Running head: AN INTEGRATIVE REVIEW 1

Circumcision and Sexually Transmitted Infections

Kaitlyn M. Spence

Bon Secours Memorial College of Nursing

Arlene Holowaychuk, MSN

Nursing Research - NUR 4122

October 30, 2017

I pledge honor code

AN INTEGRATIVE REVIEW 2

Abstract

The goal of this integrative review is to evaluate the literature regarding the use of male

circumcision (MC) as a protective or preventative intervention for sexually transmitted infections

(STI’s). The World Health Organization (WHO) currently recommends MC for the prevention

of human immunodeficiency virus (HIV), but the procedure remains optional. The research

design is an integrative review. The search for the literature was conducted using EBSCO

discovery service and Academic Search Complete databases. The searches yielded 908 and 76

results respectively, and five studies met the inclusion criteria. The results and findings of the

articles support stronger advocacy for MC for preventing sexually STI’s, especially in high risk

populations, and increased education on the benefits of the procedure. Findings showed a

correlation between MC and decreased incidence of human papilloma virus (HPV) and HIV.

Limitations include the researchers lack of experience, limited time to analyze the research

thoroughly, and limited amounts of research that met the inclusion criteria for the assignment.

Future research on this topic should include additional large multinational studies that research

the reasoning for the high correlation of MC with HIV and HPV but low correlation with other

infections.
AN INTEGRATIVE REVIEW 3

Integrative Review

The purpose of this integrative review is to search the literature regarding male

circumcision (MC) and its possible protective effect against sexually transmitted infection (STI)

rates. Circumcision is a controversial topic across all nations. Health care professionals and

patients have differing opinions on the topic as some believe that it should be done because it is

protective against infection, and some argue that it is unnecessary genital mutilation. While a

large amount of research has been conducted on the topic of MC and STI rates, the results are

still inconclusive on the procedures protective effects. The World Health Organization (WHO)

currently recommends MC for the prevention of human immunodeficiency virus (HIV), but the

procedure remains optional. If the compiled evidence produced a conclusion that MC is

protective against STI’s, a stronger advocacy for the procedure could potentially reduce the

spread of these infections globally, which would in turn save many lives. The researchers interest

on this topic was sparked from observing differing opinions and arguments regarding MC, and

the fact that such an invasive procedure is optional for new parents and males as they grow older.

The aim of this review is to compile research pertaining to the researchers PICO question: For

males, does circumcision reduce the future risk of sexually transmitted infections compared to

uncircumcised males?

Design and Research Methods

The research design is an integrative review and addresses five quantitative studies. The

search engines, EBSCO and Academic Search Complete were used to find articles relevant to the

PICO question. The search terms ‘circumcision benefits’, ‘infection’, and ‘sexually transmitted

infections’ were used. The EBSCO discovery search resulted in 908 documents and Academic

Search Complete yielded 76 results. To obtain recent and credible articles, the search was
AN INTEGRATIVE REVIEW 4

limited to quantitative peer-reviewed academic journals from the years 2012 to 2017, that were

full text and written in English. All articles that did not meet the inclusion criteria were excluded

from the review. The researcher obtained and examined five articles that met the search criteria

and were relevant to the PICO question which is as follows: For males, does circumcision reduce

the future risk of sexually transmitted infections compared to uncircumcised males?

Findings and Results

The findings and results of the five research studies identify an overall correlation with

MC and the reduction of rates of human papilloma virus (HPV) and HIV, however, no

correlation was identified with any other STI (Albero et al., 2014; Doerner et al., 2013; Homfray

et al., 2015; Maffioli, 2017; Pando et al., 2013). A summary of the research articles is presented

in Table 1. This review structure is based on the following themes: human papilloma virus and

human immunodeficiency virus.

