ABSTRACT
To investigate the prevalence of male circumcision and the willingness to undergo male circumcision and influencing factors among MSM in Maanshan City, we conducted a cross-sectional study from June 2016 to December 2019. Respondent-driven sampling (RDS) was used to recruit participants. Influential factors of willingness to accept circumcision were identified by a multivariable logistic regression model. The multivariable logistic regression model revealed that five variables were independent influential factors for willingness to participate. The factors include that used condoms during last anal intercourse (OR = 1.87, 95% CI:1.03–3.41, P = 0.04), sex with female sex partners (OR = 0.499, 95% CI:0.298–0.860, P = 0.012, level of education (junior college: OR = 0.413, 95% CI:0.200–0.854, P = 0.017; bachelor's degree or higher: OR = 0.442, 95% CI:0.208–0.938, P = 0.033), condom use during oral sex in the last six months (OR = 4.20, 95% CI:1.47–12.0, P = 0.007) and level of knowledge of PrEP (OR = 5.09, 95% CI:1.39–18.7, P = 0.014). Given the willingness of MSM to accept circumcision was low in China, establishing a proper understanding of circumcision is essential if it is to be used as a strategy to prevent HIV infection among MSM. Therefore, publicity and education on the operation should be strengthened to increase the willingness to undergo male circumcision.
Introduction
Men who have sex with men (MSM) in China, as in many developing countries, also face a rapidly spreading HIV epidemic (Baral et al., Citation2007; China Ministry of Health, Citation2009), especially in Maanshan City. It is located in Anhui Province and connects with Nanjing and Jiangsu Province. Nanjing is a city with a very large number of population. Influenced by Nanjing, the number of HIV infections in Maanshan city rapidly increased (Zhu et al., Citation2008). In 2012, 3.50% of MSM were infected with HIV in Maanshan City. Hence, HIV prevention among MSM needs to be strengthened in Maanshan City (Qin et al., Citation2014). However, the lack of prevention interventions targets Chinese MSM (Ruan et al., Citation2009).
Studies in several developing countries in Africa show that male circumcision plays a significant role in preventing HIV infection among adult heterosexual males, and it could reduce HIV infection by 50–60% (Auvert et al., Citation2005; Bailey et al., Citation2007; Gray et al., Citation2007). A recent meta-analysis found that male circumcision provides 70% of protection (Lei et al., Citation2015) during male-to-female sexual intercourse to reduce the risk of HIV infection, and can reduce HIV infection in adult heterosexual men by 72% (Sharma et al., Citation2018). A study suggests that the presence of foreskin may enhance HIV infection (Ruan et al., Citation2009). Evidence suggests that male circumcision can remove most of the target cells for HIV since these are in the foreskin (Ganor et al., Citation2010; Ganor & Bomsel, Citation2011) and that circumcision can reduce the biological sensitivity of target cells to HIV (Donoval et al., Citation2006; McCoombe & Short, Citation2006). Thus, male circumcision has been recommended as an important means of preventing HIV infection among heterosexuals (WHO & UNAIDS, Citation2009).
However, the role of male circumcision in the reduction of HIV infection through anal intercourse among MSM is ambiguous (Buchbinder et al., Citation2005; Millett et al., Citation2008; Vermund & Qian, Citation2008). No trials provide direct evidence that can reduce HIV infection of opportunity of through anal intercourse. But studies in Peru (Sánchez et al., Citation2011),South Africa (Lane et al., Citation2011) and Australia (Tmpleton et al., Citation2009) showed that circumcision has some protective effects on MSM who engage in insertive anal intercourse (IAI). A Cochrane meta-analysis that found MC was associated with 73% lower HIV infection risk among MSM having a preference for an insertive role during anal intercourse (Wiysonge et al., Citation2011). Many studies found that MC prevented HIV infection only among MSM who engaged in insertive anal sex but did not prevent STIs among MSM who played a receptive role in anal sex (Morris et al., Citation2022; Wiysonge et al., Citation2011; Yuan et al., Citation2019). A recent meta-analysis suggests that circumcision may protect MSM from HIV infection, particularly in low- and middle-income countries (Yuan et al., Citation2019). Of, course, this applies in developed countries (Morris et al., Citation2022). Circumcision reduces HIV infection in MSM overall by 23% (Yuan et al., Citation2019). High HIV incidence is found among Chinese MSM. Therefore, circumcision can be used as one of the methods for the prevention of HIV infection among MSM in China.
