title: Dorsal longitudinal foreskin cut is associated with reduced risk of HIV, syphilis and genital herpes in men: a cross-sectional study in Papua New Guinea.
abstract: Various forms of penile foreskin cutting are practised in Papua New Guinea. In the context of an ecological association observed between HIV infection and the dorsal longitudinal foreskin cut, we undertook an investigation of this relationship at the individual level.
  
  
  
  We conducted a cross-sectional study among men attending voluntary confidential HIV counselling and testing clinics. Following informed consent, participants had a face-to-face interview and an examination to categorize foreskin status. HIV testing was conducted on site and relevant specimens collected for laboratory-based Herpes simplex type-2 (HSV-2), syphilis, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) testing.
  
  
  
  Overall, 1073 men were enrolled: 646 (60.2%) were uncut; 339 (31.6%) had a full dorsal longitudinal cut; 72 (6.7%) a partial dorsal longitudinal cut; and 14 (1.3%) were circumcised. Overall, the prevalence of HIV was 12.3%; HSV-2, 33.6%; active syphilis, 12.1%; CT, 13.4%; NG, 14.1%; and TV 7.6%. Compared with uncut men, men with a full dorsal longitudinal cut were significantly less likely to have HIV (adjusted odds ratio [adjOR] 0.25, 95%CI: 0.12, 0.51); HSV-2 (adjOR 0.60, 95%CI: 0.41, 0.87); or active syphilis (adjOR 0.55, 95%CI: 0.31, 0.96). This apparent protective effect was restricted to men cut prior to sexual debut. There was no difference between cut and uncut men for CT, NG or TV.
  
  
  
  In this large cross-sectional study, men with a dorsal longitudinal foreskin cut were significantly less likely to have HIV, HSV-2 and syphilis compared with uncut men, despite still having a complete (albeit morphologically altered) foreskin. The protective effect of the dorsal cut suggests that the mechanism by which male circumcision works is not simply due to the removal of the inner foreskin and its more easily accessible HIV target cells. Exposure of the penile glans and inner foreskin appear to be key mechanisms by which male circumcision confers protection.Further research in this unique setting will help improve our understanding of the fundamental immunohistologic mechanisms by which male circumcision provides protection, and may lead to new biomedical prevention strategies at the mucosal level.
authors.affiliation: Public Health Intervention Research Group, Kirby Institute, UNSW Australia, Sydney, Australia.|Sexual and Reproductive Health Research Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Vallely
authors.affiliation: College of Medicine and Dentistry, James Cook University, Cairns, Australia.|School of Health Science, Pacific Adventist University, Port Moresby, Papua New Guinea.
authors.forename: David
authors.initials: D
authors.lastname: MacLaren
authors.affiliation: Sexual and Reproductive Health Research Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
authors.forename: Matthew
authors.initials: M
authors.lastname: David
authors.affiliation: Sexual and Reproductive Health Research Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
authors.forename: Pamela
authors.initials: P
authors.lastname: Toliman
authors.affiliation: Public Health Intervention Research Group, Kirby Institute, UNSW Australia, Sydney, Australia.|Sexual and Reproductive Health Research Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
authors.forename: Angela
authors.initials: A
authors.lastname: Kelly-Hanku
authors.affiliation: Sexual and Reproductive Health Research Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
authors.forename: Ben
authors.initials: B
authors.lastname: Toto
authors.affiliation: School of Health Science, Pacific Adventist University, Port Moresby, Papua New Guinea.
authors.forename: Rachael
authors.initials: R
authors.lastname: Tommbe
authors.affiliation: Department of Pathology, Tininga Clinic, Mt Hagen General Hospital, Papua New Guinea.
authors.forename: Zure
authors.initials: Z
authors.lastname: Kombati
authors.affiliation: Department of Pathology, Tininga Clinic, Mt Hagen General Hospital, Papua New Guinea.
authors.forename: Petronia
authors.initials: P
authors.lastname: Kaima
authors.affiliation: Sexual Health and HIV/AIDS Prevention and Control, National Department of Health, Port Moresby, Papua New Guinea.
authors.forename: Kelwyn
authors.initials: K
authors.lastname: Browne
authors.affiliation: College of Medicine and Dentistry, James Cook University, Cairns, Australia.
authors.forename: Clement
authors.initials: C
authors.lastname: Manineng
authors.affiliation: School of Health Science, Pacific Adventist University, Port Moresby, Papua New Guinea.
authors.forename: Lalen
authors.initials: L
authors.lastname: Simeon
authors.affiliation: Centre for International Health, The Burnet Institute, Melbourne, Australia.
authors.forename: Claire
authors.initials: C
authors.lastname: Ryan
authors.affiliation: Public Health Intervention Research Group, Kirby Institute, UNSW Australia, Sydney, Australia.
authors.forename: Handan
authors.initials: H
authors.lastname: Wand
authors.affiliation: School of Public Health, University of Queensland, Brisbane, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Hill
authors.affiliation: Sexual Health and HIV/AIDS Prevention and Control, National Department of Health, Port Moresby, Papua New Guinea.
authors.forename: Greg
authors.initials: G
authors.lastname: Law
authors.affiliation: Sexual and Reproductive Health Research Unit, Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Siba
authors.affiliation: College of Medicine and Dentistry, James Cook University, Cairns, Australia.
authors.forename: W John H
authors.initials: WJ
authors.lastname: McBride
authors.affiliation: Public Health Intervention Research Group, Kirby Institute, UNSW Australia, Sydney, Australia.
authors.forename: John M
authors.initials: JM
authors.lastname: Kaldor
mesh_terms: D000293:Adolescent; D000328:Adult; D002944:Circumcision, Male / Q000379:methods; D003430:Cross-Sectional Studies; D052816:Foreskin / Q000601:surgery*; D015658:HIV Infections / Q000517:prevention & control*; D006558:Herpes Genitalis / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010219:Papua New Guinea; D015995:Prevalence; D040242:Risk Reduction Behavior; D012725:Sexual Behavior; D013587:Syphilis / Q000517:prevention & control*; D055815:Young Adult
keywords: Pacific; male genital cutting; superincision