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Can Routine Neonatal Circumcision Help Prevent Human Immunodeficiency Virus Transmission in the United States?

  • SGGU Godhra Gujarat India


Primary prevention of human immunodeficiency virus (HIV) continues to pose an important challenge in the United States. Recent clinical trials conducted in Kenya, South Africa, and Uganda have demonstrated considerable benefit of male circumcision in reducing HIV seroincidence in males. These results have ignited debate over the appropriateness of implementing routine provision of neonatal circumcision in the United States for HIV prevention. This article discusses major contextual differences between the United States and the three African countries where the clinical trials were conducted, and cautions that the applicability of the scientific data from Africa to this country must be carefully considered before rational policy recommendations regarding routine neonatal circumcision can be made as a strategy to prevent the spread of HIV in the United States.
American Journal of Men's Health
The online version of this article can be found at:
DOI: 10.1177/1557988308323616
2009 3: 79 originally published online 23 September 2008Am J Mens Health
Xiao Xu, Divya A. Patel, Vanessa K. Dalton, Mark D. Pearlman and Timothy R. B. Johnson
the United States?
Can Routine Neonatal Circumcision Help Prevent Human Immunodeficiency Virus Transmission in
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routine provision of neonatal circumcision in the
United States for HIV prevention (McNeil, 2007).
Evidence on Male Circumcision as a
Preventive Strategy and Implications for
the United States
Until these recent clinical trials, there have been no
randomized studies assessing male circumcision as a
preventive strategy for heterosexual acquisition of
HIV in men (Siegfried et al., 2003). A systematic
review assessing the role of male circumcision in pre-
venting heterosexual acquisition of HIV in men using
evidence from 37 observational studies published in
or before 2004 reported that many studies failed to
control for confounding factors, such as genital ulcer
disease, co-occurring sexually transmitted infections
(STIs), unsafe medical practices, viral load, religion,
culture, socioeconomic status, condom use, migra-
tion status, age, and study location (Siegfried et al.,
2005). Because the vast majority of these 37 studies
were conducted in Africa and Asia, we have a limited
understanding of the effects of male circumcision on
HIV prevention in the United States.
rimary prevention of human immunodefi-
ciency virus (HIV) continues to pose an
important challenge in the United States. An
estimated 1.0 to 1.2 million Americans are living
with HIV (Glynn & Rhodes, 2005) and 40,000 new
infections occur each year (Centers for Disease
Control and Prevention, 2006a). Despite recent
advances in HIV/AIDS treatment, including highly
active antiretroviral therapy (HAART), HIV remains
an incurable condition (Hamers & Downs, 2004). In
2006, 14,627 Americans died of AIDS (Centers for
Disease Control and Prevention, 2008).
Recent clinical trials conducted in Kenya, South
Africa, and Uganda have demonstrated considerable
benefit of male circumcision in reducing HIV
seroincidence in males (51% to 60% reduction in
the relative risk; Auvert et al., 2005; Bailey et al.,
2007; Gray et al., 2007). These results have ignited
debate over the appropriateness of implementing
Can Routine Neonatal Circumcision
Help Prevent Human Immunodeficiency
Virus Transmission in the United States?
Xiao Xu, PhD, Divya A. Patel, PhD, MPH, Vanessa K. Dalton, MD, MPH,
Mark D. Pearlman, MD, and Timothy R. B. Johnson, MD
Primary prevention of human immunodeficiency virus
(HIV) continues to pose an important challenge in the
United States. Recent clinical trials conducted in
Kenya, South Africa, and Uganda have demonstrated
considerable benefit of male circumcision in reducing
HIV seroincidence in males. These results have ignited
debate over the appropriateness of implementing rou-
tine provision of neonatal circumcision in the United
States for HIV prevention. This article discusses major
contextual differences between the United States and
the three African countries where the clinical trials
were conducted, and cautions that the applicability of
the scientific data from Africa to this country must be
carefully considered before rational policy recommen-
dations regarding routine neonatal circumcision can
be made as a strategy to prevent the spread of HIV in
the United States.
Keywords: human immunodeficiency virus; neonatal
circumcision; prevention
From the Department of Obstetrics and Gynecology, University
of Michigan, Ann Arbor, Michigan.
