Impact of male circumcision on risk of HIV infection in men in a changing epidemic context - systematic review and meta-analysis

Validation of self-reported male circumcision status and genital ulcer disease among Ugandan men

OBJECTIVE

Voluntary medical male circumcision (MC) is a critical tool in combination HIV prevention programmes in Africa. Self-reported MC (SrMC) status is used in HIV epidemiological surveys to assess MC coverage but is subject to response bias with limited validation. This study evaluated the utility of SrMC status as a marker of MC as well as self-reported genital lesions for genital ulcer disease (GUD) among Ugandan men.

METHODS

Male participants aged 18-49 years in the cross-sectional Sexually Transmitted Infection Prevalence study, conducted between May and October 2019, responded to a questionnaire capturing SrMC status and current genital ulcer symptoms followed by clinical assessment to verify MC and presence of GUD.Sensitivity, specificity, positive predictive value, negative predictive value and corresponding CIs (95% CI) for SrMC status and GUD were estimated.

RESULTS

There were 853 male participants, of whom 470 (55.1%) self-reported being circumcised and 23 (2.7%) self-reported GUD (SrGUD). MC was clinically confirmed in 50.2% (n=428) of participants with sensitivity of SrMC status at 99% (95% CI: 98% to 100%) and specificity 89% (95% CI: 86% to 92%). Specificity of SrMC was lowest among persons living with HIV and viremic (>1000 copies/mL) at 72% (95% CI: 46% to 90%). 18 participants had clinically confirmed GUD, but only 12 SrGUD symptoms, corresponding to a sensitivity and specificity of 67% (95% CI: 41% to 87%) and 99% (95% CI: 98% to 99%), respectively.

CONCLUSIONS

SrMC status is a robust proxy for clinically confirmed MC status and may reliably be used to assess MC coverage in this setting. Conversely, GUD symptoms were under-reported, which may impact effective syndromic management of sexually transmitted infections and warrants further examination.

Comment on 'Changing relationships between HIV prevalence and circumcision in Lesotho', and 'Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa'

Two articles by Garenne (2023a,b) argue that voluntary medical male circumcision does not reduce human immunodeficiency virus transmission in Africa. Here we point out key evidence and analytical flaws that call into question this conclusion.

HIV infection

The AIDS epidemic has been a global public health issue for more than 40 years and has resulted in ~40 million deaths. AIDS is caused by the retrovirus, HIV-1, which is transmitted via body fluids and secretions. After infection, the virus invades host cells by attaching to CD4 receptors and thereafter one of two major chemokine coreceptors, CCR5 or CXCR4, destroying the host cell, most often a T lymphocyte, as it replicates. If unchecked this can lead to an immune-deficient state and demise over a period of ~2-10 years. The discovery and global roll-out of rapid diagnostics and effective antiretroviral therapy led to a large reduction in mortality and morbidity and to an expanding group of individuals requiring lifelong viral suppressive therapy. Viral suppression eliminates sexual transmission of the virus and greatly improves health outcomes. HIV infection, although still stigmatized, is now a chronic and manageable condition. Ultimate epidemic control will require prevention and treatment to be made available, affordable and accessible for all. Furthermore, the focus should be heavily oriented towards long-term well-being, care for multimorbidity and good quality of life. Intense research efforts continue for therapeutic and/or preventive vaccines, novel immunotherapies and a cure.

Factors Beyond Compensation Associated with Uptake of Voluntary Medical Male Circumcision in Zambia

Voluntary medical male circumcision (VMMC) provides partial protection against female-to-male transmission of HIV. The Maximizing the Impact of Voluntary Medical Male Circumcision in Zambia (MAXZAM) project was a phased implementation of a demand generation strategy for VMMC through economic compensation. Previously published findings showed increased uptake of VMMC when compensation was provided. This paper is a follow-up evaluation of the MAXZAM project exploring additional factors associated with uptake of VMMC. Factors found associated include the outreach setting in which men were approached, number of information sources seen, heard, or read about VMMC, their self-reported HIV risk behaviors, their self-reported intention to go through the procedure, and their behavioral-psychographic profile. The findings highlight the importance of considering general (e.g., intensifying mass communications and targeting specific settings) and person-centered demand generation approaches (e.g., considering the client's psychographic profile and HIV risk level) to maximize effect on VMMC uptake.

Traditional male circumcision and the risk for HIV transmission among men: a systematic review

OBJECTIVES

To synthesise evidence to determine whether, in contrast to medical male circumcision, traditional male circumcision (TMC) practices may contribute to HIV transmission and what the impacts of TMC are on the initiates, their families and societies.

DESIGN

Systematic review.

