Circumcision Status and Time to First Sex Among Never-Married Young Men in Malawi: Evidence from the Demographic and Health Survey

This study examines the association between circumcision status and the timing of first sexual intercourse among adolescents in Malawi. Results of survival models applied to nationally representative sample of never-married young men aged between 15 and 24 obtained from the Demographic and Health Survey data show that being circumcised is associated with earlier initiation of sexual activity in Malawi. Young men who reported being circumcised experienced their first sexual intercourse earlier in life than their uncircumcised counterparts. Although the introduction of theoretically relevant knowledge, socio-cultural, demographic, and socioeconomic variables in the multivariate models attenuated the association between circumcision and earlier sexual initiation, the relationship nonetheless remained robust. The study concludes by discussing the implications of these findings and suggests relevant policy recommendations.     

Age of MSM sexual debut and risk factors: results from a multisite study of racial/ethnic minority YMSM living with HIV

The average reported age of sexual debut for youth in the United States is 14.4 years, with approximately 7% reporting their sexual debut prior to age 13. While the research literature on sexual debut for youth addresses gender and ethnic differences (with males and African-American youth experiencing earlier sexual debut), there is limited data regarding factors associated with sexual debut for young men who have sex with men (YMSM). Early sexual debut poses potential health risks, such as contracting HIV with an increased risk of unprotected intercourse. Given current high HIV infection rates for racial/ethnic minority YMSM, learning more about their sexual debuts and associated risk factors of this population is of great importance. This study investigated risk behaviors and emotional distress, and their association with MSM sexual debut for a multisite cohort of racial/ethnic minority YMSM living with HIV. We hypothesized that a MSM sexual debut younger than age 16 would be associated with engagement in more high-risk sexual behaviors (unprotected sex and exchange sex), substance use, and emotional distress than a MSM sexual debut at age 16 or older. Results indicated that participants having a MSM sexual debut before the age of 16 reported more exchange sex; drug use (specifically marijuana); emotional/psychological problems related to substance use; and a history of suicide attempts, compared to participants with later MSM sexual debuts. Comprehensive interventions that are racially/ethnically sensitive, inquire about initial sexual experiences, and focus on sexual health and healthy relationships are needed to improve health outcomes for this population.     

The influence of male circumcision for HIV prevention on sexual behaviour among traditionally circumcised men in Cape Town, South Africa

We examined the relationship between HIV prevention beliefs related to male circumcision and sexual behaviour/sexually transmitted infection (STI) acquisition among traditionally circumcised men in Cape Town, South Africa. HIV-negative men (n = 304), circumcised for cultural/religious reasons, attending a health clinic in Cape Town, South Africa, completed cross-sectional surveys. Generalized linear models were used to analyse the relationships between unprotected vaginal sex acts, number of female sexual partners, STI diagnoses and male circumcision-related beliefs and risk perceptions. Men who were aware that circumcision offers protection against HIV (relative risk [RR] = 1.19, 95% confidence interval [CI] = 1.06-1.32, P < 0.01), endorsed risk compensation related to male circumcision (RR = 1.15, 95% CI = 1.11-1.12, P < 0.01) and perceived lower risk of HIV infection when circumcised (RR = 1.08, 95% CI = 1.04-1.12, P < 0.01) were more likely to report unprotected vaginal sex acts. Similar patterns were also identified when predicting number of female sexual partners. Men who were more likely to endorse risk compensation related to male circumcision were also more likely to be diagnosed with a chronic STI (odds ratio [OR] = 1.64, 95% CI = 1.06-2.53, P < 0.05). Our findings suggest that we must not overlook the effects of beliefs towards male circumcision for HIV prevention among men traditionally circumcised; doing so may undermine current efforts to reduce HIV transmission through male circumcision.     

