The African AIDS epidemic

The Significance of Taking Antiretroviral Medications for African-Born People Living with HIV and Residing in Minnesota

Thanks to the development of antiretroviral (ART) medications, HIV is now a chronic and manageable disease. This study aimed to (1) capture the experiences of African-born persons living with HIV and taking antiretroviral treatment, and (2) explore the impact of social and cultural factors on their decisions to follow the prescribed treatment. For this study, a qualitative approach was used. The participants were recruited via fliers, then screened for inclusion and exclusion criteria. Recruitment of the participants continued until data saturation occurred. The interview guide was developed based on the extensive literature and recommendations from the clinical team. In-person narrative interviews were conducted with 14 participants-African-born persons living with HIV and residing in Minnesota. Thematic Analysis revealed three emergent themes: "To exist I have to take the medicine"; barriers and facilitators in taking ART medications; and the power of spirituality and prayers. The findings of this study paint a picture of African-born persons living with HIV, and their experiences with ART medications. This study not only presents the participants' medication experiences and their significance, but also tells their stories of how God and prayers play a significant role in helping them to get through the difficult moments of their lives.

Conflicting Views in Narratives on HIV Transmission via Medical Care

Molecular studies suggest that HIV arose in Africa between 1880 and 1940. During this period, there were campaigns by European colonial governments that involved unsterile injections of large numbers of Africans. That, along with other unsafe therapeutic interventions, may have propelled the evolution of HIV from SIV. Since subtype B in Africa may have been concentrated in white African homosexuals, it is possible that Westerners rather than Haitians introduced the virus to the New World. Amplification of HIV subtype B took place in Haiti, where transmission was facilitated by hazardous medical procedures including plasmapheresis. Representations in the media, however, largely ignore Western contributions to the spread of AIDS. This article focuses on the value of alternative narratives in fostering a balanced view that is less stigmatizing on developing nations.

Behavioral and biomedical combination strategies for HIV prevention

Around 2.5 million people become infected with HIV each year. This extraordinary toll on human life and public health worldwide will only be reversed with effective prevention. What's more, in the next few years, it is likely at least, that no single prevention strategy will be sufficient to contain the spread of the disease. There is a need for combination prevention as there is for combination treatment, including biomedical, behavioral, and structural interventions. Expanded HIV prevention must be grounded in a systematic analysis of the epidemic's dynamics in local contexts. Although 85% of HIV is transmitted sexually, effective combinations of prevention have been shown for people who inject drugs. Combination prevention should be based on scientifically derived evidence, with input and engagement from local communities that fosters the successful integration of care and treatment.

HIV treatment as prevention: the utility and limitations of ecological observation

Results from several observational studies of HIV-discordant couples and a randomized controlled trial (HIV Prevention Trials Network 052) show that antiretroviral therapy (ART) can greatly reduce heterosexual HIV transmission in stable HIV-discordant couples. However, such data do not prove that ART will reduce HIV incidence at the population level. Observational investigations using ecological measures have been used to support the implementation of HIV treatment for the specific purpose of preventing transmission at the population level. Many of these studies note ecological associations between measures of increased ART uptake and decreased HIV transmission. Given the urgency of implementing HIV prevention measures, ecological studies must de facto be used to inform current strategies. However, the hypothesis that widespread ART can eliminate HIV infection may have raised expectations beyond what we may be able to achieve. Here we review and discuss the construct of the exposure and outcome measures and analysis methods used in ecological studies. By examining the strengths and weaknesses of ecological analyses, we aim to aid understanding of the findings from these studies to inform future policy decisions regarding the use of ART for HIV prevention.

A multilevel analysis of the determinants of high-risk sexual behaviour in sub-Saharan Africa

A number of authors have identified multiple concurrent sexual partnerships by both men and women to lie at the root of the HIV/AIDS epidemic in sub-Saharan Africa. This study applies multilevel models to Demographic and Health Survey data collected during 2003-2008 in 20 sub-Saharan African countries to examine the influence of social and cultural context on involvement with multiple sexual partnerships in the region, above and beyond the effects of individual characteristics. The findings provide support for the ecological argument that health behaviours are shaped and determined by societal conditions, in addition to the effects of individual and household characteristics. Involvement with multiple sex partners is most prevalent in societies in which sexual norms are widely permissive and where polygyny is common. Individual autonomy is substantial and attitudes towards sexuality are more liberal among men and women who live in communities in which sexual norms are widely permissive. Men and women who are most likely to have multiple sex partners in the sub-Saharan region are those who initiated sexual activity earlier and those who have the individual attributes (e.g. young age, urban residence, education, media exposure and working for cash and away from home) that bring to them more rights and/or decision-making autonomy, but not necessarily more financial resources and economic security (mostly among women). On the other hand, involvement with multiple partners is determined by cultural norms (i.e. permissive sexual norms) and social change (i.e. mass education, expansion of cash employment). The findings suggest a number of opportunities for more effective policy and programmatic responses to curb the prevalence of multiple partnerships in sub-Saharan Africa.

