中国建立男性包皮环切手术标准化和培训的重要性

尽管HIV在非洲的大流行仍然是一个严重的问题,而在其他地区,如亚洲和南美洲,HIV感染率也正在迅速上升。国际健康组织已经认识到有必要制定有效的策略来检测和控制全球HIV的传播。研究表明,男性包皮环切能显著降低HIV、人乳头状瘤病毒(HPV)、单纯疱疹病毒2型(HSV-2)和其他性传播疾病(STD)的感染率。虽然男性包皮环切技术有许多,但是没有标准化的手术方案和培训计划。研究表明,男性包皮环切技术的标准化与培训计划的实施可以大大降低并发症发生率。并发症发生率高是实施男性包皮环切服务的一个主要障碍。我们建议,在推广男性包皮环切之前应建立手术标准和培训计划。     

Biological impact of recurrent sexually transmitted infections on HIV seroconversion among women in South Africa: results from frailty models

Introduction

Understanding the impact of curable sexually transmitted infections (STIs) on HIV transmissibility is essential for effective HIV prevention programs. Investigating the impact of longitudinally measured recurrent STIs on HIV seroconversion is the interest of the current paper.

Methods

In this prospective study, data from a total of 1456 HIV-negative women who enrolled in a HIV biomedical trial were used. It was hypothesized that women who had recurrent STI diagnoses during the study share a common biological heterogeneity which cannot be quantified. To incorporate this “unobserved” correlation in the analysis, times to HIV seroconversion were jointly modelled with repeated STI diagnoses using Cox regression with random effects.

Results and discussion

A total of 110 HIV seroconversions were observed (incidence rate of 6.00 per 100 person-years). In a multivariable model, women who were diagnosed at least once were more likely to seroconvert compared to those who had no STI diagnosis [hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.04, 2.57]; women who had recurrent STI diagnoses during the study were 2.5 times more likely to be at increased risk of HIV infection (95% CI: 1.35, 4.01) with an estimated frailty variance of 1.52, with p<0.001, indicating strong evidence that there is a significant correlation (heterogeneity) among women who had recurrent STIs. In addition to this, factors associated with incidence of STIs, namely not being married and having a new sexual partner during the study follow-up, were all significantly associated with increased risk for HIV seroconversion (HR: 2.92, 95% CI: 1.76, 5.01 and HR: 2.25, 95% CI: 1.63, 3.83 respectively).

Conclusions

The results indicated that women who were at risk for STIs were also at risk of HIV infection. In fact, they share the similar risk factors. In addition to this, repeated STI diagnoses also increased women’s susceptibility for HIV infection significantly. Decreasing STIs by increasing uptake of testing and treatment and reducing partner change plays a significant role in the trajectory of the epidemic.     

The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda

Associate Editor Michael G. Wyllie Editorial Board Ian Eardley, UK Jean Fourcroy, USA Sidney Glina, Brazil Julia Heiman, USA Chris McMahon, Australia Bob Millar, UK Alvaro Morales, Canada Michael Perelman, USA Marcel Waldinger, Netherlands

OBJECTIVE

To investigate the relationship between adult male circumcision and sexual satisfaction and function in men, as observational studies on the effect of adult male circumcision on sexual satisfaction show conflicting results.

SUBJECTS AND METHODS

We investigated self‐reported sexual satisfaction and function among men enrolled in a randomized trial of male circumcision for human immunodeficiency virus (HIV) prevention conducted in Rakai, Uganda. In all, 4456 sexually experienced HIV‐negative males aged 15–49 years were enrolled; 2210 were randomized to receive immediate circumcision (intervention arm) and 2246 to circumcision delayed for 24 months (control arm). Men were followed up at 6, 12 and 24 months, and information on sexual desire, satisfaction and erectile dysfunction was collected. These variables were compared between the study arms and over time within the study arms, using chi‐square or Fisher’s exact tests. The trial registration number is NCT00425984.

