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Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male circumcision: A systematic review. J Evid Based Med 2019; 12:263-290. [PMID: 31496128 PMCID: PMC6899915 DOI: 10.1111/jebm.12361] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/03/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To systematically evaluate evidence against male circumcision (MC). METHODS We searched PubMed, Google Scholar, EMBASE and Cochrane databases. RESULTS Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. CONCLUSIONS Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.
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Affiliation(s)
- Brian J Morris
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | - John N Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattleWashington
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2
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Lee B, Lee SW, Kim DI, Kim JH. HPV prevalence in the foreskins of asymptomatic healthy infants and children: Systematic review and meta-analysis. Sci Rep 2017; 7:7050. [PMID: 28765591 PMCID: PMC5539194 DOI: 10.1038/s41598-017-07506-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/28/2017] [Indexed: 11/08/2022] Open
Abstract
The true HPV prevalence in the foreskins of infants and children has been little documented, but reporting on this prevalence is of great importance given its impact on the rationale for treating asymptomatic boys. We searched multiple databases from 1960 to 2016 for observational or prospective studies that reported on HPV prevalence in foreskins. We conducted a meta-analysis using a random-effects model to pool for HPV prevalence in the foreskins of infants and children. Eight studies, with a total of 556 infants and children with phimosis, were eligible for the meta-analysis. The pooled overall prevalence of general HPV, high-risk HPV, low-risk HPV, HPV 16/18, HPV 16, and HPV 18 were 17.3 (95%CI: 0.8-46.3), 12.1 (95% CI: 0.9-31.5), 2.4 (95% CI: 0.0-11.2), 4.8 (95% CI: 0.0-16.8), 1.7 (95% CI: 0.0-5.1), and 0 (95% CI: 0-0.5), respectively. The estimated HPV prevalence in foreskins was not zero among infants and children, which implies HPV transmission other than by sexual contact. Considering that high-risk HPV is detected in asymptomatic infants and children, future studies are warranted to determine whether preventive treatments in asymptomatic infants and children could be effective in preventing persistence or transmission of high-risk HPV.
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Affiliation(s)
- Bora Lee
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
- Department of Statistics, Graduate School of Chung-Ang University, Seoul, Korea
| | - Sang Wook Lee
- Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchuhyang University Medical College, Bucheon, Korea
| | - Dae In Kim
- Department of Pharmaceutical engineering, Soonchunhyang University, Asan, Korea
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Hospital, Soonchuhyang University Medical College, Seoul, Korea.
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3
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Ornellas AA, Ornellas P. Should routine neonatal circumcision be a police to prevent penile cancer? | Opinion: Yes. Int Braz J Urol 2017; 43:7-9. [PMID: 28124519 PMCID: PMC5293376 DOI: 10.1590/s1677-5538.ibju.2017.01.03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Antonio Augusto Ornellas
- Departamento de Urologia, Instituto Nacional do Câncer do Brasil (INCA), RJ, Brasil.,Departamento de Urologia Hospital Mário Kröeff, RJ, Brasil
| | - Paulo Ornellas
- Departamentos de Urologia, Hospital Souza Aguiar Hospital, Departamento de Patologia, Laboratório de Biometria Circulante, RJ, Brasil.,Programa de Pós-Graduação em Ciências Médicas (PGCM), Universidade Estadual Rio de Janeiro State, RJ, Brasil
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4
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Affiliation(s)
- Dominic H Tang
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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5
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Pop CA. Locating Purity within Corruption Rumors: Narratives of HPV Vaccination Refusal in a Peri-urban Community of Southern Romania. Med Anthropol Q 2016; 30:563-581. [PMID: 26990219 DOI: 10.1111/maq.12290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article locates the symbolic construction of "corrupted purity"-as a key assertion in Romanian parents' HPV vaccination refusal narratives-within a multiplicity of entangled rumors concerning reproduction and the state. Romania's unsuccessful HPV vaccination campaign is not unique. However, the shifting discourses around purity and corruption-through which some parents conveyed anxieties about their daughters being targeted for the vaccine-place a particular twist on the Romanian case of resisting the HPV vaccination. Parental discourses took the form of clusters of rumors about state medicine's failure to provide adequate reproductive health care, additive-laden foods, and exposure to radioactive contamination. In these rumors, corruption becomes literally embodied, through ingestion, consumption, contact, or inoculation. Parental discourses about what is being injected into their daughters' pristine bodies express their uncertainty around navigating the unsettled post-socialist medical landscape.
