Abstract

Background

Male circumcision (MC), or the surgical removal of the foreskin, has received intense public health attention since three large randomised trials, published between 2005 and 2007, reported that the procedure can reduce male susceptibility to heterosexual acquisition of HIV by approximately 60% [1-3]. These results confirmed earlier observational studies that documented an association between lower HIV infection rates and MC [4,5]. In 2007 it was estimated that up to 5.7 million new HIV infections could be averted over 20 years through the implementation of MC services in sub-Saharan Africa [6-8]. WHO and UNAIDS now recommend MC programs be included in comprehensive HIV prevention packages in settings of high HIV prevalence with heterosexual transmission and low MC rates [9].

MC for HIV prevention is viewed favourably across numerous high HIV prevalence settings in East and Southern Africa, both in traditionally circumcising and non-circumcising communities [10-21]. MC programs are now being implemented across this region, accompanied by ongoing acceptability studies [12,22-35]. However, a detailed understanding of local social, cultural, gender, religious and medical issues must underpin such MC programs [36-39].

MC may also play an important public health role in moderate HIV prevalence countries. However very few investigations of MC’s acceptability, feasibility and epidemiological impact have been conducted in such settings [40-46]. Papua New Guinea (PNG), the largest South Pacific Island country, has the second highest HIV prevalence of the Asia-Pacific region (after Thailand). In 2012 PNG had an estimated adult HIV seroprevalence of 0.79% (15–49 years), associated with widespread behavioural risk and high rates of sexually transmitted infections [47-49]. More females than males are infected with HIV, suggesting heterosexual intercourse as the primary driver. The PNG health system does not provide routine MC services. Investigating MC for HIV prevention is a current research priority for the PNG National AIDS Council [50].

PNG has extreme social, cultural and geographical diversity. PNG’s 7.1 million people speak over 800 distinct languages and live in different settings: from villages on remote coral atolls to highland valleys to regional and provincial towns and their associated peri-urban squatter settlements. Reflecting this diversity, HIV prevalence is unevenly distributed: Highlands and Southern Regions have 0.89% and 0.88% respectively and Momase and New Guinea Islands Regions 0.66% and 0.58% respectively [47]. PNG’s unparalleled diversity means national HIV policy formulation is complex and requires evidence from a wide range of studies [51,52].

The context of MC in PNG is also complex. Most cultural groups do not traditionally practice MC, however there is a wide variety of foreskin cutting practices across the country [53,54]. The full removal of the foreskin, commonly referred to as a ‘round cut’, is produced by a circumferential cut to the foreskin and produces results equivalent to medical MC. Local variations, with many local descriptive names, are produced by a longitudinal cut along the dorsal surface of the foreskin. This exposes the glans penis and leaves the foreskin hanging loose beneath the penis. These variations are often generically referred to as ‘straight cut’ or ‘split’. Most of these cuts take place in the community with few occurring through the formal health system [55-57]. The rich ethnographic and anthropological record in PNG has detailed descriptions of initiation and blood-letting rituals in some cultural groups that involve multiple cuts to the foreskin and penis [58-60].

In recent years there appears to have been a shift in foreskin cutting practices in PNG that have paralleled dramatic social, economic and religious change [54,60]. A National HIV/AIDS Behavioural Surveillance Study in 2006 documented 26 – 70% of men had some form of foreskin cut, however the study did not differentiate between the ‘round cut’ or ‘straight cut’ [61]. More recent studies have made the distinction [62,63] and found 25 - 50% of men had some form of foreskin cut, with considerable diversity in the extent and type of foreskin cut reported. Qualitative studies are expanding knowledge about beliefs and practices of the various styles of foreskin cutting, and their implications for HIV prevention in PNG [45,46,57]. Men in these studies were generally in favour of MC being introduced for HIV prevention, but women were cautious or not in favour because of cultural and religious concerns and fear of sexual disinhibition of husbands or partners [45,46]. Building on these studies, it was important to quantify the diversity of foreskin cutting styles, practices and beliefs in PNG and assess the proportion of men and women who may find MC acceptable for HIV prevention.

