Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis

Acceptability and feasibility of early infant male circumcision for HIV prevention in Malawi

Background

Voluntary medical male circumcision (VMMC) has been successfully implemented in 14 countries as an additional HIV prevention intervention. As VMMC programs mature in most countries, the focus is now on how to sustain the HIV prevention gains realised from VMMC. As part of preparations for the sustainability phase, countries are either piloting or preparing to pilot early infant male circumcision (EIMC). This qualitative study explored the acceptability and feasibility of EIMC in Malawi in order to inform pilot implementation.

Methods

In 2016, 23 focus group discussions were held across Malawi with participants from several ethnicities and religions/faiths. Additionally, 21 key informant interviews were held with traditional and religious leaders, traditional circumcisers (ngalibas), policy-makers, programme managers and health-care workers. Audio recordings were transcribed, translated into English (where necessary), and thematically coded using NVivo 10.

Results

Discussions highlighted the socio-cultural significance of MC in Malawi. Knowledge or experience of EIMC was poor although acceptability was high among most ethnic/religious groups and key informants. Participants identified EIMC's comparative HIV benefits although a few health-care workers expressed scepticism. All participants said EIMC should be offered within a clinical setting. In addition to fathers, maternal uncles and traditional leaders were deemed key decision-makers. Potential barriers to EIMC included concerns about procedure safety as well as cultural considerations. Key informants felt it was feasible to offer EIMC in Malawi. Participants' recommendations, including phased implementation, engagement of traditional leaders, use of external mobilisers and initially reaching out to influential parents, will be taken into account when designing a pilot EIMC program.

Conclusions

EIMC is potentially an acceptable and feasible HIV prevention intervention for most ethnic/religious groups in Malawi if wide-ranging, culturally appropriate demand-creation activities are developed, piloted, evaluated and appropriately implemented.

Progress and prospects for the control of HIV and tuberculosis in South Africa: a dynamical modelling study

BACKGROUND

In September, 2016, South Africa adopted a policy of providing antiretroviral treatment to everyone infected with HIV irrespective of their CD4 cell count. Studies of universal treatment and expanded prevention of HIV differ widely in their projections of effects and the associated costs, so we did this analysis to attempt to find a consensus.

METHODS

We used data on HIV from the Joint UN Programme on HIV and AIDS (UNAIDS) from 1988 to 2013 and from data from WHO on tuberculosis from 1980 to to 2013 to fit a dynamical model to time trends in HIV prevalence, antiretroviral therapy (ART) coverage, and tuberculosis notification rates in South Africa. We then used the model to estimate current trends and project future patterns in HIV prevalence and incidence, AIDS-related mortality, and tuberculosis notification rates, and we used data from the South African National AIDS Council to assess current and future costs under different combinations of treatment and prevention approaches. We considered two treatment strategies: the Constant Effort strategy, in which people infected with HIV continue to start treatment at the rate in 2016, and the Expanded Treatment and Prevention (ETP) strategy, in which testing rates are increased, treatment is started immediately after HIV is detected, and prevention programmes are expanded.

FINDINGS

Our estimates show that HIV incidence among adults aged 15 years or older fell from 2·3% per year in 1996 to 0·65% per year in 2016, AIDS-related mortality decreased from 1·4% per year in 2006 to 0·37% per year in 2016, and both continue to fall at a relative rate of 17% per year. Our model shows that maintenance of Constant Effort will have a substantial effect on HIV but will not end AIDS, whereas ETP could end AIDS by 2030, with incidence of HIV and AIDs-related mortality rates both at less than one event per 1000 adults per year. Under ETP the annual cost of health care and prevention will increase from US$2·3 billion in 2016 to $2·9 billion in 2018, then decrease to $1·7 billion in 2030 and $0·9 billion in 2050. Over the next 35 years, the expansion of treatment will avert an additional 3·8 million new infections, save 1·1 million lives, and save $3·2 billion compared with continuing Constant Effort up to 2050. Expansion of prevention, including provision of pre-exposure prophylaxis, condom distribution, and male circumcision, could avert a further 150 000 new infections, save 5000 lives, and cost an additional $5·7 billion compared with Constant Effort.

INTERPRETATION

Our results suggest that South Africa is on track to reduce HIV incidence and AIDS-related mortality substantially by 2030, saving both lives and money. Success will depend on high rates of HIV testing, ART delivery and adherence, good patient monitoring and support, and data to monitor progress.

FUNDING

None.

Circumcision and its effects in Africa

Male circumcision is one of the most commonly performed procedures in Africa, with a wide variation between the different regions on the practice. This is because circumcision is often done for religious and cultural or traditional reasons, which includes being part of rituals or rite of passage to adulthood. There had been few medical indications for the procedure until the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) pandemic, which is prevalent in many of the countries in the region. Evidence from randomized controlled trials conducted in the continent had shown that male circumcision could be instrumental to reducing the transmission of HIV/AIDS in heterosexual couples in high disease prevalent and low circumcision prevalent areas. This had led to the roll-out of large population-based adult male circumcisions as well as the development of tools to facilitate the procedure. Circumcision, however, is not without complications and the incidence appears related to the age of the patient, where the procedure was done, technique used and level of proficiency of the practitioners. This article reviews the practice of circumcision in Africa and highlights the impact of the procedure on the continent.

Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy

AIM

To determine whether recent evidence-based United States policies on male circumcision (MC) apply to comparable Anglophone countries, Australia and New Zealand.

METHODS

Articles in 2005 through 2015 were retrieved from PubMed using the keyword "circumcision" together with 36 relevant subtopics. A further PubMed search was performed for articles published in 2016. Searches of the EMBASE and Cochrane databases did not yield additional citable articles. Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further. The most relevant and representative of the topic were included. Bibliographies were examined to retrieve further key references. Randomized controlled trials, recent high quality systematic reviews or meta-analyses (level 1++ or 1+ evidence) were prioritized for inclusion. A risk-benefit analysis of articles rated for quality was performed. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information, including policies and Australian data on claims under Medicare for MC.

RESULTS

Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and "ballooning" during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews.

CONCLUSION

Affirmative MC policies are needed in Australia and New Zealand. Routine provision of accurate, unbiased education, and access in public hospitals, will maximize health and financial benefits.

2017 European guideline for the management of chancroid

Chancroid is a sexually acquired infection caused by Haemophilus ducreyi. The infection is characterized by one or more genital ulcers, which are soft and painful, and regional lymphadenitis, which may develop into buboes. The infection may easily be misidentified due to its rare occurrence in Europe and difficulties in detecting the causative pathogen. H. ducreyi is difficult to culture. Nucleic acid amplification tests can demonstrate the bacterium in suspected cases. Antibiotics are usually effective in curing chancroid.

Unpacking early infant male circumcision decision-making using qualitative findings from Zimbabwe

Background

Early infant male circumcision (EIMC) has been identified as a key HIV prevention intervention. Exploring the decision-making process for adoption of EIMC for HIV prevention among parents and other key stakeholders is critical for designing effective demand creation interventions to maximize uptake, roll out and impact in preventing HIV. This paper describes key players, decisions and actions involved in the EIMC decision-making process.

Methods

Two complementary qualitative studies explored hypothetical and actual acceptability of EIMC in Zimbabwe. The first study (conducted 2010) explored hypothetical acceptability of EIMC among parents and wider family through focus group discussions (FGDs, n = 24). The follow-up study (conducted 2013) explored actual acceptability of EIMC among parents through twelve in-depth interviews (IDIs), four FGDs and short telephone interviews with additional parents (n = 95). Short statements from the telephone interviews were handwritten. FGDs and IDIs were audio-recorded, transcribed and translated into English. All data were thematically coded.

Results

Study findings suggested that EIMC decision-making involved a discussion between the infant’s parents. Male and female participants of all age groups acknowledged that the father had the final say. However, discussions around EIMC uptake suggested that the infant’s mother could sometimes covertly influence the father's decision in the direction she favoured. Discussions also suggested that fathers who had undergone voluntary medical male circumcision were more likely to adopt EIMC for their sons, compared to their uncircumcised counterparts. Mothers-in-law/grandparents were reported to have considerable influence. Based on study findings, we describe key EIMC decision makers and attempt to illustrate alternative outcomes of their key actions and decisions around EIMC within the Zimbabwean context.

Conclusions

These complementary studies identified critical players, decisions and actions involved in the EIMC decision-making process. Findings on who influences decisions regarding EIMC in the Zimbabwean context highlighted the need for EIMC demand generation interventions to target fathers, mothers, grandmothers, other family members and the wider community.

Prepuce health and childhood circumcision: Choices in Canada

INTRODUCTION

Worldwide, almost 100% of boys are born with penises with a "hood" called prepuce or foreskin. In the course of the boy's life, the prepuce can be circumcised, can become affected by diseased (e.g., phimosis), or a can become infected and hurt the neonate (and his sexual partner) in adulthood. The objectives of this report are to: 1) review the state, function, fate, and care of the prepuce in childhood, with focus on the neonate, in Canada; 2) understand the current practice of childhood male circumcision in terms of age, indications, performers, techniques, outcomes, and education; and 3) consider ways to sustain a good healthcare professional-parental dialogue for safe practices that are accessible, acceptable, and culturally sensitive in the care of the prepuce.

METHODS

A literature review was carried out in the English language through the major databases: PubMed (MEDLINE), EMBASE, the Cochrane Library, CINAHL, Web of Science (WOS) Core Collection, LILAC, WHO/UNAIDS, Clinical Trials (www.clinicaltrials.gov), Google Scholar, and grey literature. Search words included: prepuce, diseases of prepuce, prepuce in the neonate, prepuce in the neonate in Canada, male circumcision, childhood male circumcision, neonatal circumcision, neonatal circumcision in Canada, complications of neonatal circumcision in Canada, and circumcision adverse events.

RESULTS

From 1970-1999, three of 10 Canadian newborn males were circumcised for religious, cultural, and medical reasons. The rest of the neonates, if alive, are living with their prepuce; <4% expected to require treatment for afflictions of the prepuce at some point. There are several providers of circumcision with different levels of training and competencies and using a diversity of devices and techniques. Neonatal and childhood circumcision in Canada is carried out to fulfill parental wishes, as well as for medical, religious, and cultural reasons. Appropriate informed consent and education regarding choices of care of the neonatal prepuce and genitals are vital.

CONCLUSIONS

Going by current prevalent rate of circumcision in Canada, most Canadian newborn males are likely to live out their lives with an intact prepuce. Despite the age-old debate, childhood circumcision is likely to remain. There is need for careful and proper discussion of the potential risks and benefits, including alternatives, costs, and personal/psychological factors. Acceptance, access, and judicious choices in a culturally sensitive environment will offer the Canadian neonate desirable care of the prepuce for life.

Male Circumcision and the Epidemic Emergence of HIV-2 in West Africa

BACKGROUND

Epidemic HIV-2 (groups A and B) emerged in humans circa 1930-40. Its closest ancestors are SIVsmm infecting sooty mangabeys from southwestern Côte d'Ivoire. The earliest large-scale serological surveys of HIV-2 in West Africa (1985-91) show a patchy spread. Côte d'Ivoire and Guinea-Bissau had the highest prevalence rates by then, and phylogeographical analysis suggests they were the earliest epicenters. Wars and parenteral transmission have been hypothesized to have promoted HIV-2 spread. Male circumcision (MC) is known to correlate negatively with HIV-1 prevalence in Africa, but studies examining this issue for HIV-2 are lacking.

METHODS

We reviewed published HIV-2 serosurveys for 30 cities of all West African countries and obtained credible estimates of real prevalence through Bayesian estimation. We estimated past MC rates of 218 West African ethnic groups, based on ethnographic literature and fieldwork. We collected demographic tables specifying the ethnic partition in cities. Uncertainty was incorporated by defining plausible ranges of parameters (e.g. timing of introduction, proportion circumcised). We generated 1,000 sets of past MC rates per city using Latin Hypercube Sampling with different parameter combinations, and explored the correlation between HIV-2 prevalence and estimated MC rate (both logit-transformed) in the 1,000 replicates.

RESULTS AND CONCLUSIONS

Our survey reveals that, in the early 20th century, MC was far less common and geographically more variable than nowadays. HIV-2 prevalence in 1985-91 and MC rates in 1950 were negatively correlated (Spearman rho = -0.546, IQR: -0.553--0.546, p≤0.0021). Guinea-Bissau and Côte d'Ivoire cities had markedly lower MC rates. In addition, MC was uncommon in rural southwestern Côte d'Ivoire in 1930.The differential HIV-2 spread in West Africa correlates with different historical MC rates. We suggest HIV-2 only formed early substantial foci in cities with substantial uncircumcised populations. Lack of MC in rural areas exposed to bushmeat may have had a role in successful HIV-2 emergence.

Needs Assessment and Theory-Based Promotion of Voluntary Medical Male Circumcision (VMMC) Among Male Sexually Transmitted Diseases Patients (MSTDP) in China

Voluntary medical male circumcision (VMMC) is an evidence-based biomedical HIV prevention method. It is under-utilized in countries outside Africa, including China. The present single-arm, non-blinded test-of-concept trial was designed to promote VMMC among 179 male sexually transmitted diseases patients (MSTDP) in Shenzhen, China. It was based on behavioral health theories and results of a formative survey. At month 4, 45.5 % of the MSTDP responded positively to the intervention (19.9 % had taken up VMMC and 25.6 % intended to do so in the next 6 months). Adjusted analysis showed that cognitive variables measured at baseline (perceived self-efficacy, subjective norm and behavioral intention) significantly predicted adoption of VMMC during the 4-month follow-up period. Process evaluation involving clinicians of the STD clinics was positive. At month 6, 36.0 % of the circumcised participants used condom less frequently with their regular sex partner. We recommend scaling up the intervention, taking prevention of risk compensation into account.

Self-selection of male circumcision clients and behaviors following circumcision in a service program in Uganda

OBJECTIVES

Sub-Saharan African countries have substantially scaled-up safe male circumcision (SMC) services. However, it is unclear whether services are reaching men most at risk of HIV and whether there is behavioral disinhibition after SMC. We compared characteristics of SMC acceptors and nonacceptors in Rakai, Uganda.

DESIGN

Cohort design.

METHODS

Through the Rakai Community Cohort Study, baseline characteristics of 587 non-Muslim men who subsequently accepted SMC were compared with those of 4907 uncircumcised non-Muslim men. Behaviors after SMC were compared with those of men who remained uncircumcised. Poisson multivariable regression was used to estimate adjusted prevalence rate ratios of behaviors in circumcised versus uncircumcised men.

RESULTS

At baseline (pre-SMC), men subsequently circumcised were younger (mean = 26.1 years), as compared with the uncircumcised (mean = 28.5 years, P < 0.001), more likely to live in urban areas (21.1 versus 12.4%, P < 0.001), less likely to have been currently or previously married (36.5 versus 45.8%, P < 0.001) and more likely to report multiple sexual partners (48.3 versus 41.6%, P = 0.05) and genital discharge (7.4 versus 4.4%, P = 0.03). At follow-up (post-SMC), behaviors and genital discharge did not differ between the groups. Genital ulcers were less reported among circumcised (6.8%) compared with uncircumcised men (10.5%; adjusted prevalence rate ratios = 0.60, 95% confidence interval = 0.42-0.87, P = 0.007).

