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Objectives: Male circumcision is linked to a reduction in the risk of HIV infection, sexually transmitted infections, penile inflammatory skin disorders, cancers, urinary tract infections, and other complications. We examined the extent to which the change in circumcision recommendation by the American Academy of Pediatrics in 1999 and Medicaid coverage status in states affected the total number of procedures performed., Methods: We used data from the Nationwide Inpatient Sample for 1998-2011 collected annually by the Healthcare Cost and Utilization Project. We examined data on all male births in the United States with Medicaid and private health insurance. We then categorized births into 4 groups: (1) births with newborn male circumcision procedure, (2) births with Medicaid or private health insurance, (3) births that occurred in states where Medicaid coverage for newborn male circumcision was removed, and (4) births that occurred before or after the policy change. We used multivariable logistic regression to estimate the adjusted odds of newborn male circumcision., Results: In the 10 states where a change in Medicaid policy occurred, circumcision frequency had a mean percentage-point decrease of 21.4% among Medicaid beneficiaries and 3.2% among private health insurance beneficiaries from before to after the policy change. In states where coverage was maintained, the change in circumcision frequency was negligible for Medicaid and private health insurance beneficiaries. These changes resulted in an estimated 163 456 potential circumcisions not performed., Conclusion: Decreases in newborn male circumcision frequency correlated with the Medicaid policy change for the procedure. Efforts should be made to reduce barriers for cost-effective preventive procedures that promote health, such as newborn male circumcision.

Background: HIV remains the largest cause of disease burden among men and women of reproductive age in sub-Saharan Africa. Voluntary medical male circumcision (VMMC) reduces the risk of female-to-male transmission of HIV by 50-60%. The World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries for VMMC campaigns and set a coverage goal of 80% for men ages 15-49. From 2008 to 2017, over 18 million VMMCs were reported in priority countries. Nonetheless, relatively little is known about local variation in male circumcision (MC) prevalence., Methods: We analyzed geo-located MC prevalence data from 109 household surveys using a Bayesian geostatistical modeling framework to estimate adult MC prevalence and the number of circumcised and uncircumcised men aged 15-49 in 38 countries in sub-Saharan Africa at a 5 × 5-km resolution and among first administrative level (typically provinces or states) and second administrative level (typically districts or counties) units., Results: We found striking within-country and between-country variation in MC prevalence; most (12 of 14) priority countries had more than a twofold difference between their first administrative level units with the highest and lowest estimated prevalence in 2017. Although estimated national MC prevalence increased in all priority countries with the onset of VMMC campaigns, seven priority countries contained both subnational areas where estimated MC prevalence increased and areas where estimated MC prevalence decreased after the initiation of VMMC campaigns. In 2017, only three priority countries (Ethiopia, Kenya, and Tanzania) were likely to have reached the MC coverage target of 80% at the national level, and no priority country was likely to have reached this goal in all subnational areas., Conclusions: Despite MC prevalence increases in all priority countries since the onset of VMMC campaigns in 2008, MC prevalence remains below the 80% coverage target in most subnational areas and is highly variable. These mapped results provide an actionable tool for understanding local needs and informing VMMC interventions for maximum impact in the continued effort towards ending the HIV epidemic in sub-Saharan Africa.

Background: Economic compensation interventions may help support higher voluntary medical male circumcision (VMMC) coverage in priority sub-Saharan African countries. To inform World Health Organization guidelines, we conducted a systematic review of economic compensation interventions to increase VMMC uptake., Methods: Economic compensation interventions were defined as providing money or in-kind compensation, reimbursement for associated costs (e.g. travel, lost wages), or lottery entry. We searched five electronic databases and four scientific conferences for studies examining the impact of such interventions on VMMC uptake, HIV testing and safer-sex/risk-reduction counseling uptake within VMMC, community expectations about compensation, and potential coercion. We screened citations, extracted data, and assessed risk of bias in duplicate. We conducted random-effects meta-analysis. We also reviewed studies examining acceptability, values/preferences, costs, and feasibility., Results: Of 2484 citations identified, five randomized controlled trials (RCTs) and three non-randomized controlled trials met our eligibility criteria. Studies took place in Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. Meta-analysis of four RCTs showed significant impact of any economic compensation on VMMC uptake (relative risk: 5.23, 95% CI: 3.13 to 8.76). RCTs of food/transport vouchers and conditional cash transfers generally showed increases in VMMC uptake, but lotteries, subsidized VMMC, and receiving a gift appeared somewhat less effective. Three non-randomized trials showed mixed impact. Six additional studies suggested economic compensation interventions were generally acceptable, valued for addressing key barriers, and motivating to men. However, some participants felt they were insufficiently motivating or necessary; one study suggested they might raise community suspicions. One study from South Africa found a program cost of US$91 per additional circumcision and US$450-$1350 per HIV infection averted., Conclusions: Economic compensation interventions, particularly transport/food vouchers, positively impacted VMMC uptake among adult men and were generally acceptable to potential clients. Carefully selected economic interventions may be a useful targeted strategy to enhance VMMC coverage., Competing Interests: The authors have declared that no competing interests exist.

