Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa

The study investigates the statistical relationship between male circumcision and HIV prevalence in Africa, in the context of the Voluntary Medical Male Circumcision (VMMC) campaigns in place since 2008. Data from the Population-based HIV Impact Assessment (PHIA) surveys conducted in African countries in 2017-2018 were utilized. Six countries with high HIV prevalence, low traditional circumcision and large VMMC programs were selected: Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe. The statistical analysis investigated the relative risk (RR) of HIV prevalence by circumcision status (circumcised vs intact) among men age 20-59, and the age-incidence of HIV in the two groups among men age 20-49, defined as the linear-logistic slope of the relationship between prevalence and age. Results show that the standardized RR was not different from 1 at older ages (50-59): RR = 0.923, 95% CI = 0.769-1.108, P = 0.390. Furthermore, the age-incidence was at least as high or higher among the circumcised groups than among the intact groups. The standardized RR was lower than 1 at younger ages, and this could be explained by selection biases. HIV prevalence at age 40-59 (27.3%) was also the same in the four groups of circumcision status (intact, traditional, medical, unknown). Results matched earlier observations made in South Africa that circumcised and intact men had similar levels of HIV infection. The study questions the current strategy of large scale VMMC campaigns to control the HIV epidemic. These campaigns also raise a number of ethical issues.

Management of penile post-circumcision ischemia by pentoxifylline infusion and hyperbaric oxygen therapy

BACKGROUND

Post-circumcision penile ischemia is a devastating complication. We will present our experience in managing children with various forms of penile ischemia.

MATERIALS AND METHODS

This cohort prospective observational and interventional study was performed on all male children with post-circumcision penile ischemia between April 2017 and October 2021. A designed and approved protocol includes a combination of early pentoxifylline infusion, hyperbaric oxygen inhalation, early catheterization, and appropriate surgical debridement were applied for patients with deep ischemia 11/23, mainly the necrotic skin and subcutaneous tissues. Data of patient age, anesthesia method, monopolar diathermy usage, early presentation and positive wound culture were collected and analyzed statistically.

RESULTS

During the study period 3,382 children were circumcised for non-medical reasons; 23 children were diagnosed with penile ischemia (0.7%), among other complications (9%). Most of the penile ischemia is associated with the use of monopolar diathermy (74%). The use of compressive wound dressing to control post-circumcision bleeding and infections is also responsible for ischemia in 52.2% and 43.5% of the cases. Inexperienced physicians were commonly responsible for ischemia (73.9%). Patients managed at first 24 h had better outcomes than those who were presented later (p = 0.001).

CONCLUSION

In children with post-circumcision penile ischemia, a combination of hyperbaric oxygen therapy and pentoxifylline is especially effective for patients with skin and facial necrosis, this management reduces penile tissue loss.

Safety, acceptability, and feasibility of male circumcision using the alisklamp device

Greater than 20 surgical circumcision devices are available worldwide for male circumcision. These have been developed so as to decrease complications. The hemostasis system classifies these devices as crush, clamp or ligature. This study assessed the safety, acceptability, and feasibility of male neonatal circumcision using the Alisklamp device (AKD). The AKD is one of the latest medical devices designed for assisted circumcision. It takes less time to install, has a better complication rate, and has a better cosmetic appearance than conventional surgical circumcision. The study was divided into two sections: assessing the safety of the AKD and evaluating parents' satisfaction. Convenience sampling was used in this study. In the first section, a form was filled by operating pediatric surgeon for children whose parents agreed to participate in the study. In the second section, a total of 100 male children were included in the study based on the sample size guidelines of the World Health Organization. The circumcision was performed by an experienced pediatric surgeon following the manufacturer's instructions. The procedures were completed without AKD failure or unwelcome preputial loss. The results showed that 63.54% of the children were circumcised in their first four weeks of life. About 60.42% of the procedures were completed within 5-10 min. Also, 95.83% of the children had no postoperative complications. Further, 90.63% of parents were satisfied with the AKD and willing to recommend it to others. During the follow-up, all of the children's parents were pleased with the cosmetic and final results of the AKD. In conclusion, the AKD has an outstanding protection profile suitable for male circumcision procedures.

Voluntary Medical Male Circumcision to Reduce HIV Acquisition and Transmission

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

The Effects of Medical Male Circumcision on Female Partners' Sexual and Reproductive Health

PURPOSE OF REVIEW

Voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition by 60% among heterosexual men, provides protection against certain sexually transmitted infections (STI), and leads to penile microbiome composition changes associated with reduced risk of HIV infection. Intuitively, the benefits of VMMC for female sex partners in relation to STI are likely and have been evaluated. The purpose of this review is to examine emerging findings of broader sexual and reproductive health (SRH) benefits of VMMC for female sex partners.

RECENT FINDINGS

Systematic reviews find strong evidence for beneficial effects of VMMC on female sex partners risk of HPV, cervical dysplasia, cervical cancer, and with likely protection against trichomoniasis and certain genital ulcerative infections. Few studies assess the direct impact of VMMC on the vaginal microbiome (VMB), though several studies demonstrate reductions in BV, which is mediated by the VMB. Studies are lacking regarding male circumcision status and outcomes associated with non-optimal VMB, such as female infertility and adverse pregnancy outcomes. VMMC has positive effects on women's perceptions of sexual function and satisfaction, and perceptions of disease risk and hygiene, without evidence of risk compensation. VMMC has consistent association with a broad range of women's SRH outcomes, highlighting the biological and non-biological interdependencies within sexual relationships, and need for couples-level approaches to optimize SRH for men and women. The paucity of information on VMMC and influence on VMB is a barrier to optimizing VMB-associated SRH outcomes in female partners.

Circumcision Knowledge and Opinions of Primary Healthcare Workers: The Case of Turkey

This study evaluates the knowledge levels and opinions of Islamic primary healthcare workers regarding the medical indications of circumcision, its mode of application, contraindications, and possible complications together with the current literature. Our study was conducted with the participation of 400 healthcare personnel having Islamic faith and working in primary healthcare centers in Kahramanmaras. Data were collected through in-person interviews with healthcare workers who completed our questionnaire consisting of 52 questions and designed based on a literature review. SPSS 21 was used to evaluate the collected data statistically. Findings were considered statistically significant if the p-value was lower than 0.05. We evaluated these participants in terms of their levels of knowledge on circumcision. None of the participants had a very high knowledge level. In correlation analysis, it was detected that age (r = 0.194, p < 0.001) and duration of employment in the profession (experience) (r = 0.164, p = 0.001) were positively correlated with knowledge level. Those who found circumcision necessary mostly justified its necessity due to medical benefits (n = 321, 80.3%) and/or religious obligations (n = 242, 60.5%). Our study demonstrates the importance of providing information about circumcision, including the information from the current literature, to primary healthcare workers together with theoretical training and practice both during their formal training and after graduation in Turkey.

Towards a context-specific understanding of masculinities in Eswatini within voluntary medical male circumcision programming

Compelling evidence from three randomised controlled trials, which showed that voluntary medical male circumcision (VMMC) reduces HIV acquisition from women to men by up to 60%, led to WHO recommending that VMMC be implemented in 14 priority countries. As one of the priority countries, Eswatini aimed to reach 80% VMMC coverage among boys and men aged 10-49 years since programme inception in 2009. By the end of 2019, however, the country had reached a modest 40%. VMMC is intrinsically tied to perceptions of masculinity and male gender identity. Comprehending the role of context-specific masculinity as it relates to VMMC may contribute to our understanding of community attitudes towards VMMC and men's decision-making. Drawing on focus group discussion data, this study aimed to explore the linkage between sexuality, masculinity and health interventions within Eswatini. Using critical discourse analysis, the study identified two discourses: sexuality, masculinity and circumcision, and income, masculinity, and circumcision. In the first discourse, participants constructed discursive linkages between circumcision as an adult and loss of penile sensitivity, decreased libido and sexual performance, and adverse events. The second discourse, income, masculinity, and circumcision located circumcision within the social and material realities faced by Swazi men, gender norms and provision within family structures.

