A cut above? Evidence-based lessons for improving the informed consent process for male circumcision in Swaziland and Zambia

Background Male circumcision (MC) is being scaled up in Zambia and Swaziland to reduce HIV infection. International guidance stresses sound informed consent (IC) procedures, using a human rights-based approach. Methods We evaluated the MC IC process at clinics in Zambia and Swaziland during 2009-2010. We administered a quantitative clients assessment (Zambia: n=115 adolescents aged 13-17, 311 adults aged 18+; Swaziland n=197 adolescents, 756 adults) between MC counseling and procedure. We conducted semi-structured interviews with clients one week post-procedure (Zambia: n=62; Swaziland n=30); and, in Zambia, focus group discussions with parents/guardians (n=36) who accepted and declined MC. Results Quantitative data showed that most participants (e.g. Zambia: 84%/98% adolescents/adults) were comfortable with their decision to undergo MC, with adults significantly more likely than adolescents to report decision comfort (p<0.001). Most clients (e.g. Swaziland 93%/76%) decided on MC before clinic arrival, influenced by friends and family. Almost all said they chose MC voluntarily; however, many were confused about the IC form's significance: some misperceived it as a release from clinic liability while others could not remember signing. Consent procedures for minors were poorly-understood and inconsistently implemented. Conclusions Recommendations have already been incorporated into provider training, including: • Expand outreach messaging recognizing that IC process begins during community sensitization; • Reinforce the IC process step at which proceeding with surgery is authorized; • Conduct refresher training for providers on consent for minors, and publicize requirements widely during outreach; • Standardize mechanisms for adolescents to actively assert assent and receive additional counseling if trepidations remain.