Importance: In Africa, the persistently high HIV incidence rate among young women is the major obstacle to achieving the goal of epidemic control., Objective: To determine trends in coverage of HIV prevention and treatment programs and HIV incidence., Design, Setting, and Participants: This cohort study consisted of 2 sequential, community-based longitudinal studies performed in the Vulindlela and Greater Edendale area in KwaZulu-Natal, South Africa. Participants enrolled from June 11, 2014, to June 22, 2015 (2014 survey), with a single follow-up visit from June 24, 2016, to April 3, 2017 (2016 cohort), or enrolled from July 8, 2015, to June 7, 2016 (2015 survey), with a single follow-up visit from November 7, 2016, to August 30, 2017 (2017 cohort). Men and women aged 15 to 49 years were enrolled in the 2014 and 2015 surveys, and HIV-seronegative participants aged 15 to 35 years were followed up in the 2016 and 2017 cohorts. Analysis was conducted from January 1 through December 31, 2018., Exposures: HIV prevention and treatment programs in a real-world, nontrial setting., Main Outcomes and Measures: Trends in sex- and age-specific HIV incidence rates, condom use, voluntary medical male circumcision, knowledge of HIV-seropositive status, uptake of antiretroviral therapy, and viral suppression., Results: A total of 9812 participants (6265 women [63.9%]; median age, 27 years [interquartile range, 20-36 years]) from 11 289 households were enrolled in the 2014 survey, and 10 236 participants (6341 women [61.9%]; median age, 27 years [interquartile range, 20-36 years]) from 12 247 households were enrolled in the 2015 survey. Of these, 3536 of 4539 (annual retention rate of 86.7%) completed follow-up in the 2016 cohort, and 3907 of 5307 (annual retention rate of 81.4%) completed follow-up in the 2017 cohort. From 2014 to 2015, condom use with last sex partner decreased by 10% from 24.0% (n = 644 of 3547) to 21.6% (n = 728 of 3895; P = .12) in men and by 17% from 19.6% (n = 1039 of 6265) to 16.2% (n = 871 of 6341; P = .002) in women. Voluntary medical male circumcision increased by 13% from 31.9% (1102 of 3547) to 36.1% (n = 1472 of 3895); P = .007) in men, and the proportion of women reporting that their partner was circumcised increased by 35% from 35.7% (n = 1695 of 4766) to 48.2% (n = 2519 of 5207; P < .001). Knowledge of HIV-seropositive status increased by 21% from 51.8% (n = 504 of 3547) to 62.9% (n = 570 of 3895; P < .001) in men and by 14% from 64.6% (n = 1833 of 6265) to 73.4% (n = 2182 of 6341; P < .001) in women. Use of antiretroviral therapy increased by 32% from 36.7% (n = 341 of 3547) to 48.6% (n = 432 of 3895; P < .001) in men and by 29% from 45.6% (n = 1251 of 6265) to 58.8% (n = 1743 of 6341; P < .001) in women; HIV viral suppression increased by 20% from 41.9% (n = 401 of 3547) to 50.3% (n = 456 of 3895; P = .005) in men and by 13% from 54.8% (n = 1547 of 6265) to 61.9% (n = 1828 of 6341; P < .001) in women. Incidence of HIV declined in women aged 15 to 19 years from 4.63 (95% CI, 3.29-6.52) to 2.74 (95% CI, 1.84-4.09) per 100 person-years (P = .04) but declined marginally or remained unchanged among men and women in other age groups., Conclusions and Relevance: This study showed a significant decline in HIV incidence in young women; however, to further reduce HIV incidence, HIV prevention and treatment program coverage must be intensified and scaled up.

