Male circumcision reduces risk of genital herpes and HPV infection, but not syphilis

Mar 25, 2009

Heterosexual men who undergo medical circumcision can significantly reduce their risk of acquiring two common sexually transmitted infections--herpes simplex virus type 2 (HSV-2), the cause of genital herpes, and human papillomavirus (HPV), which can cause cancer and genital warts, according to a report in the March 26 issue of the New England Journal of Medicine (NEJM). In the study, circumcision had no effect on their risk of becoming infected with the bacterium that causes syphilis, however.

The findings build upon earlier clinical research funded by the National Institute of Allergy and Infectious Disease (NIAID), part of the NIH, which found that decreases a man's risk of acquiring HIV infection through heterosexual intercourse by more than 50 percent.

"Medically supervised adult is a scientifically proven method for reducing a man's risk of acquiring HIV infection through heterosexual intercourse," says NIAID Director Anthony S. Fauci, M.D. "This new research provides compelling evidence that circumcision can provide some protection against and infections as well."

The study was conducted by scientists at the Rakai Health Sciences Program in Uganda in collaboration with researchers at the Johns Hopkins University Bloomberg School of Public Health in Baltimore, Makerere University in Kampala, Uganda, and NIAID's Division of Intramural Research. The collaborators examined samples from two parallel clinical trials in Rakai that successfully proved male circumcision as an HIV prevention method and also assessed the surgical procedure's ability to prevent other sexually transmitted infections, including syphilis and HSV-2. These infections cause genital ulcers and are associated with an increased risk of HIV acquisition. The research team also assessed circumcision's effect on infections, which can cause anal, cervical and penile cancers and genital warts.

The two trials, one funded by NIAID and the other by the Bill & Melinda Gates Foundation, enrolled 3,393 uncircumcised men between the ages of 15 and 49 who initially tested negative for both HIV and HSV-2. The men were assigned at random to one of two study groups: 1,684 received immediate circumcision performed by trained medical professionals in an outpatient setting (intervention group); and 1,709 received medical circumcision after a delay of 24 months (control group). The researchers evaluated the volunteers at six, 12 and 24 months for HSV-2 and syphilis infection. Additionally, a subgroup of 697 volunteers (352 participants in the intervention group; 345 in the control group) was evaluated for HPV infection at enrollment and at 24 months.

In analyzing the effect of circumcision on HSV-2 acquisition across both studies, the researchers found that the cumulative probability of HSV-2 infection was significantly lower among those volunteers who received immediate circumcision (7.8 percent) than among those in the control group who were circumcised at 24 months (10.3 percent). Overall, the researchers found that medically supervised circumcision reduced the men's risk of HSV-2 infection by 28 percent.

The combined results from both trials also demonstrated a 35 percent reduction in HPV prevalence among men in the intervention group. In evaluating a subgroup of volunteers at 24 months, high-risk HPV strains associated with certain cancers were detected in 42 of 233 men in the intervention group and in 80 of 287 men in the control group.

Circumcision did not, however, affect the incidence of syphilis. At 24 months, syphilis was detected in 50 men in the intervention group and 45 members of the control group.

"The cumulative scientific evidence supporting the public health value of medically supervised male circumcision is now overwhelming," says Thomas C. Quinn, M.D., study co-investigator, chief of the International HIV/STD Section in NIAID's Laboratory of Immunoregulation and co-author of the study. "This new research confirms the substantial health benefits of male circumcision, including reduced acquisition of HIV, genital herpes, HPV and genital ulcer disease."

Dr. David Serwadda, co-principal investigator and dean of Makerere University's School of Public Health, adds that "these findings have significant public health implications for the control of HIV, genital herpes and HPV in areas of high prevalence, such as Africa, and further suggest that efforts to scale-up male circumcision could have tremendous benefit."

"The next focus of our research will be to analyze additional data collected in the Rakai trials to assess the degree to which male circumcision may reduce transmission of HPV to female sexual partners," says Johns Hopkins professor Ronald H. Gray, M.D., co-principal investigator. "This would be of substantial significance because HPV causes cervical cancer."

The biological reasons why circumcision may reduce the risk of HSV-2 and HPV infection, but not syphilis, are not entirely known. HSV-2 and HPV multiply in epithelial cells found in the surface skin of the penis, and the foreskin may facilitate virus entry into those cells. Once circumcision has been performed, the risk of epithelial infection may be reduced, the authors note. Additionally, the analysis used to determine the effects of circumcision on syphilis had limited statistical power, and therefore, it is difficult to draw a firm conclusion as to whether or not circumcision may reduce syphilis incidence, the researchers add.

During each clinic visit, volunteers were given physical examinations, counseled on safe sex practices and offered condoms, voluntary HIV counseling and testing. Study staff also interviewed each volunteer to record sociodemographic characteristics and rates of specific sexual risk behaviors. Volunteers who acquired HIV infection during the two clinical trials were referred to Rakai Health Science Program clinics for HIV care funded by the U.S. President's Emergency Plan for AIDS Relief. Volunteers who acquired genital ulcers or syphilis were also provided with appropriate medical care and treatment.

