Understanding partial protection and HIV risk and...

By: K. L’Engle,1,* M. Lanham,1 M. Loolpapit,2 and I. Oguma2
Source: PMC
Website: https://www.ncbi.nlm.nih.gov

Understanding partial protection and HIV risk and behavior following voluntary medical male circumcision rollout in Kenya

bstract

In the midst of scaling up voluntary medical male circumcision (VMMC) in Kenya, there is concern that men do not adequately understand that circumcision provides only partial protection against HIV. The study goal was to determine men’s understanding of partial protection, perceptions of HIV risk before and after VMMC and use of protective measures following VMMC. In-depth interviews with 44 men aged 18–39 years recently circumcised or planning to undergo VMMC were conducted in two urban and rural districts in Nyanza Province, Kenya. Participants described partial protection as the need to continue using other HIV protective measures such as condoms, with numbers such as a ‘60 percent protection’ or ‘not 100 percent protection’, and described how circumcision reduces HIV transmission such as reduced penile bruising or bleeding. Most said their HIV risk before VMMC was high and that VMMC would reduce their risk moderately. Participants demonstrated good understanding of partial protection and there was little suggestion of risk compensation following VMMC.
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Introduction

Results from three large randomized controlled trials in Kenya, Uganda and South Africa documented that medical circumcision substantially reduced men’s risk of acquiring HIV infection through vaginal intercourse by approximately 50–60% [1–3]. Men in the Kenya and Uganda trials who underwent extended follow-up exhibited sustained reductions in HIV incidence of 64% at 5.5 years in Kenya and 73% at 5 years in Uganda [4–6]. Following endorsement by the World Health Organization and the Joint United Nations Programme on HIV/AIDS [7], the government of Kenya adopted voluntary medical male circumcision (VMMC) as a key strategy for HIV prevention. Nyanza Province in western Kenya has been prioritized for VMMC rollout because of its high prevalence of heterosexually transmitted HIV infection (14.9%) and low prevalence of male circumcision (48%) [8, 9]. Although most ethnic groups in Kenya traditionally circumcise men and 85% of Kenya men are estimated to be circumcised [8], the Luo, the predominant ethnic group in Nyanza Province, do not traditionally circumcise. To date, the Kenya VMMC program has circumcised more than 600 000 men (A. Ochieng’, personal communication), mostly in Nyanza Province.

VMMC reduces a man’s risk of HIV through vaginal intercourse substantially but not completely. Counseling and strategic communications are key elements of Kenya’s VMMC program and advise that VMMC provides only partial protection against HIV and therefore continued use of HIV protective measures is necessary [10]. The Communication Strategy for Voluntary Medical Male Circumcision in Kenya, for example, states that VMMC communications should emphasize (p. 18), “… that male circumcision reduces the risk of men acquiring HIV infection by 60 percent and that this protective effect is only partial as well as the fact that the procedure is additional but not a substitute for other proven HIV prevention methods.” [10] It is not clear, however, whether men currently undergoing medical circumcision understand the meaning of partial protection and intend to practice other HIV protective behaviors after VMMC.

Theories of health behavior such as the Health Belief Model, AIDS Risk Reduction Model and Extended Parallel Processing Model [11–13] posit that adoption or change in behavior starts with the newbournperception that one is at risk of a harmful health outcome. Applied to VMMC, men are motivated to undergo VMMC, in large part, because they perceive themselves to be at risk of acquiring HIV and they further believe that being circumcised will reduce their HIV risk. Beliefs about the degree of HIV protection afforded by VMMC—termed response efficacy—may moderate changes in HIV risk perception after getting circumcised and thereby influence sexual behavior. For example, if a man understands that VMMC is only partially protective against HIV, he may be inclined to practice other HIV protective behaviors. Alternatively, if he thinks that male circumcision is 100% effective at preventing HIV, he may think that he is no longer at risk of HIV infection after VMMC and engage in risky or compensatory sexual behavior. Although there is no substantive evidence, there is apprehension that medically circumcised men will engage in riskier sexual behaviors because they erroneously believe that circumcision completely reduces their risk of HIV infection—a phenomenon termed risk compensation or behavioral disinhibition [14–16].

The potential for risk compensation among users of biomedical HIV prevention technologies is a major concern [14, 17, 18], particularly as VMMC as an HIV prevention strategy is scaled up across a variety of settings in sub-Saharan Africa [19]. Data from the three seminal medical circumcision trials in Africa have found limited evidence for risk compensation [1–3, 20–23]. However, participants in these research trials received the highest standards of preventive care in a research trial setting, and these results may not generalize to VMMC scale-up in non-research settings [20, 24, 25]. Investigations of how target audiences understand partial protection and HIV risk, along with strategies for effective communication, are critical for successful implementation of new biomedical prevention technologies such as VMMC [26–29]. Some research has found that men and women in sub-Saharan Africa have high awareness of partial HIV protection from VMMC [30, 31], although the need to use protection following circumcision is not fully understood by everyone [28, 32, 33]. In this study, men recently medically circumcised or planning to undergo medical circumcision in Nyanza Province, Kenya, were targeted for in-depth interviews. The primary goals of this study were to examine men’s understanding of communications about partial HIV protection, use of HIV protective measures following VMMC and perceptions of HIV risk before and after medical circumcision in the context of VMMC rollout in Kenya.

