Increased risk of infection with human immunodeficiency virus type 1 among uncircumcised men presenting with genital ulcer disease in Kenya

Sexually transmitted infections and male circumcision: a systematic review and meta-analysis

The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.

Incremental role of male circumcision on a generalised HIV epidemic through its protective effect against other sexually transmitted infections: from efficacy to effectiveness to population-level impact

BACKGROUND

Male circumcision (MC) can reduce HIV acquisition. However, a better understanding of the indirect protective effect of MC on sexually transmitted infections (STIs) is required.

OBJECTIVE

To assess the incremental benefits conferred by MC on HIV infection at the individual level in circumcision trials (no herd immunity effect) and at the population level (with herd immunity effect) owing to its protective effect against other STIs.

METHODS

A dynamic stochastic model of HIV and STI infections in a Kenyan population was used to simulate the impact of MC offered to a few trial participants or to a large proportion of men in order to study the protective role of MC on HIV infection at the individual and population levels.

RESULTS

Fewer than 20% of the HIV infections prevented in the circumcised arm of the circumcision trials (individual level) could be attributable to the efficacy of MC against STIs rather than against HIV. At the population level, MC can significantly reduce the prevalence of HIV, especially among men and women in the longer term. However, even at the population level, the long-term incremental impact of MC on HIV due to the protection against STI is modest (even if MC efficacy against the STI and STI prevalence was high).

CONCLUSIONS

The protection of MC against STI contributes little to the overall effect of MC on HIV. Additional work is needed to determine whether, and under what conditions, the protective effect of MC efficacy against STIs can have a significant incremental benefit on the HIV epidemic.

Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review

Based on epidemiological, clinical and experimental evidence, male circumcision (MC) could have a significant impact on the HIV epidemic in selected areas. We reviewed studies of the acceptability of MC in sub-Saharan Africa to assess factors that will influence uptake of circumcision in traditionally non-circumcising populations. Thirteen studies from nine countries were identified. Across studies, the median proportion of uncircumcised men willing to become circumcised was 65% (range 29-87%). Sixty nine percent (47-79%) of women favored circumcision for their partners, and 71% (50-90%) of men and 81% (70-90%) of women were willing to circumcise their sons. Because the level of acceptability across the nine countries was quite consistent, additional acceptability studies that pose hypothetical questions to participants are unnecessary. We recommend pilot interventions making safe circumcision services available in conjunction with current HIV prevention strategies and evaluating the safety and acceptability of circumcision.

Treatment of chancroid in resource-poor countries

Chancroid, formerly a major cause of the genital ulcer disease syndrome, remains an important cofactor in both the transmission and acquisition of HIV-1 infection. Those countries with the greatest burden of HIV also have some of the highest prevalence rates of chancroid worldwide. The diagnosis of chancroid, caused by the fastidious bacterium Haemophilus ducreyi, is both expensive and difficult in many resource-poor areas. These areas of the world use syndromic management to treat genital ulcers and such an approach has proven effective in reducing rates of bacterial genital ulcer diseases. There are currently inexpensive and effective single-dose therapies available to treat chancroid. Single-dose regimens, given at first presentation, improve compliance and reduce the risk of sexually transmitted infections. Bacterial resistance to several antimicrobial agents has increased over the years and remains a continued threat to effective antimicrobial therapy. Follow-up of cases, and partner notification and treatment is carried out to limit reinfection and onward transmission of chancroid. Patients with coexistent HIV may be particularly at risk of failing single-dose therapy and should therefore be reviewed wherever possible.

Sexually Transmitted Infections Among Brothel-Based Sex Workers in Bangladesh: High Prevalence of Asymptomatic Infection

OBJECTIVE AND GOAL: The goal of this study was to study the prevalence of sexually transmitted infections (STIs)/reproductive tract infections (RTIs) among brothel-based sex workers (SWs) in Bangladesh.

STUDY

A cross-sectional study was conducted among SWs in 4 randomly selected brothels. A sociodemographic and behavioral survey and pelvic examination was conducted. Specimens including endocervical swab, high vaginal swab, and blood were collected and were examined for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, bacterial vaginosis candidiasis, and syphilis.

