Uncircumcised Men Research Articles

Sexual Risk Behaviours and Willingness to Be Circumcised among Uncircumcised Adult Men in Uganda.

BackgroundThere has been substantial demand for safe male circumcision (SMC) in Uganda in the early programme scale-up phase. Research indicates that early adopters of new interventions often differ from later adopters in relation to a range of behaviours. However, there is limited knowledge about the risk profile of men who were willing to be circumcised at the time of launching the SMC programme, i.e., potential early adopters, compared to those who were reluctant. The aim of this study was to address this gap to provide indications on whether it is likely that potential early adopters of male circumcision were more in need of this new prevention measure than others.MethodsData were from the 2011 Uganda AIDS Indictor Survey (UAIS), with a nationally representative sample of men 15 to 59 years. The analysis was based on generalized linear models, obtaining prevalence risk ratios (PRR) with 95% confidence intervals (CI) as measures of association between willingness to be circumcised and multiple sexual partners, transactional sex, non-marital sex and non-use of condoms at last non-marital sex.ResultsOf the 5,776 men in the survey, 44% expressed willingness to be circumcised. Willingness to be circumcised was higher among the younger, urban and educated men. In the unadjusted analyses, all the sexual risk behaviours were associated with willingness to be circumcised, while in the adjusted analysis, non-marital sex (Adj PRR 1.27; CI: 1.16–1.40) and non-use of condoms at last such sex (Adj PRR 1.18; CI: 1.07–1.29) were associated with higher willingness to be circumcised.ConclusionWillingness to be circumcised was relatively high at the launch of the SMC programme and was more common among uncircumcised men reporting sexual risk behaviours. This indicates that the early adopters of SMC were likely to be in particular need of such additional HIV protective measures.

Commentary: Do the Benefits of Male Circumcision Outweigh the Risks? A Critique of the Proposed CDC Guidelines.

A recent article by ethicist Brian Earp (1) criticizing draft recommendations by the Centers for Disease Control and Prevention (CDC) on the topic of male circumcision (MC) (2) is seriously flawed. Earp seems most concerned about the preservation of the foreskin at all costs. His claims that the foreskin protects the glans and has properties important for sexual pleasure are fallacious. A recent rigorous systematic literature review of penile structures found that sexual pleasure involves neuroreceptors in the glans, not the foreskin (3). It further found that sexual pleasure is derived from exposure of the glans by circumcision or, in uncircumcised men, by foreskin retraction during erection (3). The density of Meissner’s corpuscles in the foreskin decreases at puberty and free nerve endings do not correlate with sexual response (3). Research found that the foreskin was ranked last for sexual pleasure and for the density and size of sensory nerve endings when compared with eight other hairless skin types of the body (4).

Male circumcision and HIV infection among sexually active men in Malawi.

BackgroundThe HIV epidemic remains a major health challenge all over the world. In 2013, an estimated 35million people were living with HIV globally. Male circumcision is increasingly being adopted as a method of HIV prevention. WHO and UNAIDS have advised that male circumcision be added to current HIV interventions. Malawi is one of the countries hardest hit by HIV/AIDS with a prevalence rate of 11 % and male circumcision prevalence of 21.6 % in 2010. Prior to 2011, traditional male circumcision in Malawi was the dominant form of male circumcision, mainly for cultural and religious reasons. This paper looks at male circumcision as a prevention method against HIV by examining the relationship between male circumcision and HIV status among Malawian men.MethodsThe data used were collected as part of the 2010 Malawi Demographic and Health Survey. The methodology used in the 2010 MDHS has been comprehensively described by the National Statistical Office of Malawi and ICF Macro. Our analysis is based on men aged 15–54 years who were tested for HIV and responded to questions on circumcision during the survey. Sixty one percent of the 7175 men interviewed in the MDHS, qualified for this analysis. The sample was weighted to ensure representativeness. Frequencies, cross-tabulations, univariate and multivariate logistic regressions were conducted. Differences in the prevalence of HIV infection among circumcised and uncircumcised men were determined with Chi-squared tests.ResultsThere is no significant difference in HIV prevalence between circumcised (12 %) and uncircumcised men (10 %). Among circumcised men, age and number of lifetime partners are the dominant correlates of HIV status. Additionally, circumcised men who have had ritual sex are two times more likely (OR = 2.399) to be HIV+ compared to circumcised men who have never had ritual sex.ConclusionThis study has demonstrated that traditional male circumcision was not associated with HIV infection in pre-2010 Malawi. Among circumcised men, age and number of lifetime partners are correlates to HIV status while circumcised men who have had ritual sex are more likely to be diagnosed with HIV than circumcised men who have not had ritual sex.

