Male circumcision for the prevention of HSV-2 and HPV infections and syphilis

Unlocking the Interactions Between the Whole-Body Microbiome and HPV Infection: A Literature Review

The human microbiome plays a vital role in maintaining human homeostasis, acting as a key regulator of host immunity and defense mechanisms. However, dysbiotic microbial communities may cause disruption of the symbiotic relationship between the host and the local microbiota, leading to the pathogenesis of various diseases, including viral infections and cancers. One of the most common infectious agents causing cancer is the human papilloma virus (HPV), which accounts for more than 90% of cervical cancers. In most cases, the host immune system is activated and clears HPV, whereas in some cases, the infection persists and can lead to precancerous lesions. Over the last two decades, the advent of next-generation sequencing (NGS) technology and bioinformatics has allowed a thorough and in-depth analysis of the microbial composition in various anatomical niches, allowing researchers to unveil the interactions and the underlying mechanisms through which the human microbiota could affect HPV infection establishment, persistence, and progression. Accordingly, the present narrative review aims to shed light on our understanding of the role of the human microbiome in the context of HPV infection and its progression, mainly to cervical cancer. Furthermore, we explore the mechanisms by which the composition and balance of microbial communities exert potential pathogenic or protective effects, leading to either HPV persistence and disease outcomes or clearance. Special interest is given to how the microbiome can modulate host immunity to HPV infection. Lastly, we summarize the latest findings on the therapeutic efficacy of probiotics and prebiotics in preventing and/or treating HPV infections and the potential of vaginal microbiota transplantation while highlighting the significance of personalized medicine approaches emerging from NGS-based microbiome profiling and artificial intelligence (AI) for the optimal management of HPV-related diseases.

Looking Back, Moving Forward: Challenges and Opportunities for Global Cervical Cancer Prevention and Control

Despite the introduction of Pap testing for screening to prevent cervical cancer in the mid-20th century, cervical cancer remains a common cause of cancer-related mortality and morbidity globally. This is primarily due to differences in access to screening and care between low-income and high-income resource settings, resulting in cervical cancer being one of the cancers with the greatest health disparity. The discovery of human papillomavirus (HPV) as the near-obligate viral cause of cervical cancer can revolutionize how it can be prevented: HPV vaccination against infection for prophylaxis and HPV testing-based screening for the detection and treatment of cervical pre-cancers for interception. As a result of this progress, the World Health Organization has championed the elimination of cervical cancer as a global health problem. However, unless research, investments, and actions are taken to ensure equitable global access to these highly effective preventive interventions, there is a real threat to exacerbating the current health inequities in cervical cancer. In this review, the progress to date and the challenges and opportunities for fulfilling the potential of HPV-targeted prevention for global cervical cancer control are discussed.

Deficits and opportunities, pivots and shifts for scaling-up voluntary medical male circumcision in Uganda: a qualitative reflexive thematic analysis study

Despite voluntary medical male circumcision (VMMC) being a cost-effective intervention for preventing HIV transmission, its scale-up has faced challenges. Several interventions to address these challenges in priority countries, including Uganda, have not yielded the desired results. This cross-sectional qualitative study aimed to explore the factors that affect the demand for VMMC and identify possible solutions. Semi-structured phone interviews were conducted with 29 males aged at least 18 and not more than 65 drawn randomly from a database representative of the general population maintained by an independent research organisation. Reflexive thematic analysis was conducted, and data analysis was done using NVivo version 12. The results were presented in narrative format with supporting quotes. The study received ethical and regulatory clearance to be conducted in Uganda. The average age of the respondents was 28 years. Almost all respondents had some education, and most lived in rural areas. Two themes were generated, namely, 1) deficits and opportunities for VMMC, which are issues that currently hinder the uptake of VMMC but, if addressed, would lead to better demand, and 2) pivots and shifts for VMMC, which are changes that need to be made to improve the uptake of VMMC. We found that several challenges, including myths, misconceptions, health system gaps, and uncertainties about the postoperative period, hindered the uptake of VMMC. Pivots and shifts for improving the uptake of VMMC include intensifying VMMC campaigns, addressing inequities, and addressing access barriers. We concluded that several challenges, including myths and misconceptions, health system-related gaps, and uncertainties in the post-circumcision period, persist and negatively impact the scale-up of VMMC in Uganda. VMMC beneficiaries have plausible proposals for addressing challenges. The Uganda Ministry of Health should address the myths, misconceptions, health system-related gaps, and uncertainties about the postoperative period and should involve VMMC beneficiaries in reviewing interventions to address gaps.

Vaccine value profile for herpes simplex virus

Herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are chronic, highly prevalent viral infections that cause significant morbidity around the world. HSV-2 is sexually transmitted and is the leading cause of genital ulcer disease (GUD). It also increases the risk of HIV acquisition, fueling the HIV epidemic. HSV-1 is typically acquired in childhood through nonsexual contact and contributes to oral and ocular disease, but it can also be sexually transmitted to cause GUD. Both HSV-1 and HSV-2 cause neonatal herpes and neurologic disease. Given the ubiquitous nature of HSV-1 and HSV-2 infections and the limited existing prevention and control measures, vaccination would be the most efficient strategy to reduce the global burden of morbidity related to HSV infection. Vaccine strategies include prophylactic vaccination, which would prevent infection among susceptible persons and would likely be given to adolescents, and therapeutic vaccinations, which would be given to people with symptomatic genital HSV-2 infection. This document discusses the vaccine value profile of both types of vaccines. This 'Vaccine Value Profile' (VVP) for HSV is intended to provide a high-level, holistic assessment of the information and data that are currently available to inform the potential public health, economic and societal value of pipeline vaccines and vaccine-like products. This VVP was developed by subject matter experts from academia, non-profit organizations, government agencies and multi-lateral organizations. All contributors have extensive expertise on various elements of the HSV VVP and collectively aimed to identify current research and knowledge gaps. The VVP was developed using only existing and publicly available information.

20 years of herpes simplex virus type 2 (HSV-2) research in low-income and middle-income countries: systematic evaluation of progress made in addressing WHO priorities for research in HSV-2/HIV interactions, HSV-2 control and mathematical modelling

INTRODUCTION

Reviewing and updating research priorities is essential to assess progress and to ensure optimal allocation of financial and human resources in research. In 2001, WHO held a research priority setting workshop for herpes simplex virus type 2 (HSV-2) research in low-income and middle-income countries (LMICs). This study aimed to describe progress between 2000 and 2020 in three of the five key research priority areas outlined in the workshop: HSV-2/HIV interactions, HSV-2 control measures and HSV-2 mathematical modelling. The remaining priorities are addressed in a companion paper.

METHOD

A systematic literature search of MEDLINE, CINAHL, Global Health and Cochrane databases was carried out. Relevant primary research studies based in LMICs, written in English and published on 2000-2020 were included. Papers were screened by two independent reviewers, and suitable variables were selected for manual extraction from study texts. Data were organised into an Excel spreadsheet and analysed using IBM SPSS.

RESULTS

In total, 3214 discrete papers were identified, of which 180 were eligible for inclusion (HSV-2/HIV interactions, 98; control measures, 58; mathematical modelling, 24). Most studies were conducted in East Africa. The majority of the 2001 WHO HSV-2 research priorities were addressed at least in part. Overall, despite several studies describing a strong relationship between HSV-2 and the acquisition and transmission of HIV, HSV-2 control repeatedly demonstrated little effect on HIV shedding or transmission. Further, although mathematical modelling predicted that vaccines could significantly impact HSV-2 indicators, HSV-2 vaccine studies were few. Studies of antiviral resistance were also few.