 

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Circumcision: Pros and cons

By: Indian J Urol. 2010 Jan-Mar; 26(1): 12–15.
Source: NCBI
Website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878423/

Abstract

Circumcision is possibly the most frequently performed elective surgical procedure in men. It can simply be described as the excision of the preputium. There have been several studies about the association between circumcision and urinary tract infections (UTI). Many studies have demonstrated that the frequency of UTI increase in uncircumcised males, especially in the first year of life. This review discusses the embryology of the preputium, epidemiology, indications, complications and benefits of circumcision, as well as operation and anesthesiology techniques. It especially examines the association between UTI and circumcision and the importance of circumcision in congenital urinary system anomalies. In addition, this review examines the associations between circumcision and sexually transmitted diseases, including HIV, and the protective role of circumcision on penile cancer.
Keywords: Circumcision, urinary tract infections, sexually transmitted diseases, penile cancer
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INTRODUCTION

Circumcision can be defined as the excision of the foreskin. The relationship between circumcision and urinary tract infections (UTI) is confusing due to the lack of standardization of definitions in the literature. This becomes more challenging to interpret when the association between circumcision and serious urinary tract congenital problems are to be analyzed.
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EMBRYOGENESIS AND HISTOLOGY OF PREPUTIUM

The skin of the penile shaft elongates during the 8th week of gestation, and the prep utium begins to develop from this ectodermal extension. Initially, there is an adherence between the squamous epithelium of the glans penis and the inner surface of the preputium, which generally continues into the postpartum period. The prepuce can be retracted in only 4% of newborns, but this ratio rises to 90% at three years of age[1] and to 97% in uncircumcised men at 17 years of age. Retraction of the preputium involves splitting of the inner epithelium of the preputium from the glans. The separation generally occurs by desquamation of epithelial cells, which forms a caseous white structure called smegma. Nocturnal erections also play a role in the retraction of the preputium.
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EPIDEMIOLOGY

Circumcision is an ancient surgical procedure with a history of 15000 years, according to Egyptian mummies and wall reliefs, and has been performed for 5000 years in South Africa. The Middle East which presently contains the most crowded circumcised population has a slightly more recent history of 3000 years.

Twenty percent of all men worldwide are considered to be circumcised and this ratio may vary in different countries. For instance, the proportion of circumcised men is reported to be 48% in Canada, 24% in England, and 82% white men and 54% of African American men in the USA. Circumcision ratios may differ according to race and can also be performed for religious, cultural, and medical reasons as well as due to the request of the parents. Circumcision rate decreased from 90% in 1970 in the USA to 60% in 2000. Circumcision related expenses other than medical indications have not been paid since 1948 in England and since 1970 in Canada and Australia. Thirteen states of USA were added to these countries in 2004.

In previous decades, the American Academy of Pediatrics (AAP) declared different neonatal circumcision policies. In 1975 and 1977, the AAP advocated that there were no medical indications for routinely neonatal circumcision.[2] In 1989, the AAP argued that neonatal circumcision might have potential advantages besides the known disadvantages and risks.[2] In 1999, this argument was changed to, ‘Despite recent scientific proofs present the potential medical utilities of neonatal circumcision, these data are not sufficient for recommending routine circumcision.

Serious policies have been instituted recently against circumcision that depend on the idea that penile sensation diminishes nearly 50% after circumcision. Therefore, the decision should be left to the child when he gets older. The majority of anticircumcision movements refer to the procedure as, ‘genital mutilation.’ However, it has been shown that there is no difference between circumcised and uncircumcised men in their ability to sense extroceptive and tactile stimuli on the ventral and dorsal surfaces of the glans.[3] This definitely counters the idea of loss of penile sensation.

However, there are also situations where circumcision becomes inevitable. These include phymosis, paraphymosis, balanopostitis, balanitis xerotica obliterans, preputium cysts, penile lymph edema, ammonia dermatitis, and the use of clean intermittent catheterization. However, topical steroids can be used for some of these indications as alternative treatment.

cir11Although there are different theories about the accurate time of circumcision, it is generally not recommended between the ages of two and six years (phallic phase) to avoid the development of castration anxiety.

Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy

Brian J Morris, Sean E Kennedy, Alex D Wodak, Adrian Mindel, David Golovsky, Leslie Schrieber, Eugenie R Lumbers, David J Handelsman, and John B ZieglerAuthor informationArticle notesCopyright and License informationDisclaimerThis article has been cited by other articles in PMC.Go to:

Abstract

AIM

To determine whether recent evidence-based United States policies on male circumcision (MC) apply to comparable Anglophone countries, Australia and New Zealand.

METHODS

Articles in 2005 through 2015 were retrieved from PubMed using the keyword “circumcision” together with 36 relevant subtopics. A further PubMed search was performed for articles published in 2016. Searches of the EMBASE and Cochrane databases did not yield additional citable articles. Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further. The most relevant and representative of the topic were included. Bibliographies were examined to retrieve further key references. Randomized controlled trials, male circumcisionrecent high quality systematic reviews or meta-analyses (level 1++ or 1+ evidence) were prioritized for inclusion. A risk-benefit analysis of articles rated for quality was performed. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information, including policies and Australian data on claims under Medicare for MC.

RESULTS

Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and “ballooning” during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews.

Late cuts: an international look at adult circumcision

Most circumcised men have no recollection of the procedure that claimed their foreskins. A human brain retains little, if any, of what its owner experiences during infanchappy mother and boyy, when the vast majority of circumcisions occur. But there are some men who not only remember their circumcisions, they booked the appointments themselves.

Adult circumcision is not as common as infant circumcision, but it’s not exactly uncommon either. In a few countries, actually, the practise is thriving. Some men do it to improve hygiene or because they believe a hoodless penis looks better. Others do it for reasons related to health, religion or peer pressure.

African countries with high HIV rates have seen the largest bump in adult circumcision in recent years, following clinical trials in South Africa, Kenya and Uganda that found circumcised men are 51%–60% less likely to contract the virus from heterosexual intercourse than their intact countrymen (PLoS Med 2: e298. doi: 10.1371/journal.pmed.0020298 and Lancet 2007;369:64356 and Lancet 2007; 369:65766).

“The true benefits exceed risks by an astronomical amount,” Brian Morris, professor of molecular medical science at the University of Sydney in Australia, writes in an email. “At the same time, the claims that male circumcision somehow leads to impaired sexual function, sensitivity, sensation during arousal or satisfaction has been disproven by just about every good research study.”

Morris has written extensively on the health benefits of circumcision, claiming in one paper that it is a “biomedical imperative” (BioEssays 29:114758). The data from the African trials, he notes, has convinced several international organizations to support mass circumcision. “In March 2007, the WHO [World Health Organisation] therefore endorsed circumcision as an important additional weapon in the fight against AIDS,” he states in the paper. “The WHO, UNAIDS and others have done projections estimating the millions of lives that will be saved by implementation of circumcision, which has been equated to an effective vaccine.”

What to know about circumcised and uncircumcised penises

Medically reviewed by Karen Gill, M.D. on July 10, 2019 — Written by Beth Sissons

www.medicalnewstoday.com

Circumcision is a surgical procedure that removes the foreskin of the penis. In an uncircumcised penis, the foreskin remains. The main differences include appearance and hygiene practices.

People may have a circumcision for many different reasons, including:

religious reasons, such as if a person follows the Jewish or Muslim faith
cultural reasons
a family history of circumcision, so a person may decide to continue the tradition
personal preference
for health reasons, such as if a person is prone to frequent foreskin infections
Statistics

One 2016 study estimated that 37–39% of males across the world have a circumcision. The researchers estimated that 71.2% of males in the United States have a circumcision.

According to the American Urological Association, the areas of the world with the highest rates of circumcision are:

the Middle East
South Korea
the U.S.

The lowest rates of circumcision are in Europe, Latin America, and most of Asia.

According to the Centers for Disease Control and Prevention (CDC), in the U.S., rates of circumcision among newborn males decreased by around 10% between 1979 and 2010.
Appearance

An uncircumcised penis retains the foreskin, which covers the head of a nonerect penis. When the penis is erect, the foreskin pulls back to reveal the glans.painless circumcision

A circumcised penis has no foreskin, which exposes the glans when the penis is both erect and nonerect.
Effects on sex
Studies have been inconclusive regarding penile sensitivity in uncircumcised and circumcised males.

Scientific studies have produced conflicting reports on the effect of circumcision on sex.

For example, one 2013 study looked at the sexual sensations of 1,059 uncircumcised males and 310 circumcised males. The group of circumcised males reported lower rates of sensitivity in the glans than the uncircumcised males.

A 2013 review looked at studies into the effect of male circumcision on sexual function and enjoyment. The review found that in the most accurate studies, circumcision had no negative effects on sexual function, sensitivity, pain, or pleasure during sexual intercourse.

However, one 2012 study found that there was not enough scientific evidence in some previous research to suggest that circumcision affects sexual function. The study concluded that circumcision has no negative long-term impact on sexual function.

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