In the United Kingdom, men who have sex with men (MSM) are the population mostly affected by HIV; there is evidence of ongoing HIV transmission and high-risk sexual behavior1,2 as has been reported in other high-income countries.3–7 New and effective strategies for HIV prevention are urgently required.
Randomized controlled trials in sub-Saharan Africa have shown that male circumcision provides partial protection against heterosexual acquisition of HIV in men.8–10 However, evidence for an effect of circumcision on HIV transmission between MSM is weak and inconsistent11; a meta-analysis of observational studies among MSM failed to provide evidence that circumcision protects against HIV or sexually transmitted infection (STI) acquisition.12
We know little about the attitudes toward circumcision among MSM in London, United Kingdom, and the acceptability of circumcision as an HIV prevention strategy in this population. In this article, we examine the association between circumcision and HIV prevalence as well as sexual behavior among MSM living in London, as well as men's attitudes toward circumcision.
Between May and June 2008, MSM using 1 of 6 gyms in central London were invited to complete a confidential self-administered questionnaire as part of a behavioral surveillance program.13–15 Men were asked to provide information on demographic characteristics (age, ethnicity, education, employment, and country of birth). Information was also sought on relationship status, HIV status, seeking sex through the internet, recreational drug use, and HIV treatment optimism. Men could complete the questionnaire in the gym or at home; it took 10 to 15 minutes to complete.
Men were asked whether they were circumcised or not. Attitudes toward circumcision were assessed by asking men whether they had a preference for circumcised or uncircumcised sexual partners, and whether they thought there were any benefits or drawbacks of circumcision. Finally, men were asked whether they would be willing to take part in research into new ways to prevent HIV including circumcision.
Sexual Risk Behavior
Men were asked if they had had unprotected anal intercourse (UAI) in the last 3 months and if so, the HIV status of their partners. UAI was classified as either concordant (only with a partner of the same HIV status) or nonconcordant (with a partner of unknown or discordant HIV status). Men were also asked about their positioning during UAI (always insertive, mostly insertive, always receptive, mostly receptive, versatile, i.e., equally insertive and receptive).
Data were managed and analyzed in Stata 10 (Version 10, Stata corporation, College Station, TX). Univariate analysis was carried out to examine the differences in background characteristics, sexual behavior, HIV status, and STI history between circumcised and uncircumcised men. Those factors found to be significantly associated with circumcision in univariate analysis (P < 0.05) were entered into a multivariable logistic regression model in a stepwise manner starting with the variable with the strongest univariate association. Variables were retained in the model if they remained significantly associated (P < 0.05) after adjusting for other variables. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were estimated from the final logistic regression model. Men who reported that they had never tested for HIV were excluded from the multivariate analysis.
A total of 689 men returned a completed questionnaire (estimated response rate, 50%–60%). Of these, 653 men provided complete information on HIV and circumcision status and could be classified as having concordant or nonconcordant UAI. Just over a quarter of these, men (29% 188/653) were circumcised. The median age of men in the sample was 39 years and just over half of men were born in the United Kingdom. As compared with uncircumcised men, circumcised men were younger, less likely to be born in the United Kingdom or to have used recreational drugs in the last year, but more likely to belong to an ethnic minority or be in a relationship with a man (all P < 0.05, Table 1). Each of these variables remained strongly associated with circumcision in the multivariable model (Table 1). There were no significant differences between circumcised and uncircumcised men in employment status, level of education, HIV treatment optimism, or seeking sex through the Internet.
Overall 26% of men in the sample reported that they were HIV-positive. There was little evidence of a difference in HIV prevalence between circumcised and uncircumcised men in multivariate analysis (AOR, 0.79; 95% CI: 0.50–1.26), but some evidence that circumcised men were at lower risk than uncircumcised men of having been diagnosed with another STI in the previous 12 months (AOR, 0.67; 95% CI: 0.41–1.09) (Table 1).