Maximizing the Impact of Voluntary Medical Male Circumcision for HIV Prevention in Zambia by Targeting High-Risk Men: A Pre/Post Program Evaluation

A well-documented barrier to voluntary medical male circumcision (VMMC) is financial loss due to the missed opportunity to work while undergoing and recovering from VMMC. We implemented a 2-phased outcome evaluation to explore how enhanced demand creation and financial compensation equivalent to 3 days of missed work influence uptake of VMMC among men at high risk of HIV exposure in Zambia. In Phase 1, we implemented human-centered design-informed interpersonal communication. In Phase 2, financial compensation of ZMW 200 (~ US$17) was added. The proportion of men undergoing circumcision was significantly higher in Phase 2 compared to Phase 1 (38% vs 3%). The cost of demand creation and compensation per client circumcised was $151.54 in Phase 1 and $34.93 in Phase 2. Financial compensation is a cost-effective strategy for increasing VMMC uptake among high-risk men in Zambia, and VMMC programs may consider similar interventions suited to their context.

Pigmentary complications after non-medical male circumcision

BACKGROUND

A wide spectrum of complications are reported after male circumcision (MC), the non-aesthetic complications are well known, but the pigmentary complications scale are not reported precisely.

METHODS

This is a prospective cohort study of 550 circumcised boys; aged from 6 months to 14 years (62% aged 5 years) who were examined and appropriately investigated for the incidence of pigmentary complications after circumcision. Most diagnoses were clinically, but dermoscopy was done for 17 case and a skin biopsy for 14 cases. Patients with personal or family history of vitiligo, or congenital nevi were excluded. Available hospital records details and parents' statements were revised. The main outcome measures are the incidence of different pigmentary complications and circumcision details; data were analyzed by a non-parametric tests including the Mann-Whitney U test.

RESULTS

69 cases had 72 confirmed pigmentary complications discovered at 2-36 months after commencement of circumcision (mean 18). 48 cases had pigmentary complications directly related to MC, 11 cases were probably related and 10 unrelated to MC. The most common lesion is the circular hyperpigmented scar (29 cases); liner hyperpigmented scar in 13, spotted exogenous melanosis in 18 cases, melanocytic nevi (7), hypopigmentation diagnosed in 3 cases, but kissing nevus is the rarest finding (2). Topical corticosteroid was tried in 15 cases, surgical excision of pigmented scar were done for 19 cases, local laser used for 4 resistant cases and reassurance with follow up for the rest.

CONCLUSION

Pigmentary complications after male circumcision are not rare and its management is challenging.

Engagement of common pediatric urologic conditions on social media

INTRODUCTION

As social media use continues to increase, parents and caregivers report using social media platforms as a source of health information. However, there are minimal regulations for social media content and health misinformation has been shared for various medical issues and urologic conditions. While internet content related to pediatric urology has been previously described, social media engagement for various pediatric urologic conditions have yet to be described.

OBJECTIVE

To evaluate the evidence supporting articles engaged on social media that are related to common pediatric urologic conditions.

STUDY DESIGN

A social media analysis tool was used to identify articles engaged through Facebook, Reddit, Twitter, and Pinterest between July 2020-2021. The top 5 articles related to toilet training, circumcision, cryptorchidism, testicular torsion, and hypospadias were identified. Article citations were reviewed and classified by Oxford levels of evidence. The content of each article was then reviewed and compared against supporting evidence on an independent literature search. Statistical analysis was completed with descriptive statistics, Mann-Whitney U, Wilcoxon signed rank, and bivariate correlation.

RESULTS

Of the 25 articles reviewed, 8 (32%) were affiliated with medical journals, hospitals, or academic institutions and 17 (68%) were on non-affiliated websites with advertisements. There was greater social media engagement for articles related to toilet training and circumcision than testicular torsion, hypospadias, and cryptorchidism. No articles cited level 1 evidence and 32% of articles cited no evidence. Literature search for article content demonstrated a discrepancy between the level of evidence cited by articles compared to the evidence available in the literature to support article content. There was greater social media engagement for articles with no cited or supporting evidence and those not affiliated with medical journals, hospitals, or academic institutions.

DISCUSSION

The findings in this study are consistent with trends reported for other urologic conditions, including genitourinary malignancy, female pelvic medicine and reconstructive surgery, nephrolithiasis, and sexual function. Parents without a medical background may have difficulty identifying whether articles shared on social media can be a reliable resource for health information. It is important to understand how information related to pediatric urologic conditions is engaged on social media so that misinformation can be addressed in clinical, online, and regulatory settings.

CONCLUSION

There was greater social media engagement for articles with no cited or supporting evidence and those not affiliated with medical journals, hospitals, or academic institutions.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

President's Emergency Plan for AIDS Relief's Voluntary Medical Male Circumcision Program Through 2020

PURPOSE OF REVIEW

Through December 2020, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) supported more than 25 million voluntary medical male circumcisions (VMMC) as part of the combined HIV prevention strategy in 15 African countries. PEPFAR monitors defined adverse events (AEs) occurring within 30 days of VMMC through its notifiable adverse event reporting system (NAERS). All NAERS reports through December 2020 were reviewed to quantify AE type, severity, and relation to the VMMC procedure. Interventions to improve client safety based on NAERS findings are described.

RECENT FINDINGS

Fourteen countries reported 446 clients with notifiable adverse events (NAEs); 394/446 (88%) were determined VMMC-related, representing approximately 18 NAE reports per million circumcisions. Fatalities comprised 56/446 (13%) with 24/56 (43%) of fatalities determined VMMC-related, representing 0.96 VMMC-related fatalities per million circumcisions. The remaining 390 NAEs were non-fatal with 370/390 (95%) VMMC-related. Multiple programmatic changes have been made based on NAERS data to improve client safety. Client safety is paramount in this surgical program designed for individual and population-level benefit. Surveillance of rare but severe complications following circumcision has identified pre-existing or new safety concerns and guided continuous programmatic improvement.

Meatal Stenosis and Atopic Condition: A Pilot Study Demonstrating a Possible Unidentified Etiology

Meatal stenosis (MS) is known as one of the most frequent complications of circumcision. In the present study, we aimed to find any possible relationship between MS and allergic disorders. A total of 36 children with a mean±SD age of 5.84±2.03 years were referred with MS and an atopic background even in themselves or in one of their family members (Group A). There were also age-matched controls with a mean±SD age of 5.70±2.17 years who were referred to our center with allergic symptoms and no urinary complaints (Group B, n=17). The RIDA qLine allergy and allergy explorer (ALEX) tests were performed for all patients to find possible allergen sensitization. Laboratory findings revealed that IgE-sensitization to the main food and aeroallergens in Group A (with the chief complaint of MS in whom a mild atopic condition was found during concise medical history taking) were very similar to the control group with no significant difference (except for ryegrass which was higher in the control group). Although total IgE level was considerably higher in group B compared to group A, food sensitization to cow's milk and ß-lactoglobulin was higher in asthmatic patients of group A compared to the controls. It seems that not all patients with MS should be considered as a complication of circumcision and undergo a surgical procedure for correction of the stenosis. Further investigations are required to determine the role of concise medical history taking and proper treatment of the allergic disorder to reduce failed surgical attempts in atopic boys with MS.

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.

Identifying factors associated with successful implementation and uptake of an evidence-based voluntary medical male circumcision program in Zambia: the Spear and Shield 2 Program

Voluntary medical male circumcision has been shown to provide a 50%-70% reduction in the risk of HIV infection without contributing to behavioral disinhibition of safer sexual practices. This study examined the interim implementation and dissemination data of Spear and Shield 2, an HIV risk-reduction program in Zambia. The purpose of this interim review was to identify contextual challenges to implementation and implement midcourse corrections associated with sustainability of program delivery. Using a mixed-methods design, quantitative evaluations of organizational functioning, barriers to implementation, burnout, and organizational readiness, as well as qualitative data utilizing the Consolidated Framework for Implementation Research (CFIR), were examined to evaluate program implementation. Participants were 184 health care providers from 46 clinics in Zambia. Successful implementation was associated with better community and leader support, and employee readiness and motivation. Quantitative assessments were not related to implementation and provided a limited picture of implementation outcomes. Results suggest that the qualitative data underlying the CFIR constructs provided a nuanced, contextual assessment of implementation, and dissemination outcomes. The CFIR may be valuable in informing the implementation of evidence-based interventions in other parts of Zambia.