Address correspondence to Xiao Xu, PhD, Department of
Obstetrics and Gynecology, University of Michigan, L4000
Women’s Hospital, 1500 East Medical Center Drive, Ann Arbor,
MI 48109; e-mail:
American Journal of
Men’s Health
Volume 3 Number 1
March 2009 79-84
© 2009 Sage Publications
hosted at
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Furthermore, though several studies have been
conducted, the cost-effectiveness of routine neona-
tal circumcision has not yet been established for the
U.S. setting. Research by Lawler, Bisonni, and
Holtgrave (1991) and Ganiats, Humphrey, Taras, and
Kaplan (1991) in the early 1990s found minimal dif-
ferences in lifetime cost and utility between circum-
cised and uncircumcised newborns (without
considering the spread of STI). By incorporating
data on additional medical sequelae, as they became
available, particularly the transmission of HIV and
STI, Van Howe (2004) conducted the most recent
cost-effectiveness analysis in the U.S. setting. The
study demonstrated that over the lifetime, neonatal
circumcision is associated with $828 incremental
costs and a 0.0153 reduction in quality adjusted life
years (QALYs) for each neonate. Poor quality data
were identified as the “greatest handicap in the
development” of these cost-effectiveness analyses
(Van Howe, 2004). Notably, this analysis preceded
the recent clinical trials conducted in Kenya, South
Africa, and Uganda.
These clinical trials have methodological advan-
tages over most previous studies, and hence provide
better quality data. Beyond using the randomized
controlled study design, the clinical trial in Kenya
adjusted for baseline variables that were slightly
imbalanced between the two study groups (despite
randomization; Bailey et al., 2007) and the Ugandan
trial adjusted for postulated potential confounders
identified in previous studies, including baseline age,
marital status, and sexual risk behaviors (Gray et al.,
2007). Still, caution should be taken in adopting
these data in any rigorous evaluations of a policy for
routine provision of neonatal circumcision to prevent
HIV in the United States because of major contextual
differences between the United States and Africa.
Major Contextual Differences Between
the United States and Africa
Several factors differ between these two distinct
regions, such as age at circumcision, dominant mode
of HIV transmission, biological factors, HIV trans-
mission dynamics, and health care system factors.
Adult Versus Neonatal Circumcision
In the United States, the majority of adult men are
already circumcised (Xu, Markowitz, Sternberg, & Aral,
2007); male circumcision is generally practiced at
birth. National Hospital Discharge Survey data indi-
cate that the overall rate of neonatal circumcision
has remained near 65% since data collection began
in 1979, and that 56% newborn males born in U.S.
hospitals were circumcised in 2003 (Child Trends
DataBank, 2004). In contrast, the minimum age of
enrollees in the recent clinical trials in Kenya, South
Africa, and Uganda was 15 years. This major differ-
ence in age at circumcision precludes direct com-
parison of the effectiveness of circumcision between
the two geographic regions. Assessment of the effec-
tiveness of a prevention intervention initiated at
birth entails parameters beyond age at circumcision.
In particular, 39.3% of ninth grade male students in
the U.S. have had sexual intercourse and 8.8% of
male students have their first sexual intercourse
before age 13 (Centers for Disease Control and
Prevention, 2006b). Because in the United States
circumcision is generally performed at birth, sexual
exposures during young adolescent age must be con-
sidered when evaluating the effects of circumcision
on HIV prevention in the United States.
Dominant Modes of HIV Transmission
In the United States, the most common mode of
transmission for HIV infection was penile-anal sex-
ual contact, accounting for about 49% of all
reported HIV or AIDS cases diagnosed in 2006
(Centers for Disease Control and Prevention, 2008).
This is followed by high-risk heterosexual contact
and use of nonsterile drug injecting equipment,
accounting for 33% and 13% of the reported
HIV/AIDS cases diagnosed in 2006, respectively
(Centers for Disease Control and Prevention, 2008).
These patterns differ from the population in which
the three randomized trials in Kenya, South Africa,
and Uganda were conducted where heterosexual
transmission of the HIV was the predominant mode
(Chen et al., 2007; Kahn, Marseille, & Auvert,
2006). Because the African clinical trials focused on
the risk of heterosexual HIV transmission from
females to males, the potential impact of male cir-
cumcision on reducing HIV infection associated
with other modes of transmission, such as male-
to-male and injection drug use transmission, remains
largely unknown (National Institute of Allergy and
Infectious Diseases, 2006). A recent systematic
review identified only two studies of male circumci-
sion in relation to the risk of male-to-male HIV
80 American Journal of Men’s Health / Vol. 3, No. 1, March 2009
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transmission (Fankem, Wiysonge, & Hankins, 2007).
The authors of the review cautioned against any
conclusions regarding the biological effect of male
circumcision on HIV transmission in the male-to-
male population because of the potential for unmea-
sured confounding factors in these two observational
In addition, 27% of American adults and adoles-
cents living with HIV/AIDS in 2006 were women
(Centers for Disease Control and Prevention, 2008).
