Voluntary Medical Male Circumcision
1. Male circumcision reduces HIV acquisition for men and reduces the likelihood of transmission to HIV-negative women.
A Cochrane Review that reviewed Auvert et al., 2005, Bailey et al., 2007 and Gray et al., 2007 (below) found that based on these three randomized controlled trials in South Africa, Uganda and Kenya between 2002 and 2006, men had a relative risk reduction of acquiring HIV of 50% at twelve months and 54% at 24 months following circumcision. A meta-analysis of sexual behavior for Kenyan and Ugandan men found no significant differences between circumcised and uncircumcised men; however among South African men, there was a statistically significant increase in sexual contact for men who were circumcised at the 21-month visit. Medical male circumcision reduces the risk of HIV acquisition by heterosexual men by between 38% and 66%. “The background risk of HIV infection in the population should be considered in the decision to circumcise men” (Siegfried et al., 2009: 17). “Promotion of male circumcision at a country level must clearly present (male) circumcision as partly protective for the male partner and continue to advocate other prevention measures.”
A randomized controlled study from 2002 to 2004 of 3,274 young, sexually active, heterosexual men in South Africa found that with 18 months of follow-up, 60% fewer men who had been circumcised acquired HIV as compared to men who had not been circumcised. There were 20 men who acquired HIV among those who had been circumcised, an incidence rate of 0.85 per 100 person years and 49 men who acquired HIV among men who had not been circumcised, an incidence rate of 2.1 per 100 person years. Male circumcision was offered to the control group at the end of trial. At each of four visits, each participant was invited to a counseling session of 15 to 20 minutes delivered by a certified counselor about HIV. Condoms were provided. STIs were screened and treatment. No deaths occurred due to circumcision. Circumcision was conducted by general practitioners and resulted in a limited and reasonable number of adverse events.
A randomized controlled trial of 2,784 men aged 18 to 24 years in Kisumu, Kenya, with a follow up of 24 months found that 22 men who were circumcised acquired HIV compared to 47 men who had not been circumcised. The two-year HIV incidence was 2.1% in the circumcision group and 4.2% in the group of men who had not been circumcised. Circumcised men had a reduction in the risk of acquiring HIV of 53%. Adjusting for non-adherence to treatment and excluding four men who tested HIV-positive prior at enrollment in the study, the protective effect of circumcision was 60%. “Circumcision will be most effective if it is not perceived as a stand-alone procedure, but as one component of a full suite of HIV prevention and reproductive health services, including HIV testing and counseling, diagnosis and treatment of sexually transmitted infections, condom promotion, [and] behavioral change counseling and promotion….” (Bailey et al., 2007: 655).
A randomized trial in Rakai, Uganda with 4,996 uncircumcised HIV-negative men aged 15 to 49 years of age found that HIV incidence over 24 months was 0.66 cases per 100 person years among men who were circumcised and 1.33 cases per 100 person years among men who delayed circumcision for 24 months, with an estimated efficacy of 51%.
A study done in Eastern and Southern Africa found that male circumcision reduced HIV transmission between serodiscordant couples. A total of 3,297 serodiscordant couples were included in the prospective study. The HIV-positive partner was also infected with HSV-2. After the initial examination, uninfected partners had a quarterly visit consisting of a genital examination and an HIV test. Patients received risk-reduction counseling, quarterly syndromic STI treatment and no cost condoms. Plasma viral level of the infected partner was measured at enrollment, 3, 6, 12 months and at 24 months. The HIV-positive clients were interviewed every month on the number of coital acts with or without condoms, confirmed by their HIV-negative partner. HIV-positive serostatus was confirmed by Western blot if a rapid test was positive. Timing of infection was determined by PCR prior to seroconversion. The time of HIV infection was defined as the earlier positive PCR. Each confirmed transmission between the study partners was classified as “linked.” It was classified as “unlinked” if HIV was acquired from another sexual partner other than the study partner confirmed by genetic sequencing of plasma samples. Analysis was done only for linked transmissions. Sixty-seven percent of the HIV-positive partners were women. Thirty-four percent of the HIV-positive and 55% of the HIV-negative males were circumcised. Eighty-six linked transmissions occurred during the 24 months. Male circumcision decreased the risk of acquiring HIV by 47% by female HIV-negative sexual partners. For each 10-fold increase in plasma viral RNA, increased transmission by 2.9 fold was also observed.
A 2004 – 2008 prospective study in Kenya, Rwanda, South Africa, and Zambia found no increased risk, and potentially decreased risk, from male circumcision on male-to-female transmission of HIV-1 among 1,096 HIV-1 serodiscordant couples in which the HIV-1 seropositive partner was male. This effect was similar when restricted to the subset of HIV-1 transmission events confirmed by viral sequencing to have occurred within the partnership, after adjustment for male partner plasma HIV-1 concentrations, and when excluding follow-up time for male partners who initiated antiretroviral therapy. Physical examination at the time of study enrollment determined 374 (34%) male partners to be circumcised. During the median follow-up of 18 months, 64 female partners seroconverted to HIV-1, with 50 (78%) determined to be genetically linked within the partnership by viral sequencing analysis. The probability of HIV-1 acquisition was not statistically different for women whose partners became circumcised (21.7% at 24 months) compared with those whose partners remained uncircumcised (13.4%). Follow-up for HIV-1 seronegative female partners was also 18 months and a total of 1,685 person-years of follow-up were accrued. Prior to enrollment, all participants received an HIV-1 prevention package consisting of pre- and post-test counseling, risk reduction counseling (individual and couple), free condoms, and management of sexually transmitted infections (STIs) according to WHO guidelines.