Circumcision and HIV

Male circumcision reduces the risk of HIV transmission from women to men.[1][2] In 2011, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions.[3][4][5] The United States Centers for Disease Control and Prevention (CDC) states that circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner.[6]

This article is about male circumcision and HIV. For female circumcision and HIV, see Female genital cutting § HIV.

A meta-analysis of data from fifteen observational studies of men who have sex with men found "insufficient evidence that male circumcision protects against HIV infection or other STIs".[7] The CDC concludes "There are as yet no convincing data to help determine whether male circumcision will have any effect on HIV risk for men who engage in anal sex with either a female or male partner, as either the insertive or receptive partner."[6]

Recommendations

In 2007, the WHO reviewed the totality of evidence concerning male circumcision and HIV, and issued the following joint recommendations with UNAIDS.[5]

  • Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
  • Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.[4]

Kim Dickson, coordinator of the working group that authored the report, commented:

  • Male circumcision "would have greatest impact" in countries where the HIV infection rate among heterosexual males is greater than 15 percent and fewer than 20 percent of males are circumcised.
  • The procedure must be done by a trained health care professional.
  • Protection is incomplete. Men must continue to use condoms and limit the number of sexual partners.
  • Newly circumcised men should abstain from sex for at least six weeks.[8]

The World Health Organization (WHO) said: "Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counselling."[9]

Men who have sex with men

A 2008 meta-analysis of gay and bisexual men (52% circumcised) found that the rate of HIV infection was not lower among men who were circumcised.[7] For men who engaged primarily in insertive anal sex, no effect was observed. Observational studies included in the meta-analysis that were conducted prior to the introduction of highly active antiretroviral therapy in 1996 demonstrated a protective effect for circumcised MSM against HIV infection.[7]

A 2017 and 2011 review found some evidence that circumcision was protective in MSM.[10][11]

Programs

In 2011, UNAIDS prioritized 14 high HIV prevalence countries in eastern and southern Africa, with a goal of circumcising 80% of men (20.8 million) by the end of 2016.[12] In parallel, WHO developed a Framework for evaluating new, simpler circumcision techniques, which gave impetus to the development of two new devices (Prepex and Shang Ring) that are currently being scaled-up in the 14 high HIV prevalence countries.[13] Overall, 14.5 million males were circumcised as of the end of 2016.[14] UNAIDS' Fast-Track Plan for ending the AIDS Epidemic by 2030 calls for an additional 25 million circumcisions in these high-priority countries by 2020, which will require to 5 million procedures per year, nearly double the current rate.[15] To reach this goal, UNAIDS is counting on advances in circumcision techniques.[13]

Newly circumcised men must refrain from sexual activity until the wounds are fully healed. Some circumcised men might have a false sense of security that could lead to increased risky sexual behavior.[16]

Mechanism of action

Experimental evidence supports the theory that Langerhans cells (part of the human immune system) in foreskin may be a source of entry for the HIV virus.[17] Excising the foreskin removes a main entry point for the HIV virus.

History
Map showing prevalence of HIV/AIDS in Africa based on 1999–2001 figures

Hypotheses and epidemiologic studies

Valiere Alcena, in a 1986 letter to the New York State Journal of Medicine, noted that low rates of circumcision in parts of Africa had been linked to the high rate of HIV infection.[18][19] Aaron J. Fink several months later also proposed that circumcision could have a preventive role when the New England Journal of Medicine published his letter, "A possible explanation for heterosexual male infection with AIDS," in October, 1986.[20] Alcena later said that Fink had expropriated his ideas.[18]

By 2000, over 40 epidemiological studies had been conducted to investigate the relationship between circumcision and HIV infection.[21] A meta-analysis conducted by researchers at the London School of Hygiene & Tropical Medicine examined 27 studies of circumcision and HIV in sub-Saharan Africa and concluded that these showed circumcision to be "associated with a significantly reduced risk of HIV infection" that could form part of a useful public health strategy.[22]

A 2005 review of 37 observational studies expressed reservations about the conclusion because of possible confounding factors, since they were all observational (and not experimental) studies. The authors stated that three randomized controlled trials then underway in Africa would provide "essential evidence" about the effects of circumcision on preventing HIV.[23]

Randomized controlled trials in Africa

Three randomized controlled trials took place in South Africa,[24] Kenya[25] and Uganda.[26] Southern and eastern Africa has the highest rate of adult HIV infection in the world.