Routes to low mortality in poor countries revisited

In June 1986, Population and Development Review published a highly influential article by John Caldwell entitled “Routes to Low Mortality in Poor Countries.” Amid growing anxiety over decelerating world mortality decline, Caldwell explored social and political pathways to mortality success on the basis of two lists of superior mortality achievers and exceptionally poor mortality achievers, countries whose mortality rankings drastically differed from their income rankings. To mark the quarter-century since Caldwell's study and chart new pathways, this article looks at the subsequent performance of Caldwell's original exceptional achievers and develops an updated list of achievers. Analysis highlights the presence of many more poor achievers today; the rising importance of adult mortality as a marker of exceptional achievement; the increasing success of countries in Latin America and the Muslim world; the continued success of China, Vietnam, Cuba, and Costa Rica. dramatic improvements in schooling outcomes, particularly for women, have reduced the importance of education as a determinant of superior achievement. Reinforcing Caldwell's original assertions, the synthesis highlights how interactions between social consensus, health care systems, and human capital dependence offer a pathway to superior achievement. These forces may be especially powerful at moments of national crisis.

Behavioral mechanisms in HIV epidemiology and prevention: past, present, and future roles

In the 1980s, behavioral variations across geographically and socially defined populations were the central focus of AIDS research, and behavior change was seen as the primary means of controlling HIV epidemics. Today, biological mechanisms--especially other sexually transmitted infections, antiretroviral therapy, and male circumcision--predominate in HIV epidemiology and prevention. We describe several reasons for this shift in emphasis. Although the shift is understandable, we argue for a sustained focus on behavioral mechanisms in HIV research in order to realize the theoretical promise of interventions targeting the biological aspects of HIV risk. We also provide evidence to suggest that large reductions in HIV prevalence may be accomplished by small changes in behavior. Moreover, we contend that behavioral mechanisms will find their proper place in HIV epidemiology and prevention only when investigators adopt a conceptual model that treats prevalence as a determinant as well as an outcome of behavior and that explicitly recognizes the dynamic interdependence between behavior and other epidemiological and demographic parameters.

HIV control in low-income countries in sub-Saharan Africa: are the right things done?

HIV control efforts in sub-Saharan Africa meet with difficulties. Incidence and prevalence remains high, and little behaviour change seems to have taken place. The focus on HIV control has shifted to anti-retroviral therapy (ART), although this is unlikely either to be cost-effective or the reduce the incidence of HIV. There is reason to change the current approach. Three questions arise: Is there a need to adjust the view on the determinants of the HIV epidemic in sub-Saharan Africa? Are the right things being done to control HIV? Are the things that are being done, done in the right way? We try to answer these questions. The determinants of the epidemic are reviewed and summarized in Figure 2. The need to adjust the view on the determinants and get rid of myths is stressed. A possible, locally adaptable intervention mix is outlined. Male circumcision is a key intervention where socially acceptable. Operationalisation and organisational changes are briefly discussed. Conclusively, the need for a "social revolution" through the opening up of a discussion on sexuality in the community, as well as a focus on cost-effective interventions and a slimmed down, more effective organisation is underlined. Such steps might make it possible to considerably reduce HIV-incidence, even in low-income countries.

New thinking in HIV prevention: an anthropological and epidemiological viewpoint

Prior to his current faculty position in the Department of Global Health and Population at the Harvard School of Public Health, Halperin served for over 5 years as the Senior HIV Prevention and Behavior Change Advisor at the USA Agency for International Development. Halperin has conducted epidemiological and ethnographic research for 30 years on a number of health and sociocultural issues in Latin America, sub-Saharan Africa and other developing regions. Since completing his doctoral training in medical and cultural anthropology at the University of California, Berkeley, in 1995, his work has mainly focused on the heterosexual transmission of HIV and other sexually transmitted infections. Most of Halperin's research and scientific publications have dealt with some of the previously more neglected HIV co-factors, such as concurrent sexual partner networks, lack of male circumcision, ‘dry sex’ practices, alcohol use and heterosexual anal intercourse. He has conducted field research and consultations over the years in a number of countries, including Brazil, South Africa, Botswana, Zimbabwe, Mozambique, Haiti, the Dominican Republic and Peru.

Adult male circumcision outcomes: experience in a developing country setting

INTRODUCTION

We examined male circumcision outcomes among young adults in an African setting.

MATERIALS AND METHODS

Participants were healthy, sexually active, uncircumcised, HIV-seronegative males aged 18-24 years. The main outcomes measured included complications, healing, satisfaction and resumption of activities.

RESULTS

Of 1,475 procedures, 26 (1.8%) were associated with 27 adverse events, most commonly wound disruption/delayed healing (0.6%), wound infection (0.4%), and bleeding (0.3%). Adverse events per clinician averaged 3.8 and 2.1% for procedures 1-100 and 101-200, respectively, and <1% for procedures 201-300, 301-400 and >400, respectively (p < 0.001). Participants resumed normal general activities after a median of 1 postoperative day and 93% with regular employment resumed working within 1 week. After 30 days, 99% of participants reported being very satisfied. After 90 days, 65% reported having had sex, 45% reported that their partners had expressed an opinion, 92% of whom were very satisfied with the outcome.

CONCLUSIONS

Safe and acceptable adult male circumcision services can be delivered in developing country settings.

RACP's policy statement on infant male circumcision is ill-conceived

OBJECTIVE

To conduct a critical peer-review of the 2004 Policy Statement on routine male circumcision produced by the Royal Australasian College of Physicians (RACP).

METHOD

Comprehensive evaluation in the context of the research field.

