HIV and Male Circumcision

Definition: Male circumcision is the surgical removal of the foreskin from the penis.

What's the Problem?

At the end of 2007, approximately 33 million people were living with HIV infection. Sub-Saharan Africa remains the region most heavily affected by HIV, accounting for 67% of all people living with HIV and for 75% of AIDS deaths in 2007. Women account for half of all people living with HIV worldwide, and for nearly 60% of HIV infections in sub-Saharan Africa. In 2007, there were 2.7 million new HIV infections and 2 million HIV-related deaths, with 2 million children younger than 15 years were living with the virus (1). In addition, more than 14 million children have lost one or both parents to HIV/ AIDS (2).

HIV is a virus that suppresses the immune system of an infected person. It targets and destroys particular white blood cells (CD4 cells, a type of T cell) that the immune system must have to fight disease. The virus is transmitted from person to person through contact with HIV-infected blood or other infected bodily fluids such as semen.

HIV can remain in the body for over ten years without causing outward signs of illness. However, as HIV-related immune destruction progresses, symptoms may include enlarged lymph glands, depression, fatigue, fever, yeast infections of the mouth and vagina, night sweats, diarrhea, loss of appetite, loss of memory, and weight loss. The HIV-infected person is also more susceptible to illnesses that usually do not affect healthy people. These are called opportunistic infections, meaning that they take advantage of a weakened immune system. Several characteristic opportunistic infections are PCP (Pneumocystis carinii pneumonia), yeast infections of the esophagus, TB (tuberculosis), Kaposi's sarcoma, and CMV (cytomegalovirus). An HIV-infected person is considered to have AIDS when his or her CD4 cell count falls below 200/mL. AIDS is also characterized by the appearance of opportunistic infections. In the majority of cases, the absence of treatment once AIDS is acquired leads to death.

Can It Be Prevented?

Yes, the risk for sexual transmission of HIV can be managed through abstinence, or mutual monogamy between two people who know they are HIV-negative. Risk can be reduced if the number of sex partners is reduced, and condoms are used correctly and consistently.

Importantly, male circumcision can be protective against HIV transmission through sexual intercourse. Circumcision significantly reduces a man's risk of contracting HIV from an HIV-positive woman during penile-vaginal sex, as shown by several types of research. A review of 28 studies of male circumcision, as it is related to heterosexual transmission of HIV in Africa, showed that the relative risk for becoming infected with HIV was 44% lower in circumcised men. In addition, male circumcision has been associated with protection against other sexually transmitted infections such as syphilis and chancroid (3).

Biologically, there are several possible reasons why circumcised men are less likely to contract HIV: first, the foreskin is moist and helps the virus survive and reproduce. When the foreskin is removed, this moist environment is eliminated as well; second, the foreskin is not keratinized and thus may have greater susceptibility to tears during intercourse, providing a portal of entry for pathogens, including HIV (4); and third, the foreskin has a high concentration of target cells to which the virus can attach and cause infection.

The Bottom Line

Male circumcision has been found to significantly reduce the circumcised male's chance of contracting HIV and other sexually transmitted infections from an infected female. However, male circumcision confers only partial protection and should be considered as only one of several other prevention measures.

Case Examples

1. Doctor POV:
   Joseph Mpiri is a doctor in a hospital in Rwanda. For the past few weeks, he has had a big dilemma. There has been a lot of talk on television and on the radio about how circumcised men may be less prone to becoming infected with HIV, and ever since, there has been a dramatic increase in demand for circumcision in his hospital. He is concerned that young men who get circumcised are doing it to avoid using a condom during sex. This morning, he convenes the doctors and nurses in the section dealing with circumcision for a special meeting on the issue. He hopes they will agree on simple messages for their patients on the need to still have safe sex with a condom even after the surgical procedure (5).
2. Patient POV:
   Sebahive, a Rwandan man in his early thirties, is contemplating circumcision. Last month, he heard on television how new research found that circumcised men were less prone to becoming infected with HIV. He thought this would be great because he could finally sleep with his girlfriend without using a condom. He also heard from many of his male friends that being circumcised gives you more pleasure and more energy when having sex. Very excited about all of this, he goes to the hospital to ask about the procedure. However, the nurse explains that circumcision is not a miracle solution for avoiding HIV infection, and that he would still need to use a condom during sex to avoid getting the virus. He is confused and wonders if it is really worth going through the surgery after all.