CONCLUSION

In Rakai district, Uganda, the circumcision service program is attracting sexually active men at higher risk of HIV and we find no evidence of behavioral disinhibition following circumcision. The SMC program in this setting has the potential to reduce the HIV epidemic among men.

Perspectives of Parents and Health Care Workers on Early Infant Male Circumcision Conducted Using Devices: Qualitative Findings From Harare, Zimbabwe

Parents who opted for early infant male circumcision (EIMC) and health care workers felt EIMC was a safe and acceptable procedure that would likely become more widely adopted over time. Barriers to EIMC uptake such as parental fears of harm and cultural beliefs are potentially surmountable with adequate education and support.

Background:

The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend early infant male circumcision (EIMC) for prevention of HIV. Here, we present findings from a qualitative study in Zimbabwe that assessed parental and health care workers' perspectives of EIMC conducted using devices.

Methods:

This qualitative study was nested within a trial of EIMC devices. Between January and May 2013, we held 4 focus group discussions (FGDs) and 12 in-depth interviews with parents and 12 in-depth interviews with clinicians (7 trial clinicians and 5 non-trial clinicians). We also conducted 95 short telephone interviews with parents who had arranged to bring their sons for EIMC but then defaulted.

Results:

Parents who had adopted EIMC spoke of their initial anxieties about the procedure. Additionally, they commented on both the procedure and outcome. Parents who decided against EIMC cited fear of harm, specifically the infant's death, penile injury, and excessive pain. Misperceptions about male circumcision in general and EIMC specifically were a significant barrier to EIMC adoption and were prevalent among health care workers as well as parents. In particular, the findings suggest strong parental concerns about the fate of the discarded foreskin. Parents who chose EIMC for their newborn sons felt that the procedure was safe and expressed satisfaction with the outcome. For their part, health care workers largely thought that EIMC was safe and that the outcome was aesthetically pleasing. They also felt that it would be feasible to offer wide-scale EIMC for HIV prevention in the public sector; they recommended strategies to increase EIMC uptake, in addition to highlighting a few concerns.

Conclusions:

The qualitative study enables us to better understand parental and health care workers' perspectives of EIMC conducted using devices, especially their perspectives on EIMC safety, feasibility, acceptability, and barriers. These findings will be used to design demand-generation activities that support wider adoption of EIMC.

Does HIV Exploit the Inflammatory Milieu of the Male Genital Tract for Successful Infection?

In many parts of the World, medical male circumcision (MMC) is used as standard prevention of care against HIV infection. This is based on seminal reports made over 10 years ago that removal of the foreskin provides up to 60% protection against HIV infection in males and seems currently the best antiretroviral-free prevention strategy yet against the global epidemic. We explore the potential mechanisms by which MMC protects against HIV-1 acquisition and that one of the oldest, albeit re-invented, rituals of removing a foreskin underscores the exploitative nature of HIV on the anatomy and tissue of the uncircumcised penis. Furthermore, foreskin removal also reveals how males acquire HIV, and in reality, the underlying mechanisms of MMC are not known. We argue that the normal sequelae of inflammation in the male genital tract (MGT) for protection from sexually transmitted infections (STI)-induced pathology represents a perfect immune and microbial ecosystem for HIV acquisition. The accumulation of HIV-1 target cells in foreskin tissue and within the urethra in response to STIs, both during and after resolution of infection, suggests that acquisition of HIV-1, through sexual contact, makes use of the natural immune milieu of the MGT. Understanding immunity in the MGT, the movement of HIV-1 target cells to the urethra and foreskin tissue upon encounter with microbial signals would provide more insight into viral acquisition and lay the foundation for further prevention strategies in males that would be critical to curb the epidemic in all sexual partners at risk of infection. The global female-centric focus of HIV-1 transmission and acquisition research has tended to leave gaps in our knowledge of what determines HIV-1 acquisition in men and such understanding would provide a more balanced and complete view of viral acquisition.

Strong Country Level Correlation between Syphilis and HSV-2 Prevalence

Background. Syphilis is curable but Herpes Simplex Virus-2 (HSV-2) is not. As a result, the prevalence of syphilis but not HSV-2 may be influenced by the efficacy of national STI screening and treatment capacity. If the prevalence of syphilis and HSV-2 is found to be correlated, then this makes it more likely that something other than differential STI treatment is responsible for variations in the prevalence of both HSV-2 and syphilis. Methods. Simple linear regression was used to evaluate the relationship between national antenatal syphilis prevalence and HSV-2 prevalence in women in two time periods: 1990–1999 and 2008. Adjustments were performed for the laboratory syphilis testing algorithm used and the prevalence of circumcision. Results. The prevalence of syphilis was positively correlated with that of HSV-2 for both time periods (adjusted correlations, 20–24-year-olds: 1990–99: R² = 0.54, P < 0.001; 2008: R² = 0.41, P < 0.001 and 40–44-year-olds: 1990–99: R² = 0.42, P < 0.001; 2008: R² = 0.49, P < 0.001). Conclusion. The prevalence of syphilis and HSV-2 is positively correlated. This could be due to a common set of risk factors underpinning both STIs.

Mucosal cuff length to penile length ratio may affect the risk of premature ejaculation in circumcised males

Data regarding the relation between premature ejaculation (PE) and post-circumcision mucosal cuff length are controversial. The aim of this study is to analyze the relation between post-circumcision mucosal cuff length/penile length ratio (MCR) and PE. After exclusion of patients with erectile dysfunction, penile deformity, history of penile surgery and severe lower urinary tract symptoms, 49 circumcised men with PE were included. The control group is constituted of 50 healthy volunteers with normal ejaculatory function. Self-estimated intravaginal ejaculation latency time (IELT) and premature ejaculation profile (PEP) measures of all subjects were recorded, and the MCRs of patients and controls were compared. The mean age of PE patients and controls was 35.82 ± 7.73 (range 23-54) and 38.78 ± 13.42 (range 19-71) years, respectively (P=0.183). Although mucosal cuff length was not associated with either self-estimated IELT (r=-0.185, P=0.067) or PEP (r=-0.098, P=0.336), there was a negative correlation between MCR and self-estimated IELT (r=-0.205, P=0.0001) and PEP measures (r=-0.308, P=0.002). The length of the mucosal cuff after circumcision may have an impact on ejaculatory function. Surgeons should avoid leaving excessive amount of mucosa during circumcision.