Effect of rAd5-Vector HIV-1 Preventive Vaccines on HIV-1 Acquisition: A Participant-Level Meta-Analysis of Randomized Trials.

BackgroundThree phase 2b, double-blind, placebo-controlled, randomized efficacy trials have tested recombinant Adenovirus serotype-5 (rAd5)-vector preventive HIV-1 vaccines: MRKAd5 HIV-1 gag/pol/nef in Step and Phambili, and DNA/rAd5 HIV-1 env/gag/pol in HVTN505. Due to efficacy futility observed at the first interim analysis in Step and HVTN505, participants of all three studies were unblinded to their vaccination assignments during the study but continued follow–up. Rigorous meta-analysis can provide crucial information to advise the future utility of rAd5-vector vaccines.MethodsWe included participant-level data from all three efficacy trials, and three Phase 1–2 trials evaluating the HVTN505 vaccine regimen. We predefined two co-primary analysis cohorts for assessing the vaccine effect on HIV-1 acquisition. The modified-intention-to-treat (MITT) cohort included all randomly assigned participants HIV-1 uninfected at study entry, who received at least the first vaccine/placebo, and the Ad5 cohort included MITT participants who received at least one dose of rAd5-HIV vaccine or rAd5-placebo. Multivariable Cox regression models were used to estimate hazard ratios (HRs) of HIV-1 infection (vaccine vs. placebo) and evaluate HR variation across vaccine regimens, time since vaccination, and subgroups using interaction tests.FindingsResults are similar for the MITT and Ad5 cohorts; we summarize MITT cohort results. Pooled across the efficacy trials, over all follow-up time 403 (n = 224 vaccine; n = 179 placebo) of 6266 MITT participants acquired HIV-1, with a non-significantly higher incidence in vaccine recipients (HR 1.21, 95% CI 0.99–1.48, P = 0.06). The HRs significantly differed by vaccine regimen (interaction P = 0.03; MRKAd5 HR 1.41, 95% CI 1.11–1.78, P = 0.005 vs. DNA/rAd5 HR 0.88, 95% CI 0.61–1.26, P = 0.48). Results were similar when including the Phase 1–2 trials. Exploratory analyses based on the efficacy trials supported that the MRKAd5 vaccine-increased risk was concentrated in Ad5-positive or uncircumcised men early in follow-up, and in Ad5-negative or circumcised men later. Overall, MRKAd5 vaccine-increased risk was evident across subgroups except in circumcised Ad5-negative men (HR 0.97, 95% CI 0.58−1.63, P = 0.91); there was little evidence that the DNA/rAd5 vaccine, that was tested in this subgroup, increased risk (HR 0.88, 95% CI 0.61–1.26, P = 0.48). When restricting the analysis of Step and Phambili to follow-up time before unblinding, 114 (n = 65 vaccine; n = 49 placebo) of 3770 MITT participants acquired HIV-1, with a non-significantly higher incidence in MRKAd5 vaccine recipients (HR 1.30, 95% CI 0.89–1.14, P = 0.18).Interpretation and SignificanceThe data support increased risk of HIV-1 infection by MRKAd5 over all follow-up time, but do not support increased risk of HIV-1 infection by DNA/rAd5. This study provides a rationale for including monitoring plans enabling detection of increased susceptibility to infection in HIV-1 at-risk populations.