Human Papilloma Virus

Three of the five articles tested and identified and concluded that MC decreases HPV

rates (Albero et al., 2014; Homfray et.al., 2015; Pando et al., 2013). In a quantitative probability

sample survey study by Homfray et al., the researchers aimed to examine the relationship of MC

and non-ulcerative STI’s because of the lack of research on this variable. Participants completed

a computer assisted personal interview asking about MC and experience of STI diagnoses, with

HPV being the main variable. The participants also provided urine samples for testing. Men

aged 16 to 44 in Britain who reported at least one life time sexual partner were included in the

results. The survey data was analyzed and stratified using Stata version 12.1. There was no

correlation with self-reported STI’s of any kind, however circumcised men were less likely to

have any HPV type including the high-risk strains detected in urine. Therefore, this research
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study was effective in showing statistically significant results among how HPV strains effect

circumcised males contributing to the body of research. The statistically significant results of this

study contribute to the body of research that supports the theory of circumcision as a protective

measure against HPV infection.

Pando et al. (2013), addressed in the research the correlation of MC and STI’s in the

population of men who have sex with men (MSM), because this group has a higher incidence of

STI’s in comparison to heterosexual males. A cross-sectional quantitative study was conducted

with inclusion criteria of males at least 18 years of age who have had sex with another male or

transsexual person at least once in the past six months, and at least ten times in his lifetime.

Participants were asked to agree to blood sample testing and participate in a web based survey

that included questions on demographic information, sexual behavior, and circumcision status.

Data was analyzed using SPSS version 20, t-tests, Mann-Whitney tests, and Fisher’s exact test.

The results were similar to the study by Homfray et al. (2015), with uncircumcised men having

significantly larger numbers of different HPV types, specifically high-risk strains, compared with

circumcised men.

A third study by Albero et al. (2013), broadened the research to simply HPV infection

rates in relation to MC. The researchers identified the need for this study due to the outcome

inconsistency in the literature on this topic. This was a longitudinal multinational quantitative

cohort study that examined 4,033 males who were recruited universities, health-care systems,

and the general population. Each participant was required to meet the inclusion criteria of 18 to

70 years of age, no current diagnosis or symptoms of an STI, and willingness to commit to ten

scheduled visits every six months. They completed a computer assisted personal interview and

were examined every six months. Participants also provided exfoliated cell specimens from the
AN INTEGRATIVE REVIEW 6

penile shaft and scrotum that were tested for 37 types of HPV. Pearson’s chi square test and cox

proportional hazards models were used to analyze the association between HPV and

circumcision status. Incidence was significantly lower among circumcised men in comparison to

uncircumcised men for HPV types 58, 68, 42, 61, 71, 81, and IS39.

Human Immunodeficiency Virus

The findings and results of three of the five studies indicated a decrease in HIV rates with

MC. A quantitative study by Maffioli (2013), in Lesotho, focused on traditional male

circumcision (TMC) in schools, and if this method of circumcision has effects on HIV incidence

that are as beneficial as voluntary medical male circumcision (VMMC). TMC is not performed

by a medical professional and does not remove the foreskin, but is a symbolic cut. The results

were compiled through questionnaires and individual interviews. The original sample was from

the Demographic and Health Survey of Lesotho from 2009 and consisted of 3,137 men. The

original sample was then restricted to 2,735 men who reported being sexually active at least once

in their lifetime. The data collection methods consisted of collecting blood from finger prints on

filter paper and then testing the samples via the ELIZA (Enzyme-Linked Immune-Sorbent

Assay) and a Western Blot test. Of the original sample, 189 men refused to have blood samples

collected and tested for HIV. T-tests for the mean of each variable were used to adjust for any

significant difference in risky-sexual behaviors and socio-demographic status. The researchers

found that the risks outweigh the benefits of TMC initiated in school and that it does not have the

same protective effect against HIV transmission in comparison to VMMC. In addition, after

stratifying for risky sexual behavior, migration, and socio-economic characteristics, medically

circumcised men were found to be less likely to be infected by HIV than uncircumcised men.
AN INTEGRATIVE REVIEW 7

In addition to HPV, Pando et al. (2013) studied the association of MC with HIV in the

population of MSM. MC was not associated with infection of any sort when considering the

entire group, however when stratifying the group according to their sexual role in the past two

months, no cases of HIV were detected among circumcised men while 14.8% of uncircumcised

men were HIV positive. There was no significant association observed between MC and the

other infections being tested even after stratification.