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Affiliation(s)
- Cristina A Pop
- Department of Sociology and Anthropology, Montana State University
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6
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Afonso LA, Cordeiro TI, Carestiato FN, Ornellas AA, Alves G, Cavalcanti SMB. High Risk Human Papillomavirus Infection of the Foreskin in Asymptomatic Men and Patients with Phimosis. J Urol 2016; 195:1784-9. [PMID: 26796413 DOI: 10.1016/j.juro.2015.12.096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE There has been increasing interest in understanding the natural history of HPV and the diseases that it causes in men. HPV infection is strongly associated with penile cancer, lack of neonatal circumcision and phimosis. We investigated the incidence of HPV infection in asymptomatic men and patients with phimosis. MATERIALS AND METHODS We assessed 110 asymptomatic men and 30 patients who underwent circumcision due to phimosis. DNA was extracted from swabbed samples collected from asymptomatic men and from foreskin samples collected at circumcision. Polymerase chain reaction using consensus primers for detecting HPV-MY09/11 was performed to detect generic HPV DNA. HPV genotyping was done by polymerase chain reaction amplification with primers for the E6 gene DNA sequences HPV6, HPV11, HPV16, HPV18, HPV31, HPV33, HPV35, HPV45 and HPV58. RESULTS HPV was present in 46.66% of patients with phimosis, of whom 50% had high risk HPV genotypes. Of asymptomatic cases 16.36% were HPV positive but only 1 sample showed high risk HPV. We detected a significantly high rate of HPV genital infection in patients presenting with phimosis compared with asymptomatic men (p = 0.00167). The prevalence of high risk HPV genotypes in patients with phimosis was also statistically significant (p = 0.0004). CONCLUSIONS We found a robust association between phimosis and the genital HPV prevalence in men and a significant frequency of high risk HPV. Other studies are needed to investigate the occurrence of factors that can increase the incidence of penile carcinoma and determine its impact on female genital infection in cervical cancer.
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Affiliation(s)
- Larissa A Afonso
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
| | - Thaissa I Cordeiro
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
| | - Fernanda N Carestiato
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
| | - Antonio Augusto Ornellas
- Department of Urology, Brazilian National Institute of Cancer and Hospital Mário Kröeff, Rio de Janeiro, Brazil.
| | - Gilda Alves
- Department of Urology, Research Coordination, Brazilian National Institute of Cancer and Circulating Biomarkers Laboratory, Department of Pathology, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sílvia M B Cavalcanti
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, Brazil
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7
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Wamai RG, Morris BJ, Bailey RC, Klausner JD, Boedicker MN. Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress. Glob Public Health 2015; 10:639-66. [PMID: 25613581 PMCID: PMC6352987 DOI: 10.1080/17441692.2014.989532] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.
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Affiliation(s)
- Richard G. Wamai
- Department of African-American Studies, Northeastern University, Boston, Massachusetts, USA
| | - Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Robert C. Bailey
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeffrey D. Klausner
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, USA
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8
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[Actual controversies about circumcision]. Presse Med 2014; 43:1168-73. [PMID: 25218249 DOI: 10.1016/j.lpm.2014.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 03/24/2014] [Accepted: 04/09/2014] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Circumcision, the oldest and most frequently performed surgery in the world, is the subject of controversies. The aim of this study was to conduct a general review of circumcision in the light of the ten questions most frequently raised in the medical community. METHODS Automated search of scientific articles published has been used by interviewing computer databases Medline and Embase from 1990 to 2013. RESULTS The results of three randomized controlled trials have provided information on preventive contributory role of this medical male circumcision. This intervention reduces the risk of acquiring HIV infection, HSV2 infection and the carrier prevalence of HPV. Male circumcision has proven to be effective in reducing the risks of penile cancer and cervical cancer in female partners of circumcised men, urinary tract infections in infants and children. Complications are rare. CONCLUSION The health benefits of circumcision balance the procedure's risks. Circumcision could be considered as a kind of "surgical vaccine", especially in developing countries to prevent the transmission of HIV infection.
