Notat om omskæring af drenge - Sundhedsstyrelsen

Male Circumcision and Diseases,Morbidities, and Sexual Function/SatisfactionSTIs, Including HIV Task Force Recommendation:8 Evaluation of the current evidenceindicates that the healthbenefits of newborn male circumcisionoutweigh the risks, andthe benefits of newborn malecircumcision justify access tothis procedure for those familieswho choose it.The most notable research contributionsto the literature since 1995are studies of male circumcision andthe acquisition of HIV and the transmissionof other STIs. Review of theliterature revealed a consistently reportedprotective effect of 40% to 60%for male circumcision in reducing therisk of HIV acquisition among heterosexualmales in areas with high HIVprevalence due to heterosexual transmission(ie, Africa).There is also good evidence fromrandomized controlled trials thatmale circumcision is associated witha lower prevalence of human papillomavirus(HPV) infection 31,32 and herpessimplex virus type 2 (HSV-2)transmission, 31,33 as well as a decreasedlikelihood of bacterial vaginosis(BV) in female partners. 80 Theevidence for male circumcision beingprotective against syphilis is lessstrong, 65–68 however, and male circumcisionwas not found to be associatedwith decreased risk ofgonorrhea 84,85,91–93 or chlamydia. 84–89It is biologically plausible that thecircumcised state may confer protectionagainst STIs (including HIV).Possible mechanisms for the protectiveeffect of circumcision includethe fact that the foreskin’s thin innersurface is susceptible to microtearsand abrasions (especially during sexualactivity), which provides a port ofentry for pathogens. The foreskin alsocontains a high density of HIV targetcells (ie, Langerhans cells, CD4 T cells,macrophages), which facilitates HIVinfection of host cells. The preputialspace provides an environment that isthought to “trap” pathogens and bodilysecretions and favor their survival andreplication. 26,27,34 The circumcised malehas no foreskin and may likely providea less welcoming environment for suchsubstances. In addition, STI-containingsecretions have increased contact timein the prospective uncircumcised malehost, which may increase the likelihoodof transmission and infection. The exposedsurfaces of the uncircumcisedpenis do not offer the same physicalbarrier to resist infection that thehighly keratinized surface of a circumcisedpenis does. Finally, the higherrates of sexually transmitted genitalulcerative disease (eg, HSV-2) observedin uncircumcised men may alsoincrease susceptibility to HIV infection,as the presence of genitalulcers, irrespective of circumcisionstatus, increases the likelihood of HIVacquisition. 35–37HIVThe CDC estimates that 1.2 millionpeople in the United States are livingwith HIV, the virus that causes AIDS,which is incurable. Approximately 50 000Americans are newly infected withHIV each year; more than 619 000people in the United States have diedof AIDS since the epidemic began. 38In the United States, HIV/AIDS predominantlyaffects men who have sex withmen (MSM), who account for almosttwo-thirds (61%) of all new infections.Heterosexual exposure accounts for27% of new HIV infections, and injectiondrug use accounts for 9% ofnew HIV cases. In other parts of theworld (eg, Africa), heterosexual transmissionis far more common. 39Fourteen studies provide fair evidencethat circumcision is protective againstheterosexually acquired HIV infectionin men. 40–53 One study with fair evidencefound that male circumcisionbefore puberty (specifically before 12years of age) is more protective thancircumcision occurring at a laterage. 50 Three large randomized controlledtrials provide good evidence ofsuch protection. 54–56 A cross-sectionalstudy with fair evidence is neutralregarding the relationship betweencircumcision and HIV infection. 57 Twoother studies with a cross-sectionaldesign provide fair evidence that circumcisionincreases the risk of HIVinfection, although one of these studieshighlights the HIV risks associatedwith circumcision performed outsidethe hospital setting and without sterileequipment and medically trainedpersonnel. 58,59A recently published study from theCDC provides good evidence that, inthe United States, male circumcisionbefore the age of sexual debut wouldreduce HIV acquisition among heterosexualmales. 60 Although individualsexual practices are difficult to predictin the newborn period, the majorityof US males are heterosexualand could benefit from male circumcision.Mathematical modeling by theCDC shows that, taking an averageefficacy of 60% from the African trials,and assuming the protective effect ofcircumcision applies only to heterosexuallyacquired HIV, there would bea 15.7% reduction in lifetime HIV riskfor all males. This is taking into accountthe proportion of HIV that isacquired through heterosexual sexand reducing that by 60%. The percentreduction in HIV cases was determinedby assessing the proportion ofnew cases of HIV infection that couldbe prevented by analyzing whichinfections would be presumed to occurin uncircumcised males and whatthe reduction would be if those whowould not already be circumcisede764FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org by guest on June 19, 2013