“After my husband’s circumcision,I know that I am safe from diseases”: Women’s Attitudes and Risk Perceptions Towards Male Circumcision in Iringa,Tanzania

While male circumcision reduces the risk of female-to-male HIV transmission and certain sexually transmitted infections (STIs), there is little evidence that circumcision provides women with direct protection against HIV. This study used qualitative methods to assess women’s perceptions of male circumcision in Iringa, Tanzania. Women in this study had strong preferences for circumcised men because of the low risk perception of HIV with circumcised men, social norms favoring circumcised men, and perceived increased sexual desirability of circumcised men. The health benefits of male circumcision were generally overstated; many respondents falsely believed that women are also directly protected against HIV and that the risk of all STIs is greatly reduced or eliminated in circumcised men. Efforts to engage women about the risks and limitations of male circumcision, in addition to the benefits, should be expanded so that women can accurately assess their risk of HIV or STIs during sexual intercourse with circumcised men.     

The Problem of Routine Circumcision

One hundred male infants were studied at the Kingston General Hospital, Kingston, Ontario, to determine the incidence and complications of routine circumcision. The parents were also interviewed concerning the reason for operation.In these 100 infants, complications, usually minor, were very common, and included hemorrhage (35), meatal ulcers (31), infection (eight), phimosis (one) and meatal stenosis.The reasons given for operation were prophylactic—to avoid the psychological trauma of later operations for infection, phimosis and “troubles” (40), cleanliness (11) and phimosis (four). The remaining cases were for social and other non-medical reasons. Attitudes of parents and physicians regarding circumcision varied from firm belief in its value to a casual approach. One-half of the babies had partial circumcisions, confirming previous suspicions that non-Jewish males frequently had partial operations. Partial operations do not always guarantee cleanliness and probably do not eliminate the risk of penile carcinoma in all cases, if smegma is carcinogenic. Routine circumcisions spare a few children psychologically traumatic operations at a later date and relieve parents of anxiety about the future of the uncircumcised child. This should be balanced against the complications which, although usually minor, may occasionally be serious.Between 1961 and 1962, at the Kingston General Hospital, 349 (48%) of 727 male newborn babies were routinely circumcised.     

Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males

Background

HIV incidence was substantially lower among circumcised versus uncircumcised heterosexual African men in three clinical trials. Based on those findings, we modeled the potential effect of newborn male circumcision on a U.S. male''s lifetime risk of HIV, including associated costs and quality-adjusted life-years saved.

Methodology/Principal Findings

Given published estimates of U.S. males'' lifetime HIV risk, we calculated the fraction of lifetime risk attributable to heterosexual behavior from 2005–2006 HIV surveillance data. We assumed 60% efficacy of circumcision in reducing heterosexually-acquired HIV over a lifetime, and varied efficacy in sensitivity analyses. We calculated differences in lifetime HIV risk, expected HIV treatment costs and quality-adjusted life years (QALYs) among circumcised versus uncircumcised males. The main outcome measure was cost per HIV-related QALY saved. Circumcision reduced the lifetime HIV risk among all males by 15.7% in the base case analysis, ranging from 7.9% for white males to 20.9% for black males. Newborn circumcision was a cost-saving HIV prevention intervention for all, black and Hispanic males. The net cost of newborn circumcision per QALY saved was $87,792 for white males. Results were most sensitive to the discount rate, and circumcision efficacy and cost.

Conclusions/Significance

Newborn circumcision resulted in lower expected HIV-related treatment costs and a slight increase in QALYs. It reduced the 1.87% lifetime risk of HIV among all males by about 16%. The effect varied substantially by race and ethnicity. Racial and ethnic groups who could benefit the most from circumcision may have least access to it due to insurance coverage and state Medicaid policies, and these financial barriers should be addressed. More data on the long-term protective effect of circumcision on heterosexual males as well as on its efficacy in preventing HIV among MSM would be useful.     

Case--control study of counselling against neonatal circumcision.

After two serious complications had alerted physicians to the potential risks of routine neonatal circumcision, the circumcision rate in a regional general hospital decreased significantly (p less than 0.001), from approximately 40% to 20%, settling at the level claimed to prevail when physicians oppose circumcision. Following this decrease 219 consecutive pregnancies resulting in male infants were prospectively studied in order to identify factors associated with insistence on circumcision. Factors significantly associated with circumcision were the existence of an older brother (p less than 0.001), especially if circumcised (p less than 0.001), and delivery of prenatal care by an obstetrician rather than a general practitioner (p less than 0.05). Factors significantly associated with no circumcision were the fact that this infant was the first male born in the family (p = 0.001), delivery of prenatal and infant care by the same general practitioner (p less than 0.05) and a maternal age of 20 years or less (p less than 0.02). The circumcision status of the father, the marital status of the mother, the mother''s intention to breast-feed, attendance of a primigravida at prenatal classes, delivery of infant care by a pediatrician and socioeconomic status did not appear to influence whether circumcision was performed. These data may assist physicians in understanding the potential effectiveness and limitations of counselling against circumcision.     

Effectiveness of and Financial Returns to Voluntary Medical Male Circumcision for HIV Prevention in South Africa: An Incremental Cost-Effectiveness Analysis

BackgroundEmpirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach—analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC’s cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period.Methods/FindingsThe model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold—the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government.ConclusionsVMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age.     

Sexual Risk Behaviours and Willingness to Be Circumcised among Uncircumcised Adult Men in Uganda

Background

There has been substantial demand for safe male circumcision (SMC) in Uganda in the early programme scale-up phase. Research indicates that early adopters of new interventions often differ from later adopters in relation to a range of behaviours. However, there is limited knowledge about the risk profile of men who were willing to be circumcised at the time of launching the SMC programme, i.e., potential early adopters, compared to those who were reluctant. The aim of this study was to address this gap to provide indications on whether it is likely that potential early adopters of male circumcision were more in need of this new prevention measure than others.

Methods

Data were from the 2011 Uganda AIDS Indictor Survey (UAIS), with a nationally representative sample of men 15 to 59 years. The analysis was based on generalized linear models, obtaining prevalence risk ratios (PRR) with 95% confidence intervals (CI) as measures of association between willingness to be circumcised and multiple sexual partners, transactional sex, non-marital sex and non-use of condoms at last non-marital sex.

Results

Of the 5,776 men in the survey, 44% expressed willingness to be circumcised. Willingness to be circumcised was higher among the younger, urban and educated men. In the unadjusted analyses, all the sexual risk behaviours were associated with willingness to be circumcised, while in the adjusted analysis, non-marital sex (Adj PRR 1.27; CI: 1.16–1.40) and non-use of condoms at last such sex (Adj PRR 1.18; CI: 1.07–1.29) were associated with higher willingness to be circumcised.

Conclusion

Willingness to be circumcised was relatively high at the launch of the SMC programme and was more common among uncircumcised men reporting sexual risk behaviours. This indicates that the early adopters of SMC were likely to be in particular need of such additional HIV protective measures.     

Circumcision Status and Risk of HIV Acquisition during Heterosexual Intercourse for Both Males and Females: A Meta-Analysis

In this study, we evaluated if male circumcision was associated with lower HIV acquisition for HIV (−) males and HIV (−) females during normal sexual behavior. We performed a systematic literature search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared HIV acquisition for the circumcised and uncircumcised groups. The reference lists of the included and excluded studies were also screened. Fifteen studies (4 RCTs and 11 prospective cohort studies) were included, and the related data were extracted and analyzed in a meta-analysis. Our study revealed strong evidence that male circumcision was associated with reduced HIV acquisition for HIV(−) males during sexual intercourse with females [pooled adjusted risk ratio (RR): 0.30, 95% CI 0.24 0.38, P < 0.00001] and provided a 70% protective effect. In contrast, no difference was detected in HIV acquisition for HIV (−) females between the circumcised and uncircumcised groups (pooled adjusted RR after sensitivity analysis: 0.68, 95%CI 0.40–1.15, P = 0.15). In conclusion, male circumcision could significantly protect males but not females from HIV acquisition at the population level. Male circumcision may serve as an additional approach toward HIV control, in conjunction with other strategies such as HIV counseling and testing, condom promotion, and so on.     

Understanding the impact of male circumcision interventions on the spread of HIV in southern Africa

Background

Three randomised controlled trials have clearly shown that circumcision of adult men reduces the chance that they acquire HIV infection. However, the potential impact of circumcision programmes – either alone or in combination with other established approaches – is not known and no further field trials are planned. We have used a mathematical model, parameterised using existing trial findings, to understand and predict the impact of circumcision programmes at the population level.

Findings

Our results indicate that circumcision will lead to reductions in incidence for women and uncircumcised men, as well as those circumcised, but that even the most effective intervention is unlikely to completely stem the spread of the virus. Without additional interventions, HIV incidence could eventually be reduced by 25–35%, depending on the level of coverage achieved and whether onward transmission from circumcised men is also reduced. However, circumcision interventions can act synergistically with other types of prevention programmes, and if efforts to change behaviour are increased in parallel with the scale-up of circumcision services, then dramatic reductions in HIV incidence could be achieved. In the long-term, this could lead to reduced AIDS deaths and less need for anti-retroviral therapy. Any increases in risk behaviours following circumcision , i.e. ‘risk compensation’, could offset some of the potential benefit of the intervention, especially for women, but only very large increases would lead to more infections overall.

Conclusions

Circumcision will not be the silver bullet to prevent HIV transmission, but interventions could help to substantially protect men and women from infection, especially in combination with other approaches.     

Women's Beliefs about Male Circumcision,HIV Prevention,and Sexual Behaviors in Kisumu,Kenya

It is important to understand how women''s sexual practices may be influenced by male circumcision (MC) as an HIV prevention effort. Women''s beliefs about MC and sexual behaviour will likely influence the scale-up and uptake of medical MC. We conducted qualitative interviews with 30 sexually active women in Kisumu, Kenya. Women discussed MC related to perceived health benefits, condom use, sexual behaviour, knowledge of susceptibility to HIV and sexually transmitted infections (STIs), circumcision preference, and influence on circumcision uptake. Respondents had a good understanding of the partial protection of MC for acquisition of HIV for men. Women perceived circumcised men as cleaner, carrying fewer diseases, and taking more time to reach ejaculation. Male''s circumcision status is a salient factor for women''s sexual decision making, including partner choice, and condom use. It will be important that educational information affirms 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 in conjunction with MC; 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.     

Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study

Background

There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. The Rwanda National AIDS Commission modelled cost and effects of MC at different ages to inform policy and programmatic decisions in relation to introducing MC. This study was necessary because the MC debate in Southern Africa has focused primarily on MC for adults. Further, this is the first time, to our knowledge, that a cost-effectiveness study on MC has been carried out in a country where HIV prevalence is below 5%.

Methods and Findings

A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents, and adult men. Effectiveness was defined as the number of HIV infections averted, and was calculated as the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages, and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events, and promotion campaigns, and they were adjusted for the averted lifetime cost of health care (antiretroviral therapy [ART], opportunistic infection [OI], laboratory tests). One-way sensitivity analysis was performed by varying the main inputs of the model, and thresholds were calculated at which each intervention is no longer cost-saving and at which an intervention costs more than one gross domestic product (GDP) per capita per life-year gained. Results: Neonatal MC is less expensive than adolescent and adult MC (US$15 instead of US$59 per procedure) and is cost-saving (the cost-effectiveness ratio is negative), even though savings from infant circumcision will be realized later in time. The cost per infection averted is US$3,932 for adolescent MC and US$4,949 for adult MC. Results for infant MC appear robust. Infant MC remains highly cost-effective across a reasonable range of variation in the base case scenario. Adolescent MC is highly cost-effective for the base case scenario but this high cost-effectiveness is not robust to small changes in the input variables. Adult MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man.

Conclusions

The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young. Infant MC can be integrated into existing health services (i.e., neonatal visits and vaccination sessions) and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required for maximal reduction of HIV incidence. In the presence of infant MC, adolescent and adult MC would evolve into a “catch-up” campaign that would be needed at the start of the program but would eventually become superfluous. Please see later in the article for the Editors'' Summary     

Willingness of men who have sex with men (MSM) in the United States to be circumcised as adults to reduce the risk of HIV infection

Background

Circumcision reduces HIV acquisition among heterosexual men in Africa, but it is unclear if circumcision may reduce HIV acquisition among men who have sex with men (MSM) in the United States, or whether MSM would be willing to be circumcised if recommended.

Methods

We interviewed presumed-HIV negative MSM at gay pride events in 2006. We asked uncircumcised respondents about willingness to be circumcised if it were proven to reduce risk of HIV among MSM and perceived barriers to circumcision. Multivariate logistic regression was used to identify covariates associated with willingness to be circumcised.