Religious practices and ethnicity have been influential factors in male circumcision. In the twentieth century, circumcision was emphasized specifically because of health. At present, circumcision has been proven an important means of preventing HIV infection among MSM who engage in insertive anal intercourse and heterosexual men (Wiysonge et al., Citation2011; Yuan et al., Citation2019; Sharma et al., Citation2018). A recent global study of all countries found that 37–39% of all men are circumcised, and in China, based on 9 studies to 2016 only 14% of men were circumcised, including only 3 studies of MSM (Morris et al., Citation2016). Adding the data on male circumcision in China from the references, we calculated that the current overall male circumcision prevalence in China is 12.4% (Morris et al., Citation2016; Yuan et al., Citation2022; Lan et al., Citation2011; Li et al., Citation2010; Xu et al., Citation2009; Liu et al., Citation2019). The prevalence of male circumcision in China is far lower than in all parts of the United States (30%–74%) (Introcaso et al., Citation2013). Studies show that MSM in China (16.4%) (Yuan et al., Citation2022) and parts of China have a lower prevalence of circumcision. Parts of China include Guangxi (12.3%) (Lan et al., Citation2011), Beijing (6.50%) (Li et al., Citation2010), Liaoning (4.90%) (Xu et al., Citation2009), Kunming (14.3%) (Liu et al., Citation2019). Although there are considerable data on the prevalence of male circumcision in different regions of China, for Maanshan City there are little data and even less data on MSM.
Therefore, the study investigated the prevalence of male circumcision and understanding the willingness of MSM to undergo circumcision as well as its influencing factors in Maanshan City. These data are essential to planning prevention programs to provide a reference for the further improvement of HIV infection prevention and intervention measures and also to providing scientific guidance for promoting circumcision among MSM in China.
Materials and methods
Study design and sampling methods
We conducted a cross-sectional study in Maanshan from June 2016 to December 2019 by recruiting research participants through Respondent-driven Sampling (RDS) approaches. The sampling began with a set of initial participants (“seeds”) recruited with the help of MSM community-based organizations, bathhouses/spas. Briefly, this study recruited 15 MSM who were selected as seeds for the RDS completed all study procedures and received three coupons each to be given to members of their networks. Each seed recruited three other MSM from their social networks for study. All participants were offered dual incentives (for participation and each eligible person recruited) and then the above process was repeated. Finally, A total of 879 MSM were recruited.
Subjects
All participant’s information and data were collected through a structured questionnaire and collected the written informed consent of all participants. The inclusion criteria participants: (1) ≥18 years old; (2) Worked and lived in Maanshan; (3) Had sex with a man within 6 months before the survey; (3) Received HIV test results and post-test counselling. The exclusion criteria: (1) Obvious mental or neurological disease; (2) Other interference or influence on the completion of the investigation purpose; (3) Participants who are unwilling to sign the informed consent.
Questionnaire’s content
The questionnaire survey collected the participants’ basic information which included sociodemographic characteristics, injection drug use, STI diagnosis, sexual behavior, knowledge of preexposure prophylaxis, sexual orientation, and willingness to accept circumcision.
Quality control
Uniform and rigorous training was given to the project investigator and 15 seeds. 15 MSM volunteers were recruited to conduct a pre-survey and timely modified survey program and questionnaire content based on the feedback of the volunteers. Researchers reviewed the questionnaire information on-site daily and provided logistical support.
