Circumcision and STIs

Condoms are the best way to prevent the spread of STIs such as HIV

20 mar 2009--US experts have argued that “circumcision should be routinely considered as a way to reduce the risk of sexually transmitted infections,” BBC News reported. It said that circumcision is already known to greatly reduce the risk of infection from HIV, and researchers have now found that it also reduces the risk of herpes by 25%, and human papillomavirus (HPV) by a third. However, the BBC says that UK experts disagree with their US counterparts, and that “pushing circumcision as a solution sent the wrong message”.

There is some evidence that circumcision reduces the risk and spread of STIs. However, this study was carried out in Uganda, and its findings are not directly comparable to the UK. The main reason for this is the large difference in rates of STIs between the two countries. Further research in countries with a more comparable rate of STIs would give a better indication. When having sex, a condom remains the best way to avoid contracting an STI.

It is also important not to conclude that the results would be the same in other subgroups, such as men who have sex with men, or men who are circumcised as newborns. It could be that the benefits of circumcision differ among different groups.

Where did the story come from?

The research was carried out by Dr Aaron A.R. Tobian and colleagues from the Johns Hopkins University in Baltimore, US and colleagues from the Institute of Public Health at Makerere University and the Rakai Health Sciences Program in Uganda. The study was supported by grants from a range of organisations, including the National Institutes of Health and the Bill and Melinda Gates Foundation. The study was published in the peer-reviewed New England Journal of Medicine.

What kind of scientific study was this?

The study investigated whether male circumcision prevents certain sexually transmitted infections (STIs) in HIV-negative adolescent boys and men. The STIs included herpes simplex virus type 2 (HSV-2), human papillomavirus (HPV) infections as well as syphilis.

The data for this study was obtained from two previous randomised controlled trials, known as the Rakai-1 and Rakai-2 trials, and re-analysed. The Rakai-1 and Rakai-2 trials were carried out by the same researchers, and investigated circumcision and the rate of HIV infection and other STIs. These two independent trials shared the same design and used identical methods. They ran alongside each other, with Rakai-1 running from September 2003 to September 2005, and Rakai-2 running from February 2004 to December 2006. Together, both trials enrolled 6,369 males between 15 and 49 years old.

Of the 6,396 males who were initially screened in both the Rakai-1 and Rakai-2 trials, 3003 were excluded from the recent analyses because they had tested positive or had indeterminate results in tests for the HSV-2 or HIV-1 viruses.

After these exclusions, 3,393 males were included in this study and randomly allocated to either immediate circumcision (1,684 males) or circumcision after a 24-month wait (after the study has finished). In the immediate circumcision group, 134 did not eventually get circumcised, and in the waiting group 32 were circumcised elsewhere during the study.

The researchers tested the men for HSV-2 infection, HIV infection and syphilis at the start of the study and six, 12, and 24 months later. The men were also examined and interviewed at these visits. In addition, the researchers evaluated a subgroup of men for HPV infection at the beginning of the study and after 24 months.

What were the results of the study?

After 24 months, the circumcised men had a 7.8% overall chance of testing positive for the genital herpes virus, compared to a 10.3% chance in the uncircumcised group (adjusted hazard ratio 0.72, 95% confidence interval [CI] 0.56 to 0.92; P = 0.008).

In the circumcised group, the prevalence of high-risk HPV genotypes was 18% compared to 27.9% in the uncircumcised group (adjusted risk ratio 0.65, 95% CI 0.46 to 0.90; P = 0.009).

There was no significant difference between the two study groups in the proportion that developed syphilis (adjusted hazard ratio 1.10, 95% CI 0.75 to 1.65; P = 0.44).

What interpretations did the researchers draw from these results?

The researchers say that “in addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection”.

They say that other related research shows that male circumcision decreases the rates of HIV, HSV-2, and HPV infections in men. In their female partners, it reduces infections of trichomoniasis, bacterial vaginosis, other sexually transmitted infections. The researchers conclude that their findings “underscore the potential public health benefits of the procedure”.

This study has important implications for the control of sexually transmitted infections in Africa, but researchers and commentators seem to disagree about the implications closer to home and in other population groups not tested in the study.

For example, an editorial written by doctors in the US and published in the same journal said, "These new data should prompt a major reassessment of the role of male circumcision.” They suggest that maternity health providers have a responsibility to educate mothers and fathers about the benefits of circumcision soon after birth.

However, UK commentators are sceptical. This seems to be because it is unclear how circumcision might protect against STIs. There are several theories for this:

• Following circumcision, the skin covering the head of the penis becomes tougher and may protect against "microtears" during sex, which can provide a point of entry for germs.
• The lining of the foreskin, removed during circumcision, may be the point at which germs enter the underlying skin cells.
• After sex, the foreskin may prolong the amount of time that tender skin is exposed to germs.

