Tieu, Hong-Van MD, MS*; Phanuphak, Nittaya MD†‡; Ananworanich, Jintanat MD, PhD‡§; Vatanparast, Rana BS¶; Jadwattanakul, Tanate MD∥; Pharachetsakul, Nutthasun Dip†; Mingkwanrungrueng, Pravit Dip†; Buajoom, Raksakul BA†; Teeratakulpisarn, Somsong BN, MEd†; Teeratakulpisarn, Nipat MD†; Methajittiphun, Pornpen BN, MS∥; Hammer, Scott M. MD*; Ann Chiasson, Mary DrPH**; Phanuphak, Praphan MD, PHD†
From the *Division of Infectious Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; †Thai Red Cross AIDS Research Centre, Bangkok, Thailand; ‡South East Asia Research Collaboration with Hawaii, Bangkok, Thailand; §HIV Netherlands Australia Thailand Research Collaboration, Bangkok, Thailand; ¶Athena Institute, International Public Health, Vrije Universiteit, Amsterdam, The Netherlands; ∥Queen Savang Vaddhana Memorial Hospital, Chonburi, Thailand; and **Public Health Solutions of New York City, New York, NY
Supported by the American Medical Association Foundation Seed Grant Research Program and by the Center for Infectious Disease Epidemiologic Research Training Grant (NIH T32 AIO49821–07) at Columbia University Mailman School of Public Health.
Correspondence: Hong Van Tieu, MD, MS, Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, 630 West 168th St PH-876 West, Box 82, New York, NY 10032. E-mail: email@example.com.
Received for publication March 26, 2009, and accepted November 1, 2009.
Randomized, controlled studies in Africa have provided compelling evidence for the protective effect of male circumcision against human immunodeficiency virus (HIV) acquisition in heterosexual men, with a 51% to 61% risk reduction.1–3 HIV remains a major public health problem in Thailand although adult prevalence is low at 1.4%.4 Male circumcision may be considered an adjunctive HIV preventive method among Thai men, especially those with risky sexual behaviors. However, it is unclear whether this intervention would be acceptable in Thailand where male circumcision is uncommon. This study sought to determine the prevalence of male circumcision among a sample of Thai heterosexual men and to evaluate the acceptability of circumcision as an HIV preventive strategy.
We conducted a prospective study of heterosexual men presenting to 3 sites in Thailand between January and August 2008: the Thai Red Cross Anonymous Clinic (TRCAC) and 2 Mother-to-Child Transmission (MTCT) Plus Clinics. The TRCAC is an HIV voluntary counseling and testing center in Bangkok.5 The 2 MTCT Plus Clinics in Bangkok and Chonburi provide family focused HIV care and treatment and prevention counseling to HIV-infected women and their male partners (who may be HIV-infected or uninfected) and children.6 The men at these sites are highly literate.5
Men were eligible to participate in the study if they were born male with male genitalia, between 18 to 50 years of age, either heterosexual or bisexual, and able to read Thai language. In the MTCT Plus Clinics, only men with a negative HIV test in the last year were included because the study aimed to assess acceptability of circumcision to prevent HIV infection; all of these men had an HIV-positive female partner.
Written informed consent was obtained from the participants. The participants completed a self-administered questionnaire before any information on male circumcision was provided. They then read an informational pamphlet, which contained a description of the procedure, costs, risks, and benefits, including recent circumcision trial results, with any further questions about circumcision to be answered by a trained study counselor. Immediately after they had finished reading the pamphlet, the participants completed a second questionnaire, which was identical to the baseline survey. The participants in the TRCAC then underwent HIV counseling and testing if desired, with test results available to the participants only after they had completed the 2-part questionnaire. For the men in the MTCT Plus Clinics, a brief genital examination was performed by a physician to verify self-reported circumcision status. For men who were uncircumcised or had unknown circumcision status, a 3-month follow-up telephone survey assessed the rate of actual circumcision and change in perceptions.
The questionnaire covered demographics, risk behaviors, circumcision status, perceived benefits and concerns about adult circumcision, and willingness to be circumcised. Circumcision status was assessed in Thai: “Are you circumcised, meaning surgical removal of all or part of your penile foreskin?” Sample pictures of circumcised and uncircumcised penises in erect and nonerect states were provided to reduce misclassification of circumcision status. Uncircumcised men and men with unknown circumcision status were then instructed to rate their agreement or disagreement with a series of statements that incorporated a 5 point Likert scale for responses to evaluate their perceptions about risks and benefits of adult circumcision. The scaled responses were later dichotomized into agree or disagree for the analysis. The men were asked to rate their response on the same scale in Thai: “I would be willing to be circumcised as an adult.” Similarly, they were asked about willingness to have their son circumcised as a child.
In addition, 7 men from the main study who were deemed to have the highest HIV risk were selected to participate in a focus group discussion at the conclusion of the main study based on the following criteria: they were uncircumcised and HIV uninfected, had an HIV-positive female partner, and expressed unwillingness to be circumcised as an adult. The audiotaped discussion was later transcribed and translated into English, and the transcripts were coded into categories using ATLAS.ti.
The institutional review boards in Thailand and Columbia University in New York approved the study.
Eligibility screening data were available only for a part of the study, from January to March 2008: 552 men were screened, of whom 358 (65%) signed informed consent. In total, from January to August 2008, 423 men consented and enrolled in the study. Fifteen participants were excluded from the analysis because they were later found to not meet the study eligibility criteria or had substantial incomplete questionnaire data. The final analysis, therefore, included 408 men: 335 in the TRCAC and 73 in the MTCT Plus Clinics.
