Making the case for circumcision as a public health strategy: opening the dialogue

Attitudes, Beliefs and Predictors of Male Circumcision Promotion among Medical University Students in a Traditionally Non-Circumcising Region

Objective: To evaluate the beliefs of medical university students regarding male circumcision (MC), as well as attitudes and the predictors of its promotion in the case of adults at risk of HIV. Methods: A cross-sectional survey was conducted between 2013-2016 at the Medical University in Szczecin, Poland, among final year Polish/foreign students from Northern Europe, using a standardized questionnaire. Results: There were 539 participants, median age 25 years, 40.8% males, and 66.8% were Polish nationals. The MC rate was 16.7%. Regarding HIV/AIDS knowledge, 66.6% of the students scored more than 75%; and, 34.2% knew that MC reduces the risk of HIV infection. One in eleven respondents (9.1%) believed that circumcised men felt more intense sexual pleasure. More than half of the respondents (54.8%) declared that they would recommend MC to adult patients at risk for HIV. The belief that circumcised men felt more intense sexual pleasure, and knowledge on MC regarding HIV risk reduction was associated with greater odds of recommending adult MC (OR = 3.35 and OR = 2.13, respectively). Conclusions: Poor knowledge of its benefits and a low willingness to promote the procedure-strongly dependent on personal beliefs-suggest that medical students may need additional training to help them to discuss MC more openly with adult men at risk for HIV infection. Knowledge may be an effective tool when making decisions regarding MC promotion.

Impact of Health Insurance Type on Trends in Newborn Circumcision, United States, 2000 to 2010

OBJECTIVES

We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision.

METHODS

Hospital discharge data from the 2000-2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence.

RESULTS

Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses (P for trend = .008), but not in analyses adjusted for insurance status (P for trend = .46) and other predictors (P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall (P for trend = .007) and among hospitalizations with Medicaid (P for trend = .005) but not those with private insurance (P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend < .001), suggesting 390,000 additional circumcisions might have occurred nationwide had insurance coverage remained constant.

CONCLUSIONS

Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure.

Reasons for the low uptake of adult male circumcision for the prevention of HIV transmission in Swaziland

Swaziland is currently experiencing the worst impact of HIV and AIDS of any country in the world. In an effort to curb further spread of the virus, the country adopted mass male circumcision (MC) as recommended by the World Health Organization in 2007. Despite intense campaigns to promote the procedure over the past three years, the uptake of circumcision remains very low for reasons that are not very clear. The purpose of this study was to explore the reasons for the low uptake of MC in Swaziland despite the massive national MC campaigns. A qualitative research design was used, in which all men who were targeted by the mass MC campaign were eligible. Participants were identified as they came for sexual and reproductive health services at the Family Life Association of Swaziland (FLAS) Clinic, Mbabane. In-depth, individual face-to-face unstructured interviews were conducted to elicit the reasons why men were not going for circumcision. A total of 17 men were interviewed. Results showed that these reasons include fear of the procedure and the possible outcome, perception of no significant benefit of the procedure, impatience about waiting for the procedure or the healing process, religious/cultural beliefs, and worries about the fate of the foreskin. These reasons were attributed to misconceptions and lack of accurate and specific information about some aspects of the circumcision strategy of HIV preventions. Physiological changes and economic activities associated with adulthood were also found to be hindrances to MC uptake. The study recommended that a comprehensive description of the procedure and more precise facts and scientific bases of the MC strategy be incorporated and emphasised in the MC campaigns. Involvement of religious leaders will also facilitate clarification of religious or cultural misunderstandings or misconceptions. A focus on neonatal MC would also help.

Attitudes and decision making about neonatal male circumcision in a Hispanic population in New York City

OBJECTIVE

To understand attitudes and decision making regarding neonatal male circumcision.

METHODS

Parents (n = 150) with a son 3 years old were interviewed regarding demographics, communication with a medical provider, attitudes, and process by which the neonatal circumcision decision was made.

RESULTS

Thirty-three percent of sons were circumcised. In univariate analyses, choosing male circumcision was associated with parents being interviewed in English, the father being circumcised, positive attitudes, being informed of the advantages of circumcision, making a decision before birth, and being offered a choice. In the final model, parents who came from a culture and family that believed in circumcision and who believed that it was not too risky were more likely to circumcise their sons.

CONCLUSIONS

Decisions regarding circumcision appear to be influenced by values, risk perceptions, and medical providers. Future research should address ways of ensuring that families have the opportunity to make an informed decision.

Global discourses and experiential speculation: Secondary and tertiary graduate Malawians dissect the HIV/AIDS epidemic

BACKGROUND

Since the beginning of the HIV/AIDS epidemic, the perspectives of secondary and tertiary school graduates in sub-Saharan Africa regarding the effectiveness of government and international HIV/AIDS policies and programmes have not been thoroughly examined. When extensive monetary aid is directed toward "development" in a country like Malawi, it is the educated elites - secondary and tertiary graduates who are heavily involved and influential in the domestic re-distribution and implementation of millions of dollars worth of aid - on whom international expectations fall to decrease the transmission of HIV. Many Malawian jobs related to public health and HIV/AIDS are created as a direct result of this funding and are occupied by the few secondary and tertiary graduates. Thus, it is a practical venture to understand their perspectives on highly contentious and heavily funded HIV/AIDS issues that affect their nation.

METHODS

Qualitative data was collected in this study in efforts to discover in-depth perspectives on the HIV/AIDS epidemic. Thirty-eight secondary and tertiary graduate Malawians took part in semi-structured interviews. Data was analysed using an early grounded theory approach and subsequent themes of "global discourses" and "experiential knowledge of HIV/AIDS" emerged.

RESULTS

This group of Malawians frequently responded to questions regarding healthcare and access to medicine, sexual behaviours and methods of reducing the spread of HIV/AIDS by citing and explaining the widespread, international and "proper" responses. The secondary and tertiary graduate Malawians also discussed these same topics in terms of what they perceive or have experienced. Experiential responses, such as the counter-productivity of circumcision and condoms, the overestimation of HIV/AIDS prevalence, and calls for more authoritarian policing of commercial sex work, were remarkably divergent from the HIV/AIDS discourse.

CONCLUSIONS

The opinions of this group of secondary and tertiary graduate Malawians do not always coincide with the current literature and policies. They give deeper insight into what is perceived and what may be taking place, and hint at what the future holds for their people. The widespread and divergent perspectives must be seriously considered because these experiences describe the potential positive and negative consequences that occur on the ground throughout Malawi as a result of HIV/AIDS policies.

Acceptability of neonatal circumcision by Hispanics in southern Florida

This study attempted to determine the acceptability of neonatal circumcision in Hispanic expectant and new parents and to explore potential associations with lower acceptability. Overall, we found surprisingly high rates of acceptability in this community that contrasts with the actual low rates of circumcision in Hispanics in the USA. This gap is important since newborn circumcision has been suggested as an additional long-range tool in reducing longstanding ethnic disparities in HIV incidence in the USA. A larger study will be needed to determine what factors are associated with low acceptability and how one might effectively address these concerns in this population.