RESULTS

A total of 439 SWs were enrolled and 49.6% had genital symptoms. Among all SWs, 17.5% were positive for N. gonorrhoeae; 15.5% for C. trachomatis; 7.5% for T. vaginalis, and 6.6% had active syphilis. A total of 67.4% SWs were positive for at least 1 cervical and/or vaginal infection.

CONCLUSION

The prevalence of STIs/RTIs among SWs in brothels in Bangladesh is high. An intervention strategy addressing both symptomatic and asymptomatic infections and periodic screening of SWs for RTIs/STIs is essential for successful HIV and STIs prevention programs.

Gender Differences in Bacterial STIs in Canada

HEALTH ISSUE: The incidence of bacterial sexually transmitted infections (STIs) is rising in Canada. If these curable infections were prevented and treated, serious long-term sequelae including infertility, and associated treatment costs, could be dramatically reduced. STIs pose a greater risk to women than men in many ways, and further gender differences exist in screening and diagnosis. KEY FINDINGS: Reported incidence rates of chlamydia, gonorrhea, and infectious syphilis declined until 1997, when the trend began to reverse. The reported rate of chlamydia is much higher among women than men, whereas the reverse is true for gonorrhea and infectious syphilis. Increases in high-risk sexual behaviour among men who have sex with men were observed after the introduction of potent HIV suppressive therapy in 1996, but behavioural changes in women await further research. DATA GAPS AND RECOMMENDATIONS: STI surveillance in Canada needs improvement. Reported rates underestimate the true incidence. Gender-specific behavioural changes must be monitored to enhance responsiveness to groups at highest risk, and more research is needed on effective strategies to promote safer sexual practices. Geographic and ethnic disparities, gaps, and needs must be addressed. Urine screening for chlamydia should be more widely available for women as well as men, particularly among high-risk men in order to prevent re-infections in their partners. As women are more likely to present for health examinations (e.g. Pap tests), these screening opportunities must be utilized. Female-controlled methods of STI prevention, such as safer topical microbicides, are urgently needed.

Risk of HIV-1 in rural Kenya: a comparison of circumcised and uncircumcised men

BACKGROUND

Most studies that have found an association between uncircumcised status and infection with human immunodeficiency virus type 1 (HIV-1) have compared participants from various demographic backgrounds, among which the prevalence of other risk factors might have varied. We report findings from a study conducted among men within a single ethnic community in which circumcision was dictated by the religious denomination to which the men belonged.

METHODS

Of the 1217 eligible men, we included in the analysis 845 who gave blood samples for HIV-1 testing and who were confirmed as either fully circumcised (n = 398) or uncircumcised (n = 447). The seroprevalence of HIV-1 was compared between the 2 groups.

RESULTS

All correlates of HIV-1 prevalence that we measured were distributed similarly between circumcised and uncircumcised men. The seroprevalence of HIV-1 was 30% among the uncircumcised men and 20% among the circumcised men. Among uncircumcised men, HIV-1 seroprevalence was similar between men from circumcising denominations (31%; n = 111) and noncircumcising denominations (30%; n = 336). The crude prevalence ratio for HIV infection associated with not being circumcised was 1.5 (95% confidence interval = 1.2-2.0); and adjustment for other measured risk factors for HIV-1 infection had little impact on this result.

CONCLUSION

Our study provides evidence that circumcision is associated with a reduced risk of HIV-1 infection.