Acceptability of Voluntary Medical Male Circumcision (VMMC) among Male Sexually Transmitted Diseases Patients (MSTDP) in China

Voluntary Medical Male circumcision (VMMC) is an evidence-based, yet under-utilized biomedical HIV intervention in China. No study has investigated acceptability of VMMC among male sexually transmitted diseases patients (MSTDP) who are at high risk of HIV transmission. A cross-sectional survey interviewed 350 HIV negative heterosexual MSTDP in Shenzhen, China; 12.0% (n = 42) of them were circumcised at the time of survey. When the uncircumcised participants (n = 308) were informed that VMMC could reduce the risk of HIV infection via heterosexual intercourse by 50%, the prevalence of acceptability of VMMC in the next six months was 46.1%. Adjusted for significant background variables, significant factors of acceptability of VMMC included: 1) emotional variables: the Emotional Representation Subscale (adjusted odds ratios, AOR = 1.13, 95%CI: 1.06–1.18), 2) cognitive variables derived from Health Belief Model (HBM): perceived some chance of having sex with HIV positive women in the next 12 months (AOR = 2.48, 95%CI: 1.15–5.33) (perceived susceptibility), perceived severity of STD infection (AOR = 1.06, 95%CI: 1.02–1.10), perceived benefit of VMMC in risk reduction (AOR = 1.29, 95%CI: 1.16–1.42) and sexual performance (AOR = 1.45, 95%CI: 1.26–1.71), perceived barriers against taking up VMMC (AOR = 0.88, 95%CI: 0.81–0.95), and perceived cue to action (AOR = 1.41, 95%CI: 1.23–1.61) and self-efficacy (AOR = 1.38, 95%CI: 1.26–1.35) related to taking up VMMC. The association between perceived severity of STD infection and acceptability was fully mediated by emotional representation of STD infection. The relatively low prevalence of circumcision and high acceptability suggested that the situation was favorable for implementing VMMC as a means of HIV intervention among MSTDP in China. HBM is a potential suitable framework to guide the design of future VMMC promotion. Future implementation programs should be conducted in STD clinic settings, taking the important findings of this study into account.

Factors Associated with Knowledge of and Willingness for Adult Male Circumcision in Changsha, China

BACKGROUND

Male circumcision (MC) has been shown to reduce the risk of male genital diseases. MC is not commonly practiced among Chinese males and little is known about the factors associated with their knowledge of and willingness for MC. This study was to explore the knowledge regarding the foreskin among Chinese males and to identify factors associated with their willingness to undergo circumcision.

METHODS

A total of 237 patients with redundant prepuce/phimosis were interviewed through face-to-face interviews. The items on the questionnaire included: demographics, an objective scale assessing knowledge about the foreskin, willingness to have MC, the attitudes of sexual partners and doctors toward redundant prepuce/phimosis, and the approaches that patients used to acquire knowledge regarding the prepuce. Univariate analysis and multiple logistic regression analysis were performed to identify factors that are associated with willingness to be circumcised (WTC).

RESULTS

A total of 212 patients completed the interview. Multivariable logistic regression showed that three factors were significantly associated with WTC: being married (OR = 0.43), perceiving redundant prepuce/phimosis as a disease (OR = 1.93), and if a patient's partner supported MC (OR = 1.39). 58% (n = 122) had received information about the foreskin from another party: 18% (n = 37) from school, 8% (n = 17) from family, 17% (n = 36) from friends, 27% (n = 57) from health care providers. About 4% (n = 8) believed that their partners disliked their redundant prepuce/phimosis. 20% (n = 42) had received doctors' advice to undergo circumcision.

CONCLUSION

Knowledge about the foreskin was low among Chinese males. Our study elucidates the factors associated with WTC and suggests that more education of the population about the foreskin can help improve the recognition of a correctible abnormality and help patients assess the potential role of MC in their health.

The when and how of male circumcision and the risk of HIV: a retrospective cross-sectional analysis of two HIV surveys from Guinea-Bissau

Introduction

Male circumcision (MC) reduces the risk of HIV, and this risk reduction may be modified by socio-cultural factors such as the timing and method (medical and traditional) of circumcision. Understanding regional variations in circumcision practices and their relationship to HIV is crucial and can increase insight into the HIV epidemic in Africa.

Methods

We used data from two retrospective HIV surveys conducted in Guinea-Bissau from 1993 to 1996 (1996 cohort) and from 2004 to 2007 (2006 cohort). Multivariate logistical models were used to investigate the relationships between HIV risk and circumcision status, timing, method of circumcision, and socio-demographic factors.

Results

MC was protective against HIV infection in both cohorts, with adjusted odds ratios (AORs) of 0.28 (95% CI 0.12-0.66) and 0.30 (95% CI 0.09-0.93), respectively. We observed that post-pubertal (≥13 years) circumcision provided the highest level of HIV risk reduction in both cohorts compared to non-circumcised. However, the difference between pre-pubertal (≤12 years) and post-pubertal (≥13 years) circumcision was not significant in the multivariate analysis. Seventy-six percent (678/888) of circumcised males in the 2006 cohort were circumcised traditionally, and 7.7% of those males were HIV-infected compared to 1.9% of males circumcised medically, with AOR of 2.7 (95% CI 0.91-8.12).

Conclusion

MC is highly prevalent in Guinea-Bissau, but ethnic variations in method and timing may affect its protection against HIV. Our findings suggest that sexual risk behaviour and traditional circumcision may increases HIV risk. The relationship between circumcision age, sexual behaviour and HIV status remains unclear and warrants further research.

Comparing the length of penile mucosa in men with and without premature ejaculation

BACKGROUND

Premature ejaculation is one of the prevalent disorders in men; almost one out of three men between 18 and 59 years old have this disorder with its leading sequel such as lack of self-confidence, anxiety, depression and unsatisfactory intercourse in men and their partners. This study aimed to compare the length of penile mucosa in men with and without premature ejaculation.

METHOD

Three hundred and eighty patients referring to our hospital from March 2009 to March 2010 were enrolled in the study. First group comprised 190 men with premature ejaculation and second group included 190 men without premature ejaculation as control group that were chosen randomly. A questionnaire was designed to collect data and was completed for both groups. Height, weight, body mass index (BMI), length of penile mucosa, length of penis and intravaginal ejaculation latency time (IELT) were measured.

RESULTS

The mean IELT in premature ejaculation group and control group were 47.58 ± 29.55 and 410.38 ± 190.2 s, respectively (p = 0.001). The mean penis length in premature ejaculation group and control group were 127.25 ± 16.23 and 127.03 ± 17.42 mm, respectively (p = 0.901, with nonsignificant difference); the mean penile mucosa in premature ejaculation group was 33.83 ± 11.54 mm and in control group was 31.40 ± 11.97 mm (p = 0.014, with significant difference).

CONCLUSION

Longer penile mucosa can be one of the factors in causing premature ejaculation.

Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby

An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.

[Diagnosis and therapy of genitoanal ulcers of infectious etiology]

BACKGROUND/OBJECTIVES

In this review article the diagnostic and therapeutic principles of genital ulcers of infectious etiology are highlighted. Besides frequent causative infections rare but relevant diseases in the differential diagnosis are discussed in detail.

MATERIAL AND METHODS

A Pubmed literature search was carried out, guidelines from different task groups and clinical experiences are presented.

RESULTS

Infections with herpes simplex virus (first) and syphilis (second) are still the most common causes of infectious genital ulcers. An endemic occurrence, previously rare in Europe, has been observed in recent years. Particular risk groups, such as men who have sex with men (MSM), sex workers or sex tourists are affected. Even less common locations, such as the mouth or the rectum, lymphogranuloma venereum (LGV) and atypical clinical symptoms (e.g. pelvic pain in pelvic lymphadenopathy with LGV) must be considered in the differential diagnosis.

CONCLUSION

In recent years sexually transmitted infections (STI) have shown a significant increase in western industrialized nations. In all cases with unclear findings in the genital and anal areas (and also in the oral cavity) STI diseases must be reconsidered in the differential diagnosis.

[Male circumcision from an infectiological point of view]

BACKGROUND

In May 2012 a German regional court (Cologne) declared circumcision on religious grounds in minor boys an illegitimate bodily harm. This led to substantial political and religious discussions, because Jews as well as Muslims consider circumcision as an indispensable element of their religion. Still in 2012 a "circumcision law" was passed by the Federal Council of Germany, which continues to allow circumcision in boys "performed under strict medical conditions".

OBJECTIVE

How male circumcision is assessed in terms of infectiology (pros and cons)?