DATA SOURCE

PubMed, CINHAL, SCOPUS, ProQuest, Cochrane database and Medline were searched between 15 and 30 October 2022.

ELIGIBILITY CRITERIA

(1) Studies involving young men, young male adults, male adults and mixed male and female participants; (2) studies on TMC involving men living with HIV (married and non-married); (3) studies on TMC, HIV transmission and impact in low-income and middle-income countries; (4) qualitative, quantitative and mixed-method studies and (5) studies aimed at exploring TMC and how it contributes to HIV transmission and the impacts of HIV on circumcised men and their families.

DATA EXTRACTION

Data were extracted based on study details, study design, characteristics of participants and results.

RESULT

A total of 18 studies were included: 11 were qualitative studies, five were quantitative studies and two were mixed-method studies. All the studies included were conducted in areas where TMC was performed (17 in Africa and one in Papua New Guinea). The review's findings were categorised into themes: TMC as a cultural practice, consequences of not being traditionally circumcised on men and their families and TMC-related risk of HIV transmission.

CONCLUSION

This systematic review highlights that TMC practice and HIV risk could negatively impact men and their families. Existing evidence suggests that little attention has been paid to men and their families experiencing the impacts of TMC and HIV risk factors. The findings recommend the need for health intervention programmes such as safe circumcision and safe sexual behaviours following TMC and efforts to address psychological and social challenges in communities practising TMC.

PROSPERO REGISTRATION NUMBER

CRD42022357788.

A review of public health, social and ethical implications of voluntary medical male circumcision programs for HIV prevention in sub-Saharan Africa

Ideally, the benefits of public health interventions should outweigh any associated harms, burdens, and adverse unintended consequences. The intended benefit of voluntary medical male circumcision (VMMC) programs in eastern and southern Africa (ESA) is the reduction of HIV infections. We review the literature for evidence of reductions in HIV incidence, evaluate the extent to which decreases in HIV incidence can be reasonably attributed to VMMC programs, and summarize social harms and ethical concerns associated with these programs. Review findings suggest that HIV incidence had been declining across ESA since before the large-scale rollout of VMMC as a public health intervention, and that this decline may be due to the combined effects of HIV prevention and treatment interventions, such as expanded antiretroviral therapy. The independent effect of VMMC programs in reducing HIV infections at the population level remains unknown. On the other hand, VMMC-associated evidence is increasing for the existence of negative social impacts such as stigmatization and/or discrimination, and ethically problematic practices, including lack of informed consent. We conclude that the relationship between the benefits and burdens of VMMC programs may be more unfavorable than what has been commonly suggested by proponents of global VMMC campaigns.

Voluntary Medical Male Circumcision to Reduce HIV Acquisition and Transmission

PURPOSE OF REVIEW

This commentary introduces the special Global Health Section on the state of voluntary medical male circumcision (VMMC) programs and current knowledge as to role of VMMC prevention of HIV infection acquisition in men and, indirectly, women.

RECENT FINDINGS

Since the first clinical trial of VMMC in Africa was published in 2005, implementation of programs has depended on illuminating best practices and key obstacles in the effort to expand VMMC in areas of high HIV prevalence to reduce HIV acquisition among men, with consequent benefits that uninfected men will not infect others. Global efforts are focused on sub-Saharan Africa, given the favorable expected impact of VMMC deployment where HIV incidence is high and circumcision rates are low. With estimated field effectiveness estimated to exceed 60%, reduced HIV risk for circumcised men in sub-Saharan Africa based on a once-only minor surgical intervention provides extraordinary preventive benefits. Where high VMMC rates have been achieved, declining HIV incidence rates may be partially or substantially attributed to VMMC, but this remains to be investigated. Articles in this special section address achievements, obstacles and risks, and plans for future progress in partnership with affected communities.

Male Circumcision and Genital Human Papillomavirus (HPV) Infection in Males and Their Female Sexual Partners: Findings From the HPV Infection and Transmission Among Couples Through Heterosexual Activity (HITCH) Cohort Study

BACKGROUND

Previous studies examining the association between male circumcision (MC) and human papillomavirus (HPV) infections have reported inconsistent results. We used data from the HPV Infection and Transmission Among Couples Through Heterosexual Activity (HITCH) cohort study to examine the association between MC and HPV infections in males and their female sexual partners.

METHODS

We enrolled monogamous couples in a longitudinal study between 2005 and 2011 in Montreal, Canada. We used logistic and Poisson regression models with propensity score adjustment to estimate odds ratios (ORs) and rate ratios for the association between MC and the prevalence, transmission, and clearance of HPV infections.