CONCLUSION

Since 2000, LMIC HSV-2 research addressing its control, HIV interactions and mathematical modelling has largely addressed the priorities set in the 2001 WHO HSV-2 workshop. However, key knowledge gaps remain in vaccine research, antiviral cost-effectiveness, antiviral resistance and specific geographical areas.

Comparison of the penile microbiome in infant male circumcision: Mogen clamp versus Shangring

BACKGROUND

This study aimed to characterise the infant penile (coronal sulcus) microbiome and the effects of early infant male circumcision (EIMC), following a standard surgical method (Mogen Clamp) and a non-surgical alternative (ShangRing).

METHODS

We collected coronal sulcus swabs at baseline and on days 7 and 14 post-circumcision from infants assigned to receive EIMC by Mogen Clamp (n = 15) or ShangRing (n = 15), in a randomised trial in Rakai and Kakuuto, Uganda. We used 16S rRNA gene-based sequencing and broad-coverage qPCR to characterise the infant penile microbiome and assess the effects of EIMC in both study arms.

FINDINGS

Prior to EIMC, the infant penile microbiome had a mixture of facultative and strict anaerobes. In both study arms, EIMC caused penile microbiome proportional abundance changes characterised by decreases in penile anaerobes [ShangRing Prevotella: -15.0%, (SD = 19.1); Mogen clamp Prevotella: -3.6% (11.2); ShangRing Veillonella: -11.3% (17.2); Mogen clamp Veillonella: -2.6% (11.8)] and increases in skin-associated facultative anaerobes [ShangRing Corynebacterium: 24.9%, (22.4); Mogen clamp Corynebacterium: 4.7% (21.3); ShangRing Staphylococcus: 21.1% (20.5); Mogen clamp Staphylococcus: 18.1% (20.1)]. Clostridium tetani was not detected during the study.

INTERPRETATION

Mogen Clamp and ShangRing EIMC both changed the composition of the infant penile microbiome by reducing the proportional abundances of anaerobes and uropathogens, which is consistent with medical male circumcision findings in adults. C. tetani was not increased by either EIMC method.

FUNDING

Bill and Melinda Gates Foundation.

Effect of cryopreservation on CD4+ T cell subsets in foreskin tissue

Voluntary medical male circumcision (VMMC) reduces HIV acquisition by at least 60%, but the determinants of HIV susceptibility in foreskin tissues are incompletely understood. Flow cytometry is a powerful tool that helps us understand tissue immune defenses in mucosal tissue like the inner foreskin, but foreskin flow cytometry has only been validated using fresh tissue samples. This restricts immune analyses to timepoints immediately after surgical acquisition and hinders research in this area. We compared fresh analysis with whole tissue cryopreservation and later thawing and digestion to analyze CD4+ T cell populations relevant to HIV susceptibility (CCR5, CD25, CD127, CCR4, CXCR3, CCR6, CCR10, HLA-DR, and CD38). Eight foreskin samples from HIV-negative males aged >18 years were collected after VMMC. For each sample, half the foreskin was immediately cryopreserved for later digestion and flow cytometry analysis, while the remaining tissues were analyzed fresh. We demonstrate no significant impact of cryopreservation on CD4+ T cell expression of CD25, CCR4, CCR6, HLA-DR, CCR10, or CD127. Although expression levels of CCR5, CD38, and CXCR3 were increased after cryopreservation, the relative ranking of participants was retained. In conclusion, cryopreserved foreskin tissues may be suitable for subsequent digestion and flow cytometry phenotyping of HIV-susceptible T cell populations.

Substantial but spatially heterogeneous progress in male circumcision for HIV prevention in South Africa

BACKGROUND

Voluntary medical male circumcision (VMMC) reduces the risk of male HIV acquisition by 60%. Programmes to provide VMMCs for HIV prevention have been introduced in sub-Saharan African countries with high HIV burden. Traditional circumcision is also a long-standing male coming-of-age ritual, but practices vary considerably across populations. Accurate estimates of circumcision coverage by age, type, and time at subnational levels are required for planning and delivering VMMCs to meet targets and evaluating their impacts on HIV incidence.

METHODS

We developed a Bayesian competing risks time-to-event model to produce region-age-time-type specific probabilities and coverage of male circumcision with probabilistic uncertainty. The model jointly synthesises data from household surveys and health system data on the number of VMMCs conducted. We demonstrated the model using data from five household surveys and VMMC programme data to produce estimates of circumcision coverage for 52 districts in South Africa between 2008 and 2019.

RESULTS

Nationally, in 2008, 24.1% (95% CI: 23.4-24.8%) of men aged 15-49 were traditionally circumcised and 19.4% (18.9-20.0%) were medically circumcised. Between 2010 and 2019, 4.25 million VMMCs were conducted. Circumcision coverage among men aged 15-49 increased to 64.0% (63.2-64.9%) and medical circumcision coverage to 42% (41.3-43.0%). Circumcision coverage varied widely across districts, ranging from 13.4 to 86.3%. The average age of traditional circumcision ranged between 13 and 19 years, depending on local cultural practices.

CONCLUSION

South Africa has made substantial, but heterogeneous, progress towards increasing medical circumcision coverage. Detailed subnational information on coverage and practices can guide programmes to identify unmet need to achieve national and international targets.

Human Papillomavirus Infection (HPV) Prevalence in the Black Sea Region of Turkey: Primary HPV Screening for Cervical Cancer

OBJECTIVE

Planning vaccination and treatment options requires knowledge about the regional incidence of human papillomavirus infection (HPV) and its genotypes. The aim of our study was to determine the regional prevalence of HPV with genotypic subclassification and to evaluate the efficacy of HPV testing in cervical screening.  Material and Method: This retrospective cohort study analyzed records of 10,152 women aged 30-65 from the On Dokuz Mayıs University Medical Faculty's Gynecology Clinic, excluding those with a history of cervical disease, hysterectomy, or current pregnancy. Pre- and postmenopausal and total HPV prevalence were calculated. There was a total of 544 patients who underwent a colposcopic biopsy after cervical screening. The research focused on comparing the efficacy of Pap smears, HPV tests, and co-tests in detecting LSIL or more severe conditions, utilizing the BD Viper LT System for HPV screening and liquid-based cytology for smear tests.

RESULTS

The prevalence of HPV in our region was determined to be 10.9%. When considering menopausal status, HPV prevalence was found to be 9.8% in premenopausal individuals and 12.4% in postmenopausal individuals. Evaluation of the pap smear results revealed a sensitivity of 74.8% for premenopausal and 81% for postmenopausal patients, with a specificity of 51% observed in both menopausal categories. In contrast, HPV testing demonstrated a sensitivity of 90.8% in premenopausal and 92.4% in postmenopausal individuals, with a specificity of 58% for both groups. The co-test results indicated an even higher sensitivity, with 97.9% in premenopausal and 100% in postmenopausal individuals, albeit with a reduced specificity of 28% in both cases. When identifying LSIL (low-grade squamous intraepithelial lesions) and more severe conditions, the sensitivity and specificity of the primary HPV test surpassed those of the pap smear. While the primary HPV test's sensitivity is markedly lower compared to the co-test, it boasts a significantly higher specificity.

CONCLUSION

Regional HPV prevalence studies are valuable for the implementation of screening policies. The primary HPV DNA test is a reliable method for detecting preinvasive and invasive lesions in patients over 30 years of age.

Male circumcision uptake and misperceived norms about male circumcision: Cross-sectional, population-based study in rural Uganda

Background

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circumcision for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention. The prevalence of male circumcision in Uganda nearly doubled from 26% in 2011 to 43% in 2016, but remains below the 2020 target level. Little is known about how common male circumcision is perceived to be, how accurate such perceptions are, and whether they are associated with men's own circumcision uptake.

