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Bernaschina-Rivera SA, López-Chaim AI, Cordero-Pacheco JA, Fernández-Crespo R, Quesada-Olarte J, Carrión R. Circumcision and Sexual Medicine. Sex Med Rev 2023; 11:412-420. [PMID: 37085961 DOI: 10.1093/sxmrev/qead009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 01/26/2023] [Accepted: 02/18/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Male circumcision is one of the most frequently performed and debated urological procedures due to its possible implications for sexual health. OBJECTIVES The objective of this article is to review the literature on male circumcision and reconcile the scientific evidence to improve the quality of care, patient education, and clinician decision-making regarding the effects on sexual function of this procedure. METHODS A review of the published literature regarding male circumcision was performed on PubMed. The criteria for selecting resources prioritized systematic reviews and cohort studies pertinent to sexual dysfunction, with a preference for recent publications. RESULTS Despite the conflicting data reported in articles, the weight of the scientific evidence suggests there is not sufficient data to establish a direct association between male circumcision and sexual dysfunction. CONCLUSION This review provides clinicians with an updated summary of the best available evidence on male circumcision and sexual dysfunction for evidenced-based quality of care and patient education.
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Affiliation(s)
| | | | | | - Raúl Fernández-Crespo
- University of South Florida, Morsani College of Medicine, Tampa, FL 33602, United States
| | - José Quesada-Olarte
- University of South Florida, Morsani College of Medicine, Tampa, FL 33602, United States
| | - Rafael Carrión
- University of South Florida, Morsani College of Medicine, Tampa, FL 33602, United States
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Yuan T, Fitzpatrick T, Ko NY, Cai Y, Chen Y, Zhao J, Li L, Xu J, Gu J, Li J, Hao C, Yang Z, Cai W, Cheng CY, Luo Z, Zhang K, Wu G, Meng X, Grulich AE, Hao Y, Zou H. Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data. LANCET GLOBAL HEALTH 2020; 7:e436-e447. [PMID: 30879508 DOI: 10.1016/s2214-109x(18)30567-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/11/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. Previous reviews investigating the role of circumcision in preventing HIV and other STIs among MSM were inconclusive. Many new studies have emerged in the past decade. To inform global prevention strategies for HIV and other STIs among MSM, we reviewed all available evidence on the associations between circumcision and HIV and other STIs among MSM. METHODS In this systematic review and meta-analysis, we searched PubMed, Web of Science, BioMed Central, Scopus, ResearchGate, Cochrane Library, Embase, PsycINFO, Google Scholar, and websites of international HIV and STI conferences for studies published before March 8, 2018. Interventional or observational studies containing original quantitative data describing associations between circumcision and incident or prevalent infection of HIV and other STIs among MSM were included. Studies were excluded if MSM could not be distinguished from men who have sex with women only. We calculated pooled odds ratios (ORs) and their 95% CIs using random-effect models. We assessed risk of bias using the Newcastle-Ottawa scale. FINDINGS We identified 62 observational studies including 119 248 MSM. Circumcision was associated with 23% reduced odds of HIV infection among MSM overall (OR 0·77, 95% CI 0·67-0·89; number of estimates [k]=45; heterogeneity I2=77%). Circumcision was protective against HIV infection among MSM in countries of low and middle income (0·58, 0·41-0·83; k=23; I2=77%) but not among MSM in high-income countries (0·99, 0·90-1·09; k=20; I2=40%). Circumcision was associated with reduced odds of herpes simplex virus (HSV) infection among MSM overall (0·84, 0·75-0·95; k=5; I2=0%) and penile human papillomavirus (HPV) infection among HIV-infected MSM (0·71, 0·51-0·99; k=3; I2=0%). INTERPRETATION We found evidence that circumcision is likely to protect MSM from HIV infection, particularly in countries of low and middle income. Circumcision might also protect MSM from HSV and penile HPV infection. MSM should be included in campaigns promoting circumcision among men in countries of low and middle income. In view of the substantial proportion of MSM in countries of low and middle income who also have sex with women, well designed longitudinal studies differentiating MSM only and bisexual men are needed to clarify the effect of circumcision on male-to-male transmission of HIV and other STIs. FUNDING National Natural Science Foundation of China, National Science and Technology Major Project of China, Australian National Health and Medical Research Council Early Career Fellowship, Sanming Project of Medicine in Shenzhen, National Institutes of Health, Mega Projects of National Science Research for the 13th Five-Year Plan, Doris Duke Charitable Foundation.
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Affiliation(s)
- Tanwei Yuan
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China
| | | | - Nai-Ying Ko
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yong Cai
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingqing Chen
- Department of Biostatistics, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jin Zhao
- Shenzhen Center for Disease Control and Prevention, Shenzhen, China
| | - Linghua Li
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Junjie Xu
- Key Laboratory of AIDS Immunology of the National Health and Family Planning Commission, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Jing Gu
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Jinghua Li
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Chun Hao
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Zhengrong Yang
- Shenzhen Center for Disease Control and Prevention, Shenzhen, China
| | - Weiping Cai
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Chien-Yu Cheng
- Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Zhenzhou Luo
- Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Kechun Zhang
- Shenzhen Longhua Center for Disease Control and Prevention, Shenzhen, China
| | - Guohui Wu
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Xiaojun Meng
- Wuxi Municipal Center for Disease Control and Prevention, Wuxi, China
| | - Andrew E Grulich
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Yuantao Hao
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China; Shenzhen Center for Disease Control and Prevention, Shenzhen, China; School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China; Kirby Institute, University of New South Wales, Sydney, NSW, Australia.
