Effect of Wuchereria bancrofti infection on HIV incidence in southwest Tanzania: a prospective cohort study

BACKGROUND

The past decades have seen an ongoing controversial debate about whether the immune activation induced by helminths has an effect on the susceptibility of individuals to HIV. In view of this, we assessed the effect of lymphatic filariasis, a chronic helminth disease elicited by Wuchereria bancrofti, on HIV incidence in southwest Tanzania.

METHODS

In this population-based cohort study, we enrolled a geographically stratified randomly chosen sample of about 10% of the households in nine distinct sites in southwest Tanzania. All household members present were followed up and tested for HIV and circulating filarial antigen, an indicator of W bancrofti adult worm burden. Our main outcome of interest was HIV incidence in participants with or without lymphatic filariasis.

FINDINGS

Between May 29, 2006, and June 16, 2011, we enrolled 4283 households with roughly 18 000 participants. Of these, 2699 individuals from Kyela district participated in at least one round of the EMINI study. In the 1055 initially HIV-negative adolescents and adults with clearly defined lymphatic filariasis status, 32 new HIV infections were observed in 2626 person-years. HIV incidence in lymphatic filariasis-positive participants (1·91 cases per 100 person-years) was significantly higher than the incidence in lymphatic filariasis-negative participants (0·80 cases per 100 person-years). The age-adjusted and sex-adjusted incidence rate ratio was 2·17 (95% CI 1·08-4·37, p=0·0300). Lymphatic filariasis status remained an independent and significantly relevant risk factor for HIV infection when controlled for other known risk factors such as sexual behaviour and socioeconomic factors.

INTERPRETATION

To our knowledge, this is the first prospective study demonstrating a significantly increased risk of acquiring HIV for lymphatic filariasis-infected individuals. Immunological studies and interventional treatment studies that eliminate the adult worms and not only the microfilariae are needed to follow up on the results presented.

FUNDING

European Union as part of EuropAid; German Federal Ministry of Education and Research; German Center for Infection Research.

Higher HPV16 and HPV18 Penile Viral Loads Are Associated With Decreased Human Papillomavirus Clearance in Uncircumcised Kenyan Men

BACKGROUND

Whether higher penile human papillomavirus (HPV) viral load is associated with a lower rate of HPV clearance remains unknown.

OBJECTIVES

We examined the association between penile HPV16 and HPV18 viral load and subsequent HPV clearance in uncircumcised Kenyan men.

STUDY DESIGN

Participants were human immunodeficiency virus (HIV)-seronegative, sexually active, 18- to 24-year-old men randomized to the control arm of a male circumcision trial in Kisumu, Kenya. Men provided exfoliated penile cells from two anatomical sites (glans/coronal sulcus and shaft) every 6 months for 2 years. GP5+/6+ polymerase chain reaction was used to identify 44 HPV-DNA types. Human papillomavirus viral load testing was conducted using a LightCyler real-time polymerase chain reaction assay; viral load was classified as high (>250 copies/scrape) or low (≤250 copies/scrape), for nonquantifiable values. The Kaplan-Meier method and Cox regression modeling were used to examine the association between HPV viral load and HPV clearance.

RESULTS

A total of 1097 men, with 291 HPV16 and 131 HPV18 cumulative infections over 24 months were analyzed. Human papillomavirus clearance at 6 months after first HPV detection was lower for high versus low viral load HPV16 infections in the glans (adjusted hazard ratio [aHR], 0.65; 95% confidence interval [CI], 0.46-0.92)] and shaft (aHR, 0.44; 95% CI, 0.16-0.90), and HPV18 infections in the glans (aHR, 0.05; 95% CI, 0.01-0.17).

DISCUSSION

High versus low HPV viral load was associated with a reduced HPV clearance for HPV16 infections in the glans and shaft, and for HPV18 infections in the glans, among young uncircumcised men. Reduced clearance of high viral load HPV16 and HPV18 infections in men may increase HPV transmission to their female partners as well as enhance the development of penile lesions in comparison to men with low viral load HPV infections.

Transient Peripheral Immune Activation follows Elective Sigmoidoscopy or Circumcision in a Cohort Study of MSM at Risk of HIV Infection

BACKGROUND

Rectal and genital sampling in HIV prevention trials permits assessments at the site of HIV entry. Yet the safety and acceptability of circumcision and sigmoidoscopy (and associated abstinence recommendations) are unknown in uncircumcised men who have sex with men (MSM) at high risk of HIV infection.

METHODS

Twenty-nine HIV-seronegative high-risk Peruvian MSM agreed to elective sigmoidoscopy biopsy collections (weeks 2 and 27) and circumcision (week 4) in a 28-week cohort study designed to mimic an HIV vaccine study mucosal collection protocol. We monitored adherence to abstinence recommendations, procedure-related complications, HIV infections, peripheral immune activation, and retention.

RESULTS

Twenty-three (79.3%) underwent a first sigmoidoscopy, 21 (72.4%) were circumcised, and 16 (55.2%) completed a second sigmoidoscopy during the study period. All who underwent procedures completed the associated follow-up safety visits. Those completing the procedures reported they were well tolerated, and complication rates were similar to those reported in the literature. Immune activation was detected during the healing period (1 week post-sigmoidoscopy, 6 weeks post-circumcision), including increases in CCR5+CD4+T cells and α4β7+CD4+T cells. Most participants adhered to post-circumcision abstinence recommendations whereas reduced adherence occurred post-sigmoidoscopy.

CONCLUSION

Rectosigmoid mucosal and genital tissue collections were safe in high-risk MSM. Although the clinical implications of the post-procedure increase in peripheral immune activation markers are unknown, they reinforce the need to provide ongoing risk reduction counseling and support for post-procedure abstinence recommendations. Future HIV vaccine studies should also consider the effects of mucosal and tissue collections on peripheral blood endpoints in trial design and analysis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02630082.