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Pop CA. Cervical cancer narratives: invoking 'God's will' to re-appropriate reproductive rights in present-day Romania. CULTURE, HEALTH & SEXUALITY 2014; 17:48-62. [PMID: 25175839 DOI: 10.1080/13691058.2014.948491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Drawing from ethnographic fieldwork in contemporary Southern Romania, this paper scrutinises local moralities governing some women's refusal to enrol in free reproductive healthcare initiatives targeting cervical cancer through primary and secondary prevention (human papillomavirus [HPV] vaccination and Papanicolaou [Pap] testing, respectively). Women backed up their rejection of participation in official reproductive care programmes by mentioning 'God's will' as the ultimate trigger of cervical cancer. They withheld their own and their daughters' bodies from biomedical intervention and used discursive references to divine logic to imbue their refusal with moral legitimacy. However, 'God's will' is not a mere rhetorical device, since it has a correlate in many of these women's embodied reproductive experiences. As this paper argues, religious narratives, far from stripping ordinary citizens of their reproductive choices, constitute the medium through which they display individual agency. In fact, invoking 'God's will' empowers Romanian women to challenge state control and it enables them to re-appropriate their bodies by making a counter-intuitive, yet bold, choice.
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Affiliation(s)
- Cristina A Pop
- a Department of Anthropology , Tulane University , New Orleans , USA
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10
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Morris BJ, Tobian AAR, Hankins CA, Klausner JD, Banerjee J, Bailis SA, Moses S, Wiswell TE. Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. JOURNAL OF MEDICAL ETHICS 2014; 40:463-470. [PMID: 23955288 DOI: 10.1136/medethics-2013-101614] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
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.
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11
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Morris BJ, Hankins CA, Tobian AAR, Krieger JN, Klausner JD. Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny. ISRN UROLOGY 2014; 2014:684706. [PMID: 24944836 PMCID: PMC4040210 DOI: 10.1155/2014/684706] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 02/04/2014] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia
| | - Catherine A. Hankins
- Department of Global Health, Academic Medical Centre and Amsterdam Institute for Global Health and Development, University of Amsterdam, 1100DE, Amsterdam, The Netherlands
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Aaron A. R. Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - John N. Krieger
- Section of Urology University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Jeffrey D. Klausner
- Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095, USA
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12
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Chelimo C, Wouldes TA, Cameron LD, Elwood JM. Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. J Infect 2012; 66:207-17. [PMID: 23103285 DOI: 10.1016/j.jinf.2012.10.024] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Accepted: 10/21/2012] [Indexed: 02/07/2023]
Abstract
Genital HPV infection is associated with development of cervical cancer, cervical neoplasia, anogenital warts, and other anogenital cancers. A number of reviews have primarily addressed the role of HPV infection in cervical carcinogenesis, and differences in human papillomavirus (HPV) subtypes found in cervical cancer cases by histology and geographical region. This review provides an informative summary of the broad body of literature on the burden of HPV, the risk factors for HPV infection, genital warts and cervical cancer, and preventive measures against these conditions in females. Studies have identified the main risk factors for genital HPV infection in females as follows: acquisition of new male partners; an increasing number of lifetime sexual partners both in females and their male partners; and having non-monogamous male partners. Cervical cancer screening and HPV vaccination are the primary measures currently recommended to prevent cervical cancer. There is also an ongoing debate and conflicting findings on whether male circumcision and condom use protect against HPV infection and subsequent development of HPV-related illnesses in females.
