Penile Hygiene, Male Circumcision and HIV
O'Farrell N, Morison L, Moodley P, Pillay K, Vanmali T, Quigley M, Hayes R, Sturm AW. Association between HIV and subpreputial penile wetness in uncircumcised men in South Africa. J Acquir Immune Defic Syndr 2006;43:69-77
O'Farrell and colleagues describe the prevalence and characteristics of subpreputial penile wetness and investigate the association between current levels of penile wetness and HIV infection. The authors enrolled male attendees at a sexually transmitted infections clinic in Durban, South Africa, and treated them for their presenting sexually transmitted infection complaint. They were asked to return after 14 days when a structured questionnaire was administered, and the degree of wetness of the glans penis and coronal sulcus was assessed clinically. Six hundred and fifty men were enrolled, and 488 (75%) returned. Three hundred eighty-six uncircumcised men were included in the statistical analysis of whom 215 (56%) were HIV positive. One hundred and ninety-six (50.8%) had no penile wetness, and 190 (49.2%) had penile wetness. In the adjusted analysis, penile wetness was associated with younger age, low level of attained education, low income, higher lifetime numbers of sexual partners, and not washing after sex. The prevalence of HIV was greater in those with penile wetness 126 of 190 (66.3%) compared with 90 of 196 (45.9%) with no penile wetness (OR 2.38, 95% CI 1.42-3.97, P <0.001 when controlled for known predictors of HIV infection). This is the first study to show an association between sub-preputial penile wetness and HIV. The authors conclude that consideration should be given to providing advice about improving penile hygiene in uncircumcised men in areas where HIV is a significant problem. Good penile hygiene should also be promoted at the community level to become a desirable social norm.
Meier AS, Bukusi EA, Cohen CR, Holmes KK. Independent association of hygiene, socioeconomic status, and circumcision with reduced risk of HIV infection among Kenyan men. J Acquir Immune Defic Syndr 2006;43:117-8Among Kenyan men recruited as sex partners of women with genital symptoms, 22 of 150 were HIV seropositive. Because male HIV infection and male hygiene were unexpectedly found to be associated with each other, Meier and colleagues examined the relationship of five hygiene variables with HIV infection in the men in a principal components analysis, controlling for socioeconomic status and other potential confounders. By multivariate analyses, HIV infection in men was independently associated with previous illness (OR 5.1, 95% CI 1.4-19.1), inversely associated with being circumcised (OR 0.12, 95% CI 0.02-0.91), and also inversely associated with a combined measure of hygiene (OR 0.41, 95% CI, 0.19-0.90).
Editors’ note: Lack of genital hygienic practices in uncircumcised men are known to lead to development of balanitis, phimosis, paraphimosis, and breakage of the skin or lacerations which then facilitate entry of pathogenic agents. The foreskin traps HIV-contaminated vaginal secretions in a humid environment that favors longer survival of HIV and other STI. This study and the one above suggest that promoting improved penile hygiene would reduce HIV transmission to men. For example, a postcoital cleaning procedure could reduce male HIV/STI acquisition by physically eliminating potentially infectious secretions from underneath the foreskin. Bacterial vaginosis in women would likely also decrease if penile hygiene was improved before sex as well as after. Two small studies in Malawi have determined the safety, acceptability, and potential efficacy of a benzalkonium chloride topical penile microbicide wipe in reducing bacterial colonization of the penis. A Phase III study will be needed to determine the efficacy of penile wipes which improve penile hygiene on reducing HIV acquisition in men. In the meantime, now that barriers about talking about male circumcision have been broken, we should all be speaking more openly about the importance of penile hygiene for boys and men of all ages.
Agot KE, Kiarie JN, Nguyen HQ, Odhiambo JO, Onyango TM, Weiss NS. Male Circumcision in Siaya and Bondo Districts, Kenya: Prospective Cohort Study to Assess Behavioral Disinhibition Following Circumcision. J Acquir Immune Defic Syndr 2006 Oct 2[Epub ahead of print].Evidence for efficacy of male circumcision as an HIV prevention measure is increasing, but there is serious concern that men who are circumcised may subsequently adopt more risky sexual behaviours. Using a prospective cohort study, Agot and colleagues compared sexual behaviours of 324 recently circumcised and 324 uncircumcised men at 1, 3, 6, 9, and 12 months after circumcision. The main outcome indicators were incidence of sexual behaviours known to place men at increased risk of acquiring HIV, namely, having sex with partners other than their wife/wives for married men or other than "regular" girlfriends for unmarried men. During the first month following circumcision, men were 63% and 61% less likely to report having 0-0.5 and >0.5 risky sex acts/week, respectively, than men who remained uncircumcised. This difference disappeared during the remainder of follow-up, with no excess of reported risky sex acts among circumcised men. Similar results were observed for risky unprotected sex acts, number of risky sex partners, and condom use. The authors conclude that during the first year post-circumcision, men did not engage in more risky sexual behaviours than uncircumcised men, suggesting that any protective effect of male circumcision on HIV acquisition is unlikely to be offset by an adverse behavioural impact.
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