RESULTS

There were no differences between the study arms at enrolment and problems with sexual satisfaction and function were reported by <2% of participants in both study arms at all time points. At 6 months, no difficulty with penetration was reported by 98.6% of circumcised men and 99.4% of controls (P = 0.02), and no pain on intercourse was reported by 99.4% circumcised and 98.8% of uncircumcised men (P = 0.05). There were no differences between the study arms in penetration or dyspareunia at later visits. Sexual satisfaction increased from 98.0% at enrolment to 99.9% at 2 years among the controls (P < 0.001), but there was no trend in satisfaction among circumcised men (enrolment 98.5%, 2 years 98.4%, P = 0.8).

CONCLUSION

Adult male circumcision does not adversely affect sexual satisfaction or clinically significant function in men.     

男性包皮环切对降低生殖道感染和预防生殖道肿瘤的意义

越来越多的的研究结果证明,男性包皮环切显著降低包皮龟头炎和尿路感染及其他生殖道感染、降低HIV和HPV以及HSV-2与其他性传播疾病感染风险,对生殖道肿瘤,如子宫颈癌、阴茎癌和前列腺癌具有预防作用。目前在中国包皮环切率低于5%。商环包皮环切术在非洲的临床评估试验和大样本随机对照试验结果证实,商环具有安全性好、可接受性和满意度高。世界卫生组织(WHO)和联合国艾滋病规划署(UNAIDS)已将男性包皮环切推荐为艾滋病预防策略的重要干预措施之一,中国应该大力提倡安全的包皮环切术,从而降低男性及其女性伴侣生殖道感染、预防生殖道肿瘤,对改善全民生殖健康具有长期影响和深远意义。研究男性包皮环切对公共卫生的深远影响将成为今后泌尿男科工作的重点之一。     

Use of the ShangRing circumcision device in boys below 18 years old in Kenya: results from a pilot study

Introduction : Male circumcision is a proven prevention strategy against the spread of HIV. The World Health Organization's new 2016–2021 strategic framework on voluntary medical male circumcision (VMMC) targets 90% of males aged 10–29 years to receive circumcision by 2021 in 14 priority sub‐Saharan countries while anticipating an increase in the demand for infant circumcision. It also states that the use of circumcision devices is a safe and efficient innovation to accelerate attainment of these goals. The primary objective of this pilot study was to evaluate the safety and acceptability of the ShangRing, a novel circumcision device, in boys below 18 years of age. Methods : A total of 80 boys, 3 months to 17 years old, were circumcised using the no‐flip ShangRing technique. All rings were removed 5–7 days later. Participants were evaluated weekly until the wound was completely healed. Data on procedure times, adverse events (AEs), time to clinical wound healing and satisfaction were recorded and analysed. Results : Nearly all (79/80, 98.8%) circumcisions were successfully completed using the no‐flip ShangRing technique without complications. In one (1.2%) case, the outer ring slipped off after the foreskin was removed and the procedure was completed by stitching. The mean circumcision and ring removal times were 7.4 ± 3.2 and 4.4 ± 4.2 min, respectively. There were four (5%) moderate AEs, which were managed conservatively. No severe AEs occurred. The mean time to complete clinical healing was 29.8 ± 7.3 days. Participants or their parents liked ShangRing circumcision because it improved hygiene, was quick and possessed an excellent cosmetic appearance. Most (72/80, 94.7%) were very satisfied with the appearance of the circumcised penis, and all (100%) said they would recommend circumcision to others. Conclusions : Our results suggest that no‐flip ShangRing VMMC is safe and acceptable in boys below 18 years of age. Our results are to be compared those seen following ShangRing VMMC in African men. Further study with larger sample sizes are needed to explore the scalability of the ShangRing in larger paediatric cohorts in Africa. We believe that the ShangRing has great potential for use in all age groups from neonates to adults, which would simplify device implementation.     