Methods

We conducted a cross-sectional study of all adult residents of eight villages in Rwampara District, southwestern Uganda in 2020-2022. We elicited their perceptions of the adult male circumcision prevalence within their village: >50% (most men), 10% to <50% (some), <10%, (few to none), or do not know. We compared their perceived norms to the aggregated prevalence of circumcision reported in these villages. We used a modified multivariable Poisson regression model to estimate the association between perceived norms and personal circumcision uptake among men.

Results

We surveyed 1566 participants (91% response rate): 698 men and 868 women. Among the men, 167 (27%) reported being circumcised, including 167/444 (38%) men <50 years of age. Approximately one-fourth of the population (189 (27%) men and 177 (20%) women) believed that few to no men in their own village had been circumcised. In a multivariable regression model, men who underestimated the prevalence of male circumcision were less likely to be circumcised themselves (adjusted relative risk (aRR) = 0.51; 95% confidence interval (CI) = 0.37-0.83).

Conclusions

In this population-based study in rural Uganda, one-fourth of men underestimated the prevalence of male circumcision. Men who underestimated the extent of circumcision uptake were themselves less likely to be circumcised. If the observed association is causal and underestimates within the population contribute to low uptake, then interventions correcting these misperceived norms could increase uptake of voluntary medical male circumcision.

Seroprevalence and factors associated with Hepatitis B virus infection among students in two senior high schools in the Krachi Nchumuru district in Ghana-A cross-sectional study

BACKGROUND

There is paucity of hepatitis B virus (HBV) data among student populations although Ghana is HBV endemic. Screening and identification of factors associated with HBV transmission in schools will support the intervention in the elimination of the virus by 2030. This study assessed the seroprevalence and factors associated with HBV among students in two Senior High Schools in the Krachi Nchumuru District in Ghana.

METHODS

Through cross-sectional design and simple random sampling technique, 300 first-year students were enrolled from selected Senior High Schools. Structured questionnaires were used to collect data on demographic and exposure factors while rapid test kit was used to detect HBV infections. Chi-square/Fisher exact test and multivariable logistic regression were performed to determine the association between the variables at a 95% confidence interval and 0.05 significant level.

RESULTS

Seroprevalence of HBV was 14% (42/300) among the students. The prevalence was significantly (p = 0.001) higher in males 19.4% (34/175) than females 6.4% (8/125). 77.7% (233/300) were aware of HBV infection. Males who were circumcised were 4 times more likely to be infected with HBV (AOR = 4.09, 95%CI = 1.82-9.19) (p = 0.001) compared with those uncircumcised.

CONCLUSION

HBV screening and education on hygienic genital circumcision practices must be prioritized in endemic countries.

Age Patterns of HSV-2 Incidence and Prevalence in Two Ugandan Communities: A Catalytic Incidence Model Applied to Population-Based Seroprevalence Data

BACKGROUND

Herpes simplex virus type 2 (HSV-2) is an incurable sexually transmitted infection associated with increased risk of acquiring and transmitting human immunodeficiency virus (HIV). HSV-2 is highly prevalent in sub-Saharan Africa, but population-level estimates of incidence are sparse.

METHODS

We measured HSV-2 prevalence from cross-sectional serological data among adults aged 18-49 years in 2 south-central Uganda communities (fishing, inland). We identified risk factors for seropositivity, then inferred age patterns of HSV-2 with a Bayesian catalytic model.

RESULTS

HSV-2 prevalence was 53.6% (n = 975/1819; 95% confidence interval, 51.3%-55.9%). Prevalence increased with age, was higher in the fishing community, and among women, reaching 93.6% (95% credible interval, 90.2%-96.6%) by age 49 years. Factors associated with HSV-2 seropositivity included more lifetime sexual partners, HIV positive status, and lower education. HSV-2 incidence peakied at age 18 years for women and 19-20 years for men. HIV prevalence was up to 10-fold higher in HSV-2-positive individuals.

CONCLUSIONS

HSV-2 prevalence and incidence were extremely high, with most infections occurring in late adolescence. Interventions against HSV-2, such as future vaccines or therapeutics, must target young populations. Remarkably higher HIV prevalence among HSV-2-positive individuals underscores this population as a priority for HIV prevention.

Sexually Transmitted Human Papillomavirus: Update in Epidemiology, Prevention, and Management

This review presents the epidemiology, pathophysiology, prevention, and management of sexually transmitted human papillomavirus (HPV) and its associated diseases. HPV is the most common sexually transmitted infection worldwide. Prevalence varies regionally. Low-risk strains cause anogenital warts, which can be managed with patient- or provider-applied therapies. High-risk strains cause lower anogenital cancers. Primary and secondary prevention strategies include vaccination and screening for precancerous lesions, respectively. Management of abnormal screening results vary by test result, anatomic site, and individual cancer risk. Approaches include close rescreening, high-resolution visualization with biopsy, and-when biopsy-proven precancer is identified-removal or destruction of the lesion.

The 1982 Medicaid Funding Cessation for Circumcision in California and Circumcision Rates

We investigated California's 1982 decision to stop funding Medicaid neonatal circumcision. We examined male neonatal circumcision rates for those born 1977-1981 and 1983-1987 by region, race, and insurance status. Overall, West-Medicaid circumcision rates decreased from 56.5% in 1979-81 to 26.7% in 1983-85. California's 1982 decision to defund Medicaid circumcision coverage was associated with a 25.0-30.8% point decrease in West-Medicaid circumcision rates compared other groups, p < 0.01. This provides the earliest data to support that funding coverage for neonatal circumcision affects circumcision rates and magnifies healthcare disparities. Other states have since defunded Medicaid male neonatal circumcision. Circumcision have been associated with lower rates of sexually transmitted infections including HIV, and urinary tract infections. Lawmakers should consider re-funding Medicaid male neonatal circumcision.

Perceived norms about male circumcision and personal circumcision status: a cross-sectional, population-based study in rural Uganda

Introduction

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men.

Methods

We conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women reported as the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men.

Results

Overall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors.

Conclusions

Across eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.

Association between male circumcision and human papillomavirus infection in males and females: a systematic review, meta-analysis, and meta-regression

BACKGROUND

Previous studies have suggested a protective effect of male circumcision on human papillomavirus (HPV) infections in males, and that this protection may be conferred to their female sexual partners.

OBJECTIVES

To synthesize the available evidence on the association between male circumcision and HPV infections in males and females.

DATA SOURCES

We searched MEDLINE, Embase, Scopus, Cochrane, LILACS, and ProQuest Dissertations & Theses Global for records published up to 22 June 2022.

STUDY ELIGIBILITY

We considered observational and experimental studies that assessed male circumcision status and HPV prevalence, incidence, or clearance in males or females for inclusion.

PARTICIPANTS

Males and their female sexual partners who were tested for genital HPV infection.

INTERVENTIONS

Male circumcision compared to no circumcision.

RISK OF BIAS ASSESSMENT

The Newcastle-Ottawa scale was used for observational studies and the Cochrane risk-of-bias tool was used for randomized trials.

DATA SYNTHESIS

We estimated summary measures of effect and 95% confidence intervals (CI) for the prevalence, incidence, and clearance of HPV infections in males and females using random-effects meta-analysis. We assessed effect modification of circumcision on HPV prevalence by penile site in males using random-effects meta-regression.

RESULTS

Across 32 studies, male circumcision was associated with decreased odds of prevalent HPV infections (OR 0.45, CI 0.34-0.61), a reduced incidence rate of HPV infections (IRR 0.69, CI 0.57-0.83), and an increased risk of clearing HPV infections (RR 1.44, CI 1.28-1.61) at the glans penis among male subjects. Circumcision conferred greater protection against infection at the glans than shaft (OR 0.68, 95% CI 0.48-0.98). Females with circumcised partners were protected from all outcomes.

CONCLUSIONS

Male circumcision may protect against various HPV infection outcomes, suggesting its prophylactic potential. Understanding site-specific effects of circumcision on HPV infection prevalence has important implications for studies of HPV transmission.

The role of the genital microbiota in the acquisition and pathogenesis of sexually transmitted infections

PURPOSE OF REVIEW

There are an estimated 374 million new sexually transmitted infections (STIs) worldwide every year. Our review article examines the current evidence of how STI acquisition, transmission, and pathogenesis is impacted upon by the genital microbiota, with a focus on epidemiological, biochemical, and immunological features.

RECENT FINDINGS

At least in women, a genital microbiota dominated by lactobacilli has long been considered optimal for reproductive health, while depletion of lactobacilli may lead to a genital microenvironment dominated by anaerobic pathogens, which can manifest clinically as bacterial vaginosis. Recent research efforts have characterized genital microbiota composition in greater resolution, sometimes at species-level, using proteomics, metabolomics, and deep sequencing. This has enhanced our understanding of how specific microbiota members influence acquisition or clinical manifestation of STI pathogen infection. Other advances include a steady, though still slow, increase in the number of studies that sought to determine the genital (penile or urethral) microbiota of males and how it may impact that of their female partners' genital microbiota and risk of STI acquisition. Altogether, these data enabled us to explore the concept that genital microbiota may be sexually transmitted and influence pathogenesis and clinical presentation of other STI.

SUMMARY

With STI infection rates increasing worldwide, it is important now more than ever to find novel STI prevention strategies. Understanding if and how the genital microbiota is a modifiable risk factor for STI transmission, acquisition, and clinical manifestation may prove to be an important strategy in our efforts to curb morbidity in at risk populations.

Voluntary Medical Male Circumcision for HIV Prevention: a Global Overview

PURPOSE OF REVIEW

With the promise of HIV prevention, there has been a scale-up of voluntary medical male circumcision (VMMC) in high HIV incidence/low circumcision prevalence nations worldwide. Nonetheless, debates over the implementation and the effectiveness and safety of the VMMC in real-world settings persist. We revisit the role of VMMC in HIV prevention to inform health professionals, policymakers, and advocates or opponents in this new era.

RECENT FINDINGS

There has been substantial progress on VMMC scale-up to date, but this has varied considerably by region. The evidence of solid and direct protection of VMMC is available for heterosexual men and older adolescent boys in sub-Saharan Africa. The protective effect in men who have sex with men is suggested by systematic reviews but is not confirmed by clinical trials. Sexual partners, including women, likely benefit indirectly from the increased VMMC coverage through a decreased risk of exposure to infected male partners. Fortunately, the preponderance of studies does not suggest higher sexual risk behaviors among circumcised men, so-called risk compensation. VMMC requires health systems strengthening and continued promulgation of other evidence-based HIV prevention strategies to be successful. Health authorities in high HIV incidence areas that have low circumcision coverage should implement VMMC within a context of complementary biomedical and behavioral prevention strategies.

How Does Voluntary Medical Male Circumcision Reduce HIV Risk?

PURPOSE OF REVIEW

Voluntary medical male circumcision (VMMC) is a surgical procedure that reduces HIV acquisition risk by almost two-thirds. However, global implementation is lagging, in part due to VMMC hesitancy. A better understanding of the mechanism(s) by which this procedure protects against HIV may increase acceptance of VMMC as an HIV risk reduction approach among health care providers and their clients.

RECENT FINDINGS

HIV acquisition in the uncircumcised penis occurs preferentially across the inner foreskin tissues, due to increased susceptibility that is linked to elevated inflammatory cytokine levels in the sub-preputial space and an increased tissue density of HIV-susceptible CD4 + T cells. Inflammation can be caused by sexually transmitted infections, but is more commonly induced by specific anaerobic components of the penile microbiome. Circumcision protects by both directly removing the susceptible tissues of the inner foreskin, and by inducing a less inflammatory residual penile microbiome. VMMC reduces HIV susceptibility by removing susceptible penile tissues, and also through impacts on the penile immune and microbial milieu. Understanding these mechanisms may not only increase VMMC acceptability and reinvigorate global VMMC programs, but may also lead to non-surgical HIV prevention approaches focused on penile immunology and/or microbiota.

Infant Circumcision for Sexually Transmitted Infection Risk Reduction Globally

Population-based studies in high-income countries have failed to find that male circumcision protects against sexually transmitted infections. Using evidence from several sources, we show that male circumcision does protect against HIV during insertive intercourse for men who have sex with men.

Makerere's contribution to the development of a high impact HIV research population-based cohort in the Rakai Region, Uganda

Longitudinal population-based cohort studies can provide critical insights on temporal, spatial and sociodemographic changes in health status and health determinants that are not obtained by other study designs. However, establishing and maintaining such a cohort study can be challenging and expensive. Here, we describe the role of Makerere University in the development and conduct of such a cohort. We chronicle the first academia-led reports of HIV in East Africa; how this led to initiation of the Rakai Community Cohort Study in 1988, the first and oldest HIV cohort in sub-Saharan Africa; its impact on HIV prevention, care and treatment; how the cohort has been maintained; and opportunities, challenges, and future directions including non-communicable diseases.

Evidence-based circumcision policy for Australia

The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.

The Penis, the Vagina and HIV Risk: Key Differences (Aside from the Obvious)

Globally, most Human Immunodeficiency Virus type 1 (HIV) transmission occurs through vaginal–penile sex (heterosexual transmission). The local immune environment at the site of HIV exposure is an important determinant of whether exposure during sex will lead to productive infection, and the vaginal and penile immune milieus are each critically shaped by the local microbiome. However, there are key differences in the microbial drivers of inflammation and immune quiescence at these tissue sites. In both, a high abundance of anaerobic taxa (e.g., Prevotella) is associated with an increased local density of HIV target cells and an increased risk of acquiring HIV through sex. However, the taxa that have been associated to date with increased risk in the vagina and penis are not identical. Just as importantly, the microbiota associated with comparatively less inflammation and HIV risk—i.e., the optimal microbiota—are very different at the two sites. In the vagina, Lactobacillus spp. are immunoregulatory and may protect against HIV acquisition, whereas on the penis, “skin type” flora such as Corynebacterium are associated with reduced inflammation. Compared to its vaginal counterpart, much less is known about the dynamics of the penile microbiome, the ability of clinical interventions to alter the penile microbiome, or the impact of natural/induced microbiome alterations on penile immunology and HIV risk.

Dissemination of the Spear & Shield Project using a Training of Trainers Model: A reflection on challenges and successes

Several large-scale clinical trials have conclusively demonstrated that voluntary medical male circumcision (VMMC) could provide a 50%-70% reduction in HIV acquisition, but willingness to undergo VMMC has been lowest in Zambia compared to other countries in eastern and southern Africa. This manuscript describes training for "task-shifting" among local healthcare workers at Community Health Centers (CHCs) applying state of the art strategies (e.g., Training of Trainers, i.e., ToT, and Training of Facilitators, ToF) to provide novel clinical services. Staff at 96 CHCs from four Provinces in Zambia were sequentially trained to provide the Spear & Shield intervention. A total of 45,630 men (n = 23,236) and women (n = 22,394) volunteered to participate in the S&S intervention service program when offered in the CHCs. Group session (total = 5313 sessions; 2,736 men's and 2,582 women's sessions) were conducted over 4.5 years. Remarkably, both men and women's groups achieved 97% retention. Of these, 256 sessions recorded from 128 group leaders were assessed and scored for intervention fidelity; fidelity was 80%-90% among the majority of clinics. S&S program sustainment exceeded expectations among 85% of clinics (82/96) in all provinces across the duration of the study. Of note, attendance in the S&S program was encouraged by CHC staff, but no financial incentives were provided to those attending S&S. This study examined the effectiveness of the ToT/ToF model in dissemination of the S&S program, which proved to be feasible even in resource-limited settings. Benefits and challenges are discussed.