Background: Men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. Previous reviews investigating the role of circumcision in preventing HIV and other STIs among MSM were inconclusive. Many new studies have emerged in the past decade. To inform global prevention strategies for HIV and other STIs among MSM, we reviewed all available evidence on the associations between circumcision and HIV and other STIs among MSM., Methods: In this systematic review and meta-analysis, we searched PubMed, Web of Science, BioMed Central, Scopus, ResearchGate, Cochrane Library, Embase, PsycINFO, Google Scholar, and websites of international HIV and STI conferences for studies published before March 8, 2018. Interventional or observational studies containing original quantitative data describing associations between circumcision and incident or prevalent infection of HIV and other STIs among MSM were included. Studies were excluded if MSM could not be distinguished from men who have sex with women only. We calculated pooled odds ratios (ORs) and their 95% CIs using random-effect models. We assessed risk of bias using the Newcastle-Ottawa scale., Findings: We identified 62 observational studies including 119 248 MSM. Circumcision was associated with 23% reduced odds of HIV infection among MSM overall (OR 0·77, 95% CI 0·67-0·89; number of estimates [k]=45; heterogeneity I 2 =77%). Circumcision was protective against HIV infection among MSM in countries of low and middle income (0·58, 0·41-0·83; k=23; I 2 =77%) but not among MSM in high-income countries (0·99, 0·90-1·09; k=20; I 2 =40%). Circumcision was associated with reduced odds of herpes simplex virus (HSV) infection among MSM overall (0·84, 0·75-0·95; k=5; I 2 =0%) and penile human papillomavirus (HPV) infection among HIV-infected MSM (0·71, 0·51-0·99; k=3; I 2 =0%)., Interpretation: We found evidence that circumcision is likely to protect MSM from HIV infection, particularly in countries of low and middle income. Circumcision might also protect MSM from HSV and penile HPV infection. MSM should be included in campaigns promoting circumcision among men in countries of low and middle income. In view of the substantial proportion of MSM in countries of low and middle income who also have sex with women, well designed longitudinal studies differentiating MSM only and bisexual men are needed to clarify the effect of circumcision on male-to-male transmission of HIV and other STIs., Funding: National Natural Science Foundation of China, National Science and Technology Major Project of China, Australian National Health and Medical Research Council Early Career Fellowship, Sanming Project of Medicine in Shenzhen, National Institutes of Health, Mega Projects of National Science Research for the 13th Five-Year Plan, Doris Duke Charitable Foundation., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The objective of this review was to assess the trend in the US male circumcision rate and the impact that the affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circumcision practice. We searched PubMed for the term circumcision to retrieve relevant articles. This review was prompted by a recent report by the Centers for Disease Control and Prevention that found a slight increase, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the past decade. There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and 44% in Hispanic males. Because data on neonatal circumcision are equivocal, we undertook a critical analysis of hospital discharge data. After correction for underreporting, we found that the percentage had declined from 83% in the 1960s to 77% by 2010. A risk-benefit analysis of conditions that neonatal circumcision protects against revealed that benefits exceed risks by at least 100 to 1 and that over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin. Other analyses show that neonatal male circumcision is cost-effective for disease prevention. The benefits of circumcision begin in the neonatal period by protection against infections that can damage the pediatric kidney. Given the substantial risk of adverse conditions and disease, some argue that failure to circumcise a baby boy may be unethical because it diminishes his right to good health. There is no long-term adverse effect of neonatal circumcision on sexual function or pleasure. The affirmative 2012 American Academy of Pediatrics policy supports parental education about, access to, and insurance and Medicaid coverage for elective infant circumcision. As with vaccination, circumcision of newborn boys should be part of public health policies. Campaigns should prioritize population subgroups with lower circumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision., (Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: The Kenyan Ministry of Health initiated a voluntary medical male circumcision (VMMC) program in 2008. We used data from 2 nationally representative surveys to estimate trends in the number, demographic characteristics, and sexual behaviors of recently circumcised and uncircumcised HIV-uninfected men in Kenya., Methods: We compared the proportion of circumcised men between the first and second Kenya AIDS Indicator Survey (KAIS 2007 and KAIS 2012) to assess the progress of Kenya's VMMC program. We calculated the number of uncircumcised HIV-uninfected men. We conducted descriptive analyses and used multivariable methods to identify the variables independently associated with HIV-uninfected uncircumcised men aged 15-64 years in the VMMC priority region of Nyanza., Results: The proportion of men who reported being circumcised increased significantly from 85.0% in 2007 to 91.2% in 2012. The proportions of circumcised men increased in all regions, with the highest increases of 18.1 and 9.0 percentage points in the VMMC priority regions of Nyanza and Nairobi, respectively. Half (52.5%) of HIV-uninfected and uncircumcised men had never been married, and 84.6% were not using condoms at all times with their last sexual partner., Conclusions: VMMC prevalence has increased across Kenya demonstrating the success of the national program. Despite this accomplishment, the Nyanza region remains below the target to circumcise 80% of all eligible men aged 15-49 years between 2009 and 2013. As new cohorts of young men enter into adolescence, consistent focus is needed. To ensure sustainability of the VMMC program, financial resources and coordinated planning must continue.

