Condom avoidance and determinants of demand for male circumcision in Johannesburg, South Africa

Background: Circumcision is efficacious in reducing HIV acquisition in heterosexual males. The South Africa government has been reluctant to adopt a national circumcision programme, possibly due to concerns that circumcision may result in decreased condom use. Objective: To identify the determinants of demand for male circumcision, to examine variations by ethnicity, and to determine whether it is demanded to avoid condom use. Methods: 403 parents and 237 sons in Johannesburg, South Africa, were recruited through a randomized household survey, with oversampling to balance between blacks (n=220), "coloured" (mixed ethnicity) (n=202) and whites (n=218). The demand for male circumcision was estimated using a conjoint analysis, with each respondent randomly receiving four tasks comparing seven possible benefits - six identified through key informant interviews and one for condom avoidance. Respondents' choices were analysed using logistic regression, including stratified analyses to test for homogeneity. Results: Overall, circumcision's beneficial effects on HIV transmission (P<0.001), sexually transmitted infection (STI) transmission (P<0.001), hygiene (P<0.05) and sex (P<0.05) were identified as determinants of demand, but the condom avoidance hypothesis was rejected as it was "repulsive" to respondents (P<0.001). Consistent results were found for blacks (P<0.001) and coloured (P<0.001), but not for whites who found condom avoidance attractive (P<0.04), a result not explained by variations in wealth, age or paternal circumcision status. Conclusions: Male circumcision programmes should be tailored to accommodate variations in the determinants of demand across the target population. We find that circumcision's protective effect against HIV acquisition in men is the only determinant to be found consistently across all ethnic groups in Johannesburg. We also find that concerns over condom avoidance may have been overstated. This said, male circumcision strategies should reinforce a range of HIV prevention strategies, including condom use, as we find evidence that whites may view circumcision as a means to avoid condom use. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine