Male circumcision as an HIV control strategy: not a 'natural condom'

Associations Between Early Circumcision, Sexual and Protective Practices, and HIV Among a National Sample of Male Adults in Eswatini

To reduce HIV incidence in countries such as Eswatini (Swaziland), UNAIDS has recommended male circumcision as one possible effective strategy. We analyzed the 2016s Swaziland HIV Incidence Measurement Survey to explore the association between early circumcision and HIV history among 2964 sexually active adult males aged 15 to 64 years old. Early circumcision was defined as circumcision practiced at an age of 15 years old or younger. Results from logistic regression and OLS regression found that male adults with early circumcision are more likely to have multiple sexual partners and to use condoms. Multiple partners and condom use at last sex encounter remained associated with a higher odds of being HIV positive after controlling for all factors. Nevertheless, early circumcision is significantly associated with a lower odds of being HIV positive (AOR 0.53, p < 0.01). These findings suggest that HIV prevention may benefit when early male circumcision is carried out.

The Penile Microbiota in Uncircumcised and Circumcised Men: Relationships With HIV and Human Papillomavirus Infections and Cervicovaginal Microbiota

While the human microbiota especially that of the gut, cervix, and vagina continue to receive great attention, very little is currently known about the penile (glans, coronal sulcus, foreskin, and shaft) microbiota. The best evidences to date for the potential role of the penile microbiota in human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) acquisition have come from studies examining medical male circumcision. We are still at the foothills of identifying specific penile bacteria that could be associated with increased risk of STI/HIV acquisition. In this review, we summarize the available literature on the human penile microbiota and how it is impacted by circumcision. We also discuss the potential role of penile microbiota in STIs and its impact on cervicovaginal microbiota. Taken together, the findings from the penile microbiota studies coupled with observational studies on the effect of male circumcision for reduction of STI/HIV infection risk suggest that specific penile anaerobic bacteria such as Prevotella spp. potentially have a mechanistic role that increases the risk of genital infections and syndromes, including bacterial vaginosis in sexual partners. Although penile Corynebacterium and Staphylococcus have been associated with healthy cervicovaginal microbiota and have been found to increase following male circumcision, further investigations are warranted to ascertain the exact roles of these bacteria in the reproductive health of men and women. This review aims to address existing gaps and challenges and future prospects in the penile microbiota research. The information described here may have translational significance, thereby improving reproductive health and management of STI/HIV.

PREDICTORS OF MALE CIRCUMCISION AMONG MEN AGED 15-35 YEARS IN HARARE, ZIMBABWE

Medical male circumcision has been recommended by the World Health Organization as part of a comprehensive approach to HIV prevention. Zimbabwe is one of the fourteen sub-Saharan countries that embarked on the Medical Male Circumcision (MMC) programme. However, the country has not yet met male circumcision targets. This paper examines the predictors of male circumcision in Zimbabwe. A cross-sectional survey was conducted on 784 men aged 15-35 years in Harare, Zimbabwe. Negative log-log logistic regression analysis was used to determine the predictors of male circumcision. The main predictors of circumcision were age, employment status, ever tested for HIV, approval of HIV testing prior to circumcision, knowledge about male circumcision and attitudes towards male circumcision. By and large, participants had good knowledge about male circumcision and viewed HIV prevention with a reasonably positive attitude. The identification of these predictors can be used to scale up the demand for male circumcision in Zimbabwe.

HIV risk perception and behavior among medically and traditionally circumcised males in South Africa

BACKGROUND

In South Africa, voluntary medical male circumcision (VMMC) has recently been implemented as a strategy for reducing the risk of heterosexual HIV acquisition among men. However, there is some concern that VMMC may lead to low risk perception and more risky sexual behavior. This study investigated HIV risk perception and risk behaviors among men who have undergone either VMMC or traditional male circumcision (TMC) compared to those that had not been circumcised.

METHODS

Data collected from the 2012 South African national population-based household survey for males aged 15 years and older were analyzed using bivariate and multivariate multinomial logistic regression, and relative risk ratios (RRRs) with 95 % confidence interval (CI) were used to assess factors associated with each type of circumcision relative no circumcision.

RESULTS

Of the 11,086 males that indicated that they were circumcised or not, 19.5 % (95 % CI: 17.9-21.4) were medically circumcised, 27.2 % (95 % CI: 24.7-29.8) were traditionally circumcised and 53.3 % (95 % CI: 50.9-55.6) were not circumcised. In the final multivariate models, relative to uncircumcised males, males who reported VMMC were significantly more likely to have had more than two sexual partners (RRR = 1.67, p = 0.009), and males who reported TMC were significantly less likely to be low risk alcohol users (RRR = 0.72, p < 0.001).

CONCLUSION

There is a need to strengthen and improve the quality of the counselling component of VMMC with the focus on education about the real and present risk for HIV infection associated with multiple sexual partners and alcohol abuse following circumcision.

Barriers and facilitators to the uptake of voluntary medical male circumcision (VMMC) among adolescent boys in KwaZulu-Natal, South Africa

Epidemiological modelling has concluded that if voluntary medical male circumcision (VMMC) is scaled up in high HIV prevalence settings it would lead to a significant reduction in HIV incidence rates. Following the adoption of this evidence by the WHO, South Africa has embarked on an ambitious VMMC programme. However, South Africa still falls short of meeting VMMC targets, particularly in KwaZulu-Natal, the epicentre of the HIV/AIDS epidemic. A qualitative study was conducted in a high HIV prevalence district in KwaZulu-Natal to identify barriers and facilitators to the uptake of VMMC amongst adolescent boys. Focus group discussions with both circumcised and uncircumcised boys were conducted in 2012 and 2013. Analysis of the data was done using the framework approach and was guided by the Social Cognitive Theory focussing on both individual and interpersonal factors influencing VMMC uptake. Individual cognitive factors facilitating uptake included the belief that VMMC reduced the risk of HIV infection, led to better hygiene and improvement in sexual desirability and performance. Cognitive barriers related to the fear of HIV testing (and the subsequent result and stigmas), which preceded VMMC. Further barriers related to the pain associated with the procedure and adverse events. The need to abstain from sex during the six-week healing period was a further prohibiting factor for boys. Timing was crucial, as boys were reluctant to get circumcised when involved in sporting activities and during exam periods. Targeting adolescents for VMMC is successful when coupled with the correct messaging. Service providers need to take heed that demand creation activities need to focus on the benefits of VMMC for HIV risk reduction, as well as other non-HIV benefits. Timing of VMMC interventions needs to be considered when targeting school-going boys.

Correlates of consistent condom use among recently initiated and traditionally circumcised men in the rural areas of the Eastern Cape Province, South Africa

Background

Consistent use of condoms is the most effective method of preventing STIs including HIV. However, recent evidence suggests that limited knowledge about HIV prevention benefits from male circumcision leads to inconsistent condom use among traditionally circumcised men. The aim of this paper is to report on the prevalence of consistent condom use and identify its psychosocial correlates to inform future HIV prevention strategies among traditionally circumcised men in rural areas of the Eastern Cape Province of South Africa.

Methods

A cross-sectional study using interviewer administered fully structured questionnaires was conducted among 1656 men who had undergone initiation and traditional male circumcision in rural areas of the Eastern Cape Province of South Africa. Logistic regression was used to evaluate univariate and multivariate relationships of psychosocial correlates with consistent condom use.

Results

The mean age of the participants was 21.4 years. About 45% belonged to the amaXhosa ethnic group, followed by 15.1% of the amaMpondo, 11.6% of the amaHlubi, and 27.9% from other ethnic groups. A total of 72.3% reported having a main sexual partner and of those 44.8% indicated having other sexual partners as well. About 49% reported consistent condom use and 80% used free government issued condoms, varies among ethnic groups. A total of 35.1% indicated having tested for HIV. Of those who tested for HIV, 46% reported inconsistent condom use when having sex with their sexual partners. Univariate and multivariate analyses showed a positive association between consistent condom use and the general knowledge of condom use, attitude towards condom use with main and casual sexual partners, subjective norm towards condom use with the main sexual partner, perceived self-efficacy towards condom use, positive self-esteem, beliefs about traditional male circumcision and STI protection, attitude towards gender based violence, and cultural alienation.

Conclusions

The study findings reveal important target points for future cultural sensitive health education aimed at increasing consistent condom use among initiated and traditionally circumcised men in the Eastern Cape Province.

Circumcision and prostate cancer: a population-based case-control study in Montréal, Canada

Objectives

To investigate the possible association between circumcision and prostate cancer risk, to examine whether age at circumcision influences prostate cancer risk, and to determine whether race modifies the circumcision–prostate cancer relationship.

Subjects and Methods

PROtEuS (Prostate Cancer and Environment Study), a population-based case-control study set amongst the mainly French-speaking population in Montréal, Canada, was used to address study objectives. The study included 1590 pathologically confirmed prostate cancer cases diagnosed in a Montréal French hospital between 2005 and 2009, and 1618 population controls ascertained from the French electoral list, frequency-matched to cases by age. In-person interviews elicited information on sociodemographic, lifestyle and environmental factors. Unconditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) between circumcision, age at circumcision and prostate cancer risk, adjusting for age, ancestry, family history of prostate cancer, prostate cancer screening history, education, and history of sexually transmitted infections.

Results

Circumcised men had a slightly lower risk, albeit not statistically significant, of developing prostate cancer than uncircumcised men (OR 0.89, 95% CI 0.76–1.04). Circumcision was found to be protective in men circumcised aged ≥36 years (OR 0.55, 95% CI 0.30–0.98). A weaker protective effect was seen among men circumcised within 1 year of birth (OR 0.86, 95% CI 0.72–1.04). The strongest protective effect of circumcision was recorded in Black men (OR 0.40, 95% CI 0.19–0.86, P-value for interaction 0.02) but no association was found with other ancestral groups.

Conclusion

Our findings provide novel evidence for a protective effect of circumcision against prostate cancer development, especially in those circumcised aged ≥36 years; although circumcision before the age of 1 year may also confer protection. Circumcision appeared to be protective only among Black men, a group that has the highest rate of disease. Further research into the differences in effect of circumcision on prostate cancer risk by ancestry is warranted, as is the influence of age at circumcision.

Differences in risky sexual behaviors and HIV prevalence of circumcised and uncircumcised men in Uganda: evidence from a 2011 cross-sectional national survey

Background

Safe male circumcision (SMC) is a known efficacious intervention in the prevention of heterosexual HIV acquisition. However, there are perceptions that SMC may lead to behavior disinhibition towards risky sexual behaviors. We assessed the association between male circumcision, risky sexual behaviors and HIV prevalence among men in a nationally representative sample.

Methods

Data was extracted from the Uganda AIDS Indicator Survey (2011), a stratified two-stage cluster sample, with a total of 7,969 ever sexually active men aged 15–59 years. The association between risky sexual behaviors (non- marital/non-cohabiting sexual relations, non-use of condoms, transactional sex, multiple (4+) lifetime partners) and male circumcision status were determined using odds ratios (OR) and their 95% confidence intervals, through logistic regression models. All analyses were conducted in Stata version 12.