METHOD

Electronic databases were searched for articles about the infection risks of foreskin surgery, and the efficacy of circumcision in reducing the risks of sexual transmission of HIV, herpes viruses, HPV, treponema pallidum, chlamydia, hemophilus ducrey and Neisseria gonorrhoeae.

RESULTS

Contra circumcision: The highest risk of neonatal circumcision is hemorrhage (35 %). Among infections surgical wound infection (10 %), meatitis urethrae (8-20 %) and urinary tract infections (2 %) are frequent (depending on the surgical technique). Severe complications like penile necrosis or lethal sepsis are rare (1:20,000). Pro circumcision: Circumcised boys have a reduced risk for urinary tract infections in childhood (1:10). Compared to uncircumcised men circumcised adults have a 50-60 % reduced risk of becoming infected with viral sexually transmitted infections (STIs; HIV, HPV and HSV). This advantage of circumcision is also discussed for the transmission of bacterial STIs (e.g. syphilis and chancroid), but the analysis of different clinical studies is still controversial.

DISCUSSION AND CONCLUSION

Neonatal circumcisions (and circumcision in early childhood) are irreparable interventions in the physical integrity, with very few medical indications. The risk of complications is dependent on the education of the circumciser (ritual, medical), analgesia and hygiene. Circumcisions should be performed under optimal surgical and hygienic conditions in informed and self-determined young men only. In adolescents and adults circumcision reduces the risk of the transmission of viral STIs (HIV, HSV, HPV) and there is also probably some effect on the sexual transmission of treponema pallidum and hemophilus ducreyi (insufficient, controversial data). The role of circumcision as an effective procedure to reduce the transmission of STIs is still under discussion, because important additional factors like sexual risk behavior (e.g. unprotected sexual intercourse, promiscuity) have a strong influence on STI epidemiology.

Voluntary medical male circumcision: A necessary surgical intervention in curbing HIV/AIDS

An Israeli surgeon and a Global Health Specialist working in Africa address some of the persistent myths surrounding this practice.

Acceptability of Male Circumcision among College Students in Medical Universities in Western China: A Cross-Sectional Study

Background

Male circumcision (MC) has been shown to reduce the risk of female to male transmission of HIV. The goal of this survey was to explore MC’s acceptability and the factors associated with MC among college students in medical universities in western China.

Methods

A cross-sectional study was carried out in three provinces in western China (Guangxi, Chongqing and Xinjiang) to assess the acceptability of MC as well as to discover factors associated with the acceptability among college students in medical universities. A total of 1,790 uncircumcised male students from three medical universities were enrolled in this study. In addition, 150 students who had undergone MC were also enrolled in the survey, and they participated in in-depth interviews.

Results

Of all the uncircumcised participants (n = 1,790), 55.2% (n = 988) were willing to accept MC. Among those who accepted MC, 67.3% thought that MC could improve their sexual partners’ hygiene, 46.3% believed that HIV and sexually transmitted diseases (STDs) could be partially prevented by MC. The multivariable logistic regression indicates that MC’s acceptability was associated with three factors: the redundant foreskin (OR = 10.171, 95% CI = 7.629–13.559), knowing the hazard of having a redundant foreskin (OR = 1.597, 95% CI = 1.097–2.323), and enhancing sexual pleasure (OR = 1.628, 95% CI = 1.312–2.021). The in-depth interviews for subjects who had undergone MC showed that the major reason for having MC was the redundant foreskin (87.3%), followed by the benefits and the fewer complications of having MC done. In addition, most of these participants (65.3%) said that the MC could enhance sexual satisfaction.

Conclusions

MC’s acceptance among college students in medical universities is higher than it is among other populations in western China. An implementation of an MC programme among this population is feasible in the future.

In developed countries male circumcision prevalence is inversely related to HIV prevalence

A study by Chemtob and co-workers found significantly lower prevalence of HIV amongst heterosexual men and women in Israel compared with the Netherlands and France. Risk factors for heterosexual HIV infection in these countries were similar, apart from one, namely, a strikingly higher prevalence of male circumcision (MC) in Israel compared with the Netherlands and France. It is now well established that MC protects heterosexual men against becoming infected with HIV during sexual intercourse with an infected woman. In epidemic settings, such as countries in sub-Saharan Africa, in which heterosexual contact is the primary driver for HIV infection, MC is being implemented to reduce HIV prevalence. The results of the new study by Chemtob and co-workers support the evidence and recent polices in the United States advocating MC to reduce the spread of HIV. While prevalence in developed countries is generally low, it is rising. In the long term, neonatal MC is the most desirable option, since not only is it simpler, safer, cheaper and more convenient than MC later, it provides immediate protection from infections, penile inflammation, genital cancers and physical problems. It is also cost-effective. European countries have not supported MC for its public health benefits. The new findings add to calls for European and other countries with low MC prevalence to consider developing evidence-based policies favoring MC in order to reduce HIV and other infections and diseases and at the same time reduce suffering, mortality and the cost of treating these.

Male Circumcision and STI Acquisition in Britain: Evidence from a National Probability Sample Survey

BACKGROUND

It is well-established that male circumcision reduces acquisition of HIV, herpes simplex virus 2, chancroid, and syphilis. However, the effect on the acquisition of non-ulcerative sexually transmitted infections (STIs) remains unclear. We examined the relationship between circumcision and biological measures of three STIs: human papillomavirus (HPV), Chlamydia trachomatis and Mycoplasma genitalium.

METHODS

A probability sample survey of 15,162 men and women aged 16-74 years (including 4,060 men aged 16-44 years) was carried out in Britain between 2010 and 2012. Participants completed a computer-assisted personal interview, including a computer-assisted self-interview, which asked about experience of STI diagnoses, and circumcision. Additionally, 1,850 urine samples from sexually-experienced men aged 16-44 years were collected and tested for STIs. Multivariable logistic regression was used to calculate adjusted odds ratios (AOR) to quantify associations between circumcision and i) self-reporting any STI diagnosis and ii) presence of STIs in urine, in men aged 16-44 years, adjusting for key socio-demographic and sexual behavioural factors.

RESULTS

The prevalence of circumcision in sexually-experienced men aged 16-44 years was 17.4% (95%CI 16.0-19.0). There was no association between circumcision and reporting any previous STI diagnoses, and specifically previous chlamydia or genital warts. However, circumcised men were less likely to have any HPV type (AOR 0.26, 95% confidence interval (CI) 0.13-0.50) including high-risk HPV types (HPV-16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and/or 68) (AOR 0.14, 95% CI 0.05-0.40) detected in urine.

CONCLUSIONS

Circumcised men had reduced odds of HPV detection in urine. These findings have implications for improving the precision of models of STI transmission in populations with different circumcision prevalence and in designing interventions to reduce STI acquisition.

Common sexually transmitted infections in adolescents

Adolescents are often at higher risk for acquiring sexually transmitted infections (STIs). Medical providers should be alert for both asymptomatic and symptomatic STIs, and follow appropriate screening guidelines. Moreover, providers need to know how to best administer adolescent-friendly confidential care, treatment, and health education in the primary care setting. This article addresses the most common adolescent STIs and pertinent recommendations for screening, diagnosis, and management of infections, in addition to a brief focused discussion on human immunodeficiency virus and adolescents.

Infant male circumcision: healthcare provider knowledge and associated factors

BACKGROUND AND OBJECTIVES

The emerging science demonstrates various health benefits associated with infant male circumcision and adult male circumcision; yet rates are declining in the United States. The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that healthcare providers present evidence-based risk and benefit information for infant male circumcision to parent(s) and guardian(s). The purpose of this study was to assess providers' level of infant male circumcision knowledge and to identify the associated characteristics.