Potential for an intervention based on male circumcision in a South African town with high levels of HIV infection

The study aims to investigate the potential for an intervention based on male circumcision in a South African town with a high level of HIV infection. It draws on two cross-sectional studies conducted in August 2000 among a sample of 606 male adults aged 13-59 years, and in August 1999 among a sample of 723 male youth aged 14-24 years. A qualitative study was further conducted on perceptions and attitudes towards male circumcision using focus group discussions and in-depth interview. Among men aged 25-59 years, 36% reported being circumcised The median reported age at circumcision was 20. A total of 42% of 14-24-year-old circumcised men reported having been circumcised in a medical setting. Circumcised and uncircumcised men did not differ in their sexual behaviour or in sociodemographic characteristics, apart from their age and ethnic group. Among 467 uncircumcised adult men, 59% said that they would be circumcised if circumcision reduced the chances of getting HIV and STDs. Focus group discussions showed that circumcision is still important to many people, and is seen as an essential part of the transition into adulthood Reluctance to be circumcised was mainly related to the possibility of adverse outcomes of circumcision performed in non-medical settings, although initiation schools remain attractive for education and transmission of cultural values. Some misconceptions remain, however, especially about the preventative nature of circumcision for STD transmission. The cultural importance of male circumcision has weakened over the last century and when it is done it is often by a medical practitioner. An intervention that would include male circumcision seems feasible in communities such as the one where this study was conducted but needs to be carefully planned in order to ensure that participants understand that circumcision probably reduces, but certainly does not eliminate, the risk of HIV infection.     

Orphan Status and Time to First Sex Among Adolescents in Northern Malawi

This study examines the effects of orphanhood status on the timing of first sexual intercourse among youth in Malawi. Log-normal models were applied to survey data collected between May and August 2009 from 1,214 adolescents aged 12–18 in Mzuzu, Northern Malawi. Results of this study show that orphanhood is a significant predictor of age at first sex. Male double orphans experienced first sexual intercourse earlier than their male non-orphan peers. Similarly, female maternal and paternal orphans had their sexual debut faster than their non-orphan counterparts. The introduction of social support variables accounted for the orphanhood disadvantage. These findings suggest that in order to delay sexual initiation and reduce HIV risk among orphans in Malawi, policy efforts should focus on enhancing factual knowledge about HIV/AIDS, household food security, social support, and other measures that will strengthen existing social support networks and connectedness of surviving family members.     

A qualitative study of sexual behavior change and risk compensation following adult male circumcision in urban Swaziland

Male circumcision has been shown to reduce the risk of heterosexual transmission of HIV infection in men by up to 60% in three randomized controlled trials. Less is known, however, about sexual behavior change in men who have been circumcised and whether male circumcision's protective effect leads to riskier sexual behaviors. This study used qualitative in-depth interviews to understand men's sexual behavior after circumcision and to determine whether and how men participated in riskier sexual behaviors following male circumcision. Men in urban Swaziland, circumcised in the previous 12 months, were recruited and asked about their perceptions of sexual risk and sexual behavior post-circumcision. Results showed that following circumcision, men experience changes in both their sexual attitudes and behavior, which can be considered both protective and risky for HIV transmission. Most of them described protective changes (e.g., more responsible attitudes towards safe sex, reducing sexual temptation and partners, easier condom use). A minority, however, experienced increased sexual risk-taking, typically during a brief period of sexual experimentation shortly after circumcision. HIV counseling and counseling throughout the circumcision process is shown to be critical in influencing protective behaviors. Findings in this study confirm the existence of risk compensation following circumcision; however, this study adds important contextual insight about precisely when and why such risk-taking occurs. Nevertheless this study suggests that male circumcision scale-up as an HIV prevention strategy is likely to foster protective behavior change among men. The integration of HIV counseling with circumcision provision remains critical for effectively mitigating HIV risk behavior as male circumcision gains momentum as a viable HIV prevention tool.     

