Recent efforts in biomedical prevention of HIV.
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Despite major advances in HIV treatment and progress in distribution of antiretroviral therapy in the developing world, staggering rates of new HIV infections persist. Innovative approaches to prevention of transmission are needed. Recent data have confirmed previous observational studies that demonstrated a substantial reduction in acquisition risk with male circumcision and microbicide technology experienced a setback with the early termination of a large-scale vaginal microbicide trial of cellulose sulfate. Limited data from one trial of pre-exposure prophylaxis was not able to validate nor refute efficacy. This article summarizes a presentation on biomedical prevention of HIV infection made by Raphael J. Landovitz, MD, at an International AIDS Society-USA Continuing Medical Education course in Los Angeles in March 2007. (+info)
Traditional male circumcision in the Eastern Cape--scourge or blessing?
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BACKGROUND: Traditional male circumcision is still widely practised in the Xhosa population throughout South Africa. It is a rite of passage from boyhood to manhood. Unfortunately, botched circumcisions are a public health hazard and lead to tragic mutilations and deaths. OBJECTIVE AND METHODS: The present study was undertaken to assess the extent of circumcision-related complications and fatalities in the Eastern Cape. Health care data were provided by the Eastern Cape Department of Health. Hospital admissions, amputations and deaths per circumcision season were recorded as well as causes of death and the number of legal and illegal initiation schools, respectively. The aim was to establish if the Application of Health Standards in Traditional Circumcision Act of 2001 has been successful in reducing the health risks of the ritual. RESULTS: The findings show that the incidence of circumcision related complications and fatalities has remained virtually unchanged in the observation period 2001 - 2006. Unqualified surgeons, negligent nurses, irresponsible parents and youths medically unfit for the hardships of initiation continue to contribute to tragic outcomes. One of the main problems is the perception that government interference in the ritual is undesirable, and the fact that a stigma is attached to non-completion of the procedure. CONCLUSION: Progress is only possible if all the relevant stakeholders--traditional surgeons, traditional nurses, traditional leaders, traditional healers, representatives of the Department of Health, medical officers, police, parents, initiates and the communities concerned--can be made aware of the problem and rendered willing to work together in preserving a cultural tradition in the spirit of the Constitution, that is, without violating fundamental human rights. (+info)
Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda.
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OBJECTIVE: To assess whether male circumcision of the primary sex partner is associated with women's risk of HIV. DESIGN: Data were analyzed from 4417 Ugandan and Zimbabwean women participating in a prospective study of hormonal contraception and HIV acquisition. Most were recruited from family planning clinics; some in Uganda were referred from higher-risk settings such as sexually transmitted disease clinics. METHODS: Using Cox proportional hazards models, time to HIV acquisition was compared for women with circumcised or uncircumcised primary partners. Possible misclassification of male circumcision was assessed using sensitivity analysis. RESULTS: At baseline, 74% reported uncircumcised primary partners, 22% had circumcised partners and 4% had partners of unknown circumcision status. Median follow-up was 23 months, during which 210 women acquired HIV (167, 34, and 9 women whose primary partners were uncircumcised, circumcised, or of unknown circumcision status, respectively). Although unadjusted analyses indicated that women with circumcised partners had lower HIV risk than those with uncircumcised partners, the protective effect disappeared after adjustment for other risk factors [hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.69-1.53]. Subgroup analyses suggested a non-significant protective effect of male circumcision on HIV acquisition among Ugandan women referred from higher-risk settings: adjusted HR 0.16 (95% CI, 0.02-1.25) but little effect in Ugandans (HR, 1.33; 95% CI, 0.72-2.47) or Zimbabweans (HR, 1.12; 95% CI, 0.65-1.91) from family planning clinics. CONCLUSIONS: After adjustment, male circumcision was not significantly associated with women's HIV risk. The potential protection offered by male circumcision for women recruited from high-risk settings warrants further investigation. (+info)
Polyarticular septic arthritis following septic circumcision.
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Ritual circumcision during an initiation ceremony for young adults is common practice in parts of South Africa. We report on a case of polyarticular septic arthritis in a seventeen-year-old man following septicaemia after circumcision, resulting in severe fixed flexion deformities of both knees. This case illustrates an unusual cause of polyarticular septic arthritis and the treatment difficulties associated with delayed presentation. It is also a reminder of the consequences of untreated acute septic arthritis. (+info)
Declining rates in male circumcision amidst increasing evidence of its public health benefit.