In the research by Doerner et al. (2013), the question was raised on whether the HIV rates

differed with MC in MSM who take the insertive role during anal sex. This was a quantitative

cross-sectional study of 1,521 white British MSM who reported unprotected anal intercourse in

the previous three months and who reported primarily assuming the insertive role. Participants

were gathered via online advertisements and through sexual health clinics. A sample of 13,130

was restricted to 1,521 MSM who reported having anal intercourse in the previous three months.

Stata version 11.2 was used for the analysis of the data. Circumcised men were more likely to

have received an HIV test than uncircumcised men. It was concluded that there was no

significant difference in HIV rates between circumcised and uncircumcised men in each sex role

group. Among the participants that had ever received an HIV test, there was no difference

between self-reported HIV positive status between circumcised and uncircumcised men.

Discussion and Implications

The results of the research in this review concluded that all five articles agreed that MC

was an important factor when it comes to STI prevention. Doerner et al. (2017) was an outlier in

respect to the correlation of MC and a decreased risk of HIV infection, however, this could be

due to the specific population of the study, which was MSM in Buenos Aires, Argentina, who

took the insertive role during sex. It was a consensus among all five studies that MC helps
AN INTEGRATIVE REVIEW 8

prevent HIV infection because of the extensive research on the specific STI, and the new

research in this review identifies the same conclusion for HPV (Albero et al., 2014; Doerner et

al., Homfray et al., 2015; Maffioli, 2017; Pando et al., 2013). Given this correlation, the articles

included in this review support the previous research and conclusions on the topic. The studies

did not all come to the same conclusions, however they all identified a decreased risk of

infection for at least one STI with circumcised males.

The results of each study relate to the PICO question and support the idea that MC is a

protective measure for STIs in general. Nurses and the health care team should advocate for MC

because of the strong evidence that it is protective against HIV. The research compiled in this

review supports the conclusion that HPV can be added to the WHO’s evidence of the protective

effect of MC (Albero et al., 2014; Homfray et.al., 2015; Pando et al., 2013). In areas of the

world where STI rates, specifically HIV and HPV, are extremely high, strong advocacy for MC

could decrease the transmission of these infections and have a great effect on these populations.

New parents should be educated on the benefits of MC before making their decision on behalf of

their newborn son. Future research on this topic should include additional large multinational

studies that research the reasons behind the high correlation of MC and HIV and HPV and why

lack of correlation exists between MC and other STI’s. Research should be conducted in

populations where HIV and other STI’s are extremely prevalent in order to obtain larger sample

sizes.

Limitations and Conclusion

There were multiple limitations regarding the studies discussed. The majority of the

research on this topic was beyond the five-year limit that was required for this appraisal. Authors

of four of the five studies identified self-reported information as a limitation because of the
AN INTEGRATIVE REVIEW 9

possibility of reporting bias, especially when discussing sensitive and personal information

regarding STI’s (Doener et al., 2017; Homfray et al., 2015; Maffioli, 2017; Pando et al., 2013).

Three of the researchers mentioned limited generalizability because of non-adjusted sociocultural

differences, convenience sampling, and a longitudinal study with high levels of cooperation

needed (Albero et al., 2014; Doener et al.; Pando et al.). Much of the data from the studies was

collected via interviews and questionnaires with only three of the five studies using definitive

testing for STI diagnoses like urine and blood sampling. The use of questionnaires to collect

data can be subject to underreporting of STI’s because of the sensitivity and stigma of the topic.

It should also be mentioned that this review was a class assignment and the researcher does not

have any previous experience with an integrative review.