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Affiliation(s)
- Carol Chelimo
- Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
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Goodyear-Smith FA, van Driel ML, Arroll B, Del Mar C. Analysis of decisions made in meta-analyses of depression screening and the risk of confirmation bias: a case study. BMC Med Res Methodol 2012; 12:76. [PMID: 22691262 PMCID: PMC3464667 DOI: 10.1186/1471-2288-12-76] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 06/12/2012] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Depression is common in primary care and clinicians are encouraged to screen their patients. Meta-analyses have evaluated the effectiveness of screening, but two author groups consistently reached completely opposite conclusions. METHODS We identified five systematic reviews on depression screening conducted between 2001 and 2009, three by Gilbody and colleagues and two by the United States Preventive Task Force. The two author groups consistently reached completely opposite conclusions. We analyzed two contemporaneous systematic reviews, applying a stepwise approach to unravel their methods. Decision points were identified, and discrepancies between systematic reviews authors' justification of choices made were recorded. RESULTS Two systematic reviews each addressing three research questions included 26 randomized controlled trials with different combinations in each review. For the outcome depression screening resulting in treatment, both reviews undertook meta-analyses of imperfectly overlapping studies. Two in particular, pooled each by only one of the reviews, influenced the recommendations in opposite directions. Justification for inclusion or exclusion of studies was obtuse. CONCLUSION Systematic reviews may be less objective than assumed. Based on this analysis of two meta-analyses we hypothesise that strongly held prior beliefs (confirmation bias) may have influenced inclusion and exclusion criteria of studies, and their interpretation. Authors should be required to declare a priori any strongly held prior beliefs within their hypotheses, before embarking on systematic reviews.
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Affiliation(s)
- Felicity A Goodyear-Smith
- Department of General Practice & Primary Health Care, University of Auckland, PB 92019, Auckland 1142, New Zealand
| | - Mieke L van Driel
- Discipline of General Practice, The University of Queensland, Brisbane, QLD, 4029, Australia
- Department of General Practice and Primary Health Care, Ghent University, Ghent, 9000, Belgium
- Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Bruce Arroll
- Department of General Practice & Primary Health Care, University of Auckland, PB 92019, Auckland 1142, New Zealand
| | - Chris Del Mar
- Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
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Morris BJ, Bailey RC, Klausner JD, Leibowitz A, Wamai RG, Waskett JH, Banerjee J, Halperin DT, Zoloth L, Weiss HA, Hankins CA. Review: a critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care 2012; 24:1565-75. [PMID: 22452415 PMCID: PMC3663581 DOI: 10.1080/09540121.2012.661836] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A potential impediment to evidence-based policy development on medical male circumcision (MC) for HIV prevention in all countries worldwide is the uncritical acceptance by some of arguments used by opponents of this procedure. Here we evaluate recent opinion-pieces of 13 individuals opposed to MC. We find that these statements misrepresent good studies, selectively cite references, some containing fallacious information, and draw erroneous conclusions. In marked contrast, the scientific evidence shows MC to be a simple, low-risk procedure with very little or no adverse long-term effect on sexual function, sensitivity, sensation during arousal or overall satisfaction. Unscientific arguments have been recently used to drive ballot measures aimed at banning MC of minors in the USA, eliminate insurance coverage for medical MC for low-income families, and threaten large fines and incarceration for health care providers. Medical MC is a preventative health measure akin to immunisation, given its protective effect against HIV infection, genital cancers and various other conditions. Protection afforded by neonatal MC against a diversity of common medical conditions starts in infancy with urinary tract infections and extends throughout life. Besides protection in adulthood against acquiring HIV, MC also reduces morbidity and mortality from multiple other sexually transmitted infections (STIs) and genital cancers in men and their female sexual partners. It is estimated that over their lifetime one-third of uncircumcised males will suffer at least one foreskin-related medical condition. The scientific evidence indicates that medical MC is safe and effective. Its favourable risk/benefit ratio and cost/benefit support the advantages of medical MC.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, NSW, Australia.