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 comparison of the prevalence of sexually transmitted infections among circumcised and uncircumcised adult males in Rustenburg, South Africa: a cross-sectional study

BACKGROUND

South Africa has a persistent burden of sexually transmitted infections (STIs). Male circumcision has been shown to be effective in preventing HIV and STIs, but data are scarce on the protective effect of circumcision in high-risk populations such as migrant miners. The objective of this study was to assess the effect of medical and traditional circumcision on the prevalence of STIs after adjusting for other risk factors in Rustenburg, a mining town in North West Province, South Africa.

METHODS

This cross-sectional study used baseline data collected from a cohort study. Adult males in a mining town were assessed for STIs (gonorrhea, chlamydia, and trichomoniasis) using syndromic assessment. Data on circumcision status and other risk factors for STI syndromes were collected using an interviewer-administered questionnaire. The following symptoms were assessed; penile discharge, painful urination, dyspareunia or penile sores. These symptoms indicate sexually transmitted infection in general since laboratory tests were not performed. Multivariable log binomial regression was used to assess the independent effect of circumcision on STI presence after adjusting for confounders.

RESULTS

A total of 339 participants with a median age of 25 years (IQR 22-29) were included in the study, of whom 116 (34.2%) were circumcised. The overall STIs prevalence was 27.4% (95% CI 22.8 to 32.6%) and was lower in the circumcised participants compared with those who were uncircumcised (15.5% vs 33.6%, respectively, p < 0.001). Both medical (OR 0.57, 95% CI 0.34-0.95, p = 0.030) and traditional circumcision (OR 0.34, 95% CI 0.13-0.86, p = 0.022) were strongly associated with a lower risk of STIs after adjustment for employment and condom use.

CONCLUSION

In this high-risk population in a mining town in South Africa, with a relatively high prevalence of STIs, and where one third of males are circumcised, both medical and traditional circumcision appear to be protective against STIs.

Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention-15 African Countries, 2015-2019

Background

Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President’s Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions.

Methods

Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group.

Results

In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6–2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14–27).

Conclusions

Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2–3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR’s recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years.

Management of pain in newborn circumcision: a systematic review

Male circumcision (MC) is one of the most common surgical procedures performed on neonates. In the last decades, there have been consistent advances in the understanding of pain mechanisms in newborns, and analgesia has become a fundamental part of neonatal care. MC is still often performed with inappropriate analgesic methods, and there is still great variability among the various centers about surgical and anesthethic techniques to do it. The purpose of this review is to summarize the findings in the literature about pain management and analgesia during newborn MC. We performed a systematic review of neonatal MC studies published in the last 20 years. The most effective technique appeared to be the combination of pharmacological and non-pharmacological methods of analgesia.Conclusion: Combining local anesthesia with non-pharmacological analgesic strategies appears to be effective preventing procedural pain during MC. However, a standardized protocol for analgesia during MC is yet to be determined. Sensorial saturation appeared to help when used in conjunction with the local anesthesia techniques. What is Known: • Male circumcision is a painful procedure and it is frequently performed with inappropriate analgesic methods. • A gold standard practice in analgesia during male circumcision is still lacking and there is a great variability in the modus operandi between centers. What is New: • The combination of RB + EMLA + sucrose appears to be an analgesic strategy superior to other approaches. • We advocate for the integration of sensorial saturation during male circumcision in order to improve the efficacy of current analgesic practices.

VMMC clients' perception of increased risk of HIV infection, circumcision preferred choice of method, providers' socio-demographics and mode of service delivery

Introduction

Voluntary medical male circumcision (VMMC) is a scientifically proven HIV prevention intervention. Uganda, like many countries has been implementing VMMC for over 10 years but uptake is still low especially in northern Uganda. To attain 80% needed for public health impact, scale-up was recommended with many innovations implemented with sub-optimal results. This study therefore wanted to find out some of the correlates of VMMC uptake in Gulu district, northern Uganda.

Methods

Two studies were conducted separately but data was analyzed for this study. For the quantitative study, proportions and frequencies were used to measure perception of increased risk of HIV infection using age, gender, occupation, marital and circumcision status. Qualitative study provided data from FGDs, IDIs and KIIs were first transcribed in Acholi and then translated in English. Transcripts were uploaded in MAXDQA software for data management. A code book for emerging themes was developed.

Results

A total of 548 respondents were interviewed for the quantitative study, where two thirds (66%) of the participants perceived themselves to be at increased risk of HIV infection. For the qualitative study, 149 participants from 19 FGDs, 11 KIIs and 9 IDIs were interviewed. Data were analyzed thematically using both inductive and deductive approaches. Devices were preferred to conventional surgery while mobile services were preferred to static services. However, there were divergent views regarding circumcision service providers' socio-demographics and these were influenced mainly by age, level of education and location.

Conclusion

People in Northern Uganda perceived themselves to be at an increased risk of HIV infection. They preferred devices to conventional surgery, mobile services to static services but had varying views about the socio-demographics of the service providers.

Male circumcision uptake and its predictors among sexually active men aged 15-59 years living in the highest HIV prevalence region of Ethiopia: evidence from 2016 Ethiopia demographic and health survey

Background

Pieces of evidence showed that the Gambella region of Ethiopia has remained HIV hotspot area for successive years. However, the magnitude of male circumcision uptake and its associated factors are not well studied in this region. Hence, the aim of the current study is to assess the magnitude of male circumcision uptake and its predictors among sexually active men in the region using the 2016 Ethiopian Demographic and Health Survey Data.

Method

Data on 868 sexually active men residing in the Gambella region were extracted from the 2016 Ethiopian Demographic and health Survey. Descriptive statistics and logistic regression were respectively used to summarize descriptive data and measure the statistical associations. Adjusted odds ratio and confidence intervals were respectively used to measure statistical associations between variables and their statistical significances.

Results

The current study revealed that the overall prevalence of male circumcision uptake in the Gambella region was 61.2% (95% CI: 57.96,64.44). The results of multivariable logistic regression revealed that being Muslim (AOR = 9.54, 95% CI: 6.765.13.88), being Orthodox Christian (AOR = 8.5, 95%CI: 5.00–14.45), being from Poor household (AOR = 0.11, 95%CI: 0.06, 0.22), being from medium-income household (AOR = .33, 95%CI: 0.15, 0.73), listening to radio (AOR = .29, 95%CI: .16, .54), having comprehensive HIV knowledge (AOR = .44, 95%CI: .27, .71) and ever been tested for HIV (AOR = .27, 95%CI: .16,.46) were independently associated with male circumcision uptake.

Conclusion

Despite all efforts made by different stakeholders to promote the provision of male circumcision in the Gambella region, its magnitude of uptake is still unacceptably low. The federal HIV prevention and Control Office and other stakeholders working on HIV prevention and control should give due emphasis to promoting HIV-related knowledge through community-based education and through religious leaders. Integrating and streamlining HIV-related education in the academic curricula, and expanding mass media coverage should also be given due consideration by the federal government and other stakeholders. The stakeholders should also give emphasis to strengthening and empowering poor sexually active men residing in the Gambella region.

"The self-making of the scientific circumciser (fenni sünnetçi):" the medicalization of male circumcision in Turkey

This article analyzes the medicalization of male circumcision in Turkey. In the 1960s, the Turkish state launched its largest network of healthcare services in its history. As part of the network, health officers began to perform circumcisions and introduced medical expertise into male circumcision. They advertised new surgical techniques via mass media and aimed to persuade families of their benefits and replace itinerant circumcisers stigmatized in the new modern, national imaginary. To do so, this article argues, health officers turned themselves into "fenni sünnetçi (scientific circumciser)." By operationalizing the concept of ambivalence, this article investigates how "fenni sünnetçi" came to epitomize a hybrid identity that enabled health officers to differentiate themselves from itinerant circumcisers and maintain their professional status while resonating with families accustomed to the services of itinerant circumcisers. The article enriches our understanding of medicalization by paying attention to the changing subjectivities of medical professionals who initiate the medicalization process.

