Women in Kenya generally have a good understanding of the partial protection against infection with HIV provided to men by male circumcision, investigators report in PLOS ONE. Participants also perceived circumcised men as being more hygienic and as taking longer to ejaculate. The qualitative study was conducted in the city of Kisumu in western Kenya and involved 30 sexually active women aged between 18 and 35 years.
“Women will likely have a significant influence on acceptability and uptake of MC [male circumcision] as it is scaled up in western Kenya and elsewhere in sub-Saharan Africa,” write the authors. “Respondents were aware that MC provides men partial protection against HIV, but the benefits that they cited most, improved male hygiene and cleanliness, was a reason to prefer circumcised versus uncircumcised sexual partners. Some women also believed that circumcised men are slower than uncircumcised men to ejaculate, thus giving women greater sexual satisfaction.”
Randomised controlled trials conducted in sub-Saharan Africa have shown that circumcised men are approximately 60% less likely to acquire HIV than uncircumcised men. Circumcised men also have a reduced risk of infection with human papillomavirus (HPV) and herpes. Circumcision is therefore being rolled out for the purposes of HIV prevention across sub-Saharan Africa.
Investigators wanted to ascertain women’s perceptions of circumcised and uncircumcised men and also their knowledge of the extent of protection against infection that circumcision provides to men.
They therefore conducted in-depth interviews with 30 women resident in Kisumu, the fourth largest city in Kenya, and capital of Nyanza province, which has the country's highest HIV prevalence at 15%. The main ethnic group in the region is Luo. An estimated 66% of Luo men are circumcised, having risen from 45% in 2007. Circumcision has been promoted in the region since 2006.
The women had a mean age of 25 years. The majority (87%) were Luo and 84% were unmarried or were not living with a sexual partner. Participants could accurately identify modes of HIV transmission.
Over half (57%) of the sample reported having sex with both circumcised and uncircumcised men, 23% said they had sex with circumcised men only, and 20% with uncircumcised men only. Most (70%) stated their most recent sexual partner was circumcised.
Most participants were aware that male circumcision provides men with partial protection against infection with HIV and some other STIs (sexually transmitted infections). However, this was sometimes interpreted as meaning that circumcised men were less likely to be living with HIV.
Circumcision was also sometimes equated with hygiene, and a number of women expressed the belief that circumcised men took longer to ejaculate than uncircumcised men.
None of the women reported that they had changed their condom use behaviour because of a man’s circumcision status. The majority of women (70%) said that only themselves, or mostly themselves, decided on condom use.
The majority of women said that circumcision status would not change their decision about condom use because they were aware that circumcised men could still have HIV. None of the participants said that they would engage in higher risk sexual activities because a man was circumcised.
Only one woman said that circumcision status had led to a change in her sexual behaviour. She told investigators that she would not perform oral sex on an uncircumcised man.
Overall, 73% of participants knew that circumcision reduced a man’s risk of acquiring HIV. However, the women were generally unclear about the extent of protection offered by circumcision. Only two respondents knew that there was an approximately 60% reduction in HIV transmission from women to men; two respondents erroneously stated that circumcision provided total protection against HIV and STIs; three women did not know about the reduced risk for men contracting HIV and five had heard of such a relationship but did not believe it to be true.
Three-quarters (77%) of participants reported that they preferred circumcised partners. Five women reported that when they met uncircumcised men with whom they were interested in having a sexual relationship, they insisted that the men get circumcised before they have sex.
Two women preferred uncircumcised men and indeed had not had circumcised sexual partners. One reported not understanding, and the other reported not believing, the partial protection that circumcision provides against HIV. Another women – a sex worker – said she preferred circumcised men for romatic relationships but uncircumcised men as clients; she said that this was because they reached ejaculation more quickly than circumcised men.
“Our interviews…suggest that there may be a cultural preference developing for circumcised men as sexual partners,” comment the authors. This apparent preference is “based on proven (male risk reduction for HIV and STIs) and unproven (male hygiene, time to ejaculation, and sexual performance) attributes of circumcision status.”
Some women thought they influenced men to get circumcised by talking to them about circumcision. Occasionally, the women were more informed about male circumcision and HIV risk than their male partners. One respondent stated that women could influence men to get circumcised.
“MC programs afford an opportunity to engage men and women in couples counselling,” comment the authors. “Based on our results, it will be important to provide information that MC provides only partial protection against female to male transmission of HIV and some STIs; that other HIV and STI prevention methods such as condoms need to be used along with circumcision; that MC does not preclude a man from having HIV; and that couples should develop plans for not having sex while the man is healing.”
Riess TH et al. Women’s beliefs about male circumcision, HIV prevention, and sexual behaviors in Kisumu, Kenya. PLOS ONE 9(5): e97748. DOI: 10.1371/journal.pone.0097748, 2014.