Sexual Behaviors and Other HIV Risk Factors in Circumcised and Uncircumcised Men in Uganda:

Penile coital injuries in men decline after circumcision: Results from a prospective study of recently circumcised and uncircumcised men in western Kenya

Background

Penile coital injuries are one of the suggested mechanisms behind the increased risk of HIV among uncircumcised men. We evaluated the prevalence and correlates of self-reported penile coital injuries in a longitudinal community-based cohort of young (18–24 years old), newly circumcised and uncircumcised men in Western Kenya.

Methods

Self-reported penile coital injuries were assessed at baseline, 6, 12, 18 and 24 months of follow-up, and were defined as scratches, cuts or abrasions during sex, penile soreness during sex, and skin of the penis bleeding during sex. Associations between penile coital injuries, circumcision, sexual satisfaction, and other covariates were estimated with mixed effect models.

Results

Between November 2008 and April 2010 3,186 participants were enrolled (1,588 into circumcision group and 1,598 as age-matched controls). Among 2,106 (66%) participants sexually active at baseline, 53% reported any penile injury, including 44% scratches, cuts or abrasions; 32% penile pain/soreness; and 22% penile bleeding. In multivariable modeling, risk was lower for circumcised men than uncircumcised men for scratches, cuts and abrasions (aOR = 0.39; 95% CI 0.34–0.44); penile pain/soreness (aOR = 0.58; 95% CI 0.51–0.65), penile bleeding (aOR = 0.53; 95% CI 0.46–0.62), and any penile coital injuries (aOR = 0.47; 95%CI 0.42–0.53). Other significant risk factors included increasing age, history of STIs and genital sores, and multiple sex partners, while condom use was protective. Coital injuries were significantly associated with lower levels of sexual satisfaction in longitudinal analyses (scratches, cuts or abrasions: aOR = 0.87, 95% CI: 0.76–0.98; penile pain/soreness: aOR = 0.82, 95% CI: 0.72–0.93; and penile bleeding: aOR = 0.65, 95% CI: 0.55–0.76).

Conclusions

Self-reported penile coital injuries were common and decreased significantly following circumcision. Improving sexual experience through the removal of a potential source of sexual discomfort may resonate with many men targeted for circumcision services. The role of penile coital injuries in sexual satisfaction, HIV, HSV-2, and as a motivator for seeking circumcision services should be explored further.

HIV infection and circumcision: cutting through the hyperbole

The objective of this study was to determine whether the justifications given for promoting mass circumcision as a preventive measure for HIV infection are reasonable and whether mass circumcision is a feasible preventive measure for HIV infection in developing countries.

The medical literature concerning the practice of circumcision in the absence of medical indication was reviewed regarding its impact on HIV infection and related issues. The literature was analysed with careful attention to historical perspective.

Our results show that the medical literature supporting mass circumcision for the prevention of HIV infection is inconsistent and based on observation studies. Even if the two ongoing randomised controlled trials in Africa show a protective benefit of circumcision, factors such as the unknown complication rate of the procedure, the permanent injury to the penis, human rights violations and the potential for veiled colonialism need to be taken into account. Based on the best estimates, mass circumcision would not be as cost-effective as other interventions that have been demonstrated to be effective.

Even if effective, mass circumcision as a preventive measure for HIV in developed countries is difficult to justify.

A Cost-Utility Analysis of Neonatal Circumcision

A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.

Estimation of country-specific and global prevalence of male circumcision

BACKGROUND

Male circumcision (MC) status and genital infection risk are interlinked and MC is now part of HIV prevention programs worldwide. Current MC prevalence is not known for all countries globally. Our aim was to provide estimates for country-specific and global MC prevalence.

METHODS

MC prevalence data were obtained by searches in PubMed, Demographic and Health Surveys, AIDS Indicator Surveys, and Behavioural Surveillance Surveys. Male age was ≥15 years in most surveys. Where no data were available, the population proportion whose religious faith or culture requires MC was used. The total number of circumcised males in each country and territory was calculated using figures for total males from (i) 2015 US Central Intelligence Agency (CIA) data for sex ratio and total population in all 237 countries and territories globally and (ii) 2015 United Nations (UN) figures for males aged 15-64 years.

RESULTS

The estimated percentage of circumcised males in each country and territory varies considerably. Based on (i) and (ii) above, global MC prevalence was 38.7 % (95 % confidence interval [CI]: 33.4, 43.9) and 36.7 % (95 % CI: 31.4, 42.0). Approximately half of circumcisions were for religious and cultural reasons. For countries lacking data we assumed 99.9 % of Muslims and Jews were circumcised. If actual prevalence in religious groups was lower, then MC prevalence in those countries would be lower. On the other hand, we assumed a minimum prevalence of 0.1 % related to MC for medical reasons. This may be too low, thereby underestimating MC prevalence in some countries.