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15
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Hartwig S, Syrjänen S, Dominiak-Felden G, Brotons M, Castellsagué X. Estimation of the epidemiological burden of human papillomavirus-related cancers and non-malignant diseases in men in Europe: a review. BMC Cancer 2012; 12:30. [PMID: 22260541 PMCID: PMC3293758 DOI: 10.1186/1471-2407-12-30] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 01/20/2012] [Indexed: 02/07/2023] Open
Abstract
Background The role of human papillomavirus (HPV) in malignant and non-malignant genital diseases in women is well known and the corresponding epidemiological burden has been widely described. However, less is known about the role of HPV in anal, penile and head and neck cancer, and the burden of malignant and non-malignant HPV-related diseases in men. The objective of this review is to estimate the epidemiological burden of HPV-related cancers and non-malignant diseases in men in Europe. Methods The annual number of new HPV-related cancers in men in Europe was estimated using Eurostat population data and applying cancer incidence rates published by the International Agency for Research on Cancer. The number of cancer cases attributable to HPV, and specifically to HPV16/18, was calculated based on the most relevant prevalence estimates. The annual number of new cases of genital warts was calculated from the most robust European studies; and latest HPV6/11 prevalence estimates were then applied. A literature review was also performed to retrieve exhaustive data on HPV infection at all anatomical sites under study, as well as incidence and prevalence of external genital warts, recurrent respiratory papillomatosis and HPV-related cancer trends in men in Europe. Results A total of 72, 694 new cancer cases at HPV-related anatomical sites were estimated to occur each year in men in Europe. 17,403 of these cancer cases could be attributable to HPV, with 15,497 of them specifically attributable to HPV16/18. In addition, between 286,682 and 325,722 new cases of genital warts attributable to HPV6/11were estimated to occur annually in men in Europe. Conclusions The overall estimated epidemiological burden of HPV-related cancers and non-malignant diseases is high in men in Europe. Approximately 30% of all new cancer cases attributable to HPV16/18 that occur yearly in Europe were estimated to occur in men. As in women, the vast majority of HPV-positive cancer in men is related to HPV16/18, while almost all HPV-related non-malignant diseases are due to HPV6/11. A substantial number of these malignant and non-malignant diseases may potentially be prevented by quadrivalent HPV vaccination.
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Affiliation(s)
- Susanne Hartwig
- Department of Epidemiology, Sanofi Pasteur MSD, Lyon, France.
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16
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Larke N, Thomas SL, Dos Santos Silva I, Weiss HA. Male circumcision and human papillomavirus infection in men: a systematic review and meta-analysis. J Infect Dis 2011; 204:1375-90. [PMID: 21965090 DOI: 10.1093/infdis/jir523] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We systematically reviewed the evidence for an association between male circumcision and Human Papillomavirus (HPV) infection and genital warts in men. METHODS PubMed and Embase were searched to 15 September 2010. The measure of effect was the adjusted odds ratio (OR) or rate ratio (RR) when present and the crude estimate otherwise. Random effects meta-analyses were used to calculate summary measures of effect. RESULTS We identified 23 papers about the association between circumcision and HPV DNA. Circumcised men were less likely to have prevalent genital HPV infection than uncircumcised men (summary OR, 0.57, 95% confidence interval [CI], 0.45-0.71) with between-study heterogeneity (P-heterogeneity = 0.006; I(2) = 50.5%; 19 studies). Similar summary associations were seen in clinical and methodological subgroups. The effect of circumcision was stronger at the glans/corona (OR, 0.47; 95% CI, 0.37-0.60) and urethra (OR, 0.35; 95% CI, 0.12-1.05) compared with sites more distal to the foreskin. There was weak evidence that circumcision was associated with decreased HPV incidence (summary RR, 0.75, 95% CI, 0.57-0.99; 3 studies) and increased HPV clearance (summary RR, 1.33; 95% CI, 0.89-1.98; 3 studies) but no evidence of an association with prevalent genital warts (OR, 0.93, 95% CI, 0.65-1.33; 15 studies). CONCLUSIONS Several countries are expanding access to voluntary medical male circumcision to reduce HIV prevalence. This could provide additional benefit in reducing HPV prevalence.
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Affiliation(s)
- Natasha Larke
- Medical Research Council Tropical Epidemiology Group, United Kingdom.