Macrophage HIV-1 infection and the gastrointestinal tract reservoir

Excluding parenteral transmissions, virtually all vertical and homosexual transmission of human immunodeficiency virus type 1 (HIV-1) occurs via the gastrointestinal tract. Cellular routes implicated in the translocation of virus across the epithelium include M cells, dendritic cells, and epithelial cells. Intestinal epithelial cells express CCR5 and can selectively transfer CCR5-tropic HIV-1, the phenotype of the majority of transmitted viruses. In the lamina propria, virus encounters the largest reservoir of mononuclear cells in the body. Surprisingly, lamina propria lymphocytes, not macrophages, express CCR5 and CXCR4 and support HIV-1 replication, implicating intestinal lymphocytes as the initial target cell in the intestinal mucosa. From the mucosa, virus is disseminated to systemic sites, followed by profound depletion of CD4+ T cells, first in the intestinal lamina propria and subsequently in the blood. As mucosal and circulating CD4+ T cells are depleted, monocytes and macrophages assume an increasingly important role as target and reservoir cells for HIV-1. Blood monocytes, including HIV-1-infected cells, are recruited to the mucosa, where they differentiate into lamina propria macrophages in the presence of stroma-derived factors. Although the prevalence of HIV-1-infected macrophages in the mucosa is low (0.06% of lamina propria mononuclear cells), the extraordinary size of the gastrointestinal mucosa imparts to intestinal macrophages a prominent role as a HIV-1 reservoir. Elucidating the immunobiology of mucosal HIV-1 infection is critical for understanding disease pathogenesis and ultimately for devising an effective mucosal HIV-1 vaccine.

Male circumcision: an acceptable strategy for HIV prevention in Botswana

BACKGROUND

Male circumcision is known to reduce the risk of acquiring HIV, but few studies have been performed to assess its acceptability among either children or adults in sub-Saharan Africa.

METHODS

We conducted a cross sectional survey in nine geographically representative locations in Botswana to determine the acceptability of male circumcision in the country, as well as the preferred age and setting for male circumcision. Interviews were conducted using standardised questionnaires both before and after an informational session outlining the risks and benefits of male circumcision.

RESULTS

Among 605 people surveyed, the median age was 29 years (range 18-74 years), 52% were male, and >15 ethnicities were represented. Before the informational session, 408 (68%) responded that they would definitely or probably circumcise a male child if circumcision was offered free of charge in a hospital setting; this number increased to 542 (89%) after the informational session. Among 238 uncircumcised men, 145 (61%) stated that they would definitely or probably get circumcised themselves if it were offered free of charge in a hospital setting; this increased to 192 (81%) after the informational session. In a multivariate analysis of all participants, people with children were more likely to favour circumcision than people without children (adjusted odds ratio 1.8, 95% CI 1.0 to 3.4). Most participants (55%) felt that the ideal age for circumcision is before 6 years, and 90% of participants felt that circumcision should be performed in the hospital setting.

CONCLUSIONS

Male circumcision appears to be highly acceptable in Botswana. The option for safe circumcision should be made available to parents in Botswana for their male children. Circumcision might also be an acceptable option for adults and adolescents, if its efficacy as an HIV prevention strategy among sexually active people is supported by clinical trials.

Male circumcision for prevention of heterosexual acquisition of HIV in men

BACKGROUND

The findings from observational studies, reviews and meta-analyses, supported by biological theories, that circumcised men appear less likely to acquire human immunodeficiency virus (HIV) has contributed to the recent ground swell of support for considering male circumcision as a strategy for preventing sexually acquired infection. We sought to elucidate and appraise the global evidence from published and unpublished studies that circumcision can be used as an intervention to prevent HIV infection.

OBJECTIVES

1) To assess the evidence of an interventional effect of male circumcision for preventing acquisition of HIV-1 and HIV-2 by men through heterosexual intercourse 2) To examine the feasibility and value of performing individual person data (IPD) meta-analysis

SEARCH STRATEGY

We searched online for published and unpublished studies in The Cochrane Library (issue 2, 2002), MEDLINE (April 2002), EMBASE (February 2002) and AIDSLINE (August 2001). We also searched databases listing conference abstracts, scanned reference lists of articles and contacted authors of included studies.

SELECTION CRITERIA

We searched for randomized and quasi-randomized controlled trials of male circumcision or, in their absence, observational studies that compare acquisition rates of HIV-1 and HIV-2 infection in circumcised and uncircumcised heterosexual men.

DATA COLLECTION AND ANALYSIS

Independent reviewers selected studies, assessed study quality and extracted data. We stratified studies based on study design and on whether they included participants from the general population or high-risk groups (such as patients treated for sexually transmitted infections). We expressed findings as crude and adjusted odds ratios (OR) together with their 95% confidence intervals (CI) and conducted a sensitivity analysis to explore the effect of adjustment on study results. We investigated whether the method of circumcision ascertainment influenced study outcomes.