Findings discussed in this integrative review address the decreased incidence of certain

STI’s with MC. Despite the proven preventative qualities of MC, the procedure continues to be

optional for new parents and for males as they grow older. The primary reasons why MC is not a

standardized procedure include the religious and cultural background of the intervention, and the

idea that the procedure is unnecessary. Currently, there is not enough evidence supporting the

preventative correlation of MC and STI’s to change westernized standards. However, MC

should be considered for populations with high incidence of STI’s, specifically HIV and HPV,

due to the deadly consequences that can result from these diseases.
AN INTEGRATIVE REVIEW 10

References

Albero, G., Castellsagué, X., Lin, H., Fulp, W., Villa, L. L., Lazcano-Ponce, E., & ... Giuliano,

A. R. (2014). Male circumcision and the incidence and clearance of genital human

papillomavirus (HPV) infection in men: The HPV Infection in men (HIM) cohort

study. BMC Infectious Diseases, 147(5). doi:10.1186/1471-2334-14-75

Doerner, R., McKeown, E., Nelson, S., Anderson, J., Low, N., & Elford, J. (2013). Circumcision

and HIV infection among men who have sex with men in Britain: the insertive sexual

role. Archives of Sexual Behavior, 42(7), 1319-1326. doi:10.1007/s10508-012-0061-1

Homfray, V., Tanton, C., Miller, R. F., Beddows, S., Field, N., Sonnenberg, P., & ... Mercer, C.

H. (2015). Male circumcision and STI acquisition in Britain: Evidence from a national

probability sample survey. PloS ONE, 10(6), e0130396. doi:10.1371/journal.

pone.0130396

Maffioli, E. M. (2017). Is traditional male circumcision effective as an HIV prevention strategy?

Evidence from Lesotho. PloS ONE, 12(5), 1-15. doi:10.1371/journal.pone.0177076

Pando, M. A., Balan, I. C., Dolezal, C., Marone, R., Barreda, V., Carballo-Dieguez, A., & Avila,

M. M. (2013). Low frequency of male circumcision and unwillingness to be circumcised

among MSM in Buenos Aires, Argentina: Association with sexually transmitted

infections. Journal of The International AIDS Society, 16(1), 1-5. doi:10.7448/IAS.16.

AN INTEGRATIVE REVIEW
Table 1
Reference (APA)
Author (Year)/Qualifications
Introduction/
Background/Problem Statement
Theoretical Framework
Design/Research Methods/Sample/
Setting/Ethical Considerations/
Major Variable Studied/
Measurement Tool/Data Collection
11
Quantitative Article Evaluation
Homfray, V., Tanton, C., Miller, R. F., Beddows, S., Field, N., Sonnenberg, P., & ...
Mercer, C. H. (2015). Male circumcision and STI acquisition in Britain: evidence
from a national probability sample survey. PloS ONE, 10(6), e0130396.
doi:10.1371/journal. pone.0130396
Virginia Homfray, 2015, Research Department of Infection and Population Health,
University College of London
The abstract includes: background, methods, results and conclusions.
Background: Male circumcision reduces the acquisition of HIV, herpes, cancroid, and
syphilis, but it is unknown whether it affects non-ulcerative STI’s.
Introduction: A meta-analysis concluded that circumcision was strongly protective against
HPV. In a randomized trial of circumcision to prevent HIV, chlamydia acquisition was
decreased but lacked significance, but circumcision almost halved the acquisition of
Mycoplasma genitalium after controlling for behavioral risks. Few other studied have
examined the association of circumcision and these pathogens.
Problem statement: To examine the relationship between circumcision and biological
measures of three STI’s: human papillomavirus (HPV), Chlamydia trichomanias, and
Mycoplasma genitalium.
There was no theoretical framework identified
Design: A probability sample survey, computer assisted personal interview
Methods: computer assisted personal interview, including a personal interview which asked
about circumcision, and experience of STI diagnoses. Multivariable logistic regression was
used to calculate adjusted odds ratios to quantify associations between factors.
AN INTEGRATIVE REVIEW 12