Statistical analysis
The questionnaire was entered and inspected for accuracy with EpiData 3.1 software and data were analyzed using SPSS 23.0. Statistical analysis was done by chi-square (χ2) tests and the multivariable logistic regression model. Differences in sexual behavior and basic demographic characteristics of uncircumcised individuals were observed by univariate analysis. The multivariable logistic regression model estimated the willingness to undergo MC and influencing factors among MSM. P < 0.05 was considered statistically significant.
Results
Characteristics of participants
Demographic characteristics are presented in . A total of 879 MSM participants in this study were 18–65 years old with a median age of 28 years (interquartile range: 24–34). Approximately 81.8% (n = 719) were registered as Maanshan residents and the majority of participants 99.2% (n = 872) were of Han ethnicity. Nearly half of the participants had less than junior college. Besides, 30.9% (n = 272) of participants are married with female sex partners. 80.4% (n = 677) of participants’monthly income was CNY 1000-4999. Approximately two of fifth participants were farmers and workers and 13.4% (n = 118) participants were students. Demographic characteristics of circumcised MSM are shown in (Supplementary Material).
Table 1. Demographic characteristics of among 879 MSM participant.Table Footnotea
Sexual behaviors
demonstrates the sexual behavior characteristics. Among all participants, insertive anal intercourse (IAI) is for 31.2% and receptive anal intercourse (RAI) is for 18.3%. Besides, 50.5% (n = 444) preferred engaging in both the receptive and insertive roles (versatile). More than 90% of the participants have had homosexual sex, such as oral or anal and 39.6% (n = 348) had sex with female partners. Only 6.50% (n = 57) were diagnosed infection other sexually transmitted infections (STIs) in the last 12 months and 5.8% (n = 51) reported having commercial. During anal sex in the past six months, only 5.3% (n = 45) never used condoms and more than half (57.3%, n = 487) often used condoms. During oral sex in the past six months, approximately 70.0% (n = 584) never used condoms and 10.1%, (n = 84) often used condoms as well as only 4.9% (n = 41) always used condoms.
Circumcision status
Of the 879 MSM, a total of 255 (29.0%) MSM reported being circumcised while the remainder had none. Differences between uncircumcised and circumcised men were examined by univariate analysis. There were no differences between uncircumcised and circumcised participants regarding employment, ethnicity, age, level of education, marriage, sex role, sexual orientation and use of condoms. However, some variables were significantly different between uncircumcised and circumcised in the univariate analysis (all P < 0.05). These variables include monthly income, number of male sexual partners, sex with female partners, oral sex with men diagnosed infection other STIs in the last 12 months, condom use during last anal intercourse, and several other parameters. ().
Table 2. Demographic characteristics of 624 uncircumcised MSM.Table Footnotea
Willingness to be circumcised
Among 624 uncircumcised participants, 26.4% (n = 165) were willing to undergo circumcision 70.6% (n = 440) were unwilling to be circumcision and 3.00% (n = 2.20) were unsure. Those who were not sure or unwilling to undergo circumcision were combined as unwilling to participate. Therefore, 26.4% were willing to participate while the remainder were unwilling. The main reasons given for accepting male circumcision included redundant foreskin (62.4%), increased sexual pleasure (28.5%) and prevention of HIV and STIs (26.7%). The reasons for wanting to remain uncircumcised included no redundant foreskin problem (74.3%), fear of surgery (20.0%), doubts about the ability of doctors (11.1%), useless (6.50%) and inconvenient (3.30%).
Univariate analyses were to compare the participants who were willing to undergo circumcision and unwilling to undergo circumcision. shows that six variables were statistically significant including last anal sex with condoms, marriage, sexual relations with women, condom use during oral sex in the past six months, whether it is necessary to use condoms when having sex with a sexual partner who is HIV-negative, the level of knowledge of preexposure prophylaxis (PrEP).