Of them, 73% were infected during high-risk het-
erosexual contact (Centers for Disease Control and
Prevention, 2008). Moreover, 92% of HIV/AIDS
cases in children (<13 years) were attributable to
vertical transmission from mother (Centers for Disease
Control and Prevention, 2008). The Kenyan, South
African, and Ugandan trials primarily examined HIV
acquisition among circumcised versus noncircum-
cised males; hence the impact of circumcision on
reduction in male-to-female transmission is unknown
to date (Auvert et al., 2005; National Institute of
Allergy and Infectious Diseases, 2006). To fully
assess the benefit of any HIV prevention strategy, it
is essential to consider the effect among both men
and women.
Biological Factors
and Transmission Dynamics
HIV acquisition and transmission are associated
with several biologic factors including seropreva-
lence, viral load, co-occurring STI, stage of disease,
duration of infectiousness, genetic haplotype, viral
subtype, and levels of mucosal immune response
(Aral & Holmes, 1999; Quinn, 2006), several of
which differ significantly between the United States
and Africa. For instance, the prevalence of HIV
infection among adults and adolescents in the
United States was estimated at 0.14% at the end of
2005 in the 37 areas with confidential name-based
HIV infection reporting (Centers for Disease
Control and Prevention, 2006a). In contrast, HIV
prevalence in the countries in which the circumci-
sion trials were conducted range from an estimated
6.2% to 7% in Uganda and Kenya to nearly 25% in
South Africa (Joint United Nations Programme on
HIV/AIDS [UNAIDS], 2006). Applying the number
needed to treat concept (Laupacis et al., 1988), the
markedly different prevalence of HIV infection in
the United States raises considerable questions about
the number of procedures necessary to prevent a
single case of HIV transmission compared with
Africa. The number of males needed to be circum-
cised to prevent one new HIV infection could be
substantial in the United States. This raises the
potentially controversial issue of recommending
widespread prevention, when only a small targeted
group might benefit. Moreover, this makes the cost-
effectiveness of male circumcision less promising in
the United States than in African countries.
The transmission dynamics of HIV are also
influenced by the phase of the epidemic, population
prevalence, transmission probability, and specific
characteristics of transmission networks (e.g., sexual
mixing, partner concurrency). The presence of co-
occurring STIs, such as gonorrhea, chlamydia, her-
pes simplex virus, or syphilis, also increases the risk
of HIV transmission during unprotected sexual con-
tact between an infected and uninfected partner
(Cameron et al., 1989). Between- and within-
country differences in patterns of sexual behavior,
including age at sexual initiation, current and life-
time number of sex partners, frequency and consis-
tency of sexual activity, mode of recruitment of sex
partners, and duration of sexual partnerships (Aral
& Holmes, 1999) have important implications for
HIV prevention strategies. For example, studies
show that the higher likelihood of having more than
one long-term sexual partner at a time among
Ugandan men than men in Thailand and the United
States has contributed to the more generalized spread
of HIV in Uganda (Morris, 2002). Five percent of
the study participants in the Kenyan circumcision
trial had Chlamydia trachomatis (Bailey et al., 2007),
whereas in the United States the rate of chlamydial
infection was 348 per 100,000 population in 2006
(Centers for Diseases Control and Prevention,
2007). Moreover, 34% of the participants in the
Ugandan trial had two or more sexual partners in the
past 12 months (Gray et al., 2007) and 42% of
the participants in the Kenyan circumcision trial
had at least two partners in the previous 6 months
(Bailey et al., 2007). This compares with 19.5% of
American males aged 15 to 44 years who had two
or more sexual partner in the past 12 months (U.S.
Census Bureau, 2008). Regional differences in
these factors must be considered.
Health Care System
Fundamental differences between health care sys-
tems in the United States and Africa could influence
Neonatal Circumcision and HIV Prevention / Xu et al. 81
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the rates of HIV transmission, as well as the cost-
effectiveness of HIV prevention interventions. There
is better public health infrastructure and access to
clinical, laboratory, and pharmacy in the United
States, which could lead to early detection and treat-
ment of HIV-infected patients and patients with
other STIs. Moreover, utilization rates of advanced
medical technologies are higher among patients in
the United States, particularly with regard to
HAART therapy. Seventy percent of HIV-infected
Americans receive antiretroviral therapy (UNAIDS,
2007), while in sub-Saharan Africa, it is estimated
that less than one quarter (23%) of those in need of
antiretroviral treatment are receiving it (UNAIDS,
2006). Use of HAART could substantially lower
viral load and shorten the level and duration of
In addition, infection control in the health care
setting varies across countries. The transmission
probabilities for contaminated medical injections and
contaminated blood products have been estimated at
0.45% and 92.5%, respectively (Baggaley, Boily,
White, & Alary, 2006). Thus, differences between
countries in the exposure to blood-borne pathogens in
the health care setting also affect the probability of
infection among susceptible individuals (Hu, Kane, &
Heymann, 1991). It was estimated that 6% of HIV
infections in Africa was due to blood transfusions and
1.6% was due to contaminated medical injections and
other health care procedures (Chin, Sato, & Mann,
1990; Gisselquist, Potterat, Brody, & Vachon, 2003).