Clinical trials using the Shang Ring device for male circumcision in Africa: a review

Male circumcision (MC) reduces the risk of HIV and other sexually transmitted infections (STIs), including human papillomavirus (HPV) and herpes simplex virus type 2 (HSV-2), and is recommended as an important component of a comprehensive package of HIV prevention interventions. While computer modeling has demonstrated that substantial reductions in HIV could be achieved with rapid scale-up of MC services in sub-Saharan Africa, scale-up has lagged due to scarcity of trained providers coupled with relative technical difficulty of recommended surgical MC techniques. Simplified techniques, such as devices, have the potential to allow for a more rapid roll-out of MC. One such device is the Shang Ring, a novel disposable MC device that eliminates the need for suturing and has been on the Chinese market since 2005. Results from Chinese studies have demonstrated that the Shang Ring is both safe and easy to use. Since 2008, a series of studies using the Shang Ring for adult MC have been carried out in Kenya, Uganda and Zambia, according to guidelines established by World Health Organization (WHO) for clinical evaluation of new devices for adult MC. These include a proof of concept study, a study of delayed removal of the Shang Ring, two studies comparing Shang Ring circumcision to conventional surgical approaches, and a large field trial to evaluate safety of Shang Ring circumcision during routine service delivery. Results from these studies demonstrate that the Shang Ring has an excellent safety profile and that Shang Ring circumcision is relatively easy to teach and learn, making Shang Ring MC an appealing technique for use in sub-Saharan Africa where doctors are in short supply and non-physician providers such as nurses and clinical officers are playing a major role in providing MC through task shifting. Shang Ring MC and device removals were uneventfully performed by trained nurses and clinical officers, who preferred the Shang Ring to conventional surgical techniques. Adverse event rates were similar to those observed with conventional surgical circumcision and were managed with, at most, minor interventions, resolving with no long-term sequale. Perhaps one of the biggest advantages of the Shang Ring is the relatively short 3-6 minutes procedure time. Importantly, men also preferred the Shang Ring compared to conventional circumcision and satisfaction with cosmetic appearance of their circumcised penis was very high. The vast majority of participants in studies in Africa as well as China have reported few problems and little disruption to daily life while wearing the device. The Shang Ring holds great promise as an innovative technology that has the potential to facilitate the safe and effective scale-up of circumcision services in settings where MC is not widely used and where the burden of HIV-disease is high.     

男性包皮状态对女性伴侣宫颈HPV感染的影响

<正>本期刊登的南京医科大学附属南京妇幼保健院雷雨等的调查报告,回顾了2011年5月至12月来该院妇产科门诊就诊的女性人乳头瘤病毒(hu-man papillomavirus,HPV)感染状况及其与配偶阴茎包皮状态的相关性。调查问卷内容包括女性年龄、婚姻状况、近1个月内性生活次数、配偶是否包皮过     

A randomized controlled trial evaluating combination detection of HIV in Malawian sexually transmitted infections clinics

IntroductionHIV diagnosis is the necessary first step towards HIV care initiation, yet many persons living with HIV (PLWH) remain undiagnosed. Employing multiple HIV testing strategies in tandem could increase HIV detection and promote linkage to care. We aimed to assess an intervention to improve HIV detection within socio‐sexual networks of PLWH in two sexually transmitted infections (STI) clinics in Lilongwe, Malawi.MethodsWe conducted a randomized controlled trial to evaluate an intervention combining acute HIV infection (AHI) screening, contract partner notification and social contact referral versus the Malawian standard of care: serial rapid serological HIV tests and passive partner referral. Enrolment occurred between 2015 and 2019. HIV‐seropositive persons (two positive rapid tests) were randomized to the trial arms and HIV‐seronegative (one negative rapid test) and ‐serodiscordant (one positive test followed by a negative confirmatory test) persons were screened for AHI with HIV RNA testing. Those found to have AHI were offered enrolment into the intervention arm. Our primary outcome of interest was the number of new HIV diagnoses made per index participant within participants’ sexual and social networks. We also calculated total persons, sexual partners and PLWH (including those previously diagnosed) referred per index participant.ResultsA total of 1230 HIV‐seropositive persons were randomized to the control arm, and 561 to the intervention arm. Another 12,713 HIV‐seronegative or ‐serodiscordant persons underwent AHI screening, resulting in 136 AHI cases, of whom 94 enrolled into the intervention arm. The intervention increased the number of new HIV diagnoses made per index participant versus the control (ratio: 1.9; 95% confidence interval (CI): 1.2 to 3.1). The intervention also increased the numbers of persons (ratio: 2.5; 95% CI: 2.0 to 3.2), sexual partners (ratio: 1.7; 95% CI: 1.4 to 2.0) and PLWH (ratio: 2.3; 95% CI: 1.7 to 3.2) referred per index participant.ConclusionsCombining three distinct HIV testing and referral strategies increased the detection of previously undiagnosed HIV infections within the socio‐sexual networks of PLWH seeking STI care. Combination HIV detection strategies that leverage AHI screening and socio‐sexual contact networks offer a novel and efficacious approach to increasing HIV status awareness.     

