| Section one: The susceptibility of male foreskin to HIV infection in GuangxiObjective To study the immunological and biological factors that affect the susceptibility of male foreskin to HIV infection in Guangxi, and to provide more convincing biological data for the epidemiological findings. Methods Keratin of inner and outer foreskin among AIDS vulnerable groups including migrant workers, drug addicts and general people in HIV high-prevalence areas in Guangxi were detected with hematoxylin-eosin staining method and then the thickness were compared. By immunohistochemical technique Super PicTure method (one step method) the HIV-1 target cells under the foreskin mucosa of three kinds of AIDS vulnerable groups were detected, including Langerhans cells, CD4 + T cells, macrophages, and dendritic cell through their surface antigens CD1a, CD4, HLA- DR and DC-SIGN, for locating and measuring the density of the corresponding cell. Results A total of 150 subjects, including 50 migrant workers, 50 drug addicts and 50 general people in HIV high-prevalence areas respectively, were detected. (1) The average thickness of keratin on inner and outer foreskin among all subjects was 1.37 ± 0.549 and 3.23 ± 1.178 respectively, the difference was statistically significant (t = 18.191,P = 0.000). There were not statistically significant differences between different vulnerable groups, different ages, Han, Zhuang male in keratin thickness of inner foreskin, and between the man with or without genital inflammation, whether had sexual behaviour. The keratin thicknesses of outer foreskin in above different groups were not statistically significant either. (2)In all subjects, the average density of HIV target cell antigens CD1a, CD4,HLA-DR and DC-SIGN in inner foreskin was 3.06±0.800,4.65±1.200,10.20±1.860 and 9.97 ± 1.789 respectively, and in outer foreskin the average density was 1.65±0.787,4.69 ± 1.118,9.25 ±1.437 and 10.22 ± 1.938 respectively.Comparing the average density of these target cells, it was found that the density of Langerhans cells CD1a antigen in inner foreskin was higher than that in the outer foreskin and was statistically significant (t = 14.568, P = 0.000); the density of Macrophage HLA-DR antigen in inner foreskin was higher than that in the outer foreskin and was statistically significant (t = 5.012, P = 0.000). (3)Comparing the average density of these HIV target cells between different vulnerable groups, different ages, Han, Zhuang male and the man with or without genital inflammation, whether had sexual behaviour, it was found that there were no statistically significant differences of the density of HIV target cell antigens CD1a, CD4, HLA-DR and DC-SIGN in inner foreskin. But in outer foreskin, the average density of CD1a in Migrant workers, drug addicts and general people in HIV high-prevalence areas were statistically significant differences (F = 3.412, P = 0.036), But after SNK-q test (Student-Newman-Keuls q test) was used to carry out the multiple comparisons between each two average density, CD1a on the outer foreskin between each two vulnerable groups was no statistically significant; the average density of HIV target cells in outer foreskin between other comparison groups were not significantly different.Conclusions Adult males can be infected HIV through sexual behaviour is due to the cells and the molecular basis of male genital organs, if not circumcision,the meager inner foreskin and the different HIV target cells are the main portal that HIV invades the body, which may be the main reason that male circumcision can protect against HIV infection.Section two: The willingness to circumcision and its relative factors among AIDS vulnerable groups in GuangxiObjective To investigate the knowledge, attitudes, willingness to circumcision and its relative factors among AIDS vulnerable male groups in AIDS serious epidemic area in Guangxi, for designing appropriate media materials and establishing intervention modes to promote male circumcision in local male in the coming future. Methods AIDS vulnerable groups, including HIV carriers' male spouses, migrant workers, drug addicts and general people in HIV high-prevalence areas were surveyed through the conversation and asking face to face by the qualified trained investigators, the contents of questionnaire included social demographic characteristics of subjects such as the age,education level, ethnicity, marital status; AIDS knowledge and attitudes,willingness to circumcision and influential factors. Subjects who chose the options "willing" and "may be willing" were classified as the group that had the willingness to circumcision (WTC), subjects who chose "may not be willing"and "not willing" as the group that hadn't the willingness to circumcision(Non-WTC), With WTC and Non-WTC as binary dependent variable, various factors that would affect the acceptance of male circumcision were analyzed by univariate and multivariate Logistic regression. Results 26 HIV carriers' male spouses, 495 migrant workers, 430 drug addicts and 667 general people in HIV high-prevalence areas were investigated. (1) The rate of willingness and intention to circumcision in HIV carriers' male spouses, migrant workers, drug addicts and general people in HIV high-prevalence areas was 38.5% (10/26),27.7% (137/495), 48.6% ( 209/430) and 23.1% (154/667) respectively. (2)The relationship between social demographic characteristics of subjects and their willingness to circumcision: univariate analysis showed that the WTC group and the Non-WTC group of migrant workers were not significant differences in ages and ethnic, but in marital status (?2 = 7.729, P <0.05) and education level (?2 =6.149, P <0.05) there were significant differences, the ratio of unmarried and before primary school or after high school education in WTC group was more higher than Non-WTC