Voluntary Medical Male Circumcision: A Cross-Sectional Study Comparing Circumcision Self-Report and Physical Examination Findings in Lesotho

Abstract

BackgroundOverwhelming evidence, including three clinical trials, shows that male circumcision (MC) reduces the risk of HIV infection among men. However, data from recent Lesotho Demographic and Health Surveys do not demonstrate MC to be protective against HIV. These contradictory findings could partially be due to inaccurate self-reported MC status used to estimate MC prevalence. This study describes MC characteristics among men applying for Lesotho Defence Force recruitment and seeks to assess MC self-reported accuracy through comparison with physical-examination-based data.Methods and FindingsDuring Lesotho Defence Force applicant screening in 2009, 241 (77%) of 312 men, aged 18–25 y, consented to a self-administered demographic and MC characteristic survey and physician-performed genital examination. The extent of foreskin removal was graded on a scale of 1 (no evidence of MC) to 4 (complete MC). MC was self-reported by 27% (n = 64/239) of participants. Of the 64 men self-reporting being circumcised, physical exam showed that 23% had no evidence of circumcision, 27% had partial circumcision, and 50% had complete circumcision. Of the MCs reportedly performed by a medical provider, 3% were Grade 1 and 73% were Grade 4. Of the MCs reportedly performed by traditional circumcisers, 41% were Grade 1, while 28% were Grade 4. Among participants self-reporting being circumcised, the odds of MC status misclassification were seven times higher among those reportedly circumcised by initiation school personnel (odds ratio = 7.22; 95% CI = 2.29–22.75).ConclusionsApproximately 27% of participants self-reported being circumcised. However, only 50% of these men had complete MC as determined by a physical exam. Given this low MC self-report accuracy, countries scaling up voluntary medical MC (VMMC) should obtain physical-exam-based MC data to guide service delivery and cost estimates. HIV prevention messages promoting VMMC should provide comprehensive education regarding the definition of VMMC.

Association of HIV prevalence and concurrency of sexual partnerships in South Africa’s language groups: An ecological analysis

“…[11] In particular, self-described circumcision has been shown to over-estimate circumcision prevalence. [21] There is, however, no evidence to indicate that these biases vary between different language groups and, as such, they should not affect the validity of this study. Furthermore, ecological studies are susceptible to the ecological inference fallacy.…”

Impact and Cost of Scaling Up Voluntary Medical Male Circumcision for HIV Prevention in the Context of the New 90-90-90 HIV Treatment Targets

“…MC coverage was increased using linear interpolation between the base coverage levels and 2015 levels. The base coverage level was the MC prevalence among males ages 15–49 from the last DHS survey in each country before the start of their VMMC program [14–17], except that the MC prevalence for Lesotho and Malawi was divided by two to account for 50% of traditional circumcisions being incomplete or misreported [18]. For the “no VMMC” scenarios, the MC coverage level in 2015 was linearly interpolated back down to the base level by 2050, in order to represent termination of the VMMC program after 2015 and only traditional circumcisions continuing.…”

Circumcision Status and Time to Sexual Debut Among Youth in Sub-Saharan Africa: Evidence from Six Demographic and Health Surveys

“…First, a predisposition to provide socially acceptable responses and the self-reported nature of circumcision status [36] may have introduced some bias in our results as DHS could not physically validate these responses. The use of medical records or physical examination might be a better measure of circumcision status.…”