Examining Clinical Practice Guidelines for Male Circumcision: A Systematic Review and Critical Appraisal Using AGREE II

OBJECTIVE

To identify and critically appraise available clinical practice guidelines (CPGs) targeting male circumcision using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument.

STUDY DESIGN

A literature search was conducted using electronic databases, CPG databases, and national/international societies providing recommendations to guide clinical decision making for male circumcision. We selected pediatric-focused CPGs related to male circumcision published between January 2010 and December 2020. Non-English CPGs and publications involving narrative reviews, primary research, training manuals, patient and allied health professional guidelines, and technical guides were excluded from our search. Complete CPG documents (including full-text articles, supplemental documents, and associated information) were reviewed. Quality appraisal of CPGs was conducted in accordance with the AGREE II manual.

RESULTS

A total of 163 CPGs were identified, of which 93 were screened and 13 were reviewed. All AGREE II domains demonstrated good to excellent interrater reliability, with intraclass correlation coefficients ranging from 0.82 (95% CI, 0.72-0.89) to 0.93 (95% CI, 0.90-0.95). Most CPGs performed satisfactorily in the clarity of presentation domain and performed poorly in the applicability and editorial independence domains. The top 3 CPGs identified were those of the American Academy of Pediatrics, Centers for Disease Control and Prevention, and Canadian Urological Association. Consistencies among the CPGs were demonstrated across most recommendations.

CONCLUSIONS

Current CPGs are of variable quality, and our findings should be taken into consideration by clinicians and health care professionals when selecting appropriate guidelines for male circumcision.

Diagnosis and Management of Genital Herpes: Key Questions and Review of the Evidence for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

Genital herpes, caused by herpes simplex virus (HSV) type 1 or type 2, is a prevalent sexually transmitted infection (STI). Given that HSV is an incurable infection, there are important concerns about appropriate use of diagnostic tools, management of infection, prevention of transmission to sexual partners, and appropriate counseling. In preparation for updating the Centers for Disease Control and Prevention (CDC) STI treatment guidelines, key questions for management of genital herpes infection were developed with a panel of experts. To answer these questions, a systematic literature review was performed, with tables of evidence including articles that would change guidance assembled. These data were used to inform recommendations in the 2021 CDC STI treatment guidelines.

Immune milieu and microbiome of the distal urethra in Ugandan men: impact of penile circumcision and implications for HIV susceptibility

BACKGROUND

Coronal sulcus (CS) anaerobe abundance and IL-8 levels are linked to HIV acquisition, and are dramatically reduced after penile circumcision (PC). The distal urethra may be the site of some HIV acquisition before PC, and presumably most acquisition post PC. We describe the immune milieu and microbiome of the distal urethra in uncircumcised Ugandan men, and define the impact of PC. Participants consisted of HIV-negative, genital symptom-free adult Ugandan men undergoing PC (n = 51). Urethral and coronal sulcus swabs were collected at baseline and at 6- and 12-months post-PC. Soluble immune factors were quantified by multiplex ELISA, and bacterial abundance assessed by 16S rRNA qPCR and sequencing.

RESULTS

At baseline, the urethra was enriched compared to the CS for most cytokines (including IL-8 and MIP-1β) and soluble E-cadherin (sE-cadherin, an epithelial disruption marker), although CS levels of IL-1α and IL-1β were higher. Baseline total bacterial abundance was ≥ 20-fold higher in the CS than the urethra (median 27,100 vs. 1200 gene copies/swab, p = 0.001), and anaerobes comprised 58% of CS bacteria vs. 42% of urethral bacteria. PC did not alter urethral IL-8 (median 806 at baseline vs. 1130 pg/ml at 12 months; p = 0.062) and urethral sE-cadherin increased (113,223 vs. 158,385 pg/ml, p = 0.009), despite five- and sevenfold drops in total bacterial and anaerobe abundance after PC, respectively. However, PC dramatically reduced CS levels of sE-cadherin (15,843 vs. 837 pg/ml, p < 0.001) and most cytokines (IL-8; 34 vs. 3 pg/ml, p < 0.001), while reducing total bacterial and anaerobe abundance by 13-fold and 60-fold, respectively (both P ≤ 0.004).

CONCLUSIONS

The urethra is immunologically rich with characteristics of an HIV-susceptible tissue site. However, PC had no impact on urethral immunology and may have reduced epithelial integrity, despite modest reductions in total bacteria and anaerobes, suggesting that HIV protection from PC is not mediated via immune or microbiome alterations in the urethra. Video abstract.

What is the medical evidence on non-therapeutic child circumcision?

Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.

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.

Male circumcision and Sexually transmitted Infections - An update

Role of male circumcision (MC) as a tool to prevent sexually transmitted infections (STIs)/human immunodeficiency virus (HIV) was assessed. An attempt was made to search articles related to association between MC and STIs/HIV. A thorough search was carried out to find out quality articles published in indexed specialty journals. Centers for Disease Control and Prevention and World Health Organization (WHO) sites were also referred. Warm and moist environment of area under foreskin facilitates some pathogens to persist and replicate. Further, the thinness of foreskin predisposes it to minor trauma and abrasions that facilitate the entry of pathogens. MC reduces HIV infection risk by 50%–60% over time and reduces the risk of men acquiring herpes simplex virus-2 and human papillomavirus (HPV) that can cause penile and other anogenital cancers, by 30%. There is no significant reduction in risk of acquiring syphilis, but reduced risk of acquisition of Haemophilus ducreyi is reported. MC is reported to be beneficial in conditions such as traumatic injury, Balanitis Xerotica Obliterans, refractory balanoposthitis, and chronic, recurrent urinary tract infections. MC also reduces the chances of penile carcinoma by facilitating improved penile hygiene, lowering HPV/HIV transmission rates, and reducing chronic inflammatory conditions such as phimosis and balanitis. MC has been recommended by the WHO and UNAIDS in 2007 as an additional HIV prevention intervention in settings of high HIV prevalence. MC is an important adjunct to safe sex education, condom use, and vaccination (HPV) in reducing the global burden of HIV/STIs-related morbidity and mortality.

Neonatal Circumcision

Neonatal circumcision is one of the most common elective surgical procedures in the United States and globally. This procedure, to remove part of the penile prepuce or foreskin, is done for a variety of personal, social, and medical reasons. There are several proposed benefits, risks, and ethical considerations to discuss with parents before the procedure. Three equally safe and effective methods are used for circumcision, and each uses unique equipment: the Gomco clamp, the Mogen clamp, and the Plastibell device. Choice of technique should be guided by operator training and comfort.

Effectiveness of Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention in Rakai, Uganda

BACKGROUND

The efficacy of voluntary male medical circumcision (VMMC) for human immunodeficiency virus (HIV) prevention in men was demonstrated in 3 randomized trials. This led to the adoption of VMMC as an integral component of the United States President's Emergency Plan for AIDS Relief (PEPFAR) combination HIV prevention program in sub-Saharan Africa. However, evidence on the individual-level effectiveness of VMMC programs in real-world, programmatic settings is limited.