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Yuan T, Qian HZ, Wang J, Gao Y, Zou H. Is circumcision an answer for HIV prevention in men who have sex with men? - Authors' reply. LANCET GLOBAL HEALTH 2020; 7:e1012. [PMID: 31303288 DOI: 10.1016/s2214-109x(19)30270-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Tanwei Yuan
- School of Public Health (Shenzhen), Sun Yat-sen University, Guangzhou 510085, China
| | - Han-Zhu Qian
- Shanghai Jiao Tong University-Yale Joint Center for Biostatistics and Data Sciences, Shanghai, China; Yale School of Public Health, New Haven, CT, USA
| | - Junfeng Wang
- Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Yanxiao Gao
- School of Public Health (Shenzhen), Sun Yat-sen University, Guangzhou 510085, China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Guangzhou 510085, China.
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Gilbertson A, Ongili B, Odongo FS, Hallfors DD, Rennie S, Kwaro D, Luseno WK. Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets. PLoS One 2019; 14:e0224548. [PMID: 31682626 PMCID: PMC6827911 DOI: 10.1371/journal.pone.0224548] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. Methods and results The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. Conclusion Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.
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Affiliation(s)
- Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | | | | | - Denise D. Hallfors
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
| | - Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
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Zhang C, Qian HZ, Liu Y, Vermund SH. Voluntary medical male circumcision and HIV infection among men who have sex with men: Implications from a systematic review. SAGE Open Med 2019; 7:2050312119869110. [PMID: 31448119 PMCID: PMC6689924 DOI: 10.1177/2050312119869110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/21/2019] [Indexed: 01/05/2023] Open
Abstract
Background: With the rapidly-increased HIV epidemic among men who have sex with men worldwide, the effectiveness of voluntary medical male circumcision as the tool of HIV prevention still remains undetermined. Purpose: In the current study, we conducted a systematic review and meta-analysis to assess the association between voluntary medical male circumcision and HIV risk among men who have sex with men. Methods and Conclusion: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, we conducted a comprehensive literature search through multiple databases. A total of 37 articles/abstracts were included in the analysis. We employed random-effects models and subgroup analyses based upon key study characteristics derived from empirical studies. A total of 117,293 men who have sex with men were included in the meta-analysis, and no randomized control trials have been identified. The odds of being HIV positive were 7% lower among men who have sex with men who were circumcised than among men who have sex with men who were uncircumcised (adjusted odds ratio, 0.93; 95% confidence interval, 0.88–0.99). The evidence for the potential protective effect of voluntary medical male circumcision was stronger among men who have sex with men in Asia and Africa (adjusted odds ratio, 0.62; 95% confidence interval, 0.53–0.73). Our meta-analyses may suggest a protective effect of voluntary medical male circumcision against HIV infection among men who have sex with men, especially in settings like Asia/Africa.
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Affiliation(s)
- Chen Zhang
- School of Nursing, University of Rochester Medical Center, Rochester, NY, USA
| | - Han-Zhu Qian
- Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Yu Liu
- Division of Epidemiology, Department of Public Health Science, University of Rochester Medical Center, Rochester, NY, USA
| | - Sten H Vermund
- Yale School of Public Health, Yale University, New Haven, CT, USA
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Van Howe RS. Is circumcision an answer for HIV prevention in men who have sex with men? LANCET GLOBAL HEALTH 2019; 7:e1011. [PMID: 31303287 DOI: 10.1016/s2214-109x(19)30274-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/08/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics and Human Development, Michigan State University College of Medicine, Marquette, MI 49855, USA.