Tool/Data Analysis Sample: 15,162 men and women aged 16-74 in Britain took the survey, 1,850 urine samples
were collected from sexually experienced men aged 16-44.
Setting: Britain
Ethical considerations: Participants were giving an information leaflet and could ask
questions, gave written informed consent for urine samples, study was approved by
Oxfordshire Research Ethics Committee. 16-17-year-old living at home had parent or
guardian verbal assent for participation.
Major variable studied: The effect of circumcision on HPV prevalence
Measurement tool: Stata version 12.1 for statistical analyses accounting for stratification
Data collection tool: Computer assisted face-to-face and self-interviews (CASI), “Details of
urine collection methods are listed elsewhere”
Data analysis: Stata version 12.1

Findings/Results There were no associations between circumcision and the key sexual behaviors studied.
Circumcision rates were higher men from ethnic minority backgrounds in comparison to
white ethnicity. Rates were the highest in Muslim men than of any other religious
background. Circumcision was not associated with reporting previous diagnosis of any STI
in 16-44-year-old men. After adjusting for demographic and behavioral variables,
circumcised men were still less likely to have any HPV type detected in their urine when
compared to uncircumcised men. Circumcised men were also less likely to have c.
trichomanias but not. Genitalium.

Discussion/ The WHO advocated for circumcision for reduction of HIV acquisition and these results
Implications would add to the overall health benefit of circumcision. The reduction in HPV rates could
be important because of the link to cervical cancer and the low HPV vaccination coverage.

Limitations/ Limitations: The denominator was limited to men aged 16-44 years reporting one or more
Conclusions lifetime partner. Self-reporting of STI’s may be subject to reporting bias, the population
prevalence of c. trichomanias and m. genetalium was low therefore the strong association
with these diseases and circumcision should be viewed with caution because the 95%
confidence intervals are wide. HPV prevalence may be underestimated in the study.
Conclusion: Circumcised men had reduced odds of HPV detection in urine. These findings
have implications for improving the precision of models of STI transmission in populations
AN INTEGRATIVE REVIEW
Appraisal/Worth to practice
Reference (APA)
Author (Year)/Qualifications
Introduction/
Background/Problem Statement
Theoretical Framework
Design/Research Methods/Sample/
Setting/Ethical Considerations/
Major Variable Studied/
13
with different circumcision prevalence and in designing interventions to reduce STI
acquisition.
The WHO advocated for circumcision for reduction of HIV acquisition and these results
would add to the overall health benefit of circumcision.
Pando, M. A., Balan, I. C., Dolezal, C., Marone, R., Barreda, V., Carballo-Dieguez, A., &
Avila, M. M. (2013). Low frequency of male circumcision and unwillingness to be
circumcised among MSM in Buenos Aires, Argentina: association with sexually
transmitted infections. Journal of The International AIDS Society, 16(1), 1-5.
doi:10.7448/IAS.16.1.18500
Maria A. Pando, INBIRS and University of Buenos Aires, Argentina 2013
Background/introduction: Studies show that HIV prevalence among men and women is
lower in countries with high levels of male circumcision. There is also evidence that
circumcised men are at lower risk of HP and Herpes simplex. Efficacy of circumcision in
reducing HIV infection among men who have sex with men in unclear. MSM are at high
risk for HIV infection. And other STIs are highly prevalent.
Problem statement: The aims of this study were to investigate the frequency of male
circumcision among MSM in Buenos Aires argentine, the association between circumcision
and STI’s and among those uncircumcised, the willingness to be circumcised.
There was theoretical framework identified
Design: Proyecto LINKS was a cross-sectional study
Research methods: Participants recruited through respondent-driven sampling.
Sample: inclusion – male, at least 18, have has sex with another man or a trans person at
AN INTEGRATIVE REVIEW 14

Measurement Tool/Data Collection
Tool/Data Analysis
least once in the past 6 months, and at least 10 times in his lifetime, reside in Buenos Aires
metropolitan area, agree to provide blood sample for STI testing.
Ethical considerations: consent process, ethical guidelines for biomedical research involving
human subjects were followed, approval from an institutional review board and the IRD of
the New York state psychiatric institute.
Data collection tool: web based survey that included questions on demographic information
sexual behavior and circumcision among others. Receive HIV pretest counseling and
biological samples were collected. Two weeks later returned to obtain results and receive
posttest counseling.
Data analysis: SPSS version 20, t-test, Mann-Whitney test, Fisher’s exact.

