**3. NMC as a public health measure**

A lot of factors come into play in deciding whether to promote NMC as a public health measure in a country or at a specific locality. Following are the issues that need to be considered before implementation of this health intervention.

#### **3.1. Local HIV epidemic**

saturation, and facial expressions indicative of pain during the procedure [50]. Pain experienced during the procedure has long-lasting effects on the circumcised child. Circumcised infants have been observed to have a stronger pain response to subsequent routine vaccination than uncircumcised infants [51]. Various interventions, in single and in combinations, have been used to minimize pain during NMC, e.g., sucrose syrup, oral acetaminophen, topical analgesic cream, and local nerve block. Sucrose alone has not been proven effective in reducing pain from circumcision [52], while topical analgesia may have some effect [53].

There are abundance of neurones which are sensitive to the touch in the foreskin. This leads many to believe that circumcised men might have less sexual pleasure than uncircumcised men [54]. This issue is not limited to NMC but is relevant to circumcision at any age. However, most studies testing this hypothesis have not found this to be true. Recent reviews concluded that loss of the foreskin by circumcision had no adverse effect on sexual pleasure during sexual acts [55, 56].

MC reduces the risk of heterosexual HIV transmission in men, but its effect on male-to-male sexual transmission is uncertain. As the current HIV epidemic is concentrated in men who have sex with men (MSM) in many parts of the world, the lack of evidence to support that MC could reduce the risk of HIV acquisition among this population raises concerns over the implementation of this measure as a public health intervention. Observational studies on the protective effect of MC against HIV infection among MSM revealed conflicting results, with some studies showing positive results [57, 58] and others negative results [59–61]. A systematic review concluded that MC might offer HIV protection only among MSM who practice primarily insertive anal sex, but not for those who practice primarily receptive anal sex [62].

Another concern on the implementation of NMC is a long waiting period to see the HIV prevention effect. Since NMC is conducted among newborns, it may take at least 15 years before they are sexually active and for the NMC to yield HIV prevention benefits. However, if this public health intervention is to be done, sooner is better than later. The only intervention that could have yield similar effect on the HIV epidemic is a preventive vaccine. According to the current status regarding HIV vaccine development, it is probable that NMC will yield an

A lot of factors come into play in deciding whether to promote NMC as a public health measure in a country or at a specific locality. Following are the issues that need to be considered

*2.2.3.4. Effectiveness in preventing HIV in men who have sex with men (MSM)*

*2.2.3.3. Reduced sexual pleasure*

176 Selected Topics in Neonatal Care

An RCT is needed to confirm this finding.

effect before an HIV vaccine is available.

**3. NMC as a public health measure**

before implementation of this health intervention.

*2.2.3.5. Long timeframe to see the HIV reduction benefits*

Promoting NMC as a public health measure depends largely on the characteristics of the local HIV epidemic. Generally, the main reason to step up NMC service in health care facilities is to reduce the risk of HIV infection in the population. It may be not worth promoting NMC, if HIV is not a major public health problem in the country or of the target locality. As MC is proven to reduce only the risk of HIV acquisition through heterosexual transmission, it will not be appropriate to promote NMC where new HIV infections occur mainly through other routes of transmission, namely through same sex intercourse in males or intravenous drug use. An economic study using information on the local HIV epidemic as part of the analysis would help determine if NMC is justifiable for the country in the event that the country has to bear the majority of the costs of the intervention.

#### **3.2. Medical guidelines on NMC**

Soon after MC was proven to reduce the risk of HIV contraction among heterosexual males, global health authorities such as the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended that MC, including NMC, be adopted as part of comprehensive national HIV prevention strategies in countries with high prevalence of heterosexually transmitted HIV infection and low rates of male circumcision. The American Academy of Pediatrics determined that the preventive benefits of neonatal circumcision outweigh the risks of the procedure and should be offered to the families who have boy infants [63]. This statement has also been endorsed by the American College of Obstetricians and Gynecologists [64] and the American Urologic Association [65].

While these international recommendations influence some local practitioners, most health care personnel need national guidelines on NMC before they can start providing the service. Hence, local medical professional organizations should be included as important stakeholders while planning for the intervention. Their statements in favor of NMC would assist program implementation in a big way.

#### **3.3. Policies and strategies**

Clear policies and strategies will guide the respective details regarding NMC service. The magnitude and characteristics of the program will depend on the policies from a high-level authorized body, usually the Ministry of Health. The NMC implementation strategy can range from promotion of routine NMC to offering NMC only on a case-by-case basis or per request. The overall strategic plan should translate into action plans for each time interval including target numbers of NMC. The policies will also clearly specify the financial aspect of the program mainly on the payment scheme for the service.