CONCLUSIONS

The present study provides the most accurate estimate to date of MC prevalence in each country and territory in the world. We estimate that 37-39 % of men globally are circumcised. Considering the health benefits of MC, these data may help guide efforts aimed at the use of voluntary, safe medical MC in disease prevention programs in various countries.

Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby

An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.

Risk factors for HIV infection among circumcised men in Uganda: a case-control study

INTRODUCTION

Male circumcision (MC) reduces the risk of HIV infection. However, the risk reduction effect of MC can be modified by type of circumcision (medical, traditional and religious) and sexual risk behaviours post-circumcision. Understanding the risk behaviours associated with HIV infection among circumcised men (regardless of form of circumcision) is critical to the design of comprehensive risk reduction interventions. This study assessed risk factors for HIV infection among men circumcised through various circumcision approaches.

METHODS

This was a case-control study which enrolled 155 cases (HIV-infected) and 155 controls (HIV-uninfected), all of whom were men aged 18-35 years presenting at the AIDS Information Center for HIV testing and care. The outcome variable was HIV sero-status. Using SPSS version 17, multivariable logistic regression was performed to identify factors independently associated with HIV infection.

RESULTS

Overall, 83.9% among cases and 56.8% among controls were traditionally circumcised; 7.7% of cases and 21.3% of controls were religiously circumcised while 8.4% of cases and 21.9% of controls were medically circumcised. A higher proportion of cases than controls reported resuming sexual intercourse before complete wound healing (36.9% vs. 14.1%; p<0.01). Risk factors for HIV infection prior to circumcision were:being in a polygamous marriage (AOR: 6.6, CI: 2.3-18.8) and belonging to the Bagisu ethnic group (AOR: 6.1, CI: 2.6-14.0). After circumcision, HIV infection was associated with: being circumcised at >18 years (AOR: 5.0, CI: 2.4-10.2); resuming sexual intercourse before wound healing (AOR: 3.4, CI: 1.6-7.3); inconsistent use of condoms (AOR: 2.7, CI: 1.5-5.1); and having sexual intercourse under the influence of peers (AOR: 2.9, CI: 1.5-5.5). Men who had religious circumcision were less likely to have HIV infection (AOR: 0.4, 95% CI: 0.2-0.9) than the traditionally circumcised but there was no statistically significant difference between those who were traditionally circumcised and those who were medically circumcised (AOR: 0.40, 95% CI: 0.1-1.1).

CONCLUSIONS

Being circumcised at adulthood, resumption of sexual intercourse before wound healing, inconsistent condom use and having sex under the influence of peers were significant risk factors for HIV infection. Risk reduction messages should address these risk factors, especially among traditionally circumcised men.

The long-term efficacy of medical male circumcision against HIV acquisition

BACKGROUND

In three randomized trials, medical male circumcision (MMC) reduced HIV acquisition in heterosexual men in sub-Saharan Africa by approximately 60%, after 21-24 months of follow-up. We estimated the 72-month efficacy of MMC against HIV among men retained in the Kisumu randomized trial, in which HIV acquisition was reduced by 60% after 24 months.

METHODS

From 2002 to 2005, 2784 men aged 18-24 were enrolled and randomized 1 : 1 to immediate circumcision or control. At trial end in December 2006, control men were offered free circumcision. Follow-up continued to September 2010. Cox proportional hazards regression incorporating stabilized inverse probability of treatment and censoring weights generated through marginal structural modeling, was used to account for potential time-varying confounding and censoring to estimate the efficacy of MMC on HIV risk.

RESULTS

The cumulative 72-month HIV incidence was 7.21% [95% confidence interval (CI): 5.98-8.68%]: 4.81% among circumcised men, 11.0% among uncircumcised men. The crude hazard ratio of HIV seroconversion for circumcised vs. uncircumcised men was 0.38 [95% CI: 0.26-0.55]. In weight-adjusted Cox regression, the hazard ratio was 0.42 [95% CI: 0.26-0.66].

CONCLUSION

The efficacy of MMC was sustained at 58% at 72 months, similar to overall findings of the three trials under conditions of randomization. These findings provide an estimate of the long-term efficacy of circumcision against HIV acquisition. Our results support programmatic scale-up recommendations that are based on assumptions of sustained efficacy.

