Wawer, M. J. et al. Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda. Lancet 377, 209-218

Department of Population, Family, and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21287, USA.
The Lancet (Impact Factor: 45.22). 01/2011; 377(9761):209-18. DOI: 10.1016/S0140-6736(10)61967-8
Source: PubMed

ABSTRACT Randomised trials show that male circumcision reduces the prevalence and incidence of high-risk human papillomavirus (HPV) infection in men. We assessed the efficacy of male circumcision to reduce prevalence and incidence of high-risk HPV in female partners of circumcised men.
In two parallel but independent randomised controlled trials of male circumcision, we enrolled HIV-negative men and their female partners between 2003 and 2006, in Rakai, Uganda. With a computer-generated random number sequence in blocks of 20, men were assigned to undergo circumcision immediately (intervention) or after 24 months (control). HIV-uninfected female partners (648 of men from the intervention group, and 597 of men in the control group) were simultaneously enrolled and provided interview information and self-collected vaginal swabs at baseline, 12 months, and 24 months. Vaginal swabs were tested for high-risk HPV by Roche HPV Linear Array. Female HPV infection was a secondary endpoint of the trials, assessed as the prevalence of high-risk HPV infection 24 months after intervention and the incidence of new infections during the trial. Analysis was by intention-to-treat. An as-treated analysis was also done to account for study-group crossovers. The trials were registered, numbers NCT00425984 and NCT00124878.
During the trial, 18 men in the control group underwent circumcision elsewhere, and 31 in the intervention group did not undergo circumcision. At 24-month follow-up, data were available for 544 women in the intervention group and 488 in the control group; 151 (27·8%) women in the intervention group and 189 (38·7%) in the control group had high-risk HPV infection (prevalence risk ratio=0·72, 95% CI 0·60-0·85, p=0·001). During the trial, incidence of high-risk HPV infection in women was lower in the intervention group than in the control group (20·7 infections vs 26·9 infections per 100 person-years; incidence rate ratio=0·77, 0·63-0·93, p=0·008).
Our findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners. However, protection is only partial; the promotion of safe sex practices is also important.
The Bill & Melinda Gates Foundation, National Institutes of Health, and Fogarty International Center.

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Available from: Patti E Gravitt, Aug 21, 2015
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    • "Condom use and circumcision are only partially protective against HPV transmission as HPV transmission does occur through contact of the skin with the genital mucosa and does not essentially require mucosal contact (Moscicki et al., 2006; Wawer et al., 2011). However, some studies demonstrated that consistent use of condoms by the partners of newly sexually active women may decrease the woman's risk of acquiring cervical and vulvovaginal HPV infections (Winer et al., 2006). "
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    • "Randomised controlled trials conducted in developing countries have documented benefits of male circumcision on rates of sexually transmitted infections and sexual satisfaction (Kigozi et al. 2008; Krieger et al. 2008; Siegfried et al. 2009; Wawer et al. 2011). The risks associated with the procedure are mainly surgical complications and concerns about "
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    ABSTRACT: Male infant circumcision is a controversial and debated topic in both scientific and public discourses in parts of Western Europe. Debates are heated and it is not always entirely clear what is in the best interest of the male infant. In this article, we discuss the importance of returning to core principles of evidence-based, patient-centred care that may help move the discussion away from the current, increasingly polarised positions. According to principles of evidence-based medicine, systematic retrieval and critical appraisal of the best evidence available should be a core consideration in all decisions regarding healthcare policy and practice. Applying this principle to male infant circumcision, we need a careful, dispassionate critique of the evidence in relation to the benefits and risks associated with the procedure and an assessment of the potential health gains and adverse effects of any interventions (such as legislation) that may be introduced. Currently, the more robust evidence-base has tended to focus on biomedical aspects of male infant circumcision and this shows consistent evidence of important benefits of this practice, but also some risks. However, health is multidimensional and when considering male infant circumcision, there is therefore a need to broaden the perspective to also include psycho-social considerations. It is also imperative that those striving to deliver patient-centred care keep the best interests of the patient/family at the heart of their decision-making, promote autonomy and do not inadvertently exceed the fine line between beneficence and medical paternalism.In summary, we argue that a more comprehensive and robust evidence-base is needed to enable evidence-based policy-making and that these uncertainties are communicated to patients/families so they can in the light of this evidence make an informed choice.
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    • "While prophylactic HPV vaccines should reduce cervical cancer incidence and deaths, they do not cover the full spectrum of oncogenic HPV types. In contrast, circumcision partially protects against all oncogenic HPV types (Wawer et al., 2011). Circumcision and vaccination should therefore be seen as synergistic interventions. "
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