Results

Of 780 MSM, 133 (17%) were uncircumcised. Of these, 71 (53%) were willing to be circumcised. Willingness was associated with black race (exact odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.3–9.8), non-injection drug use (OR: 6.1, 95% CI: 1.8–23.7) and perceived reduced risk of penile cancer (OR: 4.7, 95% CI: 2.0–11.9). The most commonly endorsed concerns about circumcision were post-surgical pain and wound infection.

Conclusions

Over half of uncircumcised MSM, especially black MSM, expressed willingness to be circumcised. Perceived risks and benefits of circumcision should be a part of educational materials if circumcision is recommended for MSM in the United States.     

A cut above the rest? Private anthropometrics in marriage markets

A large body of economic research suggests that publicly observable anthropometric characteristics affect labor and marriage market outcomes. Private anthropometrics may not affect these outcomes. We examine male circumcision in marriage markets in Zambia. Our analysis reveals substantial variation across local marriage markets in circumcision prevalence relative to preference for circumcised partners, as well as excess aggregate demand for circumcised males. Regression estimates suggest a marriage market premium of approximately one-half to one year of additional schooling for matching with a partner of preferred anthropometric type in a local marriage market with excess demand for that anthropometric characteristic.     

Male circumcision in the general population of Kisumu, Kenya: beliefs about protection, risk behaviors, HIV, and STIs

Using a population-based survey we examined the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.     

Attitudes,Perceptions and Potential Uptake of Male Circumcision among Older Men in Turkana County,Kenya Using Qualitative Methods

Background

In many communities, older men (i.e., over 25 years of age) have not come forward for Voluntary Medical Male Circumcision (VMMC) services. Reasons for low demand among this group of men are not well understood, and may vary across geographic and cultural contexts. This paper examines the facilitators and barriers to VMMC demand in Turkana County, Kenya, with a focus on older men. This is one of the regions targeted by the VMMC program in Kenya because the Turkana ethnic group does not traditionally circumcise, and the rates of HIV and STD transmission are high.

Methods and Findings

Twenty focus group discussions and 69 in-depth interviews were conducted with circumcised and uncircumcised men and their partners to elicit their attitudes and perceptions toward male circumcision. The interviews were conducted in urban, peri-urban, and rural communities across Turkana. Our results show that barriers to circumcision include stigma associated with VMMC, the perception of low risk for HIV for older men and their “protection by marriage,” cultural norms, and a lack of health infrastructure. Facilitators include stigma against not being circumcised (since circumcision is associated with modernity), protection against disease including HIV, and cleanliness. It was also noted that older men should adopt the practice to serve as role models to younger men.

Conclusions

Both men and women were generally supportive of VMMC, but overcoming barriers with appropriate communication messages and high quality services will be challenging. The justification of circumcision being a biomedical procedure for protection against HIV will be the most important message for any communication strategy.     

Therapeutic retraction of the foreskin in childhood.

A retrospective study was conducted of 91 boys who had had a non-retractable but non-fibrosed prepuce treated by retraction under general anaesthesia. Of the 79 boys who had had symptoms, 67 (85%) obtained relief. Twelve of the 91 patients were later circumcised because of continuing problems. Retraction of the foreskin alone is a simple and effective alternative to circumcision in managing most boys with a symptomatic, non-retractable prepuce.     

Circumcision of male children for reduction of future risk for HIV: acceptability among HIV serodiscordant couples in Kampala, Uganda

Introduction

The ultimate success of medical male circumcision for HIV prevention may depend on targeting male infants and children as well as adults, in order to maximally reduce new HIV infections into the future.

Methods

We conducted a cross-sectional study among heterosexual HIV serodiscordant couples (a population at high risk for HIV transmission) attending a research clinic in Kampala, Uganda on perceptions and attitudes about medical circumcision for male children for HIV prevention. Correlates of willingness to circumcise male children were assessed using generalized estimating equations methods.

Results

318 HIV serodiscordant couples were interviewed, 51.3% in which the female partner was HIV uninfected. Most couples were married and cohabiting, and almost 50% had at least one uncircumcised male child of ≤18 years of age. Overall, 90.2% of male partners and 94.6% of female partners expressed interest in medical circumcision for their male children for reduction of future risk for HIV infection, including 79.9% of men and 87.6% of women who had an uncircumcised male child. Among both men and women, those who were knowledgeable that circumcision reduces men''s risk for HIV (adjusted prevalence ratio [APR] 1.34 and 1.14) and those who had discussed the HIV prevention effects of medical circumcision with their partner (APR 1.08 and 1.07) were significantly (p≤0.05) more likely to be interested in male child circumcision for HIV prevention. Among men, those who were circumcised (APR 1.09, p = 0.004) and those who were HIV seropositive (APR 1.09, p = 0.03) were also more likely to be interested in child circumcision for HIV prevention.