More recent data suggest that unsafe health care
exposures in sub-Saharan Africa might have played an
even larger role in the spread of HIV (Deuchert &
Brody, 2006; Gisselquist et al., 2003). In contrast, the
risk of transfusion-transmitted HIV infection is
extremely low in the United States (1 in 677,000
units; Glynn et al., 2000; Kleinman, Busch, Korelitz,
& Schreiber, 1997).
Finally, as an incurable condition, HIV/AIDS
requires costly lifelong treatment (Hamers & Downs,
2004). Differences in the cost of medical care between
countries could significantly influence the cost-
effectiveness of an HIV prevention intervention. The
per capita health expenditure in the United States
was $6,096 in 2004 compared with $748, $135, and
$86 in South Africa, Uganda, and Kenya, respec-
tively (United Nations Development Programme,
2007). An intervention found to be cost-effective in
one country may not prove to be cost-effective in
another because of such wide differences in cost of
care. Caution needs to be taken when translating
HIV-prevention strategies across countries.
Future Directions and
Emphasis for Research
Encouraging data from the recent clinical trials in
Kenya, South Africa, and Uganda have raised the
question regarding the implications for HIV preven-
tion in the United States. However, acceptability of
routine neonatal circumcision in the United States
is an issue at the intersection of medicine, public
health, religion, culture, ethics, law, and human
rights. Before neonatal circumcision can be recom-
mended as a strategy to prevent the spread of HIV in
the United States, the applicability of the clinical
trial data from Kenya, South Africa, and Uganda to
this country must be carefully considered.
Assessment of the impact of male circumcision
in the United States must consider exposures occur-
ring during adolescence (because in the United
States, circumcision is generally performed at birth),
differences in factors influencing HIV transmission
dynamics, including the heterogeneity in HIV preva-
lence, as well as differences in other biological and
behavioral factors that affect transmission. In addition,
despite the widely recognized burden of HIV-/AIDS-
related diseases, resources available to combat the
epidemic are limited (Marseille et al., 2002).
Comprehensive cost-effectiveness analysis consider-
ing the various elements of HIV transmission in the
context of the United States will be instrumental in
elucidating the potential cost, benefit, and risks of
HIV-prevention strategies.
Clearly, more research addressing the following
questions would greatly inform the discussion
regarding the utility of routine neonatal circumci-
sion in HIV prevention in the United States: What
is the effect on HIV transmission when circumcision
is performed at birth? What is the effect on HIV pre-
vention specifically in the context of the U.S. epi-
demic (particularly seroprevalence and predominant
mode of transmission)? What is the magnitude of
the impact of circumcision on reduction in male-
to-female transmission? Whether it is cost-effective
to perform routine neonatal circumcision in pre-
venting HIV transmission in the U.S. setting? These
important questions must be answered before
rational policy recommendations regarding neonatal
circumcision can be made.
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DAP is supported by a grant from the National
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... There are several factors, which have to be considered when adopting findings from recent evidence as a basis for recommendation of neonatal circumcision in more developed countries [82][83][84][85][86][87]. The large sample size, magnitude of the effect, consistent results across the 3 trials and meta-analyses, and sound statistical methods to address ...
... Only a small proportion of HIV transmission is due heterosexual activity and men who have sex with men is a group not protected by MC. 3. Variations in sexual practices and behavior (including condom usage), and differences in STI prevalence will also alter the protective effects of MC. 4. Access to health care and earlier detection and treatment for HIV infected males and HPV vaccination programs may also modify the observed protective effects. 5. Ethical considerations of parental consent and racial/ethnic acceptability further complicate the issue when implementing universal circumcision programs. 6. Cost benefit analysis compared to alternative preventive strategies, should be considered and studied in a Canadian context to allow generation of a clear recommendation [87]. 7. The trials were all conducted in sexually active adult men from HIV endemic areas in Africa who were motivated and interested in a free circumcision. ...