Randomized evaluation and cost-effectiveness of HIV and sexual and reproductive health service referral and linkage models in Zambia

BACKGROUND

Provision of HIV prevention and sexual and reproductive health services in Zambia is largely characterized by discrete service provision with weak client referral and linkage. The literature reveals gaps in the continuity of care for HIV and sexual and reproductive health. This study assessed whether improved service delivery models increased the uptake and cost-effectiveness of HIV and sexual and reproductive health services.

METHODS

Adult clients 18+ years of age accessing family planning (females), HIV testing and counseling (females and males), and male circumcision services (males) were recruited, enrolled and individually randomized to one of three study arms: 1) the standard model of service provision at the entry point (N = 1319); 2) an enhanced counseling and referral to add-on service with follow-up (N = 1323); and 3) the components of study arm two, with the additional offer of an escort (N = 1321). Interviews were conducted with the same clients at baseline, six weeks and six months. Uptake of services for HIV, family planning, male circumcision, and cervical cancer screening at six weeks and six months were the primary endpoints. Pairwise chi-square and multivariable logistic regression statistical tests assessed differences across study arms, which were also assessed for incremental cost-efficiency and cost-effectiveness.

RESULTS

A total of 3963 clients, 1920 males and 2043 females, were enrolled; 82 % of participants at six weeks were tracked and 81 % at six months; follow-up rates did not vary significantly by study arm. The odds of clients accessing HIV testing and counseling, cervical cancer screening services among females, and circumcision services among males varied significantly by study arm at six weeks and six months; less consistent findings were observed for HIV care and treatment. Client uptake of family planning services did not vary significantly by study arm. Integrated services were found to be more efficiently provided than vertical service provision; the cost-effectiveness for HIV/AIDS and cervical cancer was high in the enhanced service models.

CONCLUSIONS

Study results provide evidence for increasing the linkages and integration of a selection of HIV and sexual and reproductive health services. The study provided cost-effective service delivery models that enhanced the likelihood of clients accessing some additional needed health services.

TRIAL REGISTRATION

ISRCTN84228514 Retrospectively registered. The study was retrospectively registered in the ISRCTN clinical trials registry on 06 October 2015. The first recruitment of participants occurred on 17 December 2013.

Association of Medical Male Circumcision and Antiretroviral Therapy Scale-up With Community HIV Incidence in Rakai, Uganda

IMPORTANCE

Medical male circumcision (MMC) and antiretroviral therapy (ART) are proven HIV prevention interventions, but there are limited data on the population-level effect of scale-up of these interventions in sub-Saharan Africa. Such evaluation is important for planning and resource allocation.

OBJECTIVE

To examine whether increasing community MMC and ART coverage was associated with reduced community HIV incidence in Rakai District, Uganda.

DESIGN, SETTING, AND PARTICIPANTS

Using person-level data from population-based surveys conducted from 1999 through 2013 in 45 rural Rakai communities, community-level ART and MMC coverage, sociodemographics, sexual behaviors, and HIV prevalence and incidence were estimated in 3 periods: prior to the availability of ART and MMC (1999-2004), during early availability of ART and MMC (2004-2007), and during mature program scale-up (2007-2013).

EXPOSURES

Community MMC coverage in males and ART coverage in HIV-positive persons of the opposite sex based on self-reported MMC status and ART use.

MAIN OUTCOMES AND MEASURES

Adjusted incidence rate ratios (IRRs) for sex-specific community HIV incidence estimated using multivariable Poisson regression with generalized estimating equations.

RESULTS

From 1999 through 2013, 44,688 persons participated in 1 or more surveys (mean age at the first survey, 24.6 years [range, 15-49]; female, 56.5%; mean survey participation rate, 92.6% [95% CI, 92.4%-92.7%]). Median community MMC coverage increased from 19% to 39%, and median community ART coverage rose from 0% to 21% in males and from 0% to 26% in females. Median community HIV incidence declined from 1.25 to 0.84 per 100 person-years in males, and from 1.25 to 0.99 per 100 person-years in females. Among males, each 10% increase in community MMC coverage was associated with an adjusted IRR of 0.87 (95% CI, 0.82-0.93). Comparing communities with MMC coverage more than 40% (mean male community incidence, 1.03 per 100 person-years) with communities with coverage of 10% or less (mean male incidence, 1.69 per 100 person-years), the adjusted IRR was 0.61 (95% CI, 0.43-0.88). For each 10% increase in female self-reported ART coverage, there was no significant reduction in male HIV incidence (adjusted IRR, 0.95 [95% CI, 0.81-1.13]). Comparing communities with female ART coverage more than 20% (mean male incidence, 0.87 per 100 person-years) to communities with female ART coverage of 20% or less (mean male incidence, 1.17 per 100 person-years), the adjusted IRR was 0.77 (95% CI, 0.61-0.98). Neither MMC nor male ART coverage was associated with lower female community HIV incidence.

CONCLUSIONS AND RELEVANCE

In Rakai, Uganda, increasing community MMC and female ART coverage was associated with lower community HIV incidence in males. If similar associations are found elsewhere, this would support further scale-up of MMC and ART for HIV prevention in sub-Saharan Africa.

Maximising HIV prevention by balancing the opportunities of today with the promises of tomorrow: a modelling study

BACKGROUND

Many ways of preventing HIV infection have been proposed and more are being developed. We sought to construct a strategic approach to HIV prevention that would use limited resources to achieve the greatest possible prevention impact through the use of interventions available today and in the coming years.