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Dave S, Afshar K, Braga LH, Anderson P. Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants (full version). Can Urol Assoc J 2018; 12:E76-E99. [PMID: 29381458 PMCID: PMC5937400 DOI: 10.5489/cuaj.5033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Sumit Dave
- Department of Surgery (Urology), Western University, London, ON; Canada
| | - Kourosh Afshar
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC; Canada
| | - Luis H. Braga
- Department of Surgery (Urology), McMaster University, Hamilton, ON; Canada
| | - Peter Anderson
- Department of Urology, Dalhousie University, Halifax, NS; Canada
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Van Howe RS. Expertise or ideology? A response to Morris et al. 2016, ‘Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe’. Glob Public Health 2017; 13:1900-1918. [DOI: 10.1080/17441692.2016.1272939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Robert S. Van Howe
- Department of Pediatrics, Central Michigan University College of Medicine, Saginaw, MI, USA
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Friedman B, Khoury J, Petersiel N, Yahalomi T, Paul M, Neuberger A. Pros and cons of circumcision: an evidence-based overview. Clin Microbiol Infect 2016; 22:768-774. [PMID: 27497811 DOI: 10.1016/j.cmi.2016.07.030] [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] [Received: 04/24/2016] [Revised: 07/17/2016] [Accepted: 07/25/2016] [Indexed: 12/12/2022]
Abstract
Based on three large randomized controlled trials (RCTs) conducted in Africa, it can clearly be stated that circumcision lowers the risk of infection with the human immunodeficiency virus (HIV) and some sexually transmitted infections (STIs) among males in settings of high HIV and STI endemicity. Similar effects on STI risk may exist for females, although this may result from an indirect effect of decreasing risk of infection among male partners. It is unknown whether circumcision prevents HIV acquisition in men who have sex with men (MSM), although there might be a protective effect for men who engage mainly in insertive anal intercourse. When the effects of adult circumcision on sexual function and satisfaction of men are examined, high-quality evidence strongly supports lack of harm. Whether circumcision alters sexual satisfaction of female partners is not known as fewer and smaller studies reported conflicting results. Circumcision rarely causes serious complications if practiced by trained practitioners, in a sterile setting, and with a proper follow-up. These conclusions are limited by the lack of high-quality data from areas outside of Africa. RCTs have not been conducted to assess the effects of circumcising infants or MSM. Circumcision has well-proven benefits for people residing in areas with high prevalence of STIs, including HIV, and is not unethical for those who choose to be circumcised or have their children circumcised on religious, social, or cultural grounds. For many others, a definite pro or con recommendation, based on a risk-benefit ratio, cannot be made.
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Affiliation(s)
- B Friedman
- Department of Urology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - J Khoury
- Unit of Infectious Diseases, Rambam Medical Center, Haifa, Israel; Internal Medicine B, Rambam Medical Center, Haifa, Israel
| | - N Petersiel
- Unit of Infectious Diseases, Rambam Medical Center, Haifa, Israel; Internal Medicine B, Rambam Medical Center, Haifa, Israel
| | - T Yahalomi
- Unit of Infectious Diseases, Rambam Medical Center, Haifa, Israel
| | - M Paul
- Unit of Infectious Diseases, Rambam Medical Center, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - A Neuberger
- Unit of Infectious Diseases, Rambam Medical Center, Haifa, Israel; Internal Medicine B, Rambam Medical Center, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
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Morris BJ, Wamai RG, Krieger JN, Banerjee J, Klausner JD. Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby. Glob Public Health 2015; 12:1315-1333. [PMID: 26564989 DOI: 10.1080/17441692.2015.1104371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute, University of Sydney , Sydney , NSW , Australia
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- c Section of Urology, University of Washington School of Medicine and VA Puget Sound Health Care System , Seattle , WA , USA
| | - Joya Banerjee
- d Jhpiego, an affiliate of Johns Hopkins University , Washington , DC , USA
| | - Jeffrey D Klausner
- e Division of Infectious Diseases, Department of Medicine , David Geffen School of Medicine, University of California Los Angeles , CA , USA
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Starzyk EJ, Kelley MA, Caskey RN, Schwartz A, Kennelly JF, Bailey RC. Infant male circumcision: healthcare provider knowledge and associated factors. PLoS One 2015; 10:e0115891. [PMID: 25635664 PMCID: PMC4312077 DOI: 10.1371/journal.pone.0115891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/26/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The emerging science demonstrates various health benefits associated with infant male circumcision and adult male circumcision; yet rates are declining in the United States. The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that healthcare providers present evidence-based risk and benefit information for infant male circumcision to parent(s) and guardian(s). The purpose of this study was to assess providers' level of infant male circumcision knowledge and to identify the associated characteristics. METHODS An online survey was administered to healthcare providers in the family medicine, obstetrics, and pediatrics medical specialties at an urban academic health center. To assess infant male circumcision knowledge, a 17 point summary score was constructed to identify level of provider knowledge within the survey. RESULTS Ninety-two providers completed the survey. Providers scored high for the following knowledge items: adverse event rates, protects against phimosis and urinary tract infections, and does not prevent hypospadias. Providers scored lower for items related to more recent research: protection against cervical cancer, genital ulcer disease, bacterial vaginosis, and reduction in HIV acquisition. Two models were constructed looking at (1) overall knowledge about male circumcision, and (2) knowledge about male circumcision reduction in HIV acquisition. Pediatricians demonstrated greater overall infant male circumcision knowledge, while obstetricians exhibited significantly greater knowledge for the HIV acquisition item. CONCLUSION Providers' knowledge levels regarding the risks and benefits of infant male circumcision are highly variable, indicating the need for system-based educational interventions.
