Male circumcision (MC) status and genital infection risk are interlinked and MC is now part of HIV prevention programs worldwide. Current MC prevalence is not known for all countries globally. Our aim was to provide estimates for country-specific and global MC prevalence. MC prevalence data were obtained by searches in PubMed, Demographic and Health Surveys, AIDS Indicator Surveys, and Behavioural Surveillance Surveys. Male age was ≥15 years in most surveys. Where no data were available, the population proportion whose religious faith or culture requires MC was used. The total number of circumcised males in each country and territory was calculated using figures for total males from (i) 2015 US Central Intelligence Agency (CIA) data for sex ratio and total population in all 237 countries and territories globally and (ii) 2015 United Nations (UN) figures for males aged 15–64 years. The estimated percentage of circumcised males in each country and territory varies considerably. Based on (i) and (ii) above, global MC prevalence was 38.7 % (95 % confidence interval [CI]: 33.4, 43.9) and 36.7 % (95 % CI: 31.4, 42.0). Approximately half of circumcisions were for religious and cultural reasons. For countries lacking data we assumed 99.9 % of Muslims and Jews were circumcised. If actual prevalence in religious groups was lower, then MC prevalence in those countries would be lower. On the other hand, we assumed a minimum prevalence of 0.1 % related to MC for medical reasons. This may be too low, thereby underestimating MC prevalence in some countries. The present study provides the most accurate estimate to date of MC prevalence in each country and territory in the world. We estimate that 37–39 % of men globally are circumcised. Considering the health benefits of MC, these data may help guide efforts aimed at the use of voluntary, safe medical MC in disease prevention programs in various countries.

/pdf/estimation-of-country-specific-and-global-prevalence-of-male-53k4i2bta6.pdf

Estimation of country-specific and global prevalence of male circumcision

This paper analyses barriers to consistent condom use in the context of transactional sex among female sex workers in mainland China. It reveals how differences in socioeconomic profile and organisational hierarchies amongst different groups of sex workers create different barriers to condom use. Data was collected by means of field observation of entertainment venues and in-depth interviews. Findings suggest that, compared with other sex workers, street-walkers are less likely to use condoms with their clients, hold highly disadvantaged socioeconomic profiles and work in isolation. Major barriers to condom use link to economic deprivation and threats of violence from clients. For the women working in entertainment venues, drunkenness of clients, pricing mechanisms and familiarity with clients pose barriers to condom use. Yet within all these constraints women are not powerless and instead find ways to exercise agency and gain personal protection and economic advantage. In the newly emerging China, both structural hierarchies of work and individual agency inform condom use by female sex workers. Future HIV intervention programmes need to take these factors into account in order to meet the needs of different groups of women sex workers.

The influence of power, poverty and agency in the negotiation of condom use for female sex workers in mainland China.

Commercial sex plays a critical role in the heterosexual transmission of HIV in China. This study reviews behavioral studies in English literature on female sex workers (FSWs) in China from 1990 to 2006. Existing studies indicate that FSWs in China are young, mobile, most of them have both commercial and non-commercial sex partners; they have low rates of consistent condom use and high rates of STD infection. Some FSWs are also engaged in drug abuse. There is a great variation of sexual practices and HIV risks among FSWs across different work settings. Limited numbers of intervention studies have reported positive effects on increasing condom use and/or decreasing STD infections. Literature gaps and lessons learned from existing studies are identified and future research needs are discussed. Future behavioral intervention programs need to be multi-faceted and incorporate environmental and structural factors for different groups of FSWs.

Behavioral studies of female sex workers in China: a literature review and recommendation for future research.

Prevalence and predictors of HIV infection among female sex workers in Kaiyuan City, Yunnan Province, China.

A cross-sectional prevalence survey of sexually transmitted infections (STIs) was conducted among female sex workers (FSWs) in Kunming Yunnan Province China. A total of 505 FSWs participated in the survey. All eligible participants gave informed consent. Demographic behavioral and clinical information of the participants was gathered by direct structured interviews. Tampon swabs were collected to test for Chlamydia trachomatis Nesseria gonorrhoeae and Trichomonas vaginalis and serum specimens were collected to test for HIV antibody by enzyme-linked immunosorbent assay (ELISA) screening and Western blot confirmation syphilis with rapid plasma reagin (RPR) and T. pallidum hemagglutination (TPHA) confirmation and for HSV-2 antibodies with the HerpeSelect 2 ELISA. The most prevalent bacterial STI was Chlamydia trachomatis (58.6%) followed by Trichomonas vaginalis (43.2%) and Neisseria gonorrhoeae (37.8%). Three hundred twenty-seven (65.1%) sex workers had serologic evidence of exposure to HSV-2 infection. Ten percent were positive for HIV infection all injecting drug users (IDUs); and 9.5% had infection with syphilis. Comprehensive prevention and effective STI services for sex workers and their clients will be the key strategies to the control of STIs including HIV. Policies and prevention strategies for STI/HIV need to focus on high-risk subpopulations such as sex workers (particularly sex workers who inject drugs) and their clients. (authors)

Sexually transmitted infections among female sex workers in Yunnan, China.