METHODS

We developed a deterministic compartmental model of heterosexual HIV transmission in South Africa and formed assumptions about the costs and effects of a range of interventions, encompassing the further scale-up of existing interventions (promoting condom use, male circumcision, early antiretroviral therapy [ART] initiation for all [including increased HIV testing and counselling activities], and oral pre-exposure prophylaxis [PrEP]), the introduction of new interventions in the medium term (offering intravaginal rings, long-acting injectable antiretroviral drugs) and long term (vaccine, broadly neutralising antibodies [bNAbs]). We examined how available resources could be allocated across these interventions to achieve maximum impact, and assessed how this would be affected by the failure of the interventions to be developed or scaled up.

FINDINGS

If all interventions are available, the optimum mix would place great emphasis on the following: scale-up of male circumcision and early ART initiation with outreach testing, as these are available immediately and assumed to be low cost and highly efficacious; intravaginal rings targeted to sex workers; and vaccines, as these can achieve a large effect if scaled up even if imperfectly efficacious. The optimum mix would rely less on longer term developments, such as long-acting antiretroviral drugs and bNAbs, unless the costs of these reduced. However, if impossible to scale up existing interventions to the extent assumed, emphasis on oral PrEP, intravaginal rings, and long-acting antiretroviral drugs would increase. The long-term effect on the epidemic is most affected by scale-up of existing interventions and the successful development of a vaccine.

INTERPRETATION

With current information, a strategic approach in which limited resources are used to maximise prevention impact would focus on strengthening the scale-up of existing interventions, while pursuing a workable vaccine and developing other approaches that can be used if further scale-up of existing interventions is limited.

FUNDING

Bill & Melinda Gates Foundation.

Fatal attraction: sex, sexually transmitted infections and HIV-1

The predominant mode of HIV-1 transmission globally is from sexual practices. The risk of HIV-1 transmission by sexual means is a function of infectivity, susceptibility and mode of transmission (type of sexual practice). In addition, transmission may be enhanced by the presence of sexually transmissible infections (STIs). An understanding of the interplay between sexual practices, STIs and HIV-1 may facilitate the development of effective treatment and prevention strategies. These topics are the subject of this review.

Plasma Cell Balanitis: Clinicopathologic Study of 112 Cases and Treatment Modalities

Background:

Plasma cell balanitis or Zoon's balanitis is an idiopathic benign condition of the genitalia that mostly presents as a solitary, persistent plaque on the glans primarily in uncircumcised, middle-aged to older men.

Methods:

One hundred twelve patients with a clinical diagnosis of plasma cell balanitis were studied between January 1985 and April 2003.

Results:

The age of the patients ranged from 24 to 70 years. The majority of patients had symptoms for more than 12 months. Lesions involved the prepuce and glans in the majority of patients (66; 58.92%), the prepuce only in 26 patients (23.21%), and the glans only in 20 patients (17.85%). Tissue for histopathology was available in 96 patients. Histologically, epidermal edema, a dense upper dermal band of chronic inflammatory cells, including many plasma cells, dilated capillaries, extravasated red blood cells, and hemosiderin deposition, was seen. In most, cases, plasma cell balanitis was successfully treated by circumcision.

Conclusions:

This report describes our experience with plasma cell balanitis and reviews its clinical and histopathologic aspects. The treatment modalities are also reviewed, and the importance of circumcision as the treatment of choice is emphasized.

A Cross Sectional Study of the Prevalence of Preputial and Penile Scrotal Abnormalities among Clients Undergoing Voluntary Medical Male Circumcision in Soweto, South Africa

OBJECTIVE

Medical device use is currently approved for males without preputial or major penile scrotal abnormalities for voluntary medical male circumcision (VMMC). We determined the prevalence of preputial abnormalities at a busy VMMC centre in Soweto, South Africa.

METHODS

This was a cross-sectional record review at a high-volume VMMC centre in South Africa. We collated pre-circumcision demographic and genital examination findings from clients 8 years and older who had undergone VMMC from 01 May 2013 to 30 April 2014. Logistic regression was used to determine factors associated with preputial abnormalities.

FINDINGS

During the review period, 6861 circumcisions were conducted and 37.1% (n = 2543) were 8-13 year olds. Median age was 15 years (IQR: 12-23 years). Fifteen percent (n = 1030) had preputial abnormalities or major penile scrotal abnormalities. Age-specific prevalence of preputial or major genital abnormalities were 27.3%, 10.6% and 6.0% in 8-13, 14-18 and > 18 year olds respectively. The odds of preputial or major penile scrotal abnormality were higher in younger clients aged 8-13 years (OR = 5.9; 95% CI = 4.8-7.1) and 14-18 years (OR = 1.9; 95% CI = 1.5-2.4) compared to older clients above18 years and in those testing for HIV outside our clinic network (OR = 1.9; 95% CI = 1.4-2.7).

CONCLUSION

The high prevalence of preputial and penile scrotal abnormalities observed suggests a need for VMMC sites to provide for both open surgical and devices methods in the provision of VMMC services. This is especially so among young male subjects presenting themselves for VMMC services at the various sites being developed in sub Saharan African countries.

Newborn Male Circumcision with Parental Consent, as Stated in the AAP Circumcision Policy Statement, Is Both Legal and Ethical

Newborn male circumcision is a minor surgical procedure that has generated significant controversy. Accumulating evidence supports significant health benefits, most notably reductions in urinary tract infections, acquisition of HIV and a number of other sexually transmitted infections, penile cancer, phimosis, paraphimosis, balanitis and lichen sclerosis. While circumcision, like any surgical procedure, has risks for complications, they occur in less than 1 in 500 infants circumcised and most are minor and require minimal intervention. The CDC and the American Academy of Pediatrics (AAP) believe that health benefits of circumcision outweigh the risks. For this reason, the AAP believes that parents should be allowed to make the decision concerning circumcision of their male infants after receiving non-biased information on health risks and health benefits.

Indications for adult circumcision: a contemporary analysis

INTRODUCTION

Circumcision is the most common surgical procedure performed worldwide. However, there is a dearth of literature regarding medical indications for adult circumcisions. Here, we describe our experience with adult circumcision and contemporary demographics, indications and complications.