Multivariable analysis
shows the result of multivariable analysis. Those factors that were statistically significant (P < 0.05) in univariate analysis and level of education were entered into a multivariable analysis. The multivariable logistic regression model revealed that five variables were independent influential factors for willingness to participate. The factors include condom use during the last anal sex, sex with female partners, level of education, condom use during oral sex in the past six months, and level of knowledge of PrEP. MSM who ever had sex with female sex partners were less likely to accept circumcision than those who never had sex with female sex partners (OR = 0.499, 95% CI:0.298–0.860, P = 0.012). MSM who used condoms during the last anal intercourse were more likely to accept circumcision than individuals who had not used condoms during the last anal intercourse (OR = 1.87, 95% CI:1.03–3.41, P = 0.04). MSM who always used condoms during oral sex in the last six months were more likely to accept circumcision than those who never used condoms during oral sex in the last six months (OR = 4.20, 95% CI:1.47–12.0, P = 0.007). MSM who had completed junior college and had bachelor’s degree or higher were less likely to accept circumcision than those who had completed junior high or less (junior college: OR = 0.413, 95% CI:0.200–0.854, P = 0.017; Bachelor degree or higher: OR = 0.442, 95% CI:0.208–0.938, P = 0.033). MSM who had a good understand of knowledge of PrEP were more likely to accept circumcision than those who had insufficient knowledge of PrEP (OR = 5.09, 95% CI:1.39–18.7, P = 0.014).
Table 3. Influential factors of willingness to be circumcised (N = 624).
Discussion
According to the World Health Organization, circumcision has the advantages of low risk of infection, rapid healing of the incision and low cost of the procedure. Male circumcision significantly reduces the risk of men becoming infected with HIV, as well as the likelihood of men becoming infected with genital herpes and high-risk strains of human papillomavirus (HPV) (Centers for Disease Control and Prevention, Citation2018). Circumcision lowers the risk of other STIs, penile cancer, cervical cancer in female sexual partners, and infant urinary tract infections in male infants (Centers for Disease Control and Prevention, Citation2018).
This study explored the willingness and influencing factors of circumcision among MSM in Maanshan City. In the study more than a quarter (29.0%) of MSM reported being circumcised, which is not only higher than the prevalence of male circumcision in China (14.0%) (Morris et al., Citation2016) and higher than the prevalence of male circumcision among Chinese MSM (11.6%) (Ruan et al., Citation2009), but also higher than that in Guangxi (12.3%) (Lan et al., Citation2011), Liaoning (4.90%) (Xu et al., Citation2009), Beijing (6.50%) (Li et al., Citation2010) and Kunming (14.3%) (Liu et al., Citation2019). However, the acceptance prevalence of male circumcision in China is lower than the world average level (38.7%) (Morris et al., Citation2016) and also lower than in all parts of the United States (30%–74%) (Introcaso et al., Citation2013). Approximately one-fourth of uncircumcised responded they would be willing to undergo circumcision, and it was similar to the finding in Guangxi, China (Lan et al., Citation2011). Because lack of cultural promotion for male circumcision in China (Ben et al., Citation2008), the male’s willingness to undergo circumcision is much lower than that of the US MSM population (53.0%) (Begley et al., Citation2008) and the African male population (65.0%) (Westereamp & Bailey, Citation2007). Therefore, the promotion of circumcision among MSM may result in some potential public health benefits.
Our study found that circumcision was uncommon in Maanshan. Despite male circumcision having a chance to become an effective intervention, it is difficult to promote male circumcision among MSM. Our study showed who had sex with a woman were less likely to be circumcised, which was similar to the results of Chikutsaa (Chikutsa & Maharaj, Citation2015) and LAN Guanghua (Lan et al., Citation2011). Circumcision is acceptable to “boys” who are considered by men to have no sex. Perhaps this thinking makes men who have had sex with women more reluctant to be circumcision and may think that “circumcision” is associated with “the shame of having no sexual experience”. Some participants think that circumcision was bad for giving men the ability to have “more power” in bed.