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services,tested for STIs and diagnosed with STIs: a systematic review and meta-analysis

Introduction

Of 37.7 million people living with HIV in 2020, 6.1 million still do not know their HIV status. We synthesize evidence on concurrent HIV testing among people who tested for other sexually transmitted infections (STIs).

Methods

We conducted a systematic review using five databases, HIV conferences and clinical trial registries. We included publications between 2010 and May 2021 that reported primary data on concurrent HIV/STI testing. We conducted a random-effects meta-analysis and meta-regression of the pooled proportion for concurrent HIV/STI testing.

Results

We identified 96 eligible studies. Among those, 49 studies had relevant data for a meta-analysis. The remaining studies provided data on the acceptability, feasibility, barriers, facilitators, economic evaluation and social harms of concurrent HIV/STI testing. The pooled proportion of people tested for HIV among those attending an STI service (n = 18 studies) was 71.0% (95% confidence intervals: 61.0–80.1, I² = 99.9%), people tested for HIV among those who were tested for STIs (n = 15) was 61.3% (53.9–68.4, I² = 99.9%), people tested for HIV among those who were diagnosed with an STI (n = 13) was 35.3% (27.1–43.9, I² = 99.9%) and people tested for HIV among those presenting with STI symptoms (n = 3) was 27.1% (20.5–34.3, I² = 92.0%). The meta-regression analysis found that heterogeneity was driven mainly by identity as a sexual and gender minority, the latest year of study, country-income level and region of the world.

Discussion

This review found poor concurrent HIV/STI testing among those already diagnosed with an STI (35.3%) or who had symptoms with STIs (27.1%). Additionally, concurrent HIV/STI testing among those tested for STIs varied significantly according to the testing location, country income level and region of the world. A few potential reasons for these observations include differences in national STI-related policies, lack of standard operation procedures, clinician-level factors, poor awareness and adherence to HIV indicator condition-guided HIV testing and stigma associated with HIV compared to other curable STIs.

Conclusions

Not testing for HIV among people using STI services presents a significant missed opportunity, particularly among those diagnosed with an STI. Stronger integration of HIV and STI services is urgently needed to improve prevention, early diagnosis and linkage to care services.     

Circumcision related to urinary tract infections,sexually transmitted infections,human immunodeficiency virus infections,and penile and cervical cancer

Male circumcision has been carried out as a prophylactic measure against future diseases, as well as a rite of passage due to religious practice and definite medical indication. The present review discusses the benefits of male circumcision on the prevention of urinary tract infections, and the importance of circumcision in congenital urinary system anomalies, such as vesicoureteral reflux. Additionally the present review examines the associations between circumcision and sexually transmitted infections, including human immunodeficiency virus, and the preventive effect of circumcision on penile cancer and cervical cancer of female partners.     