Sexually transmitted infections and male circumcision: a systematic review and meta-analysis

The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.

Acceptability of male circumcision among adolescent boys and their parents, Botswana

Little is known of the acceptability of male circumcision (MC) to adolescent boys, a key target group for HIV prevention. We conducted a cluster design survey among adolescent boys and their parents/guardians in two villages in Botswana. Of 1300 households visited, 398 boys were eligible; 269 boys and 210 parents/guardians participated. MC was described correctly by 80% of boys, and 76% identified that MC reduces the risk of male HIV acquisition. After a brief informational session, 75% of boys stated that they would definitely want to be circumcised and 96% of parents/guardians would want their boy circumcised. Boys most frequently reported pain (49%) and possible health problems (19%) as concerns undergoing MC; concerns about peer or partner acceptance, sexual function, or cultural appropriateness were uncommon. Adolescent MC is likely to be highly acceptable in Botswana if done safely, for free and with adequate pain control in a hospital setting.

Acceptability of male circumcision for prevention of HIV infection among men and women in Uganda

In the last decade, three randomized controlled trials in Kenya, South Africa, and Uganda have shown that medical male circumcision (MMC) reduces the sexual transmission of HIV from women to men. Objectives of this assessment were to measure acceptability of adult MMC and circumcision of children to inform policies regarding whether and how to promote MMC as an HIV prevention strategy. This mixed-method study, conducted across four Ugandan districts, included a two-stage household survey of 833 adult males and 842 adult females, focus group discussions, and a health provider survey. Respondents' acceptability of MMC was positive and substantial after being informed about the results of recent randomized trials. In uncircumcised men, between 40% and 62% across the districts would consider getting circumcised. Across the four districts between 60% and 86% of fathers and 49% and 95% of mothers were supportive of MMC for sons. Widespread support exists among men and women in this study for promoting MMC as part of Uganda's current 'ABC + ' HIV prevention strategy.

Epidemiology of HIV infection in the Middle East and North Africa

OBJECTIVE

The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data, raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region.

METHODS

A comprehensive systematic review of HIV, sexually transmitted infections (STIs) and risk behavior studies in MENA, irrespective of design, was undertaken. Sources of data included Medline for peer-reviewed publications, Google Scholar for other scientific literature published in nonindexed local and regional journals, international organizations reports and databases, country-level reports and database including governmental and nongovernmental organizations publications, as well as various other institutional documents.

RESULTS

Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users, men who have sex with men (MSM) and to a lesser extent female sex workers, with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited.

CONCLUSION

Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.

Male circumcision for HIV prevention: developments from sub-Saharan Africa

The demonstration of a strong effect of male circumcision on reducing HIV acquisition has provided impetus for this intervention to be adopted more widely in areas of the world where HIV prevalence is high and rates of male circumcision are low. This perspective reviews recent research findings and provides a summary of progress in various countries.

Male circumcision and women's risk of incident chlamydial, gonococcal, and trichomonal infections

BACKGROUND

Male circumcision (MC) decreases the risk of human immunodeficiency virus (HIV) acquisition in men. We explored associations between MC of the primary sex partner and women's risk of acquisition of chlamydial (Ct), gonococcal (GC), or trichomonal (Tv) infections.

METHODS

We analyzed data from a prospective study on hormonal contraception and incident human immunodeficiency virus/sexually transmitted infection (STI) among women from Uganda, Zimbabwe, and Thailand. At enrollment and each follow-up visit, we collected endocervical swabs for polymerase chain reaction identification of Ct and GC; Tv was diagnosed by wet mount. Using Cox proportional hazards models, we compared time to STI acquisition for women according to their partner's MC status.

RESULTS

Among 5925 women (2180 from Uganda, 2228 from Zimbabwe, and 1517 from Thailand), 18.6% reported a circumcised primary partner at baseline, 70.8% reported an uncircumcised partner, and 9.7% did not know their partner's circumcision status. During follow-up, 408, 305, and 362 participants had a first incident Ct, GC, or Tv infection, respectively. In multivariate analysis, after controlling for contraceptive method, age, age at coital debut, and country, the adjusted hazard ratio (HR) comparing women with circumcised partners with those with uncircumcised partners for Ct was 1.25 [95% confidence interval (CI) 0.96-1.63]; for GC, adjusted HR 0.99 (95% CI 0.74-1.31); for Tv, adjusted HR 1.05 (95% CI 0.80-1.36), and for the 3 STIs combined, adjusted HR 1.02 (95% CI 0.85-1.21).

CONCLUSIONS

MC was not associated with women's risk of acquisition of Ct, GC, or Tv infection in this cohort.

Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations

Background: Women who work commercially in sex work (female sex workers [FSW]) are considered a high-risk group for sexually transmissible infections (STI), yet the level of reported pathogens varies in studies around the world. This study reviewed STI rates reported in 42 studies of FSW around the world published between 1995 and 2006 and analysed the trends and types of populations surveyed, emphasising difficult to access FSW populations. Methods:Studies were retrieved by PUBMED and other search engines and were included if two or more pathogens were studied and valid laboratory methods were reported. Results: The five most commonly assessed pathogens were Neisseria gonorrhea (prevalence 0.5–41.3), Chlamydia trachomatis (0.61–46.2), Treponema pallidum (syphilis; 1.5–60.5), HIV (0–76.6), and Trichomonas vaginalis (trichmoniasis; 0.11–51.0). Neisseria gonorrhea and C. trachomatis were the most commonly tested pathogens and high prevalence levels were found in diverse areas of the world. HIV was highly prevalent mostly in African countries. Although human papillomavirus infection was surveyed in few studies, prevalence rates were very high and its aetiological role in cervical cancer warrant its inclusion in future FSW monitoring. Hard-to-access FSW groups tended to have higher rates of STI. Conclusions: The five most commonly detected pathogens correspond to those that are highly prevalent in the general population, however there is an urgent need to develop rapid testing diagnostics for all five pathogens to increase prevention and treatment, especially in outreach programs to the most vulnerable groups among FSW.

Acceptability of male circumcision for prevention of HIV infection in Zambia

Numerous observational studies and three clinical trials have shown male circumcision (MC) to be partially protective against HIV acquisition in heterosexual men. This has led to consideration of introducing circumcision as an HIV prevention strategy in parts of sub-Saharan Africa. This study assesses the acceptability of male circumcision as an intervention to improve male genital hygiene and reduce sexually transmitted infections, including HIV-1 in Zambia. Thirty-four focus group discussions were conducted - 17 with men and 17 with women - in four districts chosen to represent urban and rural communities where circumcision is and is not traditionally practiced. In communities where circumcision is little practiced, the main facilitators for acceptance were improved genital hygiene, HIV/STI prevention, and low cost. The main barriers were cultural tradition, high cost, pain, and concerns for safety. If MC is proven to reduce risk for HIV and STIs, most participants reported that they would seek circumcision for themselves or their partners or their sons if it was free or at a minimal cost. Acceptability of male circumcision for STI and HIV prevention appears to be high in Zambia.

Risk of HIV-1 in rural Kenya: a comparison of circumcised and uncircumcised men

BACKGROUND

Most studies that have found an association between uncircumcised status and infection with human immunodeficiency virus type 1 (HIV-1) have compared participants from various demographic backgrounds, among which the prevalence of other risk factors might have varied. We report findings from a study conducted among men within a single ethnic community in which circumcision was dictated by the religious denomination to which the men belonged.

METHODS

Of the 1217 eligible men, we included in the analysis 845 who gave blood samples for HIV-1 testing and who were confirmed as either fully circumcised (n = 398) or uncircumcised (n = 447). The seroprevalence of HIV-1 was compared between the 2 groups.

RESULTS

All correlates of HIV-1 prevalence that we measured were distributed similarly between circumcised and uncircumcised men. The seroprevalence of HIV-1 was 30% among the uncircumcised men and 20% among the circumcised men. Among uncircumcised men, HIV-1 seroprevalence was similar between men from circumcising denominations (31%; n = 111) and noncircumcising denominations (30%; n = 336). The crude prevalence ratio for HIV infection associated with not being circumcised was 1.5 (95% confidence interval = 1.2-2.0); and adjustment for other measured risk factors for HIV-1 infection had little impact on this result.

CONCLUSION

Our study provides evidence that circumcision is associated with a reduced risk of HIV-1 infection.

Neonatal Circumcision: A Review of the World’s Oldest and Most Controversial Operation

Untimely old, circumcision has elicited more controversy and war of words than any surgical procedure in history. Although previous claims of benefits like curing masturbation, gout, epilepsy, and even insanity were no doubt absurd, important research has shed light on real medical benefits of circumcision. In particular, the procedure has consistently shown to result in the decreased risk of debilitating and costly diseases such as HIV, cervical cancer, and infantile urinary tract infection. Because of advances in the understanding of the anatomy of the foreskin and pain conditioning in infants, prevailing attitudes have changed about anesthesia and analgesia during the procedure. This article objectively summarizes the bulk of significant medical literature over the last century to provide an accurate statement about what we know and what we do not know about neonatal circumcision, including its history, epidemiology, medical benefits, complications, contraindications, techniques, management for pain, and current controversies.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the evolution of circumcision, to list the potential benefits of circumcision, to outline the various neonatal circumcision techniques, and to summarize the data on the use of analgesia for circumcision.