S13.3 Penile microbiota, inflammation, and hiv risk

Introduction The interplay between the genital microbiome and the host immune system may modify one’s susceptibility to sexually transmitted infections. We examined the impact of circumcision on the penile microbiome and how it affects local immune response and potentially modifies the host’s risk for HIV. Methods Using real-time PCR, DNA sequencing, and Luminex multiplex assays, we studied the penile microbiome and levels of pro-inflammatory cytokines in the coronal sulcus of adult men who were randomized to immediate or delayed male circumcision in Rakai, Uganda. Results Uncircumcised men frequently had high abundances of anaerobic bacteria, including Prevotella , Porphyromonas , and species of Clostridiales Family XI. Penile anaerobes decreased after male circumcision, replaced by low abundances of skin-associated bacteria such as Staphylococcus and Corynebacterium . Among the pro-inflammatory cytokines measured, the level of IL-8 correlated significantly with penile anaerobe abundance, which remained persistently elevated in uncircumcised men but decreased after circumcised men. Discussion Our findings suggest that the penile microbiome may play a role in host susceptibility to HIV. Circumcision significantly decreased penile anaerobes and local production of pro-inflammatory cytokines, which may reduce HIV target cells recruitment and activation in the penile epithelium.

Association of male circumcision with risk of prostate cancer: a meta-analysis.

Although early reports have suggested an association between circumcision and prostate cancer (PCa) development, results of subsequent epidemiological studies have been conflicting. Here we examine published articles that explore this association. We searched MEDLINE through PubMed and Embase for articles reporting on the association between PCa and circumcision, and performed a meta-analysis of qualifying studies. On the basis of seven reports of case-control studies published from 1971 to 2014, overall findings showed nonsignificant reduced risk (odds ratio (OR) 0.88, P=0.19) of PCa in circumcised men compared with uncircumcised men, obtained under heterogeneous conditions (I(2)=65%). Heterogeneity and nonsignificance were erased when the overall effect was subjected to outlier treatment and three studies omitted (OR 0.90, P=0.04, I(2)=0%). Furthermore, subgroup analysis showed significantly reduced risks in the following subgroups: (i) post-PSA testing publications (OR 0.88, P=0.01), (ii) population-based studies (OR 0.84, P=0.05), (iii) studies that collected data by personal interview (OR 0.83, P=0.03) and (iv) studies in black race (OR 0.59, P=0.02). The strengths of these summary effects lie in the robustness revealed by sensitivity analysis. Stability of the reduced risks observed in key subgroups suggests that the protective feature of circumcision status against PCa is best seen in the context of the post-PSA testing and population-based studies as well as in the black race subgroup.

Examining the association between male circumcision and sexual function: evidence from a British probability survey.

Objective:Despite biological advantages of male circumcision in reducing HIV/sexually transmitted infection acquisition, concern is often expressed that it may reduce sexual enjoyment and function. We examine the association between circumcision and sexual function among sexually active men in Britain using data from Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Natsal-3 asked about circumcision and included a validated measure of sexual function, the Natsal-SF, which takes into account not only sexual difficulties but also the relationship context and overall level of satisfaction.Methods:A stratified probability survey of 6293 men and 8869 women aged 16–74 years, resident in Britain, undertaken 2010–2012, using computer-assisted face-to-face interviewing with computer-assisted self-interview for the more sensitive questions. Logistic regression was used to calculate odds ratios (ORs) to examine the association between reporting male circumcision and aspects of sexual function among sexually active men (n = 4816).Results:The prevalence of male circumcision in Britain was 20.7% [95% confidence interval (CI): 19.3–21.8]. There was no association between male circumcision and, being in the lowest quintile of scores for the Natsal-SF, an indicator of poorer sexual function (adjusted OR: 0.95, 95% CI: 0.76–1.18). Circumcised men were as likely as uncircumcised men to report the specific sexual difficulties asked about in Natsal-3, except that a larger proportion of circumcised men reported erectile difficulties. This association was of borderline statistical significance after adjusting for age and relationship status (adjusted OR: 1.27, 95% CI: 0.99–1.63).Conclusion:Data from a large, nationally representative British survey suggest that circumcision is not associated with men's overall sexual function at a population level.

Erectile function in circumcised and uncircumcised men in Lusaka, Zambia: A cross-sectional study.

