Routine male neonatal circumcision and risk of infection with HIV-1 and other sexually transmitted diseases

Risk of HIV infection but not other sexually transmitted diseases is lower among homeless Muslim men in Kolkata

OBJECTIVE

To compare the risk of HIV and sexually transmitted diseases (STD) among homeless Muslim (circumcised) and Hindu (uncircumcised) men in Kolkata, India.

BACKGROUND

Many observational studies and clinical trials in Africa have demonstrated that male circumcision provides protection against HIV acquisition, but there are sparse data on circumcision and HIV in India, which has the largest number of HIV cases in the world.

METHODS

Using a two-stage probability proportionate to size cluster design among homeless men aged 18-49 years in Kolkata, India, data were obtained on religion, behavioral risk factors, and HIV/STD prevalence, by administering an anonymous questionnaire. Rapid HIV tests and testing for syphilis were performed on blood, and urine samples were obtained to test for gonorrhea.

RESULTS

The odds ratio for HIV among Muslims (circumcised) compared to Hindus (uncircumcised) was 0.43 (95% confidence interval 0.29-0.67). Despite Muslims having more partners and visits to commercial sex workers, the rates of syphilis and gonorrhea were similar. The results suggest that a biological effect of circumcision protects against HIV infection.

CONCLUSION

The beneficial effect of circumcision should be communicated to high-risk groups, as well as to the general population.

Penile cancer

Penile cancer, while relatively rare in the western world, remains a disease with severe morbidity and mortality, not to mention significant psychological ramifications. Furthermore, the disease is observed with dramatically increased incidence in other parts of the world. A review of the literature has shown that the overwhelming majority of penile cancers are in situ or invasive squamous cell carcinomas, including a well-differentiated variant, verrucous carcinoma. Important predisposing factors are lack of circumcision, human papillomavirus infections, and penile lichen sclerosus, although other factors have occasionally been reported as well. Prevention, careful monitoring of patients at risk, and early diagnosis are essential to reduce the incidence of penile carcinoma and to provide a definitive cure. Public health measures, such as prophylactic use of circumcision, have proved successful but are controversial. Also, no standard therapeutic guidelines as to the best treatment strategy according to different stages, including efficacy of conservative nonsurgical modalities and indications for lymph nodal dissection, are available so far. It is common opinion that penile cancer is an emerging problem that deserves further investigations, and physicians, especially dermatologists, should be aware of this issue.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with penile carcinoma, its risk factors, its clinical and histologic presentation, and the treatments currently available for its management.

Circumcision: a consideration of some of the controversy

This article considers the procedure known as male circumcision. This is practised throughout the world for a variety of reasons, including medically essential reasons, health promotion, health protection, cultural, religious and aesthetic. It has been estimated that approximately one-third of the male population has been circumcized. As with some other surgical interventions its use is controversial, and there are a number of ethical and moral issues that are of interest to the children's nurse. The anatomy and physiology of the prepuce is summarized and the practice of circumcision and some of the risks and proposed benefits of the procedure are considered. This article is intended to be culturally sensitive and it is hoped that it will inform others and provoke discussion. It may enable the children's nurse to raise awareness of the issues among the general population.

Male circumcision as an HIV control strategy: not a 'natural condom'

Recent epidemiological studies have shown fairly convincingly that in high-risk populations in sub-Saharan Africa, male circumcision is associated with a reduced risk of HIV infection. Following a consultation at the XIII International AIDS Conference in July 2000 in Durban, there was growing interest in such an intervention. This paper explores what is known about male circumcision, the risks associated with it, its relationship with sexual health, including HIV and other sexually transmitted infections (STIs), and the potential problems with implementing circumcision as an intervention internationally, particularly in traditionally non-circumcising communities and those where access to medical facilities is limited. Proponents of male circumcision as an HIV prevention strategy are convinced and convincing, but circumcision is a surgical procedure with associated risks and has strong religious and cultural significance for many groups. Hence, there are ethical and practical barriers to implementing it as a public health intervention. The evidence suggests that circumcision may reduce the risk of infection, but circumcision does not appear to have any impact on transmission rates from HIV positive men to their partners. Until we know why and how circumcision is protective, exactly what the relationship is between circumcision status and other STIs, and whether the effect seen in high-risk populations is generalisable to other groups, the wisest course is to recommend risk reduction strategies of proven efficacy, such as condom use.

