Circumcision and HIV

The relationship between circumcision and HIV has been researched since the late 1980s. Voluntary male circumcision reduces the risk of HIV transmission from HIV+ 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.

Efficacy

Heterosexual couples

A 2009 systematic review from the Cochrane Collaboration reported 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 in HIV prevention guidelines.[6]

The number needed to treat, to prevent one HIV infection during ten years, is between five and fifteen men. 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 fifteen male circumcisions performed, and costs to avert one HIV infection ranging from US$150 to US$900 using a 10-y time horizon".[7] 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]

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.[8] 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 men who have sex with men (MSM) against HIV infection.[8]

Reviews in 2011[9] and 2018 found some evidence that circumcision was protective in MSM.[10]

A 2019 meta-analysis of MSM found circumcision was associated with a 42% reduction in the odds of HIV in low and middle income countries, but not in high income countries.[8] The CDC stated in 2013: "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."[11]

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.[12]

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."[13]

Aside from circumcision, there are other ways to prevent HIV. In developed countries, other factors, such as behavioral factors, may have more of an effect on HIV prevention than circumcision. Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, some medical organizations in developed countries, including the American Academy of Family Physicians and the Royal Dutch Medical Association, have questioned the applicability of those studies to their countries' public health policy and have not included circumcision in their HIV prevention recommendations.[14][15]

Process

The WHO recommends voluntary medical male circumcision, as opposed to circumcision by traditional healers or untrained individuals.

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

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] 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 all studies to date had been observational as opposed to randomized controlled trials. 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]

In 2009, a Cochrane review which included the results of the three 2000s trials found "strong" evidence that the acquisition of HIV by a man during sex with a woman was decreased by 38% and 66% over 24 months if the man was circumcised. The review also found a low incidence of adverse effects from circumcision in the trials reviewed.[24] In 2020, a review including post-study follow up from the three randomized controlled trials, as well as newer observational studies, found a 59% reduction in HIV incidence across the three randomized controlled trials, as well as continued protection for up to 6 years after the studies began.[25]

In 2011, a Cochrane review of observational studies found that circumcision may provide some protection for men during insertive anal sex with men, but noted that there have been no randomized controlled trials examining men who have sex with men and circumcision and that the evidence is not as strong as for heterosexual intercourse.[26]

Society and culture

The prevalence of circumcision varies across Africa.[27][28] 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, Eswatini, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Uganda, Tanzania, Zambia and Zimbabwe.[29]

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.[30] 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.[31] Overall, 14.5 million males were circumcised as of the end of 2016.[32]

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.[33] To reach this goal, UNAIDS is counting on advances in circumcision techniques.[31]

See also

References
  1. Farley TM, Samuelson J, Grabowski MK, Ameyan W, Gray RH, Baggaley R (June 2020). "Impact of male circumcision on risk of HIV infection in men in a changing epidemic context - systematic review and meta-analysis". Journal of the International AIDS Society. 23 (6): e25490. doi:10.1002/jia2.25490. PMC 7303540. PMID 32558344.
  2. Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J (2018). Harrison's Principles of Internal Medicine (20th ed.). New York: McGraw-Hill Education. p. 1400. ISBN 978-1-259-64403-0. OCLC 1029074059.
  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) (Report). World Health Organization. March 28, 2007. Retrieved 2007-08-13.
  5. "WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention". World Health Organisation. March 2007.
  6. 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 (Review) (2): CD003362. doi:10.1002/14651858.CD003362.pub2. PMID 19370585.
  7. Hankins C, Hargrove J, Williams B, Abu Raddad L, Auvert B, Bollinger L, et al. (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.
  8. Yuan T, Fitzpatrick T, Ko NY, Cai Y, Chen Y, Zhao J, et al. (April 2019). "Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data". The Lancet. Global Health. 7 (4): e436–e447. doi:10.1016/S2214-109X(18)30567-9. PMID 30879508.
  9. 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.
  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. "Male Circumcision". Centers for Disease Control and Prevention. 2013. Archived from the original on 2013-12-21.
  12. "WHO hails circumcision as vital in HIV fight". New Scientist. March 28, 2007. Retrieved 2008-09-18.
  13. "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.
  14. "Non-therapeutic circumcision of male minors - KNMG Viewpoint".
  15. "Neonatal Circumcision - AAFP Policy".
  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 (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). 86 (8): 446. PMID 3463895.
  19. Alcena V (August 1986). "AIDS in Third World countries". New York State Journal of Medicine (Letter). 86 (8): 446. PMID 3463895.
  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". AIDS (Meta-analysis). 14 (15): 2361–70. doi:10.1097/00002030-200010200-00018. PMID 11089625. S2CID 21857086. Archived from the original (PDF) on 2014-01-10.
  23. Siegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, et al. (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. Siegfried, Nandi; Muller, Martie; Deeks, Jonathan J; Volmink, Jimmy (15 April 2009). "Male circumcision for prevention of heterosexual acquisition of HIV in men". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD003362.pub2.
  25. Farley, Timothy MM; Samuelson, Julia; Grabowski, M Kate; Ameyan, Wole; Gray, Ronald H; Baggaley, Rachel (June 2020). "Impact of male circumcision on risk of HIV infection in men in a changing epidemic context – systematic review and meta‐analysis". Journal of the International AIDS Society. 23 (6). doi:10.1002/jia2.25490.
  26. Wiysonge, Charles Shey; Kongnyuy, Eugene J; Shey, Muki; Muula, Adamson S; Navti, Osric B; Akl, Elie A; Lo, Ying-Ru (15 June 2011). "Male circumcision for prevention of homosexual acquisition of HIV in men". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD007496.pub2.
  27. Marck J (1997). "Aspects of male circumcision in sub-equatorial African culture history" (PDF). Health Transition Review (Review). 7 Suppl (Suppl): 337–60. PMID 10173099. Archived from the original (PDF) on 2008-09-06. Retrieved 2009-03-23.
  28. "Male circumcision: global trends and determinants of prevalence, safety and acceptability" (PDF). Who/Unaids. 2007. Retrieved 2008-10-16.
  29. "Towards Universal access: Scaling up priority HIV/AIDS interventions in the health sector" (PDF). Who/Unaids/Unicef: 75. 2008. Retrieved 2008-10-16.
  30. 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.
  31. 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.
  32. Voluntary medical male circumcision for HIV prevention in 14 priority countries in eastern and southern Africa, Progress brief (PDF) (Report). WHO. 2017.
  33. "Voluntary medical male circumcision: a core campaign to reach the Fast-Track Targets". UNAIDS. 2016.

Further reading
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