Experience with implementation of a nurse practitioner-led newborn circumcision clinic

INTRODUCTION/BACKGROUND

The Nurse Practitioner (NP)-Led Newborn Circumcision Clinic (NCC), developed in 2016, provides clamp-style circumcision to newborns without general anesthesia. There is a paucity of research regarding outcomes, satisfaction, and the cost benefit of such NP-led clinics.

OBJECTIVE

The purpose of this descriptive study was to describe the impact of the NCC including family satisfaction, clinical and demographic characteristics, and cost.

STUDY DESIGN

This study utilized a mixed-method approach to describe the impact of the NP-led NCC using survey methodology to describe family satisfaction, a single center retrospective chart review to describe clinical and demographic characteristics and outcomes, and investigation of charges in NCC versus operating room (OR) circumcisions. Descriptive statistics were used to present survey results and chart review data.

RESULTS

Results of the patient satisfaction survey revealed 89.8% of patients rated the overall quality of care as excellent or very good. Of the 234 patients reviewed, the median age and weight of patients was 4.30 weeks and 4.39 kg, respectively. Of the patients with comorbidities (30.3%), the most common were related to prematurity (12.8%). The most common reason for referral was concern for anatomical abnormality of the penis (53.8%). The median length of procedure was 20 minutes. No patients in our cohort experienced penile amputations, infections, strictures, intraoperative bleeding, or wounds. Ten patients (4.3%) had bleeding events during the recovery period which were treated with a topical medication (StatSeal). Two patients (0.9%) had bleeding after discharge requiring Emergency Department evaluation and application of a pressure dressing. Two patients (0.9%) required circumcision revision. Investigation of charges revealed a savings of 92.9% for circumcisions in the NCC versus OR.

DISCUSSION

This study reveals that the NP-led NCC has high family satisfaction, few adverse outcomes, and cost benefits as compared to OR circumcision. There are a limited number of publications presenting outcome data for circumcisions and even fewer for NP- led circumcision clinics. Furthermore, a lack of standardized definitions for adverse events makes comparison difficult.

CONCLUSIONS

Critical to the success of the NP-led NCC is appropriately selecting patients, a NP training program, and intra-professional collaboration. This ambulatory clinic offers another option for select infants who were not immediately circumcised in the newborn period. By expanding opportunities for NPs to practice to the full extent of their education and expertise, our institution continues to develop opportunities to improve access to care, control costs, and increase patient and family satisfaction.

Sutureless versus interrupted sutures techniques for neonatal circumcision; a randomized clinical trial

INTRODUCTION

and objective: Male circumcision is a common procedure all over the world; in Saudi Arabia, circumcision is the most frequent elective surgical procedure performed on males. The use of sutures for neonatal circumcision may decrease bleeding; however, it may lead to skin sinus formation. The objective of this study was to compare the sutureless to the interrupted sutures technique for neonatal circumcision with Gamco clamp.

PATIENTS AND METHODS

We performed a randomized controlled clinical trial between 2017 and 2018. The study included 182 newborns assigned into two groups. Group 1 (n = 94) included neonates who had sutureless circumcision, and group 2 (n = 89) included neonates who underwent circumcision using interrupted absorbable 6/0 sutures. Study endpoints were bleeding, wound gaping, skin tunneling or sinus, and cyst formation.

RESULTS

There was no significant difference in patients' age and weight between groups. The procedure was significantly longer in group 2 (12.24 ± 2.17 vs. 6.54 ± 1.42 min; p < 0.001). There was no difference in bleeding between both groups (4 (4.26%) vs. 2 (2.27%) in groups 1 and 2, respectively, p = 0.683). Cyst formation was significantly reduced in group 1 (2 (2.13%) vs. 13 (14.77%); p = 0.002) and skin sinus formation increased in group 2 (14 (15.91%) vs. 0 in group 2 and 1, respectively; p < 0.001).

DISCUSSION

Circumcision can be performed with several techniques, and the superiority of one approach over the other is still debated. Many surgeons use interrupted sutures to oppose the skin edges, and in some reports, tissue glue was used for skin edges re-approximation with acceptable cosmetic results. In our study, the mean time taken for sutureless circumcision was about 7 min, and for the suture circumcision, it took around 11 min. In addition, the formation of a skin tunnel or sinuses rate was high despite the use of very thin sutures.

CONCLUSION

Male circumcision is a common and safe technique with minor and treatable complications. Risks of bleeding and sinus track formation are low with the sutureless method. The sutureless technique is recommended after Gamco circumcision as the standard technique for male circumcision in the newborn.

"Getting to Zero New HIV Infections in the Caribbean": Knowledge and Attitudes Toward Male Circumcision Among Adolescent Males in The Bahamas

Male circumcision (MC) plays a significant role in reducing new HIV infections, particularly in high prevalence countries. This cross-sectional study assesses the prevalence of MC and attitudes toward MC among youth aged 15-18 years in The Bahamas, a medium HIV prevalence country. The survey included 797 young men who completed a questionnaire on MC. Data analyses included chi-squared tests. The self-reported prevalence of MC among youth was 16.7% (121/759). Most of the circumcised youth were circumcised as infants, 84% (107/121) were pleased with their circumcision, and 71% would recommend it to others. For uncircumcised youth, 35% (189/533) would consider voluntary male circumcision (VMC) and 26% would recommend MC to others. In all scenarios, circumcised youth were more likely to be positive about MC. Among uncircumcised young men, being older (17-18 years compared to 15-16 years) was the only variable statistically associated with considering MC or recommending MC. After being presented with information on the benefits of MC for HIV prevention, the number of men who were positive about MC increased. Most of the young men in this cohort would consider VMC for reducing HIV incidence. Also, many stated that, if they had a male child, they would have him circumcised. The attitudes of these youth emphasize the need to provide information on HIV in addition to general health benefits of MC if there were to be a sustainable MC program within this population.

Mapping male circumcision for HIV prevention efforts in sub-Saharan Africa

BACKGROUND

HIV remains the largest cause of disease burden among men and women of reproductive age in sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk of female-to-male transmission of HIV by 50-60%. The World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries for VMMC campaigns and set a coverage goal of 80% for men ages 15-49. From 2008 to 2017, over 18 million VMMCs were reported in priority countries. Nonetheless, relatively little is known about local variation in male circumcision (MC) prevalence.

METHODS

We analyzed geo-located MC prevalence data from 109 household surveys using a Bayesian geostatistical modeling framework to estimate adult MC prevalence and the number of circumcised and uncircumcised men aged 15-49 in 38 countries in sub-Saharan Africa at a 5 × 5-km resolution and among first administrative level (typically provinces or states) and second administrative level (typically districts or counties) units.

RESULTS

We found striking within-country and between-country variation in MC prevalence; most (12 of 14) priority countries had more than a twofold difference between their first administrative level units with the highest and lowest estimated prevalence in 2017. Although estimated national MC prevalence increased in all priority countries with the onset of VMMC campaigns, seven priority countries contained both subnational areas where estimated MC prevalence increased and areas where estimated MC prevalence decreased after the initiation of VMMC campaigns. In 2017, only three priority countries (Ethiopia, Kenya, and Tanzania) were likely to have reached the MC coverage target of 80% at the national level, and no priority country was likely to have reached this goal in all subnational areas.

CONCLUSIONS

Despite MC prevalence increases in all priority countries since the onset of VMMC campaigns in 2008, MC prevalence remains below the 80% coverage target in most subnational areas and is highly variable. These mapped results provide an actionable tool for understanding local needs and informing VMMC interventions for maximum impact in the continued effort towards ending the HIV epidemic in sub-Saharan Africa.

