Male Circumcision as a Bio-medical HIV Intervention Targeting Male Heterosexual Sexually Transmitted Disease (STD) Patients in China - An Acceptability Study and a Single-arm Test-of-concept Trial

Introduction: The HIV and sexually transmitted diseases (STD) epidemics are severe in China. Male circumcision (MC) is a newly developed yet under-utilized, evidence-based HIV intervention. The World Health Organization (WHO) and joint United Nations Programme on HIV/AIDS (UNAIDS) recommend its usage as a means of HIV prevention among heterosexual males. Despite the significance, there is no published study investigating the implementation of MC among male STD patients who are of high risk of HIV infection and serve as "bridge population" transmitting HIV from high risk population to low risk population.;Objectives: In Phase I cross-sectional study, we aimed to investigate the prevalence and associated factors of willingness to take up MC conditional on STD risk reduction and HIV risk reduction among uncircumcised male STD patients in Shenzhen, China. We also investigated the prevalence and associated factors of anticipated risk compensation due to MC. In Phase II, an intervention was developed based on the results of the acceptability study. A test-of-concept trial was conducted to test the effectiveness and sustainability of the intervention in promoting MC.;Method: In Phase I, 308 HIV negative, uncircumcised and consented heterosexual male STD patients recruited from three STD clinics in Shenzhen were interviewed anonymously. In Phase II, another sample of 179 such patients participated in an intervention promoting MC. They were followed up by telephone at month 4. Participants who had taken up MC received another telephone follow up at month 6. A qualitative process evaluation among intervention administrators, clinicians and the directors of the STD clinics was also conducted at month 6. Statistical methods such as Chi-square test, Logistic regression and Cox regression were used in this study.;Results: Respectively 45.1% and 46.1% of the participants were willing to take up MC in the next six months conditional on STD risk reduction and conditional on HIV risk reduction. We found out that factors associated with acceptability included younger age, HIV/STD-related knowledge, overly long foreskin, cognitive factors including those related to Health Belief Model (HBM) and subjective norm (a TPB construct), as well as emotional factors. Our analysis also found out that subjective norm did not add explanatory power to the HBM factors. In addition, results show a potential mediating effect of emotional representation of STD infection between perceived severity of STD infection and acceptability of MC.;26.9% anticipated at least one type of the aforementioned risk compensation due to MC. Intention to reduce condom use with regular female sex partner (RP) was the most prevalent type of anticipated risk compensation. Two relative risk assessment variables, perceived risk gap and perceived risk reduction, were both found to be significant factors. Negative condom attitude was another significant factor. Our analysis further showed that the level of negative attitudes toward condom use moderated the association between perceived risk gap and anticipated risk compensation. No interaction was found between intention to take up MC and various associated factors.;It is satisfactory that of the sampled male STD patients, 19.9% did actually take up MC within the 4-month follow-up period. This may be a conservative response to the health promotion due to the short follow-up period as 40 uncircumcised participants (25.6%) showed an intention to take up MC. Participants in the TOC trial who had discussed the benefits of MC with their female sex partners, perceived higher behavioral control, had behavioral intention or plans made for taking up MC at the baseline were more likely than others to have actually taken up MC during the study period. Process evaluation obtained from the stakeholders has been extremely positive. However, over one third of circumcised participants reported reducing frequency of condom use with RP after taking up MC. The possibility of risk compensation with non-regular female sex partners or female sex workers cannot be ruled out due to potential reporting bias.;Conclusion: MC is an evidence-based but under-utilized HIV intervention. We conducted a formative research which was followed by a TOC trial showing potential effectiveness and issues to be addressed. We proposed a stage-approach in improving scaling up of the intervention by promoting MC. We believe that our study is a good starting point integrating biomedical and behavioral HIV intervention in China, which will create a significant impact on prevention of HIV and STD in China. Moreover, as Asian countries share some similar cultural contexts. Our experiences may contribute to improving their HIV prevention programs. We believe that, through the scaling up of MC, this study will contribute to the control of HIV/STD in China. It is also our sincere wish that this study leads to more implementation studies on HIV/STD prevention in China in the future.