MATERIALS AND METHODS

We reviewed all circumcisions performed in our institution between July 2008 and January 2015. Patient demographics, procedure indications and postoperative complications were recorded, and patients were grouped by age as either less than 50 years old or 50 years and older.

RESULTS

A total of 202 charts were reviewed. The most common indications for circumcision were phimosis (46.5%), dyspareunia (17.8%), balanitis (14.4%), and concurrent phimosis and balanitis (8.9%). Older patients were more likely to undergo circumcision for concurrent phimosis and balanitis or cancer, whereas younger patients sought circumcision for dyspareunia. The complication rate was 3.5% and there was no significant difference in complication rates between the two age groups.

CONCLUSION

Circumcision is performed in the adult population for a variety of reasons. Circumcision remains a safe surgical option for patient management with a low complication rate.

Women's Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia

Women’s perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women’s health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men’s risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman’s HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women’s misperception regarding MC. Programs should address women’s informational needs and continue to emphasize that condoms remain critical, regardless of male partner’s circumcision status.

Preputial bacterial colonisation in uncircumcised male children: Is it related to phimosis?

OBJECTIVE

To evaluate the presence of uropathogens in the periurethral skin and the effect of phimosis on bacterial colonisation.

METHODS

The observational cohort study was conducted in Samsun Research and Training Hospital, Samsun, Turkey from June to December, 2014, and comprised patients undergoing circumcision. Before circumcision, all children were examined in the operating room and the presence of phimosis was recorded. All patients had circumcision performed by the same surgical team under general anaesthesia. Before the procedure, samples were taken from preputial skin of all patients by swab before cleansing with polyvidone-iodine. The samples were inoculated on 5% sheep blood agar and eosin-methylene blue agar.

RESULTS

The median age of the 117 children was 5 years (range: 1-12). Of the total, 19(16.2%) children had complete phimosis, and 72(61.5%) had partial phimosis. In all,91(77.7%) children had phimosis and 26(22.3%) had no phimosis. Of the 91 patients with different degrees of phimosis, 52(57.1%) had clinically significant uropathogenic bacterial colonisation >100,000 colony-forming units per millilitre [cfu/ml]). Of the 26 patients without phimosis, 13(50%) had clinically significant colonisation. Thus, there was no effect of the presence of phimosis on bacteria colonisation (p=0.655).

CONCLUSIONS

Important uropathogens colonise the preputium in uncircumcised male children. There was no effect of phimosis on colonisation.

In defence of genital autonomy for children

Arora and Jacobs (2016) assume that liberal societies should tolerate non-therapeutic infant male circumcision, and argue that it follows from this that they should similarly tolerate-or even encourage-what the authors regard as 'de minimis' forms of female genital mutilation (as defined by the World Health Organization). In this commentary, I argue that many serious problems would be likely to follow from a policy of increased tolerance for female genital mutilation, and that it may therefore be time to consider a less tolerant attitude toward non-therapeutic infant male circumcision. Ultimately, I suggest that children of whatever sex or gender should be free from having healthy parts of their most intimate sexual organs either damaged or removed, before they can understand what is at stake in such an intervention and agree to it themselves.

[Benefit of post-circumcision application of skin wound induction gel in the treatment of phimosis in children]

OBJECTIVE

To study the effects of skin wound induction gel on the glans scabbing rate, class-A wound healing rate, and wound healing time of circumcision for phimosis in pediatric patients.

METHODS

We randomly assigned 48 six to thirteen years old children with phimosis to an experimental group (n = 25) and a control group (n = 23) to be treated by circumcision. After surgery, the patients in the experimental group received application of skin wound induction gel while those in the control group received that of povidone iodine only to the glans and incision. We recorded and compared the glans scabbing rate, class-A wound healing rate, and wound healing time between the two groups of patients.

RESULTS

Glans scabbing was observed in 3 cases in the experimental group and 17 cases in the control group (12.0% vs 73.9%, P < 0.01). No statistically significant differences were found in the rate of class-A wound healing between the two groups (100% vs 91.3%, P > 0.05). The wound healing time was significantly shorter in the experimental than in the control group ([10.7 ± 1.7] d vs [11.9 ± 2.1] d, P < 0.05).

CONCLUSION

Post-circumcision application of skin wound induction gel to the glans and incision can effectively reduce glans secreta, alleviate inflammatory reaction, and shorten the healing time in the treatment of phimosis in children.

A comparison of risky sexual behaviours between circumcised and uncircumcised men aged 30-44 years in Botswana

BACKGROUND

The principal mode of HIV transmission in Southern Africa is through sexual intercourse, and this has prompted uptake of safe male circumcision. Engaging in risky sexual behaviour by circumcised men increases the risks of acquiring HIV, though male circumcision coupled with preventive behaviour reduces this risk.

OBJECTIVE

To compare the factors associated with risky sexual behaviour among circumcised and uncircumcised men in Botswana.

METHODS

Nationally representative data from the Botswana AIDS Impact Survey III were used. A sample of 313 sexually active men was used. The data was analysed by cross-tabulation and logistic regression.

RESULTS

The study revealed that uncircumcised men (odds ratio, 5.711) were more likely to have sex while intoxicated with alcohol compared to circumcised men. Low levels of education (odds ratio, 8.736), urban residency (city/town: odds ratio, 1.238 and urban village: odds ratio, 1.098) were more likely to influence risky behaviour (more than one sexual partner) for circumcised men. The results also show that marital status (never married) (odds ratio, 1.947) influences risky behaviour (having sex while intoxicated with alcohol) among uncircumcised men.

CONCLUSION

Low level of education, place of residence and alcohol consumption influences risky sexual behaviour for both circumcised and uncircumcised men. Policies and programmes should thus focus on the attitudes underlying sexual behaviour.