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Affiliation(s)
- Erin J. Starzyk
- University of Illinois at Chicago, School of Public Health, Division of Community Health Sciences, Chicago, Illinois, United States of America
| | - Michele A. Kelley
- University of Illinois at Chicago, School of Public Health, Division of Community Health Sciences, Chicago, Illinois, United States of America
| | - Rachel N. Caskey
- University of Illinois at Chicago, College of Medicine, Department of Internal Medicine and Pediatrics, Chicago, Illinois, United States of America
| | - Alan Schwartz
- University of Illinois at Chicago, College of Medicine, Department of Medical Education, Chicago, Illinois, United States of America
| | - Joan F. Kennelly
- University of Illinois at Chicago, School of Public Health, Division of Community Health Sciences, Chicago, Illinois, United States of America
| | - Robert C. Bailey
- University of Illinois at Chicago, School of Public Health, Division of Epidemiology and Biostatistics, Chicago, Illinois, United States of America
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Doerner R, McKeown E, Nelson S, Anderson J, Low N, Elford J. Circumcision and HIV infection among men who have sex with men in Britain: the insertive sexual role. ARCHIVES OF SEXUAL BEHAVIOR 2013; 42:1319-1326. [PMID: 23358857 DOI: 10.1007/s10508-012-0061-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 09/28/2012] [Accepted: 09/28/2012] [Indexed: 06/01/2023]
Abstract
The objective was to examine the association between circumcision status and self-reported HIV infection among men who have sex with men (MSM) in Britain who predominantly or exclusively engaged in insertive anal intercourse. In 2007-2008, a convenience sample of MSM living in Britain was recruited through websites, in sexual health clinics, bars, clubs, and other venues. Men completed an online survey which included questions on circumcision status, HIV testing, HIV status, sexual risk behavior, and sexual role for anal sex. The analysis was restricted to 1,521 white British MSM who reported unprotected anal intercourse in the previous 3 months and who said they only or mostly took the insertive role during anal sex. Of these men, 254 (16.7 %) were circumcised. Among men who had had a previous HIV test (n = 1,097), self-reported HIV seropositivity was 8.6 % for circumcised men (17/197) and 8.9 % for uncircumcised men (80/900) (unadjusted odds ratio [OR], 0.97; 95 % confidence interval [95 % CI], 0.56, 1.67). In a multivariable logistic model adjusted for known risk factors for HIV infection, there was no evidence of an association between HIV seropositivity and circumcision status (adjusted OR, 0.79; 95 % CI, 0.43, 1.44), even among the 400 MSM who engaged exclusively in insertive anal sex (adjusted OR, 0.84; 95 % CI, 0.25, 2.81). Our study provides further evidence that circumcision is unlikely to be an effective strategy for HIV prevention among MSM in Britain.
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Affiliation(s)
- Rita Doerner
- School of Health Sciences, City University London, 20 Bartholomew Close, London, EC1A 7QN, UK
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Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. JOURNAL OF MEDICAL ETHICS 2013; 39:434-441. [PMID: 23508208 DOI: 10.1136/medethics-2013-101346] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits 'justify access to this procedure for families who choose it,' claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.
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Affiliation(s)
- J Steven Svoboda
- Attorneys for the Rights of the Child, 2961 Ashby Avenue, Berkeley, CA 94707, USA.
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14
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Sexually transmitted infections and male circumcision: a systematic review and meta-analysis. ISRN UROLOGY 2013; 2013:109846. [PMID: 23710368 PMCID: PMC3654279 DOI: 10.1155/2013/109846] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/22/2013] [Indexed: 01/19/2023]
Abstract
The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.
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Mor Z, Grayeb E, Beany A, Grotto I. Increasing trend of HIV/AIDS among Arab and Jewish male persons in Israel, 1986-2010. HIV Med 2012; 14:316-20. [DOI: 10.1111/hiv.12003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - A Beany
- Department of Internal Medicine C; Bnai Zion Medical Center; Haifa; Israel
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Lee JGL. Ecologic fallacy and the social ecology of circumcision. Aust N Z J Public Health 2012; 36:293-4; author reply 294-5. [PMID: 22672040 DOI: 10.1111/j.1753-6405.2012.00875.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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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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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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Wiysonge CS, Kongnyuy EJ, Shey M, Muula AS, Navti OB, Akl EA, Lo YR. Male circumcision for prevention of homosexual acquisition of HIV in men. Cochrane Database Syst Rev 2011:CD007496. [PMID: 21678366 DOI: 10.1002/14651858.cd007496.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Previous systematic reviews found inconsistent effects of male circumcision on HIV acquisition in men who have sex with men (MSM). However, a number of new studies have become available in the three years since the last systematic review. OBJECTIVES To assess the effects of male circumcision for preventing HIV acquisition by men through sex with men. SEARCH STRATEGY In June 2010 we electronically searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, AIDS Education Global Information System, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform; hand-searched reference lists of relevant articles; and contacted relevant organisations and experts. We updated the search in March 2011. SELECTION CRITERIA We looked for randomised controlled trials (RCTs) and observational studies that assessed the effects of male circumcision on HIV acquisition in MSM. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and methodological quality, and extracted data. We expressed study results as odds ratios (OR) with 95% confidence intervals (CI), and conducted random-effects meta-analysis. MAIN RESULTS We found no completed RCT and included 21 observational studies with 71,693 participants. The only eligible RCT is currently ongoing among MSM in China. The pooled effect estimate for HIV acquisition was not statistically significant (20 studies; 65,784 participants; OR 0.86, 95% CI 0.70 to 1.06) and showed significant heterogeneity (I²=53%). In a subgroup analysis, the results were statistically significant in studies of men reporting an insertive role (7 studies, 3465 participants; OR 0.27, 95% CI 0.17 to 0.44; I²=0%) but not in studies of men reporting a receptive role (3 studies, 1792 participants; OR 1.20, 95% CI 0.63 to 2.29; I² = 0%). There was no significant association between male circumcision and syphilis (8 studies; 34,999 participants: OR 0.96, 95% CI 0.82 to 1.13; I² = 0%), herpes simplex virus 1 (2 studies, 2740 participants; OR 0.90, 95% CI 0.53 to 1.52; I²=0%), or herpes simplex virus 2 (5 studies;10,285 participants; OR 0.86, 95% CI 0.62 to 1.21; I²=0%). The overall GRADE quality of evidence was low. None of the included studies assessed adverse effects associated with male circumcision. AUTHORS' CONCLUSIONS Current evidence suggests that male circumcision may be protective among MSM who practice primarily insertive anal sex, but the role of male circumcision overall in the prevention of HIV and other sexually transmitted infections among MSM remains to be determined. Therefore, there is not enough evidence to recommend male circumcision for HIV prevention among MSM at present. Further research should be of high quality and further explore interaction with the predominant sexual role.
