Dorsal longitudinal foreskin cut is associated with reduced risk of HIV, syphilis and genital herpes in men: a cross‐sectional study in Papua New Guinea

Abstract

Introduction: Various forms of penile foreskin cutting are practised in Papua New Guinea. In the context of an ecological association observed between HIV infection and the dorsal longitudinal foreskin cut, we undertook an investigation of this relationship at the individual level.Methods: We conducted a cross-sectional study among men attending voluntary confidential HIV counselling and testing clinics. Following informed consent, participants had a face-to-face interview and an examination to categorize foreskin status. HIV testing was conducted on site and relevant specimens collected for laboratory-based Herpes simplex type-2 (HSV-2), syphilis, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) testing.Results: Overall, 1073 men were enrolled: 646 (60.2%) were uncut; 339 (31.6%) had a full dorsal longitudinal cut; 72 (6.7%) a partial dorsal longitudinal cut; and 14 (1.3%) were circumcised. Overall, the prevalence of HIV was 12.3%; HSV-2, 33.6%; active syphilis, 12.1%; CT, 13.4%; NG, 14.1%; and TV 7.6%. Compared with uncut men, men with a full dorsal longitudinal cut were significantly less likely to have HIV (adjusted odds ratio [adjOR] 0.25, 95%CI: 0.12, 0.51); HSV-2 (adjOR 0.60, 95%CI: 0.41, 0.87); or active syphilis (adjOR 0.55, 95%CI: 0.31, 0.96). This apparent protective effect was restricted to men cut prior to sexual debut. There was no difference between cut and uncut men for CT, NG or TV.Conclusions: In this large cross-sectional study, men with a dorsal longitudinal foreskin cut were significantly less likely to have HIV, HSV-2 and syphilis compared with uncut men, despite still having a complete (albeit morphologically altered) foreskin. The protective effect of the dorsal cut suggests that the mechanism by which male circumcision works is not simply due to the removal of the inner foreskin and its more easily accessible HIV target cells. Exposure of the penile glans and inner foreskin appear to be key mechanisms by which male circumcision confers protection.Further research in this unique setting will help improve our understanding of the fundamental immunohistologic mechanisms by which male circumcision provides protection, and may lead to new biomedical prevention strategies at the mucosal level.

The penile microbiota of Black South African men: relationship with human papillomavirus and HIV infection

“…The best evidence to date for a potential role of the penile microbiome in sexually transmitted infections (STIs) and HIV acquisition have come from studies examining medical circumcision [5,6]. Male circumcision reduces the risk of HPV and HIV infection in men [7][8][9][10][11]. Male circumcision has been found to alter the penile microbiome by significantly reducing bacterial diversity and load [12,13].…”

The Penile Microbiota in Uncircumcised and Circumcised Men: Relationships With HIV and Human Papillomavirus Infections and Cervicovaginal Microbiota

“…Removal of the prepuce by MMC significantly reduces the risk of STIs, including herpes simplex virus type 2 (HSV-2), syphilis, gonorrhea, HPV, and HIV ( 6 – 8 , 12 , 14 , 15 , 17 – 19 , 54 ). Three RCTs, conducted in South Africa ( 6 ), Kenya ( 7 ), and Uganda ( 8 ) observed that MMC reduced heterosexual HIV transmission in men without behavioral disinhibition (risk compensation behavior) by about 60%.…”

“…The differences in the protective effect of TMC on HIV infection are presumably due to variations in the age of coitarche (sexual debut) and amount of foreskin removed during circumcision ( 45 – 47 , 50 , 51 , 54 ). A study that assessed the variations in TMC practices and their association with HIV status among South African men observed that partially circumcised and uncircumcised men had the same risk for HIV infection, which was significantly greater than that of fully circumcised men ( 63 ).…”

Re-establishing safer medical-circumcision-integrated initiation ceremonies for HIV prevention in a rural setting in Papua New Guinea. A multi-method acceptability study

“…Likewise, establishing a contemporary version of MICs will be in-line with a joint United Nations Educational, Scientific and Cultural Organization (UNESCO) and UNAIDS recommendation for HIV/AIDS education to include the teaching of life-skills and balanced gender roles [ 67 ]. Moreover, aligning MMC with a local cultural program would fulfil a PNG health priority for MMC to be made accessible for men who undergo high-risk foreskin cutting at non-clinical settings in PNG [ 68 – 70 ].…”