Other points to note about this study are that:

• After six months, reported condom use was higher in the circumcision group than in the control group (P<0.001),>
• About 18% of men from both groups were lost to follow-up, died or were enrolled for an insufficient period (less than 24 months) for the analysis. This is a large proportion of those who enrolled, and it is possible that there were differences in the rates of infection between those completing the trial and those who dropped out, which could influence the overall results.
• One of the commentators’ main concerns over this study is that it was carried out in Uganda, and the results may not be directly applicable to more developed countries. It is also important not to conclude that the results would be the same in other subgroups, such as men who have sex with men, and men who are circumcised as newborns. It could be that the benefits of circumcision differ in different groups.

The differences between the US and UK interpretations of this study may be more cultural than scientific, and circumcision has historically been much more common in the US. More research in areas with a lower prevalence of HIV will be needed in order to test the relevance of this study outside of Uganda.

Study: Male circumcision helps prevent 2 STDs

By ALICIA CHANG

LOS ANGELES,26 mar 2009 – Circumcision not only protects against HIV in heterosexual men, but it also helps prevent two other sexually transmitted infections, a large new study found. Circumcised males reduced their risk of infection with HPV, or human papillomavirus, by 35 percent and herpes by 28 percent. However, researchers found circumcision had no effect on the transmission of syphilis.

Landmark studies from three African countries including Uganda previously found circumcision lowered men's chance of catching the AIDS virus by up to 60 percent. The new study stems from the Uganda research and looked at protection against three other STDs. The findings are reported in Thursday's New England Journal of Medicine

"Evidence now strongly suggests that circumcision offers an important prevention opportunity and should be widely available," Drs. Matthew Golden and Judith Wasserheit of the University of Washington wrote in an accompanying editorial.

Worldwide, only about 30 percent of men are circumcised. The figure is higher in the United States, where about 79 percent of men are circumcised, according to surveys by the National Center for Health Statistics.

An international team of researchers who conducted the study said circumcision, the surgical removal of the foreskin from the penis, should be an accepted method to reduce sexually transmitted infections among heterosexuals.

"It must be emphasized that protection was only partial, and it is critical to promote the practice of safe sex," they wrote.

HPV can cause cervical cancer and genital warts. Herpes greatly increases the chances of infection with HIV.

The American Academy of Pediatrics previously said there was not enough evidence to recommend routine circumcision of infants. The doctor's group is reviewing its position based on recent studies. About 2,800 herpes cases in newborns occur in the U.S. every year transmitted from mothers to infants that can lead to disability or death.

The latest research involved 3,393 HIV-negative heterosexual adolescent boys and men from Uganda who were part of the original HIV study. About half were randomly selected to undergo circumcision right away while the rest had the procedure 2 years later. All had physical exams and were offered voluntary HIV counseling and condoms.

After two years, herpes infection was detected in 114 circumcised men compared with 153 uncircumcised men. HPV was detected in 42 circumcised men compared with 80 uncircumcised men. There was no significant difference between the two groups on rate of syphilis infections. The researchers considered condom use, number of sex partners and other factors to calculate the risk reductions.

Why circumcision may reduce the risk of infection is not entirely known. But researchers think cells in the foreskin of the penis may be susceptible to HPV and the herpes virus.

The study was funded by the National Institutes of Health and the Bill and Melissa Gates Foundation. It was conducted by the Rakai Health Sciences Program and Makerere University in Uganda, Johns Hopkins Bloomberg School of Public Health and a division of the National Institutes of Health.

The results were similar to two recent studies from South Africa that found circumcision reduced HPV and herpes by up to a third.

Researchers plan to study whether circumcision reduces the spread of HPV to female sex partners.

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On the Net:

New England Journal: http://www.nejm.org

Circumcised men no less likely to get sex diseases

Circumcision does not appear to shield men from the types of sexually transmitted diseases (STDs) common in the developed world, according to new research from New Zealand.
While there is "compelling evidence" that circumcision protects men from contracting HIV through sex with women, it is unclear whether circumcised men are at lower risk of other types of STDs, Dr. Nigel P. Dickson and colleagues note in their report in the Journal of Pediatrics.
To investigate, the researchers, at the University of Otago in Dunedin, followed 499 men born in 1972 and 1973 up to age 32. About 40 percent of the men had been circumcised in early childhood.
Among circumcised men, 23.4 percent reported having had any type of STD by age 32, compared to 23.5 percent of the uncircumcised men.
The most common STDs reported were genital warts, Chlamydia and genital herpes. There was no statistically significant difference in rates of STDs even after the researchers adjusted for sexual behavior and socioeconomic factors.
Another recent study from New Zealand found that circumcision appeared to halve the rate of STDs among men up to age 25, Dickson and his colleagues note. However, they add, that study was done in a smaller group of individuals with a lower rate of STDs than that reported in the current study, while fewer men in that group had been circumcised.
"Although the reason for the different findings in the 2 cohorts is unclear, when our findings are considered in the context of other recent population-based studies in developed countries, it appears unlikely that circumcision has a major protective effect against common sexually transmitted infections in these populations, although a small effect cannot be ruled out," the researchers conclude.