#### **3.4. Public education and demand creation**

The general public needs to be educated about NMC before the service is promoted. Public education can be rolled out in a variety of ways. Educational materials should be straightforward, comprehensive, and attractive. The main contents of the media should include benefits and risks of NMC as well as other supporting information such as availability and cost. The design of the education campaign should follow dedicated steps starting with a formative research targeting different audiences such as the general population and pregnant mothers. The formative research and subsequent baseline survey will define the content of the message and explore its suitability along with other relevant issues such as the dissemination channels.

evaluated. The evaluators could be from internal and/or external entities as appropriate. The information from the M&E system should be analyzed and used to improve the service and

Update on Neonatal Male Circumcision: A Public Health Perspective

http://dx.doi.org/10.5772/intechopen.71948

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Soon after it was confirmed that MC was effective in reducing the heterosexual transmission of HIV among men, the author formed a research team at Chiang Mai University, in Northern Thailand, to investigate the possibility of adopting NMC as a public health intervention in Thailand. A critical review compiling related information and the author's thoughts was the first publication [7]. A series of surveys have been conducted to gain insight on related issues in the country including knowledge and opinions of health staff on the intervention [10], the experiences of health staff on the procedure and capability of the Thai health care system to implement NMC [8], and acceptability as well as concerns of NMC among postpartum

Following are the findings of the abovementioned studies. This case study can serve as an example for other countries that share a similar context to Thailand and are considering

Thailand is an upper middle income country [67] and located in Southeast Asia. The country was categorized as a "high" human development country according to the most recent Human Development Index (HDI) report [68]. Thailand has a well-established health care system. The infant mortality rate is considered low at 11:1000 live births [69]. The coverage of antenatal care among pregnant women and rate of delivery at the health facilities are high. The country has three major health insurance systems that cover almost all of its citizens namely the Universal Health Coverage Scheme, the Civil Servant Medical Benefit Scheme, and Social Security Scheme. People who can afford or have private health insurance could go

Thailand was one of the Asian countries hardest-hit by the HIV epidemic during the early 1990s. The AIDS Epidemic Model (AEM) estimates that more than 1 million Thais were infected by the HIV virus. High quality and good coverage of antiretroviral treatment has saved a lot of lives. It is estimated that there are currently more than 400,000 people living with HIV in the country [70]. Thailand's MC rate in general is quite low [13]. It is prevalent

Thailand is a good candidate country for promoting NMC as a public health measure for many reasons. Most HIV infections in Thailand occur through heterosexual transmission, of which the risk is substantially reduced by MC. Theoretically, the effect of MC on HIV risk

only in Muslim communities especially in the southern most provinces.

**4.2. Why should Thailand consider promoting NMC?**

guarantee the quality of the service.

adopting NMC as a public health measure.

**4.1. Background on Thailand**

to private hospitals for convenience.

**4. Thailand and NMC**

mothers [9].

Clear and scientifically accurate information about NMC can prevent misconceptions and rumors about the procedure in the community. Perceived benefits of NMC at the societal level together with high level of satisfaction among early adopters will help increase the demand for the services.

#### **3.5. Finance**

NMC represents an added expenditure for the health care system even though the unit cost of NMC is lower than for circumcision at a later age. How the expenses are covered will depend on the nature of the program. However, the parents of the newborns should not have to pay for the total cost if NMC is promoted as a public health intervention. In developing countries, where resources are limited and a high number of recruitments are targeted in a short period of time, local governments usually do not have to pay, as the programs are supported by international agencies. In some other circumstances, the health insurance system may pay for the service. Partial payment by the parents is another possible option.

#### **3.6. Readiness of health system and staff training**

A baseline assessment of the readiness and capability of the health system should be conducted. For health facilities, the issues to be assessed should include the antenatal and child delivery service and availability of necessary medical equipment and supplies. Knowledge and attitudes toward NMC should be explored among health care personnel. The information gained from the surveys will help identify the basic elements needed for the service that are still lacking and the aspects that should be emphasized while training health care personnel.

Safety is the first priority when implementing NMC as a public health measure. The surgery should be performed by trained health staff. The health staff who performs the surgery should be educated comprehensively on all aspects related to delivery of NMC, and not just the operation. A training package on NMC developed by the WHO and its partners is available online [66].

#### **3.7. Monitoring and evaluation (M&E) and quality assurance**

A system to routinely monitor the performance of the NMC program should be established. The indicators should cover both medical and public health aspects of the intervention. Newly trained staff should conduct first NMC cases under the supervision of more experienced persons. The results of the monitoring system will indicate whether the program is being implemented as intended and should be used to adjust the program to meet the goals in a timely manner. On an interval basis, the outcomes of the program should be comprehensively evaluated. The evaluators could be from internal and/or external entities as appropriate. The information from the M&E system should be analyzed and used to improve the service and guarantee the quality of the service.