BackgroundEvidence from three randomised control trials in South Africa, Uganda and Kenya showing that male circumcision can reduce heterosexual transmission of human immunodeficiency virus (HIV) infection from infected females to their male partners by up to 60% has led to an increase in circumcisions in most African countries. This has created anxieties around possible deleterious effects of circumcision on erectile function (EF).AimTo compare EF in circumcised and uncircumcised men aged 18 years and older.SettingFour primary healthcare facilities in Lusaka, Zambia.MethodsUsing a cross-sectional survey 478 participants (242 circumcised and 236 uncircumcised) from four primary healthcare facilities in Lusaka, Zambia were asked to complete the IIEF-5 questionnaire. EF scores were calculated for the two groups, where normal EF constituted an IIEF-5 score ≥ 22 (out of 25).ResultsCircumcised men had higher average EF scores compared to their uncircumcised counterparts, (p < 0.001). The prevalence of erectile dysfunction was lower in circumcised men (56%) compared to uncircumcised men (68%) (p < 0.05). EF scores were similar in those circumcised in childhood and those who had the procedure in adulthood, (p = 0.59). The groups did not differ significantly in terms of age, relationship status, smoking, alcohol and medication use. A statistically significant difference was observed in education levels, with the circumcision group having higher levels of education (p < 0.005).ConclusionThe higher EF scores in circumcised men show that circumcision does not confer adverse EF effects in men. These results suggest that circumcision can be considered safe in terms of EF. A definitive prospective study is needed to confirm these findings.

Penile Microbiota and Female Partner Bacterial Vaginosis in Rakai, Uganda.

ABSTRACTBacterial vaginosis (BV) is a common vaginal bacterial imbalance associated with risk for HIV and poor gynecologic and obstetric outcomes. Male circumcision reduces BV-associated bacteria on the penis and decreases BV in female partners, but the link between penile microbiota and female partner BV is not well understood. We tested the hypothesis that having a female partner with BV increases BV-associated bacteria in uncircumcised men. We characterized penile microbiota composition and density (i.e., the quantity of bacteria per swab) by broad-coverage 16S rRNA gene-based sequencing and quantitative PCR (qPCR) in 165 uncircumcised men from Rakai, Uganda. Associations between penile community state types (CSTs) and female partner’s Nugent score were assessed. We found seven distinct penile CSTs of increasing density (CST1 to 7). CST1 to 3 and CST4 to 7 were the two major CST groups. CST4 to 7 had higher prevalence and abundance of BV-associated bacteria, such as Mobiluncus and Dialister, than CST1 to 3. Men with CST4 to 7 were significantly more likely to have a female partner with a high Nugent score (P = 0.03). Men with two or more extramarital partners were significantly more likely to have CST4 to 7 than men with only marital partners (CST4 to 7 prevalence ratio, 1.84; 95% confidence interval [CI], 1.16 to 2.92). Female partner Nugent BV is significantly associated with penile microbiota. Our data support the exchange of BV-associated bacteria through intercourse, which may explain BV recurrence and persistence.

Histological Correlates of Penile Sexual Sensation: Does Circumcision Make a Difference?

IntroductionThe question of whether removal of sensory receptors in the prepuce by circumcision affects sensitivity and/or sexual pleasure is often debated.AimsTo examine histological correlates relevant to penile sensitivity and sexual pleasure.MethodsSystematic review of the scientific literature on penile structures that might affect sensitivity and sexual sensation. Articles were included if they contained original data on human male penile histology or anatomy. Individual articles, including reference lists, were evaluated. They were then considered in relation to physiological data from articles retrieved by a previous systematic review.ResultsWe retrieved 41 publications on penile structure. Considered in the light of 12 reporting physiological measurements, our evaluation finds that sexual response is unlikely to involve Meissner’s corpuscles, whose density in the prepuce diminishes at the time of life when male sexual activity is increasing. Free nerve endings also show no correlation with sexual response. Because tactile sensitivity of the glans decreases with sexual arousal, it is unrelated to sexual sensation. Thermal sensitivity seems part of the reward mechanism of intercourse. Vibrational sensitivity is not related to circumcision status. Observations that penile sexual sensation is higher post circumcision are consistent with greater access of genital corpuscles to sexual stimuli after removal of the prepuce. This is based on the distribution of these corpuscles (which are located in the glans) and, in uncircumcised men, the position of the retracted prepuce during intercourse, rather than any change in the number of genital corpuscles. The scientific literature suggests that any sexual effect of circumcised men may depend solely on exposure of the glans and not on the absence of the prepuce.ConclusionBased on histological findings and correlates of sexual function, loss of the prepuce by circumcision would appear to have no adverse effect on sexual pleasure. Our evaluation supports overall findings from physiological measurements and survey data.