RESULTS

We find that the current Statement downplays the wide-ranging life-long benefits of circumcision in prevention of urinary tract infections (UTIs), penile and cervical cancer, genital herpes and chlamydia in women, HIV infection, phimosis, and various penile dermatoses, and at the same time overstates the complication rate. We highlight the many errors in the RACP Statement and note that it sidesteps making a conclusion based on circumcision's well-documented prophylactic health benefits by instead referring to the status of the foreskin at birth. In the era of preventative medicine we view this as irresponsible.

CONCLUSION

The RACP's Statement on routine male circumcision is not evidence-based and should be retracted.

IMPLICATIONS

In the interests of public health and individual well-being an extensive, comprehensive, evidence-based revision should be conducted so as to provide scientifically accurate, balanced information on the advantages, and also the low rate of mostly minor complications, associated with this simple procedure, which for maximum benefits and minimal risk should ideally be performed in the neonatal period.

Acceptability of male circumcision for prevention of HIV infection in Zambia

Numerous observational studies and three clinical trials have shown male circumcision (MC) to be partially protective against HIV acquisition in heterosexual men. This has led to consideration of introducing circumcision as an HIV prevention strategy in parts of sub-Saharan Africa. This study assesses the acceptability of male circumcision as an intervention to improve male genital hygiene and reduce sexually transmitted infections, including HIV-1 in Zambia. Thirty-four focus group discussions were conducted - 17 with men and 17 with women - in four districts chosen to represent urban and rural communities where circumcision is and is not traditionally practiced. In communities where circumcision is little practiced, the main facilitators for acceptance were improved genital hygiene, HIV/STI prevention, and low cost. The main barriers were cultural tradition, high cost, pain, and concerns for safety. If MC is proven to reduce risk for HIV and STIs, most participants reported that they would seek circumcision for themselves or their partners or their sons if it was free or at a minimal cost. Acceptability of male circumcision for STI and HIV prevention appears to be high in Zambia.

Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa

Background

Recent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-to-male transmission risk by 60% or more. However, the public health impact of large-scale male circumcision programs for HIV prevention is unclear.

Methods

Two mathematical models were examined to explore this issue: a random mixing model and a compartmental model that distinguishes risk groups associated with sex work. In the compartmental model, two scenarios were developed, one calculating HIV transmission and prevalence in a context similar to the country of Botswana, and one similar to Nyanza Province, in western Kenya.

Results

In both models, male circumcision programs resulted in large and sustained declines in HIV prevalence over time among both men and women. Men benefited somewhat more than women, but prevalence among women was also reduced substantially. With 80% male circumcision uptake, the reductions in prevalence ranged from 45% to 67% in the two "countries", and with 50% uptake, from 25% to 41%. It would take over a decade for the intervention to reach its full effect.

Conclusion

Large-scale uptake of male circumcision services in African countries with high HIV prevalence, and where male circumcision is not now routinely practised, could lead to substantial reductions in HIV transmission and prevalence over time among both men and women.

HIV/AIDS and the construction of Sub-Saharan Africa: Heuristic lessons from the social sciences for policy

There is no doubt that Sub-Saharan African countries face major problems due to the HIV/AIDS pandemic that has ravaged the region. Yet the Eurocentric construction of the region as the source of the virus not only creates negative stereotypes in social science disciplines like geography, but also glosses over the potential of social science disciplines to provide knowledge and influence policy about HIV/AIDS. This oppositional construction of the region has unfortunately contributed to a glossing over of many aspects of Sub-Saharan Africa's people, their environment, culture, history, politics, economics, gender relations, and the region's global status that would provide important input for policy aimed at curbing the devastating spread of HIV in the region. This paper argues that once we recognize that HIV is a global virus with trans-cultural implications, social science disciplines, such as geography, can reveal certain attributes about the region and its HIV/AIDS pandemic that can be used in policy formulation to combat the spread of the virus.

Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries

Background

Both religious practices and male circumcision (MC) have been associated with HIV and other sexually-transmitted infectious diseases. Most studies have been limited in size and have not adequately controlled for religion, so these relationships remain unclear.

Methods

We evaluated relationships between MC prevalence, Muslim and Christian religion, and 7 infectious diseases using country-specific data among 118 developing countries. We used multivariate linear regression to describe associations between MC and cervical cancer incidence, and between MC and HIV prevalence among countries with primarily sexual HIV transmission.

Results

Fifty-three, 14, and 51 developing countries had a high (>80%), intermediate (20–80%), and low (<20%) MC prevalence, respectively. In univariate analyses, MC was associated with lower HIV prevalence and lower cervical cancer incidence, but not with HSV-2, syphilis, nor, as expected, with Hepatitis C, tuberculosis, or malaria. In multivariate analysis after stratifying the countries by religious groups, each categorical increase of MC prevalence was associated with a 3.65/100,000 women (95% CI 0.54-6.76, p = 0.02) decrease in annual cervical cancer incidence, and a 1.84-fold (95% CI 1.36-2.48, p < 0.001) decrease in the adult HIV prevalence among sub-Saharan African countries. In separate multivariate analyses among non-sub-Saharan African countries controlling for religion, higher MC prevalence was associated with a 8.94-fold (95% CI 4.30-18.60) decrease in the adult HIV prevalence among countries with primarily heterosexual HIV transmission, but not, as expected, among countries with primarily homosexual or injection drug use HIV transmission (p = 0.35).

Conclusion

Male circumcision was significantly associated with lower cervical cancer incidence and lower HIV prevalence in sub-Saharan Africa, independent of Muslim and Christian religion. As predicted, male circumcision was also strongly associated with lower HIV prevalence among countries with primarily heterosexual HIV transmission, but not among countries with primarily homosexual or injection drug use HIV transmission. These findings strengthen the reported biological link between MC and some sexually transmitted infectious diseases, including HIV and cervical cancer.