... Before effective interventions to promote MC can be introduced on a national scale in traditionally non-circumcising European regions, thorough studies need to be conducted. MC rates and its cost-effectiveness need to be analyzed in order to determine whether the policy of promoting and providing inexpensive access to voluntary circumcision for adult men would indeed result in lower overall societal healthcare costs [14]. Of note, in Poland, MC performed for non-medical reasons has to be covered by the patient and costs on average, around 260-400 USD. ...
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Objective : To evaluate the beliefs of medical university students regarding male circumcision (MC), as well as attitudes and the predictors of its promotion in the case of adults at risk of HIV.Methods:A cross-sectional survey was conducted between 2013-2016 at the Medical University in Szczecin, Poland, among final year Polish/foreign students from Northern Europe, using a standardized questionnaire.Results:There were 539 participants, median age 25 years, 40.8% males, and 66.8% were Polish nationals. The MC rate was 16.7%. Regarding HIV/AIDS knowledge, 66.6% of the students scored more than 75%; and, 34.2% knew that MC reduces the risk of HIV infection. One in eleven respondents (9.1%) believed that circumcised men felt more intense sexual pleasure. More than half of the respondents (54.8%) declared that they would recommend MC to adult patients at risk for HIV. The belief that circumcised men felt more intense sexual pleasure, and knowledge on MC regarding HIV risk reduction was associated with greater odds of recommending adult MC (OR = 3.35 and OR = 2.13, respectively).Conclusions: Poor knowledge of its benefits and a low willingness to promote the procedure-strongly dependent on personal beliefs-suggest that medical students may need additional training to help them to discuss MC more openly with adult men at risk for HIV infection. Knowledge may be an effective tool when making decisions regarding MC promotion.
... They also point out that campaigners encourage the mutilation of the male body without sufficient reliable scientific evidence (Boyle et al. 2002; Goldman 1997). Most recent controversies centre on two main issues: public health implications of scaling-up adult male circumcision due to the 'conclusive evidence that male circumcision offers significant protection for men from HIV infection' (Weiss et al. 2008) and the relevance of enforcing routine neonatal and child circumcision (Xu et al. 2009, 79) as a 'longer-term HIV prevention strategy' (UNAIDS 2010, 5–6). Despite the American Academy of Paediatrics having newly released guidelines on the health benefits of infant circumcision, 'especially with regard to a decrease in risk of acquiring a sexually transmitted infection' (The Lancet 2012), the procedure has not been universally recommended . ...
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In-depth repeat interviews with 14 male Japanese urologists and plastic surgeons are analysed to shed light on male circumcision: a procedure largely conducted at beauty clinics to deal with gender and sexual matters. The urologists strongly oppose male circumcision because it is a surgery promoted by plastic surgeons without any prophylactic benefit and which works only as a placebo. This suggests a critical public health matter within current international debates on adult and paediatric male circumcision. Urologists encourage the practice of the ‘informed parent’ to challenge male circumcision and promote penile hygiene. Plastic surgeons, in comparison, argue that male circumcision can be effectively used to deal with issues concerning male’s self-confidence, erectile dysfunction and premature ejaculation. Despite urologist and plastic surgeons exhibiting clear divergent positions, their viewpoint converge on the sexual script that sexuality arises from the genitals and the master narrative that the penis is central in the construction of masculinity.
... 6,7 Presumed effectiveness of circumcision in HIV and sexually transmitted diseases has also been questioned. 8 Therefore, early surgical intervention in the absence of any symptoms might be unwarranted. The authors found an increased incidence of pain while using the device as compared with the standard open surgical technique. ...
... Within these controversies, neonatal and child circumcision has been considered as a 'longer-term HIV prevention strategy' because 'circumcising males at a younger versus older age' means a 'lower risk of complications, faster healing and lower costs' (UNAIDS 2010, 5–6). This has triggered 'debates over the appropriateness of implementing routine provision of neonatal circumcision' (Xu et al. 2009, 79). Nevertheless, further paediatric male-circumcision studies are required 'to ensure that the procedure is conducted as safely as possible where it is routinely undertaken for religious or cultural reasons' (UNAIDS 2010, 5–6). ...
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This paper analyses the views of 20 Japanese mothers concerning paediatric male circumcision and penile hygiene. In Japan, routine male circumcision has never been implemented for newborns and children, and adult males are mostly circumcised at aesthetic clinics. However, media reports indicate a trend of Japanese mothers willing to have their sons circumcised. In discussing penile hygiene and male circumcision, the construct of a 'sexual script' becomes relevant to understanding how linguistic and gender barriers made references to male genitalia and penile hygiene largely appear as 'vulgar' and 'unfeminine' in daily life conversations. Peers were often identified as the main source of information and only mothers who have struggled with their children's penile infections have learnt about male genital hygiene, a domain of knowledge largely transmitted by men. Male circumcision becomes a double-edged sword that could help prevent penile infections but also an embarrassing conversational topic that could elicit discrimination because most Japanese children are uncircumcised.