METHODS

An online survey was administered to healthcare providers in the family medicine, obstetrics, and pediatrics medical specialties at an urban academic health center. To assess infant male circumcision knowledge, a 17 point summary score was constructed to identify level of provider knowledge within the survey.

RESULTS

Ninety-two providers completed the survey. Providers scored high for the following knowledge items: adverse event rates, protects against phimosis and urinary tract infections, and does not prevent hypospadias. Providers scored lower for items related to more recent research: protection against cervical cancer, genital ulcer disease, bacterial vaginosis, and reduction in HIV acquisition. Two models were constructed looking at (1) overall knowledge about male circumcision, and (2) knowledge about male circumcision reduction in HIV acquisition. Pediatricians demonstrated greater overall infant male circumcision knowledge, while obstetricians exhibited significantly greater knowledge for the HIV acquisition item.

CONCLUSION

Providers' knowledge levels regarding the risks and benefits of infant male circumcision are highly variable, indicating the need for system-based educational interventions.

Herpes simplex virus type 2 among mobile pastoralists in northwestern Namibia

BACKGROUND

Although herpes simplex virus type 2 (HSV-2) epidemiology has been described for many western and/or urban populations, disease burden has not been characterized for remote, non-western, under treated populations, where patterns of risk and vulnerability may be very different.

AIMS

To understand demographic, behavioural and geographic influences on risk for HSV-2 in a population of mobile, rural pastoralists in northwestern Namibia.

SUBJECTS AND METHODS

The authors conducted a cross-sectional survey of reproductively aged adults (n = 445) across 28 villages in Kaokoveld, Namibia. All participants completed a questionnaire of demographic data, ecological interactions and sexual behaviour, and a rapid test specific for HSV-2.

RESULTS

HSV-2 status was significantly associated with being female (OR = 3.1, 95% CI = 2.00, 4.71), increasing age (men: OR = 7.5, 95% CI = 2.67, 20.85; women: OR = 6.2, 95% CI = 2.48, 15.50) and with higher wealth among men (OR = 5.1, 95% CI = 1.98, 13.09).

CONCLUSIONS

Higher risk among women can be explained, in part, by local hygiene practices and a preference for "dry" sex. There was considerable variation in prevalence by region, which appears to be linked to geographic remoteness. Culturally contextualized epidemiologic studies of remote, vulnerable populations can provide essential information for limiting the introduction and spread of new infections.

Association between male circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples

BACKGROUND

Male circumcision is a primary HIV-1 prevention intervention for men, but whether the procedure reduces the risk of syphilis among men and their female partners is uncertain. We aimed to assess whether male circumcision was associated with incident syphilis in men and in their female partners.

METHODS

In this large prospective cohort study, participants were members of Kenyan and Ugandan HIV-1 serodiscordant heterosexual couples enrolled in a randomised safety and efficacy clinical trial of pre-exposure prophylaxis for HIV-1 prevention (the Partners PrEP Study). Participants attended monthly or quarterly follow-up visits for up to 36 months. Annually, syphilis serology testing was done and male circumcision status was assessed. We used multivariate Andersen-Gill survival methods, adjusted for age, sexual behaviour, and plasma HIV RNA levels of the HIV-infected partner.

FINDINGS

4716 HIV-1 serodiscordant couples (38%) with a man with HIV were followed for a median of 2·75 years. At enrolment, 1575 (53%) men with HIV and 560 (32%) men without HIV were circumcised; an additional 69 (4%) men with HIV and 132 (5%) men without HIV were circumcised during study follow-up. 221 incident syphilis infections were reported: 46 (21%) in men with HIV (incidence 1·10 per 100 person-years), 76 (34%) in men without HIV (1·09), 54 (24%) in women with HIV (0·77), and 45 (24%) in women without HIV (1·11). Male circumcision was associated with a 42% reduction in incident syphilis in men (adjusted hazard ratio [aHR] 0·58, 95% CI 0·37-0·91) including a 62% reduction in men with HIV (0·38, 0·18-0·81), and a non-significant reduction in incident syphilis in men without HIV (0·64, 0·36-1·11). In women, circumcision of their male partners was associated with a 59% reduction in incident syphilis (aHR 0·41, 95% CI 0·25-0·69), including a 75% reduction in women without HIV (0·25, 0·08-0·76) and a 48% reduction in women with HIV (0·52, 0·27-0·97).

INTERPRETATION

Male circumcision was associated with decreased risk of incident syphilis in men and women. If confirmed, these results suggest that medical male circumcision could substantially reduce incidence of syphilis and its sequelae.

FUNDING

Bill & Melinda Gates Foundation and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

A review of the current state of the male circumcision literature

INTRODUCTION

Male circumcision is one of the most commonly performed surgical procedures worldwide and a subject that has been the center of considerable debate. Recently, the American Association of Pediatrics released a statement affirming that the medical benefits of neonatal circumcision outweigh the risks. At present, however, the majority of the literature on circumcision is based on research that is not necessarily applicable to North American populations, as it fails to take into account factors likely to influence the interpretability and applicability of the results.

AIMS

The purpose of this review is to draw attention to the gaps within the circumcision literature that need to be addressed before significant changes to public policy regarding neonatal circumcision are made within North America.

METHODS

A literature review of peer-reviewed journal articles was performed.

MAIN OUTCOME MEASURES

The main outcome measure was the state of circumcision research, especially with regard to new developments in the field, as it applies to North American populations.

RESULTS

This review highlights considerable gaps within the current literature on circumcision. The emphasis is on factors that should be addressed in order to influence research in becoming more applicable to North American populations. Such gaps include a need for rigorous, empirically based methodologies to address questions about circumcision and sexual functioning, penile sensitivity, the effect of circumcision on men's sexual partners, and reasons for circumcision. Additional factors that should be addressed in future research include the effects of age at circumcision (with an emphasis on neonatal circumcision) and the need for objective research outcomes.

CONCLUSION

Further research is needed to inform policy makers, health-care professionals, and stakeholders (parents and individuals invested in this debate) with regard to the decision to perform routine circumcision on male neonates in North America.

Male Circumcision and HIV Transmission; What Do We Know?

Male circumcision (MC) has been shown to be protective against heterosexual HIV transmission and is being explored in some parts of the world as a means of combating the epidemic. The World Health Organization (WHO) recommends that MC be considered as an important component of HIV prevention in high prevalence settings.

We review evidence that demonstrates that the inner foreskin is likely to be the main portal of entry for the HIV virus in males. Whether removal of the inner foreskin accounts for all the protection afforded by circumcision is yet to be established.

The proposed mechanisms of protection range from inherent immunohistological factors of foreskin such as difference in thickness of keratin layer and density of target cells for HIV between inner and outer foreskin to physiological mechanisms that follow male circumcision such as drying of secretions underneath foreskin after sexual intercourse, loss of microbiome that attract target cells to the genital mucosa and lack of priming the genital mucosa with less abundant sexual transmitted infections among circumcised men.

The aim of this review is to give an updated account on the mechanisms proposed so far on the demonstrated 50-70% protection from HIV transmission through heterosexual intercourse, by male circumcision.