The first trial to publish, in 2005, was that from South Africa, named ANRS-1265 or the "Orange Farm trial".[24] After 18 months, there were 20 HIV infections (incidence rate = 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, a finding which led to suspension of the trial on ethical grounds. The other two African trials were also halted on ethical grounds, again because those in the circumcised group had a lower rate of new HIV infections than the control group.

The Orange Farm trial report concluded that circumcision offered protection against HIV infection "equivalent to what a vaccine of high efficacy would have achieved".[24]

A 2009 systematic review from the Cochrane Collaboration included these 3 randomized controlled trials. It provided strong evidence that medical male circumcision reduces the acquisition of HIV by heterosexual men by about 60%, while adverse events are rare, and recommended inclusion of male circumcision into current HIV prevention guidelines.[27] Sites for these studies were chosen specifically because of the high rates of HIVin those geographic areas.

Society and culture

The prevalence of circumcision varies across Africa.[28][29] Studies were conducted to assess the acceptability of promoting circumcision; in 2007, country consultations and planning to scale up male circumcision programmes took place in Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Uganda, Tanzania, Zambia and Zimbabwe.[30]

The UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention found "large benefits" of circumcision in settings with high HIV prevalence and low circumcision prevalence. The Group estimated "one HIV infection being averted for every five to 15 male circumcisions performed, and costs to avert one HIV infection ranging from US$150 to US$900 using a 10-y time horizon".[31] The World Health Organisation states that circumcision is "highly cost-effective" in comparison to other HIV interventions when data from the South African trial are used, but less cost-effective when data from the Ugandan trial are used.[3]