MAIN RESULTS

We identified no completed randomized controlled trials. Three randomized controlled trials are currently underway or commencing shortly. We found 34 observational studies: 16 conducted in the general population and 18 in high-risk populations. It seems unlikely that potential confounding factors were completely accounted for in any of the included studies. In particular, important risk factors, such as religion and sexual practices, were not adequately accounted for in many of the included studies. General population study results:The single cohort study (N = 5516) showed a significant difference in HIV transmission rates between circumcised and uncircumcised men [OR = 0.58; 95% CI: 0.36 to 0.96]. Results for the 14 cross-sectional studies were inconsistent, with point estimates for unadjusted odds ratios varying between 0.28 and 1.73. Six studies had statistically significant results, four in the direction of benefit and two in the direction of harm. The test for heterogeneity between the cross-sectional studies was highly significant (chi-square = 77.59; df = 13; P-value < 0.00001). Nine studies reported adjusted odds ratios with eight in the direction of benefit, ranging from 0.26 to 0.80. Use of adjusted results tended to show stronger evidence of an association although they remained heterogenous (chi-square = 75.2; df = 13; P-value < 0.00001). Only one case-control study was found (N = 51) which had a non-significant result [OR = 1.90; 95% CI: 0.50 to 7.20]. High-risk group study results:The four cohort studies identified found a protective effect from circumcision with point estimates for unadjusted odds ratios varying from 0.10 to 0.39. Two of these studies had statistically significant results. Two studies reported adjusted odds ratios, both protective with one being significant. The chi-square test for between-study heterogeneity was not significant (chi-square = 5.21; df = 3; P-value = 0.16). All eleven cross-sectional studies reporting unadjusted results found benefit from circumcision, eight of which had statistically significant results. Estimates of effnal studies reporting unadjusted results found benefit from circumcision, eight of which had statistically significant results. Estimates of effect varied from an unadjusted odds ratio of 0.10 to 0.66. Between-study heterogeneity was significant with the chi-square = 29.77; df = 10; P-value = 0.0009. Four of these studies reported adjusted odds ratios ranging from 0.20 to 0.59 and all were significant. One additional cross-sectional study only reported an adjusted odds ratio in the direction of benefit which was statistically significant. All three case-control studies found a protective effect of circumcision on HIV status, two being statistically significant. Point estimates varied from unadjusted odds ratios of 0.37 to 0.88. One reported an adjusted odds ratio showing a significant protective effect. Adverse effects:No studies reported on the adverse effects of circumcision. In most studies, circumcision had taken place during childhood or adolescence before the studies commenced.

REVIEWER'S CONCLUSIONS

We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.

Haemophilus ducreyi requires the flp gene cluster for microcolony formation in vitro

Haemophilus ducreyi, the etiologic agent of chancroid, has been shown to form microcolonies when cultured in the presence of human foreskin fibroblasts. We identified a 15-gene cluster in H. ducreyi that encoded predicted protein products with significant homology to those encoded by the tad (for tight adhesion) locus in Actinobacillus actinomycetemcomitans that is involved in the production of fimbriae by this periodontal pathogen. The first three open reading frames in this H. ducreyi gene cluster encoded predicted proteins with a high degree of identity to the Flp (fimbria-like protein) encoded by the first open reading frame of the tad locus; this 15-gene cluster in H. ducreyi was designated flp. RT-PCR analysis indicated that the H. ducreyi flp gene cluster was likely to be a polycistronic operon. Mutations within the flp gene cluster resulted in an inability to form microcolonies in the presence of human foreskin fibroblasts. In addition, the same mutants were defective in the ability to attach to both plastic and human foreskin fibroblasts in vitro. An H. ducreyi mutant with an inactivated tadA gene exhibited a small decrease in virulence in the temperature-dependent rabbit model for experimental chancroid, whereas another H. ducreyi mutant with inactivated flp-1 and flp-2 genes was as virulent as the wild-type parent strain. These results indicate that the flp gene cluster is essential for microcolony formation by H. ducreyi, whereas this phenotypic trait is not linked to the virulence potential of the pathogen, at least in this animal model of infection.

