In 2009 there were 5.7 million people with HIV in South Africa (SA), accounting for 18% of all infections internationally. 1 Although prevalence rates are higher in women, 1 in 4 (25.8%) men aged 30 -34 years is infected. 2 Despite significant steps towards universal access to antiretroviral therapy, the ever-increasing number of HIV-infected South Africans makes uptake and improvement of prevention interventions urgent.Male circumcision is an effective prevention tool for reducing female-to-male HIV transmission. Randomised controlled trials conducted in SA, Kenya and Uganda have reported point efficacies of 60%, 53% and 51%, respectively. 3-5 Modelled data from 2006 have shown the potential population impact of circumcision rollout, 6 projecting the prevention of approximately 2 million new HIV infections and 300 000 AIDS deaths in sub-Saharan Africa in the next 10 years. Additional health benefits associated with the procedure include a lower risk of other sexually transmitted infections (STI) such as chancroid and syphilis. 7 For medical circumcision (MC) to be effective as an HIV prevention measure, it will need to be acceptable and accessible to young men in SA and should take place before sexual debut. A national survey found that the majority of circumcised men aged 15 years or older had been circumcised traditionally (57%). 8 Within the Xhosa tribe, who comprise 23% of black South African men, 9 traditional circumcision (TC) is considered a 'rite of passage to manhood' . 10 The age and extent of foreskin removal in TC, and the acceptability of replacing the procedure with MC, is poorly understood.We investigated a cohort of mainly Xhosa men to determine the proportion who had undergone TC, the extent of foreskin removal, and attitudes towards MC as an HIV prevention tool, for themselves and their sons.
MethodsThe study was conducted at an HIV prevention trial site in a periurban settlement close to Cape Town, SA, which has an estimated population of 350 000, 11 an HIV prevalence of 23% 12 and a 99% black African and 95% Xhosa-speaking demographic. 11 Volunteers were eligible for the study if they were male, aged 15 -42 years, and living in the settlement at the time of the study. Participants were recruited from an observational cohort and the voluntary counselling and testing (VCT) service and were sequentially enrolled. Volunteers were offered regular HIV and STI screening as well as risk reduction counselling. All study participants gave written informed consent and the study was approved by the University of Cape Town's Research Ethics Committee.Demographic and screening data were kept in a central database. Participation required a single study visit, wherein volunteers were screened for eligibility and enrolled. Participants completed an interviewer-administered questionnaire assessing self-reported circumcision status, context of and reasons for previous or planned circumcision, and willingness to undergo MC and/or willingness to permit a son's MC. Recognising that TC comprises several cultural c...