[Comparing efficacy of selective penile denervation and circumcision for primary premature ejaculation]

OBJECTIVE

To compare the efficacy and safety of selective penile denervation to that of circumcision for primary premature ejaculation (PPE).

MATERIALS AND METHODS

A prospective study comprised 138 patients with PPE, divided into two groups. Patients in Group 1 (n=50) underwent selective penile denervation by dissecting about a half of dorsal penile nerve branches. Large nerves (> 2 mm) were subjected to microsurgical neurorrhaphy. In group 2 (n=88) circumcision was carried out using guillotine technique. The evaluation of treatment efficacy was carried out using the Criteria for premature ejaculation questionnaire (CriPE), measuring intravaginal ejaculation latency time (IELT) with a stopwatch and testing penile vibration sensitivity. These examinations were performed at baseline and after 2, 4, 6, 8, 10 and 12 months after operation.

RESULTS

By the end of follow-up, 88% and 10.2% of patients of group 1 and group 2 had no signs of PPE, respectively. At 12 months IELT index increased 6-fold in patients of group 1 from 53,6+/-12,7 to 335,6+/-81,5 seconds, while remaining unchanged in group 2 with 51,8+/-10,4 seconds at baseline and 53.9+/-20.1 seconds at the end of follow-up. Group 1 showed statistically significant and sustained reduction in penile vibration sensitivity compared with baseline (p<0,001). In group 2, the baseline and endpoint characteristics of bio-tensiometry did not differ significantly (p>0,05).

CONCLUSIONS

The resulting effectiveness of selective penile denervation and circumcision for PPE was 88% and 10.2%, respectively, with comparable safety.

Phimosis with Preputial Fissures as a Predictor of Undiagnosed Type 2 Diabetes in Adults

Diabetes is usually asymptomatic in its early stage. Early diagnosis may improve outcomes by enabling initiation of treatment before end organ damage has progressed. The aim of this study was to determine whether the clinical sign of phimosis with preputial fissures is predictive of type 2 diabetes in patients not previously diagnosed with diabetes. Twenty-eight patients with acquired phimosis and preputial fissures were collected prospectively. Twenty-eight controls with acquired phimosis without preputial fissures were selected. Statistically significant differences were found in body mass index, random plasma glucose, glucosuria and glycosylated haemoglobin levels, but not in age, family history of diabetes, hypertension and classical hyperglycaemic symptoms. Diabetes was confirmed in all 28 patients in the preputial fissures group, but only 2 (7.1%) patients in the non-preputial fissures group (p < 0.0001). In conclusion, phimosis with preputial fissures may be a specific sign of undiagnosed diabetes mellitus.

Using Option Grids: steps toward shared decision-making for neonatal circumcision

OBJECTIVES

To assess the impact, acceptability and feasibility of a short encounter tool designed to enhance the process of shared decision-making and parental engagement.

METHODS

We analyzed video-recordings of clinical encounters, half undertaken before and half after a brief intervention that trained four clinicians how to use Option Grids, using an observer-based measure of shared decision-making. We also analyzed semi-structured interviews conducted with the clinicians four weeks after their exposure to the intervention.

RESULTS

Observer OPTION(5) scores were higher at post-intervention, with a mean of 33.9 (SD=23.5) compared to a mean of 16.1 (SD=7.1) for pre-intervention, a significant difference of 17.8 (95% CI: 2.4, 33.2). Prior to using the intervention, clinicians used a consent document to frame circumcision as a default practice. Encounters with the Option Grid conferred agency to both parents and clinicians, and facilitated shared decision-making. Clinician reported recognizing the tool's positive effect on their communication process.

CONCLUSIONS

Tools such as Option Grids have the potential to make it easier for clinicians to achieve shared decision-making.

PRACTICE IMPLICATIONS

Encounter tools have the potential to change practice. More research is needed to test their feasibility in routine practice.

The Association of Circumcision and Prostate Cancer: A Meta-Analysis

BACKGROUND

To investigate any association between circumcision and prostate cancer.

MATERIALS AND METHODS

We searched PubMed, EMBASE, the Cochrane Library, and Chinese biomedicine literature databases up to August 2015. All case-control studies were identified which investigated associations of circumcision with prostate cancer. Three authors independently assessed study quality and extracted data. All data were analyzed using RevMan 5.3 and STATA version 11.0.

RESULTS

Six case-control studies met the inclusion criteria. The pooled meta-analysis showed that there was a lower incidence of circumcision in prostate cancer patients compared with controls (OR=0.90, 95% con dence interval [CI] 0.82-0.98, P=0.01). The results of meta-analysis also showed that no significant difference was found between circumcision and less aggressive prostate cancer (OR=0.93, 95% CI 0.83-1.04, P=0.19); however, there was a lower incidence of circumcision in more aggressive prostate cancers compared with controls (OR =0.84, 95% CI 0.72-0.97, P=0.02). The Egger's results did not show any evidence of publication bias(P=0.798).

CONCLUSIONS

In summary, within the limits of available data, males with circumcision appears to have a lower incidence of prostate cancer. In the future, high-quality multicenter studies are needed to thoroughly verify the outcome.

A Reevaluation of the Voluntary Medical Male Circumcision Scale-Up Plan in Zimbabwe

BACKGROUND

The voluntary medical male circumcision (VMMC) program in Zimbabwe aims to circumcise 80% of males aged 13-29 by 2017. We assessed the impact of actual VMMC scale-up to date and evaluated the impact of potential alterations to the program to enhance program efficiency, through prioritization of subpopulations.

