Male Circumcision And HIV Prevention, Munich, Germany 2nd April 2007

Main Category: HIV / AIDS
Also Included In: Urology / Nephrology;  Men's health;  Sexual Health / STDs
Article Date: 02 Apr 2007 - 9:00 PDT

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Male circumcision (MC) markedly decreases the acquisition of HIV infection, the major epidemic of our time. This is the first biological intervention shown to prevent HIV infection and will not depend upon continuing behaviour change to give protection. In 1986, five years after the description of AIDS, the first article suggesting that male circumcision is associated with lower risk of human immunodeficiency virus (HIV) infection was published. During the following 15 years, different studies - almost exclusively from sub-Saharan Africa, which quickly became the centre of HIV epidemic - increasingly supported this hypothesis. For example, tribes and other defined populations with low prevalence of MC had high prevalence of HIV infection, suggesting a correlation between MC and HIV prevention.

Despite that, there was still uncertainty among many scientists and public health scientific societies, mainly due to the fear that circumcised men have different (safer) sexual practices than men who are not, and that this and not male circumcision led to lower rates of HIV infection in circumcised men and in populations where circumcision is common. To eliminate this concern, three specifically designed trials were carried out.

In 2005, the results of the first trial showed a 60% protective effect against HIV infection among the men who were circumcised (Bertran Auvert and colleagues, PLoS Med. 2005;2:e209). The study has been conducted on the behalf of the South African National Institute for Communicable Diseases (Johannesburg) and the Institut National de la Santé et de la Recherche Médicale (ANRS Paris, France), involving 3,274 men who were randomized to receive circumcision or not. The subjects were followed over a mean period of 18.1 months, and the trial was stopped prematurely because of the high efficacy observed among circumcised patients.

In February 2007, the second and third studies found a protective effect of 53% and 51% respectively in men who were circumcised, compared to those who were not (Robert Bailey and colleagues, Lancet 2007; 369:643-56 - Ronald Gray and colleagues, Lancet. 2007; 369:657-66). The second trial enrolled 2,784 men and was carried out on the behalf of the U.S. National Institutes of Health and the Canadian Institute for Health Research, while the third study, also sponsored by the National Institutes of Health, randomised 4,996 men. Each of these trials was also stopped prematurely on 12 December 2006, due to an extremely high efficacy rate. The findings of the studies are similar, and remarkably consistent with the protective effect (58% on average) found in a systematic review of observational studies available in medical literature.

"Current data show that circumcision of adult men results in an approximately 60% reduction in acquisition of HIV infection", said Dr. George Schmid (Dept. of HIV / AIDS, World Health Organization, Geneva, Switzerland).

About 30% of men are estimated to be circumcised worldwide, although this rate is still less than 20% in Europe. In European countries, MC is uncommon, but also the prevalence of HIV is lower than Africa. Therefore, encouraging male circumcision in Europe is unlikely to be a reasonable measure for HIV prevention purposes. However, different studies show the existence of additional benefits provided by MC, such as the reduction of urinary tract infections in infants and prevention of penile cancer. Circumcision in the neonatal period has beneficial effects other than HIV prevention.

Is male circumcision a reasonable mean of HIV prevention in the developing world?

Surprising to some, multiple studies have consistently shown that populations which do not traditionally circumcise their children or young adults will readily accept MC. In 13 studies carried out in sub-Saharan Africa, 65% of men were willing to be circumcised and 69% of women favoured MC for their male partners. Improved hygiene, sexual satisfaction, and partial protection from HIV are cited as principal reasons. The widespread implementation of MC in Southern sub-Saharan Africa, where prevalence of MC is generally low and HIV is very common, could prevent 2,000,000 infections over a 10-year period. While it is unclear if a circumcised man who is HIV-positive is less likely to transmit HIV to a woman than if he is not circumcised, women in general would benefit from increasing rates of male circumcision because fewer men would become infected with HIV. Male circumcision is also a cost-effective intervention, quite competitive in cost with other proven means of preventing HIV infection.

Male circumcision does not offer a complete protection against HIV infection. Other behavioural prevention measures must be maintained. Men may adopt risky sexual behaviours following circumcision, believing that they are protected against acquiring HIV infection ("risk compensation" phenomenon). Men opting for MC procedure and their partners should be carefully counseled on the need to adopt other HIV preventive measures. Counseling is necessary to prevent circumcised men developing a false sense of protection and engaging in high risk behaviors that could reverse the partial protection provided by circumcision. "This is perhaps the biggest risk related to the promotion of MC as an HIV preventive method", pointed out Prof. Schmid.

WHO recommends that countries - where the incidence of heterosexually acquired HIV infection is high and the diffusion of male circumcision is low - urgently consider implementing the access to male circumcision services as a priority. WHO examined all the available data about the effectiveness of male circumcision in preventing HIV infection, and recognized MC as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men. "Adequate resources should be rapidly mobilized to support the expansion of safe male circumcision services within the context of moving towards universal access to comprehensive HIV prevention, treatment and care", concluded Prof. Schmid.

17th European Congress of Clinical Microbiology and Infectious Diseases
and 25th International Congress of Chemotherapy
Munich/Germany, 31 March - 3 April 2007
www.eccmid-icc.org

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