Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) Indonesia, Pakistan, Philippines) remains extremely low, despite patterns of risk factors for HIV and other STIs similar to those found elsewhere in the region. Table 1.1. HIV prevalence according to frequency of male circumcision Low circumcision rate (80%) Country HIV prevalence (%) Country HIV prevalence (%) Sub-Saharan Africa Botswana 24.1 Benin 1.8 Malawi 14.1 Cameroon 5.4 Mozambique 16.1 Democratic 3.2 Republic of Congo Namibia 19.6 Gabon 7.9 Rwanda 3.1 Gambia 2.4 Swaziland 33.4 Ghana 2.3 Zambia 17.0 Guinea 1.5 Zimbabwe 20.1 Kenya 6.1 Liberia 5.9 Nigeria 3.9 Sierra Leone 1.6 South and south-east Asia Cambodia 1.6 Bangladesh
Male circumcision under local anaesthesia Version 3.1 (Dec09) Randomized controlled trials to assess the efficacy of male circumcision in reducing risk of HIV infection In July 2005 the results of the Orange Farm Intervention Trial in South Africa were made public; they were subsequently published in November 2005. 6 This was the first report from a randomized controlled trial of male circumcision as a means to prevent HIV infection. A total of 3274 uninfected men, aged 18–24 years, were randomly assigned to undergo circumcision either immediately or after 21 months. The incidence of HIV infection was found to be 60% lower among those who were circumcised. On the strength of these results, the Independent Data Monitoring Committee recommended that the men initially assigned to the delayed circumcision group should be offered the procedure without further delay, without waiting the full 21 months. Two further trials on male circumcision and HIV infection were stopped in December 2006 and published in early 2007. Both trials involved random allocation of HIV-negative volunteers to either immediate circumcision, performed by trained medical professionals in a clinic setting (intervention group), or circumcision delayed for 2 years (control group). The first trial, in Kisumu, western Kenya, was conducted among men aged 18–24 years, and showed a 53% reduction in HIV incidence. 7 The second study was conducted in Rakai, Uganda, among men aged 15–49 years, and showed a 51% reduction in HIV incidence. 8 Following release of the study results, circumcision was offered without further delay to the men in both nonintervention groups. Possible biological explanations for the protective effect of male circumcision The primary cells through which HIV enters the body are Langerhans cells. These cells are present in high density in the epithelium of the inner foreskin, and are close to the surface because the layer of 18, 19 keratin is thin. In an in vitro study, viral uptake by cells from the mucosal surface of foreskin was 7 times more efficient than that by tissue from the female cervix. 20 The inner mucosal surface of the foreskin lacks the thick layer of keratin that covers most exposed skin. This leaves numerous mucosal Langerhans cells and other immune cell targets easily accessible to HIV infection. 21 The highly vascularized foreskin mucosa, and in particular the frenulum, is prone to tearing and bleeding during intercourse. These micro-injuries allow easy access of HIV to the bloodstream. A further factor that may facilitate entry of the virus is the presence of an ulcerative STI, such as herpes simplex, chancroid or syphilis, which tend to be more common in uncircumcised men. 5 Male circumcision and HIV infection Chapter 1-5
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Manual for Male Circumcision under Local Anaesthesia

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