METHODS AND FINDINGS

We implemented a recently developed analytical approach: the age-structured mathematical (ASM) model and accompanying three-level conceptual framework to assess the impact of VMMC as an intervention. By September 2014, 364,185 males were circumcised, an initiative that is estimated to avert 40,301 HIV infections by 2025. Through age-group prioritization, the number of VMMCs needed to avert one infection (effectiveness) ranged between ten (20-24 age-group) and 53 (45-49 age-group). The cost per infection averted ranged between $811 (20-24 age-group) and $5,518 (45-49 age-group). By 2025, the largest reductions in HIV incidence rate (up to 27%) were achieved by prioritizing 10-14, 15-19, or 20-24 year old. The greatest program efficiency was achieved by prioritizing 15-24, 15-29, or 15-34 year old. Prioritizing males 13-29 year old was programmatically efficient, but slightly inferior to the 15-24, 15-29, or 15-34 age groups. Through geographic prioritization, effectiveness varied from 9-12 VMMCs per infection averted across provinces. Through risk-group prioritization, effectiveness ranged from one (highest sexual risk-group) to 60 (lowest sexual risk-group) VMMCs per infection averted.

CONCLUSION

The current VMMC program plan in Zimbabwe is targeting an efficient and impactful age bracket (13-29 year old), but program efficiency can be improved by prioritizing a subset of males for demand creation and service availability. The greatest program efficiency can be attained by prioritizing young sexually active males and males whose sexual behavior puts them at higher risk for acquiring HIV.

HIV Prevalence Correlates with High-Risk Sexual Behavior in Ethiopia's Regions

BACKGROUND

HIV prevalence varies between 0.9 and 6.5% in Ethiopia's eleven regions. Little has been published examining the reasons for this variation.

METHODS

We evaluated the relationship between HIV prevalence by region and a range of risk factors in the 2005 and 2011 Ethiopian Demographic Health Surveys. Pearson's correlation was used to assess the relationship between HIV prevalence and each variable.

RESULTS

There was a strong association between HIV prevalence and three markers of sexual risk: mean lifetime number of partners (men: r = 0.87; P < 0.001; women: r = 0.60; P = 0.05); reporting sex with a non-married, non-cohabiting partner (men: r = 0.92; P < 0.001, women r = 0.93; P < 0.001); and premarital sex. Condom usage and HIV testing were positively associated with HIV prevalence, while the prevalence of circumcision, polygamy, age at sexual debut and male migration were not associated with HIV prevalence.

CONCLUSION

Variation in sexual behavior may contribute to the large variations in HIV prevalence by region in Ethiopia. Population-level interventions to reduce risky sexual behavior in high HIV incidence regions should be considered.

"If You Are Not Circumcised, I Cannot Say Yes": The Role of Women in Promoting the Uptake of Voluntary Medical Male Circumcision in Tanzania

Voluntary Medical Male Circumcision (VMMC) for HIV prevention in Tanzania was introduced by the Ministry of Health and Social Welfare in 2010 as part of the national HIV prevention strategy. A qualitative study was conducted prior to a cluster randomized trial which tested effective strategies to increase VMMC up take among men aged ≥20 years. During the formative qualitative study, we conducted in-depth interviews with circumcised males (n = 14), uncircumcised males (n = 16), and participatory group discussions (n = 20) with men and women aged 20–49 years in Njombe and Tabora regions of Tanzania. Participants reported that mothers and female partners have an important influence on men’s decisions to seek VMMC both directly by denying sex, and indirectly through discussion, advice and providing information on VMMC to uncircumcised partners and sons. Our findings suggest that in Tanzania and potentially other settings, an expanded role for women in VMMC communication strategies could increase adult male uptake of VMMC services.

Lack of Effectiveness of Antiretroviral Therapy in Preventing HIV Infection in Serodiscordant Couples in Uganda: An Observational Study

Background

We examined the real-world effectiveness of ART as an HIV prevention tool among HIV serodiscordant couples in a programmatic setting in a low-income country.

Methods

We enrolled individuals from HIV serodiscordant couples aged ≥18 years of age in Jinja, Uganda from June 2009 – June 2011. In one group of couples the HIV positive partner was receiving ART as they met clinical eligibility criteria (a CD4 cell count ≤250 cells/ μL or WHO Stage III/IV disease). In the second group the infected partner was not yet ART-eligible. We measured HIV incidence by testing the uninfected partner every three months. We conducted genetic linkage studies to determine the source of new infections in seroconverting participants.

Results

A total of 586 couples were enrolled of which 249 (42%) of the HIV positive participants were receiving ART at enrollment, and an additional 99 (17%) initiated ART during the study. The median duration of follow-up was 1.5 years. We found 9 new infections among partners of participants who had been receiving ART for at least three months and 8 new infections in partners of participants who had not received ART or received it for less than three months, for incidence rates of 2.09 per 100 person-years (PYRs) and 2.30 per 100 PYRs, respectively. The incidence rate ratio for ART-use was 0.91 (95% confidence interval 0.31-2.70; p=0.999). The hazard ratio for HIV seroconversion associated with ART-use by the positive partner was 1.07 (95% CI 0.41-2.80). A total of 5/7 (71%) of the transmissions on ART and 6/7 (86%) of those not on ART were genetically linked.

Conclusion

Overall HIV incidence was low in comparison to previous studies of serodiscordant couples. However, ART-use was not associated with a reduced risk of HIV transmission in this study.

What Do People Actually Learn from Public Health Campaigns? Incorrect Inferences About Male Circumcision and Female HIV Infection Risk Among Men and Women in Malawi

Qualitative studies and polling data from sub-Saharan Africa indicate that many individuals may mistakenly believe that male circumcision directly protects women from contracting HIV. This study examines whether individuals who learn that male circumcision reduces female-to-male HIV transmission also erroneously infer a reduction in direct male-to-female transmission risk (i.e. from an HIV-positive man to an uninfected woman). We used data on Malawian men (n = 917) randomized to receive information about voluntary medical male circumcision (VMMC) and HIV risk in 2008 and a random sample of their wives (n = 418). We found that 72 % of men and 82 % of women who believed that male circumcision reduces HIV risk for men also believed that it reduces HIV risk for women. Regression analyses indicated that men randomly assigned to receive information about the protective benefits of circumcision were more likely to adopt the erroneous beliefs, and that the underlying mechanism was the formation of the belief that male circumcision reduces HIV risk for men. The results suggest the need for VMMC campaigns to make explicit that male circumcision does not directly protect women from HIV-infection.