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BACKGROUND: Recent experimental evidence has demonstrated the benefits of male circumcision for the prevention of human immunodeficiency virus (HIV) infection. Studies have also shown that male circumcision is cost-effective and reduces the risk for certain ulcerative sexually transmitted diseases (STDs). The epidemiology of male circumcision in the United States is poorly studied and most prior reports were limited by self-reported measures. The study objective was to describe male circumcision trends among men attending the San Francisco municipal STD clinic, and to correlate the findings with HIV, syphilis and sexual orientation. METHODS AND FINDINGS: A cross sectional study was performed by reviewing all electronic records of males attending the San Francisco municipal STD clinic between 1996 and 2005. The prevalence of circumcision over time and by subpopulation such as race/ethnicity and sexual orientation were measured. The findings were further correlated with the presence of syphilis and HIV infection. Circumcision status was determined by physical examination and disease status by clinical evaluation with laboratory confirmation. Among 58,598 male patients, 32,613 (55.7%, 95% Confidence Interval (CI) 55.2-56.1) were circumcised. Male circumcision varied significantly by decade of birth (increasing between 1920 and 1950 and declining overall since the 1960's), race/ethnicity (Black: 62.2%, 95% CI 61.2-63.2, White: 60.0%, 95% CI 59.46-60.5, Asian Pacific Islander: 48.2%, 46.9-49.5 95% CI, and Hispanic: 42.2%, 95% CI 41.3-43.1), and sexual orientation (gay/bisexual: 73.0%, 95% CI 72.6-73.4; heterosexual: 66.0%, 65.5-66.5). Male circumcision may have been modestly protective against syphilis in HIV-uninfected heterosexual men (PR 0.92, 95% C.I. 0.83-1.02, P = 0.06). CONCLUSIONS: Male circumcision was common among men seeking STD services in San Francisco but has declined substantially in recent decades. Male circumcision rates differed by race/ethnicity and sexual orientation. Given recent studies suggesting the public health benefits of male circumcision, a reconsideration of national male circumcision policy is needed to respond to current trends. (+info)
Herpes simplex virus type 2 infection among young uncircumcised men in Kisumu, Kenya.
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OBJECTIVES: To identify factors associated with herpes simplex virus type 2 (HSV-2) infection among men aged 18-24 in Kisumu, Kenya. METHODS: Baseline data from a randomised trial of male circumcision were analysed. Participants were interviewed for sociodemographic and behavioural risks. The outcome was HSV-2 by antibody status. Risk factors were considered singly and in combination through logistic regression models. RESULTS: Among 2771 uncircumcised men, 766 (27.6%; 95% confidence interval (CI) 26.0% to 29.3%) tested antibody positive for HSV-2. The median age at first sex was 16 years, and the median number of lifetime sexual partners was four. HSV-2 seroprevalence increased from 19% among 18-year-olds to 43% among 24-year-olds (p<0.001). In multivariable analysis, statistically significant risks for infection were increasing age (adjusted odds ratio (AOR) = 1.22-2.58), being married or having a live-in female partner (AOR = 1.80; 95% CI 1.28 to 2.53), preferring "dry" sex (AOR = 1.39; 95% CI 1.14 to 1.69), reported penile cuts or abrasions during sex (AOR = 1.58; 95% CI 1.32 to 1.91), increasing lifetime sex partners (multiple response categories; AORs ranging from 1.65 to 1.97), and non-student occupation (multiple response categories; AORs ranging from 1.44 to 1.93). Risk decreased with reported condom used at last sex (AOR = 0.82; 95% CI 0.68 to 0.99). CONCLUSION: Primary prevention efforts should be initiated at an early age. The same behavioural interventions used currently for HIV prevention-abstinence, reducing the number of sex partners and increasing condom use-should be effective for HSV-2 prevention. (+info)
Pathologic and physiologic phimosis: approach to the phimotic foreskin.
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OBJECTIVE: To review the differences between physiologic and pathologic phimosis, review proper foreskin care, and discuss when it is appropriate to seek consultation regarding a phimotic foreskin. SOURCES OF INFORMATION: This paper is based on selected findings from a MEDLINE search for literature on phimosis and circumcision referrals and on our experience at the Children's Hospital of Eastern Ontario Urology Clinic. MeSH headings used in our MEDLINE search included "phimosis," "referral and consultation," and "circumcision." Most of the available articles about phimosis and foreskin referrals were retrospective reviews and cohort studies (levels II and III evidence). MAIN MESSAGE: Phimosis is defined as the inability to retract the foreskin. Differentiating between physiologic and pathologic phimosis is important, as the former is managed conservatively and the latter requires surgical intervention. Great anxiety exists among patients and parents regarding non-retractile foreskins. Most phimosis referrals seen in pediatric urology clinics are normal physiologically phimotic foreskins. Referrals of patients with physiologic phimosis to urology clinics can create anxiety about the need for surgery among patients and parents, while unnecessarily expanding the waiting list for specialty assessment. Uncircumcised penises require no special care. With normal washing, using soap and water, and gentle retraction during urination and bathing, most foreskins will become retractile over time. CONCLUSION: Physiologic phimosis is often seen by family physicians. These patients and their parents require reassurance of normalcy and reinforcement of proper preputial hygiene. Consultation should be sought when evidence of pathologic phimosis is present, as this requires surgical management. (+info)
Penile oleogranuloma among Wisconsin Hmong.
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Injection of viscous or semisolid materials into the penile shaft to increase its size, to correct erectile dysfunction, and/or to satisfy a sexual partner has only been sporadically reported in Eastern and Western European and American men. However, this practice appears to be more widespread in the countries of Southeast Asia. We present 3 cases of Hmong patients seen in a urology clinic in Wausau, Wis. We describe the presentation, correction, and difficulties experienced in convincing patients to undergo adequate treatment. (+info)