group. In drug addicts, only the age distribution was significantly different (?2 = 14.906, P <0.05), the proportion of 35 to 39 year old population in WTC group was the highest. The marital status distribution of general people in HIV high-prevalence areas in the two groups was significantly different (?2 = 4.918, P <0.05), the proportion of unmarried in WTC group was higher than Non-WTC group. (3) The relationship between the AIDS knowledge of the AIDS vulnerable groups and willingness to circumcision was analyzed,and it was founded that only in drug addicts the AIDS prevention knowledge levels was significantly difference between WTC and Non-WTC group, the proportion in WTC group whose HIV prevention knowledge score >average score was higher than Non-WTC group (?2 = 3.960, P <0.05). (4) The relationship between the cognition on circumcision of the AIDS vulnerable groups and their willingness to circumcision was analyzed, and it was founded that in migrant workers the proportions who were aware of phimosis or redundant prepuce easily causing genital inflammation (?2 = 5.682, P <0.05),impeding the growth of penis (?2 = 10.529, P <0.05) and easily causing urinary tract infection (?2 = 5.966, P <0.05) of WTC group were higher than Non-WTC group. In drug addicts, the proportions who had heard of circumcision (?2 =4.503, P <0.05), were aware of circumcision can be applied to treat phimosis or redundant prepuce (?2 = 4.454, P <0.05), recognized that phimosis and redundant prepuce is easy to form smegma (?2 = 5.346, P <0.05) and could easily cause genital inflammation (?2 = 10.304, P <0.05), surgery will cause pain (?2 = 16.112, P <0.05) and can improve sexual function (?2 = 8.506, P<0.05) in WTC group and Non-WTC group were statistically significant difference. In general people in HIV high-prevalence areas, the differences of awareness rate about circumcision can prevent AIDS and sexually transmitted diseases (?2 = 5.518, P <0.05), protect the reproductive health and the health of sexual partners (?2 = 10.053, P <0.05), phimosis and redundant prepuce is easy to form smegma (?2 = 14.321, P <0.05) , could easily cause genital inflammation (?2 = 7.853, P <0.05) and easily lead to urinary tract infection (?2=12.845, P <0.05) between WTC group and Non-WTC group were statistically significant. (5) The relationship between the foreskin disorders of the AIDS vulnerable groups and their willingness to circumcision was analyzed, and it was founded that in four AIDS vulnerable groups the proportion who felt themselves suffering from phimosis or redundant prepuce in WTC group were much higher than Non-WTC group. (6) Variables which P was less than 0.10 in univariate analysis were analyzed by multivariate Logistic regression model. It was found that in migrant workers, the unmarried (OR = 0.425, 95%CI = 0.235 ?0.772), awareness of redundant prepuce can impede the growth of penis, affect sex life(OR = 1.875, 95%CI = 1.178 ?2.984), and foreskin disorders(OR =7.380, 95% CI = 3.815 ?14.275) were the favorable factors which affect their willingness to circumcision. In drug addicts, awareness of pain is a complication of circumcision (OR=1.791,95%CI= 1.150 ?2.788), redundant prepuce is susceptible to genital inflammation (OR = 2.022, 95%CI=1.335 ?3.063), and foreskin disorders (OR=5.601,95%CI= 3.081? 10.184) were the favorable factors which affect their willingness to circumcision. In general people in HIV high-prevalence areas, the awareness of phimosis and redundant prepuce is easy to form smegma, affect the reproductive health (OR = 2.025,95%CI= 1.303 ?3.147),and foreskin disorders(OR = 18.258, 95%CI= 10.137?32.885) were the favorable factors which affect their willingness to circumcision. Conclusions (1) The willing or intention to circumcision of drug addicts is highest of three AIDS vulnerable groups, followed by migrant workers and general people in HIV high-prevalence areas. (2) From the point of demand of health, treatment foreskin disorders is the same reason for four groups people why choose to circumcision; From the point of avoiding the risk of HIV infection, the willing or intention to circumcision of drug addicts and HIV carriers' male spouses are higher than migrant workers and general people in HIV high-prevalence areas, because they consider themselves have the higher risk of HIV infection than the other. In addition, other factors such as the social demographic characteristics of four AIDS vulnerable groups and their AIDS knowledge, cognition of circumcision are more or less influential on their willingness to circumcision. (3) According to the factors influence on the willingness to circumcision of four AIDS vulnerable groups, this study proposes following preliminary strategies to promote male circumcision for AIDS prevention in AIDS vulnerable groups. First, use certain information carriers and mass media to show scientific evidence of circumcision preventing AIDS to target population, provide them with scientific and accurate information about circumcision and HIV prevention, to eliminate their concerns on the effect of male circumcision to prevent AIDS; Secondly, through a variety of ways such as project support, international financial support and medical insurance, health policy support to guarantee they can receive secure, qualified surgery that meet the health requirements on the medical technology level, from the point of medical costs, to ensure that they can enjoy reasonable prices or even free operation, according to these preparatory work to build up the green channel and long-term mechanism of circumcision to prevent AIDS in AIDS vulnerable people in the future; Meanwhile, from the perspective of medical ethics, strictly follow the principle of confidentiality on their medical information, protect their privacy, and avoid the social discrimination they suffered and