This paper reports on the collaborative ‘Acceptability of Male Circumcision for HIV Prevention in PNG’ study carried out from July 2010 to February 2011. Here we report quantitative results for two objectives of the study: (i) describe and categorise male genital cutting, which includes MC; to ii) examine social, cultural and religious practices and their influence on the acceptability of MC for HIV prevention.

Methods

This was an observational cross-sectional study, conducted in collaboration between researchers from Papua New Guinean and Australian universities and partnering with companies at two ‘rural development’ sites.

Results

Circumstances of foreskin cutting

Most cut men (82% longitudinal cut men; 72% circumferential cut men) reported having their foreskin cut between the ages of 10 and 20, with mean age 17 years (SD 4.77; Range 2–38) at longitudinal and 15 years (SD 6.66; Range 1–30) at circumferential cut (p < 0.001). The place and person performing the cuts varied significantly between longitudinal and round cut (p < 0.001). Longitudinal cuts were most frequently done in the village by a friend. Round cuts were most frequently done in a clinic by a health professional. Razors and surgical blades were the most utilized tools in all cuts (>90%), with scissors or bamboo used for 6% of circumferential cuts and a needle and rubber used for 5% of longitudinal cuts. For more details on place, person and tool used for foreskin cutting see Figure 1.

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Figure 1

Place, person and tool used for foreskin cutting for men with longitudinal cut (in blue) and circumferential cut (in red).

Discussion

This is the first study conducted in PNG that combines the investigation of prevalence, beliefs, attitudes and practices about foreskin cutting and the acceptability of male circumcision. It thus addresses a vital area for public health and HIV prevention in the country. Results expand the evidence vital for the National AIDS Council, National Department of Health and other policy makers to more effectively plan HIV prevention strategies.

The overall prevalence of foreskin cutting in the study was 57%, however only 10% of men reported the complete removal of the foreskin, the procedure on which international HIV prevention strategies and recommendations are based upon. The prevalence of foreskin cutting in this study was higher than the 25.8% longitudinal cut and 3.4% circumferential cut documented in recent studies in plantation workers in the Highlands region, but similar to studies in the national capital [61-63,65]. The deliberate approach to include participants from diverse geographic locations and cultural backgrounds allowed a sample with a similar regional proportionality to the PNG population. Although this does not automatically imply representativeness or generalisability across the PNG population, this characteristic does enable closer analysis of the diversity of opinions and experience. The highest prevalence of both longitudinal and circumferential cuts in this study were from men from New Guinea Islands and Momase. This was not surprising given the numerous cultural groups with a tradition of foreskin cutting in these regions. However around half of men from the Highlands and Southern regions also reported having a cut foreskin (most often longitudinal cut). This was surprising given there are far fewer cultural groups with a tradition of foreskin cutting in these regions. Older men from Highlands and Southern regions were less likely to have a foreskin cut, or have detailed knowledge about foreskin cutting. This reflects recent rapid changes that enable modern education, travel and work practices that facilitate the exchange of knowledge, beliefs and practices, including foreskin cutting.