Results

Overall, the prevalence of male circumcision was 28%; higher among men aged 25–34 years, 32%, and lowest among those aged 45–59 years, 18%. HIV prevalence was significantly lower among the circumcised, 4.8% compared to the uncircumcised men, 7.8% (p < 0.001). The commonest risky sexual behaviors were multiple life-time sexual partners (4+), 59%; non-use of condoms with non-marital sexual partners, 55%; and having non-marital sex, 33%. In comparison with the uncircumcised, circumcised men had higher odds of engaging in non-marital sex AOR = 1.26 (95% CI: 1.05-1.52), reporting multiple (4+) life-time partners, AOR = 1.46 (95% CI: 1.27-1.67). The odds of non-use of condoms with a non-marital partner were also significantly lower among the circumcised compared to the uncircumcised men, AOR = 0.79 (95% CI: 0.63-0.98).

Conclusions

Although risky sexual behaviors were more common among circumcised men, HIV prevalence was lower among the circumcised men relative to the uncircumcised. These observations suggest a need to promote the already known HIV intervention strategies especially among the circumcised men.

Paediatric male circumcision and penile hygiene: a Japanese mothers' view

This paper analyses the views of 20 Japanese mothers concerning paediatric male circumcision and penile hygiene. In Japan, routine male circumcision has never been implemented for newborns and children, and adult males are mostly circumcised at aesthetic clinics. However, media reports indicate a trend of Japanese mothers willing to have their sons circumcised. In discussing penile hygiene and male circumcision, the construct of a 'sexual script' becomes relevant to understanding how linguistic and gender barriers made references to male genitalia and penile hygiene largely appear as 'vulgar' and 'unfeminine' in daily life conversations. Peers were often identified as the main source of information and only mothers who have struggled with their children's penile infections have learnt about male genital hygiene, a domain of knowledge largely transmitted by men. Male circumcision becomes a double-edged sword that could help prevent penile infections but also an embarrassing conversational topic that could elicit discrimination because most Japanese children are uncircumcised.

Impediments for the uptake of the Botswana government's male circumcision initiative for HIV prevention

Botswana remains one of the countries with high prevalence of HIV infection with a population prevalence rate of 17.6 in 2008. In 2009, the Ministry of Health launched male circumcision as an additional strategy to the already existing HIV preventive efforts. The purpose of this paper is to share what the participants of a survey to evaluate a short-term male circumcision communication strategy in seven health districts of Botswana reported as impediments for the program's uptake. Qualitative data were obtained from 32 key informants and 36 focus group discussions in 2011. Content analysis method was used to analyze data and to derive themes and subthemes. Although male circumcision was generally acceptable to communities in Botswana, the uptake of the program was slow, and participants attributed that to a number of challenges or impediments that were frustrating the initiative. The impediments were organized into sociocultural factors, knowledge/informational factors, and infrastructural and system factors.

HIV voluntary counselling and testing among recently initiated and traditionally circumcised men in the Eastern Cape Province of South Africa

HIV voluntary counselling and testing (VCT) is a cornerstone of the national strategic plan for HIV/AIDS treatment, care and support in South Africa. However, research shows that the utilisation of VCT services is disappointingly low, particular among males. This article focuses on the factors associated with the intention to test for HIV-infection among recently initiated and traditionally circumcised men in the rural areas of Eastern Cape Province, South Africa. Individual face-to-face interviews were conducted among 1656 sexually active men. Logistic regression analyses were used to explore the association between intention to test for HIV and psychosocial factors. Overall, 35.1% of the participants reported ever having tested for HIV. Intention to test for HIV was positively associated with perceived probability of getting an STI, positive attitudes towards gender-based violence, received general teachings about being a responsible man and highest grade passed. These findings provide specific information that can be used in the development of a focused cultural sensitive STI/HIV prevention programme aimed to increase VCT uptake among sexually active young men, which can be integrated into initiation and health education practices.

How the circumcision solution in Africa will increase HIV infections

The World Health Organization and UNAIDS have supported circumcision as a preventive for HIV infections in regions with high rates of heterosexually transmitted HIV; however, the circumcision solution has several fundamental flaws that undermine its potential for success. This article explores, in detail, the data on which this recommendation is based, the difficulty in translating results from high risk adults in a research setting to the general public, the impact of risk compensation, and how circumcision compares to existing alternatives. Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.