Baseline demographic and risk behavior characteristics are depicted in Table 1. Among the men in the TRCAC, 6.5% tested HIV-positive after completing the questionnaires.
Overall, 50 (12.3%) men reported being circumcised in the past; 335 (82.1%) were uncircumcised, while 23 (5.6%) did not know their status (Table 1). Among the men in the MTCT Plus Clinics who underwent a genital examination, concordance between self-reported circumcision status and examination finding was high (p0 = 0.98). Being circumcised was not significantly associated with HIV serostatus (P = 0.50). Reasons for circumcision included medical indications, family tradition, and religion.
Of the 358 uncircumcised/unknown status men, 51 (14.2%) indicated that they would be willing to be circumcised before and 89 (24.9%) after education (P < 0.01). Forty (11.9%) men in the TRCAC expressed willingness to be circumcised before and 76 (22.7%) after education (P < 0.01), whereas 11 (15.1%) in the MTCT Plus Clinics conveyed willingness before and 13 (17.8%) after education (P = 0.48). No demographic characteristic was associated with willingness to be circumcised before and after education.
Agreement with statements about perceived risks of adult circumcision before and after education was not significantly different except for fear of infection and fear that circumcision would lower his sexual pleasure, which were improved after education (Table 2). Similarly, agreement with the following statements about perceived circumcision benefits substantially improved after education: improvement in genital cleanliness, reduction in risk of penile cancer, HIV, and other sexually transmitted diseases (STDs), and reduction in partner's risk of HIV and cervical cancer. Before education, 106 (29.6%) agreed to have their son circumcised to reduce his risk of HIV and other STDs; after education, 186 (52.0%) agreed (P < 0.01).
Among 358 men who were uncircumcised/unknown status, 237 (66.2%) men were successfully contacted during the 3-month follow-up. Only 1 (0.3%) participant underwent the surgery to reduce his risk of HIV acquisition. A majority of the men reported no interest in circumcision for various reasons, including fear of pain and other risks of surgery, having no time for surgery because of work constraints, and belief that they were not at risk for contracting HIV and other STDs.
The most common reasons for unwillingness to be circumcised as an adult expressed during the focus group discussion were a lack of knowledge about male circumcision and its role in HIV prevention, time required away from work for the surgery and postoperative healing, and association of circumcision with good genital hygiene. All participants mentioned that even with the brief educational session about circumcision, they did not have much knowledge about circumcision's effects on reducing HIV infection risk. They conveyed that since they already had good genital hygiene by cleaning their penis regularly, they did not feel the need to perform circumcision.
In this study of high-risk heterosexual men in Thailand, the prevalence of self-reported circumcision was low at 12.3%. The low circumcision prevalence is consistent with prior limited studies in Thailand, and is similarly seen in other predominantly Buddhist countries in Asia.7–9 Not surprisingly, willingness to be circumcised at baseline was low as 14.2%. After education, 24.9% of them expressed willingness to be circumcised, a significant increase from baseline. This represented a low level of circumcision acceptability although 69.9% concurred that circumcision might reduce HIV risk after education. Other perceptions about the risks and benefits of circumcision were significantly altered after education.
Uptake of circumcision during the follow-up period was low, with only one participant undergoing surgery. The informational pamphlet was brief and not sufficient in addressing the major concerns of the participants, namely fear of pain and other surgical risks. During the follow-up survey, many of the men who practiced unsafe sex had misperceptions about their HIV risk. This highlights the need for a longer educational session or a series of educational sessions that address basic HIV knowledge while incorporating the rationale, risks and benefits of circumcision as part of a comprehensive HIV prevention and risk reduction package. Men were normally the primary income producers in their families. Circumcision would necessitate time (i.e., one or more days) away from work, a major barrier for these men. It is interesting to note that cost of circumcision, which ranges from $30 USD at public hospitals to $200 to $600 USD at private hospitals, was not a major concern. Male circumcision in Thailand is currently available and covered by private and public insurance for Muslim boys and for medical indications. Nevertheless, access to medical providers who are willing to perform adult circumcision to prevent HIV is limited and may partially explain the low uptake of the procedure during follow-up.
Although willingness to be circumcised and uptake was low overall, the participants' willingness to circumcise their sons after education was relatively high, 52.0%. Given this finding, a public campaign to promote neonatal circumcision as a long-term strategy to stem the HIV epidemic in Thailand would likely be more effective and acceptable than endorsement of adult male circumcision.
1. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomized trial. Lancet 2007; 369:657–666.
2. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized controlled trial. Lancet 2007; 369:643–656.
3. Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2005; 2:e298.
5. Khongphatthanayothin M, Tantipaibulvut S, Nookai S, et al. Demographic predictors of a positive HIV test result among clients attending a large metropolitan voluntary counseling and testing centre in Thailand. HIV Med 2006; 7:281–284.
6. Phanuphak N, Apornpong T, Teeratakulpisarn S, et al. Nevirapine-associated toxicity in HIV-infected Thai men and women, including pregnant women. HIV Med 2007; 8:357–366.
7. Violante T. Attitudes and Beliefs of Thai Expectant Parents and Physicians regarding Male Circumcision for HIV and Sexually Transmitted Infections Prevention. [Doctoral dissertation]. Berkeley, CA: University of California, 2003.
8. Drain PK, Halperin DT, Hughes JP, et al. Male circumcision, religion, and infectious diseases: An ecologic analysis of 118 developing countries. BMC Infect Dis 2006; 6:172.
9. Sullivan SG, Ma W, Duan S, et al. Attitudes towards circumcision among Chinese men. J Acquir Immun Defic Syndr 2009; 50: 238–240.