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WHAT'S NEW THIS WEDNESDAY: THREE ON CIRCUMCISION:REVISED AAP POSITION, TWO ITEMS FROM AFRICA

Monday, 27th of August 2012

• THREE ON MALE CIRCUMCISION
  
•  BENEFITS OF CIRCUMCISION ARE SAID TO OUTWEIGH RISKS

By RONI CARYN RABIN

Published: New York Times, August 27, 2012

[See also full AAP statement at http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990.full.pdf+html]

The American Academy of Pediatrics has shifted its stance on infant male circumcision, announcing on Monday that new research, including studies in Africa suggesting that the procedure may protect heterosexual men against H.I.V., indicated that the health benefits outweighed the risks.

But the academy stopped short of recommending routine circumcision for all baby boys, saying the decision remains a family matter. The academy had previously taken a neutral position on circumcision.

The new policy statement, the first update of the academy’s circumcision policy in over a decade, appears in the Aug. 27 issue of the journal Pediatrics. The group’s guidelines greatly influence pediatric care and decisions about coverage by insurers; in the new statement, the academy also said that circumcision should be covered by insurance.

The long-delayed policy update comes as sentiment against circumcision is gaining strength in the United States and parts of Europe. Circumcision rates in the United States declined to 54.5 percent in 2009 from 62.7 percent in 1999, according to one federal estimate. Critics succeeded last year in placing a circumcision ban on the ballot in San Francisco, but a judge ruled against including the measure.

In Europe, a government ethics committee in Germany last week overruled a court decision that removing a child’s foreskin was “grievous bodily harm” and therefore illegal. The country’s Professional Association of Pediatricians called the ethics committee ruling “a scandal.”

A provincial official in Austria has told state-run hospitals in the region to stop performing circumcisions, and the Danish authorities have commissioned a report to investigate whether medical doctors are present during religious circumcision rituals as required.

Officials with the Centers for Disease Control and Prevention in Atlanta, which for several years have been pondering circumcision recommendations of their own, have yet to weigh in and declined to comment on the academy’s new stance. Medicaid programs in several states have stopped paying for the routine circumcision of infants.

“We’re not pushing everybody to circumcise their babies,” Dr. Douglas S. Diekema, a member of the academy’s task force on circumcision and an author of the new policy, said in an interview. “This is not really pro-circumcision. It falls in the middle. It’s pro-choice, for lack of a better word. Really, what we’re saying is, ‘This ought to be a choice that’s available to parents.’ ”

But opponents of circumcision say no one — not even a well-meaning parent — has the right to make the decision to remove a healthy body part from another person.

“The bottom line is it’s unethical,” said Georganne Chapin, founding director of Intact America, a national group that advocates against circumcision. “A normal foreskin on a normal baby boy is no more threatening than the hymen or labia on your daughter.”

In updating its 1999 policy, the academy’s task force reviewed the medical literature on benefits and harms of the surgery. It was a protracted analysis that began in 2007, and the result is a 30-page report, which includes seven pages of references, including 248 citations.

Among those are 14 studies that provide what the experts characterize as “fair” evidence that circumcision in adulthood protects men from H.I.V. transmission from a female partner, cutting infection rates by 40 to 60 percent. Three of the studies were large randomized controlled trials of the kind considered the gold standard in medicine, but they were carried out in Africa, where H.I.V. — the virus the causes AIDS — is spread primarily among heterosexuals.

Circumcision does not appear to reduce H.I.V. transmission among men who have sex with men, Dr. Diekema said. “The degree of benefit, or degree of impact, in a place like the U.S. will clearly be smaller than in a place like Africa,” he said.

Two studies have found that circumcision actually increases the risk of H.I.V. infection among sexually active men and women, the academy noted.

Other studies have linked male circumcision to lower rates of infection with human papillomavirus and herpes simplex Type 2. But male circumcision is not associated with lower rates of gonorrhea or chlamydia, and evidence for protection against syphilis is weak, the review said.

The procedure has long been recognized to lower urinary tract infections early in life and reduce the incidence of penile cancer.

Although newborn male circumcision is generally believed to be relatively safe, deaths are not unheard of, and the review noted that “the true incidence of complications after newborn circumcision is unknown.”