Acceptability of male circumcision for prevention of HIV infection in Malawi

Numerous epidemiological and biological studies report male circumcision (MC) to have a significant protective effect against HIV-1 acquisition. This study assesses the acceptability of MC in four districts in Malawi, a country with high HIV-1 prevalence and low prevalence of MC. Thirty-two focus group discussions were conducted with 159 men and 159 women ages 16-80 years. Acceptability was lower in the north where the practice was little known, higher in younger participants and higher in central and southern districts where MC is practiced by a minority Muslim group (Yao). Barriers to circumcision included fear of infection and bleeding, cost, and pain. Facilitators included hygiene, reduced risk of STI, religion, medical conditions, and enhanced sexual pleasure. If MC services are introduced in Malawi, acceptance is likely to vary by region, but many parents and young men would use the services if they were safe, affordable and confidential.

The economics of HIV/AIDS in low-income countries: the case for prevention

There are two approaches to reducing the burden of sickness and death associated with the human immunodeficiency virus (HIV), which leads to acquired immunodeficiency syndrome (AIDS): treatment and prevention. Despite large international aid flows for HIV/AIDS, the needs for prevention and treatment in low- and middle-income countries outstrip the resources available. Thus, it becomes necessary to set priorities. With limited resources, should the focus of efforts to combat HIV/AIDS be on prevention or treatment? I discuss the range of prevention and treatment alternatives and examine their cost effectiveness. I consider various arguments that have been raised against the use of cost-effectiveness analysis in setting public policy priorities for the response to HIV/AIDS in developing countries. I conclude that promoting AIDS treatment using antiretrovirals in resource-constrained countries comes at a huge cost in terms of avoidable deaths that could be prevented through interventions that would substantially lower the scale of the epidemic.

Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya

OBJECTIVE

To develop a standard procedure for male circumcision in a resource-poor medical setting and prospectively evaluate the outcome in a randomized, controlled trial with the incidence of human immunodeficiency virus (HIV) as the main outcome, as studies suggest that circumcision is associated with a lower incidence of HIV and other sexually transmitted infections in high-risk populations.

SUBJECTS AND METHODS

Healthy, uncircumcised, HIV-seronegative men aged 18-24 years from Kisumu District, Kenya, were offered participation in a clinical trial using a standard circumcision procedure based on "usual" medical procedures in Western Kenya. The follow-up included visits at 3, 8 and 30 days after circumcision, with additional visits if necessary. Healing, satisfaction and resumption of activities were assessed at these visits and 3 months from randomization.

RESULTS

Overall, 17 (3.5%) of the 479 circumcisions were associated with adverse events judged definitely, probably or possibly related to the procedure. The most common adverse events were wound infections (1.3%), bleeding (0.8%), and delayed wound healing or suture line disruption (0.8%). After 30 days, 99% of participants reported being very satisfied with the procedure; approximately 23% reported having had sex and 15% reported that their partners had expressed an opinion, all of whom were very satisfied with the outcome. About 96% of the men resumed normal general activities within the first week after the procedure.

CONCLUSION

Safe and acceptable adult male circumcision services can be delivered in developing countries should male circumcision ultimately be advocated as a public-health measure.

Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial

BACKGROUND

Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted in a general population of South Africa to test this hypothesis.

METHODS AND FINDINGS

A total of 3,274 uncircumcised men, aged 18-24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95% CI. Protection against HIV infection was calculated as 1 - RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0-21.0) when the data were analyzed. There were 20 HIV infections (incidence rate = 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95% CI: 0.24%-0.68%; p < 0.001). This RR corresponds to a protection of 60% (95% CI: 32%-76%). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%-77%).

CONCLUSION

Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.).

Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya

Numerous epidemiologic studies report significant associations between lack of male circumcision and HIV-1 infection, leading some to suggest that male circumcision be added to the limited armamentarium of HIV prevention strategies in areas where HIV prevalence is high and the mode of transmission is primarily heterosexual. This cross-sectional survey of 107 men and 110 women in Nyanza Province, Kenya, assesses the attitudes, beliefs, and predictors of circumcision preference among men and women in a traditionally non-circumcising region. Sixty per cent (n=64) of uncircumcised men and 69% (n=68) of women who had uncircumcised regular partners reported that they would prefer to be circumcised or their partners to be circumcised. Men's circumcision preference was associated with the belief that it is easier for uncircumcised men to get penile cancer, sexually transmitted diseases, and HIV/AIDS, and that circumcised men have more feeling in their penises, enjoy sex more, and confer more pleasure to their partners. Women with nine or more years of school were more likely to prefer circumcised partners. Men who preferred to remain uncircumcised were concerned about the pain and cost of the procedure, and pain was a significant deterrent for women to agree to circumcision for their sons. If clinical trials prove circumcision to be efficacious in reducing risk of HIV infection, it is likely that the procedure will be sought by a significant proportion of the population, especially if it is affordable and minimally painful.