This study shows that MSM with more frequency of condom use were more willing to be circumcised. Although only never using and always using condoms were statistically significant the willingness to accept surgery showed an upward trend, which was similar to the reports in Guangxi (Lan et al., Citation2011). The acceptance prevalence of circumcision and awareness of disease prevention increased with the increasing frequency of condom use. Therefore, publicity about circumcision should be enhanced to increase the willingness to accept circumcision.
Our results showed the higher the level of education the more reluctant to undergo circumcision which was similar to the reports in Elin B. Begley (Begley et al., Citation2008). On the one hand, the HIV awareness rate increases with the level of education. Thus, there is no need for surgery to prevent the disease. On the other hand, they think circumcision may contribute to a loss of sexual desire. Because circumcision removed the “warming cover” of the penis, which make the penis becoming “cold”. Therefore, even with a high level of education. There is still a need to strengthen the promotion of circumcision.
Our results also showed that had a better level of knowledge of PrEP were more willing to be circumcised. A study by Closson et al. (Citation2019) has shown that participation in AIDS programs such as PrEP can effectively improve AIDS prevention knowledge and increase the understanding and awareness of circumcision. Knowledge of circumcision can increase the willingness of MSM to undergo circumcision.
These findings suggest that establishing a proper understanding of circumcision is essential if it is to be used as a strategy to prevent HIV infection among MSM. Therefore, there is a need to improve not only knowledge of circumcision but also knowledge of HIV. It is suggested to strengthen the publicity of circumcision through various channels to increase the willingness to accept circumcision to reduce the risk of HIV infection. First, the surgery is performed by professionals to improve the safety of circumcision. Second, it is publicizing the benefits of circumcision. For example, circumcision reduces the risk of contracting HIV, male genital herpes and HPV and also the risk of penile cancer and urinary tract infections in male infants (Centers for Disease Control and Prevention, Citation2018). Third, circumcision strengthen the awareness and education of the community. Fourth, it normalizes circumcision surgery in the public through the promotion of relevant health education by the mass media (Yuan et al., Citation2022). Fifth, the state should pay more attention to education to improve the educational level of the public.
Of course, there's more to preventing HIV infection than just raising awareness about circumcision. First, it gives behavioral education to enhance safe sex practices. For example, it promotes condom use and the limitation of the number of sexual partners. Second, it controls injection drug use and unsafe blood transfusions. Third, it concentrates on the rational use of preexposure and postexposure prophylaxis.
There are some limitations in our study. First, this is a cross-sectional questionnaire study, and the ability to demonstrate causal associations is not strong. Second, the MSM recruited for this study included only those who were currently MSM and did not include transgender individuals. Thirdly, The sample size of this study is 879. The sample was representative of Maanshan City. Since MSM were not recruited from other provinces, these results may not be generalizable to MSM in other provinces. Finally, the population of our study cannot represent the general population of China. So we suggest conducting the survey in multiple cities and verifying the result in a bigger sample size.
Conclusions
The factors influencing willingness to undergo male circumcision in the study include condom use during the last anal sex, sex with female partners, level of education, condom use during oral sex in the past six months, and level of knowledge of PrEP. We should do more research on the relationship between circumcision and HIV infection in China, and improve the prevention of HIV infection.
Ethics approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (The study was approved by Anhui Medical University Ethics Committee; study number 20200594) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Author contributions
FYG and QQR developed the study idea. ZXH, LJW and TG designed the study protocol. ZXH, LJW, WZW, GQ and GQS collected the data. ZXH, GQ, TG, and WZW carried out analysis and interpretation of data. ZXH and LJW drafted the manuscript. FYG and QQR verified the analytical methods and reviewed the manuscript. All authors read and approved the final manuscript.
Consent participate
Informed consent was obtained from all individual participants included in the study.