Medical Male Circumcision and Associations Among Sexually Transmitted Infections Service Attendees

Medical male circumcision (MMC) is a proven intervention for preventing HIV acquisition among males. We describe the circumcision status, eligibility for MMC referral and associations with HIV positivity among symptomatic males attending sexually transmitted infections (STI) services. This study was a secondary analysis of cross-sectional data collected during sentinel surveillance for STI aetiologies. In the sentinel surveillance conducted at primary care facilities located in six South African provinces, an anonymous questionnaire was administered followed by collection of appropriate genital and blood specimens for laboratory testing including HIV, rapid plasma reagin (RPR) and HSV-2 serological testing. During analysis, multivariable logistic regression was used to determine association between prevalent HIV infection and male circumcision among males who were HSV-2 AND/OR RPR serology positive and among those who were negative. A total of 847 males were included the analysis, among whom the median age was 28 years (IQR 24-32 years) with 26.3% aged < 25 years. Of these, 166 (19.6%) were medically circumcised, 350 (41.4%) traditionally circumcised while 324 (39%) were not circumcised. The yield of assessment for MMC referral was 27.7%. Overall HIV positivity was 23.1%. Compared to no circumcision, MMC had a statistically insignificant 62% lower odds of being HIV positive -among males who were HSV-2 and RPR negative- adjusted odds ratio [aOR] 0.38 [95% confidence interval (CI) 0.12-1.18], p = 0.094. Among those HSV-2 AND/OR RPR positive, MMC had a statistically insignificant 26% lower odds of being HIV positive- aOR 0.74 (95% CI 0.41-1.36), p = 0.334. In both groups HIV positivity increased with age but was positively associated with condom use at last sexual encounter [aOR 3.41 (95% CI 1.43-8.15)] and previous treatment for an STI syndrome [aOR 3.81 (95% CI 1.60-9.05)] among those HSV-2 and RPR negative. High HIV positivity and high yield of eligibility for VMMC referral among males attending STI services points to the need for better integration of HIV prevention and treatment with STI care.

Case series of glans injuries during voluntary medical male circumcision for HIV prevention - eastern and southern Africa, 2015-2018

BACKGROUND

Male circumcision confers partial protection against heterosexual HIV acquisition among men. The President's Emergency Plan for AIDS Relief (PEPFAR) has supported > 18,900,000 voluntary medical male circumcisions (VMMC). Glans injuries (GIs) are rare but devastating adverse events (AEs) that can occur during circumcision. To address this issue, PEPFAR has supported multiple interventions in the areas of surveillance, policy, education, training, supply chain, and AE management.

METHODS

Since 2015, PEPFAR has conducted surveillance of GIs including rapid investigation by the in-country PEPFAR team. This information is collected on standardized forms, which were reviewed for this analysis.

RESULTS

Thirty-six GIs were reported from 2015 to 2018; all patients were < 15 years old (~ 0·7 per 100,000 VMMCs in this age group) with a decreasing annual rate (2015: 0.7 per 100,000 VMMCs; 2018: 0.4 per 100,000 VMMC; p = 0.02). Most (64%) GIs were partial or complete amputations. All amputations among 10-14 year-olds occurred using the forceps-guided (FG) method, as opposed to the dorsal-slit (DS) method, and three GIs among infants occurred using a Mogen clamp. Of 19 attempted amputation repairs, reattached tissue was viable in four (21%) in the short term. In some cases, inadequate DS method training and being overworked, were found.

CONCLUSION

Following numerous interventions by PEPFAR and other stakeholders, GIs are decreasing; however, they have not been eliminated and remain a challenge for the VMMC program. Preventing further cases of complete and partial amputation will likely require additional interventions that prevent use of the FG method in young patients and the Mogen clamp in infants. Improving management of GIs is critical to optimizing outcomes.

Management of post-circumcision necrosis of the penis: the medicolegal aspect

PURPOSE

To perform a medical evaluation of penile necrosis causes and treatment approaches by examining patients who had penile necrosis after circumcision surgery.

METHODS

A total of 24 patients with penile necrosis after circumcision surgery, who presented at various hospitals in Turkey between September 2003 and April 2013 and whose cases were being reviewed at the Institution of Forensic Medicine with regard to malpractice, were evaluated retrospectively.

RESULTS

The mean age of the patients was 5 ± 3.7 years, and the mean time of the necrosis diagnosis after circumcision was 5.2 ± 6.3 days. In etiologic terms, the predictive factors were monopolar cautery use in ten (41.6%) patients, post-circumcision infection in eight (33.3%), compartment syndrome due to post-circumcision dressing in three (12.5%), local anesthetic agent used for dorsal nerve blockage in two (8.3%), and methemoglobinemia in one (4.1%) patient. The first approaches to necrosis treatment were surgical intervention in 15 (62.5%) patients, hyperbaric oxygen treatment (HBOT) in 6 (25%), the conservative approach in 2 (8.3%), and HBOT plus surgical intervention in 1 (4.1%) patient.

CONCLUSION

Penile necrosis is a preventable complication that requires early intervention. The current study will be helpful in preventing penile necrosis and in guiding surgeons in approaches following its occurrence.

Male circumcision and the risk of gonorrhoea, syphilis, HIV and human papillomavirus among men in Tanzania

To examine the association between male circumcision and the risk of gonorrhoea, syphilis, HIV and high-risk (hr) human papillomavirus (HPV). We used data from a cross-sectional study conducted among 1902 men in Tanzania. Circumcision status was assessed at a clinical examination and history of gonorrhoea and syphilis was obtained from questionnaire data. Penile samples were tested for HPV using Hybrid Capture 2 and genotyped by the INNO-LiPA HPV Genotyping Extra test. Blood samples were tested for HIV. Using logistic regression the association between male circumcision and gonorrhoea, syphilis, HIV and hr HPV was assessed estimating odds ratios (ORs) and 95% confidence intervals (CIs). All analyses were adjusted for age and lifetime number of sexual partners. In the multivariable analysis, the odds of gonorrhoea were lower in circumcised men compared with uncircumcised men (OR = 0.52; 95% CI: 0.37–0.74). Likewise, the odds of HIV were considerably lower in circumcised men (OR = 0.42; 95% CI: 0.26–0.67). Furthermore, lower odds of hr HPV were seen in circumcised men compared with uncircumcised men, although not statistically significant (OR = 0.81; 95% CI: 0.56–1.17). Finally, the odds of HPV16 (OR = 0.48; 95% CI: 0.23–0.98) and multiple (≥2) hr HPV types (OR = 0.71; 95% CI: 0.44–1.12) were lower in circumcised men than in uncircumcised men. Circumcised men have a significantly lower risk of gonorrhoea, HIV and HPV16, compared with uncircumcised men.

Traditional Male Circumcision is Associated with Sexual Risk Behaviors in Sub-Saharan Countries Prioritized for Male Circumcision

To understand the sexual risk behavior of men with traditional male circumcision and medical male circumcision in the context of the World Health Organization's (WHO) campaign for voluntary medical male circumcision (VMMC) scale-up, we investigated ten countries prioritized for the scale-up from the Demographic and Health Surveys. Male respondents aged 15-49 were selected. Ordinal regression was used to analyze the relationship between three sexual risk behaviors-condom use with non-cohabiting partners, number of non-cohabiting partners, and partner type-and circumcision status (traditionally circumcised before and after the VMMC scale-up, medically circumcised before and after the scale-up, and not circumcised), while controlling for social demographic covariates. We found evidence that some sexual risky behavior, specifically lower condom use and higher number of sexual partners, was associated with traditional circumcision. This finding suggests that messages about the protective effect of male circumcision may not have reached men with traditional circumcision. We suggest that WHO's VMMC campaign should include communities where traditional male circumcision is popular. We looked for, but did not find, evidence of differences between groups circumcised at different times, which could have indicated sexual risk compensation.

Enhancers and barriers to uptake of male circumcision services in Northern Uganda: a qualitative study

Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda.