As with most strategies to prevent sexually transmitted infections, including HIV, adult male circumcision is not completely effective. Therefore, the authors note, safe sex practices, including consistent condom use, are still necessary to provide the best protection against such infections.

Source: NIH/National Institute of Allergy and Infectious Diseases (news : web)

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User comments : 13

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Modernmystic
1.5 / 5 (8) Mar 25, 2009
To quote Meatloaf...two out of three aint bad...
chelfyn
3.5 / 5 (4) Mar 25, 2009
I could be wrong here , but does this study account for the recovery period from circumcision and it's affect on sexual behaviour? It doesn't seem to, and I'd be willing to bet that at least 3 of those 24 months measured will be at a significantly lower rate of sexual activity than someone who hasn't had a large wound on their nethers to recover from.

For what it's worth, I still think telling the pope to STFU and showering the place with free condoms would do more good..
freethinking
2.1 / 5 (7) Mar 25, 2009
Chelfyn, Im not catholic, but the Pope was misquoted by the media (no supprise, the media mischaracterizes almost everything Catholic, or Christian). Also statistically speaking, showering condoms to people havent reduced any infection rates. Generally when they supply free condoms infection rates go up.

Now to circumcision. Other studies have shown no differnce to cicumcision and infection rates. I for one believe nature or God (and lets not get into the Jewish thing) intended for us to have those parts and that they serve some positive use, therefor unless their is a good reason, it shouldnt be cut off.
ml66uk
4 / 5 (4) Mar 25, 2009
1) A 29 year study of males in New Zealand showed a slightly *higher* rate of STI's among circumcised men:
http://www.jpeds....abstract

2) If we found out that cutting off part of a girl's genitals reduced her risk of contracting an STI, would that make it acceptable?
This study shows exactly that: http://www.ias-20...AID=3138
ler177
1.5 / 5 (2) Mar 26, 2009
Chelfyn, Im not catholic, but the Pope was misquoted by the media (no supprise, the media mischaracterizes almost everything Catholic, or Christian).

I doubt Fox news misquoted him (that's where I heard it).

Would this ever be considered if it wasn't already a deeply ingrained tradition?

FYI, Penn & Teller's BS episode on this very subject is on Youtube.
El_Nose
2.7 / 5 (3) Mar 26, 2009
there are many many many arguement for and against this topic -- from easier to keep it clean to you deserve to get a disease from being that dirty -- or i would never put holes in my ear(earing w/o clasps) but i would cut my sons penis --- or what ever you may personally belive

the article does not seem to account for recovery period and it would seem to me that every one in the group, control or otherwise would need to be very sexually active people -- and then would have to be actively haveing sex with people who they knew to have the said diseases -- because everything could just be well luck.

freethinking
1 / 5 (6) Mar 26, 2009
I agree with the following....he says it better than I can.

http://www.dallas...3d7.html
Scire
1.8 / 5 (5) Mar 26, 2009
We have to be careful not to take evidence from one part of the world and apply it uncritically to others.
dbren
2.3 / 5 (3) Mar 26, 2009
Why does this article repeatedly use the phrase "male circumcision?" Isn't that a little redundant? Yes, there is a form of female genital mutilation practiced by misogynous cultures that some refer to as "female circumcision", but that is a politically loaded term intended to portray penile circumcision as simply another form of horrendous genital mutilation. This kind of political correctness has no place in a scientific article.
ml66uk
5 / 5 (1) Mar 26, 2009
dbren: The people who support and promote female circumcision get really upset if you call it "mutilation", and they don't see much of a difference between male and female circumcision even if you do. Try debating with them.

Are you aware that the USA also used to practise female circumcision? Fortunately, it never caught on the same way as male circumcision, but there are middle-aged white US American women walking round today with no clitoris because it was removed. Some of them don't even realise what has been done to them. There are frequent references to the practice in medical literature up until the late 1950's. Most of them point out the similarity with male circumcision, and suggest that it should be performed for the same reasons. Blue Cross/Blue Shield had a code for clitoridectomy till 1977.

One victim wrote a book about it:
Robinett, Patricia (2006). "The rape of innocence: One woman's story of female genital mutilation in the USA."
Scire
2 / 5 (3) Mar 27, 2009
Removing the labia is analogous to male circumcision; removing the clitoris is one step too far.

I don't see how one could be against female circumcision (labiaplasty) but for male circumcision; or vice versa.
kinnala
3 / 5 (3) Mar 28, 2009
You can't really compare male circumcision and female genital mutilation. Basically female mutilation is the same as cutting mans penis glans away.
ml66uk
4 / 5 (1) Apr 01, 2009
Some forms of female circumcision do a lot less damage than the usual form of male circumcision. One is the exact equivalent (removing the prepuce). Just making an incision on a girl's genitals is illegal though, even if no tissue is removed. Why don't boys get the same protection?

Try debating with the women that cut their girls. They don't see a difference between male and female circumcision. If people are serious about stopping female circumcision, they also have to be against male circumcision. Even if you see a fundamental difference, the people that cut girls don't (and they get furious if you call it "mutilation"). The sooner boys are protected from genital mutilation in the west, the sooner those peoples that practice fgm will interpret western objections as something more than blindly hypocritical cultural imperialism.

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