HIV infection in rural villages of Cameroon

OBJECTIVE

To evaluate HIV-1 antibody seroprevalence and risk factors for HIV seropositivity in rural areas of Cameroon.

METHOD

The prevalences of HIV antibodies in 53 villages in rural Cameroon visited during May-October 2000 were determined with an HIV1/2 rapid assay, standard ELISA, and western blot. Demographic data and risk factors were elicited via face-to-face interviews with a structured questionnaire.

RESULTS

HIV seroprevalence was 5.8% (243/4156, 95% confidence interval [CI] = 5.1-6.6) overall, 6.3% (151/2394, 95% CI = 5.4-7.4) among females and 5.2% (92/1762, 95% CI = 4.3-6.4) among males. HIV seroprevalence among persons aged 15 - 70 years did not differ significantly by province (5.6% in Center, 4.5% in East, 6.9% in South, and 5.8% in South-West) ( =.10). Analysis of age- and gender-standardized prevalence by village across provinces indicated a near-significant difference (nonparametric Wilcoxon signed rank test, =.06), with highest prevalence in South-West, followed by South, Center, and East. Multivariate analysis revealed that single women were significantly more likely to be HIV seropositive than were married or widowed women. Women with a history of sexual relations while traveling were at significantly increased risk of HIV seropositivity (OR adjusted for age and marital status = 2.4, 95% CI = 1.4-9.7). Among men, those who reported ever having a sexually transmitted disease were at significantly increased risk of HIV-seropositivity (OR adjusted for age = 1.8, 95% CI = 1.1-2.8).

CONCLUSION

We have documented a wide range of HIV prevalences among rural villages of Cameroon. Age, marital status (in women) and sexual risk factors appear to be associated with HIV infection in this setting.

The impact of the work environment on condom use among female bar workers in the Philippines

The purpose of this research is to examine how condom use is affected by specific aspects of the work environment: (1) social-structural and environmental influences and constraints, (2) mandatory condom use policy, and (3) the level of social influence and reinforcement between manager and employee. A total of 1,340 bar workers and 308 nonestablishment freelance workers comprise the study group. In establishments where a condom use policy exists, female bar workers were 2.6 times more likely to consistently use condoms during sexual intercourse compared with establishments that do not have such a policy in place. The results suggest a need for the development of comprehensive educational policies in all entertainment establishments, including regular meetings with employees, reinforcing attendance at the Social Hygiene Clinic, promoting AIDS awareness, making condoms available in the workplace, and mandating 100% condom use behavior among all employees.

The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya

Compelling epidemiological evidence showing a significant association between lack of male circumcision and HIV infection has prompted calls for consideration of male circumcision interventions as a strategy for reducing HIV prevalence in highly affected areas where circumcision is little practiced and transmission is predominantly heterosexual. Little is known about whether male circumcision interventions would be acceptable or feasible in traditionally non-circumcisng areas of Africa. This study assesses the acceptability of male circumcision in the Luo, a large, traditionally non-circumcising ethnic group in western Kenya. Separate focused group discussions with adult Luo men and women and semi-structured interviews with clinicians were conducted in Nyanza Province, Kenya. The primary barriers to acceptance of male circumcision were cultural identification, fear of pain and excessive bleeding and cost. The main facilitators were association of male circumcision with better hygiene and reduced risk of infection. Both men and women were eager for promotion of genital hygiene and male circumcision, and they desired availability of circumcision clinical services in the Province's health facilities. Clinicians lacked the knowledge and resources to offer safe circumcision counselling and services. If results from this study are valid for other areas of sub-Saharan Africa, acceptability of male circumcision as a means to reduce STDs and HIV is higher than previously suspected. Further studies are needed in other regions to assess the feasibility of introducing acceptable male circumcision information and services to reduce HIV transmission.

Male circumcision as a measure to control HIV infection and other sexually transmitted diseases

There is growing epidemiological evidence from sub-Saharan Africa that male circumcision reduces the risk of HIV acquisition. We review the recent evidence of the protective effect on HIV and other sexually transmitted diseases, including discussion of possible biological mechanisms and highlighting the limitations of the observational studies on which these findings are based. We conclude by discussing the public health implications of these findings, including issues such as safety, acceptability, feasibility and cost-effectiveness of promoting male circumcision in African populations.