Circumcision Not Protective Against HIV Seroconversion in Homosexual Men

Bonnie Darves

August 2, 2007 (Seattle) — Circumcision status may have little effect on whether men who have sex with men go on to develop HIV, according to the results of a new study of more than 1400 homosexual men, presented here at the 17th Meeting of the International Society for Sexually Transmitted Diseases Research. Although several recent randomized controlled trials of heterosexual men have found that adult circumcision reduces the risk of HIV acquisition by 50% or more, little is known about the association between circumcision and HIV risk in homosexual men, said the study's chief author, David Templeton, MD, from the University of New South Wales, Sydney, Australia.
"The data on circumcision and heterosexual men are compelling, but there are few data on circumcision and HIV risk in homosexual men," said Dr. Templeton. "We found no relationship at all between circumcision and HIV seroconversion in this cohort." That lack of association or protective effect, he added, may be because most HIV occurs "following receptive rather than insertive intercourse," but further studies would be needed to confirm that theory.
"Based on these findings, we cannot make a recommendation for circumcision in homosexual men" as a protective measure against HIV seroconversion, Dr. Templeton said.
The longitudinal study of 1427 initially HIV-negative homosexual Australian men, initiated in 2001, found that in the 49 who developed HIV, circumcision status appeared to have no effect (risk ratio was 1.07, with a confidence interval of 95%). At baseline, 66% of participants reported being circumcised, mostly as infants, and circumcision was more prevalent among men aged 45 or older (83%) than in men aged 25 or younger; only 50% of the latter group reported being circumcised. Circumcision status in all participants was later validated by physical examination.
Although the Australian study's results showed no benefit in circumcision for homosexual men as a means of protecting against HIV, the association might merit further study in light of the findings of larger African trials about the potentially protective effect of circumcision overall, said Matthew Hogben, PhD, a research scientist from the Centers for Disease Control and Prevention's National Center for HIV, STD, and TB Prevention, Atlanta, Georgia.
"The Australian study showed that circumcision was not a factor one way or the other in whether [individuals] developed HIV, which probably makes sense," said Dr. Hogben, who moderated the session. He added that although "receptor sex" was "clearly was the manner of acquisition," in the Australian study, it's understandable that "with the findings of the trials that ran in Africa, [researchers] might want to expand study of the association to see to what extent they could take advantage of those findings to look at secondary effects. It might be worthwhile to see whether there's less transmission or 'burden' with a foreskin intervention, but I suspect we would need more data, and more clean data, to confirm this."
Dr. Templeton and Dr. Hogben report no relevant financial relationships.
17th Meeting of the International Society for Sexually Transmitted Diseases Research: Abstract 215. Presented July 30, 2007.

Circumcision could save millions from HIV infection, conference told

2 hours, 38 minutes ago
Male circumcision could prevent millions of HIV infections every year and play a major role in controlling the virus' spread in developing nations, a major AIDS conference was told Tuesday.
US researcher Richard Bailey called on health authorities to actively promote circumcision, saying the scientific evidence left no doubt that it could reduce HIV infection rates by up to 60 percent.
Bailey, from the University of Illinois, said three studies in Africa had all confirmed a long-standing belief about the effectiveness of circumcision in reducing the risk of HIV infection.
"The last two were actually stopped early because they showed such a high level of efficacy that it wouldn't be ethical to continue the trial and withhold circumcision from the control group," Bailey told reporters at the International AIDS Society conference in Sydney.
He said universal circumcision could avert two million new infections and 300,000 deaths in sub-Saharan Africa over 10 years.
Bailey said while health authorities would rush to implement a vaccine that was 60 percent effective, there was an element of squeamishness in some cultures about promoting male circumcision.
"It's been a really long haul because it's the penis after all, so it's not that easy to accept that kind of intervention," he said.
"Circumcision is not just simply a medical procedure, it's tied up in a complex web of cultural and religious practices and beliefs, so it's not easy for politicians and ministries of health to very quickly come out in favour of circumcision in countries where it's not traditionally practiced."
Bailey said leaders in developing nations needed to endorse circumcision because international health authorities would not impose it because they feared being seen as culturally insensitive.
"But the time to act is right now," he said. "Delaying the roll-out of circumcision could be causing more harm, not just because more people are getting infected with HIV than necessary but also people are going to unqualified practitioners."
The conference also heard that the practice, common in Africa, of women rinsing themselves with lemon juice after sex did not reduce the risk of HIV infection.
Nigerian researcher Atiene Sagay said a study of more than 300 Nigerian prostitutes found that women douched to avoid infection but it was totally ineffective.
"People suggested it could be a microbicide (but) we know much better than that now," Sagay said.
He said the practice was not an effective contraceptive measure either, as alkaline semen easily neutralised citric acid.