the unnecessary medical disputes. These measures may be effective to increase the acceptance of circumcision among AIDS vulnerable people.Section three: The modes and effectiveness to promote male circumcision in AIDS vulnerable groupsObjective Design effective media materials to promote circumcision for AIDS prevention and then select the best suitable combination of these materials that can increase effectively the circumcision rate of vulnerable adult male in the AIDS serious epidemic area, give full play to circumcision that can reduce HIV infection by sexual behaviour in the adult male in AIDS serious epidemic area,finally to form the application mode to promote circumcision in adult male in China's AIDS epidemic areas. Methods (1) Media materials were designed and produced to promote circumcision for AIDS prevention. (2) AIDS vulnerable groups were enrolled, the intervention modes of male circumcision protecting against HIV infection were used to carry out for health education in them, the evaluation information of subjects on the intervention modes were collected, and the intervention effect of the modes were assessed. (3) After intervention, the subjects who were willing to accept surgery were circumcised,and their operation time, process, blood loss in the surgery, postoperative wound hemorrhage, hematoma, edema, pain, infection and other complications were investigated. Results (1) A series of media materials including traditional handbook, display panels, Flash animation and scenario educational films integrated of modernized communication measures and more loved by the masses were designed in this study, combining with on-site mission of university student volunteers by their own surgery experience, three intervention modes to promote circumcision for AIDS prevention were established. (2) 405 migrant workers, 316 drug addicts met the inclusion criteria were recruited and randomly divided into three groups, and were respectively intervened with three modes of male circumcision protected against HIV prevention. After the first intervention, the three modes of intervention effects were assessed. It was found that the knowledge, attitude, and practice (KAP) changes of migrant workers were not statistically significant difference after the first intervention by the three kinds of modes promoting circumcision (P> 0.05). The awareness rate of reasons of circumcision, surgical complications and the attitude that circumcision can prevent AIDS changes in drug addicts were not statistically significant difference after the first intervention by the three kinds of modes (P>0.05), the circumcision rate of drug addicts was significantly increased by Mode 3, and reached 39.3%, compared with the other two modes were statistically significant (?2 = 8.097, P <0.05). Compared the costs of three intervention modes on the KAP of the subjects, it was found that in migrant workers the total cost of the Mode 3 to change the attitude that circumcision can prevent AIDS was the highest, needed 2567.1 Yuan for every 1% increasing, followed by Mode 2 (2391.3 Yuan) and Mode 1 (1823.6 Yuan), for attitude change, the paper material costs were little different in three modes, audiovisual material costs and total costs of the Mode 2 and Mode 3 were similar, and both higher than the Mode 1; for the change of willingness to circumcision, Mode 3 was required for the highest costs, while the total cost of Mode 2 was the lowest; for circumcision behavior change, the same rule was found that the total cost of Mode 3 was the highest, followed by Mode 1, Mode 2 cost the lowest of three modes. In drug addicts, the paper and audiovisual costs to changes their attitude of Mode 2 were highest, the total cost of Mode 3 was the highest, but little difference with the Mode 2, the total cost of Mode 1 to change attitude was the lowest; for the change of willingness to circumcision in drug addicts, the paper and audiovisual costs of Mode 2 is highest, while the total cost of Mode 3 was the highest, the cost of Mode 1 was the lowest; for circumcision behavior change, the paper, audio, and total costs of mode 3 were the lowest. (3) There were 63 migrant workers and 96 drug addicts who circumcised after intervention,in all the recent complications of the surgery, the postoperative wound edema had the highest incidence rate, it reached 8.6% and 10.4% of the migrant workers and drug addicts respectively, Other complications were excessive bleeding and severe pain, but the incidence rate was low, there was no mortality,infection and wound rupture in the subjects. The total incidence of complications in the migrant workers and drug addicts was 11.1% and 13.5%respectively. Conclusions (1) In this study, three intervention modes were established and the awareness rate of the reasons for circumcision and the circumcision complications of subjects were increased to varying degrees.Meanwhile, the attitude that circumcision can prevent AIDS of subjects was improved, which directly led to the rate of circumcision increase. The effects of three modes designed in this study were undoubted; the KAP of target audience could be changed to different degree by these modes. (2) From the cost - effectiveness of point of view, Mode 1 should be chose if the aim is to improve the attitude that circumcision can prevent HIV infection of migrant workers, and Mode 2 should be chose if the aim is to increase the willingness to circumcision and the circumcision behaviour of migrant workers; In drug addicts, Mode 1 will be the preferred choice to change their attitude and willingness, and Mode 3 will be the preferred choice to change their circumcision behaviour. Thus limited health resources can be rationally allocated and utilized, and minimum capital investment can maximize the benefits. |
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