[Male circumcision and HIV heterosexual transmission]

Since the early years of the AIDS epidemic significant geographic differences in HIV prevalence were reported within neighboring countries and neighboring regions within the same country in sub-Saharan Africa. These differences could not be fully explained by factors such as sexual behavior and condom use. Mounting epidemiological data have demonstrated that male circumcision is a major protective factor against male heterosexual HIV infection in sub-Saharan Africa and probably contributes to these significant differences in HIV prevalence. This is a review of African studies on the association between male circumcision and HIV infection, the origin of circumcision practices in human societies, potential prepuce mechanisms for increasing male vulnerability to heterosexual HIV infection, its association with other infectious and neoplastic diseases, controversies on the convenience of male circumcision as an HIV control strategy in Africa, the scarce Brazilian literature on male circumcision and perspectives of future research.

Melanin and HIV in sub-Saharan Africa

HIV is common in sub-Saharan Africa. Sexually transmitted bacterial and fungal infections increase the chance of HIV infection. Melanin can prevent the penetration of skin and mucus membranes by microorganisms, and soluble melanin can inhibit HIV replication. We suggest that melanin may reduce the incidence of HIV infection through venereally acquired skin lesions, thus reducing the risk of sero-conversion and slow the progress to AIDS. Indigenous sub-Saharan peoples are highly melanized, but there is pigment variation between populations. We show that skin reflectance, a negative correlate of melanin, is positively associated with adult rate of HIV in sub-Saharan countries. There is no such relationship in populations outside sub-Saharan Africa. We suggest that melanin concentration in black people may correlate with resistance to HIV infection.

Prevalence of HIV with conjunctival squamous cell neoplasia in an African provincial hospital

PURPOSE

To evaluate the prevalence of HIV seropositivity among patients with malignant conjunctival squamous cell carcinoma (SCC) and carcinoma in situ (CIS) and to reassess the potential linkage, albeit well documented, between ocular surface epithelial dysplasia (OSED) and HIV infection.

PATIENTS AND METHODS

A case-control design study was conducted in an African provincial hospital. Twenty-three African black patients underwent excisional biopsy of conjunctival malignant lesions. In 18 of these patients, ELISA for HIV antibodies was performed prior to the excisional biopsy.

RESULTS

Pathological evaluation revealed SCC in 12 (52%) patients, CIS in six (26%) patients, and Kaposi sarcoma (KS) in five (22%) patients. Eighteen patients (78.3%) agreed to take a serological HIV test, and among these, seropositivity for HIV was significantly (p < 0.01) higher (92.3%, 12 of 13) in the SCC/CIS subgroup than in a control group with benign conjunctival lesions (28.5%, two of seven). The most common (91.7%) clinical finding in the SCC/CIS/HIV group (12 patients) was corneal overriding. Conjunctival malignancy was the first presenting sign for AIDS in 50% of our patients.

CONCLUSIONS

A significantly high rate of HIV seropositivity was found in a group of African black patients with conjunctival SCC/CIS compared with a control group with benign conjunctival lesions. The direct correlation between HIV infection and SCC/CIS was reconfirmed in a case-control study. Therefore, an HIV test should probably be performed in cases of conjunctival SCC/CIS or dysplasia, especially among patients in high-risk populations.

Circumcision: a consideration of some of the controversy

This article considers the procedure known as male circumcision. This is practised throughout the world for a variety of reasons, including medically essential reasons, health promotion, health protection, cultural, religious and aesthetic. It has been estimated that approximately one-third of the male population has been circumcized. As with some other surgical interventions its use is controversial, and there are a number of ethical and moral issues that are of interest to the children's nurse. The anatomy and physiology of the prepuce is summarized and the practice of circumcision and some of the risks and proposed benefits of the procedure are considered. This article is intended to be culturally sensitive and it is hoped that it will inform others and provoke discussion. It may enable the children's nurse to raise awareness of the issues among the general population.

The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya

Compelling epidemiological evidence showing a significant association between lack of male circumcision and HIV infection has prompted calls for consideration of male circumcision interventions as a strategy for reducing HIV prevalence in highly affected areas where circumcision is little practiced and transmission is predominantly heterosexual. Little is known about whether male circumcision interventions would be acceptable or feasible in traditionally non-circumcisng areas of Africa. This study assesses the acceptability of male circumcision in the Luo, a large, traditionally non-circumcising ethnic group in western Kenya. Separate focused group discussions with adult Luo men and women and semi-structured interviews with clinicians were conducted in Nyanza Province, Kenya. The primary barriers to acceptance of male circumcision were cultural identification, fear of pain and excessive bleeding and cost. The main facilitators were association of male circumcision with better hygiene and reduced risk of infection. Both men and women were eager for promotion of genital hygiene and male circumcision, and they desired availability of circumcision clinical services in the Province's health facilities. Clinicians lacked the knowledge and resources to offer safe circumcision counselling and services. If results from this study are valid for other areas of sub-Saharan Africa, acceptability of male circumcision as a means to reduce STDs and HIV is higher than previously suspected. Further studies are needed in other regions to assess the feasibility of introducing acceptable male circumcision information and services to reduce HIV transmission.