Clinicopathological Pattern of Penile Cancer in a Tertiary Care Centre in Nepal

INTRODUCTION

Carcinoma of penis is an uncommon entity. The higher incidence in developing country may be because of poor hygiene, less common practice of circumcision and unsafe sexual practice. Timely diagnosis and intervention gives the patient a chance of cure. Data on penile cancer is sparse from Nepal so treatment of penile cancer in our centre is presented here.

METHODS

This was a retrospective cross-sectional study done at Urology unit of Department of Surgery of Tribhuvan University Teaching Hospital, Nepal from November, 2007 to December, 2013. Data was retrieved from case records and those with penile carcinoma were included. Patient demographics, lesion characteristics, mode of treatment with outcome measures were noted and analyzed.

RESULTS

Total 17 patients underwent treatment for primary penile lesion. Mean age of the patients was 51.5 years. Penile growth was the most frequent presentation with five patients coming with more than one symptom. The most common site was over glans of penis (n=13) with the mean size of 3.55 cm. Partial penectomy was offered in 16 with one patient undergoing circumcision only. Inguinal lymph node dissection was done in four patients. Squamous cell carcinoma was the histological diagnosis in 15 patients.

CONCLUSIONS

Penile carcinoma is primarily a disease of old. Growth over glans penis is the most common presentation and partial penectomy is feasible in most of the patients to allow oncological cure while preserving the organ for its native function.

[Seizures and respiratory failure following local anaesthesia administered for circumcision]

We present two cases in which two boys of four weeks and four and a half months, respectively, experienced seizures and respiratory insufficiency as complications to the local anaesthesia administered for ritual circumcision. They both needed intubation and anticonvulsive therapy and acquired an aspiration pneumonia, which was treated with antibiotics. Both recovered without sequelae. Surgeons should be careful with calculating the maximum safe dose of local anaesthesia for young children and should be prepared to treat complications.

Introduction of male circumcision for HIV prevention in Uganda: analysis of the policy process

BACKGROUND

Health policy analysis is important for all health policies especially in fields with ever changing evidence-based interventions such as HIV prevention. However, there are few published reports of health policy analysis in sub-Saharan Africa in this field. This study explored the policy process of the introduction of male circumcision (MC) for HIV prevention in Uganda in order to inform the development processes of similar health policies.

METHODOLOGY

Desk review of relevant documents was conducted between March and May 2012. Thematic analysis was used to analyse the data. Conceptual frameworks that demonstrate the interrelationship within the policy development processes and influence of actors in the policy development processes guided the analysis.

RESULTS

Following the introduction of MC on the national policy agenda in 2007, negotiation and policy formulation preceded its communication and implementation. Policy proponents included academic researchers in the early 2000s and development partners around 2007. Favourable contextual factors that supported the development of the policy included the rising HIV prevalence, adoption of MC for HIV prevention in other sub-Saharan African countries, and expertise on MC. Additionally, the networking capability of proponents facilitated the change in position of non-supportive or neutral actors. Non-supportive and neutral actors in the initial stages of the policy development process included the Ministry of Health, traditional and Muslim leaders, and the Republican President. Using political authority, legitimacy, and charisma, actors who opposed the policy tried to block the policy development process. Researchers' initial disregard of the Ministry of Health in the research process of MC and the missing civil society advocacy arm contributed to delays in the policy development process.

CONCLUSIONS

This study underscores the importance of securing top political leadership as well as key implementing partners' support in policy development processes. Equally important is the appreciation of the various forms of actors' power and how such power shapes the policy agenda, development process, and content.

Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies

By the end of 2014, an estimated 8.5 million men had undergone voluntary medical male circumcision (VMMC) for HIV prevention in 14 priority countries in eastern and southern Africa, representing more than 40% of the global target. However, demand, especially among men most at risk for HIV infection, remains a barrier to realizing the program's full scale and potential impact. We analyzed current demand generation interventions for VMMC by reviewing the available literature and reporting on field visits to programs in 7 priority countries. We present our findings and recommendations using a framework with 4 components: insight development; intervention design; implementation and coordination to achieve scale; and measurement, learning, and evaluation. Most program strategies lacked comprehensive insight development; formative research usually comprised general acceptability studies. Demand generation interventions varied across the countries, from advocacy with community leaders and community mobilization to use of interpersonal communication, mid- and mass media, and new technologies. Some shortcomings in intervention design included using general instead of tailored messaging, focusing solely on the HIV preventive benefits of VMMC, and rolling out individual interventions to address specific barriers rather than a holistic package. Interventions have often been scaled-up without first being evaluated for effectiveness and cost-effectiveness. We recommend national programs create coordinated demand generation interventions, based on insights from multiple disciplines, tailored to the needs and aspirations of defined subsets of the target population, rather than focused exclusively on HIV prevention goals. Programs should implement a comprehensive intervention package with multiple messages and channels, strengthened through continuous monitoring. These insights may be broadly applicable to other programs where voluntary behavior change is essential to achieving public health benefits.

[Expression of ZEB1 in the prepuce of hypospadias children and its implication]

OBJECTIVE

To investigate the expression of zinc finger E-box binding homebox 1 (ZEB1) in the prepuce of hypospadias children and its relationship to the incidence of hypospadias.

METHODS

Prepuce tissues were collected from 37 children aged 6-15 months undergoing hypospadias repair and 11 age-matched controls receiving circumcision. Based on the position of the urethral meatus, the hypospadias cases were classified as severe (n = 13) and mild-moderate (n = 24). The mRNA and protein expressions of ZEB1 were determined by immunohistochemistry and RT-PCR.