HIV/AIDS, STIs and condom use beliefs among male prison inmates in two South African provinces: Mpumalanga and KwaZulu-Natal

The purpose of this study was to describe the characteristics of a random sample of prison inmates from two provinces in South Africa with respect to correct knowledge regarding HIV/AIDS and sexual transmitted infection (STI) risk and beliefs about condom use. This cross-sectional descriptive study of 357 prison inmates formed part of a larger longitudinal investigation designed to implement a health education intervention for prison inmates in the KwaZulu-Natal (KZN) and Mpumalanga (MP) provinces of South Africa. Mean differences for groups were compared across sites using Analysis of Variance (ANOVA). Inmates from KZN were less likely to agree that 'It is important to use condoms every time you have sex' F (1355) = 25.8, p<0.0001 when compared with inmates in MP. However, they were more likely to agree that 'Condoms work well to prevent the spread of HIV' F (1355) = 11.7, p<0.001; 'Condoms also prevent pregnancy' F (1355) = 5.1, p<0.05. Overall, the demonstrated differences in condom use behaviour suggested that future prevention efforts focus on the importance of using condoms to prevent the spread of HIV/AIDS and other STIs.

Nontherapeutic male circumcision: tackling the difficult issues

INTRODUCTION

Male circumcision is the most commonly performed surgical procedure in the world. Circumcision may be performed to treat an underlying pathological process ("therapeutic circumcision"). However there may be religious, cultural, and social indications.

AIM

This article addresses the religious, cultural, social, and ethical issues surrounding nontherapeutic male circumcision (NTMC).

MAIN OUTCOME MEASURES

Any religious, social, cultural, or ethical issues relating to NTMC.

METHODS

Because of the absence of high level evidence, a concise literature review was undertaken to identify articles published between January 1990 and February 2009 summarizing current knowledge on NTMC.

RESULTS

There are complex religious, cultural, social, and prophylactic incentives for NTMC. The procedure may have associated clinical and psychosocial adverse events and raises such ethical issues as bodily integrity and consent. Because of the strength of the incentives for NTMC, there may be important implications in denying patients the procedure. Several important issues must be considered when introducing mass circumcision as a preventative strategy for HIV/AIDS.

CONCLUSION

When assessing whether NTMC will benefit or harm a patient, clinicians must take his religious, cultural, and social circumstances into account. Males requiring mandatory religious or cultural NTMC are likely to suffer significant harm if they do not receive circumcision and should be considered separately to males in general.

Cost-effectiveness of male circumcision for HIV prevention in a South African setting

BACKGROUND

Consistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa.

METHODS AND FINDINGS

Cost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year. For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189-428) infections over 20 years. The cost is 181 dollars (80% CI 117-306 dollars) per HIA, and net savings are 2.4 million dollars (80% CI 1.3 million to 3.6 million dollars). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is 551 dollars (80% CI 344-1,071 dollars) and net savings are 753,000 (80% CI 0.3 million to 1.2 million dollars). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage.

CONCLUSIONS

In settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.

Anthropology and Circumcision

This chapter reviews the anthropology of male and female circumcision over the past century. After surveying classic sociocultural and psychodynamic interpretations of male circumcision, I shift to the biblical and Jewish rite, focusing on gender symbolism and counter-hegemonic practice within European-Christian society. The chapter then reviews the relationship between male circumcision in sub-Saharan Africa and reduced rates of HIV. Next, I address female circumcision, focusing again on symbolism but especially on highly impassioned debates over cultural relativism and human rights, medical complications, criticism and imperialism, and female agency versus brute patriarchy. What are the moral, political, and scientific obligations of anthropology to a cultural practice that is increasingly vilified in Western popular culture and jurisprudence? Should anthropology advocate eradication, contextualize Western opposition, or critique one's own bodily practices? Finally, I critically analyze the growing movement to ban the medical and ritual circumcision of infant boys in the West.