Stages of Change for Voluntary Medical Male Circumcision and Sexual Risk Behavior in Uncircumcised Zambian Men: The Spear and Shield Project

Dissemination and scale up of voluntary medical male circumcision (VMMC) programs is well supported by evidence that VMMC reduces HIV risk in populations with high HIV prevalence and low rates of circumcision, as is the case in Zambia. At both individual and population levels, it is important to understand what stages of change for VMMC are associated with, especially across cultures. This study evaluated VMMC knowledge, misinformation, and stages of change for VMMC of uncircumcised men and boys (over 18 years), as well as the concurrent relationship between VMMC stages of change and sexual risk behaviors. Uncircumcised (N = 800) adult men and boys (over 18) were screened and recruited from urban community health centers in Lusaka, Zambia, where they then completed baseline surveys assessing knowledge, attitudes, HIV risk behaviors, and stages of change for VMMC. A series of analyses explored cross-sectional relationships among these variables. VMMC was culturally acceptable in half of the sample; younger, unmarried, and more educated men were more ready to undergo VMMC. Stage of change for VMMC was also related to knowledge, and those at greater HIV risk reported greater readiness to undergo VMMC. Efforts to increase VMMC uptake should address the role of perceived HIV risk, risk behaviors, readiness, accurate knowledge, cultural acceptance, and understanding of the significant degree of HIV protection conferred as part of the VMMC decision making process. These results support incorporating comprehensive HIV risk reduction in VMMC promotion programs.

Visualization of HIV-1 interactions with penile and foreskin epithelia: clues for female-to-male HIV transmission.

To gain insight into female-to-male HIV sexual transmission and how male circumcision protects against this mode of transmission, we visualized HIV-1 interactions with foreskin and penile tissues in ex vivo tissue culture and in vivo rhesus macaque models utilizing epifluorescent microscopy. 12 foreskin and 14 cadaveric penile specimens were cultured with R5-tropic photoactivatable (PA)-GFP HIV-1 for 4 or 24 hours. Tissue cryosections were immunofluorescently imaged for epithelial and immune cell markers. Images were analyzed for total virions, proportion of penetrators, depth of virion penetration, as well as immune cell counts and depths in the tissue. We visualized individual PA virions breaching penile epithelial surfaces in the explant and macaque model. Using kernel density estimated probabilities of localizing a virion or immune cell at certain tissue depths revealed that interactions between virions and cells were more likely to occur in the inner foreskin or glans penis (from local or cadaveric donors, respectively). Using statistical models to account for repeated measures and zero-inflated datasets, we found no difference in total virions visualized at 4 hours between inner and outer foreskins from local donors. At 24 hours, there were more virions in inner as compared to outer foreskin (0.0495 +/− 0.0154 and 0.0171 +/− 0.0038 virions/image, p = 0.001). In the cadaveric specimens, we observed more virions in inner foreskin (0.0507 +/− 0.0079 virions/image) than glans tissue (0.0167 +/− 0.0033 virions/image, p<0.001), but a greater proportion was seen penetrating uncircumcised glans tissue (0.0458 +/− 0.0188 vs. 0.0151 +/− 0.0100 virions/image, p = 0.099) and to significantly greater mean depths (29.162 +/− 3.908 vs. 12.466 +/− 2.985 μm). Our in vivo macaque model confirmed that virions can breach penile squamous epithelia in a living model. In summary, these results suggest that the inner foreskin and glans epithelia may be important sites for HIV transmission in uncircumcised men.

Circumcision: Is it worth it for 21st-century Australian boys?

Circumcision: Is it worth it for 21st-century Australian boys?