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Affiliation(s)
- Charles Shey Wiysonge
- School of Child and Adolescent Health, University of Cape Town, Institute of Infectious Disease and Molecular Medicine, Anzio Road, Observatory, Cape Town, South Africa, 7925
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Male circumcision and HIV infection risk. World J Urol 2011; 30:3-13. [PMID: 21590467 DOI: 10.1007/s00345-011-0696-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 05/03/2011] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Male circumcision is being promoted to reduce human immunodeficiency virus type 1 (HIV) infection rates. This review evaluates the scientific evidence suggesting that male circumcision reduces HIV infection risk in high-risk heterosexual populations. METHODS We followed the updated International Consultation on Urological Diseases evidence-based medicine recommendations to critically review the scientific evidence on male circumcision and HIV infection risk. RESULTS Level 1 evidence supports the concept that male circumcision substantially reduces the risk of HIV infection. Three major lines of evidence support this conclusion: biological data suggesting that this concept is plausible, data from observational studies supported by high-quality meta-analyses, and three randomized clinical trials supported by high-quality meta-analyses. CONCLUSIONS The evidence from these biological studies, observational studies, randomized controlled clinical trials, meta-analyses, and cost-effectiveness studies is conclusive. The challenges to implementation of male circumcision as a public health measure in high-risk populations must now be faced.
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Londish GJ, Templeton DJ, Regan DG, Kaldor JM, Murray JM. Minimal impact of circumcision on HIV acquisition in men who have sex with men. Sex Health 2011; 7:463-70. [PMID: 21062588 DOI: 10.1071/sh09080] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 04/20/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Men who have sex with men (MSM) are disproportionately affected by HIV. The proven efficacy of circumcision in reducing the risk of HIV acquisition among African heterosexual males has raised the question of whether this protective effect may extend to MSM populations. We examined the potential impact of circumcision on an HIV epidemic within a population of MSM. METHODS A mathematical model was developed to simulate HIV transmission in an MSM population. The model incorporated both circumcision and seropositioning, and was used to predict the reduction in HIV prevalence and incidence as a result of the two interventions. Estimates for the time required to achieve these gains were also calculated. RESULTS We derive simple formulae for the decrease in HIV prevalence with increased circumcision. Our model predicts that if an initially uncircumcised MSM population in a developed country with a baseline HIV prevalence of 10% underwent universal circumcision, HIV incidence would only be reduced to 95% of pre-intervention levels and HIV prevalence to 9.6% after 20 years. In the longer term, our model predicts that prevalence would only decrease from 10% to 6%, but this would take several generations to achieve. The effectiveness of circumcision increases marginally with higher degrees of seropositioning. CONCLUSIONS The results of these calculations suggest that circumcision as a public health intervention will not produce a substantial decrease in HIV prevalence or incidence among MSM in the near future, and only modest reductions are achievable in the long-term.
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Affiliation(s)
- Gregory J Londish
- School of Mathematics and Statistics, University of New South Wales, Sydney, NSW 2052, Australia
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Van Howe RS, Storms MR. How the circumcision solution in Africa will increase HIV infections. J Public Health Afr 2011; 2:e4. [PMID: 28299046 PMCID: PMC5345479 DOI: 10.4081/jphia.2011.e4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 12/09/2010] [Indexed: 11/23/2022] Open
Abstract
The World Health Organization and UNAIDS have supported circumcision as a preventive for HIV infections in regions with high rates of heterosexually transmitted HIV; however, the circumcision solution has several fundamental flaws that undermine its potential for success. This article explores, in detail, the data on which this recommendation is based, the difficulty in translating results from high risk adults in a research setting to the general public, the impact of risk compensation, and how circumcision compares to existing alternatives. Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.
