Male Circumcision: A Globally Relevant but Under-Utilized Method for the Prevention of HIV and Other Sexually Transmitted Infections

Tobian, Aaron A.R.; Kacker, Seema; Quinn, Thomas C.

doi:10.1146/annurev-med-092412-090539

Cited by 79 publications

(60 citation statements)

References 81 publications

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“…32 A meta-analysis of studies reporting on the association of male circumcision and syphilis, essentially among HIV-1 uninfected men, reported a summary relative risk of 0·69, (95% CI 0·50–0·94) similar to our findings. 9 Two prior randomized trials have assessed the effect of male circumcision (versus delayed male circumcision) on syphilis acquisition among HIV-1 uninfected men; neither found a protective effect: adjusted HR 1·10, 95% CI 0·75–1·65 and risk ratio 1·23, 95% CI 0·41–3·65.…”

Section: Discussionsupporting

confidence: 88%

Association between male circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples

Pintye

Baeten

Manhart

et al. 2014

The Lancet Global Health

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Background Male circumcision is a primary HIV-1 prevention intervention for men. It is uncertain whether male circumcision reduces the risk of syphilis among men and their female partners. Methods Using data from a prospective study among HIV-1 serodiscordant heterosexual couples from Kenya and Uganda, we assessed whether male circumcision was associated with incident syphilis in men and in their female partners. Multivariate Andersen-Gill survival methods were used, adjusted for age, sexual behavior, and plasma HIV-1 RNA levels of the HIV-1 infected partner. Findings 4716 HIV-1 serodiscordant couples (37·5% with an HIV-1 infected male) were followed for a median of 2·75 years. At enrollment, 1575 (53·5%) HIV-1 uninfected and 560 (32·4%) HIV-1 infected men were circumcised; an additional 69 (4·2%) HIV-1 infected and 132 (4·8%) HIV-1 uninfected men became circumcised during study follow up. 221 incident syphilis infections were observed: 46 among HIV-1 infected men (incidence 1·10 per 100 person-years), 76 among HIV-1 uninfected men (1·09 per 100 person-years), 54 among HIV-1 infected women (0·77 per 100 person-years) and 45 among HIV-1 uninfected women (1·11 per 100 person-years). Male circumcision was associated with a 42% reduction in incident syphilis in men (adjusted hazard ratio [aHR] 0.58 95% CI 0·37–0·91) including a 62% reduction among HIV-1 infected men (aHR 0·38, 95% CI 0·18–0·81) and a non-significant reduction in incident syphilis among HIV-1 uninfected men (aHR 0·64, 95% CI 0·36–1·11). Among women, circumcision of their male partners was associated with a 59% reduction in incident syphilis (aHR 0.41 95% CI 0.25–0.69), including a 75% reduction among HIV-1 uninfected women (aHR 0·25, 95% CI 0·08–0·76) and a 48% reduction among HIV-1 infected women (aHR 0·52, 95% CI 0·27–0·97). Interpretation In this large prospective cohort study among HIV-1 serodiscordant couples, male circumcision was associated with decreased risk of incident syphilis in men and women. If confirmed, these results suggest that medical male circumcision could substantially reduce incidence of syphilis and its sequelae. Funding Bill & Melinda Gates Foundation (grant OPP47674) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K99HD076679).

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Section: Discussionsupporting

confidence: 88%

Association between male circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples

Pintye

Baeten

Manhart

et al. 2014

The Lancet Global Health

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“…Global health leaders have called for further research that will help explain the low uptake of VMMC compared to coverage targets [4]. The present study responds to this call.…”

Section: Introductionmentioning

confidence: 64%

Behavior Change Pathways to Voluntary Medical Male Circumcision: Narrative Interviews with Circumcision Clients in Zambia

et al. 2014

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As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.