METHODS

A cohort of initially uncircumcised, non-Muslim, HIV-uninfected men in the Rakai Community Cohort Study in Uganda was followed between 2009 and 2016 during VMMC scale-up. Self-reported VMMC status was collected and HIV tests performed at surveys conducted every 18 months. Multivariable Poisson regression was used to estimate the incidence rate ratio (IRR) of HIV acquisition in newly circumcised vs uncircumcised men.

RESULTS

A total of 3916 non-Muslim men were followed for 17 088 person-years (PY). There were 1338 newly reported VMMCs (9.8/100 PY). Over the study period, the median age of men adopting VMMC declined from 28 years (interquartile range [IQR], 21-35 years) to 22 years (IQR, 18-29 years) (P for trend < .001). HIV incidence was 0.40/100 PY (20/4992.8 PY) among newly circumcised men and 0.98/100 PY (118/12 095.1 PY) among uncircumcised men with an adjusted IRR of 0.47 (95% confidence interval, .28-.78). The effectiveness of VMMC was sustained with increasing time from surgery and was similar across age groups and calendar time.

CONCLUSIONS

VMMC programs are highly effective in preventing HIV acquisition in men. The observed effectiveness is consistent with efficacy in clinical trials and supports current recommendations that VMMC is a key component of programs to reduce HIV incidence.

Non-therapeutic male circumcision in infancy or childhood and risk of human immunodeficiency virus and other sexually transmitted infections: national cohort study in Denmark

Whether male circumcision in infancy or childhood provides protection against the acquisition of human immunodeficiency virus (HIV) or other sexually transmitted infections (STIs) in adulthood remains to be established. In the first national cohort study to address this issue, we identified 810,719 non-Muslim males born in Denmark between 1977 and 2003 and followed them over the age span 0–36 years between 1977 and 2013. We obtained information about cohort members’ non-therapeutic circumcisions, HIV diagnoses and other STI outcomes from national health registers and used Cox proportional hazards regression analyses to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status (i.e., circumcised v. genitally intact). During a mean of 22 years of follow-up, amounting to a total observation period of 17.7 million person-years, 3375 cohort members (0.42%) underwent non-therapeutic circumcision, and 8531 (1.05%) received hospital care for HIV or other STIs. Compared with genitally intact males, rates among circumcised males were not statistically significantly reduced for any specific STI. Indeed, circumcised males had a 53% higher rate of STIs overall (HR = 1.53, 95% CI: 1.24–1.89), and rates were statistically significantly increased for anogenital warts (74 cases in circumcised males v. 7151 cases in intact males, HR = 1.51; 95% CI: 1.20–1.90) and syphilis (four cases in circumcised males v. 197 cases in intact males, HR = 3.32; 95% CI: 1.23–8.95). In this national cohort study spanning more than three decades of observation, non-therapeutic circumcision in infancy or childhood did not appear to provide protection against HIV or other STIs in males up to the age of 36 years. Rather, non-therapeutic circumcision was associated with higher STI rates overall, particularly for anogenital warts and syphilis.

Association of medical male circumcision and sexually transmitted infections in a population-based study using targeted maximum likelihood estimation

Background

Epidemiological theory and many empirical studies support the hypothesis that there is a protective effect of male circumcision against some sexually transmitted infections (STIs). However, there is a paucity of randomized control trials (RCTs) to test this hypothesis in the South African population. Due to the infeasibility of conducting RCTs, estimating marginal or average treatment effects with observational data increases interest. Using targeted maximum likelihood estimation (TMLE), a doubly robust estimation technique, we aim to provide evidence of an association between medical male circumcision (MMC) and two STI outcomes.

Methods

HIV and HSV-2 status were the two primary outcomes for this study. We investigated the associations between MMC and these STI outcomes, using cross-sectional data from the HIV Incidence Provincial Surveillance System (HIPSS) study in KwaZulu-Natal, South Africa. HIV antibodies were tested from the blood samples collected in the study. For HSV-2, serum samples were tested for HSV-2 antibodies via an ELISA-based anti-HSV-2 IgG. We estimated marginal prevalence ratios (PR) using TMLE and compared estimates with those from propensity score full matching (PSFM) and inverse probability of treatment weighting (IPTW).

Results

From a total 2850 male participants included in the analytic sample, the overall weighted prevalence of HIV was 32.4% (n = 941) and HSV-2 was 53.2% (n = 1529). TMLE estimates suggest that MMC was associated with 31% lower HIV prevalence (PR: 0.690; 95% CI: 0.614, 0.777) and 21.1% lower HSV-2 prevalence (PR: 0.789; 95% CI: 0.734, 0.848). The propensity score analyses also provided evidence of association of MMC with lower prevalence of HIV and HSV-2. For PSFM: HIV (PR: 0.689; 95% CI: 0.537, 0.885), and HSV-2 (PR: 0.832; 95% CI: 0.709, 0.975). For IPTW: HIV (PR: 0.708; 95% CI: 0.572, 0.875), and HSV-2 (PR: 0.837; 95% CI: 0.738, 0.949).

Conclusion

Using a TMLE approach, we present further evidence of a protective association of MMC against HIV and HSV-2 in this hyper-endemic South African setting. TMLE has the potential to enhance the evidence base for recommendations that embrace the effect of public health interventions on health or disease outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11705-9.

Impact of Sexual Activity on the Risk of Male Genital Tumors: A Systematic Review of the Literature

Most cancers are related to lifestyle and environmental risk factors, including smoking, alcohol consumption, dietary habits, and environment (occupational exposures). A growing interest in the association between sexual activity (SA) and the development of different types of tumors in both men and women has been recorded in recent years. The aim of the present systematic review is to describe and critically discuss the current evidence regarding the association between SA and male genital cancers (prostatic, penile, and testicular), and to analyze the different theories and biological mechanisms reported in the literature. A comprehensive bibliographic search in the MEDLINE, Scopus, and Web of Science databases was performed in July 2021. Papers in the English language without chronological restrictions were selected. Retrospective and prospective primary clinical studies, in addition to previous systematic reviews and meta-analyses, were included. A total of 19 studies, including 953,704 patients were selected. Case reports, conference abstracts, and editorial comments were excluded. Men with more than 20 sexual partners in their lifetime, and those reporting more than 21 ejaculations per month, reported a decreased risk of overall and less aggressive prostate cancer (PCa). About 40% of penile cancers (PCs) were HPV-associated, with HPV 16 being the dominant genotype. Data regarding the risk of HPV in circumcised patients are conflicting, although circumcision appears to have a protective role against PC. Viral infections and epididymo-orchitis are among the main sex-related risk factors studied for testicular cancer (TC); however, data in the literature are limited. Testicular trauma can allow the identification of pre-existing TC. SA is closely associated with the development of PC through high-risk HPV transmission; in this context, phimosis appears to be a favoring factor. Sexual behaviors appear to play a significant role in PCa pathogenesis, probably through inflammatory mechanisms; however, protective sexual habits have also been described. A direct correlation between SA and TC has not yet been proven, although infections remain the most studied sex-related factor.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of penile cancer

Squamous cell carcinoma of the penis (SCCP) is uncommon in some countries (including the U.S.), but is an important malignancy elsewhere. As a rare disease, progress has been slow compared to more common tumor types discussed in this anniversary issue and most often limited to single-center or retrospective datasets.  In this section we describe developments leading to the current standard approach with current research questions.

Male Circumcision Reduces Penile HPV Incidence and Persistence: A Randomized Controlled Trial in Kenya

BACKGROUND

Male circumcision reduces the risk of human immunodeficiency virus infection in men. We assessed the effect of male circumcision on the incidence and natural history of human papillomavirus (HPV) in a randomized clinical trial in Kisumu, Kenya.