An evidence-based approach to male circumcision: what do we know?

Midwives care for women throughout their childbearing years, guiding them through decisions made about themselves and their newborn children. The decision to circumcise a male infant depends on a number of factors, including medical, social, cultural, and religious considerations. Data surrounding medical benefits and risks of this surgery are inconsistent and, therefore, confusing. However, substantial data exist to support the conclusions that uncircumcised males have greater incidences of urinary tract infections, especially in the first 6 months of life when complications are greatest, greater incidences of ulcerative sexually transmitted infections, and increased transmission of human immunodeficiency virus. This article reviews available research on the medical benefits and risks of infant circumcision. Informed consent is essential for all parents who must make this decision.

Fleeting foreskins: the misclassification of male circumcision status

BACKGROUND

Errors in the classification of male circumcision status could bias studies linking infection to lack of circumcision.

GOAL

To determine the frequency and factors associated with the reproducibility of reporting circumcision status.

STUDY DESIGN

Secondary analysis of data using logistic regression modeling from a multicenter randomized controlled trial was performed.

RESULTS

At follow-up assessment, 15.6% of clinician reports on circumcision status disagreed with baseline reports. Disagreement was more common if both clinicians were women than if both were men (odds ratio [OR], 2.8; 95% CI, 1.9-4.1). As compared with whites reported as circumcised (4%, 19/532 visits), the highest disagreement involved uncircumcised Hispanic (OR, 3.3; 95% CI, 1.7-6.3), white (OR, 12.2; 95% CI, 5.8-25.6), or black (OR, 17.1; 95% CI, 10.4-27.9) men.

CONCLUSIONS

This is one study among a small number of studies examining the reproducibility of clinician-reported circumcision status by comparing multiple clinical examinations of the same patient. The magnitude of the misclassification discovered could bias results and indicates the need for greater accuracy in reporting circumcision status in future studies.

Circumcision and STD in the United States: cross sectional and cohort analyses

BACKGROUND

Male circumcision status has been shown to be associated with sexually transmitted disease (STD) acquisition in some, but not all, studies. Most studies have been cross sectional.

OBJECTIVES

We examined the association between circumcision status and the prevalence and incidence of gonorrhoea, chlamydia, and syphilis.

METHODS

We analysed cross sectional and cohort study data from a multicentre controlled trial in the United States. Between July 1993 and September 1996, 2021 men visiting public inner city STD clinics in the United States were examined by a clinician at enrolment and 1456 were examined at follow up visits 6 and 12 months later. At each visit, men had laboratory tests for gonorrhoea, chlamydia, and syphilis and were examined for circumcision status. We used multiple logistic regression to compare STD risk among circumcised and uncircumcised men adjusted for potentially confounding factors.

RESULTS

Uncircumcised men were significantly more likely than circumcised men to have gonorrhoea in the multivariate analyses, adjusted for age, race, and site, in both the cross sectional (odds ratio (OR), 1.3; 95% confidence interval (CI), 0.9 to 1.7) and in the cohort analysis (OR, 1.6; 95% CI, 1.0 to 2.6). There was no association between lack of circumcision and chlamydia in either the cross sectional (OR, 1.0; 95% CI 0.7-1.4) or the cohort analysis (OR, 0.9; 95% CI 0.5-1.5). The magnitude of association between lack of circumcision and syphilis was similar in the cross sectional (OR, 1.4; 95% CI 0.6 to 3.3) and cohort analysis (OR, 1.5; 95% CI 0.4 to 6.1).

CONCLUSION

Uncircumcised men in the United States may be at increased risk for gonorrhoea and syphilis, but chlamydia risk appears similar in circumcised and uncircumcised men. Our results suggest that risk estimates from cross sectional studies would be similar to cohort findings.

Circumcision of the young infant in a developing country using the Plastibell

Circumcision of the male infant by conventional methods is common practice in Tanzania. This study reports the use of the Plastibell to circumcise 386 young infants between 1992 and 1998 and shows differences in age at circumcision between African and Asian infants. The Plastibell has been found to be cheap and easy to use and was associated with minor, remediable complications in less than 3% of infants.