一次性包皮环切缝合器在男性包皮环切术中的临床应用

目的:探讨一次性包皮环切缝合器在包皮环切术中的安全性及有效性。方法:将到门诊就诊的包茎和包皮过长要求手术的患者随机分成2组,采用两种手术方法,一次性包皮环切缝合器组129例,传统组120例,对其安全性及疗效性等方面进行对比。结果:包皮环切缝合器组和传统组手术时间分别为(4.02±0.69)min和(30.8±4.05)min;出血量分别为(1.07±1.29)ml和(8.72±2.15)ml,手术时疼痛评分分别为(0.81±0.81)分、(2.42±1.15)分;术后24 h疼痛评分分别为(1.84±1.02)分、(4.99±1.36)分;术后并发症发生率分别为13.95%(18/129)、9.17%(11/120);创口愈合时间分别为(13.99±9.06)d、(17.48±3.49)d;术后外观满意率分别为98.4%(127/129)、95.0%(109/120);治疗费用分别为(2215.62±17.67)元、(576.47±15.58)元;与传统手术组相比,一次性包皮环切缝合器组手术时间短,失血量少,患者痛苦小,创口愈合时间短,外观满意率高(P均0.05),但术后并发症发生率较高(P0.05),且治疗费用较高(P0.05)。结论:采用一次性包皮环切缝合器行包皮环切术时具有良好的临床效果,值得临床推广应用。     

Update on strategies of controlling sexually transmitted infections: Taiwan experience

Sexually transmitted infections (STIs) are a variety of clinical infectious conditions caused by pathogens that are transmitted through sexual activity. In recent years, the incidence of STIs has been gradually rising, according to the statistics of the World Health Organization. Although the recommended management of people who have, or are at risk, for STIs were provided by the association of Europe and the United States, the pathogens of STIs still have a great diversity of epidemiology in different ethnic communities and countries. However, to our knowledge, there have been very few studies updating the status of STIs in the Taiwan population. In this article, we focus on evaluations and announcements for common pathogens of STIs in Taiwan. The strategies for prevention and control of STIs are also discussed in this article. We hope that our experience can be shared to the neighboring countries and lead to an Asian consensus of STI.     

Adverse event profile of a mature voluntary medical male circumcision programme performing PrePex and surgical procedures in Zimbabwe

Introduction : The frequency of adverse events (AEs) is a widely used indicator of voluntary medical male circumcision (VMMC) programme quality. Though over 11.7 million male circumcisions (MCs) have been performed, little published data exists on the profile of AEs from mature, large‐scale programmes. No published data exists on routine implementation of PrePex, a device‐based MC method. Methods : The ZAZIC Consortium began implementing VMMC in Zimbabwe in 2013, supporting services at 36 facilities. Aggregate data on VMMC outputs are collected monthly from each facility. Detailed forms are completed describing the profile of each moderate and severe AE. Bivariate and multivariable analyses were conducted using log‐binomial regression models. Results : From October 2014 through September 2015, 44,868 clients were circumcised with 156 clients experiencing a moderate or severe AE. 96.2% of clients had a follow‐up visit within 14 days of their procedure. AEs were uncommon, with 0.3% (116/41,416) of surgical and 1.2% (40/3,452) of PrePex clients experiencing a moderate or severe AE. After adjusting for VMMC site, we found that PrePex was associated with a 3.29‐fold (95% CI: 1.78–6.06) increased risk of experiencing an AE compared to surgical procedures. Device displacements, when the PrePex device is intentionally or accidentally dislodged during the 7‐day placement period, accounted for 70% of PrePex AEs. The majority of device displacements were intentional self‐removals. Overall, infection was the most common AE among VMMC clients. Compared to clients aged 20 and above, clients aged 10–14 were 3.07‐fold (95% CI: 1.36–6.91) more likely to experience an infection and clients aged 15–19 were 1.80‐fold (95% CI: 0.82–3.92) more likely to experience an infection, adjusted for site. Conclusions : This exploratory analysis found that clients receiving PrePex were more likely to experience an AE than surgical circumcision clients. This is largely attributable to the occurrence of device displacements, which require prompt access to corrective surgical MC procedures as part of their clinical management. Most device displacements were self‐removals which are preventable if client behaviour could be modified through counselling interventions. We also found that infection after MC is more common among younger clients, who may benefit from additional counselling or increased parental involvement.     

