Circumcision and HIV - Revision history

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Philippines: Wikify.

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	=== Philippines ===		=== Philippines ===
	[[Tuli]] or male circumcision, a nearly compulsory cultural practice in the Philippine Islands, causes 93 percent of Filipino males to be circumcised.		[[Tuli]] or male circumcision, a nearly compulsory cultural practice in the Philippine Islands, causes 93 percent of Filipino males to be [[circumcised]].
	In the 2010 Global [[AIDS]] report released by UNAIDS in late November, the Philippines was one of seven nations in the world which reported over 25 percent in new [[HIV]] infections between 2001 and 2009, whereas other countries have either stabilized or shown significant declines in the rate of new infections. Among all countries in Asia, only the Philippines and Bangladesh are reporting increases in [[HIV]] cases, with others either stable or decreasing. <ref>http://globalnation.inquirer.net/news/breakingnews/view/20110102-312124/Philippines-HIVAIDS-problem-worries-UN</ref>		In the 2010 Global [[AIDS]] report released by UNAIDS in late November, the Philippines was one of seven nations in the world which reported over 25 percent in new [[HIV]] infections between 2001 and 2009, whereas other countries have either stabilized or shown significant declines in the rate of new infections. Among all countries in Asia, only the Philippines and Bangladesh are reporting increases in [[HIV]] cases, with others either stable or decreasing. <ref>http://globalnation.inquirer.net/news/breakingnews/view/20110102-312124/Philippines-HIVAIDS-problem-worries-UN</ref>

	The statistics suggest that removal of the protective [[foreskin]] by circumcision increases the risk of contracting [[HIV]] infection.		The statistics suggest that removal of the protective [[foreskin]] by [[circumcision]] increases the risk of contracting [[HIV]] infection.

	=== [[Israel]] ===		=== [[Israel]] ===

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wikify Israel

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	Alcena and Fink lacked a hypothesis to explain why the foreskin would be an entry point for HIV infection, but this was supplied by circumcision promoter [[Gerald N. Weiss]] and two colleagues. Weiss et al. (1993) produced the plausible but incorrect hypothesis that [[Langerhans cells]] attracted HIV. A medical journal in Israel was willing to publish the paper by Weiss et al.<ref name="weiss1993">{{REFjournal		Alcena and Fink lacked a hypothesis to explain why the foreskin would be an entry point for HIV infection, but this was supplied by circumcision promoter [[Gerald N. Weiss]] and two colleagues. Weiss et al. (1993) produced the plausible but incorrect hypothesis that [[Langerhans cells]] attracted HIV. A medical journal in [[Israel]] was willing to publish the paper by Weiss et al.<ref name="weiss1993">{{REFjournal
	\|last=Weiss		\|last=Weiss
	\|first=Gerald N.		\|first=Gerald N.
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	The statistics suggest that removal of the protective [[foreskin]] by circumcision increases the risk of contracting [[HIV]] infection.		The statistics suggest that removal of the protective [[foreskin]] by circumcision increases the risk of contracting [[HIV]] infection.

	=== Israel ===		=== [[Israel]] ===
	Despite circumcision being near-universal, [[HIV]] is an increasing problem in Israel.<ref>{{REFweb		Despite circumcision being near-universal, [[HIV]] is an increasing problem in [[Israel]].<ref>{{REFweb
	\|url=https://www.haaretz.com/1.4998790		\|url=https://www.haaretz.com/1.4998790
	\|title=Failing the AIDS Test		\|title=Failing the AIDS Test

WikiModEn2: /* The immunological function of the foreskin */ Wikify.

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The immunological function of the foreskin: Wikify.

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	== The immunological function of the foreskin ==		== The immunological function of the foreskin ==

	The foreskin's inner fold and the glans of the penis are comprised of [[Preputial mucosa\|mucous membrane]] tissue. These are also present in your eyes, mouth, and all other bodily orifices including the female genitals. These are the first line of immunological defense for the body's orifices. These mucous membranes perform many immunological and hygienic functions.		The [[foreskin]]'s inner fold and the [[glans]] of the penis are comprised of [[Preputial mucosa\|mucous membrane]] tissue. These are also present in your eyes, mouth, and all other bodily orifices including the female genitals. These are the first line of immunological defense for the body's orifices. These mucous membranes perform many immunological and hygienic functions.