Male circumcision as an HIV control strategy: not a 'natural condom'

Recent epidemiological studies have shown fairly convincingly that in high-risk populations in sub-Saharan Africa, male circumcision is associated with a reduced risk of HIV infection. Following a consultation at the XIII International AIDS Conference in July 2000 in Durban, there was growing interest in such an intervention. This paper explores what is known about male circumcision, the risks associated with it, its relationship with sexual health, including HIV and other sexually transmitted infections (STIs), and the potential problems with implementing circumcision as an intervention internationally, particularly in traditionally non-circumcising communities and those where access to medical facilities is limited. Proponents of male circumcision as an HIV prevention strategy are convinced and convincing, but circumcision is a surgical procedure with associated risks and has strong religious and cultural significance for many groups. Hence, there are ethical and practical barriers to implementing it as a public health intervention. The evidence suggests that circumcision may reduce the risk of infection, but circumcision does not appear to have any impact on transmission rates from HIV positive men to their partners. Until we know why and how circumcision is protective, exactly what the relationship is between circumcision status and other STIs, and whether the effect seen in high-risk populations is generalisable to other groups, the wisest course is to recommend risk reduction strategies of proven efficacy, such as condom use.

Male circumcision and HIV prevention: current knowledge and future research directions

Over the past decade, numerous epidemiological studies have reported a significant association between lack of male circumcision and risk for HIV infection, leading to recommendations for male circumcision to be added to the armamentarium of effective HIV prevention strategies. We review the epidemiological data from studies that have investigated this association, including ecological, cross-sectional/case-control, and prospective studies. We discuss problematic issues in interpreting the epidemiological data, including the presence of other sexually transmitted infections, age of circumcision, and potential confounders such as religion, cultural practices, and genital hygiene. In addition, we review studies of biological mechanisms by which the presence of the foreskin may increase HIV susceptibility, data on risks associated with the circumcision procedure, and available data on the acceptability and feasibility of introducing male circumcision in societies where it is traditionally not practised. Although the evidence in support of male circumcision as an effective HIV prevention measure is compelling, residual confounding in observational studies cannot be excluded. Taken together with concerns over the potential disinhibiting effect of male circumcision on risk behaviour, and safety of the circumcision procedure, randomised trials of male circumcision to prevent HIV infection are recommended. An individual's choice to undergo male circumcision or a community's decision to promote the practice should be made in the light of the best available scientific evidence. More knowledge is required to assist individuals and communities in making those decisions. We conclude with recommendations for future research.

Varieties of male circumcision: a study from Kenya

BACKGROUND

Because male circumcision has been linked to a lower risk of HIV infection, it is advocated tentatively as a possible preventive intervention. Most studies, however, have relied on men's self-reports of their circumcision status.

GOAL

To document varied techniques of male circumcision in one area of Kenya and the visible results.

STUDY DESIGN

Researchers interviewed men who had performed or undergone various forms of circumcision. They also did genital observations on a subsample of respondents.

RESULTS

All the men reported undergoing circumcision during adolescence, and most were able to tell which technique was used. According to the circumcisers, in type A, approximately 4 cm of the prepuce is removed; in type B, 1 to 2 cm of the prepuce and some of its inner surface are removed. Types A and B result in the same genital appearance. In type C, 1 to 2 cm of the prepuce and some of the inner surface are removed. The remaining prepuce is slit and suspended below the penile shaft.

CONCLUSIONS

Asking a man "Are you circumcised?" is not sufficient. Classifying his circumcision status requires both a genital examination and an understanding of the precise local surgical techniques used. Even in a small geographic area, considerable variety may exist in the techniques of cutting, removing, altering, or leaving different portions of the foreskin. Each variation may affect the transmission of HIV and other infections.

Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life

OBJECTIVE

To assess the effect of newborn circumcision on the incidence and medical costs of urinary tract infection (UTI) during the first year of life for patients in a large health maintenance organization.

SETTING

Kaiser Permanente Medical Care Program of Northern California (KPNC).

PATIENTS

The population consisted of members of KPNC. The study group consisted of a cohort of 28 812 infants delivered during 1996 at KPNC hospitals; of the 14 893 male infants in the group, 9668 (64.9%) were circumcised. A second cohort of 20 587 infants born in 1997 and monitored for 12 months was analyzed to determine incidence rates.

DESIGN

Retrospective study of all infants consecutively delivered at 12 facilities.

OUTCOME MEASURES

Diagnosis of UTI was determined from the KPNC computerized database using the International Classification of Diseases, Ninth Revision code for inpatients and KPNC Outpatient Summary Clinical Record codes for outpatients. A sample of 52 patient charts was reviewed to confirm the International Classification of Diseases, Ninth Revision and KPNC Outpatient Summary Clinical Record codes and provide additional data.

RESULTS

Infants <1 year old who were born in 1996 had 446 UTIs (292 in females; 154 in males); 132 (86%) of the UTIs in males occurred in uncircumcised boys. The mean total cost of managing UTI was 2 times as high in males ($1111) as in females ($542). This higher total cost reflected the higher rate of hospital admission in uncircumcised males with UTIs (27.3%) compared with females (7.5%); mean age at hospitalization for UTI was 2.5 months old for uncircumcised boys and 6.5 months old for girls. In 1996, total cost of managing UTI in uncircumcised males ($155 628) was 10 times higher than for circumcised males ($15 466) despite the fact that uncircumcised males made up only 35.1% of the male patient base in 1996, reflecting the more frequent occurrence of UTI in uncircumcised males (132 episodes) than in circumcised males (22 episodes), and the larger number of hospital admissions in uncircumcised males (38) than in circumcised males (4). The incidence of UTI in the first year of life was 1:47 (2.15%) in uncircumcised males, 1:455 (.22%) in circumcised males, and 1:49 (2. 05%) in females. The odds ratio of UTI in uncircumcised:circumcised males was 9.1:1.