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Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA
| | - Michelle R Storms
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA
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Gust DA, Wiegand RE, Kretsinger K, Sansom S, Kilmarx PH, Bartholow BN, Chen RT. Circumcision status and HIV infection among MSM: reanalysis of a Phase III HIV vaccine clinical trial. AIDS 2010; 24:1135-43. [PMID: 20168206 DOI: 10.1097/qad.0b013e328337b8bd] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Determine whether male circumcision would be effective in reducing HIV transmission among men who have sex with men (MSM). DESIGN Retrospective analysis of the VAXGen VAX004 HIV vaccine clinical trial data. METHODS Survival analysis was used to associate time to HIV infection with multiple predictors. Unprotected insertive and receptive anal sex predictors were highly correlated, thus separate models were run. RESULTS Four thousand eight hundred and eighty-nine participants were included in this reanalysis; 86.1% were circumcised. Three hundred and forty-two (7.0%) men became infected during the study; 87.4% were circumcised. Controlling for demographic characteristics and risk behaviors, in the model that included unprotected insertive anal sex, being uncircumcised was not associated with incident HIV infection [adjusted hazards ratio (AHR) = 0.97, confidence interval (CI) = 0.56-1.68]. Furthermore, while having unprotected insertive (AHR = 2.25, CI = 1.72-2.93) or receptive (AHR = 3.45, CI = 2.58-4.61) anal sex with an HIV-positive partner were associated with HIV infection, the associations between HIV incidence and the interaction between being uncircumcised and reporting unprotected insertive (AHR = 1.78, CI = 0.90-3.53) or receptive (AHR = 1.26, CI = 0.62-2.57) anal sex with an HIV-positive partner were not statistically significant. Of the study visits when a participant reported unprotected insertive anal sex with an HIV-positive partner, HIV infection among circumcised men was reported in 3.16% of the visits (80/2532) and among uncircumcised men in 3.93% of the visits (14/356) [relative risk (RR) = 0.80, CI = 0.46-1.39]. CONCLUSIONS Among men who reported unprotected insertive anal sex with HIV-positive partners, being uncircumcised did not confer a statistically significant increase in HIV infection risk. Additional studies with more incident HIV infections or that include a larger proportion of uncircumcised men may provide a more definitive result.
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Male circumcision to reduce the risk of HIV and sexually transmitted infections among men who have sex with men. Curr Opin Infect Dis 2010; 23:45-52. [PMID: 19935420 DOI: 10.1097/qco.0b013e328334e54d] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW The success of male circumcision in reducing HIV acquisition among African heterosexuals has led to renewed interest in this biological intervention for HIV/sexually transmissible infection (STI) prevention in men who have sex with men (MSM). This review summarizes the available data on the association of circumcision and HIV/STI among MSM populations. RECENT FINDINGS Results of observational studies indicate that circumcision has limited impact on HIV/STI acquisition among MSM populations overall. Longitudinal data suggest that circumcision may reduce the risk of incident syphilis, but there is little evidence of a protective effect for other STIs. The subgroup of MSM who predominantly practise the insertive role in anal intercourse may be at lower risk of HIV, although the relative inefficiency of HIV acquisition for insertive compared with receptive partners has resulted in imprecise estimates of effect. SUMMARY The evidence that circumcision reduces HIV and other STIs among MSM is weak and inconsistent. However, recent studies have found that circumcised MSM who predominantly take the insertive role in anal intercourse may be at a lower risk of HIV infection. Although MSM may be willing to undergo adult circumcision, should it be proven to reduce HIV acquisition risk, there is substantial potential that behavioural disinhibition could offset any benefits achieved by a circumcision intervention.
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Jameson DR, Celum CL, Manhart L, Menza TW, Golden MR. The association between lack of circumcision and HIV, HSV-2, and other sexually transmitted infections among men who have sex with men. Sex Transm Dis 2010; 37:147-52. [PMID: 19901865 PMCID: PMC10938871 DOI: 10.1097/olq.0b013e3181bd0ff0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Observational studies evaluating the association of circumcision and HIV infection among men who have sex with men (MSM) have yielded mixed results. We examined the relationship between circumcision and HIV, herpes simplex virus type-2 (HSV-2), syphilis, urethral gonorrhea, and urethral chlamydia among MSM stratified by anal sexual role. METHODS Between October 2001 and May 2006, 4749 MSM who reported anal intercourse in the previous 12 months attended the Public Health-Seattle and King County STD clinic for 8337 evaluations. Clinicians determined circumcision status by examination and anal sexual role in the previous year by interview. Blood samples were used to test HIV, syphilis, and HSV-2 serostatus. Urethral gonorrhea and chlamydia were tested by culture or nucleic acid amplification. We used generalized estimating equations to evaluate the association between circumcision and specific diagnoses, adjusted for race/ethnicity and age. RESULTS Among the 3828 men whose circumcision status was assessed, 3241 (85%) were circumcised and 587 (15%) were not. The proportion of men newly testing HIV-positive or with previously diagnosed HIV did not differ by circumcision status when stratified by men's anal sexual role in the preceding year, even when limited to men who reported only insertive anal intercourse in the preceding 12 months (OR = 1.45; 95% CI: 0.30, 7.12). Similarly, we did not observe a significant association between circumcision status and the other sexually transmitted infections (STI). CONCLUSIONS Our findings suggest that male circumcision would not be likely to have a significant impact on HIV or sexually transmitted infections acquisition among MSM in Seattle.
