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Efforts to understand male to female sexual transmission of HIV must include semen analysis. Estimating sexual infectiousness using blood HIV RNA concentrations as a surrogate marker may be biased.1 Semen is routinely collected in Europe and the United States for HIV research2 and has recently been collected in clinical trials in sub-Saharan Africa3; however, there are no published data about issues associated with semen collection.
We conducted a study at the Central Hospital in Lilongwe, Malawi, from January 2000 to June 2001 to better understand the relation between trichomonas and HIV-1 viral load.4 Men attending STI and dermatology clinics consented and were enrolled. All men with Trichomonas vaginalis and a comparison group of HIV positive men attending the dermatology clinic without trichomonas or STI symptoms were asked to provide semen. Both male and female clinic staff asked men to donate semen at the baseline visit. If subjects agreed to provide semen they were given a wide mouthed specimen container, escorted to a designated toilet near the examination rooms, and asked to provide semen by masturbation. To determine independent predictors of collection, a multivariate logistic regression model was created utilising those factors associated (p ⩽0.10) with semen collection on bivariate analyses. Eight randomly selected subjects who had been asked to donate semen were invited to participate in a focus group about semen collection.
In all, 212 men were asked to provide semen and 145 succeeded (table 1). The table shows the adjusted results controlling for factors associated with collection. Having a genital ulcer or being married were both associated with failure to successfully masturbate and produce a semen sample; 87% of men without symptomatic STIs successfully produced semen.
The Chichewa word for semen, umuna, is derived from the word for man, amuna, and can be translated as “the essence of man.” Reflecting this linguistic point, the focus group reported that semen was seen as a powerful, supernatural substance that could be used to inflict harm upon the donor if it were misused. However, seven of eight focus group members understood the importance of collecting semen for research purposes. The focus group also revealed additional barriers to successful semen collection beyond having an STD including time pressure and perceived privacy. The focus group did not reach a consensus about why married men may be less successful at donating semen, but there was the suggestion that single men are more likely to masturbate as part of their daily lives so they are more comfortable doing it when asked to donate semen.
We found that the collection of semen for HIV and STI research is possible in a sub-Saharan African setting. To optimise the semen collection success rate we recommend minimising semen requests for men with acute genital symptoms and creating a quiet, non-urgent climate for sample donation. The techniques we have used to improve our success rate are (1) to give subjects the option of providing the semen sample at home as long as they agree to comply with the specimen collection requirements, specifically to deliver the sample no more than 2 hours after collection, and (2) to provide a semen collection space away from busy clinic corridors and allow ample time for collection.
This study has been approved by the UNC Chapel Hill School of Medicine ethics board (Chapel Hill, NC, USA), and the Malawi Health Sciences Research Committee (Lilongwe, Malawi).
No authors have competing interests and all have contributed to the creation of this manuscript.