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Morris BJ, Waskett JH, Gray RH, Halperin DT, Wamai R, Auvert B, Klausner JD. Exposé of misleading claims that male circumcision will increase HIV infections in Africa. J Public Health Afr 2011; 2:e28. [PMID: 28299069 PMCID: PMC5345501 DOI: 10.4081/jphia.2011.e28] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/06/2011] [Indexed: 01/17/2023] Open
Abstract
Despite over two decades of extensive research showing that male circumcision protects against heterosexual acquisition of HIV in men, and that includes findings from large randomized controlled trials leading to acceptance by the WHO/UNAIDS and the Cochrane Committee, opponents of circumcision continue to generate specious arguments to the contrary. In a recent issue of the Journal of Public Health in Africa, Van Howe and Storms claim that male circumcision will increase HIV infections in Africa. Here we review the statements they use in support of their thesis and show that there is no scientific basis to such an assertion. We also evaluate the statistics used and show that when these data are properly analyzed the results lead to a contrary conclusion affirming the major role of male circumcision in protecting against HIV infection in Africa. Researchers, policy makers and the wider community should rely on balanced scholarship when assessing scientific evidence. We trust that our assessment may help refute the claims by Van Howe and Storms, and provide reassurance on the importance of circumcision for HIV prevention.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, Australia
| | - Jake H. Waskett
- Circumcision Independent Reference and Commentary Service, Radcliffe, Manchester, UK
| | - Ronald H. Gray
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel T. Halperin
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Richard Wamai
- Department of African-American Studies, Northeastern University, Boston, MA, USA
| | | | - Jeffrey D. Klausner
- Divisions of AIDS & Infectious Diseases, University of California, San Francisco, CA, USA
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Morris BJ, Gray RH, Castellsague X, Bosch FX, Halperin DT, Waskett JH, Hankins CA. The Strong Protective Effect of Circumcision against Cancer of the Penis. Adv Urol 2011; 2011:812368. [PMID: 21687572 PMCID: PMC3113366 DOI: 10.1155/2011/812368] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 03/09/2011] [Indexed: 01/30/2023] Open
Abstract
Male circumcision protects against cancer of the penis, the invasive form of which is a devastating disease confined almost exclusively to uncircumcised men. Major etiological factors are phimosis, balanitis, and high-risk types of human papillomavirus (HPV), which are more prevalent in the glans penis and coronal sulcus covered by the foreskin, as well as on the penile shaft, of uncircumcised men. Circumcised men clear HPV infections more quickly. Phimosis (a constricted foreskin opening impeding the passage of urine) is confined to uncircumcised men, in whom balanitis (affecting 10%) is more common than in circumcised men. Each is strongly associated with risk of penile cancer. These findings have led to calls for promotion of male circumcision, especially in infancy, to help reduce the global burden of penile cancer. Even more relevant globally is protection from cervical cancer, which is 10-times more common, being much higher in women with uncircumcised male partners. Male circumcision also provides indirect protection against various other infections in women, along with direct protection for men from a number of genital tract infections, including HIV. Given that adverse consequences of medical male circumcision, especially when performed in infancy, are rare, this simple prophylactic procedure should be promoted.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Ronald H. Gray
- Population and Family Planning, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Xavier Castellsague
- Institut Català d'Oncologia (ICO), IDIBELL, CIBERESP, RTICC, 08908 L'Hospitalet de Llobregat, Catalonia, Spain
| | - F. Xavier Bosch
- Institut Català d'Oncologia (ICO), IDIBELL, CIBERESP, RTICC, 08908 L'Hospitalet de Llobregat, Catalonia, Spain
| | - Daniel T. Halperin
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115, USA
| | - Jake H. Waskett
- Circumcision Independent Reference and Commentary Service, Radcliffe, Manchester M261JR, UK
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19
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Regan DG, Philp DJ, Waters EK. Unresolved questions concerning human papillomavirus infection and transmission: a modelling perspective. Sex Health 2010; 7:368-75. [PMID: 20719229 DOI: 10.1071/sh10006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 06/03/2010] [Indexed: 01/02/2023]
Abstract
Mathematical transmission models are widely used to forecast the potential impact of interventions such as vaccination and to inform the development of health policy. Effective vaccines are now available for the prevention of cervical cancer and other diseases attributable to human papillomavirus (HPV). Considerable uncertainties remain regarding the characterisation of HPV infection and its sequelae, infectivity, and both vaccine-conferred and naturally-acquired immunity. In this review, we discuss the key knowledge gaps that impact on our ability to develop accurate models of HPV transmission and vaccination.
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Affiliation(s)
- David G Regan
- The National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Coogee, NSW 2034, Australia.
