SHOULD MALE CIRCUMCISION BE PROMOTED IN DEVELOPING COUNTRIES AS MAJOR MEANS OF HIV PREVENTION by Wazhma Hakimi.pdf
Creators: name: Wazhma Hakimi
Publisher: name: figshare
Year: 2020
Subjects: subject: 110309 Infectious Diseases
subject: FOS: Health sciences
subject: FOS: Health sciences
subject: 111716 Preventive Medicine
subject: 111708 Health and Community Services
subject: 111712 Health Promotion
subject: 110799 Immunology not elsewhere classified
subject: FOS: Clinical medicine
subject: FOS: Clinical medicine
subject: 111402 Obstetrics and Gynaecology

description: Globally, around 30% males are circumcised; mainly in Asia, the Middle East and North Africa. However, male circumcision (MC) has been known as a religious or traditional ritual, it was suggested as a mean for prevention of sexually transmitted infections (STIs) in 1850s. Then in 1980s, MC was considered as a method of human immunodeficiency virus (HIV) prevention (Sharma et al., 2018). Following many randomized controlled trials (RCTs) which proved that MC prevents HIV transmission and has protective effect; in 2007, the WHO/UNAIDS recommended MC as a strategy for the prevention of this disease and SSA was identified as priority setting for its quick scale-up (Kong et al., 2012; Mati et al., 2016). Different theories have been suggested on how MC reduces the risk of HIV. One of the theories states that MC decreases the risk of STIs and therefore indirectly reduces vulnerability to HIV, because STIs increase the risk of acquiring this virus. The other rationale is that there are Langerhans’ cells and CD4+ T lymphocytes under the surface of foreskin, which are target cells of the HIV. Therefore, by removing the foreskin, these cells will be removed and they will not be the target anymore. The third justification is that when tiny tears happens in the fragile foreskin, they can be the entry points for this virus. The foreskin provides a suitable environment for the virus to grow. Therefore, by removing the foreskin, we destroy the warm and moist environment for the virus (Sharma et al., 2018). In addition, large number of data have been published on this issue, of which most of them reports protective effect of MC against HIV, while some other studies show concerns about MC.<br>Surprisingly, many studies explored the association between MC and HIV prevalence. For instance, Kacker et al. (2012) reports in his study that continued decreases in MC rates are associated with increased HIV infection prevalence. Also, meta-analysis by Sharma et al. (2018), provides convincing evidence that circumcision was associated with a 40% reduction in HIV risk in both homosexual and heterosexual men. Besides, Kong et al. (2011) in his analysis of posttrial HIV incidence among RCT participants found that the effectiveness of MC on HIV prevention is 67%. However, it is not well-known whether MC prevents HIV transmission in MSM, there is protective effect for men who are involved in anal sex (Friedman et al., 2016).<br>Among the many concerns that have been raised regarding MC; desire of men toward more unsafe sex after circumcision, engaging in unethical behavior, not being effective in reducing STIs, negative effects on erectile function and sexual satisfaction, and its complications are discussed through many researches. To illustrate, a study showed that after circumcision, men were more involved in riskier sexual behavior like reduction in condom use especially in settings where risk reduction education, counselling, and follow up was limited. Whereas another follow-up study of MC acceptors showed significant reduction in engagement of circumcised men in nonmarital relations (Kong et al., 2012). In addition, Herman et al. (2011) in his study on perceptions of uncircumcised men on MC explored that they think MC makes young men promiscuous to have sex without any risk. In contrast, Friedman et al. (2016) reports that circumcision is not unethical for those who choose to be circumcised for religious, social, or cultural purposes.To discuss the prevention of STIs by MC, Van Howe (2013), states that MC is not decreasing the risk of all STIs. It is contradicted with the findings of other RCTs, which proved that MC lowers the risk of transmission of many other STIs, such as HPV, HSV, bacterial vaginosis, Trichomonas vaginalis infection, chancroid, syphilis and genital ulcers (Friedman et al., 2016; Homfray at al., 2015; Kong et al., 2012; Sharma et al., 2018; Tobian et al., 2010). Moreover, there are many high-quality evidences that strongly support lack of harm due to MC as reported by Friedman et al. (2016). He supports that MC has no negative consequence on sexual satisfaction and function and it will not have serious complications if done by a trained practitioner, in a sterile setting, and with appropriate follow-up. Hoschke et al. (2013), conducted a study on 10,000 men in Brandenburg, Germany which is one of the largest surveys globally. He measured International Index of Erectile Function (IIEF-6), sexual satisfaction and sexual quality of life. He came with the conclusion that there is no significant correlation between sexual satisfaction of men and a history of circumcision. He also added that the prevalence of Erectile Dysfunction is not increased in men following circumcision. However, the other concern is engaging circumcised men in sexual intercourse before wound healing, three clinical trials found that men who started sex early, were not at an increased risk of HIV acquisition [Sharma et al., 2018].Considering the above-mentioned evidences and the largest effect of MC on HIV risk reduction, it is clear that the complication rate of the MC procedure is lowest than HIV risk reduction rate and the potential advantages of MC. Therefore, voluntary MC should be promoted in developing world as a major strategy to reduce HIV acquisition. It can be effective if it is promoted together with the following interventions. 1) increasing knowledge of HIV reduction by MC and its benefits in women through campaigns in order to strengthen their support of MC as they play a central role in its scale-up 2) counselling and give precautionary advice to circumcised men not to be engaged in sexual intercourse shortly after circumcision till wound healing and to delay intercourse in order to reduce the risk of HIV 3) health and risk reduction education for circumcised men that they are not yet fully protected from HIV, so they should not take part in sexually risky behavior 4) developing policies and programs that can empower married women to negotiate safer sex 5) and follow up of circumcised men. These interventions decrease the negative consequences associated with MC and will lead to a successful program for HIV prevention.<br>