Significant complications are believed to occur in approximately one in 500 procedures. Botched operations can result in damage or even amputation of parts of the penis, and by one estimate about 117 boys die each year.

Anesthesia is often not used, and the task force recommended that pain relief, including penile nerve blocks, be used regularly, a change that may raise the rate of complications.

A version of this article appeared in print on August 27, 2012, on page A3 of the New York edition with the headline: Benefits of Circumcision Are Said to Outweigh Risks.

 

PLoS One. 2012;7(7):e40507. Epub 2012 Jul 6.

• RAPID INCREASE IN PREVALENCE OF MALE CIRCUMCISION IN RURAL TANZANIA IN THE ABSENCE OF A PROMOTIONAL CAMPAIGN.

Forbes HJ, Doyle AM, Maganja K, Changalucha J, Weiss HA, Ross DA, Hayes RJ.

Source

London School of Hygiene and Tropical Medicine, London, United Kingdom.

Abstract below; full text is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0040507

OBJECTIVES:

To estimate the prevalence of circumcision among young men in rural Mwanza, North-Western Tanzania, and document trends in circumcision prevalence over time. To investigate associations of circumcision with socio-demographic characteristics, reported sexual behaviours and sexually transmitted infections (STIs).

DESIGN:

A cross-sectional survey in communities which had previously participated in a cluster-randomized trial of an adolescent sexual health intervention that did not include male circumcision in 20 rural communities.

METHODS:

In 2007/08, 7300 young men (age 16-23 years) were interviewed and examined by a clinician. The prevalence of circumcision by age was compared with data collected during the trial in 1998-2002. Odds ratios (OR) and 95% confidence intervals (CI) for the association of circumcision with socio-demographic characteristics, reported sexual behaviours and with HIV and other STIs were estimated using multivariable conditional logistic regression.

RESULTS:

The prevalence of male circumcision was 40.6%, and age-specific prevalence had more than doubled since 2001/2002. Circumcised men reported less risky sexual behaviours, being more likely to report having ever used a condom (adjusted OR = 2.62, 95%CI:2.32-2.95). Men circumcised before sexual debut were at reduced risk of being HIV seropositive compared with non-circumcised men (adjusted OR = 0.50, 95%CI:0.25-0.97), and also had reduced risks of HSV-2 infection and genital ulcer syndrome in the past 12 months compared with non-circumcised men.

CONCLUSIONS:

There was a steep increase in circumcision prevalence between 2001/02 and 2007/08 in the absence of a promotional campaign. Circumcised men reported safer sexual practices than non-circumcised men and had lower prevalence of HIV and HSV-2 infection.

• IMPACT OF MALE CIRCUMCISION ON HIV RISK COMPENSATION THROUGH THE IMPEDIMENT OF CONDOM USE IN BOTSWANA.

 

Afr Health Sci. 2011 Dec;11(4):550-9.

 

Ayiga N, Letamo G.

Source

Population Training and Research Unit, North West University Mafikeng Campus, Private Bag x2046, Mmabatho 2735, South Africa. natalayiga@yahoo.com

Abstract below; full text, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362967/

BACKGROUND:

Male circumcision has been recommended as a method of reducing the risk of transmitting HIV. However, widespread uptake of male circumcision may lead to HIV risk compensation by impeding condom use.

OBJECTIVE:

To investigate the impact of male circumcision on condom use.

METHODS:

The study used cross-sectional data from the Botswana AIDS Impact Survey III on 1,257 men aged 15 years or older who were sexually active. Data were analyzed using Pearson's chi-square statistic and binary logistic regression.

RESULTS:

The study found that 15% of circumcised men did not use condoms compared to 12% of uncircumcised men, and circumcision was not significantly associated with condom use. Non-use of condoms was significantly affected by religious beliefs, low level of education, marriage, drunkenness, and misconceptions regarding antiretroviral therapy (ART).

CONCLUSIONS:

We conclude that male circumcision does not impede condom use. Condom use is impeded by low level of education, marriage, drunkenness, and misconceptions regarding ART. We recommend the emphasis of consistent condom use targeting people with low education, those in marriage, users of alcohol, and people receiving ART.