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Open Access Highly Accessed Research article

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

David MacLaren1*, Rachael Tommbe2, Tracie Mafile’o3, Clement Manineng4, Federica Fregonese5, Michelle Redman-MacLaren1, Michael Wood6, Kelwyn Browne7, Reinhold Muller89, John Kaldor10 and William John McBride1

Author Affiliations

1 School of Medicine and Dentistry, James Cook University, McGregor Road, Smithfield, Cairns 4878, Queensland, Australia

2 School of Health Science, Pacific Adventist University, Port Moresby, National Capital District, Papua New Guinea

3 Deputy Vice Chancellor, Pacific Adventist University, Port Moresby, National Capital District, Papua New Guinea

4 Faculty of Health Science, Divine Word University, Madang, Madang Province, Papua New Guinea

5 Global Health Unit, University of Montreal Hospital Research Centre, Montreal, Quebec, Canada

6 School of Arts and Social Science, James Cook University, Cairns, Queensland, Australia

7 Rural Primary Health Services Delivery Project, National Department of Health, Port Moresby, Papua New Guinea

8 School of Public Health, Tropical Medicine and Rehabilitation Science, James Cook University, Cairns, Queensland, Australia

9 Tropical Health Solutions, Townsville, Australia

10 Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia

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BMC Public Health 2013, 13:818  doi:10.1186/1471-2458-13-818

Published: 9 September 2013

Abstract

Background

Male 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.

Methods

Cross-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.

Results

Questionnaires 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.

Conclusion

Although 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.

Keywords:
Male circumcision; Acceptability; Foreskin cutting; Papua New Guinea; HIV; Prevention; Beliefs; Foreskin cutting practices; Longitudinal Foreskin cut; Circumferential Foreskin cut