	Certain components such as [[Langerhans cells]],<ref>{{REFjournal		Certain components such as [[Langerhans cells]],<ref>{{REFjournal
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	}}</ref>		}}</ref>

	All of these function to sequester and “digest” foreign pathogens. All these substances play an important role in protecting the penis from viral and bacterial pathogens. The immunological functions of the human prepuce have been extensively documented by respected researchers for quite some time.<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref>		All of these function to sequester and “digest” foreign pathogens. All these substances play an important role in protecting the [[penis]] from viral and bacterial pathogens. The immunological functions of the human [[prepuce]] have been extensively documented by respected researchers for quite some time.<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref>

	Circumcision destroys the natural [[Immunological and protective function of the foreskin\| immunological protections of the foreskin]] and [[preputial sac]], so it results in increased risk of contracting [[infection]].		Circumcision destroys the natural [[Immunological and protective function of the foreskin\| immunological protections of the foreskin]] and [[preputial sac]], so it results in increased risk of contracting [[infection]].

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Bacterial environment hypothesis: Wikify.

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	==== Bacterial environment hypothesis ====		==== Bacterial environment hypothesis ====
	This hypothesis attempts to identify the change in bacterial environment that results in the penis as a result of circumcision, as the mechanism whereby circumcision reduces the spread of [[HIV]] transmission. A desperate ad-hoc hypothesis, the explanation is rather farfetched. The argument is that the change in bacterial environment after circumcision makes it difficult for bacteria that cause diseases to live; there are less chances for penile inflammation, a condition that facilitates the transmission of viruses. The chances for penile inflammation are reduced, thereby reducing the chances of sexually transmitted viruses, such as [[HIV]].<ref>{{REFjournal		This hypothesis attempts to identify the change in [[microbiome\| bacterial environment]] that results in the [[penis]] as a result of [[adult circumcision]], as the mechanism whereby circumcision reduces the spread of [[HIV]] transmission. A desperate ad-hoc hypothesis, the explanation is rather farfetched. The argument is that the change in bacterial environment after circumcision makes it difficult for bacteria that cause diseases to live; there are less chances for penile inflammation, a condition that facilitates the transmission of viruses. The chances for penile inflammation are reduced, thereby reducing the chances of sexually transmitted viruses, such as [[HIV]].<ref>{{REFjournal
	\|last=Price		\|last=Price
	\|first=Lance B.		\|first=Lance B.
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	}}</ref>		}}</ref>

	Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the randomized control trials were measuring frequency in [[HIV]] transmission, not for frequency in penile bacterial inflammation, and whether said inflammation facilitated sexually transmitted [[HIV]]. And secondly, circumcision advocates give themselves the new burden of proving the newly introduced hypothesis, that change in bacterial infection does indeed result in a significant reduction of [[HIV]] transmission. A new study is needed to measure [[HIV]] transmission in men who have been [[circumcised]], [[intact]] men with constant penile inflammations, and [[intact]] men who don't suffer constant penile inflammation. Unless the randomized controlled studies were limited to only [[intact]] men who suffered constant penile inflammation.		Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the discredited randomized control trials were measuring frequency in [[HIV]] transmission, not for frequency in penile bacterial inflammation, and whether said inflammation facilitated sexually transmitted [[HIV]]. And secondly, circumcision advocates give themselves the new burden of proving the newly introduced hypothesis, that change in bacterial infection does indeed result in a significant reduction of [[HIV]] transmission. A new study is needed to measure [[HIV]] transmission in men who have been [[circumcised]], [[intact]] men with constant penile inflammations, and [[intact]] men who don't suffer constant penile inflammation. Unless the randomized controlled studies were limited to only [[intact]] men who suffered constant penile inflammation.

	== The immunological function of the foreskin ==		== The immunological function of the foreskin ==

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	==== Swaziland ====		==== Swaziland ====
	DHS 2006-2007 - 22 vs 20		DHS 2006-2007 - 22 vs 20
	:"As Table 14.10 shows, the relationship between [[HIV]] prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher [[HIV]] infection rate than men who are not circumcised (22 percent compared with 20 percent).<ref>{{REFweb		:"As Table 14.10 shows, the relationship between [[HIV]] prevalence and circumcision status is not in the expected direction. [[Circumcised]] men have a slightly higher [[HIV]] infection rate than men who are [[Intact\| not circumcised]] (22 percent compared with 20 percent).<ref>{{REFweb
	\|url=http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf		\|url=http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf
	\|title=Swaziland Demographic and Health Survey		\|title=Swaziland Demographic and Health Survey

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Bacterial environment hypothesis: Correct URL

