhangara, 2011). Furthermore, various factors were expected to militate against the acceptability and uptake of VMMC (Gwandure, 2011). However, it must be clarified that such studies did not take a linear approach and assume that knowledge leads to acceptance, since knowing is one thing and accepting a preventative strategy is another thing. As such, others have argued that the
41
acceptability of a public health intervention may not solely rely on its efficacy (Berer, 2007).
However, knowledge and acceptability of VMMC as an HIV prevention strategy was and continues to be critical because this is a first in the history of public health that a surgical procedure has been included as a population health measure (Buve et al., 2007).
Zimbabwe introduced VMMC for HIV prevention through the National Male Circumcision Policy of 2009. This policy sought to promote the provision of VMMC for HIV prevention across the broader male population (NAC, 2011). A study by Mhangara (2011) focused on establishing the level of knowledge among workers at Border Timbers Limited in Manicaland province on the benefits offered by VMMC in preventing HIV incidence. The aim was to gather baseline information on VMMC as a prevention intervention to inform future health promotion programming. The study was in the form of a cross-sectional survey and it focused on both male and female adults.
An ethnographic study by Daimon (2013) explored the practice of male circumcision among the Yao community of Malawian ancestry staying in the commercial farming and mining areas of the Mashonaland West province with the view to creating synergy with the biomedical approach of medicalised circumcisions. Basing on data from pregnant women attending antenatal clinics (ANC), HIV prevalence among mining and commercial farming areas was excessively high (Daimon, 2013; MoHCW, 2007). As such, this high prevalence of HIV provided the impetus for implementing VMMC to mitigate the epidemic in this typical AIDS ‘hot spot’. By design, VMMC targets priority locations, which areas characterised by high HIV prevalence and low percentages of circumcised males (WHO/UNAIDS, 2007).
Furthermore, the Yao, along with the Lemba, Tonga, Shangani and Xhosa/Fengu constitute minority groups practising male circumcision as a rite of passage in Zimbabwe (Chamuka, 2014; Mandova, 2013; Shumba & Lubombo, 2017). Zimbabwe’s National Male
42
Circumcision Policy of 2009 foregrounds the need to offer VMMC in a culturally congruent
“manner that fosters respect and collaboration with traditionally circumcising communities and their practices” (Newsday, 2014). Daimon’s study revealed that despite initial resistance, the Yao have since embraced medicalised circumcisions among their initiates.
In another study, Shumba (2014) conducted a qualitative exploration of Lemba perspectives on VMMC for HIV prevention in the Midlands province’s Mberengwa district.
Like the Yao and the Shangani of south-eastern Zimbabwe, the Lemba culturally circumcise their young males in a highly secretive manner (Shoko, 2009; Shumba, 2014). It emerged that the Lemba cultural circumcisers appreciate the benefits of medicalised circumcisions. As such, they expressed willingness to create synergies with those who offer VMMC on condition that Lemba values such as secrecy and male dominance are not compromised in the process (Shumba, 2014).
The Lemba, regard their culture as both dynamic and progressive, thereby creating opportunities for collaborative work with biomedical circumcisers since health and well-being are critical pillars of this Semitic culture (Davis, 2004; Doyle, 2005). The flexibility and dynamism of the Lemba complements Gausset’s (2001) argument that culture has the potential to adapt to new conditions, particularly in the context of health challenges confronting its members. Related literature is often replete with allegations that cultural circumcisions are responsible for transmitting HIV (Gausset, 2001; Gwandure, 2011). In this study, apart from Lemba circumcisions being adequately sanitised, it also emerged that their teachings reiterate that initiates must demonstrate, and exercise sexual restraint, delay sexual debut, and remain faithful in monogamous relationships. This is contrary to anecdotal reports that cultural circumcisers encourage promiscuity to test virility (Mavundla et al., 2009).
43
Chamuka (2014) conducted a study in Harare, Zimbabwe’s capital, among sexually active adult men who had undergone VMMC for HIV prevention. The study sought to understand and explore post circumcision behaviour among men in concurrent sexual partnerships (CSP). Literature on VMMC often highlights the ambivalence that circumcision status may trigger risk compensation. Risk compensation refers to an increase is potentially risky behaviour caused by a decrease in either real or perceived risk (Grund & Hennink, 2012).
The concept of risk compensation is linked to the work of Richens, Imrie, and Copas (2000) postulating that the introduction of car seat belts resulted in some motorists experiencing a false and increased sense of safety to the extent of disregarding road safety rules. In the context of VMMC, it is feared that the partial protection conferred on the circumcised male may lead to increased risky behaviour such as unprotected sex, CSPs and early sexual debut for adolescents. The Zimbabwe 2010-2011 Demographic Health Survey (DHS) indicated that risk compensation was particularly prevalent among VMMC graduates (Shoko, 2012;
ZIMSTAT, 2012). Similarly, a study by Grund and Hennink (2012) documents the prevalence of risk compensation or behaviour disinhibition among Swazi men during the post circumcision phase.
While Chamuka (2014) reports evidence of risky sexual practices following circumcision, evidence of risk compensation at population level is generally scarce. The prevalence of unsafe sex reported by participants in this study (Chamuka, 2014) was not motivated by risk compensation. Participants cited several factors that lead to the practice of unsafe sex, such as condom unavailability, drunkenness and the embarrassment associated with purchasing condoms (Chamuka, 2014). Elsewhere in the eastern and southern African region (ESA), a study conducted in both Siaya and Bondo districts of Kenya did not show any significant levels of risk compensation (Agot et al., 2007).
44