Acceptability of newborn circumcision to prevent HIV infection in the United States

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Factors Associated with Knowledge of and Willingness for Adult Male Circumcision in Changsha, China

BACKGROUND

Male circumcision (MC) has been shown to reduce the risk of male genital diseases. MC is not commonly practiced among Chinese males and little is known about the factors associated with their knowledge of and willingness for MC. This study was to explore the knowledge regarding the foreskin among Chinese males and to identify factors associated with their willingness to undergo circumcision.

METHODS

A total of 237 patients with redundant prepuce/phimosis were interviewed through face-to-face interviews. The items on the questionnaire included: demographics, an objective scale assessing knowledge about the foreskin, willingness to have MC, the attitudes of sexual partners and doctors toward redundant prepuce/phimosis, and the approaches that patients used to acquire knowledge regarding the prepuce. Univariate analysis and multiple logistic regression analysis were performed to identify factors that are associated with willingness to be circumcised (WTC).

RESULTS

A total of 212 patients completed the interview. Multivariable logistic regression showed that three factors were significantly associated with WTC: being married (OR = 0.43), perceiving redundant prepuce/phimosis as a disease (OR = 1.93), and if a patient's partner supported MC (OR = 1.39). 58% (n = 122) had received information about the foreskin from another party: 18% (n = 37) from school, 8% (n = 17) from family, 17% (n = 36) from friends, 27% (n = 57) from health care providers. About 4% (n = 8) believed that their partners disliked their redundant prepuce/phimosis. 20% (n = 42) had received doctors' advice to undergo circumcision.

CONCLUSION

Knowledge about the foreskin was low among Chinese males. Our study elucidates the factors associated with WTC and suggests that more education of the population about the foreskin can help improve the recognition of a correctible abnormality and help patients assess the potential role of MC in their health.

Acceptability of Male Circumcision among College Students in Medical Universities in Western China: A Cross-Sectional Study

Background

Male circumcision (MC) has been shown to reduce the risk of female to male transmission of HIV. The goal of this survey was to explore MC’s acceptability and the factors associated with MC among college students in medical universities in western China.

Methods

A cross-sectional study was carried out in three provinces in western China (Guangxi, Chongqing and Xinjiang) to assess the acceptability of MC as well as to discover factors associated with the acceptability among college students in medical universities. A total of 1,790 uncircumcised male students from three medical universities were enrolled in this study. In addition, 150 students who had undergone MC were also enrolled in the survey, and they participated in in-depth interviews.

Results

Of all the uncircumcised participants (n = 1,790), 55.2% (n = 988) were willing to accept MC. Among those who accepted MC, 67.3% thought that MC could improve their sexual partners’ hygiene, 46.3% believed that HIV and sexually transmitted diseases (STDs) could be partially prevented by MC. The multivariable logistic regression indicates that MC’s acceptability was associated with three factors: the redundant foreskin (OR = 10.171, 95% CI = 7.629–13.559), knowing the hazard of having a redundant foreskin (OR = 1.597, 95% CI = 1.097–2.323), and enhancing sexual pleasure (OR = 1.628, 95% CI = 1.312–2.021). The in-depth interviews for subjects who had undergone MC showed that the major reason for having MC was the redundant foreskin (87.3%), followed by the benefits and the fewer complications of having MC done. In addition, most of these participants (65.3%) said that the MC could enhance sexual satisfaction.

Conclusions

MC’s acceptance among college students in medical universities is higher than it is among other populations in western China. An implementation of an MC programme among this population is feasible in the future.

Counseling parents who are considering newborn male circumcision

The American Academy of Pediatrics recently issued a statement that the health benefits of newborn male circumcision exceed the risks and therefore justify access to the procedure for families who choose it. Further, clinicians are charged with providing factually correct information that communicates the risks and benefits of elective newborn male circumcision in a nonbiased manner. However, many clinicians lack adequate information to discuss the risks and benefits of male circumcision. The purpose of this review is to highlight evidence on the risks and benefits of newborn male circumcision and provide clinicians with counseling points that can be used to guide discussion with parents considering newborn male circumcision.