Circumcision is not a mild, neutral medical intervention like a vaccination, but a culturally-loaded amputation of a highly significant and functionally valuable body part that the medical profession should be working to protect against pathological conditions. Instead, a small, vocal, influential group is calling for universal amputation of the foreskin, comparing it to a vaccination. While the average adult is willing to get himself vaccinated against diseases, the vast majority of adult males are not willing to get circumcised. Falling rates of circumcision in the United States may have prompted a surge in circumcision promotion. Demonstrating a circumcision benefit in the United States has been disappointing, so the research moved to Africa, where the latest health crisis, the AIDS epidemic, was at its zenith. Armed with a few studies performed by a handful of investigators, circumcision proponents (CPs) are saturating the medical literature with their opinions and calling on national medical organization to recommend universal infant male circumcision. Policies and recommendations should be evidence-based rather than relying on opinion pieces with selective bibliographies and a narrowly focused perspective (Schoen 2006; Flynn et al. 2007; Dickerman 2007; Morris 2007a; Weiss et al. 2008; Morris et al. 2006; Golden and Wasserheit 2009; Rennie et al. 2007; Gostin and Hankins 2008; Clark et al. 2007; Morris 2007b; Morris 2008; Sawires et al. 2007; Newell and Bärnighausen 2007a; Sullivan et al. 2007; Brusa and Barilan 2008; Katz and Wright 2008; Potts et al. 2006). The purpose of this chapter is to address the issues that the CPs have failed to mention, such as bioethics, human rights, the function of the foreskin, and conflicting information, to present the information their bibliographies selected out, and to itemize the barriers to making a convincing case for universal circumcision.
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The role of circumcision in preventing STIs. • Male circumcision affords substantial protection against genital ulcer disease (GUD), human immunodeficiency virus (HIV), high-risk types of human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), Treponema pallidum (syphilis), Haemophilus ducreyi (chancroid), Trichomonas vaginalis and Candida albicans (thrush). • It offers little or no protection against Neisseria gonorrhoea, Chlamydia trachomatis and non-specific urethritis. • In the female sexual partner, circumcision of the male partner is associated with greatly reduced HPV, Chlamydia, HSV-2, Trichomonas, and bacterial vaginosis. • At the population level, increased rate of male circumcision should reduce heterosexually-acquired HIV/AIDS, as well as genital HPV, penile and cervical cancer, prostate cancer, genital herpes, infertility in each sex, pelvic inflammatory disease, and ectopic pregnancy. • Male circumcision is an important component of strategies to reduce the global burden of many STIs.
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To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection. These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues. Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random-controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a 'surgical vaccine' is criticised as polemical and unscientific. Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.
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The US blood supply is the safest it has ever been due to a combination of donor education, donor screening, and new laboratory test procedures. Risks of transfusion- transmitted viral infections are extremely low 1-3: estimated to be I in 677,000 units for human immunodeficiency virus (HIV); 3 I in 641,000 for human T-lymphotropic virus (HTLV); 1 I in 103,000 for hepatitis C virus (HCV); 1 and I in 63,000 for hepatitis B virus (HBV). 1 Blood centers have implemented education programs and screening procedures aimed at reducing risk of transfusion-transmitted viral infections 4 and efforts are under way to improve behavioral screening of donors. Most infectious units are believed to be from donors who donate in the window period, the time between infection and detectability by screening tests. Thus, there has also been continuous effort to develop more sensitive and specific screening tests as exemplified by the introduction of HCV enzyme immunoassay (EIA) 2.0 in 1992, implementation of HIV- I p24 antigen screening and HCV EIA 3.0 in 1996, and introduction of HCV nucleic acid amplification testing in April
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Recent reports of the transmission of human immunodeficiency virus (HIV) in health care settings have caused considerable public health concern. HIV as well as hepatitis B virus (HBV) and other bloodborne pathogens do constitute infectious hazards in certain settings. Transmission has been reported from patient to patient, patient to health care workers, and rarely, from health care worker to patient. Although the risk of bloodborne pathogen transmission is largely preventable, it may occur due to the use of infected blood for transfusion, the use of improperly sterilized medical or dental equipment, and accidental punctures with contaminated instruments. The risk of transmission of bloodborne pathogens is dependent on a number of factors and appears to be greater for HBV than for HIV. General guidelines for the prevention of transmission in health care settings are given, including the concept of "universal precautions", the need for adequate supplies of sterile equipment, the reduction of unnecessary injections and transfusions, and the appropriate use of hepatitis B vaccine. In addition, areas for research are highlighted that could improve understanding of transmission risks in different health situations and provide the information necessary to develop more effective measures to protect both care providers and patients.
