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Sexually Transmitted Infections and Male Circumcision: A Systematic Review and Meta-Analysis  [PDF]
Robert S. Van Howe
ISRN Urology , 2013, DOI: 10.1155/2013/109846
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. 1. Background The earliest report of circumcision status as potential risk factor for sexually transmitted infections (STIs) was published in 1855 by Hutchinson, who noted that in men who were treated for STIs (primarily gonorrhea and syphilis), Jews were less likely to have syphilis [1]. This report is still referenced by circumcision proponents as a validation of their claim that circumcision prevents STIs, but the converse of Hutchinson’s finding, namely that when compared to Gentiles, Jews were at greater risk for gonorrhea, is typically ignored. The claim of reduction of the risk of STIs to justify neonatal circumcision continues today, often supported by selective bibliographies [2–12]. When the entire medical literature is reviewed, these claims become difficult to substantiate. The American Academy of Pediatrics, 1999, Task Force on Circumcision concluded that “evidence regarding the relationship of circumcision to STD in general is complex and conflicting.” [13] In 2012, using a selective bibliography, consistent with the practices of circumcision proponents, the American Academy of Pediatrics concluded that “evaluation of current evidence
The role of sexually transmitted infections in male circumcision effectiveness against HIV – insights from clinical trial simulation
Kamal Desai, Marie-Claude Boily, Geoff P Garnett, Beno?t R Masse, Stephen Moses, Robert C Bailey
Emerging Themes in Epidemiology , 2006, DOI: 10.1186/1742-7622-3-19
Abstract: Focusing on the MC trial in Kisumu, we used a stochastic prevention trial simulator (1) to determine whether statistical analyses can validly estimate efficacy, (2) to determine whether MC efficacy against STI alone can produce large effectiveness against HIV and (3) to estimate the fraction of all HIV infections prevented that are attributable to efficacy against STI when both efficacies combine.Valid estimation of separate efficacies against HIV and STI as well as MC effectiveness is feasible with available STI and HIV trial data, under Kisumu trial conditions. Under our parameter assumptions, high overall effectiveness of MC against HIV was observed only with a high MC efficacy against HIV and was not possible on the basis of MC efficacy against STI alone. The fraction of all HIV infections prevented which were attributable to MC efficacy against STI was small, except when efficacy of MC specifically against HIV was very low. In the three MC trials which reported between 48% and 61% effectiveness (combining STI and HIV efficacies), the fraction of HIV infections prevented in circumcised males which were attributable to STI was unlikely to be more than 10% to 20%.Estimation of efficacy, attributable fraction and effectiveness leads to improved understanding of trial results, gives trial results greater external validity and is essential to determine the broader public health impact of circumcision to men and women.The role of male circumcision (MC) in protecting against HIV infection in sub-Saharan Africa has been controversial since the beginning of the HIV epidemic. This is because evidence derived from observational studies is prone to bias due to confounding risk factors and because MC as a HIV prevention strategy can be seen as unethical [1-3]. There is mounting epidemiological evidence and plausible biological explanation to indicate that MC can protect against HIV both directly and indirectly [4-11]. Risk due to abrasions suffered by foreskin in uncircumcis
Male circumcision and its association with HIV infection and sexually transmitted diseases: evidence from 18 demographic and health surveys in sub-Saharan Africa
S Gebremedhin
SAHARA J (Journal of Social Aspects of HIV/AIDS Research Alliance) , 2011,
Abstract: The study aimed to assess the association between male circumcision and HIV infection and STDs. The issue is controversial as various studies reported conflicting findings. A cross-sectional comparative study based on the secondary data of 18 Demographic Health Surveys (DHS), carried out in Sub-Saharan Africa starting from 2003, was conducted. From all surveys, information on 70 554 males aged 15 - 59 years was extracted. The association between male circumcision and HIV infection and STD symptoms (genital discharge or genital ulcer/sore) was assessed using binary logistic regression. Adjustment was made for sexual history and basic socio-demographic variables. The weighted prevalence of HIV among men 15 - 59 years was 3.1%. In the bivariate analysis uncircumcised status was significantly associated with risk of HIV, with odds ratio (OR) of 4.12 (95% CI: 3.85 - 4.42). The association was even more significant (4.95 (95% CI: 4.57-5.36)) after adjustment for number of lifetime sexual partners and socio-demographic variables. The risk associated with uncircumcised status is significantly lower among younger men aged 15 - 29 years than those in 30 – 59-year age category. About 5.5% of the study subjects reported either genital discharge or genital sore/ulcer in the preceding 12 months of the surveys. Circumcision status was not significantly associated with either of the symptoms, with adjusted OR of 1.07 (95% CI: 0.99 - 1.15). The study concludes that there is a strong association between uncircumcised status and HIV infection. Hence, male circumcision can be considered as a possible way of reducing the spread of HIV infection in areas where the practice is rare. A comprehensive study to assess the association between circumcision and different types of STDs is recommended.