Men's attitudes: A hindrance to the demand for voluntary medical male circumcision – A qualitative study in rural Mhondoro-Ngezi, Zimbabwe

Male circumcision has witnessed a paradigm shift from being regarded as a religious and cultural practice to a global intervention strategy meant to curb transmission of HIV. This is particularly evident in sub-Saharan African countries where the HIV prevalence is greater than 15%. Zimbabwe adopted the voluntary medical male circumcision (VMMC) strategy in 2009; however, since then the uptake of the intervention has only 10% of the adult male population has reported having been circumcised. To better understand this limited uptake of VMMC, we conducted a qualitative study with uncircumcised men aged 15–79 years in Mhondoro-Ngezi, Zimbabwe. Through assessing men's attitudes towards VMMC in seven focus group discussions, conducted between July and August 2012, this article seeks to provide improved strategies for delivering this intervention in Zimbabwe. These data reveal that, in general, men have a negative attitude towards VMMC. Specific barriers to the uptake of VMMC included the perceived challenge to masculinity, post-circumcision stigma, lack of reliable and adequate information and perceptions about the appropriateness of VMMC. These results suggest that structural interventions aimed at reducing stigma related to circumcision, in addition to increased efforts to disseminate accurate information about VMMC, are required in order to dispel men's attitudes that hinder demand for VMMC.

Male Circumcision Linked to Reduction in Risk of Syphilis

Circumcision may protect both men and their partners from syphilis, according to an analysis of data from an HIV prevention trial conducted in Uganda and Kenya. (1) During the study's three-year follow-up period, the risk of a new syphilis infection was lower among circumcised men than among their uncircumcised peers (hazard ratio, 0.6), and lower among their partners than among the partners of uncircumcised men (0.4). In analyses that stratified participants by HIV status, circumcision was associated with reductions in syphilis risk among HIV-infected men (0.4), HIV-infected women (0.5) and women without HIV (0.3), though not among men without HIV. Data from at least three clinical trials have shown that circumcision reduces the risk of HIV acquisition among heterosexual men, and observational studies have suggested that it may also reduce transmission of HPV, herpes and other STIs. At least some of these benefits may extend to women as well. Evidence concerning syphilis transmission is less conclusive, however; although observational studies suggest that circumcision reduces the risk of syphilis, two clinical trials have failed to show protective effects, and no data are available on women. In the current study, Pintye and colleagues analyzed syphilis data from a prospective clinical trial (the Partners PrEP Study) designed to examine whether pre-exposure therapy reduced the risk of HIV transmission between HIV-serodiscordant partners. All participants received HIV prevention services, including referrals for circumcision, and those randomized to the treatment group received antiretroviral drugs. Participants were recruited from 2008 to 2010 and followed for up to three years; the placebo group was discontinued in 2011 when an interim analysis revealed convincing evidence that outcomes were superior in the treatment group. Throughout follow-up, uninfected partners had monthly counseling visits and infected partners had quarterly visits; testing for syphilis was done annually or at interim visits if clinically indicated. At enrollment, participants provided information on their demographic characteristics, medical history and sexual behavior in the past 30 days; circumcision status was determined via physical exam at baseline and annually thereafter. The relationship between circumcision and syphilis incidence was assessed using Andersen-Gill survival models that treated circumcision as a time-dependent event (i.e., researchers were able to account for circumcisions that occurred during follow-up). Analyses were conducted separately for men and women by HIV status to examine whether the relationship between circumcision status and syphilis incidence differed by HIV status. All statistical models adjusted for age at enrollment, whether the participant had had unprotected sex in the past 30 days and serum level of HIV RNA in the infected partner; other demographic and behavioral variables were not included in models because they did not have a meaningful impact on odds ratios. The analytic sample consisted of 4,716 couples; the HIV-infected partner was male in 38% of couples and female in 62%. Median age at enrollment was 36 for men and 30 for women; nearly all couples were married. …

Effects of adult male circumcision on premature ejaculation: results from a prospective study in China.