Findings/Results Findings/Results: No differences between circumcised and uncircumcised men in terms of

demographic or sexual behavior characteristics, Circumcision was not associated with HIV,
HBV, t. pallidum, or HPV infections, however stratifying the group according to their
sexual role in the past two months and restricting the analysis or those who do not practice
RAI, no incidence of HIV infection were detected among circumcised men while 14.8% of
uncircumcised men were HIV positive. Regarding HPV uncircumcised men had a
significantly larger number of different HPV types compared with circumcised men. And a
higher frequency of high -risk HPV genotypes

Discussion/ First study of its kind in Argentina, Previous studies reported circumcision may offer some
Implications level of protection against HIV for MSM, the effect is expected to be modest given that
compared to heterosexual men, MSM engage in other sexual practices such as receptive
anal intercourse (RAI), which carry a high risk of infection.

Limitations/ Limitations: the proportion of circumcised men in the samples was small, so a larger sample
Conclusions is needed to provide a reliable statistical comparison. Circumcision was self-reported.
Sociocultural differences between MSM could make this finding not generalizable to our
group This data suggests that such a study may not be feasible among MSM in Buenos
Aires because only a small proportion of MSM reported willingness to be circumcised.
Conclusion: These findings suggest that if circumcision was to be introduced as and HIV
prevention strategy, education about the risks and benefits of circumcision would have to be
developed and conduced prior to this intervention. Even though no cases of HIV infection
AN INTEGRATIVE REVIEW
Appraisal/Worth to practice
Reference (APA)
Author (Year)/Qualifications
Introduction/
Background/Problem Statement
Theoretical Framework
Design/Research Methods/Sample/
Setting/Ethical Considerations/
Major Variable Studied/
15
were detected among circumcised men who do not practice RAI, a larger sample of
circumcised MSM is needed to provide a reliable statistical association between
circumcision and protection from HIV infection.
Relevant but small sample size and not generalizable because only small population in
Buenos Aires Argentina.
Doerner, R., McKeown, E., Nelson, S., Anderson, J., Low, N., & Elford, J. (2013).
Circumcision and HIV infection among men who have sex with men in Britain: the
insertive sexual role. Archives of Sexual Behavior, 42(7), 1319-1326.
doi:10.1007/s10508-012-0061-1
Rita Doerner, School of Health Sciences, City University London, 2012
Introduction: In Britain men who have sex with men are disproportionately affected by HIV
and accounted for nearly half of the new HIV diagnoses.
Background: Circumcision has been shown to reduce the risk of HIV acquisition in
randomized control trials in Africa, these trials raised the possibility that circumcision might
also be protective for men who have sex with men who take the insertive role during anal
sex. Few studies have taken sexual role into account when examining the relationship.
Problem statement: To examine the association between circumcision status and self-
reported HIV infection among men who have sex with men in Britain who predominantly or
exclusively engaged in insertive anal intercourse.
There no was theoretical framework identified
Design: Cross sectional study
Methods: Participants were collected via advertisements to complete an online survey for
the Men and Sexual Health project via anonymous questionnaires,
AN INTEGRATIVE REVIEW 16

Measurement Tool/Data Collection
Tool/Data Analysis
Sample: Convenience sample of MSM from across Britain, restricted to 1,521 white British
men who have sex with men who reported unprotected anal intercourse in the previous 3
months and who said they only or mostly took the insertive role during anal sex.
Setting: Britain
Ethical Considerations: Anonymous and confidential survey
Major Variable: Association between circumcision and HIV acquisition in men who have
sex with men in Britain who assume the insertive role.
Measurement tool: Multivariable logistic model adjusted for known risk factors of HIV
infection
Data collection tool: Online self-reporting survey
Data analysis: Stata version 11.2

Findings/Results Circumcised and uncircumcised men did not differ in terms of sexual identity, HIV
treatment optimism, drug use, sexual behaviors or having syphilis. Self-reported HIV
seropositivity was lower among men who were only inservtive compared to men who were
mostly insertive.