Syphilis 1855 and HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms

In this paper, I discuss the parallels between responses to syphilis in nineteenth century Britain and HIV/AIDS in contemporary Africa. In each case, an incurable disease connected with sexual behaviour aroused fear, stigmatisation and moralistic responses, as well as a desperate scramble to find an effective means of control. In both cases, circumcision of adult males, and then of children or infants, was proposed as the key tactic. In the ensuing debates over the effectiveness and propriety of this approach, three questions occupied health authorities in both Victorian Britain and the contemporary world: (1) Were circumcised men at significantly lower risk of these diseases? (2) If there was evidence pointing to an affirmative answer, was it altered anatomy or different behaviour that explained the difference? (3) Given that circumcision was a surgical procedure with attendant risks of infection, was it possible that circumcision spread syphilis or HIV? I show that in both situations the answers to these questions were inconclusive, argue that circumcision played little or no role in the eventual control of syphilis and suggest that attention to nineteenth century debates may assist contemporary policy-makers to avoid the treatment dead-ends and ethical transgressions that marked the war on syphilis.

Microbiome in human immunodeficiency virus infection

Human immunodeficiency virus (HIV) primary infection occurs at mucosa tissues, suggesting an intricate interplay between the microbiome and HIV infection. Recent advanced technologies of high-throughput sequencing and bioinformatics allow researchers to explore nonculturable microbes, including bacteria, virus, and fungi, and their association with diseases. HIV/simian immunodeficiency virus infection is associated with microbiome shifts and immune activation that may affect the outcome of disease progression. In this review, the authors focus on microbiome in HIV infection at various mucosal compartments. Understanding the relationship between microbiome and HIV may offer insights into development of better strategies for HIV prevention and treatment.

Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision

In a recent issue of the Journal of Medical Ethics,Svoboda and Van Howe commented on the 2012 changein the American Academy of Pediatrics (AAP) policy on newborn male circumcision, in which the AAP stated that benefits of the procedure outweigh the risks. Svoboda and Van Howe disagree with the AAP conclusions. We show here that their arguments against male circumcision are based on a poor understanding of epidemiology,erroneous interpretation of the evidence, selective citation of the literature, statistical manipulation of data, and circular reasoning. In reality, the scientific evidence indicates that male circumcision, especially when performed in the newborn period, is an ethically and medically sound low-risk preventive health procedure conferring a lifetime of benefits to health and well-being.Policies in support of parent-approved elective newborn circumcision should be embraced by the medical,scientific and wider communities.

Skin care: Historical and contemporary views

Primary prevention, specifically skin care, is an important principle in Islamic theology just as it is emphasized in contemporary medicine. Many skin diseases can be prevented by a proactive approach to skin care, such as proper hygiene and routine inspections, principles that are constantly highlighted in the Islamic literature. Islam promotes primary prevention of disease, including recommendations for skin care practices. The recommendations for skin care practices in Islamic teachings are analogous to current medical guidelines. Sun avoidance, which is recommended by Islam, is mandatory for diseases such as systemic lupus erythematosus, melasma and skin cancers. Skin care and hygiene practices are recommended in Islam and it is considered an important mechanism for reducing the transmission of infections in modern medicine. The body creases and hair are ideal sites for malicious infestations to grow. The practice of "Wudu" includes washing the hands, feet, and hair with clean water. It is an indispensible part of daily prayers which is mandatory for every Muslim. Oral hygiene is also an integral part of both preventive medicine and Islamic teachings. Genital hygiene, particularly after urination and defecation, is recommended in Islamic teachings and is known to prevent urinary and vaginal infections in contemporary medicine. Male circumcision is an Islamic practice. Recently, it was proven that circumcised men are less likely to have sexually transmitted diseases, including HIV. This paper reviews skin care from an Islamic perspective and its relevance to contemporary medicine by translating the simple self care principles into practical guidelines in everyday use.

Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny

We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered original data, in the case of human papillomavirus (HPV), by questionable adjustments for "sampling bias," (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health policy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.

Halting and reversing HIV epidemics in Asia by interrupting transmission in sex work: experience and outcomes from ten countries

HIV epidemics spread rapidly through Asian sex work networks two decades ago under conditions of high vulnerability, low condom use, intact male foreskins and ulcerative STIs. Experiences implementing interventions to prevent transmission in sex work in ten Asian countries were reviewed. All report increasing condom use trends in sex work. In the seven countries where condom use exceeds 80%, surveillance and other data indicate declining HIV trends or low and stable HIV prevalence with declining STI trends. All four countries with national-level HIV declines among sex workers have also documented significant HIV declines in the general population. While all interventions in sex work included outreach, condom programing and STI services, the largest declines were found in countries that implemented structural interventions on a large scale. Thailand and Cambodia, having controlled transmission early, are closest to providing universal access to HIV care, support and treatment and are exploring HIV elimination strategies.

Circumcision rates in the United States: rising or falling? What effect might the new affirmative pediatric policy statement have?

The objective of this review was to assess the trend in the US male circumcision rate and the impact that the affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circumcision practice. We searched PubMed for the term circumcision to retrieve relevant articles. This review was prompted by a recent report by the Centers for Disease Control and Prevention that found a slight increase, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the past decade. There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and 44% in Hispanic males. Because data on neonatal circumcision are equivocal, we undertook a critical analysis of hospital discharge data. After correction for underreporting, we found that the percentage had declined from 83% in the 1960s to 77% by 2010. A risk-benefit analysis of conditions that neonatal circumcision protects against revealed that benefits exceed risks by at least 100 to 1 and that over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin. Other analyses show that neonatal male circumcision is cost-effective for disease prevention. The benefits of circumcision begin in the neonatal period by protection against infections that can damage the pediatric kidney. Given the substantial risk of adverse conditions and disease, some argue that failure to circumcise a baby boy may be unethical because it diminishes his right to good health. There is no long-term adverse effect of neonatal circumcision on sexual function or pleasure. The affirmative 2012 American Academy of Pediatrics policy supports parental education about, access to, and insurance and Medicaid coverage for elective infant circumcision. As with vaccination, circumcision of newborn boys should be part of public health policies. Campaigns should prioritize population subgroups with lower circumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision.

Differences in risky sexual behaviors and HIV prevalence of circumcised and uncircumcised men in Uganda: evidence from a 2011 cross-sectional national survey

Background

Safe male circumcision (SMC) is a known efficacious intervention in the prevention of heterosexual HIV acquisition. However, there are perceptions that SMC may lead to behavior disinhibition towards risky sexual behaviors. We assessed the association between male circumcision, risky sexual behaviors and HIV prevalence among men in a nationally representative sample.

Methods

Data was extracted from the Uganda AIDS Indicator Survey (2011), a stratified two-stage cluster sample, with a total of 7,969 ever sexually active men aged 15–59 years. The association between risky sexual behaviors (non- marital/non-cohabiting sexual relations, non-use of condoms, transactional sex, multiple (4+) lifetime partners) and male circumcision status were determined using odds ratios (OR) and their 95% confidence intervals, through logistic regression models. All analyses were conducted in Stata version 12.

Results

Overall, the prevalence of male circumcision was 28%; higher among men aged 25–34 years, 32%, and lowest among those aged 45–59 years, 18%. HIV prevalence was significantly lower among the circumcised, 4.8% compared to the uncircumcised men, 7.8% (p < 0.001). The commonest risky sexual behaviors were multiple life-time sexual partners (4+), 59%; non-use of condoms with non-marital sexual partners, 55%; and having non-marital sex, 33%. In comparison with the uncircumcised, circumcised men had higher odds of engaging in non-marital sex AOR = 1.26 (95% CI: 1.05-1.52), reporting multiple (4+) life-time partners, AOR = 1.46 (95% CI: 1.27-1.67). The odds of non-use of condoms with a non-marital partner were also significantly lower among the circumcised compared to the uncircumcised men, AOR = 0.79 (95% CI: 0.63-0.98).