Evaluation of the safety and efficiency of the dorsal slit and sleeve methods of male circumcision provided by physicians and clinical officers in Rakai, Uganda

Study Type – Therapy (outcomes research) Level of Evidence 2c What’s known on the subject? and What does the study add? MC reduces heterosexual acquisition of HIV in men for safe and efficient rapid scale‐up; task shifting from physicians to clinical officers is safe and the use of bipolar cautery will reduce operative time, but is associated with higher adverse events.

OBJECTIVE

? To assess the safety and efficiency of the dorsal slit and sleeve male circumcision (MC) procedures performed by physicians and clinical officers (COs).

PATIENTS AND METHODS

? We evaluated the time required for the MC procedure (efficiency) and moderate/severe adverse events (AEs) for MC (safety) by trained physicians and COs using the sleeve and dorsal slit MC methods in a service programme. ? Univariate and multiple regressions with robust variance estimation were used to assess factors associated with operative duration (linear) and AEs (logistic).

RESULTS

? Six physicians and eight COs conducted 1934 and 3218 MCs, respectively; there were 2471 dorsal slit and 2681 sleeve MC procedures. The overall mean operative duration was 33 min for newly trained providers, whichdecreased to ≈20 min after ≈100 MCs. ? The adjusted mean operative duration for dorsal slit MC was significantly shorter than that for the sleeve MC method (Δ? 2.7 min, P < 0.001). ? The operative duration was longer for COs than physicians for the sleeve procedure, but not the dorsal slit procedure; however this difference reduced with increasing numbers of MCs completed. ? The unadjusted AE rates were 0.6% for dorsal slit MC and 1.4% for the sleeve method (P= 0.006) and 1.5% for physicians and 0.68% for COs (P= 0.003); however, there were no significant differences after multivariate adjustment. ? Use of bipolar cautery significantly reduced operative duration (Δ? 4.0 min, P= 0.008), but was associated with higher AE rates (adjusted odds ratio 2.13, 95% confidence interval 1.26–3.61, P= 0.005).

CONCLUSION

? The dorsal slit MC method is faster than sleeve resection, and can be safely performed by non‐physicians; however, use of bipolar cautery may be inadvisable in this setting.     

Adult circumcision outcomes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction

PURPOSE: Evidence concerning the effect of circumcision on sexual function is lacking. Men circumcised as adults are potentially in a unique position to comment on the effect of a prepuce on sexual intercourse. We examine sexual function outcomes in men who have experienced sexual intercourse in the uncircumcised and circumcised states. MATERIALS AND METHODS: Men 18 years old or older when circumcised were identified by billing records during a 5-year period at an academic medical center. Medical charts were reviewed for confirmation of the procedure and to identify the indication(s). These men were surveyed to assess erectile function, penile sensitivity, sexual activity and overall satisfaction. Data were analyzed using paired t tests to compare category scores before and after circumcision. RESULTS: A total of 123 men were circumcised as adults. Indications for circumcision included phimosis in 64% of cases, balanitis in 17%, condyloma in 10%, redundant foreskin in 9% and elective in 7%. The response rate was 44% among potential responders. Mean age of responders was 42 years at circumcision and 46 years at survey. Adult circumcision appears to result in worsened erectile function (p = 0.01), decreased penile sensitivity (p = 0.08), no change in sexual activity (p = 0.22) and improved satisfaction (p = 0.04). Of the men 50% reported benefits and 38% reported harm. Overall, 62% of men were satisfied with having been circumcised. CONCLUSIONS: Our findings may help urologists better counsel men undergoing circumcision as adults. Prospective studies are needed to better understand the relationship between circumcision and sexual function.