This study provides further evidence that longitudinal cuts are the major forms of foreskin cutting in PNG[54,57,66,67]. Of men with dorsal longitudinal cuts in this study, more than half reported a variant where the glans penis is totally exposed. In this variant, the remnant foreskin hangs loosely on the ventral surface of the penis permanently exposing the inner surface of the foreskin. The foreskin then reduces in size, becomes dry and is visually similar to the outer surface of the foreskin. In some men with this variant, the foreskin reduces to such an extent that the penis appears very similar to a circumcised penis (See Figure 2). It is unclear what the implications of such longitudinal cuts are for HIV prevention. The major explanation of how MC protects against HIV is that the inner aspect of the foreskin is the prime site for HIV entry on the penis. The inner aspect (and the frenulum) have a thinner keratin layer than the glans or penile shaft and so enable HIV entry to Langerhans cells which carry specific HIV receptors [68]. Removing the foreskin through MC removes the prime site for HIV entry and so reduces the risk of HIV infection. This leads to the potential that changes to the exposed inner surface and reduction in the surface area of the remnant foreskin may provide some protection against HIV infection for men with this variant. However the potential protective effect is currently unknown [57,69]. A concerted research effort to investigate the potential protective effects of longitudinal cuts for HIV acquisition in PNG is essential given the scale of longitudinal cuts documented. This is particularly important given that most of the foreskin cutting does not occur within traditional initiation rituals or within the formal health sector, but predominantly between peers as an evolving contemporary socio-cultural practice. Moreover, many men with longitudinal cuts in PNG consider themselves as ‘circumcised’ because of the appearance of their penis and because the commonly used Tok Pisin terms katim skin bilong kok or katim kok do not differentiate between longitudinally cut or totally removed foreskin [46]. Studies from PNG, Rwanda, Swaziland and Kenya have highlighted regional and cultural variations of foreskin cutting that do not completely remove the foreskin, and that many of these men consider themselves ‘circumcised’. This re-enforces the need for further research and more nuanced understanding of MC for HIV prevention in such settings [33,57,70,71]. This is particularly important given cultural contexts are constantly evolving and adapting to new influences and circumstances [72].

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Figure 2

Longitudinal Foreskin cut: Variant (i) Foreskin cut but still partially covers the glans penis; Variant (ii) Foreskin cut and remains loose behind the glans penis.

MC for adult men was viewed positively. Three quarters of uncut men (76%) stated that they would remove their foreskin if it had a health benefit and 71% if it reduced the risk of HIV infection. These results reflect similarly high proportions (86%) of male university students willing to have the foreskin removed in a pilot study [65] and qualitative findings showing PNG men to be generally in favour of MC for HIV prevention [46]. Further, men with an existing longitudinal cut were overwhelmingly in favour of having the remnant foreskin removed if it reduced the risk of HIV infection. Most of these men had their longitudinal cut in a community setting, but almost all stated they would prefer to have the removal procedure conducted in a health facility by a health professional which they considered a safer option. The high proportion of men willing to have MC is similar to studies in high HIV prevalence settings in Africa (median 65%) but somewhat greater than studies in other moderate prevalence settings, such as India (58%), Thailand (14% and 25% before and after information) and Dominican Republic (29% and 67% before and after information) [13,40,41,43]. Methodology, study population, HIV prevalence and socio-cultural context are so different across these studies that comparisons are hard to interpret. Moreover men in these studies were categorised in a circumcised – uncircumcised dichotomy, making interpretation even more difficult for the PNG context where the longitudinal cut is the major form of cutting. However, these studies do reflect the need to investigate understandings and cultural contexts of specific populations to inform if, or how, MC may be a part of the local response to HIV.

MC for children was viewed positively. More than 90% of men and three quarters of women stated they would remove the foreskin of their child if it had a health benefit and/or reduced the risk of HIV. These rates are similar to parents in some high prevalence African settings and provide some of the first evidence about parents’ willingness to circumcise their sons in a moderate HIV setting [13]. This provides a unique challenge to the PNG health system that struggles to provide even basic primary health care services for the majority of the population. There are only 0.5 doctors and 5 nurses/midwives per 10 000 people in PNG and only 39% of births are supervised by skilled birth attendants [73,74]. Having a large number of adults, adolescents or infants present for MC would require considerable training, infrastructure and resource allocation across the entire health system.