Sexual risk behaviors following circumcision among HIV-positive men in Rakai,Uganda

Objective: To determine whether circumcision of HIV-positive men is associated with increased subsequent sexual risk behaviors which may place their female partners at risk.

Methods: Newly circumcised and uncircumcised HIV-positive men in the Rakai Community Cohort Study were followed from baseline (July 2013–January 2015) to determine trend in sexual risk behaviors and association of circumcision with subsequent sexual risk behaviors at follow up (February 2015–September 2016). Risk behaviors included sexual activity, alcohol before sex, transactional sex, multiple sex partners, casual sex partners, and inconsistent condom use with casual partners. The association was evaluated using modified Poisson regression, and sensitivity analyses were performed after multiple imputation with chained equations for missing data.

Results: We identified 538 eligible men, of whom 113(21.0%) were circumcised at baseline and 425(79.0%) were uncircumcised. Men in fishing communities were more likely to be circumcised (p?=?0.032) as well as those exposed to targeted HIV messaging (p?p?=?0.020). Among those followed up, behaviors remained largely unchanged with no differences by circumcision status. Transactional sex appeared to be associated with circumcision in unadjusted analyses (PR?=?1.58, 95%CI?=?1.01,2.48; p?=?0.045, p?=?0.05) and adjusted analyses (adj.PR?=?1.54, 95%CI?=?1.06,2.23; p?=?0.022). However, the association was no longer significant in sensitivity analyses after accounting for loss to follow up (adj.PR?=?1.43, 95%CI?=?0.98,2.08; p?=?0.066). No association with circumcision was observed for other sexual risk behaviors.

Conclusion: We found no association between circumcision of HIV-positive men and subsequent sexual risk behavior.     

The protective effect of male circumcision on HIV infection in a sample of Kenyan men

This article examines the association between male circumcision and HIV infection in a national sample. The analysis is based on the 2003 Kenya Demographic and Health Survey (KDHS), a nationally representative household-based population survey of adults, in which male respondents self-reported their circumcision status. In addition, in some households eligible for individual interview, blood samples were subsequently anonymously obtained for HIV testing, making this the first study linking socio-demographic information to HIV status at the national level. The study sample is limited to 3 413 men aged 15–54 years who gave valid information on their circumcision and HIV statuses. Nearly 5% of the men were HIV-positive, and 86% had been circumcised. HIV prevalence was significantly higher among the uncircumcised men (12%) than among the circumcised men (3%). This indication of the protective effect of male circumcision on HIV infection remained statistically significant (OR 0.15; 95%CI: 0.09–0.23) even after controlling for the effects of socio-demographic variables, age at first sexual intercourse, and use of paid sex. Based on these results, we recommend that HIV-prevention advocates and activists, scholars, bio-medical communities and political leaders find ways to include this oldest surgical procedure in their HIV/AIDS discourses and programmes in sub-Saharan Africa.     

Correlates of condom use among sexually experienced secondary school male students in Nairobi,Kenya

This study aimed to examine perceptual factors associated with condom use, and the relationship between condom use and the timing of sexual debut among male secondary school students in Nairobi, Kenya. Data are from the TeenWeb study, a school-based project that used the World Wide Web to assess the health needs of secondary school students, and tested the web's utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 – 20 years who completed webbased questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently, only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However, contrary to expectation, agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn, having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times, and elevated general condom use (‘most or all the time’) by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV, delay sexual initiation, and teach proper condom use among secondary-school students in Nairobi are needed.     

