Abstract

Introduction

By the end of 2011, it was estimated that 780,000 people were living with HIV/AIDS in China.¹ Sexual transmission accounts for more than half of the cases (63.8%), with 46.5% through heterosexual contact and 17.4% through homosexual contact.¹ Although the national prevalence remains low in China (0.058%),¹ challenges in HIV/AIDS prevention and control remain critical in certain regions. For example, six provinces with the highest cumulative number of reported HIV/AIDS cases (Yunnan, Guangxi, Henan, Sichuan, Xinjiang, and Guangdong) represent 75.8% of the national total.¹ Four of these provinces are located in western China. A poor economic environment, widespread high-risk sexual behavior, and a lower level of public awareness of HIV/AIDS are considered to account for the high HIV/AIDS prevalence in the western region of China.²

Traditional interventions have not been known to be very effective in HIV prevention. It is important to include new approaches for HIV prevention, such as male circumcision (MC), which is recommended by the Joint United Nations Program on HIV/AIDS (UNAIDS) and is recognized to be an additional and important strategy for the prevention of heterosexually acquired HIV infection in men.³ Randomized controlled trials (RCTs) in South Africa, Kenya, and Uganda have shown that MC reduces human immunodeficiency virus (HIV) acquisition in heterosexual men by 50–60%.^4–6 Several other studies also suggested that uncircumcised men have a higher risk of acquiring sexually transmitted diseases (STDs) including syphilis, gonorrhea, and chlamydia than circumcised men.^7,8 MC may be more effective in preventing or controlling HIV transmission in countries where the HIV prevalence is high, the MC rate is low, and the predominant transmission is through heterosexual behaviors.^9,10

The migrants are a high-risk group for HIV infection. The epidemiology of HIV/AIDS is closely linked to the process of migration.^11,12 China has the largest floating population in the world. Approximately 150 million migrants who work in the cities as laborers, restaurant workers, and sex workers have acted as the “tipping point” for the HIV/STI epidemic in China.^13,14 It was shown that rural-to-urban migration may play a crucial role in shifting the HIV/STI epidemic by broadening social and sexual mixing.^15,16 Many HIV infections are believed to be among the nation's rural-to-urban migrants.^17,18 About 73% of migrants come from poor areas of the country. Among them, the perceived HIV risk, the knowledge of HIV, and the rates of condom use were low.¹⁹ Compared to general residents in urban areas, HIV/STI prevalence among rural-to-urban migrants was relatively high.²⁰

In China, rural-to-urban migrants move from rural areas to urban areas for jobs without establishing permanent urban residency. Because of the strict household registration policy in China, it is difficult for these migrants to obtain a permanent urban residence, and most of them work in the city for a period of time and go back to their home village, or they travel back and forth between the rural areas and cities seasonally.¹⁹ Separated from their spouse/family and away from the social constraints of home, migrant men have increased opportunities to engage in high-risk behaviors including paying for commercial sex,¹⁴ and migrant women who are unable to find a source of income in urban areas may engage in commercial sex work.^21,22 Data from the Beijing Health Bureau suggest that migrants accounted for 80% of new HIV cases in Beijing in 2006.¹⁸

Overall, the average MC rate worldwide was estimated at 30–34%. MC is very common in western Africa, parts of areas in central and eastern Africa, the United States, and the Republic of Korea.²³ However, in China MC is not a common practice. Less than 5% of males were circumcised and many of these were performed just for medical reasons such as a tight foreskin.²⁴ Limited information is available about MC among Chinese male migrants. To date, no investigations have yet been conducted on understanding MC acceptability and related factors, such as socioeconomic status, family environments, and frequency of migration among this population in China. In this study, we carried out an investigation to explore the acceptability of MC and documented the factors associated with MC among male rural-to-urban migrants in western China.

Materials and Methods

Results

Discussion

In this study, for the first time we investigated the acceptance of MC and related factors among a special population in China, the male rural-to-urban migrants. The investigation indicates that the overall MC acceptance rate is 37.1%, which is lower than the acceptance rate from sub-Saharan Africa (65%),²⁶ men who have sex with men (MSM) in the United States (87.7%),²⁷ heterosexual men in Thailand (39.2%),²⁸ and other Chinese populations, such as the general population (44.6%)²⁹ and the MSM population (46.3%).²⁵ Our study shows that residents in Xinjiang, where many Muslims were centralized, had a higher acceptability of MC (44.0%) than those in Chongqing (41.0%) and Guangxi (25.6%). As a religious tradition, Muslims were circumcised when they were infants, which may influence the opinion of non-Muslim residents in the same area and contribute to the greater MC acceptability in Xinjiang.

Westercamp and Bailey reviewed 13 studies on MC acceptability and concluded that the identified factors associated with MC acceptability included beliefs that MC leads to improved hygiene; protection from sexually transmitted infections (STIs) and HIV infection; improved sexual pleasure and performance; ethnic, pain, culture and religion, cost, and possible adverse events (AEs); and the potential for risk compensation (i.e., an increase in risky sexual behavior following MC).²⁶ Because of differences in their conclusions, we found that the associated factors among male rural-to-urban migrants included education level, redundant foreskin, having one or more circumcised friends, and having had sexual intercourse with temporary partners in the past year.

Our investigation indicates that the acceptability of MC depends on education level. Consistent with previous studies,^26,30 we found the people with a higher education level had better knowledge of MC/HIV and were more likely to accept MC. We also found that targeted education could effectively improve the acceptability of MC. In the non-WTC group, more than half of the subjects (62.2%) considered that MC was not necessary or not effective. However, after being provided with information about the benefits of MC, 44.1% of non-WTC subjects changed their mind and said they were willing to accept MC.

Our investigation also shows that subjects who had sexual intercourse with temporary partners in the past year were more likely to accept MC. The possible reason is that they knew this risky sexual behavior was dangerous and made them vulnerable to HIV/STD infection. Paradoxically, these people had a low rate (31.4%) of consistently using condoms, indicating a sign of “separation between knowledge and practice.” Another finding of our study is the effect on the acceptability of MC based on participants' friends. If people have one or more circumcised friends, they might know more about MC, which might decrease their fear of MC and make them more comfortable with MC. In addition, our study shows that the common reasons for rejecting MC were that it was not necessary or effective, fear of infection, the cost and potential danger of MC surgery, and the fear of reduced penile sensitivity. These results are consistent with previous studies.^31,32 Furthermore, we found that there was no significant difference in MC acceptability between different age groups, which differs from the results of previous studies conducted in other countries or other populations in China.^29,33,34

Several limitations of our study need to be acknowledged. First, we used convenience sampling to extrapolate results to the rural-to-urban migrant population in the three western provinces in China, which may lead to selection bias. Those who participated in the study were perhaps more concerned about their health and more interested in the topic. Second, the collected information was mainly based on reported behaviors or characteristics such as the self-reported long foreskin without any clinical examination or other confirmation.

In summary, for the first time in China we investigated the acceptance of MC in rural-to-urban migrants. This provided evidence concerning MC acceptance among this population and identified factors that can be used for future programs to promote MC. The acceptability of MC among the rural-to-urban migrants is lower than among other populations in China and worldwide. However, appropriate education could greatly improve the acceptability of MC, suggesting that targeted public programs are necessary to promote MC for HIV prevention among this population in China.

References