AC-2023-01-0056-File005.doc
Download MS Word (66 KB)Acknowledgements
We thank all MSM participants investigators and site staff.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- Auvert, B., Taljaard, D., Lagarde, E., Tambekou, S. J., Sitta, R., & Puren, A. (2005). Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Medicine, 2(11), e298. https://doi.org/10.1371/journal.pmed.0020298
- Bailey, R. C., Moses, S., Parker, C. B., Agot, K., Maclean, I., Krieger, J. N., Williams, C. F., Campbell, R. T., Ndinya-Achola, J. O. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. The Lancet, 369(9562), 643–656. https://doi.org/10.1016/S0140-6736(07)60312-2
- Baral, S., Sifakis, F., Cleghorn, F., & Beyrer, C. (2007). Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000–2006: A systematic review. PLoS Medicine, 4(12), e339. https://doi.org/10.1371/journal.pmed.0040339
- Begley, E. B., Jafa, K., Voetsch, A. C., Heffelfinger, J. D., Borkowf, C. B., & Sullivan, P. S. (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. PLoS One, 3(7), e2731. https://doi.org/10.1371/journal.pone.0002731
- Ben, K. L., Xu, J. C., Lu, L., Yao, J. P., Min, X. D., Li, W. Y., Tao, J., Wang, Y., Li, J. J., Cao, X. M. (2008). Promoting male circumcision in China for preventing HIV infection and improving reproductive health. National Joumal of Andrology, 14(4), 291–297.
- Buchbinder, S. P., Vittinghoff, E., Heagerty, P. J., Celum, C. L., Seage, G. R., Judson, F. N., McKirnan, D., Mayer, K. H., Koblin, B. A. (2005). Sexual risk nitrite inhalant use and lack of circumcision associated with HIV seroconversion in men who have sex with men in the United States. JAIDS Journal of Acquired Immune Deficiency Syndromes, 39(1), 82–89. https://doi.org/10.1097/01.qai.0000134740.41585.f4
- Centers for Disease Control and Prevention (2018). Background, methods, and synthesis of scientific information used to inform “Information for Providers to Share with Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, Sexually Transmitted Infections, and other Health Outcomes”. https://stacks.cdc.gov/view/cdc/58457
- Chikutsa, A., & Maharaj, P. (2015). Social representations of male circumcision as prophylaxis against HIV/AIDS in Zimbabwe. BMC Public Health, 15(1), 603. https://doi.org/10.1186/s12889-015-1967-z
- China Ministry of Health. (2009). 2009 estimates for the HIV/AIDS epidemic in China. http://www.unaids.org.cn/ download/200920China20Estimation%20Report-En.pdf
- Closson, K., Chown, S., Armstrong, H. L., Wang, L., Bacani, N., Ho, D., Jollimore, J., Olarewaju, G., Moore, D. M., Roth, E. A., Hogg, R. S., Lachowsky, N. J. (2019). HIV leadership programming attendance is associated with PrEP and PEP awareness among young, gay, bisexual, and other men who have sex with men in Vancouver, Canada. BMC Public Health, 19(1), 429. https://doi.org/10.1186/s12889-019-6744-y
- Donoval, B. A., Landay, A. L., Moses, S., Agot, K., Ndinya-Achola, J. O., Nyagaya, E. A., MacLean, I., Bailey, R. C. (2006). HIV-1 target cells in foreskins of African men with varying histories of sexually transmitted infections. American Journal of Clinical Pathology, 125(3), 386–391. https://doi.org/10.1309/JVHQVDJDYKM58EPH
- Ganor, Y., & Bomsel, M. (2011). HIV-1 transmission in the male genital tract. American Journal of Reproductive Immunology, 65(3), 284–291. https://doi.org/10.1111/j.1600-0897.2010.00933.x
- Ganor, Y., Zhou, Z., Tudor, D., Schmitt, A., Vacher-Lavenu, M.-C., Gibault, L., Thiounn, N., Tomasini, J., Wolf, J. P., Bomsel, M. (2010). Within 1 h, HIV-1 uses viral synapses to enter efficiently the inner, but not outer, foreskin mucosa and engages Langerhans-T cell conjugates. Mucosal Immunology, 3(5), 506–522. https://doi.org/10.1038/mi.2010.32
- Gray, R. H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., Kiwanuka, N., Moulton, L. H., Chaudhary, M. A., Chen, M. Z., Sewankambo, N. K., Wabwire-Mangen, F., Bacon, M. C., Williams, C. F., Opendi, P., Reynolds, S. J., Laeyendecker, O., Quinn, T. C., Wawer, M. J. (2007). Male circumcision for HIV prevention in men in Rakai, Uganda: A rangdomised trial. The Lancet, 369(9562), 657–666. https://doi.org/10.1016/S0140-6736(07)60313-4
- Introcaso, C. E., Xu, F., Kilmarx, P. H., Zaidi, A., & Markowitz, L. E. (2013). Prevalence of circumcision among men and boys aged 14 to 59 years in the United States, national health and nutrition examination surveys 2005-2010. Sexually Transmitted Diseases, 40(7), 521–525. https://doi.org/10.1097/01.OLQ.0000430797.56499.0d
- Lan, G. H., Liu, W., Huang, Y. M., & Liang, H. (2011). Acceptability of male circumcision among men who have sex with men in Guangxi. Journal Of Guangxi Medical University, 28(4), 503–505.