This Cochrane systematic review assesses the evidence for an interventional effect of male circumcision in preventing acquisition of HIV-1 and HIV-2 by men through heterosexual intercourse. The review includes a comprehensive assessment of the quality of all 37 included observational studies. Studies in high-risk populations consisted of four cohort studies, 12 cross-sectional studies, and three case-control studies; general population studies consisted of one cohort study, 16 cross-sectional studies, and one case-control study. There is evidence of methodological heterogeneity between studies, and statistical heterogeneity was highly significant for both general population cross-sectional studies (χ²=132.34; degrees of freedom [df]=15; p<0.00001) and high-risk cross-sectional studies (χ²=29.70; df=10; p=0.001). Study quality was very variable and no studies measured the same set of potential confounding variables. Therefore, conducting a meta-analysis was inappropriate. Detailed quality assessment of observational studies can provide a useful visual aid to interpreting findings. Although most studies show an association between male circumcision and prevention of HIV, these results may be limited by confounding, which is unlikely to be adjusted for.
As is the case for most other infectious diseases, sexually transmitted diseases (STD) are common in many parts of the developing world. This may have multiple causes, such as a larger pool of infected individuals, lack of control programs, antimicrobial resistance of causative organisms, poor health care facilities in general, poor health-seeking behavior, and socioeconomic factors [1]. Table 24.1 shows infection rates of various sexually transmitted agents in pregnant women.
From population based studies and couple studies, the probability of HIV transmission and acquisition has been associated with the blood and genital viral load, male circumcision, STDs, stage of disease, genetic haplotype, viral subtype, and levels of mucosal immune response. This presentation will review the relationship between male circumcision and HIV transmission and discuss policy implications in promoting circumcision as a prevention modality. A systematic meta-analysis of 38 studies, mostly in Africa, found that circumcised men appear to have a 50% or more reduction in HIV infection as uncircumcised men. A sub-analysis of 16 of these studies found a 70% reduction in HIV infection among higher-risk men. Mapping of the HIV epidemic has demonstrated a strong correlation between regions with higher rates of HIV infection and those with lower circumcision rates. A two-year cohort study of male partners of HIV-positive women in Rakai, Uganda, found that 40 of 137 uncircumcised men became infected compared to 0 of 50 circumcised men over 2.1 years(p = 0.0004). Biological explanations include greater ability of the internal foreskin to absorb HIV more efficiently due to the greater presence of Langerhans and other HIV target cells and its greater susceptibility to tears, abrasions, and consequently infection by STDs and HIV. One RCT in South Africa demonstrated that circumcision afforded a 61% (95% CI: 34%–77%) reduction in HIV incidence even after controlling for behavioral factors (Auvert et al., PLoS Medicine 2005;298). Two other RCT trials of male circumcision in Uganda and Kenya are in progress. In summary, these epidemiologic, biological, and clinical trial results provide very strong evidence that male circumcision significantly lowers the risk of HIV acquisition. Mathematical models of implementing male circumcision in countries with high incident rates suggest marked reductions in HIV incidence in men with subsequent decreased transmission rates to women. Policy implications of recommending male circumcision to populations in high-risk countries need to take into consideration cultural norms, religious traditions, national and local laws. Circumcision may represent one important biological intervention to decreasing the acquisition of HIV, but will need to be carefully integrated into other HIV prevention and STD control programs in order to prevent subsequent behavioral disinhibition" among circumcised men.