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20
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Bosch FX, Albero G, Castellsagué X. Male circumcision, human papillomavirus and cervical cancer: from evidence to intervention. ACTA ACUST UNITED AC 2010; 35:5-7. [PMID: 19126309 DOI: 10.1783/147118909787072270] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- F Xavier Bosch
- Unit of Infections and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology, IDIBELL, Avda. Gran Via, s/n Km 2.7, L'Hospitalet de Llobregat, Barcelona 08907, Spain.
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21
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Mougin C, Bourgault-Villada I, Coursaget P. [HPV immunization for the prevention of cervical cancer]. Presse Med 2009; 38:1750-68. [PMID: 19765945 DOI: 10.1016/j.lpm.2009.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 06/10/2009] [Accepted: 06/15/2009] [Indexed: 10/20/2022] Open
Abstract
CONTEXT Human Papillomaviruses (HPV) infect epithelial cells of the skin and mucosae. Mucosal high-risk HPV types (mainly HPV 16 and 18) are involved in the development of cervical cancer, one of the most common cancers in young women. HPV infection is usually asymptomatic and clears spontaneously, but 10 - 15 % of high-risk HPV infections are persistent and increase the risk of precancerous and cancerous lesions of the cervix. Two HPV vaccines have been licensed to provide protection against cervical cancer. OBJECTIVES To report the different aspects of HPV infection in order to improve the understanding of the particular problems of HPV vaccination and to review the most recent findings related to HPV vaccines, particularly regarding the protective efficacy of vaccines and the roles of adjuvants and immune response in protection. METHODS Articles were selected from the PubMed database (National Library of Medicine- National Institute of Health) with the following Keywords "HPV", "Prevention", "HPV vaccines", "Immune response", "Antibody". Abstracts of oral presentations from international meetings were also selected for the more recent findings. a critical analysis of the majority of papers published was undertaken and relevant information summarized. RESULTS Virus-like particle production by expressing the major protein of the HPV capsid was carried out in the early 90's, leading to the recent development of two HPV vaccines. These vaccines are now licensed in many countries and have been demonstrated to be highly immunogenic. In subjects that are non-infected at the time of vaccination, HPV vaccines are highly effective in preventing persistent HPV 16 - 18 infections (90 %) and precursors lesions of cervical cancer associated with these two HPV types (close to 100 %). Clinical trials have also confirmed that HPV vaccines are well tolerated by recipients. CONCLUSIONS The present paper is a detailed review published in French on HPV vaccines, their efficacy in the prevention of HPV infections and unresolved questions regarding the use of HPV vaccines. This report also includes biological and immunological information to improve the understanding of HPV vaccination.
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Affiliation(s)
- Christiane Mougin
- UFR des Sciences Médicales et Pharmaceutiques, EA 3181, IFR 133, Université de Franche-Comté, F-25000 Besançon, France
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Yang SSD, Hsieh CH, Chang SJ. Effects of Circumcision on urinary Tract Infection and Sexually Transmitted Disease. Tzu Chi Med J 2009. [DOI: 10.1016/s1016-3190(09)60037-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Golden MR, Wasserheit JN. Prevention of viral sexually transmitted infections--foreskin at the forefront. N Engl J Med 2009; 360:1349-51. [PMID: 19321872 DOI: 10.1056/nejme0900762] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Dickson NP, Ryding J, van Roode T, Paul C, Herbison P, Dillner J, Skegg DCG. Male circumcision and serologically determined human papillomavirus infection in a birth cohort. Cancer Epidemiol Biomarkers Prev 2009; 18:177-83. [PMID: 19124496 DOI: 10.1158/1055-9965.epi-08-0353] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Circumcision has been reported to protect against infection with human papillomavirus (HPV) in men, but results have been inconsistent. We followed males in a birth cohort born in Dunedin, New Zealand, in 1972 and 1973 from age 3 to 32 years. Seropositivity at age 32 years for the oncogenic types HPV-16 and 18, and the nononcogenic types 6 and 11, was studied in relation to maternal reports of circumcision status at age 3 for 450 men. Seropositivity to any of these types was associated with lifetime number of sexual partners (P = 0.03), and lower moral-religious emphasis of the family of origin (P < 0.001). Circumcision was not found to be protective, with the adjusted odds ratio (95% confidence interval) for HPV6/11/16/18 seropositivity among the circumcised compared with the uncircumcised being 1.4 (0.89-2.2).