Voluntary medical male circumcision (VMMC) is a cost-effective HIV-prevention intervention that reduces the risk of HIV acquisition in men by 60%. Although some countries are successfully scaling up VMMC, not all are doing this. When VMMC scale-up experiences are viewed in the context of models for the diffusion of innovation, some important themes emerge. Successful VMMC programs have in common locally led campaigns, a cultural tolerance of VMMC, strong political leadership and coordination, and adequate human and material resources. Challenges with VMMC scale-up have been marked by less flexible implementation models that seek a full integration of VMMC services at public medical facilities and by struggles to achieve geographic parity in access to care. Innovation diffusion models, especially the endogenous technology model, and multiple levels of influence on diffusion--individual males and their sex partners, communities, and health systems--remind us that the adoption of a prevention intervention, such as VMMC, is expected to start out slowly and, as information spreads, gradually speed up. In addition, the diffusion models suggest that customizing approaches to different populations is likely to accelerate VMMC scale-up and help achieve a long-term, sustainable impact on the HIV epidemic.

Background: Autism and Autism Spectrum Disorder (ASD) are complex neurodevelopmental disorders. Susceptibility is believed to be the interaction of genetic heritability and environmental factors. The synchronous rises in autism/ASD prevalence and paracetamol (acetaminophen) use, as well as biologic plausibility have led to the hypothesis that paracetamol exposure may increase autism/ASD risk., Methods: To explore the relationship of antenatal paracetamol exposure to ASD, population weighted average autism prevalence rates and paracetamol usage rates were compared. To explore the relationship of early neonatal paracetamol exposure to autism/ASD, population weighted average male autism prevalence rates for all available countries and U.S. states were compared to male circumcision rates - a procedure for which paracetamol has been widely prescribed since the mid-1990s. Prevalence studies were extracted from the U.S. Centers for Disease Control and Prevention Summary of Autism/ASD Prevalence Studies database. Maternal paracetamol usage and circumcision rates were identified by searches on Pub Med., Results: Using all available country-level data (n = 8) for the period 1984 to 2005, prenatal use of paracetamol was correlated with autism/ASD prevalence (r = 0.80). For studies including boys born after 1995, there was a strong correlation between country-level (n = 9) autism/ASD prevalence in males and a country's circumcision rate (r = 0.98). A very similar pattern was seen among U.S. states and when comparing the 3 main racial/ethnic groups in the U.S. The country-level correlation between autism/ASD prevalence in males and paracetamol was considerably weaker before 1995 when the drug became widely used during circumcision., Conclusions: This ecological analysis identified country-level correlations between indicators of prenatal and perinatal paracetamol exposure and autism/ASD. State level correlation was also identified for the indicator of perinatal paracetamol exposure and autism/ASD. Like all ecological analyses, these data cannot provide strong evidence of causality. However, biologic plausibility is provided by a growing body of experimental and clinical evidence linking paracetamol metabolism to pathways shown to be important in autism and related developmental abnormalities. Taken together, these ecological findings and mechanistic evidence suggest the need for formal study of the role of paracetamol in autism.