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.

Fleeting foreskins: the misclassification of male circumcision status

BACKGROUND

Errors in the classification of male circumcision status could bias studies linking infection to lack of circumcision.

GOAL

To determine the frequency and factors associated with the reproducibility of reporting circumcision status.

STUDY DESIGN

Secondary analysis of data using logistic regression modeling from a multicenter randomized controlled trial was performed.

RESULTS

At follow-up assessment, 15.6% of clinician reports on circumcision status disagreed with baseline reports. Disagreement was more common if both clinicians were women than if both were men (odds ratio [OR], 2.8; 95% CI, 1.9-4.1). As compared with whites reported as circumcised (4%, 19/532 visits), the highest disagreement involved uncircumcised Hispanic (OR, 3.3; 95% CI, 1.7-6.3), white (OR, 12.2; 95% CI, 5.8-25.6), or black (OR, 17.1; 95% CI, 10.4-27.9) men.

CONCLUSIONS

This is one study among a small number of studies examining the reproducibility of clinician-reported circumcision status by comparing multiple clinical examinations of the same patient. The magnitude of the misclassification discovered could bias results and indicates the need for greater accuracy in reporting circumcision status in future studies.

Enhanced efficiency of female-to-male HIV transmission in core groups in developing countries: the need to target men

BACKGROUND

The spread of heterosexual HIV in developing countries is heterogeneous. Factors that explain the wide diversity of HIV prevalences in different countries are undetermined. International aid organizations currently appear to be focusing activities mainly on women rather than on men.

GOAL

To identify critical determinants contributing to the high rates of heterosexual HIV transmission in developing countries through a review of studies investigating HIV per-act transmission rates, and to discuss how these factors might be prioritized through HIV-prevention interventions.

STUDY DESIGN

Studies investigating the per-act HIV transmission rate were identified through a MEDLINE search and a review of the abstracts of the Annual International AIDS Conferences.

RESULTS

When the summary mean per-act HIV transmission rates were calculated, the ratio of female-to-male HIV transmission in developing countries compared with that in the developed world was 341, whereas that for male-to-female transmission was 2.9.

CONCLUSION

Enhanced female-to-male HIV transmission in male core groups is a critical determinant of high-prevalence HIV epidemics among heterosexuals in developing countries. In addition to condom promotion, there is a need for an increased emphasis on HIV-prevention activities in men to decrease their susceptibility in developing countries, particularly in the countries most affected by the epidemic.

Circumcision and STD in the United States: cross sectional and cohort analyses

BACKGROUND

Male circumcision status has been shown to be associated with sexually transmitted disease (STD) acquisition in some, but not all, studies. Most studies have been cross sectional.

OBJECTIVES

We examined the association between circumcision status and the prevalence and incidence of gonorrhoea, chlamydia, and syphilis.

METHODS

We analysed cross sectional and cohort study data from a multicentre controlled trial in the United States. Between July 1993 and September 1996, 2021 men visiting public inner city STD clinics in the United States were examined by a clinician at enrolment and 1456 were examined at follow up visits 6 and 12 months later. At each visit, men had laboratory tests for gonorrhoea, chlamydia, and syphilis and were examined for circumcision status. We used multiple logistic regression to compare STD risk among circumcised and uncircumcised men adjusted for potentially confounding factors.

RESULTS

Uncircumcised men were significantly more likely than circumcised men to have gonorrhoea in the multivariate analyses, adjusted for age, race, and site, in both the cross sectional (odds ratio (OR), 1.3; 95% confidence interval (CI), 0.9 to 1.7) and in the cohort analysis (OR, 1.6; 95% CI, 1.0 to 2.6). There was no association between lack of circumcision and chlamydia in either the cross sectional (OR, 1.0; 95% CI 0.7-1.4) or the cohort analysis (OR, 0.9; 95% CI 0.5-1.5). The magnitude of association between lack of circumcision and syphilis was similar in the cross sectional (OR, 1.4; 95% CI 0.6 to 3.3) and cohort analysis (OR, 1.5; 95% CI 0.4 to 6.1).