Association of Male Circumcision with Women's Knowledge of its Biomedical Effects and With Their Sexual Satisfaction and Function: A Systematic Review

Male circumcision (MC) is a key HIV prevention intervention for men in countries with high HIV prevalence. Women's understanding of MC is important but poorly understood. We conducted a systematic review including women's knowledge of MC's biomedical impacts and its association with female sexual satisfaction and function through October 2017. Thirty-eight articles were identified: thirty-two with knowledge outcomes, seven with sexual satisfaction, and four with sexual function (N = 38). Respondent proportions aware MC protects men from HIV were 9.84-91.8% (median 60.0%). Proportions aware MC protects men from STIs were 14.3-100% (72.6%). Proportions aware MC partially protects men from HIV were 37.5-82% (50.7%). Proportions aware MC is not proven to protect women from infection by an HIV-positive partner were 90.0-96.8% (93.0%). No increases over time were noted. Women's MC knowledge is variable. Education could help women support MC and make better-informed sexual decisions.

Thermal cautery-assisted circumcision and principles of its use to decrease complication rates

INTRODUCTION

Circumcision is one of the most frequently applied surgical procedures all over the world and a number of techniques and devices have been described concerning its method. Especially in developing countries where circumcision has been performed intensively under local anaesthesia, the thermocautery device developed to perform circumcisions in a short time and safely has found a widespread application.

OBJECTIVE

We aim to share our experiences concerning application principles of the thermocautery device so as to be able to achieve better cosmetic results with lower complication rates.

MATERIALS AND METHODS

Between the years 2009 and 2016, a total of 12,355 children between the ages of 40 days and 16 years (mean: 5.1 ± 2.0 years) were circumcised at our hospital. All circumcisions were performed by urologists under local anaesthesia using a thermocautery device (Thermo-Med TM 802B device; Thermo Medikal, Adana, Turkey).

RESULTS

Bleeding that required surgical intervention did not occur in any patient. Compressive dressing was applied to 62 patients who had moderate degrees of bleeding, for haemostasis purposes. Twelve syncopes and four epileptic seizures developed secondary to local anaesthesia were managed in consultation with the Department of Children Health and Diseases. The most serious complication, trapped penis, was seen in 48 patients. All these complications were resolved using surgical interventions. Infection developed in 15 patients, and it was relieved with the administration of oral antibiotherapy. Penile adhesions were relieved in 25 cases, and anti-inflammatory treatment was organised. Meatal stenosis occurred in three cases, and two cases of inclusion cysts were treated with surgical intervention.

DISCUSSION

In countries where circumcision is routinely applied, developing swift and safer methods are of the utmost importance. To this end, we prefer thermocautery, which can satisfy patient demands swiftly and safely.

CONCLUSION

To reduce the complications after circumcision using thermocautery, we think that it is appropriate to pay attention to the following issues during circumcision: The cautery should be turned in a serial manner and both sides of the blade should be used for cutting, and temperature of the thermocauter should be adjusted according to the skin thickness. The cutting process should be achieved in two steps, and another method should be preferred for buried penis. If these rules are followed, we think that the thermocautery-supported method can be a very safe and fast circumcision method.

Modeling economic and epidemiological impact of voluntary medical male circumcision among men who have sex with men in Beijing, China

Voluntary medical male circumcision (VMMC) among men who have sex with men (MSM) may protect against HIV acquisition. We conducted a series of analyses to assess if expanded VMMC might reduce HIV incidence among MSM effectively and economically. We used a deterministic compartmental model to project new HIV cases (2016-2026) under annual VMMC coverage rates (λ) ranging from 0.0001 to 0.15. The 'number needed to avert' (NNA) is defined as the cumulative number of VMMCs conducted up to that year divided by the cumulative number of HIV cases averted in that specific year. Compared with the baseline circumcision coverage rate, we projected that new HIV cases would be reduced with increasing coverage. By 2026 (last year simulated), the model generated the lowest ratio (11.10) when the annual circumcision rate was the most optimistic (λ = 0.15). The breakeven point was observed at the year of 2019 with the annual VMMC coverage rate of 0.001. The total cost saved by averting HIV cases would range from 2.5 to 811 million US dollars by the end of 2026 with different hypothetical coverage rates. Our model suggests that acceleration in VMMC implementation among MSM could help stem the HIV/AIDS epidemic.

Comparison of preputioplasty and circumcision in distal hypospadias correction: long-term follow-up

OBJECTIVE

A normal penile cosmesis is an important goal in distal hypospadias repair. Depending on cultural standards, repairs are combined with a preputioplasty or circumcision to attain a 'normal' penile appearance. Although short-term complication rates of preputioplasty are available, data on long-term outcomes are scarce. Therefore, this study assessed long-term functional and cosmetic outcomes of distal hypospadias repair with either a preputioplasty or a circumcision.

PATIENTS AND METHODS

Eligible for inclusion were patients with distal hypospadias operated in childhood between 1987 and 1993. Complications and reasons for secondary circumcision were extracted from the medical charts. Participants completed a questionnaire including the International Index of Erectile Function (IIEF-15), the International Prostate Symptom score (IPSS), and additional non-validated questions. Penile cosmesis was judged with the Penile Perception Score (PPS), stretched penile length was measured, and uroflowmetry was performed.

RESULTS

Of the 86 eligible and traceable patients, 40 (47%) participated; of them, 27 had a preputioplasty and 13 a circumcision. Six patients underwent a secondary circumcision due to a preputial defect (n = 2), unsatisfactory cosmetic result (n = 2), religious reason (n = 1), or phimosis (n = 1). Complication rates were similar in both the groups. Long-term outcomes in the preputioplasty and circumcision group were comparable regarding cosmetic, sexual, and micturition outcomes.

CONCLUSIONS

Distal hypospadias correction combined with preputioplasty had complication rates similar to those of hypospadias repair with circumcision. In these patients, preputioplasty had a failure rate of 22%. In both the groups, long-term outcomes of urinary function, sexual function, and cosmesis were good.

Surgical management of genitourinary lichen sclerosus et atrophicus in boys in England: A 10-year review of practices and outcomes

INTRODUCTION

Circumcision has long been the mainstay of management for genitourinary lichen sclerosus et atrophicus (LS); however, there has been growing interest in surgical techniques that preserve the foreskin.

OBJECTIVE

The aim of this study was to assess population-based surgical management of LS in England and determine surgical outcomes.

STUDY DESIGN

Cases of LS treated in English NHS trusts (2002-2011) were extracted from the Hospital Episode Statistics (HES) Database. Cases were identified by both an ICD-10 code for LS and either an OPCS4.6 code for circumcision or preputioplasty (with/without injection of steroid). Subsequent admissions were analysed for related complications/procedures. Data are presented as median (interquartile range) unless otherwise stated.

RESULTS

7893 patients had surgery for LS, of whom 7567 (95.8%) underwent circumcision (Table). Primary preputioplasty was performed in 326 (4.1%) in 44/130 centres; of these 151/326 had concomitant injection of steroid. Age at surgical intervention was 9 (6-11) years. There were no postoperative bleeds following preputioplasty. Of those treated with preputioplasty, 74 (22%) had subsequent circumcision at a median of 677 (277-1203) days post operation. Concomitant steroid injection reduced the risk of subsequent circumcision (21/151 (14%) vs. 53/175 (30%), p < 0.001). More children underwent a second operative procedure following preputioplasty than those having had a primary circumcision (27.9% vs. 7.9%, p < 0.001).

CONCLUSION

Although circumcision is the predominant treatment for LS, these data suggest that preputioplasty is a valid option in management, albeit with a higher re-intervention rate. Selection bias may play a role and a randomized controlled trial is needed. Preputioplasty combined with steroid injection appears to reduce the chance of completion circumcision.

Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up

Oral pre-exposure prophylaxis (PrEP) has the ability to curb HIV incidence worldwide and bring us closer to ending the HIV epidemic. Scale up of PrEP service delivery has many similar challenges to those faced by voluntary medical male circumcision (VMMC) services roll-out. This article outlines ten important lessons learned during the scale up of VMMC services in sub-Saharan Africa and their application to current oral PrEP implementation efforts to promote faster expansion for public health impact.

Novel Devices for Adolescent and Adult Male Circumcision

There is an abundance of devices for adolescent and adult male circumcision (MC). It has been shown that the safety and efficacy of device-assisted MC are equal to or better than those for MC via conventional surgery. MC devices have the potential to simplify the procedure and increase the acceptability of circumcision among patients.