Overall 37% of men reported UAI in the previous 3 months; this did not vary by circumcision status (Table 1). Similarly, there was little difference in the proportion who reported concordant or nonconcordant UAI by circumcision status. Among the 244 men who reported having had UAI in the previous 3 months, 26% said that they were exclusively insertive during that time, 42% said that they were versatile (both insertive and receptive), and 19% said that they were always receptive. This distribution was similar for circumcised and uncircumcised men (Table 1). When stratified by HIV status, there was also no significant difference in the sexual behavior of circumcised and uncircumcised men (data available from authors on request).
Attitudes Toward Circumcision
Substantial differences in attitudes toward circumcision were observed by circumcision status (Table 2). Overall, more than half of the men (61%) did not express a preference for an uncircumcised or circumcised sexual partner. However, among uncircumcised men who expressed a preference, almost all (154/172) said that they would prefer a partner who was also uncircumcised. In contrast, circumcised men were only slightly more likely to prefer a circumcised partner than an uncircumcised partner (45/78 vs. 33/78; Table 2).
As compared with uncircumcised men, circumcised men were more likely to think that there were benefits of being circumcised (65% vs. 31%), and less likely to think that there were drawbacks (34% vs. 41%; Table 2).
Finally, men were asked whether they would be willing to participate in a variety of HIV prevention research studies. Only 10% of uncircumcised men said that they would be willing to participate in research into circumcision and HIV prevention. In contrast, more than half said that they would participate in research investigating behavior change, rectal microbicides, and vaccine studies.
This is the first study to examine attitudes toward circumcision and its potential as an HIV prevention strategy among MSM in London. Circumcision was more common among younger men, those born outside the United Kingdom and those belonging to an ethnic minority. The percentage of men who were circumcised in our sample (29%) is higher than in other studies among MSM in the United Kingdom (range, 15.8%–22.1%).16–18 This is probably due to the large number of men in our study who were born outside the United Kingdom. Like many previous studies among MSM, including a meta-analysis of more than 50,000 men,12,18–21 we did not find a strong association between HIV status and circumcision.
It has been suggested that a randomized controlled trial among MSM could provide conclusive evidence for or against the use of circumcision as an HIV prevention strategy in this population.12 However, our data indicate that conducting such a trial among MSM in London is unlikely to be feasible because few uncircumcised men would be willing to participate in such research. This finding is consistent with recent research in Scotland18 and the United States where very few uncircumcised men reported that they would be willing to take part in a circumcision trial.22
Based on randomized controlled trials conducted among heterosexual men and women8–10 and observational studies among MSM, it has been suggested that circumcision would provide protection against acquisition of HIV for the insertive partner.18,19,23 In our sample, only a quarter of the men said that they were exclusively insertive when they had UAI. This suggests that circumcision would not be an appropriate HIV prevention strategy for the majority of MSM because the risk of acquiring HIV from receptive anal intercourses would remain.
As might be expected, uncircumcised men were less likely to think that there are benefits to circumcision and more likely to think that there are drawbacks to circumcision than circumcised men. This provides further evidence that circumcision would not be an acceptable HIV prevention strategy for this group of men without a prior education campaign about the risks and benefits of circumcision. These attitudes toward circumcision are consistent with a recent US study in which more than half of the uncircumcised men thought that there were risks around circumcision.24
Our study has some limitations. Like most research conducted among MSM, we recruited a convenience sample, in this case men attending gyms in central London. Consequently, the findings may not be generalizable to all MSM in London or in the United Kingdom, nor to MSM in other countries with substantially different behavior patterns.25 We do not have information about MSM who declined to take part in the survey. However, our results are consistent with a similar study in Scotland.18 All information gathered in our survey was self reported. There is the possibility that some participants did not disclose sensitive information such as high-risk sexual behavior or an HIV-positive status. However, we believe that bias resulting from this is minimal due to the anonymous and confidential nature of the questionnaire. There is also the possibility for participants to incorrectly report circumcision status. However, a previous validation study conducted among MSM in Australia showed high agreement between reported and actual circumcision status.26 Finally, all analyses were based on cross-sectional data.
Our study suggests that it is unlikely that circumcision would be a feasible option for HIV prevention among MSM in London. We recommend that research into effective HIV prevention strategies for MSM in the United Kingdom focuses on strengthening behavioral interventions and supporting the development of biomedical interventions such as rectal microbicides, pre-exposure prophylaxis, or prophylactic vaccines.
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