Specific attitudes and beliefs documented in this study have direct relevance for policy makers. When given the ability to respond yes, no, or unsure to statements about foreskin cutting it was common for around a third of men and often more than half of women responded ‘unsure’. Although this high level of uncertainly may be of concern to some service providers or policy makers, it reflects the dynamic socio-cultural context in PNG and that many people are aware of foreskin cutting but may not have fixed attitudes or beliefs towards foreskin cutting. This provides an opportunity for public health campaigns, as called for by Kelly et al. [46], to provide accurate information in a culturally sensitive way that builds on the strength of culture, rather than destroying it. In a country where one’s culture and religion is so explicitly referred to in everyday life, it is important to note that few men and women stated foreskin cutting was forbidden by their custom/tradition or religion. Further, none of the beliefs about culture, religion or sexual practice documented in this study contradict the positive views of men and parents towards MC, or the appropriateness of providing MC services in this setting.

It is pleasing to note that the majority of both men and women believe men with a cut (or removed) foreskin still need to use condoms to prevent STI and HIV. However, of concern is one quarter of men and 40% of women stated they were unsure. This requires current public health messages about STI and HIV prevention to emphasise that condoms are for everyone regardless of a man’s foreskin cutting status. It is also encouraging that almost all men and women think it is unsafe to use the same blade to cut many men. This is likely to be due to cultural beliefs about the contagion potential of blood re-enforced by public HIV prevention messages about the danger of sharing tools for body cutting, tattooing or scarification practices [75]. Nevertheless, 19% of men and 52% of women were not sure or do not think it is necessary to avoid sexual contact in the days after the foreskin cut, highlighting the need for more specific MC education.

As in other low-moderate HIV burden settings with heterosexual transmission, a key challenge is how to expand existing clinical MC services, increase the safety of existing community foreskin cutting practices and/or introduce new MC services appropriate to local contexts. Decision makers must consider programs that deliver the greatest epidemiological and public health impact while being responsive to diverse socio-cultural practices and health service capacity [33,45,46]. In this context, researchers and policy makers in PNG are actively considering international and local evidence to inform policy making and future research [76,77].

The major strength of this study was that it was a partnership between PNG and Australian universities and two large resource companies across four provinces at sites where people from across PNG come to study or work. This allowed access to a great diversity of men and women who provided data on traditional and contemporary foreskin cutting practices and beliefs. However, only some major descriptive analysis of this large quantitative data set on foreskin cutting practices and beliefs could be presented in this paper. Further more detailed analyses of quantitative data and findings from qualitative interviews and focus group discussions will be published separately. Given the hyper-diversity of having more than 800 languages, and thus diverse sets of beliefs and practices in the country, this study provides a limited, although valuable snapshot of current foreskin cutting and the acceptability of MC in PNG.

Conclusion

This study considerably expands the evidence base of current foreskin cutting practices in this moderate HIV prevalence setting. The major form of foreskin cut is the longitudinal cut along the dorsal surface resulting in the remnant foreskin hanging from the ventral surface of the penis. In most cases this totally exposes the glans penis and results in a remnant foreskin that is dry, reduced in size and with the inner surface visually similar to the outer surface. Foreskin removal (MC), from both uncut men and men with an existing longitudinal cut was considered appropriate and acceptable by most men and women in this study. Potential MC services will need to be responsive to the great diversity of local socio-cultural beliefs and practices and existing health service constraints. Research evidence of the protection conferred by longitudinal cuts is urgently needed to inform HIV prevention strategies in this setting. This study provides vital evidence on current foreskin cutting beliefs and practices and the implications for the acceptability of MC for HIV prevention in PNG. It thus enables more effective planning of HIV prevention in PNG and other populations with dynamic and varied socio-cultural foreskin cutting practices.

Competing interests

The authors declare there they have no competing interests.

Authors’ contributions

DM and WJM conceived, designed and coordinated the study and drafted the manuscript. RT, TM, CM, FF, MRM, MW, KB participated in the design and coordination of the study; collected, managed and analysed data; helped draft and revise the manuscript. RM and JK managed, analysed and interpreted data and help to draft and revise the manuscript. All authors have read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2458/13/818/prepub

Supplementary Material

References