Discussion/ No evidence of association between circumcised and self-reporting HIV positivity among
Implications MSM who predominantly or exclusively engaged in insertive anal intercourse.

Limitations/ Convenience sample therefore findings not generalizable to all MSM in the UK. Restricted
Conclusions to white British men because of large variations in circumcision and other ethnic
backgrounds. Self-reported so may not have reported sensitive information.
Conclusion: This study adds to the growing body of evidence that shows a lack of
association between circumcision and HIV infection among MSM even for those who take
the insertive role during sex.

Appraisal/Worth to practice Sexual health promotion and HIV prevention programs which focus on all MSM regardless
of their circumcision status are more likely to be affective long term. Little to no worth to
practice.

Reference (APA) Albero, G., Castellsagué, X., Lin, H., Fulp, W., Villa, L. L., Lazcano-Ponce, E., & ...
AN INTEGRATIVE REVIEW
Author (Year)/Qualifications
Introduction/
Background/Problem Statement
Theoretical Framework
Design/Research Methods/Sample/
Setting/Ethical Considerations/
Major Variable Studied/
Measurement Tool/Data Collection
Tool/Data Analysis
17
Giuliano, A. R. (2014). Male circumcision and the incidence and clearance of
genital human papillomavirus (HPV) infection in men: the HPV Infection in men
(HIM) cohort study. BMC Infectious Diseases, 1475. doi:10.1186/1471-2334-14-75
Ginesa Albero, Unit of Infections and Cancer, Cancer epidemiology research program,
Program in Public health and the methodology of biomedical research university of
Barcelona, 2014
Introduction/background: The majority of sexually active men and women will acquire
HPV at some point during their lifetime. Little is known about HPV infection in men.
Findings regarding the role of circumcision in the incidence and clearance of HPV
infections have not been consistent across studies.
Problem statement: To determine whether circumcision affects the incidence and clearance
of HPV infections in a large, multinational cohort study of healthy men in Brazil, Mexico,
and the United States.
There was theoretical framework identified
Design: Ongoing longitudinal Multinational cohort study
Research methods: Men examined every 6 months, collected exfoliated cell specimens from
penis, penile shaft, and scrotum, samples tested for 37 HPV types
Sample: men recruited from various sources, inclusion criteria, 4,033 health men
Setting: southern Florida, USA, Cuernavaca, Mexico, Sao Paulo, Brazil.
Ethical considerations: Participants reviewed and signed a written consent form, Human
Subjects Committee of the University of Florida, and the National institute of public health
of Mexico approved the research protocol
Major Variable Studied: Circumcision’s association with incidence and clearance of genital
HPV detection
Measurement tool: CASI
Data collection tool: 88 item computers assisted self-interview, collected information about
AN INTEGRATIVE REVIEW 18

sociodemographic info, tobacco consumption, and sexual behavior, males were examined
for circumcision status, samples were collected with pre-wetted Dacron swabs, samples
were stored at -80 degrees Celsius
Data analysis: specimens were tested for the presence of HPV, Pearson’s Chi square test
used for comparison of characteristics, Cox proportional hazards models were used to
assess the association between HPC incidence and circumcision status.

Findings/Results Findings/results: No differences in the risk of HPV and incidence of circumcision status
was observed, however incidence was significantly lower among circumcised men for HPC
types 58, 68, 42, 61, 71, 81, and IS39, median time to clearance of and HPC infection was
significantly longer among circumcised men than uncircumcised men.

Discussion/ Discussion: Other longitudinal studies also found no association with either variable tested,
Implications this is the largest and first international study reporting HPV incidence and clearance by
specific HPV types in circumcised and uncircumcised men.

