Before the informational session, 408 (68%) responded that they would definitely or probably circumcise a male child if circumcision was offered free of charge in a hospital setting; this number increased to 542 (89%) after the informational session. In a multivariate analysis of all participants, people with children were more likely to favour circumcision than people without children (adjusted odds ratio 1.8, 95% CI 1.0 to 3.4). Most participants (55%) felt that the ideal age for circumcision is before 6 years, and 90% of participants felt that circumcision should be performed in the hospital setting.

Ritual male circumcision is among the most secretive and sacred of rites practiced by the Xhosa of South Africa. This paper attempts to understand how some of these cultural and social meanings have shifted, particularly with respect to attitudes towards sex and the role that circumcision schools traditionally played in the sexual socialisation of Xhosa youth.

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. 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.

For example, one of the highest acceptability levels (81%) was recorded in Botswana after an informational session in which participants were told about the health benefits and risks associated with the procedure (Kebaabetswe et al., 2003 ). In some studies, adults were asked if they would be circumcised or prefer their partner to be circumcised “if MC were proven to be protective against HIV and STIs” (Halperin et al., 2005 ; Lagarde et al., 2003 ; Rain-Taljaard et al., 2003 ; Tsela & Halperin, 2006 ). In others, participants were asked if they would accept MC “if it were safe and affordable” (Bailey et al., 1999 ; Kebaabetswe et al., 2003 ; Mattson et al., 2005 ; Scott et al., 2005 ). Fig. 2 Levels of male circumcision (MC) acceptability from eight quantitative studies in six sub-Saharan African countries Full size image Table 2 Circumcision preference and conditions for acceptability reported in eight studies from six sub-Saharan African countries Full size table In general, approximately the same proportion of women would prefer circumcision for their partners or their sons as men would prefer circumcision for themselves or their sons. Cost The cost of the procedure was a significant barrier to MC acceptability by participants in many studies (Bailey, Unpublished report to AIDSMARK, 2002; Bailey et al., 2002 ; Lagarde et al., 2003 ; Lukobo & Bailey, Submitted; Mattson et al., 2005 ). Some participants expressed the opinion that if circumcision were promoted by the government, it should be provided at health clinics and hospitals for free or at reduced cost (Bailey et al., 2002 ; Lukobo & Bailey, Submitted; Ngalande et al., 2006 ). Others recognized the need to pay for services because a free circumcision was viewed as being of potentially poor quality (Ngalande et al., 2006 ). Male and female participants in Zambia believed that, if the MC procedure were free or extremely inexpensive, more men would be willing to get circumcised (Lukobo & Bailey, Submitted). In one study as many as 34% of participants who initially stated that their preference was to remain uncircumcised changed their minds when the proposed cost of the procedure was set at US$3.00 (Mattson et al., 2005 ). Cost of traditional circumcision was considered to be high in many areas and there is a gradual shift from traditional to medical circumcision in part for this reason (Bailey & Egesah, 2006 ; Lukobo & Bailey, Submitted; Ngalande et al., 2006 ; Rain-Taljaard et al., 2003 ). Traditional circumcision is often expensive due to the costs of food, drink, special clothing and other items required during a sometimes prolonged celebration.

In the first randomized controlled trial (RCT) to report on MC, Auvert and colleagues [9 ] have shown that MC reduces transmission from women to men by 60% (32%−76%; unless otherwise stated ranges are 95% CI). An earlier meta-analysis of observational studies found an adjusted relative risk for HIV in circumcised men of 0.42 (0.34−0.54) [10 ], although a Cochrane review gave a more cautious interpretation [11 ]. In sub-Saharan Africa, estimates of HIV prevalence [12 ] (Figure 1 ) are significantly associated with the estimated prevalence of MC (correlation coefficient, ρ = −0.61; p < 0.0001). In countries where fewer than 30% of men are circumcised, the median prevalence of HIV is 17% (IQR: 6% to 27%, n = 9 countries); where more than 90% of men are circumcised it is 2.9% (IQR: 1.5% to 5.5%, n = 13 countries). In a multi-centre study in Africa, Herpes simplex 2 and not being circumcised were independent risk factors for HIV [13 ]; the prevalence of HIV was negatively correlated with the proportion of men who were circumcised (correlation co-efficient, ρ = −0.85; p < 0.001) [14 ]. RCTs in Kenya [15 ] and Uganda [16 ] will provide further information on the impact of MC on HIV and in particular on the possible impact of MC on male-to-female transmission of HIV. Then assuming an effective contact rate c, and probabilities of infection per contact of ϕm for female-to-male transmission and ϕf for male-to-female transmission, the model is Early in the epidemic, if and im are both much less than 1, the initial growth rate is the ratio of the prevalence in women to that in men in the early stages of the epidemic is while the case reproduction number is In the endemic state, the ratio of the prevalence in women to that in men is For the South African epidemic, if no men were circumcised, we estimate that R 0 = 7.2 ± 1.8 so that with δ = 0.102 ± 0.005/y and ϕf /ϕm = 2.0 ± 0.5 Equation 6 gives cϕm = 0.52 ± 0.16/year and cϕf = 1.04 ± 0.29/y. From Equation 7 the proportion of infected adults who are women is 52% ± 1%. (A more detailed examination of the proportion of infected adults who are women is given in Protocol S1 and Figure S2 .) Collapsing the Two-Sex Model to a One-Group Model To determine rates of infection, averaged over men and women, we replace Equations 2 and 3 by where i is the population prevalence averaged over men and women, and so that R 0 for Equation 8 is the same as in Equation 6 . It follows that reducing ϕm by a factor of 1 − π is equivalent to reducing both ϕm and ϕf by a factor of . To allow for the fact that not all men are circumcised, we let χ be the proportion of men who are circumcised and π be the reduction in female-to-male infectiousness when men are circumcised.

