Foreskin cutting beliefs and practices and the acceptability of male circumcision for HIV prevention in Papua New Guinea

Abstract

BackgroundMale circumcision (MC) reduces HIV acquisition and is a key public health intervention in settings with high HIV prevalence, heterosexual transmission and low MC rates. In Papua New Guinea (PNG), where HIV prevalence is 0.8%, there is no medical MC program for HIV prevention. There are however many different foreskin cutting practices across the country’s 800 language groups. The major form exposes the glans but does not remove the foreskin. This study aimed to describe and quantify foreskin cutting styles, practices and beliefs. It also aimed to assess the acceptability of MC for HIV prevention in PNG.MethodsCross-sectional multicentre study, at two university campuses (Madang Province and National Capital District) and at two ‘rural development’ sites (mining site Enga Province; palm-oil plantation in Oro Province). Structured questionnaires were completed by participants originating from all regions of PNG who were resident at each site for study or work.ResultsQuestionnaires were completed by 861 men and 519 women. Of men, 47% reported a longitudinal foreskin cut (cut through the dorsal surface to expose the glans but foreskin not removed); 43% reported no foreskin cut; and 10% a circumferential foreskin cut (complete removal). Frequency and type of cut varied significantly by region of origin (p < .001). Most men (72-82%) were cut between the ages of 10 – 20 years. Longitudinal cuts were most often done in a village by a friend, with circumferential cuts most often done in a clinic by a health professional. Most uncut men (71%) and longitudinal cut men (84%) stated they would remove their foreskin if it reduced the risk of HIV infection. More than 95% of uncut men and 97% of longitudinal cut men would prefer the procedure in a clinic or hospital. Most men (90%) and women (74%) stated they would remove the foreskin of their son if it reduced the risk of HIV infection.ConclusionAlthough 57% of men reported some form of foreskin cut only 10% reported the complete removal of the foreskin, the procedure on which international HIV prevention strategies are based. The acceptability of MC (complete foreskin removal) is high among men (for themselves and their sons) and women (for their sons). Potential MC services need to be responsive to the diversity of beliefs and practices and consider health system constraints. A concerted research effort to investigate the potential protective effects of longitudinal cuts for HIV acquisition is essential given the scale of longitudinal cuts in PNG.

High prevalence and incidence of HIV, sexually transmissible infections and penile foreskin cutting among sexual health clinic attendees in Papua New Guinea

“…13,16,31 We have previously postulated 13 that the dorsal longitudinal slit may confer some degree of protection against HIV acquisition in men in a similar way to full removal of the foreskin, because the lateral retraction and eversion of the foreskin that follows a full dorsal slit results in complete exposure of the glans and inner foreskin, and a final appearance that closely resembles medical circumcision (Fig. 1a).…”

Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea

“…Although the acceptability of MC programs has been cited as a key consideration in determining program appropriateness in different contexts [12,13], further understanding of how to engage communities and facilitate uptake following confirmation of acceptability is integral for ongoing success of any public health program [7,14-16]. In Papua New Guinea (PNG), a country where a significant number of diverse penile cutting practices have been described to be already apart of the socio-cultural fabric of many communities, interest in aligning MC with other HIV intervention programs has been raised [17-20]. This study is an exploratory study using interviews and participatory tools to investigate the potentials and challenges of integrating community participation into health service delivery.…”

“…For example, penile cutting practises in PNG are embedded in customary rituals and contemporary practices (influenced by peers and the socio-cultural environment) [17-20]. These practices also encompass various forms of penile cutting that do not commonly involve circumferential cutting or full excision of the foreskin as currently indicated for HIV prevention [9,17,19,20,33,34].…”

Impact of Male Circumcision on the HIV Epidemic in Papua New Guinea: A Country with Extensive Foreskin Cutting Practices

“…On the other hand evidence from PNG and other settings indicate it is unlikely risk compensation, in terms of lower condom usage, would completely offset reductions in HIV incidence following an MC program. A recent study in PNG found no difference in condom use at last sex between men with MC ("round cut"), long cut and no cut (35%, 32%, and 33% respectively) [14]. Similarly there were no differences in condom use with non-spousal partners between circumcised and uncircumcised men in a South African township that was the site of a randomized controlled trial of MC [3].…”

“…Furthermore, foreskin cutting is often performed away from counseling services and outside of a clinic setting resulting in health complications [14], [20]. These factors complicate assessments of the additional benefits provided by population-based MC programs in PNG.…”