Factors associated with acceptability of circumcision among male drug users in western China: a cross-sectional study

This study is aimed to investigate whether male circumcision (MC) is feasible among IDUs in China. 1304 drug users who attended methadone maintenance therapy clinics in Guangxi, Chongqing and Xinjiang were selected for participation by using convenience sampling, and completed a self-administered questionnaire. The factors associated with the acceptability of MC were examined via multiple logistic regression models. 45.2% (589/1304) of the participants reported an acceptance of MC. Many of the participants who were initially not willing to accept MC (715/1304) had changed their mind when they were informed that MC would reduce the risk of HIV and STDs (43.4%; 310/715), that MC is associated with few surgery-related complications (23.1%; 165/715), that the surgical procedure could be arranged free of charge (20.1%, 144/715). In the multivariate analysis, higher acceptability of MC was associated with knowledge of the hazards of phimosis (OR=2.22), the presence of phimosis (OR=14.87), and knowledge that MC can prevent AIDS and STDs (OR=1.49); while lower acceptability was associated with residing in Chongqing province (OR=0.41) and an educational level of junior (OR=0.64) and senior high (OR=0.63) school. The MC policy targeting IDUs in China should take into account these factors associated with MC acceptability.

Acceptability of early infant male circumcision among Chinese parents: strategy implications of HIV prevention for China

BACKGROUND

Recent evidence has confirmed that circumcision can be performed as a preventive strategy for HIV and early infant male circumcision (EIMC) is regarded to be safer than circumcision in adulthood; however, limited data are available in the literature about EIMC in China. Therefore, the present study was designed to determine the willingness and attitudes of Chinese parents on newborn male circumcision so as to provide data for exploring the feasibility of implementing EIMC as an HIV prevention strategy in China.

METHODS

Simple random sampling was used to draw participants from parents who had a newborn son delivered at Nanjing Maternity and Child Health Care Hospital, which is affiliated to Nanjing Medical University, between March and December 2010. A questionnaire was used to determine general medical knowledge or information about circumcision, attitudes about EIMC, and level of decision-making on circumcision for the newborn son.

RESULTS

Data derived from 558 responses were analyzed and the ratio of respondents was 56.3% for fathers and 43.6% for mothers. Of the respondents, 34.4% agreed to circumcise their newborn son, and the level of agreement was 3.25 ± 1.17 (range, 1-5 with "1" being "reluctantly agree" and "5" being "very strongly agree"). The major reason for EIMC was for health (44.8%), followed by doctor's advice (31.2%). The major reason not to agree to EIMC was concern about pain (50.5%), followed by the risk of the procedure (23.5%).

CONCLUSION

The willingness and acceptability of EIMC in China is low and the parents of newborn sons are usually not very affirmative when making a decision on such a procedure, suggesting that significant effort will be needed if EIMC is to be implemented as an HIV prevention strategy for China.

A 'snip' in time: what is the best age to circumcise?

BACKGROUND

Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves.

DISCUSSION

We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used.

SUMMARY

Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.

Factors influencing Chinese male's willingness to undergo circumcision: a cross-sectional study in western China

BACKGROUND

Male circumcision (MC) has been shown to reduce the risk of female to male transmission of HIV. The goal of this survey was to explore the acceptability of MC among the Chinese and to identify factors associated with circumcision preference.

METHODS

A cross-sectional survey was conducted between September 2009 and December 2010. We interviewed 2,219 male community participants, from three high HIV prevalence provinces in western China. A structured questionnaire was used to collect data on MC knowledge, willingness to accept MC, reasons to accept or refuse MC, and sexual behaviors and health. For those who refused MC, a health education intervention providing information on the benefits of circumcision was conducted. We used multiple logistic regression models to identify factors associated with the acceptability of MC.

RESULTS

Of the respondents (n = 2,219), 44.6% (989/2,219) reported they would accept MC for the following reasons: promotion of female partners' hygiene (60.3%), redundant foreskin (59.4%), prevention of penile cancer (50.2%), enhanced sexual pleasure (41.4%), and protection against HIV and STDs (34.2%). The multivariable logistic regression showed that five factors were associated with MC willingness: long foreskin (OR = 15.98), residing in Xinjiang province (OR = 3.69), being younger than 25 (OR = 1.60), knowing hazards of redundant foreskin (OR = 1.78), and having a friend who underwent circumcision (OR = 1.36).

CONCLUSION

The acceptability of male circumcision was high among the general population in China. Our study elucidates the factors associated with circumcision preference and suggests that more health education campaigns about positive health effects are necessary to increase the MC rate in China.