CONCLUSIONS

Newborn circumcision results in a 9. 1-fold decrease in incidence of UTI during the first year of life as well as markedly lower UTI-related medical costs and rate of hospital admissions. Newborn circumcision during the first year of life is, thus, a valuable preventive health measure, particularly in the first 3 months of life, when uncircumcised males are most likely to be hospitalized with severe UTI.

Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda

OBJECTIVE

To study the differences in sexual practices, hygienic behaviors, and other HIV risk factors between circumcised and uncircumcised men.

DESIGN

A cross-sectional study of men >17 years of age selected by single stage cluster sampling in the Industrial Borough, Mbale, Uganda.

METHODS

Using a structured questionnaire, 188 circumcised and 177 uncircumcised consenting Ugandan men were interviewed in one of four native languages during April and May, 1997.

RESULTS

Among non-Muslims, circumcised men had a higher risk profile than uncircumcised men in that they were more likely to drink alcohol in conjunction with sex (odds ratio [OR], 1.86: 95% confidence interval [CI], 1.09-3.16), to have sexual contacts with women on the first day of meeting (OR, 2.37; 95% CI, 1.39-4.04), to have had sexual contacts in exchange for money or gifts (OR, 2.08; 95% CI, 1.21-3.09), to have experienced episodes of pain on urination or to have experienced penile discharge (OR, 1.68; 95% CI, 1.07-2.64), had an earlier age at sexual debut (15.7 versus 16.9 years), and had more extramarital sex partners in the last year (1.13 versus 0.62). Circumcised men also reported a preference for nonwet sex. Muslims generally had a lower risk profile than other circumcised men except they were less likely to have ever used a condom (OR, 0.34; 95% CI, 0.15-0.78) or to have used a condom during the last sex encounter (OR, 0.37; 95% CI, 0.14-0.87).

CONCLUSIONS

These results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally noncircumcising societies are warranted.

Nigerian university students' knowledge, perceptions, and behaviours about HIV/AIDS: are these students at risk?

The purpose of the study was to determine the knowledge level of undergraduate students of a Nigerian university about HIV/AIDS, their perception of risk of contracting HIV/AIDS based on their sexual behaviour, and to assess how students acquire information about HIV/AIDS. The sample consisted of 380 students from five faculties of the university who volunteered to participate in the study. Participants completed a survey asking about their knowledge about transmission, symptomatology and prevention of HIV/AIDS. The survey included questions about their sexual orientation, past and present sexual practices as well as sources of information about HIV/AIDS. The results indicated that the students were knowledgeable about transmission and symptomatology but there were some misconceptions about the mode of transmission of HIV. Few students identified themselves to be at high risk even though majority of them (92%) were sexually experienced. The study also showed that even though these students are knowledgeable and concerned about contracting HIV/AIDS from their partners, this did not prevent them from engaging in unprotected sexual intercourse. It appears, however, that students are exercising caution when negotiating new sexual relationships, as they are likely to discuss (and insist on) using condoms and ask to have a monogamous relationship. Students obtained information about HIV/AIDS primarily from the media rather than from school classrooms and homes, which suggests a need to increase educational efforts at the university. Many students of this university may be at risk of becoming HIV-infected due to their age bracket, level of sexual activity and past/present sexual behaviors. University faculty can be actively involved in developing and implementing HIV/AIDS education and prevention strategies on their campuses. Health educators must go beyond providing accurate and gender-specific information about HIV/AIDS; they must also help students realistically assess their own risk of infection, and develop communication processes which enable them to negotiate safer sexual practices.

Circumcision and HIV infection: review of the literature and meta-analysis

Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded.

Male circumcision: assessment of health benefits and risks

OBJECTIVES

Globally approximately 25% of men are circumcised for religious, cultural, medical, or parental choice reasons. However, controversy surrounds the procedure, and its benefits and risks to health. We review current knowledge of the health benefits and risks associated with male circumcision.

METHODS

We have used, where available, previously conducted reviews of the relation between male circumcision and specific outcomes as "benchmarks", and updated them by searching the Medline database for more recent information.

RESULTS

There is substantial evidence that circumcision protects males from HIV infection, penile carcinoma, urinary tract infections, and ulcerative sexually transmitted diseases. We could find little scientific evidence of adverse effects on sexual, psychological, or emotional health. Surgical risks associated with circumcision, particularly bleeding, penile injury, and local infection, as well as the consequences of the pain experienced with neonatal circumcision, are valid concerns that require appropriate responses.

CONCLUSION

Further analyses of the utility and cost effectiveness of male circumcision as a preventive health measure should, in the light of this information, be research and policy priorities. A decision as to whether to recommend male circumcision in a given society should be based upon an assessment of the risk for and occurrence of the diseases which are associated with the presence of the foreskin, versus the risk of the complications of the procedure. In order for individuals and their families to make an informed decision, they should be provided with the best available evidence regarding the known benefits and risks.

A proposed relationship between circumcision and neural reorganization

Humans are intensely biocultural beings. The linkages and causal feedback loops among their symbolic world, their cultural world, and their physical bodies can be exquisitely complex and subtle. It is suggested in this article that one cultural event--circumcision--exemplifies that subtlety and complexity. It is hypothesized that circumcision reorganizes the male's sensory somato-cortex to raise the threshold of sexual excitability/distraction. This threshold shift thereby allows the young men of a social group (a) to be slightly more tractable in executing corporate activities beneficial to the community and (b) to be slightly more restrained sexually and more cooperative in the pair bond. The practice is accepted because the procedure is deeply enmeshed in the ritual and symbolic life of the social group and is applicable to all young males. Suggestions are made on how to test this hypothesis empirically.