See also

References
  1. Krieger JN (February 2012). "Male circumcision and HIV infection risk". World Journal of Urology (Review). 30 (1): 3–13. doi:10.1007/s00345-011-0696-x. PMID 21590467.
  2. Siegfried N, Muller M, Deeks JJ, Volmink J (April 2009). Siegfried N (ed.). "Male circumcision for prevention of heterosexual acquisition of HIV in men". The Cochrane Database of Systematic Reviews (Review) (2): CD003362. doi:10.1002/14651858.CD003362.pub2. PMID 19370585.
  3. "Male circumcision: Global trends and determinants of prevalence, safety and acceptability" (PDF). World Health Organization. 2007. Retrieved 2009-03-04.
  4. "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" (PDF). World Health Organization. March 28, 2007. Retrieved 2007-08-13. Cite journal requires |journal= (help)
  5. "WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention". World Health Organisation. March 2007.
  6. "Male Circumcision". Centers for Disease Control and Prevention. 2013. Archived from the original on 2013-12-21.
  7. Millett GA, Flores SA, Marks G, Reed JB, Herbst JH (October 2008). "Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis". JAMA (Meta-analysis). 300 (14): 1674–84. doi:10.1001/jama.300.14.1674. PMID 18840841.
  8. "WHO hails circumcision as vital in HIV fight". New Scientist. March 28, 2007. Retrieved 2008-09-18.
  9. "WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk". World Health Organization. February 23, 2007. Retrieved 2007-02-23.
  10. Sharma SC, Raison N, Khan S, Shabbir M, Dasgupta P, Ahmed K (April 2018). "Male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition: a meta-analysis". BJU International. 121 (4): 515–526. doi:10.1111/bju.14102. PMID 29232046.
  11. Wiysonge CS, Kongnyuy EJ, Shey M, Muula AS, Navti OB, Akl EA, Lo YR (June 2011). "Male circumcision for prevention of homosexual acquisition of HIV in men". The Cochrane Database of Systematic Reviews (6): CD007496. doi:10.1002/14651858.CD007496.pub2. PMID 21678366.
  12. Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa, 2012-2016. WHO. 2014.
  13. Framework for Clinical Evaluation of Devices for Adult Male Circumcision (PDF) (Report). WHO. 2007. Archived from the original (PDF) on 2011-11-14. Retrieved 2017-08-20.
  14. Voluntary medical male circumcision for HIV prevention in 14 priority countries in eastern and southern Africa, Progress brief (PDF) (Report). WHO. 2017.
  15. "Voluntary medical male circumcision: a core campaign to reach the Fast-Track Targets". UNAIDS. 2016.
  16. Kalichman S, Eaton L, Pinkerton S (March 2007). "Circumcision for HIV prevention: failure to fully account for behavioral risk compensation". PLoS Medicine. 4 (3): e138, author reply e146. doi:10.1371/journal.pmed.0040138. PMC 1831748. PMID 17388676.
  17. Weiss HA, Dickson KE, Agot K, Hankins CA (October 2010). "Male circumcision for HIV prevention: current research and programmatic issues". AIDS (Randomized controlled trial). 24 Suppl 4: S61–9. doi:10.1097/01.aids.0000390708.66136.f4. PMC 4233247. PMID 21042054.
  18. Alcena V (19 October 2006). "AIDS in Third World countries". PLOS Medicine (Comment).
  19. Alcena V (August 1986). "AIDS in Third World countries". New York State Journal of Medicine (Letter). 86 (8): 446.
  20. Fink AJ (October 1986). "A possible explanation for heterosexual male infection with AIDS". The New England Journal of Medicine (Letter). 315 (18): 1167. doi:10.1056/nejm198610303151818. PMID 3762636.
  21. Szabo R, Short RV (June 2000). "How does male circumcision protect against HIV infection?". BMJ (Review). 320 (7249): 1592–4. doi:10.1136/bmj.320.7249.1592. PMC 1127372. PMID 10845974.
  22. Weiss HA, Quigley MA, Hayes RJ (October 2000). "Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis" (PDF). AIDS (Meta-analysis). 14 (15): 2361–70. doi:10.1097/00002030-200010200-00018. PMID 11089625.
  23. Siegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, Walker S, Williamson P (March 2005). "HIV and male circumcision--a systematic review with assessment of the quality of studies". The Lancet. Infectious Diseases (Review). 5 (3): 165–73. doi:10.1016/S1473-3099(05)01309-5. PMID 15766651.
  24. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A (November 2005). "Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial". PLoS Medicine (Randomized controlled trial). 2 (11): e298. doi:10.1371/journal.pmed.0020298. PMC 1262556. PMID 16231970.
  25. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CF, Campbell RT, Ndinya-Achola JO (February 2007). "Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial". Lancet (Randomized controlled trial). 369 (9562): 643–56. doi:10.1016/S0140-6736(07)60312-2. PMID 17321310.
  26. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH, Chaudhary MA, Chen MZ, Sewankambo NK, Wabwire-Mangen F, Bacon MC, Williams CF, Opendi P, Reynolds SJ, Laeyendecker O, Quinn TC, Wawer MJ (February 2007). "Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial". Lancet (Randomized controlled trial). 369 (9562): 657–66. doi:10.1016/S0140-6736(07)60313-4. PMID 17321311.
  27. Siegfried N, Muller M, Deeks JJ, Volmink J (April 2009). "Male circumcision for prevention of heterosexual acquisition of HIV in men". The Cochrane Database of Systematic Reviews (2): CD003362. doi:10.1002/14651858.CD003362.pub2. PMID 19370585.
  28. Marck J (1997). "Aspects of male circumcision in sub-equatorial African culture history" (PDF). Health Transition Review (Review). 7 Suppl (Supplement): 337–60. PMID 10173099. Archived from the original (PDF) on 2008-09-06. Retrieved 2009-03-23.
  29. "Male circumcision: global trends and determinants of prevalence, safety and acceptability" (PDF). Who/Unaids. 2007. Retrieved 2008-10-16.
  30. "Towards Universal access: Scaling up priority HIV/AIDS interventions in the health sector" (PDF). Who/Unaids/Unicef: 75. 2008. Retrieved 2008-10-16.
  31. UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention (September 2009). "Male circumcision for HIV prevention in high HIV prevalence settings: what can mathematical modelling contribute to informed decision making?". PLoS Medicine (Review). 6 (9): e1000109. doi:10.1371/journal.pmed.1000109. PMC 2731851. PMID 19901974.

Further reading
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