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Affiliation(s)
- Nigel P Dickson
- Department of Preventive and Social Medicine, University of Otago Medical School, P.O. Box 913, Dunedin, New Zealand.
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Waskett JH, Morris BJ, Weiss HA. Errors in meta-analysis by Van Howe. Int J STD AIDS 2009; 20:216-8; author reply 218-20. [DOI: 10.1258/ijsa.2009.008126] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- J H Waskett
- Circumcision Independent Reference and Commentary Service, 157 Stand Lane, Radcliffe, Manchester M26 1JR, UK
| | - B J Morris
- School of Medical Sciences, University of Sydney, Sydney, NSW 2006, Australia
| | - H A Weiss
- Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Nielson CM, Schiaffino MK, Dunne EF, Salemi JL, Giuliano AR. Associations between male anogenital human papillomavirus infection and circumcision by anatomic site sampled and lifetime number of female sex partners. J Infect Dis 2009; 199:7-13. [PMID: 19086813 DOI: 10.1086/595567] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Male circumcision may lower men's risk of human papillomavirus (HPV) infection and reduce transmission to sex partners. Reported associations between circumcision and HPV infection in men have been inconsistent. METHODS Four hundred sixty-three men in 2 US cities were tested at 6 anogenital sites and in semen for 37 types of HPV. Men were eligible if they reported sex with a woman within the past year, no history of genital warts or penile or anal cancer, and no current diagnosis of a sexually transmitted infection. Participants completed a self-administered questionnaire. Circumcision status was assessed by the study clinician. Logistic regression was used to examine associations between circumcision and HPV detection at each site and in semen, with adjustment for potential confounders. RESULTS Seventy-four men (16.0%) were uncircumcised. Adjusted odds ratios (AORs) for any HPV genotype and circumcision were 0.53 (95% confidence interval [CI], 0.28-0.99) for any anatomic site/specimen, 0.17 (95% CI, 0.05-0.56) for the urethra, 0.44 (95% CI, 0.23-0.82) for the glans/corona, and 0.53 (95% CI, 0.28-0.99) for the penile shaft. AORs were <1.0 but not statistically significant for the scrotum, semen, anal canal, and perianal area. CONCLUSIONS Circumcision may be protective against HPV infection of the urethra, glans/corona, and penile shaft.
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Auvert B, Sobngwi-Tambekou J, Cutler E, Nieuwoudt M, Lissouba P, Puren A, Taljaard D. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis 2009; 199:14-9. [PMID: 19086814 DOI: 10.1086/595566] [Citation(s) in RCA: 193] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A causal association links high-risk human papillomavirus (HR-HPV) and cervical cancer, which is a major public health problem. The objective of the present study was to investigate the association between male circumcision (MC) and the prevalence of HR-HPV among young men. METHODS We used data from a MC trial conducted in Orange Farm, South Africa, among men aged 18-24 years. Urethral swab samples were collected during a period of 262 consecutive days from participants in the intervention (circumcised) and control (uncircumcised) groups who were reporting for a scheduled follow-up visit. Swab samples were analyzed using polymerase chain reaction. HR-HPV prevalence rate ratios (PRRs) were assessed using univariate and multivariate log Poisson regression. RESULTS In an intention-to-treat analysis, the prevalences of HR-HPV among the intervention and control groups were 14.8% (94/637) and 22.3% (140/627), respectively, with a PRR of 0.66 (0.51-0.86) (P = .002). Controlling for propensity score and confounders (ethnic group, age, education, sexual behavior [including condom use], marital status, and human immunodeficiency virus status) had no effect on the results. CONCLUSIONS This is the first randomized controlled trial to show a reduction in the prevalence of urethral HR-HPV infection after MC. This finding explains why women with circumcised partners are at a lower risk of cervical cancer than other women.
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Affiliation(s)
- Bertran Auvert
- Assistance Publique-Hôpitaux de Paris, University of Versailles, France.
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