The (Mis)Reporting of Male Circumcision Status among Men and Women in Zambia and Swaziland: A Randomized Evaluation of Interview Methods

Abstract

BackgroundTo date, male circumcision prevalence has been estimated using surveys of men self-reporting their circumcision status. HIV prevention trials and observational studies involving female participants also collect data on partners' circumcision status as a risk factor for HIV/STIs. A number of studies indicate that reports of circumcision status may be inaccurate. This study assessed different methods for improving self- and partner reporting of circumcision status.Methods/FindingsThe study was conducted in urban and rural Zambia and urban Swaziland. Men (N = 1264) aged 18–50 and their female partners (N = 1264), and boys (N = 840) aged 13–17 were enrolled. Participants were recruited from HIV counseling and testing sites, health centers, and surrounding communities. The study experimentally assessed methods for improving the reporting of circumcision status, including: a) a simple description of circumcision, b) a detailed description of circumcision, c) an illustration of a circumcised and uncircumcised penis, and d) computerized self-interviewing. Self-reports were compared to visual examination. For men, the error in reporting was largely unidirectional: uncircumcised men more often reported they were circumcised (2–7%), depending on setting. Fewer circumcised men misrepresented their status (0.05–5%). Misreporting by women was significantly higher (11–15%), with the error in both directions. A sizable number of women reported that they did not know their partner's circumcision status (3–8%). Computerized interviewing did not improve accuracy. Providing an illustration, particularly for illiterate participants, significantly improved reporting of circumcision status, decreasing misreporting among illiterate participants from 13% to 10%, although misreporting was not eliminated.ConclusionsStudy results suggest that the prevalence of circumcision may be overestimated in Zambia and Swaziland; the error in reporting is higher among women than among men. Improved reporting when a description or illustration is provided suggests that the source of the error is a lack of understanding of male circumcision.

The accuracy of women's reports of their partner's male circumcision status in Rakai, Uganda

“…Similar findings were reported for women (including both married and unmarried women in urban and rural Zambia (7% and 5% misreporting, respectively), and in urban Swaziland (13% misreporting)[14]. Our results suggest that MC prevalence estimated from women’s reports would overestimate the true MC prevalence, since female misreporting was more common when men were in fact uncircumcised.…”

A cross-sectional analysis ofTrichomonas vaginalisinfection among heterosexual HIV-1 serodiscordant African couples

“…Adjusting for characteristics of the male partner, the female partner and the couple allowed us to thoroughly explore factors associated with T. vaginalis risk. Interviewing and performing genital exams for both members of sexual partnerships, rather than relying on one individual to report their partner's characteristics, likely reduced misclassification 32. Our ability to analyse data from 7531 couples provided us with the statistical power to identify associations between T. vaginalis and factors that have weaker associations or are less common.…”

Female Sex Workers, Male Circumcision and HIV: A Qualitative Study of Their Understanding, Experience, and HIV Risk in Zambia

“…Fourth, information sources that may filter to FSWs – such as HIV prevention counseling provided at VCT clinics – should also be clear and direct about the limits of MC's protective effects and the importance of refraining from sex during wound healing. Finally, it is imperative that MC counseling intensify efforts to impress upon men – particularly those men who have riskier sex [29] –the importance of refraining from sex during wound healing, as well as the need for continued use of condoms. By including consideration of FSWs in a national MC strategy to decrease HIV prevalence, we can support a vulnerable and stigmatized population, strategically counter men predisposed to engage in risk compensation, target sexual network nodes that are at very high risk even before MC-related risk compensation, and thus hopefully increase the effectiveness of national HIV prevention efforts.…”