Conclusions

A high proportion of men and women in Ugandan heterosexual HIV serodiscordant partnerships were willing to have their male children circumcised for eventual HIV prevention benefits. Engaging both parents may increase interest in medical male circumcision for HIV prevention.     

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

Several sub-Saharan African countries, including Zambia, have initiated national voluntary medical male circumcision (MC) programs to reduce HIV incidence. In-depth interviews were conducted with twenty female sex workers (FSWs) in Lusaka to examine their understanding of MC and experiences with circumcised clients. Knowledge of MC was derived primarily through informal sources, with very few FSWs reporting exposure to MC educational campaigns. MC was not widely believed to be protective against HIV, however it was viewed by some as protective against STIs. Three FSWs reported having sex with recently circumcised clients, and most reported that men often used their MC status to try to convince FSWs to forego condoms. Findings suggest that FSWs, already at high risk for HIV infection, may face additional pressure toward higher risk behavior as a result of MC. As MC services are expanded, programs should support FSWs'' efforts to protect themselves by providing information about what MC can - and cannot - offer for HIV/STI infection prevention.     

Male circumcision and sexually transmitted infections in Botswana

This study set out to investigate the influence of male circumcision and other factors on sexually transmitted infections in Botswana. A syndromic approach, which diagnoses a sexually transmitted infection based on the presence of urethral discharge or genital ulcers rather than on laboratory tests, was used. The data were from the 2001 Botswana AIDS Impact Survey where a nationally representative, randomly selected sample of men and women aged 10-64 years were interviewed in both urban and rural areas. The sample selected for this study consisted of 216,480 men aged 15-64 years who had ever had sexual intercourse. The logistic regression technique was executed to examine the association between male circumcision and self-reported urethral discharge or genital ulcers, while controlling for all other independent variables in the analysis. The main finding of this study was that among men who are circumcised, the odds for self-reported urethral discharge or genital ulcers are significantly lower than for those men who are not circumcised in both urban and rural Botswana. The analysis also showed that the odds in favour of self-reported urethral discharge or genital ulcers, for men who drink alcohol, are twice as large as those for men who do not drink alcohol, controlling for all other independent variables in the analysis. Religion and ethnicity also came through as factors exerting a protective influence against self-reported symptoms of sexually transmitted infections. The conclusion is that while male circumcision appears to be significantly associated with the risk for self-reported urethral discharge or genital ulcers, it is man's behaviour, irrespective of ethnicity or religious dictates, that continues to play a vital role in protection against self-reported symptoms of sexually transmitted infections in Botswana.     

三种包皮环切术的临床比较与分析

目的:观察并评价改良后一钳式环切法临床应用优势。方法:回顾2009年12月至2012年3月间在我院实施的870例包皮环切术资料,对比分析改良一钳法(470例)、传统一钳法(337例)、袖套切除法(63例)三组术式在手术时间、术中疼痛发生率、系带损伤率、患者对外观满意率及并发症(血肿、水肿、延迟愈合、切口狭窄)等临床指标间的差异。结果:改良一钳法的手术时间(min)、术中疼痛发生率小于传统一钳法及袖套切除法(20.88±4.96 vs 26.6±6.48 vs 56.22±7.09,5.5%vs 28.2%vs 100%,P<0.01),袖套切除法在术后短期水肿发生率方面低于改良一钳法和传统一钳法(1.6%vs 10.9%vs 14.8%,P<0.05),改良一钳法的系带损伤率、血肿发生率、切口狭窄率均低于传统一钳法(0 vs 3.6%,0.4%vs 5.9%,0 vs 0.9%,P<0.01),改良一钳法的外观满意度高于传统一钳法及袖套切除法(98.1%vs 93.2%vs 95.2%,P<0.01),而各组的术后切口延迟愈合发生率无统计学差异。结论:根据患者具体情况选择包皮环切术式。其中改良一钳法因适用范围广、手术时间短,系带安全及外形美观,适用于绝大部分的包皮过长及包茎患者。