Limitations/ Limitations: Combined samples with potential for misclassification of HPV infection,
Conclusions potentially limited generalizability because only men willing to complete the questionnaire
with multiple clinical visits over 4 years were included, and the potential for confounding as
there may have been relevant factors related to religious or cultural practice that may be
associated with circumcision and HPV status.
Conclusion: Circumcision is not associated with the incidence and clearance of HPV
detection, except for certain HPV types

Appraisal/Worth to practice Relevant findings that constitute no change in practice needed but further research should
be conducted.

Reference (APA) Maffioli, E. M. (2017). Is traditional male circumcision effective as an HIV prevention

strategy? Evidence from Lesotho. PloS ONE, 12(5), 1-15.

doi:10.1371/journal.pone.0177076
AN INTEGRATIVE REVIEW
Author (Year)/Qualifications
Introduction/
Background/Problem Statement
Conceptual/Framework
Design/Research Methods/Sample/
Setting/Ethical Considerations/
Major Variable Studied/
Measurement Tool/Data Collection
Tool/Data Analysis
19
Elisa M. Maffioli, Department of Economics, Duke University Durham NC, Duke Global
Health Institute
Introduction/Background: In Lesotho HIV prevalence in adults aged 15 to 49 is 23.4%
which is the highest in the world. A national circumcision program was launched to combat
it. TMC type of circumcision may not be protective because it does not remove the foreskin
and it a symbolic cut. Circumcision may be overreported with Bathso men because many
believe they are circumcised according to their own definition which may be different from
the medical one.
Problem Statement: Investigates weather traditional male circumcision has medical effects
on individual HIV status that are as beneficial as those shown for voluntary medical male
circumcision.
There was theoretical framework identified
Design: Demographic Health Survey
Research methods: Questionnaire and individual interview, used information from the
demographic health survey about background, reproduction, marriage, and sexual activity,
employment, HIV/AIDS status, and MC related questions. Sample was merged with 2009
AIDS indicator survey. Collecting blood spots on a filter paper from a finger prick and
transporting them to a lab for testing. ELIZA and western-blot test performed on samples.
Sample: 3,317 men agreed to participate in the interview, restricted the sample to 2,735
sexually active men for the analysis. 189 men refused to be tested for HIV and t-tests for the
means were used to determine any significant difference in sociodemographic
characteristics or risky sexual behaviors.
Ethical considerations: Every respondent received educational materials and referrals for
free testing and counseling. The DHS testing protocol provides anonymous, informed, and
voluntary testing
Major variable studied: The association between circumcision and in particular traditional
male circumcision and individual HIV status.
Measurement tool: ELIZA and Western Blot, t-test for significance difference for
socioeconomic status
AN INTEGRATIVE REVIEW
Findings/Results
Discussion/
Implications
Limitations/Conclusions
Appraisal/Worth to practice
20
Different types of MC were associated with individual HIV status. Men circumcised in
health clinics were less likely to be HIV positive. Traditionally circumcised men were more
likely to be HIV positive compared to medically circumcised men. Having a high number of
lifetime partners slightly increased the chances of being HIV positive. No association
between the two types of circumcision and risky sexual behaviors.
Vast majority of men in Lesotho are traditionally circumcised so this study was important
for this population also because they have one of the highest HIV rates. Controlling for
risky sexual behavior, migration, and socio-economic characteristics, medically circumcised
men were found to be less likely to be infected by HIV than uncircumcised men. TMC does
not have any medical benefits unlike VMMC. Results are in line with past studies.
Limitations: Concerns about other unaddressed variables that were not adjusted for like
beliefs about contracting HIV. Measures of MC used in the analysis are self-reported and
individuals may not have accurate knowledge about the surgical operation and how it
should be performed. Cannot determine if the participants contracted HIV before or after
circumcision.
Conclusion: need for further research into how the operation in initiation schools is
performed and its medical benefits.
Positive correlation of STI’s and non-circumcised males, contributes to the body of
research.