Peer Review reports Background Male Circumcision (MC) has been recommended as one of the preventive measures against sexual HIV transmission in 2007 by the World Health Organization (WHO) and UNAIDS [1 ]. Three Randomized Controlled Trials (RCT) conducted in South Africa, Uganda and Kenya, strongly supported the efficacy of MC at reducing the risk of HIV transmission from infected women to circumcised men, by approximately 60% [2 –5 ]. Studies also reported a substantially reduced risk of other Sexually Transmitted Infections (STIs) such as syphilis, chancroid, and Herpes Simplex-2 (HSV) in circumcised men [6 ]. The MC procedure is cost effective particularly in adolescent and infant MC [7 ]. WHO has advocated countries with a generalized HIV epidemic and with a male circumcision rate below 20% to adopting extensively MC for the benefit of the whole population [1 ]. A recent review from 13 African countries reported that on average 65% of uncircumcised men were willing to get circumcised and 71% were willing to have a son circumcised, although MC was not a common practice in these communities [8 ]. Higher odds of being circumcised among adults were associated with improved hygiene and a reduced risk of STIs. Significant association was found with men having secondary education (OR=: 8), University (OR=: 58) education, and being Protestants (OR=: 2.18). With other factors controlled, being circumcised was significantly associated with men who had either secondary (aOR=: 4), or university education (aOR=: 17), and those who mentioned hygiene as a reason to go for circumcision (aOR=: 4). Other associated factors were living in Southern (aOR=: 0.10), Northern (aOR = 0.09), or Eastern (aOR = 0.17) province, and men who were in cohabitation (aOR=: 0.35) (Table 2 ). Table 2 Determinants of circumcision among non Muslim men, 2010 Full size table Factors associated with the willingness to circumcise amongst UCM and their support to circumcise their son/s In the uni variate analysis, it was found that younger men (30-39, 20-29, < = 19 years) were more likely to get circumcised compared to the older ones (OR = 2.89, 4.36, 4.76), as well as education, living in Eastern Province, marital status, MC knowledge, and preventive role of MC also are significantly associated with the willingness to circumcise.

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. 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.

Figures Citation: Begley EB, Jafa K, Voetsch AC, Heffelfinger JD, Borkowf CB, Sullivan PS (2008) Willingness of Men Who Have Sex with Men (MSM) in the United States to Be Circumcised as Adults to Reduce the Risk of HIV Infection. We then asked uncircumcised MSM to rate their agreement or disagreement with a series of statements that used a Likert scale for responses (values: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree) to assess their perceptions about risks of adult circumcision (pain, bleeding, or infection of the penis after the surgery) and benefits of adult circumcision (increased sexual pleasure, increased personal hygiene, reduced risk of penile cancer, and reduced risk of sexually transmitted diseases). We dichotomized the scaled responses into agree (neither agree nor disagree, agree, or strongly agree) or disagree (disagree or strongly disagree). We asked uncircumcised respondents the following question and asked them to rate their willingness on a Likert scale (values: 1 = very unlikely, 2 = unlikely, 3 = somewhat likely, 4 = likely, 5 = very likely), “If scientific studies in the United States among men who have sex with men showed that circumcision reduced the risk of HIV infection, would you be willing to be circumcised as an adult?” Preliminary analyses of willingness as an ordinal outcome variable with 5 levels in logistic regression indicated that ordinal regression violated the assumption of proportional odds; therefore we chose to analyze the dichotomized outcome, classified as willing (somewhat likely, likely, or very likely) and unwilling (unlikely or very unlikely). We restricted the analysis to respondents who did not report that they were HIV-positive and who either identified as homosexual or bisexual or who reported having had sex with a male partner in the past 12 months.

Both men and women were eager for promotion of genital hygiene and male circumcision, and they desired availability of circumcision clinical services in the Province's health facilities. Further studies are needed in other regions to assess the feasibility of introducing acceptable male circumcision information and services to reduce HIV transmission.

Peer Review reports Background The protective effect of adult male circumcision (AMC) on HIV acquisition has been reported in a review of epidemiological studies [1 ] and demonstrated by three randomized controlled trials conducted in Southern and Eastern Africa, which found that the risk of HIV acquisition among circumcised adult men was reduced by about 60% [2 –4 ]. As a health intervention, AMC is predicted to be significantly life- and cost-saving in terms of averted HIV infections and related medical costs [5 –8 ]. In 2007, WHO/UNAIDS recommended AMC as an important, additional intervention which should be delivered as part of a comprehensive HIV prevention package in communities with generalized HIV epidemics and low AMC prevalence [9 ]. Since this recommendation, efforts are being applied to roll-out safe and effective AMC services in several Eastern and Southern African countries [10 –12 ]. A review of studies investigating the acceptability of AMC as an intervention against HIV among Sub-Saharan African communities not practicing male circumcision was conducted in 2006 [13 ]. AMC acceptability among men was defined as their willingness to undergo the procedure. The first published randomized clinical trial on the effect of AMC on HIV acquisition was conducted in this community in 2002-2005 [2 ]. The township has an estimated population of 200,000 living in an area of about 50 km2 . A study conducted in a neighboring, comparable township, estimated self-reported circumcision prevalence at 22.4%, and clinical circumcision prevalence (lack of foreskin) at 13%, with male circumcision being perceived positively [16 ]. HIV prevalence in the province is estimated at 15.2% among adults aged 15 to 49 [17 ]. Study recruitment Screening for the biomedical survey was conducted according to a method designed for a community-based cross-sectional study conducted in the same area [16 ]. Briefly, a random sample of 1680 households was selected from Statistics South Africa Enumerator Area aerial photographs.