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“…36 We obtained the adjusted prevalence ratio (aPR) using a model that controlled for demographics and previously-identified correlates of BV (age, education, parity, partner circumcision status, sexual frequency, vaginal hygiene practices, condom use, and HSV-2 serostatus). 10, 37-38 …”

Section: Methodsmentioning

confidence: 99%

Serum vitamin D status and bacterial vaginosis prevalence and incidence in Zimbabwean women

Turner

Reese

Chen

et al. 2016

American Journal of Obstetrics and Gynecology

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BACKGROUND Bacterial vaginosis, a highly prevalent vaginal condition, is correlated with many adverse reproductive outcomes. In some studies, low vitamin D (measured as serum 25-hydroxy-vitamin D, 25(OH)D) has been associated with increased prevalence of bacterial vaginosis. OBJECTIVES We examined the cross-sectional association between vitamin D status and prevalence of bacterial vaginosis, separately for pregnant and non-pregnant women. Using prospectively-collected data, we also characterized the effect of time-varying vitamin D status on incident bacterial vaginosis. STUDY DESIGN We quantified 25(OH)D in stored sera collected quarterly from 571 Zimbabwean women participating in the Hormonal Contraception and Risk of HIV Acquisition Study. The analysis was restricted to women not using hormonal contraception. We characterized associations between vitamin D insufficiency (defined as 25(OH)D ≤30 ng/mL vs. >30 ng/mL) and prevalence of bacterial vaginosis among non-pregnant women at the enrollment visit, and among pregnant women at the first follow-up visit that pregnancy was detected. Among women who were negative for bacterial vaginosis at enrollment (n=380), we also assessed the effect of time-varying vitamin D status on incident bacterial vaginosis. We used the Liaison 25 OH vitamin D total assay to measure 25(OH)D. Bacterial vaginosis was diagnosed via Nugent score. RESULTS At enrollment, prevalence of bacterial vaginosis was 31% and overall median 25(OH)D was 29.80 ng/mL (interquartile range: 24.70-34.30 ng/mL): 29.75 ng/mL (interquartile range: 25.15-33.95 ng/mL) among women with bacterial vaginosis and 29.90 ng/mL (interquartile range: 24.70-34.50 ng/mL) among women without bacterial vaginosis. Among pregnant women, the prevalence of bacterial vaginosis was 27% and overall median 25(OH)D was 29.90 ng/mL (interquartile range: 24.10-34.00 ng/mL): 30.80 ng/mL (interquartile range: 26.10-36.90 ng/mL) among women with bacterial vaginosis and 29.10 ng/mL (interquartile range: 23.80-33.45 ng/mL) among women without BV. Vitamin D levels ≤30 ng/mL were not associated with prevalence of bacterial vaginosis in non-pregnant women (adjusted prevalence ratio: 1.04; 95% confidence interval: 0.81-1.34) or pregnant women (adjusted prevalence ratio: 0.88, 95% confidence interval: 0.51-1.54). Vitamin D levels ≤30 ng/mL were similarly not associated with incident bacterial vaginosis (adjusted hazard ratio: 0.98, 95% confidence interval: 0.73-1.31). Our findings were robust to alternative specifications of vitamin D status including using a cutpoint for vitamin D deficiency of <20 ng/ml vs. ≥20 ng/mL, and modeling 25(OH)D as a continuous variable. CONCLUSION Among reproductive-age Zimbabwean women, insufficient vitamin D was not associated with increased BV prevalence or incidence. Given established associations between BV and poor reproductive outcomes, identification of factors leading to high BV prevalence is urgently needed.

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Male Circumcision: A Globally Relevant but Under-Utilized Method for the Prevention of HIV and Other Sexually Transmitted Infections

Cited by 79 publications

References 81 publications

Association between male circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples

Association between male circumcision and incidence of syphilis in men and women: a prospective study in HIV-1 serodiscordant heterosexual African couples

Behavior Change Pathways to Voluntary Medical Male Circumcision: Narrative Interviews with Circumcision Clients in Zambia

Serum vitamin D status and bacterial vaginosis prevalence and incidence in Zimbabwean women

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