Role of the Haemophilus ducreyi Ton system in internalization of heme from hemoglobin

By cloning into Escherichia coli and construction of isogenic mutants of Haemophilus ducreyi, we showed that the hemoglobin receptor (HgbA) is TonB dependent. An E. coli hemA tonB mutant expressing H. ducreyi hgbA grew on low levels of hemoglobin as a source of heme only when an intact H. ducreyi Ton system plasmid was present. In contrast, growth on heme by the E. coli hemA tonB mutant expressing hgbA was observed only at high concentrations of heme, was TonB independent, and demonstrated that H. ducreyi HgbA was not sufficient to function as a typical TonB-dependent heme receptor in E. coli. Allelic replacement of the wild-type H. ducreyi exbB, exbD, and tonB loci with the exbB, exbD, and tonB deletion resulted in an H. ducreyi isogenic mutant unable to utilize hemoglobin but able to utilize hemin at the same levels as the parent strain to fulfill its heme requirement. This finding confirms the TonB dependence of HgbA-mediated hemoglobin utilization and suggests that uptake of hemin in H. ducreyi is TonB independent. Additionally, the H. ducreyi Ton system mutant synthesized increased amounts of HgbA and other heme-regulated outer membrane proteins, consistent with derepression of these proteins due to lower intracellular heme and/or iron concentrations in the mutant. Sequencing of the Ton system genes revealed that the arrangement of the genes was exbB exbD tonB. The proximity and structure of these genes suggested that they are transcribed as an operon. This arrangement, as well as the DNA and deduced amino acid sequences of these H. ducreyi genes, was most similar to those from other pasteurellae.

Prophylactic neonatal surgery and infectious diseases

Infections worldwide are the primary cause of morbidity and mortality today. The need for prevention is essential. Prophylactic surgery with the reduction of infectious disease has been available for many millennia, but its recognition has been questionably accepted. This article presents evidence of former times when circumcision was performed in the ancient Egyptian, Coptic and Ethiopian cultures, probably as a therapeutic measure to combat the ravages of schistosomal infectious symptomatology. How this health measure was converted to a religious rite and the confusion caused by this misunderstanding is fully explored. The association of an operative procedure as a religious ritual among Jews, and Christian Biblical ambiguity toward it, has further clouded the issue. Neonatal circumcision has been perpetuated in many societies and cultures, not because of the Jews and their Covenant of Circumcision, but because of its merit as a secular surgical prophylactic health measure. This article explores an interesting issue from its beginning to contemporary research and findings that justify the procedure as a viable option in maintaining and promoting quality genital health care for males of all ages.

A biocultural analysis of circumcision

The phenomenon of circumcision may well serve a range of religious and symbolic functions. In addition to these conceptual categories, we argue that circumcision also serves a more mundane, practical function of lowering excitability and distractibility quotients--sexual arousal--of pubescent males, i.e., biasing young males more toward increased tractability which would enhance group efforts and less toward individual goals of amorous exchanges. Neurological data suggest that early lesions of the prepuce/foreskin tissues would generate a re-organization/atrophy of the brain circuitry. This re-organization/atrophy, in turn, is suggested to lower sexual excitability. Epithelial data indicate that keratinization of the more exposed glans penis would lower the sensibility, hence sexual excitability, of the circumcised male's genitalia. In addition, circumcision removes the foreskin-prepuce which, by secreting smegma, would also minimize any pheromonic qualities which the smegma may generate. Inferential data support the hypothesis that a practical consequence of circumcision, complementary to any religious-symbolic function, is to make a circumcised male less sexually excitable and distractible, and, hence, more amenable to his group's authority figures.

The distribution of selenium and mortality owing to acquired immune deficiency syndrome in the continental United States

A hypothesis has been proposed that Selenium (Se) concentration in the environment as measured by its uptake by alfalfa, which sorbs Se from the soil in proportion to what is present, exerted an apparent effect on incidence of (acquired immune deficiency syndrome) AIDS such that AIDS' mortality within the conterminous United States was lower where the Se quantity in the soil was high than where the amount was low. The object of this study was to test this hypothesis for statistical significance and to discover whether the apparent pattern of AIDS mortality in relation to Se distribution holds true with respect to all ages, both races (Black and White), and both genders. The statistical analysis employed was analysis of variance. Age-specific data as well as age-adjusted data were subject to statistical analysis. Ages where AIDS mortality rates per 100,000 were greatest were in the range from 25-54 yr for low-, medium-, and high-Se areas of the US. Black mortality owing to AIDS showed highly statistically significant results for the three Se regions, both genders, and six age groups, whereas White mortality was not as significantly affected by Se. A hypothesis is proposed that the Black population during the last decade or so has been less migratory than the White population. Thus, their food supply and hence its Se content have been more stable than that of the White population, which is more prone to consume imported foods to unknown Se content and be more migratory. A second hypothesis is advanced that suggests that medical care is not equally available to the poor and especially poor Blacks. Black men and women die at a greater death rate than do Whites. This implies that a lack of medical care is the true cause. This article suggests that a pattern exists between the geographical distribution of Se using alfalfa as a dietary guide and AIDS' mortality such that an inverse relationship persists between Se quantity in an area and AIDS' mortality in the same area.