The purpose of this study is to investigate the effects of adult male circumcision on premature ejaculation (PE). Therefore, between December 2009 and March 2014, a total of 575 circumcised men and 623 uncircumcised men (control group) were evaluated. Detailed evaluations (including circumcision and control groups) on PE were conducted before circumcision and at the 3-, 6-, 9-, and 12-month follow-up visits after circumcision. Self-estimated intravaginal ejaculatory latency time (IELT), Patient-Reported Outcome measures, and 5-item version of the International Index of Erectile Function were used to measure the ejaculatory and erectile function for all subjects. The results showed that, during the one-year follow-up, men after circumcision experienced higher IELT and better scores of control over ejaculation, satisfaction with sexual intercourse, and severity of PE than men before circumcision (P < 0.001 for all). Similarly, when compared with the control group, the circumcised men reported significantly improved IELT, control over ejaculation, and satisfaction with sexual intercourse (P < 0.001 for all). These findings suggested that circumcision might have positive effects on IELT, ejaculatory control, sexual satisfaction, and PE severity. In addition, circumcision was significantly associated with the development of PE.

Male circumcision from an infectiological point of view

In May 2012 a German regional court (Cologne) declared circumcision on religious grounds in minor boys an illegitimate bodily harm. This led to substantial political and religious discussions, because Jews as well as Muslims consider circumcision as an indispensable element of their religion. Still in 2012 a "circumcision law" was passed by the Federal Council of Germany, which continues to allow circumcision in boys "performed under strict medical conditions". How male circumcision is assessed in terms of infectiology (pros and cons)? Electronic databases were searched for articles about the infection risks of foreskin surgery, and the efficacy of circumcision in reducing the risks of sexual transmission of HIV, herpes viruses, HPV, treponema pallidum, chlamydia, hemophilus ducrey and Neisseria gonorrhoeae. Contra circumcision: The highest risk of neonatal circumcision is hemorrhage (35 %). Among infections surgical wound infection (10 %), meatitis urethrae (8-20 %) and urinary tract infections (2 %) are frequent (depending on the surgical technique). Severe complications like penile necrosis or lethal sepsis are rare (1:20,000). Pro circumcision: Circumcised boys have a reduced risk for urinary tract infections in childhood (1:10). Compared to uncircumcised men circumcised adults have a 50-60 % reduced risk of becoming infected with viral sexually transmitted infections (STIs; HIV, HPV and HSV). This advantage of circumcision is also discussed for the transmission of bacterial STIs (e.g. syphilis and chancroid), but the analysis of different clinical studies is still controversial. Neonatal circumcisions (and circumcision in early childhood) are irreparable interventions in the physical integrity, with very few medical indications. The risk of complications is dependent on the education of the circumciser (ritual, medical), analgesia and hygiene. Circumcisions should be performed under optimal surgical and hygienic conditions in informed and self-determined young men only. In adolescents and adults circumcision reduces the risk of the transmission of viral STIs (HIV, HSV, HPV) and there is also probably some effect on the sexual transmission of treponema pallidum and hemophilus ducreyi (insufficient, controversial data). The role of circumcision as an effective procedure to reduce the transmission of STIs is still under discussion, because important additional factors like sexual risk behavior (e.g. unprotected sexual intercourse, promiscuity) have a strong influence on STI epidemiology.

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

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.

Correction: HIV Acquisition Is Associated with Increased Antimicrobial Peptides and Reduced HIV Neutralizing IgA in the Foreskin Prepuce of Uncircumcised Men

Correction: HIV Acquisition Is Associated with Increased Antimicrobial Peptides and Reduced HIV Neutralizing IgA in the Foreskin Prepuce of Uncircumcised Men

Buschke-Löwenstein tumor of the vulva in a patient with a history of squamous cell carcinoma of the cervix

Background Buschke-Lowenstein tumor (BLT) is a very rare sexually-transmitted disease associated with human papillomavirus (HPV) type 6 and 11, but rare cases of oncogenic HPV types including HPV 16 and HPV 18 were also reported. It is characterized by slow, locally invasive growth and clinically presents as exophytic masses with a cauliflower-like morphology. It usually occurs in uncircumcised men and location in sites other than the penis is very rare. It is a premalignant disorder with a low incidence of metastasis but with a considerable risk of malignant transformation to squamous cell carcinoma (SCC).