DOI: 10.1097/QAD.0b013e328336675e
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PMID: 20215885
Issn Print: 0269-9370
Publication Date: 2010/03/13
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Excerpt
In reviewing their data, it would appear that the incidence of HIV in those less than or equal to 75th centile foreskin surface area (0.80, 0.92 and 0.90 per 100 person-years, respectively) is much lower than those in the highest quartile (2.48 per 100 person-years). These lower incidence rates are similar to those in two-thirds of the intervention groups in the male circumcision intervention trials, including the Rakai population (0.66 and 0.85 per 100 person-years) [2,3]. We have compared the HIV incidence rates in their study in those with a foreskin surface area 75th centile or less against those in the highest quartile in a 2 × 2 table and found a significant difference (relative risk = 2.76, 95% confidence interval 1.5–5.1, P = 0.0003). It must be questionable, therefore, whether it is really worthwhile circumcising those with short foreskin.
We have also assessed the size of the foreskin in a clinical study [4] to determine factors associated with penile wetness, a clinical finding that may reflect poor genital hygiene [5]. We assessed foreskin length by observing whether men had a visible urinary meatus on direct inspection. We found that penile wetness was associated with not having a visible urinary meatus on direct inspection, that is, in men with longer foreskin [5]. In our study in London, we found that 144/278 had a visible meatus and an additional 68 either sometimes retracted the foreskin when urinating or had phimosis. Thus, at least 144/346 (41.8%) would be classified as having a short foreskin and at much lower risk of HIV.
It would seem that male circumcision is most likely to benefit those with longer foreskins and it may be more cost-effective to leave those with shorter foreskins intact, assuming they have neither penile wetness nor phimosis. This would enable circumcision services that are already stretched to deliver a more timely service to those in more urgent need of the procedure.