Conclusions

Although risky sexual behaviors were more common among circumcised men, HIV prevalence was lower among the circumcised men relative to the uncircumcised. These observations suggest a need to promote the already known HIV intervention strategies especially among the circumcised men.

Epidemiology, clinical features, diagnosis and treatment of Haemophilus ducreyi - a disappearing pathogen?

Chancroid, caused by Haemophilus ducreyi, has declined in importance as a sexually transmitted pathogen in most countries where it was previously endemic. The global prevalence of chancroid is unknown as most countries lack the required laboratory diagnostic capacity and surveillance systems to determine this. H. ducreyi has recently emerged as a cause of chronic skin ulceration in some South Pacific islands. Although no antimicrobial susceptibility data for H. ducreyi have been published for two decades, it is still assumed that the infection will respond successfully to treatment with recommended cephalosporin, macrolide or fluoroquinolone-based regimens. HIV-1-infected patients require careful follow-up due to reports of treatment failure with single dose regimens. Buboes may need additional treatment with either aspiration or excision and drainage.

Is Sex Like Driving? HIV Prevention and Risk Compensation

Risk compensation has been called the "Achilles' heel" of HIV prevention policies (Cassell et al 2006). This paper examines the behavioral response to male circumcision, a major HIV prevention policy currently being implemented throughout much of Sub-Saharan Africa. Contrary to the presumption of risk compensation, we find that the response due to the perceived reduction in HIV transmission appears to have been a reduction in risky sexual behavior. We suggest a mechanism for this finding: circumcision may reduce fatalism about acquiring HIV/AIDS and increase the salience of the tradeoff between engaging in additional risky behavior and avoiding acquiring HIV. We also find what appears to be a competing effect that does not operate through the circumcision recipient's belief about the reduction in the risk of acquiring HIV.

The effect of circumcision on young adult sexual function

Whether sexual function is affected by circumcision is a subject of considerable debate among advocate and opponent opinions. We analyzed the sexual function of young men, and the differences between those who were uncircumcised and circumcised, in Taiwan. A total of 506 patients who received circumcision between January 2009 and March 2011 at the urology department in our center were enrolled. Before circumcision, the patients' sexual performances were evaluated using the International Index of Erectile Function-5 (IIEF-5), and the Brief Male Sexual Function Inventory (BMSFI) questionnaires. They were evaluated using the questionnaires again, after a postoperative interval of 90 days. Furthermore, intravaginal ejaculation latency times (IELT) of the patients were also measured. The IELT and scores in five main domains of the BMSFI, and IIEF, before and after circumcision, were analyzed. A total of 442 patients were available for follow up. The mean age was 25.14 ± 4.46 years (range = 19-35 years). The differences in the BMSFI scores were statistically significant (p < 0.001), especially in increasing sex drive after circumcision (p < 0.001). The IIEF-5 score showed no statistically difference before and after circumcision (p = 0.141). However, after the circumcision, the participants had more erection confidence (p < 0.001), more difficulty in maintaining erections in completing intercourse (p = 0.01), and showed lower IELT scores (p = 0.06). The sexual performance, especially with regards to sex drive and mental erection confidence, seemed to have improved among the patients after circumcision. Our findings may help urologists to better counsel young men receiving circumcisions.

Acceptance of male circumcision among male rural-to-urban migrants in western China

To describe the acceptability of male circumcision (MC) and explore potential factors associated with MC acceptability among male rural-to-urban migrants in western China, a cross-sectional survey of MC acceptability was conducted with 1,904 subjects in three western provinces with high HIV prevalence (Guangxi, Chongqing, and Xinjiang) in China between June 2009 and November 2009. Through face-to-face interviews, the participants completed a self-administered questionnaire about demographics, MC knowledge, willingness and reasons to accept or refuse MC, sexual behaviors, and other psychosocial variables. Factors associated with acceptability of MC were identified by multiple logistic regression analysis. Of the participants (n=1,904), 710 men were willing to accept MC (37.3%); the reasons included promotion of the partners' genital hygiene (54.9%), redundant prepuce or phimosis (43.1%), enhancement of sexual pleasure (40.6%), prevention of penile inflammation or cancer (35.5%), and protection against HIV and sexual transmitted diseases (STDs)(31.1%). A multivariable logistic regression showed that four factors were associated with acceptability of MC, including education level (OR=1.286, 95% CI=1.025~1.614), redundant prepuce or phimosis (OR=13.751, 95% CI=10.087~18.745), having one or more circumcised friends (OR=2.468, 95% CI=1.953~3.119), and having sexual intercourse with a temporary partner in the past year (OR=1.543, 95% CI=1.101~2.162). Compared with previously published data among the general population in China or worldwide, the acceptability of MC (37.3%) was low among the male rural-to-urban migrants in western China. Nevertheless, appropriate education could greatly improve the acceptability of MC. More public campaigns and health education on MC are needed to increase the rate of MC in China.

Medical male circumcision and herpes simplex virus 2 acquisition: posttrial surveillance in Kisumu, Kenya

BACKGROUND

We estimated the 72-month efficacy of medical male circumcision (MMC) against herpes simplex virus 2 (HSV-2) incidence among men in the Kisumu MMC randomized trial.

METHODS

From 2002 to 2005, 2784 men aged 18-24 were enrolled and randomized 1:1 to immediate circumcision or control. Cox proportional hazards regression incorporating stabilized inverse probability of treatment and censoring weights generated through marginal structural modeling was used to estimate the efficacy of MMC on HSV-2 risk. Conventional conditional Cox regression identified multivariable risks for HSV-2 seroconversion.

RESULTS

Among 2044 HSV-2 seronegative men at baseline, the cumulative 72-month HSV-2 incidence was 33.5% (32.7% among circumcised men, 34.6% among uncircumcised men). In weight-adjusted Cox regression, the hazard ratio was 0.88 (95% confidence interval, .77-1.10). In multivariable analyses, risks for HSV-2 included human immunodeficiency virus (HIV) infection, genital ulcer disease (GUD), penile epithelial trauma, multiple recent sex partners, and being married /cohabiting.

CONCLUSIONS

MMC had no effect on acquisition of HSV-2 during 72 months of follow-up. The temporal sequence and limited correlation between HSV-2, GUD, and penile epithelial trauma suggests that these are distinct phenomena rather than misclassification of HSV-2 symptoms. Determining the etiology of non-sexually transmitted infection GUD and penile epithelial trauma is needed, as both are commonly occurring risks for HSV-2 and HIV acquisition.

CLINICAL TRIALS REGISTRATION

NCT0005937.

Non-therapeutic male circumcision performed on immigrant children from Africa in Spain

OBJECTIVES

To study the frequency, characteristics, and complications of non-therapeutic male circumcision on immigrant children from Africa in Spain.

METHODS

This descriptive study focused on primary care consultations conducted at 21 Aragon health centres during 2010 and 2011. The data were gathered through interviewer-administered questionnaires to the parents of African children. Sociodemographic variables were studied, along with others related to the practice of circumcision.

RESULTS

283 questionnaires were obtained. 98.93 % of the children had undergone or were planning to undergo circumcision. 68.2 % were circumcised. Circumcisions were most frequently performed during a vacation to the country of origin (67.04 %), especially so for the Maghreb population. The remaining circumcisions had been performed in Spain. Half of the circumcisions practiced in Spain were performed at home, and 84 % of these were performed on Gambian children.

CONCLUSIONS

The current study demonstrates that, in Aragon, Spain, almost all immigrant children from Africa have been or will be circumcised and that a considerable proportion has been circumcised at home by unqualified individuals. Gambians are particularly at risk of performing unsafe circumcision.