Individual and community-level tolerance of spouse abuse and the association with the circumstances of first sex among youth from six sub-Saharan African countries

Youth who engage in early and premarital sex are at risk of HIV and sexually transmitted infections. Most prevention programs ignore the mediating influence of the threat and experience of violence on these outcomes. Using nationally representative data from Lesotho, Malawi, Zimbabwe, Kenya, Tanzania, and Uganda, multivariate analyses examined the association between individual- and community-level tolerance of spouse abuse on the age and circumstances of sexual debut among female youth. The youth sample sizes ranged from a high of 5007 in Malawi to a low of 3050 in Lesotho. In the study countries, there were between 521 and 367 communities included in the analysis. Youth who approved of spouse abuse were more likely to have sexually debuted at each age. In Kenya, youth from communities with high female spouse abuse tolerance were more likely to have initiated sex at each age. In Malawi and Zimbabwe, youth from high tolerance communities were less likely to have sexually debuted at each age or to have had premarital sex; the same effect on premarital sex was found for men's tolerance in Kenya and Tanzania. Programs are needed to reduce violence risk and increase youth negotiating power and delayed sexual debut, with the objective of reducing young people's risk of negative outcomes.     

A Protective Effect of Circumcision Among Receptive Male Sex Partners of Indian Men Who Have Sex with Men

The role of circumcision in the transmission of human immunodeficiency virus (HIV) among men who have sex with men (MSM) in resource restricted regions is poorly understood. This study explored the association of circumcision with HIV seroprevalence, in conjunction with other risk factors such as marriage and sex position, for a population of MSM in India. Participants (n = 387) were recruited from six drop-in centers in a large city in southern India. The overall HIV prevalence in this sample was high, at 18.6%. Bivariate and multivariable analyses revealed a concentration of risk among receptive only, married, and uncircumcised MSM, with HIV prevalence in this group reaching nearly 50%. The adjusted odds of HIV infection amongst circumcised men was less than one fifth that of uncircumcised men [adjusted odds ratio (AOR) 0.17; 95% CI 0.07–0.46; P < 0.001]. Within the group of receptive only MSM, infection was found to be lower among circumcised individuals (AOR, 0.30, 95% CI 0.12–0.76; P < 0.05) in the context of circumcised MSM engaging in more UAI, having a more recent same sex encounter and less lubricant use when compared to uncircumcised receptive men. To further explain these results, future studies should focus on epidemiologic analyses of risk, augmented by social and sexual network analyses of MSM mixing.     

Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya

Numerous epidemiologic studies report significant associations between lack of male circumcision and HIV-1 infection, leading some to suggest that male circumcision be added to the limited armamentarium of HIV prevention strategies in areas where HIV prevalence is high and the mode of transmission is primarily heterosexual. This cross-sectional survey of 107 men and 110 women in Nyanza Province, Kenya, assesses the attitudes, beliefs, and predictors of circumcision preference among men and women in a traditionally non-circumcising region. Sixty per cent (n=64) of uncircumcised men and 69% (n=68) of women who had uncircumcised regular partners reported that they would prefer to be circumcised or their partners to be circumcised. Men's circumcision preference was associated with the belief that it is easier for uncircumcised men to get penile cancer, sexually transmitted diseases, and HIV/AIDS, and that circumcised men have more feeling in their penises, enjoy sex more, and confer more pleasure to their partners. Women with nine or more years of school were more likely to prefer circumcised partners. Men who preferred to remain uncircumcised were concerned about the pain and cost of the procedure, and pain was a significant deterrent for women to agree to circumcision for their sons. If clinical trials prove circumcision to be efficacious in reducing risk of HIV infection, it is likely that the procedure will be sought by a significant proportion of the population, especially if it is affordable and minimally painful.     

Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda

OBJECTIVE: To assess whether male circumcision of the primary sex partner is associated with women's risk of HIV. DESIGN: Data were analyzed from 4417 Ugandan and Zimbabwean women participating in a prospective study of hormonal contraception and HIV acquisition. Most were recruited from family planning clinics; some in Uganda were referred from higher-risk settings such as sexually transmitted disease clinics. METHODS: Using Cox proportional hazards models, time to HIV acquisition was compared for women with circumcised or uncircumcised primary partners. Possible misclassification of male circumcision was assessed using sensitivity analysis. RESULTS: At baseline, 74% reported uncircumcised primary partners, 22% had circumcised partners and 4% had partners of unknown circumcision status. Median follow-up was 23 months, during which 210 women acquired HIV (167, 34, and 9 women whose primary partners were uncircumcised, circumcised, or of unknown circumcision status, respectively). Although unadjusted analyses indicated that women with circumcised partners had lower HIV risk than those with uncircumcised partners, the protective effect disappeared after adjustment for other risk factors [hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.69-1.53]. Subgroup analyses suggested a non-significant protective effect of male circumcision on HIV acquisition among Ugandan women referred from higher-risk settings: adjusted HR 0.16 (95% CI, 0.02-1.25) but little effect in Ugandans (HR, 1.33; 95% CI, 0.72-2.47) or Zimbabweans (HR, 1.12; 95% CI, 0.65-1.91) from family planning clinics. CONCLUSIONS: After adjustment, male circumcision was not significantly associated with women's HIV risk. The potential protection offered by male circumcision for women recruited from high-risk settings warrants further investigation.     

Women’s role in male circumcision promotion in Rakai,Uganda

Medical male circumcision (MMC) has expanded in sub-Saharan Africa, yet uptake remains sub-optimal. We sought to understand women’s perceptions of and influence on MMC in Rakai, Uganda. We conducted in-depth interviews with 27 women in fishing and trading communities, including women married to circumcised and uncircumcised men, single women, and sex workers. Data analysis followed a team-based framework approach. All female participants preferred circumcised men because of perceived reduced HIV and sexually transmitted infection (STI) risk, improved penile hygiene, and increased sexual pleasure. Perceived negative aspects included abstinence during wound healing, potentially increased male sexual risk behaviors, fear of being blamed for HIV acquisition, and economic insecurity due to time off work. Participants felt women could persuade their partners to be circumcised, accompany them to the clinic, refuse sex with uncircumcised men, and participate in community MMC activities. Findings support women’s important role in MMC acceptance.     

Factors associated with HIV infection among sexually experienced adolescents in Africa: a pooled data analysis

The article examines the factors associated with HIV status among adolescents aged 15–19 years in 13 African countries: Côte d'Ivoire, Democratic Republic of Congo, Guinea, Kenya, Liberia, Mali, Malawi, Rwanda, Sierra Leone, Swaziland, Tanzania, Zambia and Zimbabwe. The data were derived from demographic and health surveys or AIDS indicator surveys conducted between 2004 and 2009. The levels of HIV prevalence among adolescents varied considerably across the countries. There was significantly higher HIV prevalence among female adolescents as compared with their male counterparts. For male adolescents, circumcision was the only variable significantly associated with HIV status. Nonetheless, the data suggest that the association between male circumcision and HIV status may be exaggerated. Indeed, regional-level random effects became insignificant once male circumcision was introduced into the estimated models, indicating a strong correlation between unmeasured regional-level factors and male circumcision. For female adolescents, multiple sexual partnerships, time elapsed since sexual debut, marital status, household wealth, and the regional prevalence of male circumcision were strongly and positively associated with HIV status. Moreover, for female adolescents there appear to be significant unmeasured variables operating at the regional level which influence the levels of HIV infection. The implications of the findings for HIV-prevention programming, policy and research are discussed.     

Age at Sexual Initiation and Sexual and Health Risk Behaviors Among Jamaican Adolescents and Young Adults

Current policies limit access to sexual and reproductive health services for adolescents younger than 16 years in Jamaica. Using data from a national survey, we explored the relationship between age at sexual initiation and subsequent sexual risk behaviors in a random sample of 837 Jamaican adolescents and young adults aged 15–24 years. In the sample overall, 21.0% had not yet had sex. Among the 661 sexually active participants, the mean age at first sex was 14.7 years. High percentages of sexually active youth reported engaging in risk behaviors such as inconsistent condom use (58.8%), multiple sex partners (44.5%), and transactional sex (43.0%). Age of sexual initiation for males was unrelated to subsequent sexual risk behaviors. However, earlier sexual debut for females was associated with their number of partners during the preceding year. Findings underscore the potential benefits of access to sexual and reproductive education and services at earlier ages than current policies allow. Interventions before and during the period of sexual debut may reduce sexual risk for Jamaican adolescents and young adults.     

