Biomedical Engineering – From Theory to Applications

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Biomedical Engineering – From Theory to Applications
Chlamydia trachomatis that can cause pelvic inflammatory disease, ectopic pregnancy and
infertility, as well reducing the risk of bacterial vaginosis (Morris, 2007; Morris, 2010; Tobian et
al., 2010; Morris et al., 2011; Wawer et al., 2011).
If one tallies up all of the conditions listed above, 1 in 3 uncircumcised men will require
medical attention from a condition stemming from their uncircumcised state (Morris, 2007).
Moreover, such an analysis shows that the benefits exceed the risks by over 100 to 1, and far
more if one factors in the severity of the consequences, including mortality and morbidity,
that can occur in uncircumcised males and their sexual partners in adulthood.
MC is, without doubt, a multi-benefit procedure. Yet many analyses of its benefits make the
mistake of addressing its effect with respect to just one medical condition. For a true
assessment of its value it is necessary to carry out a summation of all the benefits, quoting
the total inclusive of spin-offs every time.
Because of the current focus on efficient and effective MC in regions of the world where HIV
prevalence is high, in the present chapter we will begin by summarizing the HIV findings.
In the context of biomedical engineering, we will then examine the devices that have been
devised for the surgical procedure itself. The intention of these devices has been to help
reduce risk to delicate penile structures during surgery and also to ensure a favourable
cosmetic outcome of the circumcision procedure.
2. Male circumcision for HIV prevention
In 2007 MC was endorsed by the World Health Organization (WHO) and the Joint United
Nations Programme on HIV/AIDS (World Health Organisation and UNAIDS, 2007a) as
being an important, proven strategy for prevention of heterosexually-transmitted HIV in
high prevalence settings. Such advice was the culmination of 20 years of research that led to
the findings of three large randomized controlled trials in different parts of sub-Saharan
Africa (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). After rigorous examination of
the data, the Cochrane committee concluded that “inclusion of male circumcision into
current HIV prevention guidelines is warranted” and that “No further trials are required”
(Siegfried et al., 2009; Siegfried et al., 2010). A recent analysis of data from 18 sub-Saharan
African countries found the protective effect after adjustment for number of lifetime sexual
partners and socio-demographic variables was 5-fold (Gebremedhin, 2010). As a result,
large-scale MC programmes are being rolled out across sub-Saharan Africa in societies
where traditional circumcision has not in recent times been the norm.
Therefore, whilst the long-term goal should be one of circumcising in infancy, the
immediate need in settings where life-threatening HIV prevalence is high is to circumcise
uninfected heterosexually-active adult and adolescent males.
Critics of this approach cite the "ABC" policy (Abstinance, Behaviour, Condoms) (Coates et
al., 2008) as being sufficient. While condoms are 80–90% effective if always used properly
(Halperin et al., 2004), including during foreplay, the reality is that for a host of reasons such
as passion over-riding common sense, dislike for condoms, reckless behaviour often fuelled
by inebriation, and/or not having a condom available, many people either do not use them
consistently or at all (Donovan & Ross, 2000; Szabo & Short, 2000; Caballero-Hoyos &
Villasenor-Sierra, 2001; Ferrante et al., 2005; Jadack et al., 2006; Kang et al., 2006; Sanchez et
al., 2006; Yahya-Malima et al., 2007; Munro et al., 2008; Wawer et al., 2009). This research
included RCTs in which men were given counselling and free condoms (Wawer et al., 2009).
A review of 10 studies from Africa found that overall there was no association between