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	\|volume=5		\|volume=5
	\|issue=1		\|issue=1
	\|url=~~http~~://~~www~~.~~plosone~~.org/article~~/info%3Adoi%2F10~~.1371~~%2Fjournal~~.pone.~~0015552~~		\|url=https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0008422
	\|quote=The anoxic microenvironment of the subpreputial space may support pro-inflammatory anaerobes that can activate Langerhans cells to present HIV to CD4 cells in draining lymph nodes. Thus, the reduction in putative anaerobic bacteria after circumcision may play a role in protection from HIV and other sexually transmitted diseases.		\|quote=The anoxic microenvironment of the subpreputial space may support pro-inflammatory anaerobes that can activate Langerhans cells to present HIV to CD4 cells in draining lymph nodes. Thus, the reduction in putative anaerobic bacteria after circumcision may play a role in protection from HIV and other sexually transmitted diseases.
	\|DOI=10.1371/journal.pone.0008422		\|DOI=10.1371/journal.pone.0008422

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Bacterial environment hypothesis: Wikify.

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	}}</ref>		}}</ref>

	Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the randomized control trials were measuring frequency in [[HIV]] transmission, not for frequency in penile bacterial ~~inflamation~~, and whether said ~~inflamation~~ facilitated sexually transmitted [[HIV]]. And secondly, circumcision advocates give themselves the new burden of proving the newly introduced hypothesis, that change in bacterial infection does indeed result in a significant reduction of [[HIV]] transmission. A new study is needed to measure [[HIV]] transmission in men who have been circumcised, intact men with constant penile ~~inflamations~~, and intact men who don't suffer constant penile inflammation. Unless the randomized controlled studies were limited to only intact men who suffered constant penile inflammation.		Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the randomized control trials were measuring frequency in [[HIV]] transmission, not for frequency in penile bacterial inflammation, and whether said inflammation facilitated sexually transmitted [[HIV]]. And secondly, circumcision advocates give themselves the new burden of proving the newly introduced hypothesis, that change in bacterial infection does indeed result in a significant reduction of [[HIV]] transmission. A new study is needed to measure [[HIV]] transmission in men who have been [[circumcised]], [[intact]] men with constant penile inflammations, and [[intact]] men who don't suffer constant penile inflammation. Unless the randomized controlled studies were limited to only [[intact]] men who suffered constant penile inflammation.

	== The immunological function of the foreskin ==		== The immunological function of the foreskin ==

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	\|date=2015-02-03		\|date=2015-02-03
	\|accessdate=2022-06-15		\|accessdate=2022-06-15
	}}</ref> while in most countries in Europe, circumcision is uncommon. One would expect for there to be a lower transmission rates in the [[United States]], and for [[HIV]] to be rampant in Europe; [[HIV]] transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are [[intact]].<ref>http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf</ref>		}}</ref> while in most countries in Europe, [[circumcision]] is uncommon. One would expect for there to be a lower transmission rates in the [[United States]], and for [[HIV]] to be rampant in Europe; [[HIV]] transmission rates are in fact higher in the [[United States]], where most men are [[circumcised]], than in various countries in Europe, where most men are [[intact]].<ref>http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf</ref>

	A common explanation given for this difference is the fact that sex education and instruction in the proper use of condoms is better executed in Europe than in the United States, where sex education is poor.		A common explanation given for this difference is the fact that sex education and instruction in the proper use of condoms is better executed in Europe than in the United States, where sex education is poor.

	However, it is precisely these reasons given, that sex education and condoms aren't catching on in Africa, why circumcision advocates say "mass circumcision campaigns" should be promoted in Africa. What failed in the United States is somehow supposed to work miracles in Africa.		However, it is precisely these reasons given, that sex education and condoms aren't catching on in Africa, why circumcision advocates say "mass circumcision campaigns" should be promoted in Africa. What failed in the [[United States]] is somehow supposed to work miracles in Africa.

	== Studies with contrary conclusions ==		== Studies with contrary conclusions ==

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	=== Countries in Africa ===		=== Countries in Africa ===

	According to demographic health studies performed in other countries in Africa, [[HIV]] transmission was prevalent in circumcised men in at least 6 different countries:		According to demographic health studies performed in other countries in Africa, [[HIV]] transmission was prevalent in [[circumcised]] men in at least 6 different countries:

