To the Editor:
Recently, there has been considerable excitement over the role of male circumcision in reducing HIV transmission. Two trials have already been prematurely stopped due to overwhelming evidence of the efficacy of this intervention.1,2 In these trials, a 51%-53% reduction in HIV infection was observed among men who were circumcised-equivalent to what a vaccine of high efficacy would have achieved.3 In countries with a high rate of sexual transmission of HIV, circumcision could considerably reduce the rate of HIV transmission.
China is currently a low-prevalence country, although there are pockets of high prevalence among certain high-risk groups. Injection drug users are among those groups with the highest prevalence. However, HIV has spread from this high-risk group to the general population through sexual transmission,4 and sexual transmission is now the most common transmission route among new infections.5
We examined attitudes toward accepting circumcision for prevention of HIV transmission in Xinjiang Uyghur Autonomous Region and Yunnan Province-areas with the highest rates of both HIV infection and drug use in China. The survey was conducted in detoxification centers, reform through labor centers, and voluntary counseling and testing (VCT) clinics and sexually transmitted disease (STD) clinics. Participation was anonymous, and participants were asked for their verbal consent before answering any questions. Staff informed clients about the recent evidence that circumcision could reduce, but not eliminate, the risk of contracting HIV. Clients were then asked the following: (1) if they were already circumcised; (2) would they consider circumcision to protect themselves; and (3) to protect their wife/girlfriend. Demographic data (age, marital status, and ethnic/religious group) were also collected.
In total, 662 men were surveyed from detoxification centers (n = 375), reform through labor centers (n = 85), VCT clinics (n = 95), and STD clinics (n = 107). The mean age was 32.15 years (range: 16-68 years). Men were of various ethnicities, including Han (n = 309), Dai (n = 130), Uyghur (n = 82), Jingpo (n = 74), Hui (n = 24), A'Chang (n = 17), and others (n = 26). One hundred thirty-two men were already circumcised (40 Han, 2 Dai, 72 Uyghur, and 18 Hui). Among the 530 uncircumcised men, 207 (39.1%) were willing to consider undergoing circumcision to protect themselves from infection, and 241 (45.5%) would consider it to protect their partner (Table 1).
Willingness to be circumcised to protect themselves was not associated with ethnicity (χ2 = 3.73, P = 0.81), marital status (χ2 = 0.19, P = 0.658), or the type of venue from which a respondent was recruited (χ2 = 5.24, P = 0.155). Men willing to be circumcised were about 3 years younger than unwilling men (30.4 years versus 33.4, P = 0.0003). Men in Yunnan were more likely than men in Xinjiang to consider the procedure to protect themselves (χ2 = 6.57, P = 0.01), but there were no differences between provinces if the procedure was to protect a sexual partner (χ2 = 0.012, P = 0.913). This change arose because willingness to be circumcised among drug users in Urumqi doubled when they thought it would protect their partners. This survey was conducted before the recent evidence suggesting that circumcision confers no protection for women from HIV infection.6
The overall proportion of uncircumcised men reporting that they would consider circumcision in this survey was lower than that seen in studies from Africa, where the average acceptability rate from 13 different studies was reported as 65%.7 Moreover, the percentage of men randomized to the circumcision group who actually underwent the procedure was over 90% in the 2 African trials.1,2 The acceptance rate observed in this study is substantially lower but promising. However, studies of intent versus action in China have shown that social desirability bias is strong; for example, in Guizhou province, just 3.7% of participants given a voucher for VCT actually underwent testing and obtained their results, versus 43.5% who said they would.8 Thus, it is likely that even if circumcision were to be routinely and freely offered, its uptake would be substantially lower than 39%.
The number of men already circumcised was higher in Urumqi because almost half the men belonged to either the Uyghur (34.5%) or Hui (10.7%) Muslim minorities. Muslims number at least 20 million in China. Thus, China may already have enough experienced doctors to easily integrate circumcision into routine medical care, should social acceptability of the procedure increase. Among Chinese men who have sex with men there is already a small movement toward preference for being “cut,” and it may be possible to promote this trend in the general population (Zou H.C., MPH, personal communication 2007).
The efficacy of this intervention in high prevalence settings suggests that other countries-even those with small epidemics-should consider large-scale campaigns to encourage its use. This may be more feasible in Africa where there is a long history of circumcision among different ethnic groups or even in western countries, which previously routinely circumcised newborn males, such as Australia, Canada, New Zealand, and the United States.9 However, in China, there is almost no history of routine circumcision in the majority Han population. Given the low acceptability seen in this sample, it would seem that significant groundwork would first need to be done before considering such a trial. Moreover, acceptability of circumcision among the parents of newborn boys also needs to be studied before considering introducing the procedure as routine practice.
Sheena G. Sullivan, MPH*
Wei Ma, PhD*
Song Duan, Dip Public Health†
Fan Li, Dip Public Health‡
Zunyou Wu, MD, PhD*
Roger Detels, MD, MS§
*National Center for AIDS/STD Control and Prevention
Chinese Center for Disease Control and Prevention
†Dehong Prefecture Center for Disease Control and Prevention
‡Xinjiang Center for Disease Control and Prevention
§Department of Epidemiology
University of California
Los Angeles, CA
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2. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet
3. Sawires SR, Dworkin SL, Fiamma A, et al. Male circumcision and HIV/AIDS: challenges and opportunities. Lancet
4. Li XJ, Kusagawa S, Xia X, et al. Molecular epidemiology of the heterosexual HIV-1 transmission in Kunming, Yunnan Province of China suggests origin from the local IDU epidemic. AIDS Res Hum Retroviruses
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. Beijing, China: China Ministry of Health; 2007.
6. Roehr B. Circumcision of men did not cut HIV transmission to their wives. BMJ
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8. Ma W, Detels R, Feng Y, et al. Acceptance of and barriers to voluntary HIV counselling and testing among adults in Guizhou province, China. AIDS
. 2007;21(Suppl 8):S129-S135.
9. UNAIDS. Male Circumcision: Global Trends and Determinants of Prevalence, Safety and Acceptability
. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2007.