METHODS

Sexually active, 18- to 24-year-old men provided penile exfoliated cells for HPV DNA testing every 6 months for 2 years. HPV DNA was detected via GP5+/6+ PCR in glans/coronal sulcus and in shaft samples. HPV incidence and persistence were assessed by intent-to-treat analyses.

RESULTS

A total of 2,193 men participated (1,096 randomized to circumcision; 1,097 controls). HPV prevalence was 50% at baseline for both groups and dropped to 23.7% at 24 months in the circumcision group, and 41.0% in control group. Incident infection of any HPV type over 24 months was lower among men in the circumcision group than in the control group [HR = 0.61; 95% confidence interval (CI), 0.52-0.72]. Clearance rate of any HPV infection over 24 months was higher in the circumcision group than in the control group (HR = 1.87; 95% CI, 1.49-2.34). Lower HPV point-prevalence, lower HPV incidence, and higher HPV clearance in the circumcision group were observed in glans but not in shaft samples.

CONCLUSION

Male circumcision reduced the risk of HPV acquisition and reinfection, and increased HPV clearance in the glans.

IMPACT

Providing voluntary, safe, and affordable male circumcision should help reduce HPV infections in men, and consequently, HPV-associated disease in their partners.

Prevalence of human papillomavirus in young men who have sex with men after the implementation of gender-neutral HPV vaccination: a repeated cross-sectional study

BACKGROUND

Anal infection with high-risk human papillomavirus (HPV) genotypes 16 and 18 and anal cancer are overrepresented in men who have sex with men (MSM). This study investigated HPV prevalence in young MSM before and after the implementation of a school-based quadrivalent HPV (genotypes 6, 11, 16, and 18) vaccination programme for boys in Australia in 2013.

METHODS

In this repeated cross-sectional study, MSM aged 16-20 years were recruited from two successive birth cohorts via sexual health clinics and the community in Melbourne, Australia. The first cohort was before the implementation of gender-neutral vaccination (HYPER1 study, done in 2010-12, NCT01422356), and the second was the post-vaccination cohort (HYPER2 study, done in 2017-18, NCT03000933). Men who self-identified as being same-sex attracted were enrolled, and those recruited via the HYPER2 study had to be resident in Australia since 2013 to ensure eligibility. Study procedures were done in the Melbourne Sexual Health Centre. A clinician-collected anal swab and self-collected penile swab and oral rinse were tested for 28 HPV genotypes, and data on demographics and sexual health practices were collected via questionnaires. Only assessable samples were included in the analyses. We compared anatomical site-specific prevalence of HPV genotypes between cohorts by calculating the prevalence ratio, adjusting for age, circumcision, and sex with women. Herd protection was also assessed, by calculating the adjusted prevalence ratios by vaccination status.

FINDINGS

400 MSM, 200 per cohort, were included in the study. In both cohorts, the median number of lifetime male partners was ten (IQR 5-25). The prevalence of any anal quadrivalent vaccine-preventable HPV genotype was higher in the pre-vaccination cohort (54 [28%] of 193) than in the post-vaccination cohort (14 [7%] of 193; adjusted prevalence ratio [PR] 0·24, 95% CI 0·14-0·42), largely driven by decreases in HPV6, followed by HPV11, 16, and 18. Nevertheless, there was also a significant reduction in anal HPV16 and 18 in the post-vaccination cohort from the pre-vaccination cohort (0·31, 0·14-0·68). The prevalence of any penile quadrivalent vaccine-preventable HPV genotype was also higher in the pre-vaccination cohort (21 [12%] of 177) than in the post-vaccination cohort (11 [6%] of 179; 0·48, 0·24-0·97), driven by decreases in HPV 6 and 11, but not by 16 and 18. The prevalence of any oral quadrivalent vaccine-preventable HPV genotype was higher in the pre-vaccination cohort (seven [4%] of 200) than in the post-vaccination cohort (one [1%] of 199; 0·10, 0·01-0·97); there were no cases of oral HPV6 or 11 detected in HYPER2. Comparing the pre-vaccinated cohort with the 149 confirmed vaccinated men from HYPER2 showed a reduction in any quadrivalent vaccine-preventable HPV genotype for anal (0·09, 0·03-0·25) and penile (0·18, 0·05-0·59) infection but not for oral infection (0·17, 0·03-1·08).

INTERPRETATION

A reduction in anal, penile, and oral quadrivalent vaccine-targeted genotypes occurred in young MSM following the implementation of a school-based gender-neutral HPV vaccination programme. The fall in anal HPV16 and 18 may lead to a reduction in the incidence of anal cancer.

FUNDING

Merck and the Australian Government Department of Health.

Genitourinary Infections Related to Circumcision and the Potential Impact on Male Infertility

Male circumcision (MC) is one of the oldest surgical procedures still completed today. Medical indications for MC include phimosis, recurrent balanitis, cosmesis, and infection prevention. In this review, we mainly focus on the role of MC in the prevention of human immunodeficiency virus, human papillomavirus, herpes simplex virus, gonorrhea, chlamydia, chancroid, and syphilis, and the subsequent impact of these genitourinary infections on male fertility. Overall, many compelling data support that MC may play an essential role in both genitourinary infection prevention and male fertility.

A Cross-sectional Study on the Prevalence of Cervical Dysplasia Among Women With Female Genital Mutilation/Cutting

OBJECTIVE

The aim of the study was to assess the prevalence of cervical dysplasia among migrant women with female genital mutilation/cutting (FGM/C) at a specialized clinic in Switzerland.

MATERIALS AND METHODS

This is a descriptive retrospective cross-sectional study. We reviewed the electronic medical records of all women who attended a specialized FGM/C clinic at the Geneva University Hospitals between 2010 and 2016. We examined sociodemographic data, sexually transmitted infections, FGM/C types, Pap smear results, and follow-up in women diagnosed with cervical dysplasia.

RESULTS

Three hundred sixty records were reviewed and 338 women were included. The average age was 33 years (SD = 7.47 years). Most women were from Eritrea and Somalia (n = 204, 60.4%) and had FGM/C type III (n = 188, 55.6%). A total of 12.4% (n = 42) of the patients had abnormal Pap smears: 1.5% (n = 5) with atypical squamous cells of undetermined significance (ASCUS) with high-risk human papillomavirus (HPV), 7.9% (n = 27) with low-grade squamous intraepithelial lesion (LSIL), and 2.9% (n = 10) with high-grade squamous intraepithelial lesion or higher (HSIL +). Of the 37 patients with dysplasia, 22 (59.4%) completed follow-up and 15 (40.5%) received incomplete follow-up.

CONCLUSIONS

The prevalence of high-grade squamous intraepithelial lesion+ among migrant women with FGM/C is high (2.95%) compared with the general Swiss population (0.58%). Follow-up for cervical dysplasia must be improved by increasing provider knowledge of this patient population and by addressing barriers to care.

Update on the Medical and Surgical Management of Urethral Condyloma

INTRODUCTION

Condyloma acuminata (CA) of the urethra presents a management challenge due to high recurrence rates, difficulty in accessing urethral lesions, risk of stricture formation, and potential for sexual dysfunction. While standard treatment modalities are acceptable for some external genital condyloma, they are not always feasible or appropriate for urethral lesions.

OBJECTIVES

We sought to review the literature on epidemiology, presentation, diagnosis and treatment of urothelial CA with a focus on surgical treatment options.

METHODS

We performed a comprehensive literature search of PubMed to identify all studies pertaining to urethral CA through November 2020.