- Lane, T., Raymond, H. F., Dladla, S., Rasethe, J., Struthers, H., McFarland, W., McIntyre, J. (2011). High HIV prevalence among men who have sex with men in Soweto, South Africa: Results from the Soweto men’s study. AIDS and Behavior, 15(3), 626–634. https://doi.org/10.1007/s10461-009-9598-y
- Lei, J. H., Liu, L. R., Wei, Q., Yan, S. B., Yang, L., Song, T. R., Yuan, H. C., Lv, X., Han, P. (2015). Circumcision status and risk of HIV acquisition during heterosexual intercourse for both males and females: A meta-analysis. PLoS One, 10(5), e0125436. https://doi.org/10.1371/journal.pone.0125436
- Li, D. L., Li, Q. C., Li, S. M., Liu, Y. J., Jiang, S. L., Luo, F. J., Zhang, Z., Zhou, Z. H., Shi, W., Ruan, Y. H., Shao, Y. M. (2010). Attitude toward circumcision for prevention of HIV infection among men who have sex with men. Chinese Journal of Public Health, 26(6), 728–729.
- Liu, H. B., Chen, Y. L., Yang, Y., Li, Y. F., & Jia, M. H. (2019). A survey of perceptions of circumcision among men who have sex with men. Chinese Journal of AIDS & STD, 25(5), 514–515. https://doi.org/10.13419/j.cnki.aids.2019.05.21
- McCoombe, S. G., & Short, R. V. (2006). Potential HIV-1 target cells in the human penis. Aids (London, England), 20(11), 1491–1495. https://doi.org/10.1097/01.aids.0000237364.11123.98
- Millett, G. A., Flores, S. A., Marks, G., Reed, J. B., & Herbst, J. H. (2008). Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: A meta-analysis. JAMA, 300(14), 1674–1684. https://doi.org/10.1001/jama.300.14.1674
- Morris, B. J., Moreton, S., Krieger, J. N., & Klausner, J. D. (2022). Infant circumcision for sexually transmitted infection risk reduction globally. Global Health: Science and Practice, 10(4), e2100811. https://doi.org/10.9745/GHSP-D-21-00811
- Morris, B. J., Wamai, R. G., Henebeng, E. B., Tobian, A. A., Klausner, J. D., & Banerjee, J. (2016). Estimation of country-specific and global prevalence of male circumcision. Population Health Metrics, 14(4), 11. https://doi.org/10.1186/s12963-016-0073-5
- Qin, Q. R., Feng, S., Zhang, Q., Cao, S. F., Zhu, H. B., Zhang, Z., Gao, Y., Cao, D. Z., Zhan, S. W., Ye, D. Q. (2014). Survey on KABP of AIDS among MSM in Maanshan city. Chinese Journal of Disease Control & Prevention, 18(7), 621–624.