Women's role in male circumcision promotion in Rakai, Uganda

Medical male circumcision (MMC) has expanded in sub-Saharan Africa, yet uptake remains sub-optimal. We sought to understand women's perceptions of and influence on MMC in Rakai, Uganda. We conducted in-depth interviews with 27 women in fishing and trading communities, including women married to circumcised and uncircumcised men, single women, and sex workers. Data analysis followed a team-based framework approach. All female participants preferred circumcised men because of perceived reduced HIV and sexually transmitted infection (STI) risk, improved penile hygiene, and increased sexual pleasure. Perceived negative aspects included abstinence during wound healing, potentially increased male sexual risk behaviors, fear of being blamed for HIV acquisition, and economic insecurity due to time off work. Participants felt women could persuade their partners to be circumcised, accompany them to the clinic, refuse sex with uncircumcised men, and participate in community MMC activities. Findings support women's important role in MMC acceptance.

Effectiveness of an "Exclusive Intervention Strategy" to increase medical male circumcision uptake among men aged 25-49 years in South Africa

BACKGROUND

South Africa introduced medical male circumcision (MMC) to reduce HIV incidence. Mathematical modeling suggested that targeting MMC services to men aged 20-34 years could provide the most immediate impact on HIV incidence. However the majority of MMCs performed have been among males aged ≤25 years. We evaluated an intervention package to increase MMC uptake among men aged 25-49 years.

METHODS

We conducted a pre-post study to compare the proportion of men (aged 25-49 years) presenting for MMC during the formative (Phase 1) and intervention (Phase 2) phases in Ekurhuleni, Johannesburg, South Africa. The intervention included infrastructure changes that separated adults from adolescents at the MMC site, an exclusive men's health club, adult-specific demand generation materials, and discussions with community members.

RESULTS

Overall 2817 enrolled in the study with 1601 from Phase 1 and 1216 in Phase 2. A higher proportion of participants aged 25-49 years accessed MMC in Phase 2 compared to Phase 1 (59.4% vs. 54.9%; Prevalence Ratio = 1.08; 95% Confidence Interval: 1.01-1.15; p = 0.019). Participants with multiple partners in the past 12 months in Phase 2 were more likely to access MMC services compared to participants in Phase 1 (unadjusted Odds Ratio, 1.37; 95% CI:1.17-1.61; p < 0.001). After adjusting for age, multiple partners remained a risk factor in Phase 2 (adjusted OR, 1.39; 95% CI: 1.18-1.63; p < 0.001).

CONCLUSIONS

The "Exclusive Intervention Strategy" was associated with a slight increase in the proportion of participants aged 25-49 years accessing MMC services, and an increase in those with HIV risk behaviors, during the intervention phase. These findings may provide important insights to overcoming barriers for accessing MMC services among men aged 25-49 years.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov , number NCT02352961 .

Male circumcision for HIV prevention: female risk compensatory behaviour in South Africa

South Africa promotes male circumcision (MC) as an HIV prevention method and implemented a national plan to scale-up MC in the country from 2012 to 2016. Literature has suggested that female risk compensatory behaviours (RCBs) are occurring in countries where these programmes have been implemented. Behaviours such as decreased condom use, concurrent sexual partners and sexual activity during the circumcision wound-healing period have the potential to jeopardise the campaigns' objectives. Literature has shown that directly providing women with MC information results in correct knowledge however, previous studies have not directly sought women's views and ideas on engagement with the information. This study aims to identify and explore female RCBs in relation to MC campaigns in South Africa, and to identify interventions that would result in greater female involvement in the campaigns. Snowball sampling was used to conduct twelve qualitative vignette-facilitated semi-structured interviews with women residing in a municipal housing estate in Durban, Kwa-Zulu Natal, South Africa. Interviews were audio-recorded, verbatim transcribed and analysed using framework analysis. MC knowledge and understanding varied, with some participants mistaking MC as direct HIV protection for females. Despite a lack in knowledge, the majority of women did not report signs of RCBs. Even with a lack of evidence of RCBs, misinterpretation of the MC protective effect has the potential to lead to RCBs; a concept acknowledged in the literature. Several women expressed that MC campaigns are directed to males only and expressed a keenness to be more involved. Suggested interventions include couple counselling and female information sessions in community clinics. Exploring women's attitude towards involvement in MC campaigns fills in a research knowledge gap that is important to international health, as women have a vital role to play in reducing the transmission of HIV.

Attitude Toward One's Circumcision Status Is More Important than Actual Circumcision Status for Men's Body Image and Sexual Functioning

Research exploring the impact of circumcision on the sexual lives of men has failed to consider men's attitudes toward their circumcision status, which may, in part, help to explain inconsistent findings in the literature. The current study explored the potential relationship between attitudinal factors toward one's circumcision status, timing of one's circumcision, and sexual correlates. A total of 811 men (367 circumcised as neonates, 107 circumcised in childhood, 47 circumcised in adulthood, and 290 intact) aged 19-84 years (M = 33.02, SD = 12.54) completed an online survey. We assessed attitudes toward one's circumcision status, three domains of body image (Male Genital Image Scale, Body Exposure during Sexual Activities Questionnaire, Body Image Satisfaction Scale), and self-reported sexual functioning (International Index of Erectile Function). Men who were circumcised as adults or intact men reported higher satisfaction with their circumcision status than those who were circumcised neonatally or in childhood. Lower satisfaction with one's circumcision status-but not men's actual circumcision status-was associated with worse body image and sexual functioning. These findings identify the need to control for attitudes toward circumcision status in the study of sexual outcomes related to circumcision. Future research is required to estimate the number of men who are dissatisfied with their circumcision status, to explore the antecedents of distress in this subpopulation, and to understand the extent of negative sexual outcomes associated with these attitudes.

Use of the ShangRing circumcision device in boys below 18 years old in Kenya: results from a pilot study

Introduction: Male circumcision is a proven prevention strategy against the spread of HIV. The World Health Organization’s new 2016–2021 strategic framework on voluntary medical male circumcision (VMMC) targets 90% of males aged 10–29 years to receive circumcision by 2021 in 14 priority sub-Saharan countries while anticipating an increase in the demand for infant circumcision. It also states that the use of circumcision devices is a safe and efficient innovation to accelerate attainment of these goals. The primary objective of this pilot study was to evaluate the safety and acceptability of the ShangRing, a novel circumcision device, in boys below 18 years of age.

Methods: A total of 80 boys, 3 months to 17 years old, were circumcised using the no-flip ShangRing technique. All rings were removed 5–7 days later. Participants were evaluated weekly until the wound was completely healed. Data on procedure times, adverse events (AEs), time to clinical wound healing and satisfaction were recorded and analysed.

Results: Nearly all (79/80, 98.8%) circumcisions were successfully completed using the no-flip ShangRing technique without complications. In one (1.2%) case, the outer ring slipped off after the foreskin was removed and the procedure was completed by stitching. The mean circumcision and ring removal times were 7.4 ± 3.2 and 4.4 ± 4.2 min, respectively. There were four (5%) moderate AEs, which were managed conservatively. No severe AEs occurred. The mean time to complete clinical healing was 29.8 ± 7.3 days. Participants or their parents liked ShangRing circumcision because it improved hygiene, was quick and possessed an excellent cosmetic appearance. Most (72/80, 94.7%) were very satisfied with the appearance of the circumcised penis, and all (100%) said they would recommend circumcision to others.

Conclusions: Our results suggest that no-flip ShangRing VMMC is safe and acceptable in boys below 18 years of age. Our results are to be compared those seen following ShangRing VMMC in African men. Further study with larger sample sizes are needed to explore the scalability of the ShangRing in larger paediatric cohorts in Africa. We believe that the ShangRing has great potential for use in all age groups from neonates to adults, which would simplify device implementation.