The objective of this study was to investigate the prevalence and risk factors of syphilis infection among female sex workers in a southwestern Chinese city along a drug trafficking route. From December 2004 to January 2005 343 female sex workers (FSWs) were recruited through community outreach and peer referring. Confidential questionnaire interviews were administered to collect information on sexual and other sexually transmitted diseases/HIV risk behaviors. Cervical and blood samples were collected to test for syphilis and HIV antibodies and Neisseria gonorrhoeae infection; Condyloma acuminatum infection was diagnosed clinically. Of 343 FSWs 15.7% were infected with syphilis. The prevalence of HIV gonorrhea and C. acuminatum was 0.6% 2.0% and 1.5% respectively. The subtype of 2 HIV-1 infections was both CRF 07BC. Nearly 10% of FSWs reported using illicit drugs. Consistent use inconsistent use and never use of condoms with commercial sex clients in the last month were reported by 53.9% 38.5% and 7.6% FSWs respectively. Longer duration of sex work (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.08 -3.62) working at low-end establishments (OR = 2.03; 95% CI = 1.10 -3.76) and if primary sex partners had sex with other women in the past 6 months (OR = 2.06; 95% CI = 1.08 -3.91) were independently associated with syphilis infection. High prevalence of syphilis and overlapped unprotected commercial sex and drug using behaviors among FSWs along a drug-trafficking route may suggest a potential for rapid spread of HIV from injection drug users to FSWs and then to the general population and underscore the urgency of preventive interventions to break the bridge of FSWs for HIV/sexually transmitted disease spread. (authors)

Syphilis among female sex workers in southwestern China : Potential for HIV transmission

Male circumcision can reduce the risk of HIV acquisition among heterosexual men, but its effectiveness is uncertain in men who have sex with men (MSM). Additionally, its acceptability among Chinese men is unknown given a lack of history and cultural norms endorsing neonatal and adult circumcision. This study evaluated the willingness to participate in a clinical trial of circumcision among 328 Chinese MSM. Some 11.6% respondents reported having been circumcised, most of them due to a tight foreskin. Of 284 uncircumcised MSM, 16.9% said they were absolutely willing to participate, 26.4% were probably, 28.9% were probably not, and 27.8% were absolutely not; 81% said male circumcision would help maintain genital hygiene. The major motivators for willingness to participate included contribution to AIDS scientific research and getting free medical service. Men also had concerns about ineffectiveness of circumcision in reducing HIV/sexually transmitted infection (STI) risks and side effects of the surgery. Those who did not have a Beijing resident card (adjusted odds ratio [AOR], 1.99; 95% confidence interval [CI], 1.17–3.38), did not find sexual partners through the Internet (AOR, 2.13; 95% CI, 1.21–3.75), and were not concerned about the effectiveness of circumcision (AOR, 2.37; 95% CI, 1.34–4.19) were more likely to be willing to participate in a trial. The study suggests that circumcision is uncommon among Chinese MSM. Considerable community education will be needed in circumcision advocacy among MSM in China. A clinical trial for efficacy among MSM should be considered.

Willingness to Be Circumcised for Preventing HIV among Chinese Men Who Have Sex with Men

To investigate factors associated with online sex-seeking behaviors among men who have sex with men (MSM) in Beijing, China. MSM participants were recruited from two cohort studies with multiple enrollment methods from November 2006 to February 2007 and from March to June 2008, respectively. Data collected included demographics and sexual behaviors. Of the 901 participants, 68.1% were single; 69.3% were non-Beijing residents; 94.4% considered themselves to be homosexual; 65.2% received college or higher levels of education; the median age was 26 years; 73.0% sought male sex partners via the Internet in the past 3 months; 66.2% had ≥2 sex partners. Younger age, higher levels of education and having had ≥2 male sex partners in the past 3 months were independently associated with seeking sex partners on the Internet. These findings indicate that Internet-based intervention programs could encourage younger high-risk MSM to use condoms and reduce their numbers of sexual partners.

/pdf/online-sex-seeking-behaviors-among-men-who-have-sex-with-men-48wbay3eir.pdf

Online sex-seeking behaviors among men who have sex with men: implications for investigation and intervention.

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Syphilis among female sex workers in southwestern China : Potential for HIV transmission

Willingness to Be Circumcised for Preventing HIV among Chinese Men Who Have Sex with Men

Online sex-seeking behaviors among men who have sex with men: implications for investigation and intervention.