Background: To investigate the changing circumcision rate in South Korea in the last decade and to propose underlying causes for this change, in the context of the present fluctuating world-wide trends in circumcision., Methods: From 2009 to 2011, 3,296 South Korean males (or their parents) aged 0-64 years were asked about their circumcision status, their age at circumcision, and their information level regarding circumcision. We employed non-probability sampling considering the sensitive questions on the study theme., Results: Currently the age-standardized circumcision rate for South Korean males aged 14-29 is found to be 75.8%. In an earlier study performed in 2002, the rate for the same age group was 86.3%. Of particular interest, males aged 14-16 show a circumcision rate of 56.4%, while the same age group 10 years ago displayed a much higher percentage, at 88.4%. In addition, the extraordinarily high circumcision rate of 95.2% found 10 years ago for the 17-19 age group is now reduced to 74.4%. Interestingly, of the circumcised males, the percentage circumcised in the last decade was only 25.2%; i.e., the majority of the currently circumcised males had undergone the operation prior to 2002, indicating that the actual change in the last decade is far greater. Consistent with this conjecture, the 2002 survey showed that the majority of circumcised males (75.7%) had undergone the operation in the decade prior to that point. Focusing on the flagship age group of 14-16, this drop suggests that, considering the population structure of Korean males, approximately one million fewer circumcision operations have been performed in the last decade relative to the case of non-decline. This decline is strongly correlated with the information available through internet, newspapers, lectures, books, and television: within the circumcised population, both the patients and their parents had less prior knowledge regarding circumcision, other than information obtained from person to person by oral communication. Within the uncircumcised population, the prior knowledge was far greater, suggesting that information discouraging circumcision played an important role., Conclusion: South Korean male circumcision is likely to be undergoing a steep decline. The cause for this decline seems to be the increase in information available on the pros and cons of circumcision.

As the science demonstrating strong evidence for voluntary medical male circumcision (VMMC) for HIV prevention has evolved, the President's Emergency Plan for AIDS Relief (PEPFAR) has collaborated with international agencies, donors, and partner country governments supporting VMMC programming. Mathematical models forecast that quickly reaching a large number of uncircumcised men with VMMC in strategically chosen populations may dramatically reduce community-level HIV incidence and save billions of dollars in HIV care and treatment costs. Because VMMC is a 1-time procedure that confers life-long partial protection against HIV, programs for adult men are vital short-term investments with long-term benefits. VMMC also provides a unique opportunity to reach boys and men with HIV testing and counseling services and referrals for other HIV services, including treatment. After formal recommendations by WHO in 2007, priority countries have pursued expansion of VMMC. More than 1 million males have received VMMC thus far, with the most notable successes coming from Kenya's Nyanza Province. However, a myriad of necessary cultural, political, and ethical considerations have moderated the pace of overall success. Because many millions more uncircumcised men would benefit from VMMC services now, US President Barack Obama committed PEPFAR to provide 4.7 million males with VMMC by 2014. Innovative circumcision methods-such as medical devices that remove the foreskin without injected anesthesia and/or sutures-are being rigorously evaluated. Incorporation of safe innovations into surgical VMMC programs may provide the opportunity to reach more men more quickly with services and dramatically reduce HIV incidence for all.

Objective: To evaluate the epidemiological factors associated to medical circumcision, based on data from the Brazilian public health system., Methods: Using the Unified Health System public database between 1984 and 2010, hospital admissions associated with surgical treatment of phimosis were searched. A total of 668,818 men admitted to public hospitals who underwent circumcision were identified and included in the present study., Results: A mean±standard deviation of 47.8±13.4 circumcisions/100,000 men/year was performed through the Unified Health System for medical reasons. During the 27-year period evaluated, 1.3% of the male population required circumcision for medical reasons. Total number of circumcisions and circumcision rate increased in childhood, declined progressively after 5 years of age and rose again progressively after the sixth decade of life. In the regions of the country with better access to healthcare, 5.8% of boys aged 1 to 9 years old required circumcisions. From 1992 to 2010 there were 63 deaths associated with circumcisions (mortality rate of 0.013%)., Conclusion: In conclusion, yearly circumcision rates could be estimated in Brazil, and a very low mortality rate was associated with this procedures. Circumcision is mostly performed in children in the first decade of life and a second peak of incidence of penile foreskin diseases occurs after the sixth decade of life, when circumcision is progressively performed again.

The publication of three recent studies showing that circumcision of adult, African, heterosexual men reduces their risk for acquiring human immunodeficiency virus infection and other sexually transmitted infections has stimulated interest in the practice of routine newborn male circumcision (NMC) and the benefits it might confer for HIV prevention. In the United States, rates of in-hospital NMC increased from 48.3% during 1988-1991 to 61.1% during 1997-2000. To monitor trends in in-hospital NMC during 1999-2010, CDC used three independent data sources (the National Hospital Discharge Survey [NHDS] from the National Center for Health Statistics, the Nationwide Inpatient Sample [NIS] from the Agency for Healthcare Research and Quality, and the Charge Data Master [CDM] from SDIHealth) to estimate rates of NMC. Each system collects discharge data on inpatient hospitalization.