CONCLUSION

Uncircumcised men in the United States may be at increased risk for gonorrhoea and syphilis, but chlamydia risk appears similar in circumcised and uncircumcised men. Our results suggest that risk estimates from cross sectional studies would be similar to cohort findings.

Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVE

To systematically review studies of male circumcision and the risk of HIV-1 infection in men in sub-Saharan Africa, and to summarize the findings in a meta-analysis.

DESIGN

A meta-analysis of observational studies.

METHODS

A systematic literature review was carried out of studies published up to April 1999 that included circumcision as a risk factor for HIV-1 infection among men in sub-Saharan Africa. A random effects meta-analysis was used to calculate a pooled relative risk (RR) and 95% confidence interval (CI) for all studies combined, and stratified by type of study population. Further analyses were conducted among those studies that adjusted for potential confounding factors.

RESULTS

Twenty-seven studies were included. Of these, 21 showed a reduced risk of HIV among circumcised men, being approximately half that in uncircumcised men (crude RR = 0.52, CI 0.40-0.68). In 15 studies that adjusted for potential confounding factors, the association was even stronger (adjusted RR = 0.42, CI 0.34-0.54). The association was stronger among men at high risk of HIV (crude RR = 0.27; adjusted RR = 0.29, CI 0.20-0.41) than among men in general populations (crude RR = 0.93; adjusted RR = 0.56, CI 0.44-0.70).

CONCLUSION

Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised.

HIV/AIDS in Bangladesh: an assessment of biomedical risk factors for transmission

Behavioural risk factors for HIV/AIDS in Bangladesh were reviewed in a preceding article in this journal. Omitted from that review was a discussion of potential biomedical risk factors including: (i) an unregulated blood supply system in which blood used in transfusions is not screened for HIV and is donated primarily by professional donors: (ii) unsterile injections in non-formal and formal health-care settings; and (iii) a high prevalence in high-risk groups of other sexually transmitted diseases (STDs) which may function as co-factors for HIV transmission, particularly if chronically untreated. Studies elsewhere in the world suggest that the unregulated blood supply system, in particular, poses a serious danger in terms of the spread of the HIV epidemic. While certain socio-cultural factors may be contributing to low levels of HIV in Bangladesh, the prevalence of biomedical and behavioural risk factors suggest the importance of implementing targeted cost-effective interventions now.

Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.

Age of male circumcision and risk of prevalent HIV infection in rural Uganda

OBJECTIVE

To assess whether circumcision performed on postpubertal men affords the same level of protection from HIV-1 acquisition as circumcisions earlier in childhood.

DESIGN

Cross-sectional study of a population-based cohort.

SETTING

Rakai district, rural Uganda.

METHODS

A total of 6821 men aged 15-59 years were surveyed and venous blood samples were tested for HIV-1 and syphilis. Age at circumcision was dichotomized into men who were circumcised before or at age 12 years (prepubertal) and men circumcised after age 12 years (postpubertal). Postpubertal circumcised men were also subdivided into those reporting circumcision at ages 13-20 years and > or = 21 years.

RESULTS

HIV-1 prevalence was 14.1% in uncircumcised men, compared with 16.2% for men circumcised at age > or = 21 years, 10.0% for men circumcised at age 13-20 years, and 6.9% in men circumcised at age < or = 12 years. On bivariate analysis, lower prevalence of HIV-1 associated with prepubertal circumcision was observed in all age, education, ethnic and religious groups. Multivariate adjusted odds ratio of prevalent HIV-1 infection associated with prepubertal circumcision was 0.39 [95% confidence interval (CI), 0.29-0.53]. In the postpubertal group, the adjusted odds ratio for men circumcised at ages 13-20 years was 0.46 (95% CI, 0.28-0.77), and 0.78 (95% CI, 0.43-1.43) for men circumcised after age 20 years.

CONCLUSIONS

Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection. Age at circumcision and reasons for circumcision need to be considered in future studies of circumcision and HIV risk.

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.

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.