RESULTS

Urethral CA is a relatively rare, but challenging disease to manage with a considerable amount of treatment side effects and downstream morbidity associated. In our comprehensive review we have found a wide selection of treatment modalities ranging from minimally invasive strategies to surgical reconstructive techniques. Proper follow-up to monitor for disease recurrence at the 3-4 month mark is appropriate and will determine subsequent treatment strategies as needed. Future studies and treatment directions include novel drug delivery models to optimize minimally invasive topical drug efficacy.

CONCLUSION

Treatment of urethral CA should be approached in a step-wise fashion. Medical therapy would be an appropriate option for asymptomatic or minimally symptomatic patients with small lesions who desire to avoid any interventions. If patient is symptomatic, has extensive disease burden or has failed medical therapy intervention should be considered with options including PDT, laser ablation or surgical excision with or without urethral reconstruction. Appropriate selection depends on patient characteristics and preferences along with prior treatment history. Kim CJ, Campbell SP, Allkanjari A, et al. Update on the Medical and Surgical Management of Urethral Condyloma. Sex Med Rev 2021;xxx:xxx-xxx.

Circumcision in childhood and male sexual function: a blessing or a curse?

Male circumcision (MC) is the first planned surgical procedure ever performed. Nowadays many of these procedures are not necessarily carried out in a medical environment, therefore the real number remains unknown but it is estimated that one third of the men are circumcised. Some authors argue the negative impact of MC on men psychology and sexual life, but objective data are lacking. The purpose of this review is to summarize in the best possible way the literature to clarify this matter. A non-systematic narrative review was performed including articles between 1986 and 2019. The search for literature was carried out between July 2019 to October 2019 and any updates as of March 30, 2020. Although many authors support the hypothesis that circumcision status has an impact on sexual functioning, a negative outcome has not yet been entirely proven. Circumcision might affect how men perceive their body image, and consequently affect their sexual life. We should consider this when analysing the literature about MC and sexual dysfunction, as many of the results are based on specific populations with different attitudes towards this procedure. Sexual function consists of many elements that not only relate to measurable facts such as anatomy, somatosensory and histology. An objective evaluation of the impact of circumcision on sexuality is still challenging, as it affects a wide variety of people that confront sexuality differently due to their sociocultural and historical background. Therefore, individuals can either perceive their circumcision status as a blessing or a curse depending on the values and preferences of the different communities or social environments where they belong.

Brief Report: Modeling the Impact of Voluntary Medical Male Circumcision on Cervical Cancer in Uganda

BACKGROUND

In addition to providing millions of men with lifelong lower risk for HIV infection, voluntary medical male circumcision (VMMC) also provides female partners with health benefits including decreased risk for human papillomavirus (HPV) and resultant cervical cancer (CC).

SETTING

We modeled potential impacts of VMMC on CC incidence and mortality in Uganda as an additional benefit beyond HIV prevention.

METHODS

HPV and CC outcomes were modeled using the CC model from the Spectrum policy tool suite, calibrated for Uganda, to estimate HPV infection incidence and progression to CC, using a 50-year (2018-2067) time horizon. 2016 Demographic Health Survey data provided baseline VMMC coverage. The baseline (no VMMC scale-up beyond current coverage, minimal HPV vaccination coverage) was compared with multiple scenarios to assess the varying impact of VMMC according to different implementations of HPV vaccination and HPV screening programs.

RESULTS

Without further intervention, annual CC incidence was projected to rise from 16.9 to 31.2 per 100,000 women in 2067. VMMC scale-up alone decreased 2067 annual CC incidence to 25.3, averting 13,000 deaths between 2018 and 2067. With rapidly-achieved 90% HPV9 vaccination coverage for adolescent girls and young women, 2067 incidence dropped below 10 per 100,000 with or without a VMMC program. With 45% vaccine coverage, the addition of VMMC scaleup decreased incidence by 2.9 per 100,000 and averted 8000 additional deaths. Similarly, with HPV screen-and-treat without vaccination, the addition of VMMC scaleup decreased incidence by 5.1 per 100,000 and averted 10,000 additional deaths.

CONCLUSIONS

Planned VMMC scale-up to 90% coverage from current levels could prevent a substantial number of CC cases and deaths in the absence of rapid scale-up of HPV vaccination to 90% coverage.

Protection and Risk: Male and Female Genital Microbiota and Sexually Transmitted Infections

Unique compositional and functional features of the cervicovaginal microbiota have been associated with protection against and risk for sexually transmitted infections (STI). In men, our knowledge of the interaction between the penile microbiota and STI is less developed. The current state of our understanding of these microbiota and their role in select STIs is briefly reviewed, along with strategies that leverage existing findings to manipulate genital microbiota and optimize protection against STIs. Finally, we focus on major research gaps and present a framework for future studies.

The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models

Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.

Vaginal and Penile Microbiome Associations with HSV-2 in Women and their Male Sex Partners

Background

We determined how the vaginal and penile microbiomes contribute to herpes simplex virus type 2 (HSV-2) serostatus within sexual partnerships.

Methods

Microbiomes were characterized in cervicovaginal lavage and penile meatal swab specimens through high-throughput 16s ribosomal RNA gene amplicon sequencing. HSV-2 antibody was detected in serum specimens. We modeled vaginal and penile taxa and covariates contributing to HSV-2 status in women and men using bivariate probit analysis.

Results

Among 231 couples, HSV-2 was detected in both partners in 78 couples (33.8%), in the woman only in 52 (22.5%),in the man only in 27 (11.7%), and in neither in 74 (32.0%). Among the women (median age, 22 years) 10.9% had human immunodeficiency virus (HIV), and 21.4% had Bacterial vaginosis. Among men (median age, 26 years), 11.8% had HIV, and 55.0% circumcised. In an analysis with adjustment for sociodemographics and Bacterial vaginosis, enrichment of vaginal Gardnerella vaginalis and Lactobacillus iners was associated with increased likelihood of HSV-2 in both partners. Penile taxa (including Ureaplasma and Aerococcus) were associated with HSV-2 in women.

Conclusions

We demonstrate that penile taxa are associated with HSV-2 in female partners, and vaginal taxa are associated with HSV-2 in male partners. Our findings suggest that couples-level joint consideration of genital microbiome and sexually transmitted infection or related outcomes could lead to new avenues for prevention.

The Penile Microbiota in Uncircumcised and Circumcised Men: Relationships With HIV and Human Papillomavirus Infections and Cervicovaginal Microbiota

While the human microbiota especially that of the gut, cervix, and vagina continue to receive great attention, very little is currently known about the penile (glans, coronal sulcus, foreskin, and shaft) microbiota. The best evidences to date for the potential role of the penile microbiota in human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) acquisition have come from studies examining medical male circumcision. We are still at the foothills of identifying specific penile bacteria that could be associated with increased risk of STI/HIV acquisition. In this review, we summarize the available literature on the human penile microbiota and how it is impacted by circumcision. We also discuss the potential role of penile microbiota in STIs and its impact on cervicovaginal microbiota. Taken together, the findings from the penile microbiota studies coupled with observational studies on the effect of male circumcision for reduction of STI/HIV infection risk suggest that specific penile anaerobic bacteria such as Prevotella spp. potentially have a mechanistic role that increases the risk of genital infections and syndromes, including bacterial vaginosis in sexual partners. Although penile Corynebacterium and Staphylococcus have been associated with healthy cervicovaginal microbiota and have been found to increase following male circumcision, further investigations are warranted to ascertain the exact roles of these bacteria in the reproductive health of men and women. This review aims to address existing gaps and challenges and future prospects in the penile microbiota research. The information described here may have translational significance, thereby improving reproductive health and management of STI/HIV.