	==== Cameroon ====		==== Cameroon ====
	In Cameroon, where 91% of the male population is circumcised, the ratio of circumcised men vs. intact men who contracted [[HIV]] was 4.1 vs. 1.1. <ref>{{REFbook		In Cameroon, where 91% of the male population is circumcised, the ratio of [[circumcised[[ men vs. [[intact]] men who contracted [[HIV]] was 4.1 vs. 1.1. <ref>{{REFbook
	\|last=Mosoko		\|last=Mosoko
	\|first=Jembia J.		\|first=Jembia J.
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	==== Lesotho ====		==== Lesotho ====
	In Lesotho, the ratio is 22.8 vs 15.2 (23% circumcised).		In Lesotho, the ratio is 22.8 vs 15.2 (23% circumcised).
	''"The relationship between male circumcision and [[HIV]] levels in Lesotho does not conform to the expected pattern of higher rates among [[uncircumcised]] men than circumcised men. The [[HIV]] rate is in fact substantially higher among circumcised men (23 percent) than among men who are not circumcised (15 percent). Moreover, the pattern of higher infection rates among circumcised men compared with [[uncircumcised]] men is virtually uniform across the various subgroups for which results are shown in ~~thetable~~. This finding could be explained by the Lesotho custom to conduct male circumcision later in life, when the individuals have already been exposed to the risk of [[HIV]] infection. (Additional analysis is necessary to better understand the unexpected pattern in Table 12.9.)"''<ref>{{REFbook		''"The relationship between male circumcision and [[HIV]] levels in Lesotho does not conform to the expected pattern of higher rates among [[uncircumcised]] men than circumcised men. The [[HIV]] rate is in fact substantially higher among circumcised men (23 percent) than among men who are not circumcised (15 percent). Moreover, the pattern of higher infection rates among circumcised men compared with [[uncircumcised]] men is virtually uniform across the various subgroups for which results are shown in the table. This finding could be explained by the Lesotho custom to conduct male circumcision later in life, when the individuals have already been exposed to the risk of [[HIV]] infection. (Additional analysis is necessary to better understand the unexpected pattern in Table 12.9.)"''<ref>{{REFbook
	\|last=		\|last=
	\|first=		\|first=
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	}}</ref>		}}</ref>

	::''An interesting defense of male circumcision, given the fact that the latest "studies," if they can even be called that, observed [[HIV]] transmission in men circumcised as adults. Then again, this demographic health survey was conducted in 2004, BEFORE the newer "studies" in 2006. None the less, the unproven assertion that "circumcision is only effective in reducing the risk of [[HIV]] when done in infancy" persists in some circles.''		::''An interesting defense of male circumcision, given the fact that the latest "studies," if they can even be called that, observed [[HIV]] transmission in men [[circumcised]] as adults. Then again, this demographic health survey was conducted in 2004, BEFORE the newer "studies" in 2006. None the less, the unproven assertion that "circumcision is only effective in reducing the risk of [[HIV]] when done in infancy" persists in some circles.''

	==== Malawi ====		==== Malawi ====
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	[[Michel Garenne\|Garenne]] & Matthews (2019) report:		[[Michel Garenne\|Garenne]] & Matthews (2019) report:
	<blockquote>		<blockquote>
	In a multivariate analysis, based on the 2013 DHS survey, circumcised men were found to have the same level of infection as [[uncircumcised]] men, after controlling for age, sexual behaviour and socioeconomic status. Lastly, circumcised men tended to have somewhat riskier sexual behaviour than [[uncircumcised]] men. This study, based on large representative samples of the Zambian population, questions the current strategy of mass circumcision campaigns in southern and eastern Africa.<ref name="garenne-matthews2019">{{REFjournal		In a multivariate analysis, based on the 2013 DHS survey, [[circumcised]] men were found to have the same level of infection as [[uncircumcised]] men, after controlling for age, sexual behaviour and socioeconomic status. Lastly, circumcised men tended to have somewhat riskier sexual behaviour than [[uncircumcised]] men. This study, based on large representative samples of the Zambian population, questions the current strategy of mass circumcision campaigns in southern and eastern Africa.<ref name="garenne-matthews2019">{{REFjournal
	\|last=Garenne		\|last=Garenne
	\|init=M		\|init=M

WikiModEn2: /* The immunological function of the foreskin */ Wikify.

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The immunological function of the foreskin: Wikify.

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	All of these function to sequester and “digest” foreign pathogens. All these substances play an important role in protecting the penis from viral and bacterial pathogens. The immunological functions of the human prepuce have been extensively documented by respected researchers for quite some time.<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref>		All of these function to sequester and “digest” foreign pathogens. All these substances play an important role in protecting the penis from viral and bacterial pathogens. The immunological functions of the human prepuce have been extensively documented by respected researchers for quite some time.<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref>

	Circumcision destroys the natural immunological protections of the foreskin and results in increased risk of contracting infection.		Circumcision destroys the natural [[Immunological and protective function of the foreskin\| immunological protections of the foreskin]] and [[preputial sac]], so it results in increased risk of contracting [[infection]].

	== African RCTs ==		== African RCTs ==