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Affiliation(s)
- Damon R Jameson
- Department of Epidemiology, University of Washington, 404 E. Harrison St. 301, Seattle, WA 98102, USA.
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Templeton DJ, Jin F, Prestage GP, Donovan B, Imrie JC, Kippax SC, Cunningham PH, Kaldor JM, Mindel A, Cunningham AL, Grulich AE. Circumcision and risk of sexually transmissible infections in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. J Infect Dis 2009; 200:1813-9. [PMID: 19911990 DOI: 10.1086/648376] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Circumcision status was examined as an independent risk factor for sexually transmissible infections (STIs) in the Health in Men cohort of homosexual men in Sydney. METHODS From 2001 through 2004, 1427 initially human immunodeficiency virus (HIV)-negative men were enrolled and followed up until mid-2007. All participants were offered annual STI testing. The history of STIs was collected at baseline, and information on sexual risk behaviors was collected every 6 months. At annual face-to-face visits, participants reported STI diagnoses received during the previous year. RESULTS Circumcision was not associated with prevalent or incident herpes simplex virus 1, herpes simplex virus 2, or self-reported genital warts. There was also no independent association of circumcision with incident urethral gonorrhea or chlamydia. Being circumcised was associated with a significantly reduced risk of incident (hazard ratio, 0.35 [95% confidence interval, 0.15-0.84]) but not prevalent (odds ratio, 0.71 [95% confidence interval, 0.35-1.44]) syphilis. The association was somewhat stronger among men who reported predominantly insertive unprotected anal intercourse (hazard ratio, 0.10 [95% confidence interval, 0.01-0.82]). CONCLUSIONS These are the first prospective data obtained from homosexual men to assess circumcision status as a risk factor for STIs. Circumcised men were at reduced risk of incident syphilis but no other prevalent or incident STIs. Circumcision is unlikely to have a substantial public health impact in reducing acquisition of most STIs in homosexual men.
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Affiliation(s)
- David J Templeton
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW 2010, Australia.
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Abstract
OBJECTIVE To assess circumcision status as a risk factor for HIV seroconversion in homosexual men. DESIGN, SETTING AND PARTICIPANTS The Health in Men (HIM) study was a prospective cohort of homosexual men in Sydney, Australia. HIV-negative men (n = 1426) were recruited primarily from community-based sources between 2001 and 2004 and followed to mid-2007. Participants underwent annual HIV testing, and detailed information on sexual risk behaviour was collected every 6 months. MAIN OUTCOME MEASURE HIV incidence in circumcised compared with uncircumcised participants, stratified by whether or not men predominantly practised the insertive role in anal intercourse. RESULTS There were 53 HIV seroconversions during follow-up; an incidence of 0.78 per 100 person-years. On multivariate analysis controlling for behavioural risk factors, being circumcised was associated with a nonsignificant reduction in risk of HIV seroconversion [hazard ratio 0.78, 95% confidence interval (CI) 0.42-1.45, P = 0.424]. Among one-third of study participants who reported a preference for the insertive role in anal intercourse, being circumcised was associated with a significant reduction in HIV incidence after controlling for age and unprotected anal intercourse (UAI) (hazard ratio 0.11, 95% CI 0.03-0.80, P = 0.041). Those who reported a preference for the insertive role overwhelmingly practised insertive rather than receptive UAI. CONCLUSIONS Overall, circumcision did not significantly reduce the risk of HIV infection in the HIM cohort. However, it was associated with a significant reduction in HIV incidence among those participants who reported a preference for the insertive role in anal intercourse. Circumcision may have a role as an HIV prevention intervention in this subset of homosexual men.
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Krieger JN, Heyns CF. Male circumcision and HIV/AIDS risk — Analysis of the scientific evidence. AFRICAN JOURNAL OF UROLOGY 2009. [DOI: 10.1007/s12301-009-0021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Warner L, Ghanem KG, Newman DR, Macaluso M, Sullivan PS, Erbelding EJ. Male circumcision and risk of HIV infection among heterosexual African American men attending Baltimore sexually transmitted disease clinics. J Infect Dis 2009; 199:59-65. [PMID: 19086815 DOI: 10.1086/595569] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Male circumcision has received international attention as an intervention for reducing HIV infection among high-risk heterosexual men; however, few US studies have evaluated its association with the risk of HIV infection. METHODS We analyzed visit records for heterosexual African American men who underwent HIV testing while attending sexually transmitted disease (STD) clinics in Baltimore, Maryland, from 1993 to 2000. We used multivariable binomial regression to evaluate associations between circumcision and the risk of HIV infection among visits by patients with known and unknown HIV exposure. RESULTS Overall, 1096 (2.7%) of 40,571 clinic visits yielded positive HIV test results. Among 394 visits by patients with known HIV exposure, circumcision was significantly associated with lower HIV prevalence (10.2% vs. 22.0%; adjusted prevalence rate ratio [PRR], 0.49 [95% confidence interval [CI], 0.26-0.93]). Conversely, among 40,177 visits by patients with unknown HIV exposure, circumcision was not associated with reduced HIV prevalence (2.5% vs. 3.3%; adjusted PRR, 1.00 [95% CI, 0.86-1.15]), and age >or=25 years old and diagnosis of ulcerative STD were associated with increased prevalence. CONCLUSIONS Circumcision was associated with substantially reduced HIV risk in patients with known HIV exposure, suggesting that results of other studies demonstrating reduced HIV risk for circumcision among heterosexual men likely can be generalized to the US context.