Circumcision-incision orchidopexy: A novel technique for palpable, low inguinal undescended testis

Given that both orchidopexy and circumcision are commonly done in a single operative setting, we adopted a technique of combined orchidopexy and circumcision using a single circumcision incision. We applied this new technique to boys with palpable, low inguinal cryptorchidism. Here we describe a case series of 7 boys who underwent concurrent orchidopexy via the circumcision site. We present this novel technique and discuss our preliminary outcomes, including the anatomic basis and feasibility. The technique appears to be an alternative for concurrent circumcision and cryptorchid cases with palpable, low inguinal testes.

"Now that you are circumcised, you cannot have first sex with your wife": post circumcision sexual behaviours and beliefs among men in Wakiso district, Uganda

Introduction: Safe male circumcision is an important biomedical intervention in the comprehensive HIV prevention programmes implemented in 14 sub-Saharan African countries with high HIV prevalence. To sustain its partial protective benefit, it is important that perceived reduced HIV risk does not lead to behavioural risk compensation among circumcised men and their sexual partners. This study explored beliefs that may influence post circumcision sexual behaviours among circumcised men in a programme setting.

Methods: Forty-eight in-depth interviews were conducted with newly circumcised men in Wakiso district, central Uganda. Twenty-five men seeking circumcision services at public health facilities in the district were recruited from May to June 2015 and, interviewed at baseline and after 6 months. Participants’ beliefs and sexual behaviours were compared just after circumcision and at follow up to explore changes. Data were managed using atlas.ti7 and analysed following a thematic network analysis framework.

Results: Four themes following safe male circumcision emerged from this study. Beliefs related to: (1) sexual cleansing, (2) healing, (3) post SMC sexual capabilities and (4) continued HIV transmission risk. Most men maintained or adopted safer sexual behaviour; being faithful to their partner after circumcision or using condoms with extramarital partners following the knowledge that there was continued HIV risk post circumcision. The most prevalent risky belief was regarding sexual cleansing post circumcision, and as a result of this belief, some men had one off condom-less sexual intercourse with a casual partner. Some resumed sex before the recommended period due to misunderstanding of what comprised healing.

Conclusions: Although most men maintained or adopted safer sexual behaviour, there were instances of risky sexual behaviour resulting from beliefs regarding the first sexual intercourse after circumcision or misunderstandings of what comprised wound healing. If not addressed, these may attenuate the safe male circumcision benefits of risk reduction for HIV.

Impact of a community health worker HIV treatment and prevention intervention in an HIV hotspot fishing community in Rakai, Uganda (mLAKE): study protocol for a randomized controlled trial

Background

Effective yet practical strategies are needed to increase engagement in HIV treatment and prevention services, particularly in high-HIV-prevalence hotspots. We designed a community-based intervention called “Health Scouts” to promote uptake and adherence to HIV services in a highly HIV-prevalent fishing community in Rakai, Uganda. Using a situated Information, Motivation, and Behavioral skills theory framework, the intervention consists of community health workers, called Health Scouts, who use motivational interviewing strategies and mobile health tools to promote engagement in HIV treatment and prevention services.

Methods/design

The Health Scout intervention is being evaluated through a pragmatic, parallel, cluster-randomized controlled trial with an allocation ratio of 1:1. The study setting is a single high-HIV-prevalence fishing community in Rakai, Uganda divided into 40 contiguous neighborhood clusters each containing about 65 households. Twenty clusters received the Health Scout Intervention; 20 clusters received standard of care. The Health Scout intervention is delivered within the community at the household level, targeting all residents aged 15 years or older. The primary programmatic outcomes are self-reported HIV care, antiretroviral therapy, and male circumcision coverage; the primary biologic outcome is population-level HIV viremia prevalence. Follow-up is planned for about 3 years.

Discussion

HIV treatment and prevention service engagement remains suboptimal in HIV hotspots. New, community-based implementation approaches are needed. If found to be effective in this trial, the Health Scout intervention may be an important component of a comprehensive HIV response.

Trial registration

ClinicalTrials.gov, ID: NCT02556957. Registered on 20 September 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2243-6) contains supplementary material, which is available to authorized users.

Adverse event profile of a mature voluntary medical male circumcision programme performing PrePex and surgical procedures in Zimbabwe

INTRODUCTION

The frequency of adverse events (AEs) is a widely used indicator of voluntary medical male circumcision (VMMC) programme quality. Though over 11.7 million male circumcisions (MCs) have been performed, little published data exists on the profile of AEs from mature, large-scale programmes. No published data exists on routine implementation of PrePex, a device-based MC method.

METHODS

The ZAZIC Consortium began implementing VMMC in Zimbabwe in 2013, supporting services at 36 facilities. Aggregate data on VMMC outputs are collected monthly from each facility. Detailed forms are completed describing the profile of each moderate and severe AE. Bivariate and multivariable analyses were conducted using log-binomial regression models.

RESULTS

From October 2014 through September 2015, 44,868 clients were circumcised with 156 clients experiencing a moderate or severe AE. 96.2% of clients had a follow-up visit within 14 days of their procedure. AEs were uncommon, with 0.3% (116/41,416) of surgical and 1.2% (40/3,452) of PrePex clients experiencing a moderate or severe AE. After adjusting for VMMC site, we found that PrePex was associated with a 3.29-fold (95% CI: 1.78-6.06) increased risk of experiencing an AE compared to surgical procedures. Device displacements, when the PrePex device is intentionally or accidentally dislodged during the 7-day placement period, accounted for 70% of PrePex AEs. The majority of device displacements were intentional self-removals. Overall, infection was the most common AE among VMMC clients. Compared to clients aged 20 and above, clients aged 10-14 were 3.07-fold (95% CI: 1.36-6.91) more likely to experience an infection and clients aged 15-19 were 1.80-fold (95% CI: 0.82-3.92) more likely to experience an infection, adjusted for site.

CONCLUSION

This exploratory analysis found that clients receiving PrePex were more likely to experience an AE than surgical circumcision clients. This is largely attributable to the occurrence of device displacements, which require prompt access to corrective surgical MC procedures as part of their clinical management. Most device displacements were self-removals which are preventable if client behaviour could be modified through counselling interventions. We also found that infection after MC is more common among younger clients, who may benefit from additional counselling or increased parental involvement.

Implications of male circumcision for women in Papua New Guinea: a transformational grounded theory study

Background

Male circumcision reduces the risk of female-to-male transmission of human immunodeficiency virus (HIV) and is being explored for HIV prevention in Papua New Guinea (PNG). PNG has a concentrated HIV epidemic which is largely heterosexually transmitted. There are a diverse range of male circumcision and penile modification practices across PNG. Exploring the implications of male circumcision for women in PNG is important to inform evidence-based health policy that will result in positive, intended consequences.

Methods

The transformational grounded theory study incorporated participatory action research and decolonizing methodologies. In Phase One, an existing data set from a male circumcision study of 861 male and 519 female participants was theoretically sampled and analyzed for women’s understanding and experience of male circumcision. In Phase Two of the study, primary data were co-generated with 64 women in seven interpretive focus group discussions and 11 semi-structured interviews to develop a theoretical model of the processes used by women to manage the outcomes of male circumcision. In Phase Three participants assisted to refine the developing transformational grounded theory and identify actions required to improve health.

Results

Many women know a lot about male circumcision and penile modification and the consequences for themselves, their families and communities. Their ability to act on this knowledge is determined by numerous social, cultural and economic factors. A transformational grounded theory was developed with connecting categories of: Women Know a Lot, Increasing Knowledge; Increasing Options; and Acting on Choices. Properties and dimensions of each category are represented in the model, along with the intervening condition of Safety. The condition of Safety contextualises the overarching lived realty for women in PNG, enables the inclusion of men in the transformational grounded theory model, and helps to explain relationships between men and women. The theory presents the core category as Power of Choice.

Conclusions

This transformational grounded theory provides a means to explore how women experience male circumcision and penile modification in PNG, including for HIV prevention. Women who have had opportunities for education have a greater range of choices and an increased opportunity to act upon these choices. However, women can only exercise their power of choice in the context of safety. The concept of Peace drawn from the Social Determinants of Health is applied in order to extend the explanatory power of the transformational grounded theory. This study shows that women’s ambivalence about male circumcision is often related to lack of safety, a consequence of gender inequality in PNG.