RESULTS

Four hundred thirteen couples were included in our study. The prevalence OR for the association between MC and baseline infections was 0.81 (95% confidence interval [CI], .56-1.16) in males and 1.05 (95% CI, .75-1.46) in females. The incidence rate ratio for infection transmission was 0.59 (95% CI, .16-2.20) for male-to-female transmission and 0.77 (95% CI, .37-1.60) for female-to-male transmission. The clearance rate ratio for clearance of infections was 0.81 (95% CI, .52-1.24).

CONCLUSIONS

We found little evidence of an association between MC and HPV infection prevalence, transmission, or clearance in males and females. Further longitudinal couple-based studies are required to investigate this association.

Voluntary medical male circumcision in selected provinces in South Africa: Outcomes from a programmatic setting

Introduction

Voluntary medical male circumcision (VMMC) remains an effective biomedical intervention for HIV prevention in high HIV prevalence countries. In South Africa, United States Agency for International Development VMMC partners provide technical assistance to the Department of Health, at national and provincial levels in support of the establishment of VMMC sites as well as in providing direct VMMC services at site level since April 2012. We describe the outcomes of the Right to Care (RTC) VMMC program implemented in South Africa from 2012 to 2017.

Methods

This retrospective study was undertaken at RTC supported facilities across six provinces. Young males aged ≥10 years who presented at these facilities from 1 July 2012 to 31 September 2017 were included. Outcomes were VMMC uptake, HIV testing uptake and rate of adverse events (AEs). Using a de-identified observational database of these clients, summary statistics of the demographic characteristics and outcomes were calculated.

Results

There were a total 1,001,226 attendees of which 998,213 (99.7%) were offered VMMC and had a median age of 15 years (IQR = 12–23 years). Of those offered VMMC, 99.6% (994,293) consented, 96.7% (965,370) were circumcised and the majority (46.3%) were from Gauteng province. HIV testing uptake was 71% with a refusal rate of 15%. Of the newly diagnosed HIV positives, 64% (6,371 / 9,972) referrals were made. The rate of AEs, defined as bleeding, infection, and insufficient skin removal) declined from 3.26% in 2012 to 1.17% in 2017. There was a reduction in infection-related AEs from 2,448 of the 2,602 adverse events (94.08%) in 2012 to 129 of the 2,069 adverse events (6.23%) in 2017.

Conclusion

There was a high VMMC uptake with a decline in AEs over time. Adolescent men contributed the most to the circumcised population, an indication that the young population accesses medical circumcision more. VMMC programs need to implement innovative demand creation strategies to encourage older males (20–34 years) at higher risk of HIV acquisition to get circumcised for immediate impact in reduction of HIV incidence. HIV prevalence in the total population increased with increasing age, notably in clients above 25 years.

Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns

The Middle East and north Africa is one of only two world regions where HIV incidence is on the rise, with most infections occurring among key populations: people who inject drugs, men who have sex with men, and female sex workers. In this Review, we show a trend of increasing HIV prevalence among the three key populations in the Middle East and north Africa. Although the epidemic continues at a low level in some countries or localities within a country, there is evidence for concentrated epidemics, with sustained transmission at considerable HIV prevalence among people who inject drugs and men who have sex with men in over half of countries in the region with data, and among female sex workers in several countries. Most epidemics emerged around 2003 or thereafter. The status of the epidemic among key populations remains unknown in several countries due to persistent data gaps. The HIV response in Middle East and north Africa remains far below global targets for prevention, testing, and treatment. It is hindered by underfunding, poor surveillance, and stigma, all of which are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19. Investment is needed to put the region on track towards the target of eliminating HIV/AIDS as a global health threat by 2030. Reaching this target will not be possible without tailoring the response to the needs of key populations, while addressing, to the extent possible, the complex structural and operational barriers to success.

Ethical implications of economic compensation for voluntary medical male circumcision for HIV prevention and epidemic control

Despite tremendous efforts in fighting HIV over the last decades, the estimated annual number of new infections is still a staggering 1.5 million. There is evidence that voluntary medical male circumcision (VMMC) provides protection against men's heterosexual acquisition of HIV-1 infection. Despite good progress, most countries implementing VMMC for HIV prevention programmes are challenged to reach VMMC coverage rates of 90%. Particularly for men older than 25 years, a low uptake has been reported. Consequently, there is a need to identify, study and implement interventions that could increase the uptake of VMMC. Loss of income and incurred transportation costs have been reported as major barriers to uptake of VMMC. In response, it has been suggested to use economic compensation in order to increase VMMC uptake. In this discussion paper, we present and review relevant arguments and concerns to inform decision-makers about the ethical implications of using economic compensation, and to provide a comprehensive basis for policy and project-related discussions and decisions.

Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges

PURPOSE OF REVIEW

Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations.

RECENT FINDINGS

Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.

The lived experience of HIV-infected patients in the face of a positive diagnosis of the disease: a phenomenological study

Background

AIDS as a human crisis may lead to devastating psychological trauma and stress for patients. Therefore, it is necessary to study different aspects of their lives for better support and care. Accordingly, this study aimed to explain the lived experience of HIV-infected patients in the face of a positive diagnosis of the disease.

Methods

This qualitative study is a descriptive phenomenological study. Sampling was done purposefully and participants were selected based on the inclusion and exclusion criteria. Data collection was conducted, using semi-structured interviews. Data analysis was performed using Colaizzi’s method.

Results

12 AIDS patients participated in this study. As a result of data analysis, 5 main themes and 12 sub-themes were identified, which include: emotional shock (loathing, motivation of social isolation), the fear of the consequences (fear of the death, fear of loneliness, fear of disgrace), the feeling of the guilt (feeling of regret, feeling guilty, feeling of conscience-stricken), the discouragement (suicidal ideation, disappointment), and the escape from reality (denial, trying to hide).

Conclusion

The results of this study showed that patients will experience unpleasant phenomenon in the face of the positive diagnosis of the disease and will be subjected to severe psychological pressures that require attention and support of medical and laboratory centers.

Patients will experience severe psychological stress in the face of a positive diagnosis of HIV.

Patients who are diagnosed with HIV are prone to make a blunder and dreadful decisions.

AIDS patients need emotional and informational support when they receive a positive diagnosis.

As a piece of bad news, presenting the positive diagnosis of HIV required the psychic preparation of the patient

Barriers, benefits, and behaviour: Voluntary medical male circumcision ideation in a population-based sample of Zambian men

Reaching ambitious voluntary medical male circumcision (VMMC) coverage targets requires a deeper understanding of the multifaceted processes shaping men's willingness to access VMMC. Guided by the Ideation Model for Health Communication, this population-based study identifies correlates of Zambian men's future VMMC intentions. Multistage cluster sampling was used to identify households with adult men in 14 districts. Multivariable Poisson regression with robust standard errors modelled associations of future VMMC intent with ideational factors (e.g. perceived benefits and barriers) and sexual behaviours respectively. Forty per cent (40%) of uncircumcised men (N = 1 204) expressed future VMMC intentions. In multivariable analysis, VMMC intent was associated with secondary education or higher (Adjusted Prevalence Ratio [APR] 1.30, 95% Confidence Interval [95% CI]: 1.02-1.66), perceiving VMMC to increase sexual satisfaction (APR 1.45, 95% CI: 1.11-1.89), reporting distance to services as a barrier to VMMC uptake (APR = 0.54, 95% CI: 1.27-1.87), unprotected last sex (APR 1.54, 95% CI: 1.11-2.14), and ≥ 2 sexual partners in the past 12 months (APR 1.45, 95% CI: 1.05-1.99). Being aged ≥ 45 years (vs 18-24 years: APR 0.23, 95% CI: 0.13-0.40) and perceiving that circumcision: (1) is unimportant (APR 0.71, 95% CI: 0.51-0.98); (2) is incompatible with local customs (APR 0.41, 95% CI: 0.18-0.94); or (3) reduces sexual satisfaction (APR 0.10, 95% CI: 0.02-0.62) were inversely associated with future VMMC intent. Demand-creation efforts must confront salient cognitive and social barriers to VMMC uptake, including concerns around incompatibility with local customs. Simultaneously, promotional efforts should emphasise relevant VMMC benefits beyond HIV prevention that resonate with men (e.g. penile hygiene) without reinforcing harmful gender norms.

Genital Abnormalities, Hormonal Contraception, and Human Immunodeficiency Virus Transmission Risk in Rwandan Serodifferent Couples

BACKGROUND

We explored the role of genital abnormalities and hormonal contraception in human immunodeficiency virus (HIV) transmission among heterosexual serodifferent couples in Rwanda.

METHODS

From 2002 to 2011, HIV-serodifferent couples who were not using antiretroviral treatment were followed up, and sociodemographic and clinical data were collected, family planning provided, and HIV-negative partners retested. Couples were assessed for genital ulcers; nonulcerative genital sexually transmitted infection (STIs), including gonorrhea, chlamydia, and trichomoniasis; and non-STI vaginal infections, including bacterial vaginosis and candida. Multivariable models evaluated associations between covariates and HIV transmission genetically linked to the index partner.