- Ruan, Y., Qian, H. Z., Li, D., Shi, W., Li, Q., Liang, H., Yang, Y., Luo, F., Vermund, S. H., Shao, Y. (2009). Willingness to be circumcised for preventing HIV among Chinese men who have sex with men. AIDS Patient Care and STDs, 23(5), 315–321. https://doi.org/10.1089/apc.2008.0199
- Sánchez, J., Sal y Rosas, V. G., Hughes, J. P., Baeten, J. M., Fuchs, J., Buchbinder, S. P., Koblin, B. A., Casapia, M., Ortiz, A., Celum, C. (2011). Male circumcision and risk of HIV acquisition among MSM. Aids (london, England), 25(4), 519–523. https://doi.org/10.1097/QAD.0b013e328340fd81
- Sharma, S. C., Raisor, N., Khan, S., Shabbir, M., Dasgupta, P., & Ahmed, K. (2018). Male circumcision for the prevention of human inmunodeficiency virus (HIV) acquisition: A meta-analysis. BJU International, 121(4), 515–526. https://doi.org/10.1111/bju.14102
- Tmpleton, D. J., Jin, F., Mao, L., Prestage, G. P., Donovan, B., Imrie, J., Kippax, S., Kaldor, J. M., Grulich, A. E. (2009). Circumcision and risk of HIV infection in Australian homosexual men. Aids (london, England), 23(17), 2374–2351. https://doi.org/10.1097/QAD.0b013e32833202b8
- Vermund, S. H., & Qian, H.-Z. (2008). Circumcision and HIV prevention among men who have sex with men: No final word. JAMA, 300(14), 1698–1700. https://doi.org/10.1001/jama.300.14.1698
- Westereamp, N., & Bailey, R. C. (2007). Acceptability of male circumcision for prevention of HIV/AIDS in Sub-Saharan Africa: A review. AIDS and Behavior, 11(3), 341–355. https://doi.org/10.1007/s10461-006-9169-4
- WHO & UNAIDS (2009). Operational guidance for scaling up male circumcision services for HIV prevention. http://www.who.int/hiv/pub/malecircumcision/op_guidance/en/index.html
- Wiysonge, C. S., Kongnyuy, E. J., Shey, M., Muula, A. S., Navti, O. B., Akl, E. A., Lo, Y. R. (2011). Male circumcision for prevention of homosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews, 15(6), CD007496. https://doi.org/10.1002/14651858.CD007496.pub2
- Xu, J. L., Zhang, M., Cu, Z. X., Hu, Q. H., Liu, J., Ding, H. B., Zhao, B., Shang, H. (2009). Acceptability of male circumcision among men who have sex with men. Chinese Journal of Public Health Decision, 25(12), 1414–1415.
- Yuan, T., Fitzpatrick, T., Ko, N.-Y., Cai, Y., Chen, Y., & Zhao, J. (2019). Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: A systematic review and meta-analysis of global data. The Lancet Global Health, 7(4), e436–e447. https://doi.org/10.1016/S2214-109X(18)30567-9
- Yuan, T., Gao, Y., Wang, Z., Huang, R., Wang, J., Li, P., Meng, X., Zhang, K., Wang, G., Zhou, Y., Luo, D., Cai, Y., Fan, S., Ouyang, L., Zhao, J., Yu, M., Qian, H. Z., Wu, G., Zou, H. (2022). Acceptability of male circumcision for HIV prevention among men who have sex with men in China: A short report. AIDS Care, 34(3), 371–378. https://doi.org/10.1080/09540121.2021.1917759
- Zhu, H. B., Cao, D. Z., Ma, Z. H., Xu, X. Q., Yuan, H. M., Zhu, M., Ye, D. Q. (2008). Effective analysis of STD/AIDS high-risk behaviour intervention among commercial sex workers in Maanshan. Chinese Journal of Disease Control& Prevention, 12(6), 534–537. http://wfo.lib.ustc.edu.cn/D/Periodical_jbkzzz200806006.aspx