There is now grade 1 evidence that male circumcision (MC) reduces the risk of a man acquiring HIV. Modelling studies indicate MC could in the next 10 years save up to 2 million lives in those African countries with high HIV prevalence. Several African countries are now scaling up public health MC programmes. The most effective immediate public health MC programmes in Africa will need to target 18-20 years old men. In the longer term there is a need for infant circumcision programmes. In order to implement more widespread MC there is a need to make the surgical procedures as simple as possible so that safe operations can be performed by paramedical staff. The WHO Manual of Male Circumcision under local anaesthetic was written with these objectives in mind. Included in the manual are three adult techniques and four paediatric procedures. The adult procedures are the dorsal slit, the forceps guided and the sleeve resection methods. Paediatric methods included are the plastibell technique, the Mogen and Gomco shield method and a standard surgical dorsal slit procedure. Each method is described in a step by step manner with photographic and line drawing illustrations. In addition to the WHO manual of surgical technique a teaching course has been developed and using this course it has been possible in one week to train a circumcision surgeon who has had no or minimal previous surgical experience. Further scaling will require training of circumcision surgeons, monitoring performance, training the trainer workshops as well as advocacy at national, international and government meetings. In addition to proceeding with standardised methods work is in progress to assess novel techniques in adults such as stay on ring devices and policies are being formulated as to how to assess new devices. Also work is in progress to explore efficiencies in surgical processing by task sharing. Proper informed consent and safety remain paramount and great care has to be taken as programmes in Africa scale up. In continental China where the HIV epidemic is at a much earlier stage there may be a case for considering infant circumcision but great care will be needed to ensure that there is no harm.

Purpose: Studies undertaken in England and Scotland have identified a decrease in the number of circumcision operations being performed during childhood. The aims of this study were two-fold. Firstly, to determine the trend in circumcision operations performed in boys in Northern Ireland over a ten year period. Secondly, to compare the number of operations performed by paediatric surgeons with the number performed by general surgeons over the same period., Method: Data were collected from the Northern Ireland Department of Health and Social Services and Public Safety. A retrospective analysis was conducted of the number of circumcisions performed in boys aged between 0 and 13 years for the year beginning 1(st) September 1991 to the 1(st) of September 1992 and for the year beginning 1(st) September 2001 until the 1(st) of September 2002., Results: 769 circumcisions were performed in the year 1991 to 1992 compared with 264 in the year 2001 to 2002, representing a 66% decrease. In the ten year study period, the number of circumcisions performed by general surgeons fell by 71% whilst specialist paediatric surgeons performed 56% less., Conclusions: The decrease in rates of circumcision in boys aged 0 to 13 years in Northern Ireland is consistent with trends in the remainder of the United Kingdom. The results also suggest a greater decrease in the proportion of circumcisions being performed by general surgeons in district general hospitals compared to those performed by paediatric surgeons.

People who use and abuse alcohol and other drugs are an important population to target for HIV prevention because they are more likely to engage in sexual behaviors that increase their likelihood of acquiring or transmitting HIV. A variety of biomedical approaches to HIV prevention have been evaluated or currently are being studied. These approaches include an anti-HIV vaccine; topical protection treatments; and additional biomedical and barrier approaches, such as controlling sexually transmitted diseases, male circumcision, diaphragm use, and substance abuse treatment. The article also reviews topical versus oral antiretrovirals to prevent HIV transmission, antiretroviral treatment as prevention, and the role of alcohol and other drug use in HIV prevention.

Ritual circumcision, an ancient tradition with deep religious significance, is practiced by many cultures including those of the Jewish faith. As with any surgical procedure, there are some risks involved. Parents who choose to have their child circumcised in a ritual manner would benefit from the teaching that an informed nurse could provide in order to make an informed choice.

Nonmedical circumcision can no longer be considered routine in a new era of children's rights and more careful scrutiny of the medical necessity of surgical procedures. Although the minor procedure has been practised for centuries, custom and cultural factors may have had greater influence on the incidence of circumcision than the prevalence of problems such as penile cancer and urinary-tract infection that it was thought to prevent.