RESULTS

The expression of the ZEB1 protein was remarkably higher in the severe (100% [13/13]) and mild-moderate hypospadias patients (75.0% [18/24]) than in the controls (9.1% [1/11]), with statistically significant differences between any two groups (P < 0.05). RT-PCR showed the integrated density value (IDV) of the ZEB1 mRNA expression to be (0.67 ± 0.21), (0.81 ± 0.24), and (1.55 ± 0.29) in the control, mild-moderate, and severe hypospadias patients, respectively, significantly higher in the severe hypospadias than in the control and mild-moderate hypospadias groups (P < 0.05), but with no significant difference between the latter two (P = 0.64).

CONCLUSION

The expression of ZEB1 is significantly increased in hypospadias patients, and its upregulation is positively correlated with the severity of hypospadias, which suggests that the overexpression of ZEB1 may contribute to the development of hypospadias.

Rotation of the corpora cavernosa for the treatment of congenital penile curvature

INTRODUCTION

Congenital penile curvature (CPC) is caused by a disorder in the embryonic development of the urethra and corpora cavernosa. The condition causes difficulty for penetration, requiring surgical correction when it prevents intercourse.

MATERIAL AND METHODS

We present the cases of 2 men in their 40s who had ventral curvature greater than 60° of 2 years of evolution, with maintained erections. The patients underwent surgery for rotation of the corpora cavernosa. After the complete denudation of the penis, athermal release of the neurovascular bundle of the penis from the ventral side to the dorsal was performed. Once the curvature was verified using artificial erection, an incision was performed in the tunica albuginea of both corpora cavernosa, continuously suturing both internal and external margins with resorbable monofilament. The rectification of the curvature was then checked, and the mucocutaneous plane was reconstructed.

RESULTS

The surgical time was 120minutes and there were no intraoperative complications. Both patients were discharged 24h after the surgery. At 1 week, the patients experienced spontaneous night-time erections and were able to maintain sexual relations 1 month after the surgery. At 6 months, the residual curvature was less than 20°, the penile shortening was less than 1 centimeter and the International Index of Erectile Function-5 was 25 for both cases.

CONCLUSIONS

Surgery for rotation of the corpora cavernosa helps correct CPC without significant penile shortening or erectile dysfunction. In our opinion, the procedure is an appropriate treatment for patients with CPC but requires studies with long-term follow-up in order to consider it the technique of choice.

Men in Papua New Guinea accurately report their circumcision status

Background

Male circumcision (MC) is a well-established component of HIV prevention in countries with high HIV prevalence and heterosexually driven epidemics. Delivery and monitoring of MC programs are reliant on good quality MC data. Such data are often generated through self-reported MC status surveys. This study examined self-reported MC status in comparison with genital photographs from men in Papua New Guinea (PNG).

Methods

This retrospective non-interventional study collated self-reported MC status data from the ‘acceptability and feasibility of MC’ study at 4 sites in PNG during 2010–2011. Participants reported their MC status based on an 8-category photographic classification covering the range of foreskin cutting practices in PNG. Genital photographs of 222 participants from this study were independently classified by 2 investigators. The 8-category photographic classification was simplified into a 3 category classification of ‘no cut’, ‘straight cut’ and ‘round cut’ before comparing for agreement between self-reporting and investigator assessment using Cohen’s Kappa measure.

Results

Using the 3-category classification, there was 90.6% (201/222) agreement between self-assessment and investigator classification (κ value 0.805). Of the discordant 9.4% (21/222), 3.6% (8/222) self-classified as having a cut foreskin (5 straight cut; 3 round cut) while investigators classified as having no cut; 4.1% (9/222) self-classified as having no cut while investigators classified them as having had a cut (6 straight cut; 3 round cut) and 1.8% (4/222) self-classified as having a round cut while investigators classified as having a straight cut. Given the great variety of foreskin cutting practices and appearances, feasible explanations are suggested for two-thirds (13/21) of these discordant results.

Conclusions

This study demonstrates a high level of agreement between self-reporting and investigator assessment of MC status in PNG and suggests self-reporting of MC status to be highly reliable among men in PNG.

ADENOSINE DIPHOSPHATE RIBOSE PYROPHOSPHOHYDROLASE IN HUMAN SKIN

Adenosine diphosphate ribose (ADPR) pyrophosphohydrolase (ADPR-PPase), which catalyzes the hydrolysis of ADPR to yield adenosine monophosphate (AMP) and ribose-5'-phosphate, was assayed in human penile foreskin. Since ADPR is formed from nicotinamide adenine dinucleotide (NAD) by NAD glycohydrolase (NADase), NADase was also assayed in human skin. The skin tissue obtained by circumcision was separated into three layers; epidermis of the outer prepuce, epidermis of the inner prepuce, and dermis. ADPR-PPase was found to be present in all of the three layers with nearly equal activity. NADase was also present in the epidermis of both the outer and inner prepuce, being about two times higher in the latter, but no activity was found in the dermis. When expressed in units of the same specific activity; i.e., micromoles product formed per hour per mg protein, the ADPR-PPase of human skin had two to five times greater activity than did NADase. The ADPR-PPase of human skin was activated by Mg(+2), but inhibited by AMP and ATP. These results suggest that the breakdown of NAD occurs in human skin via ADPR to AMP and ribose-5'-phosphate by sequential action of NADase and ADPR-PPase.

WITHDRAWN: Lidocaine-prilocaine cream for analgesia during circumcision in newborn boys

The authors have requested this review to be withdrawn. The reason is the intervention, lidocaine‐prilocaine cream for analgesia during neonatal circumcision, is covered in the Cochrane Review of "Pain relief for neonatal circumcision" (Brady‐Fryer 2004).

The editorial group responsible for this previously published document have withdrawn it from publication.