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Affiliation(s)
- Lee Warner
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
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Is neonatal circumcision clinically beneficial? Argument against. NATURE CLINICAL PRACTICE. UROLOGY 2009; 6:74-5. [PMID: 19153572 DOI: 10.1038/ncpuro1292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 12/05/2008] [Indexed: 11/08/2022]
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Begley EB, Jafa K, Voetsch AC, Heffelfinger JD, Borkowf CB, Sullivan PS. Willingness of men who have sex with men (MSM) in the United States to be circumcised as adults to reduce the risk of HIV infection. PLoS One 2008; 3:e2731. [PMID: 18628946 PMCID: PMC2443289 DOI: 10.1371/journal.pone.0002731] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 06/20/2008] [Indexed: 12/02/2022] Open
Abstract
Background Circumcision reduces HIV acquisition among heterosexual men in Africa, but it is unclear if circumcision may reduce HIV acquisition among men who have sex with men (MSM) in the United States, or whether MSM would be willing to be circumcised if recommended. Methods We interviewed presumed-HIV negative MSM at gay pride events in 2006. We asked uncircumcised respondents about willingness to be circumcised if it were proven to reduce risk of HIV among MSM and perceived barriers to circumcision. Multivariate logistic regression was used to identify covariates associated with willingness to be circumcised. Results Of 780 MSM, 133 (17%) were uncircumcised. Of these, 71 (53%) were willing to be circumcised. Willingness was associated with black race (exact odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.3–9.8), non-injection drug use (OR: 6.1, 95% CI: 1.8–23.7) and perceived reduced risk of penile cancer (OR: 4.7, 95% CI: 2.0–11.9). The most commonly endorsed concerns about circumcision were post-surgical pain and wound infection. Conclusions Over half of uncircumcised MSM, especially black MSM, expressed willingness to be circumcised. Perceived risks and benefits of circumcision should be a part of educational materials if circumcision is recommended for MSM in the United States.
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Affiliation(s)
- Elin B Begley
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
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Pask AJ, McInnes KJ, Webb DR, Short RV. Topical oestrogen keratinises the human foreskin and may help prevent HIV infection. PLoS One 2008; 3:e2308. [PMID: 18523637 PMCID: PMC2396280 DOI: 10.1371/journal.pone.0002308] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Accepted: 04/23/2008] [Indexed: 11/19/2022] Open
Abstract
With the growing incidence of HIV, there is a desperate need to develop simple, cheap and effective new ways of preventing HIV infection. Male circumcision reduces the risk of infection by about 60%, probably because of the removal of the Langerhans cells which are abundant in the inner foreskin and are the primary route by which HIV enters the penis. Langerhans cells form a vital part of the body's natural defence against HIV and only cause infection when they are exposed to high levels of HIV virions. Rather than removing this natural defence mechanism by circumcision, it may be better to enhance it by thickening the layer of keratin overlying the Langerhans cells, thereby reducing the viral load to which they are exposed. We have investigated the ability of topically administered oestrogen to induce keratinization of the epithelium of the inner foreskin. Histochemically, the whole of the foreskin is richly supplied with oestrogen receptors. The epithelium of the inner foreskin, like the vagina, responds within 24 hours to the topical administration of oestriol by keratinization, and the response persists for at least 5 days after the cessation of the treatment. Oestriol, a cheap, readily available natural oestrogen metabolite, rapidly keratinizes the inner foreskin, the site of HIV entry into the penis. This thickening of the overlying protective layer of keratin should reduce the exposure of the underlying Langerhans cells to HIV virions. This simple treatment could become an adjunct or alternative to surgical circumcision for reducing the incidence of HIV infection in men.
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Affiliation(s)
- Andrew J. Pask
- Department of Zoology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kerry J. McInnes
- Prince Henry's Institute of Medical Research, Clayton, Victoria, Australia
| | - David R. Webb
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Austin Health, Heidelberg, Victoria, Australia
| | - Roger V. Short
- The Dean's Ganglion, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
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Green LW, McAllister RG, Peterson KW, Travis JW. Male circumcision is not the HIV ‘vaccine’ we have been waiting for! ACTA ACUST UNITED AC 2008. [DOI: 10.2217/17469600.2.3.193] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Lawrence W Green
- Department of Epidemiology & Biostatistics, University of California at San Francisco, 185 Berry St., Suite 6650, San Francisco, CA 94143, USA
| | - Ryan G McAllister
- Georgetown University, 506 Reiss Science Building, 37th and O St. NW, Washington, DC 20057, USA
| | - Kent W Peterson
- Occupational Health Strategies, Inc., 901 Preston Ave, S-400, Charlottesville, VA 22903, USA
| | - John W Travis
- Wellness Associates, PO Box 8422, Asheville, NC 28814, USA
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