Male circumcision is defined as the surgical removal of all or part of the foreskin of the penis and may be practiced as part of a religious ritual, as a medical procedure, or as part of a traditional ritual performed as an initiation into manhood. Since the 1980s, over 30 observational studies have suggested a protective effect of male circumcision on HIV acquisition in heterosexual men. In 2002, three randomised controlled trials to assess the efficacy of male circumcision for preventing HIV acquisition in men commenced in Africa. This review evaluates the results of these trials, which analysed the effectiveness and safety of male circumcision for preventing acquisition of HIV in heterosexual men. To assess the evidence of an interventional effect of male circumcision for preventing acquisition of HIV-1 and HIV-2 by men through heterosexual intercourse We formulated a comprehensive and exhaustive search strategy in an attempt to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress). In June 2007 we searched the following electronic journal and trial databases: MEDLINE, EMBASE, and CENTRAL. We also searched the electronic conference databases NLM Gateway and AIDSearch and the trials registers and Current Controlled Trials. We contacted researchers and relevant organizations and checked reference lists of all included studies. Randomised controlled trials of male circumcision versus no circumcision in HIV-negative heterosexual men with HIV incidence as the primary outcome. Two review authors independently assessed study eligibility, extracted data, and graded methodological quality. Data extraction and methodological quality were checked by a third author who resolved differences when these arose. Data were considered clinically homogeneous and meta-analyses and sensitivity analyses were performed. Three large RCTs of men from the general population were conducted in South Africa (N = 3 274), Uganda (N = 4 996) and Kenya (N = 2 784) between 2002 and 2006. All three trials were stopped early due to significant findings at interim analyses. We combined the survival estimates for all three trials at 12 months and also at 21 or 24 months in a meta-analysis using available case analyses using the random effects model. The resultant incidence risk ratio (IRR) was 0.50 at 12 months with a 95% confidence interval (CI) of 0.34 to 0.72; and 0.46 at 21 or 24 months (95% CI: 0.34 to 0.62). These IRRs can be interpreted as a relative risk reduction of acquiring HIV of 50% at 12 months and 54% at 21 or 24 months following circumcision. There was little statistical heterogeneity between the trial results (chi(2) = 0.60; df = 2; p = 0.74 and chi(2) = 0.31; df = 2; p = 0.86) with the degree of heterogeneity quantified by the I(2) at 0% in both analyses. We investigated the sensitivity of the calculated IRRs and conducted meta-analyses of the reported IRRs, the reported per protocol IRRs, and reported full intention-to-treat analysis. The results obtained did not differ markedly from the available case meta-analysis, with circumcision displaying significant protective effects across all analyses.We conducted a meta-analysis of the secondary outcomes measuring sexual behaviour for the Kenyan and Ugandan trials and found no significant differences between circumcised and uncircumcised men. For the South African trial the mean number of sexual contacts at the 12-month visit was 5.9 in the circumcision group versus 5 in the control group, which was a statistically significant difference (p < 0.001). This difference remained statistically significant at the 21-month visit (7.5 versus 6.4; p = 0.0015). No other significant differences were observed.Incidence of adverse events following the surgical circumcision procedure was low in all three trials.Reporting of methodological quality was variable across the three trials, but overall, the potential for significant biases affecting the trial results was judged to be low to moderate given the large sample sizes of the trials, the balance of possible confounding variables across randomised groups at baseline in all three trials, and the employment of acceptable statistical early stopping rules. There is strong evidence that medical male circumcision reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months. Incidence of adverse events is very low, indicating that male circumcision, when conducted under these conditions, is a safe procedure. Inclusion of male circumcision into current HIV prevention measures guidelines is warranted, with further research required to assess the feasibility, desirability, and cost-effectiveness of implementing the procedure within local contexts.
A cost-utility analysis was performed to evaluate the relative importance of each of the various elements in the current circumcision debate. Elements used in the analysis included the cost of the procedure, the pain associated with the procedure, the risk of urinary tract infections, and the risk of penile cancer. The net, discounted lifetime dollar cost of routine circumcision is $102 per person, while the net, discounted lifetime health cost is 14 hours of healthy life. These results suggest that the financial and medical advantages and disadvantages of routine neonatal circumcision cancel each other and that factors other than cost or health outcomes must be used in decision making.
Routine neonatal circumcision has long been controversial. Presented here is a cost-effectiveness analysis of the consequences of the treatment choices (circumcision versus no circumcision) using a decision tree model. For a simulated 85-year life expectancy, routine neonatal circumcision had an expected lifetime cost of $164.61 per patient circumcised and a quality-adjusted survival of 84.999 years. Conversely, for the noncircumcision approach, the expected average lifetime cost was $139.26 per patient, and the quality-adjusted survival was 84.971 years. The net cost-effectiveness ($919.87 per quality-adjusted life year) is within the range usually considered worthwhile for public health policy. However, because of the minor differences in lifetime cost ($25) and benefit (10 days of life) for an individual and the tenuous values available for disease incidence and surgical risk, we conclude that there is no medical indication for or against circumcision. Additional analyses suggested that reported benefits in preventing penile cancer and infant urinary tract infections are insignificant compared to the surgical risks of post neonatal circumcision. The decision regarding circumcision may most reasonably be made on nonmedical factors such as parent preference or religious convictions.