Risk Compensation Following Male Circumcision: Results from a Two-Year Prospective Cohort Study of Recently Circumcised and Uncircumcised Men in Nyanza Province,Kenya

We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30–14 vs. 24–21 % in controls) and increased sexual activity among the youngest participants (18–24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.     

Acceptability of circumcision as a means of HIV prevention among men who have sex with men in China

Conclusive evidence-based research has shown that circumcision reduces the risk of HIV transmission via heterosexual intercourse, whilst ongoing studies are investigating similar effects via homosexual transmissions and the results are equivocal. Few acceptability studies regarding circumcision were conducted among men who have sex with men (MSM). In this cross-sectional study, a total of 307 MSM were recruited by snowball sampling and were interviewed anonymously by some peer field workers in Yangzhou, China. Amongst all uncircumcised participants (93.4% of all participants were uncircumcised), the willingness to be circumcised increased from 8.1% to 30.7%, before and after the participants were briefed about a hypothetical potential benefit of a 50% risk reduction of circumcision in preventing HIV transmission among MSM. In the multivariate analysis, perception of overly long foreskin (odds ratio [OR] = 6.04), unprotected sexual intercourse with male regular sex partners in the last six months (OR = 2.04), and seeing no chance for contracting HIV in the next 12 months (OR = 0.54) were significantly associated with conditional willingness for circumcision. Adjusting for these variables, other significant factors were identified by multiple logistic regression analysis, including number of perceived disadvantages for having overly long foreskin (adjusted OR = 2.60), variables that were derived from the Theory of Planned Behaviors (TPB), and having some circumcised MSM peers (adjusted OR = 0.45-4.38). Some risk compensation behaviors however, may be practiced by 15.9% of the MSM who were willing to undergo circumcision. The acceptability would increase slightly with the effect size of circumcision in protecting MSM from HIV transmission via homosexual intercourse. However, it was only around 30%, even if circumcision could result in a large (50%) risk reduction in HIV transmission among MSM. If future studies can establish efficacy of circumcision, relevant promotion programs need to guard against risk compensation, though the magnitude of risk compensation may be moderate.     

Circumcision among adolescent boys in rural northwestern Tanzania

Objective  Male circumcision reduces risk of HIV among heterosexual men by about 60%. Modelling the impact of circumcision on HIV transmission, and planning service expansion, relies on self-reported circumcision status. We investigated the validity of self-reported status.
Methods  Survey and in-depth interview (IDI) data from adolescents enrolled in a community randomized sexual health intervention trial in rural Mwanza, Tanzania were analysed.
Results  The 5354 male school attenders (median age 15.5 years) were recruited in 1998 and followed for 3 years. At baseline, circumcision prevalence was 13.7% by self-report and 11.8% by clinical examination, rising to 17.3% by clinical examination at final survey. Only 61.5% of Muslim males were circumcised at the final survey. Of 506 participants who reported being circumcised at baseline, only 78.9% reported this at interim. Similarly, only 84.2% of participants clinically assessed as circumcised at baseline were also assessed as circumcised at interim. At both baseline and interim surveys, about 80% of participants who reported being circumcised were also found to be so at clinical examination. There was a high tolerance and respect for circumcision among male IDI respondents, with widespread belief that it was beneficial for penile hygiene and disease prevention. The majority of female IDI respondents said that they did not know what male circumcision was.
Discussion  Attitudes to male circumcision were positive in this population despite its low prevalence. There were substantial inconsistencies in both self-reported and clinically assessed circumcision status. Methods are needed to improve self-report and training of clinicians in this setting.