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.
Highlights
Various forms of penile foreskin cutting are practised in Papua New Guinea
Six clinics accredited by the National Department of Health (NDoH) located in Enga (2 clinics), Simbu (2), Jiwaka (1) and Western Highlands (1) Provinces were selected as study sites based on the quality of their HIV testing and counselling services; client attendance figures; provincial and clinic-level interest in study participation; and earlier surveillance and research data indicating relatively high prevalences of both HIV infection and penile foreskin cutting in these settings [3,6,12]
We found that men with a full dorsal longitudinal foreskin cut were significantly less likely to have HIV, Herpes simplex virus type-2 (HSV-2) or active syphilis compared with uncut men
Summary
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. 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. We have postulated that this type of cut, like circumcision, could confer protection against acquisition of HIV and certain other STIs [8,9,10,11] as it results in lateral retraction and eversion of the foreskin [4,6] This hypothesis is supported by the geographic association between high prevalence of this type of foreskin cut and lower prevalence of HIV infection within PNG [12]. It was this type of ecological association observed in Africa which first signalled the possibility, subsequently proven in largescale clinical trials, that male circumcision might be protective against HIV and other infections in Africa [13,14]
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