RESULTS

Among 877 couples in which the man was HIV positive, 37 linked transmissions occurred. Factors associated with women's HIV acquisition included genital ulceration in the female partner (adjusted hazard ratio, 14.1) and nonulcerative STI in the male partner (8.6). Among 955 couples in which the woman was HIV positive, 46 linked transmissions occurred. Factors associated with HIV acquisition in men included nonulcerative STI in the female partner (adjusted hazard ratio, 4.4), non-STI vaginal dysbiosis (7.1), and genital ulceration in the male partner (2.6). Hormonal contraception use was not associated with HIV transmission or acquisition.

CONCLUSIONS

Our findings underscore the need for integrating HIV services with care for genital abnormalities. Barriers (eg, cost of training, demand creation, advocacy, and client education; provider time; and clinic space) to joint HIV/STI testing need to be considered and addressed.

Creation of a pioneering interdisciplinary genital dermatology unit for Hispanic men: First 269 patients

The role of circumcision in partially protecting against sexually transmitted infections (STIs) and other dermatoses has been documented. Neonatal circumcision is not routinely practiced in South America. Although it is logical to assume that male genital dermatoses are more prevalent in Hispanic men, they are underrepresented in the existing literature. Objective: To describe the epidemiological characteristics from our male genital dermatology unit in Montevideo (Uruguay), the diagnoses, and correlate them with circumcision status and comorbidities. Methods: A retrospective observational cohort study was conducted. A dermatologist and urologist evaluated all patients using standard questionnaires. In 3 years and 8 months, 269 patients were seen. Median age was 41, prevalence of neonatal circumcision was 0.7%, HIV was 4.2%, STIs were 24.9%, non-STIs were 63.9%, and both (STI + non-STI) were 11.2%. Most frequent entities: eczema/balanoposthitis (27.1%), condyloma (24.9%), and lichen sclerosus (15.6%). Data correlating circumcision and other diagnoses did not reach statistical significance. HIV was positively associated with other STIs (p < 0.05), and an association with balanoposthitis was seen; however, it did not reach statistical significance (p < 0.1). Main limitation was small sample size. This is the first study of its kind based on Hispanic patients. Collaboration between specialties proved to be fundamental. Further studies are needed in this demographic to find an association between circumcision, comorbidities, and genital dermatoses.

A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device

INTRODUCTION

A novel type of a disposable circumcision suture device (DCSD) has been proved to be effective and safe; however, a few cases of severe bleeding took place after circumcisions.

AIM

To evaluate the effectiveness of a modified double-layer pressure dressing to avoid severe bleeding after circumcision with the DCSD, in our department in a prospective randomized controlled study, and discuss the mechanism of bleeding with DCSD.

METHODS

Patients with redundant foreskin or phimosis were included between September 2018 and November 2019 and divided into 2 groups: In group A, the conventional pressure dressing was performed; in group B, an modified double-layer pressure dressing was performed.

MAIN OUTCOME MEASURE

The main outcomes and complications (surgical time, incidence of glans ischemia, severe bleeding rate, infection rate, pain level, total cost, and overall satisfaction) were collected and analyzed.

RESULTS

A total of 624 patients were recruited for this study. There was no difference in the average age and body mass index between 2 groups. No patient suffered obvious glans ischemia. In group B, lower pain level, lower incidences of severe bleeding, and better satisfaction were recorded.

CONCLUSION

The mechanism of bleeding with the DCSD was discussed in this study, and the modified pressure dressing was proved effective, safe, and easy to perform. W Jiang, J-li Fu, W-l Guo, et al. A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device. Sex Med 2021;9:100288.

The Role of Nurses and Midwives in Expanding and Sustaining Voluntary Medical Male Circumcision Services for HIV Prevention: A Systematic and Policy Review

ABSTRACT

Male circumcision reduces men's risk of acquiring HIV through heterosexual sex, and voluntary medical male circumcision (VMMC) is central to HIV prevention strategies in 15 sub-Saharan African countries. Nurses have emerged as primary VMMC providers; however, barriers remain to institutionalizing nurse-led VMMC. Patient safety concerns have hindered task sharing, and regulations governing nurse-performed VMMC are not always supportive or clear. We performed a systematic review on VMMC safety by provider cadre and a desk review of national policies governing the VMMC roles of nurses and midwives. Also, VMMC by nurses is safe and has become standard practice. Countries had multiple policy combinations among different documents, with only one disallowing VMMC by these cadres. Countries with alignment between policies often ensured that nursing workforces were equipped with clinical competencies through national certification. Regulatory clarity and formalized certification for nurse-performed VMMC can increase program sustainability and build nursing capacity to meet other critical basic surgical needs.