Characteristic Male Urine Microbiomes Associate with Asymptomatic Sexually Transmitted Infection  [PDF]
David E. Nelson,Barbara Van Der Pol,Qunfeng Dong,Kashi V. Revanna,Baochang Fan,Shraddha Easwaran,Erica Sodergren,George M. Weinstock,Lixia Diao,J. Dennis Fortenberry
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0014116
Abstract: The microbiome of the male urogenital tract is poorly described but it has been suggested that bacterial colonization of the male urethra might impact risk of sexually transmitted infection (STI). Previous cultivation-dependent studies showed that a variety of non-pathogenic bacteria colonize the urethra but did not thoroughly characterize these microbiomes or establish links between the compositions of urethral microbiomes and STI.
Male midwives: preferred managers of sexually transmitted infections in men in developing countries?
Hsieh,Evelyn J.; García,Patricia J.; La Rosa Roca,Sayda;
Revista Panamericana de Salud Pública , 2008, DOI: 10.1590/S1020-49892008001000007
Abstract: objectives: to describe demographic and practice characteristics of male and female midwives in private practice (mipps) in 10 cities of peru, and their role in the delivery of reproductive health care, specifically management of sexually transmitted infections (stis). methods: as part of an intervention trial in 10 cities in the provinces of peru designed to improve sti management, detailed information was collected regarding the number of midwives in each city working in various types of practices. a door-to-door survey of all medical offices and institutions in each city was conducted. each mipp encountered was asked to answer a questionnaire regarding demographics, training, practice type(s), number of sti cases seen per month, and average earnings per consultation. results: of the 905 midwives surveyed, 442 reported having a private practice, either exclusively or concurrently with other clinical positions; 99.3% of these mipps reported managing sti cases. andean cities had the highest density of mipps, followed by jungle and coastal cities, respectively. jungle cities had the largest proportion of male mipps (35.5%). while both male and female mipps reported seeing male patients, male mipps saw a significantly greater number than their female counterparts. conclusions: in areas of peru where physicians are scarce, mipps provide needed reproductive health services, including sti management. male mipps in particular appear to serve as health care providers for male patients with stis. this trend, which may exist in other developing countries with similar healthcare workforce demographics, highlights the need for new areas of training and health services research.
Neonatal circumcision – violation of children’s rights or public health necessity?
YA Vawda, LN Maqutu
South African Journal of Bioethics and Law , 2011,
Abstract: There is a growing body of scientific evidence that medical male circumcision substantially reduces the risk of contracting HIV and other sexually transmitted infections. The procedure has been hailed as offering partial protection against HIV infection for men during sexual intercourse, raising the hope that widespread male circumcision could significantly reduce the incidence of HIV transmission in South Africa. The literature also suggests that this procedure may prevent transmission of the human papillomavirus to women. Neonatal circumcision, which is considered to carry the lowest risk, is viewed as a vital component of the goal of realising generalised circumcision in the population. This paper investigates the ethical, legal and public health considerations underlying an HIV prevention strategy that includes neonatal circumcision. It reviews the impact of the practice on the rights of children to bodily integrity, and explores whether proxy consent by a parent or guardian on behalf of a child is appropriate and justifiable on grounds of parental preference, religion, culture or public health policy. This is a complex debate and transcends routine classifications when exploring ethical dilemmas. The article concludes that the rights of neonates to bodily integrity should not be tampered with lightly, and that only a severe public health hazard such as the HIV/AIDS pandemic may justify incursion into this constitutionally protected right.
Human Papillomavirus Infection in a Male Population Attending a Sexually Transmitted Infection Service  [PDF]
Marta Elena álvarez-Argüelles, Santiago Melón, Maria Luisa Junquera, Jose Antonio Boga, Laura Villa, Sonia Pérez-Castro, María de O?a
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0054375
Abstract: Objective Human Papillomavirus (HPV) infection in men may produce cancer and other major disorders. Men play an important role in the transmission of the virus and act as a reservoir. The aim of this study was to determine the HPV-genotypes and their prevalence in a group of men attending a Sexually Transmitted Infection service. Patients and Samples Between July 2002 and June 2011, 1392 balanopreputial, 435 urethral, 123 anal, and 67 condyloma lesions from 1551 men with a mean age of 35.8±11.3 years old (range: 17–87) were collected for HPV-DNA testing. Methods A fragment of the L1-gene and a fragment of the E6/E7-genes were amplified by PCR. Positive samples were typed by hybridization. Results The HPV genome was detected in 36.9% (486/1318) balanopreputial and in 24.9% (101/405) urethral (p<0.0001) swabs from 38.1% (538) of 1469 men. Co-infections were present in 5.4% (80/1469) of cases. HPV was found in 43.9% (373/850) of men younger than 35 vs. 31.7% (187/589) of men aged >35. HPV was found in 59.4% (104) of 165 men with lesions (macroscopic or positive peniscopy), and in 22.8% (61/267) without clinical alterations. HPV was also detected in 71.4% (40/56) men with condylomata and in 58.7% (64/109) of men with positive peniscopy. Conclusions HPV prevalence in men was high and decreased with age. HPV was found more frequently in balanopreputial than in urethral swabs. There was a low rate of co-infections. Low-risk HPV vaccine genotypes were the most recurrent especially in younger. Although HPV has been associated with clinical alterations, it was also found in men without any clinical presentation. Inclusion of men in the national HPV vaccination program may reduce their burden of HPV-related disease and reduce transmission of the virus to non-vaccinated women.
Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study  [PDF]
Agnes Binagwaho ,Elisabetta Pegurri,Jane Muita,Stefano Bertozzi
PLOS Medicine , 2010, DOI: 10.1371/journal.pmed.1000211
Abstract: Background There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. The Rwanda National AIDS Commission modelled cost and effects of MC at different ages to inform policy and programmatic decisions in relation to introducing MC. This study was necessary because the MC debate in Southern Africa has focused primarily on MC for adults. Further, this is the first time, to our knowledge, that a cost-effectiveness study on MC has been carried out in a country where HIV prevalence is below 5%. Methods and Findings A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents, and adult men. Effectiveness was defined as the number of HIV infections averted, and was calculated as the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages, and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events, and promotion campaigns, and they were adjusted for the averted lifetime cost of health care (antiretroviral therapy [ART], opportunistic infection [OI], laboratory tests). One-way sensitivity analysis was performed by varying the main inputs of the model, and thresholds were calculated at which each intervention is no longer cost-saving and at which an intervention costs more than one gross domestic product (GDP) per capita per life-year gained. Results: Neonatal MC is less expensive than adolescent and adult MC (US$15 instead of US$59 per procedure) and is cost-saving (the cost-effectiveness ratio is negative), even though savings from infant circumcision will be realized later in time. The cost per infection averted is US$3,932 for adolescent MC and US$4,949 for adult MC. Results for infant MC appear robust. Infant MC remains highly cost-effective across a reasonable range of variation in the base case scenario. Adolescent MC is highly cost-effective for the base case scenario but this high cost-effectiveness is not robust to small changes in the input variables. Adult MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the
HIV among pregnant women in Moshi Tanzania: the role of sexual behavior, male partner characteristics and sexually transmitted infections
Sia E Msuya, Elizabeth Mbizvo, Akhtar Hussain, Jacqueline Uriyo, Noel E Sam, Babill Stray-Pedersen
AIDS Research and Therapy , 2006, DOI: 10.1186/1742-6405-3-27
Abstract: The prevalence of HIV was 6.9%. The risk for HIV was greater among women whose male partner; had other sexual partners (adjusted odds ratio [AOR], 15.11; 95% confidence interval [CI], 8.39–27.20), traveled frequently (AOR, 1.79; 95% CI, 1.22–2.65) or consumed alcohol daily (AOR, 1.68; 95% CI, 1.06–2.67). Other independent predictors of HIV were age, number of sex partners, recent migration, and presence of bacterial vaginosis, genital ulcer, active syphilis and herpes simplex virus type 2.Development of programs that actively involve men in HIV prevention is important in reducing transmission of HIV in this population. Further, interventions that focus on STI control, the mobile population, sexual risk behavior and responsible alcohol use are required.The HIV epidemic continues to take its greatest toll in sub-Saharan Africa, where more than 60% of the world's 40 million infected persons live [1]. Tanzania, a country with a population of 34.5 million is among the worst affected, having 7% of the adults infected with HIV [2]. There is a diverse pattern of trends in HIV prevalence for different geographical areas in the country. In some areas the reports show a decreased trend in the prevalence and incidence of HIV, especially among individuals aged 15–24 years [3,4]. In others, there is a gradual and continuing spread of HIV [4,5]. In all areas however, women continue to experience higher rates of prevalence and incidence than men [2-5], and 58% of the HIV-infected in the whole country are women [6]. There is therefore a need to elucidate risk factors continuing to contribute to the HIV epidemic among women of reproductive age.In this study we report social, behavioral and biological determinants for HIV, among pregnant women in Moshi urban, Tanzania, including male partner's characteristics and behavior. The study is part of a prospective cohort study that aimed to describe the acceptability of HIV perinatal interventions at the primary health care level as well as
Male circumcision: review and authors perspective  [cached]
Hegazy AA,Al-Rukban MO
theHealth , 2012,
Abstract: Background: The aim of this article was to evaluate the proposed benefits and consequences of male circumcision and highlight the penile prepuce, the poorly understood and much controversial part of the human body.Methods: Databases of Pubmed, Science Direct, Springer Link, Wiley Interscience and others were searched. The research papers were studied and discussed. Finally, the opinion of the authors was recorded.Results: Male circumcision is a legacy of the human civilization, originating in Egypt. It confers many prophylactic benefits for the recipient and his female partner. The benefits include protection against urinary tract infections, sexually transmitted diseases including HIV, penile and prostate cancer and cervical cancer in the female partner. At the same time, it is a simple and safe procedure, having minimal risks. The removed prepuce is not a vestigial but an important and unique structure, being used in repair of the common malformations of the penile urethra. Conclusion: Benefits of circumcision vastly outweigh its potential risks. Newborns with penile anomalies are best treated by deferring the procedure until the defect can be corrected using prepuce at few months of age.
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