Male circumcision for HIV prevention: current research and programmatic issues

Abstract

Randomized controlled trials in sub-Saharan Africa have shown that adult male circumcision reduces the risk of HIV acquisition in men by about 60%. In this article, we review recent data on the association of male circumcision and HIV/sexually transmitted infection in men and women. This includes a summary of data showing some evidence of an effect of male circumcision against genital ulcer disease, HSV-2 infection, human papillomavirus and Trichomonas vaginalis, but not Chlamydia trachomatis or Neisseria gonorrhoea in men. Longitudinal studies among HIV discordant couples suggest that male circumcision may provide some direct long-term benefit to women, which may start after complete wound healing. Circumcision may also protect against HIV acquisition in men who have sex with men (MSM) and those who practice unprotected anal intercourse (either exclusively or predominantly), although these data are not consistent. To date, there is little evidence from the few studies available of either unsafe practices or reported increases in risky behaviour, or adverse changes in sexual satisfaction and function. As countries in southern and eastern Africa scale up services, operational research will likely be useful to iteratively improve programme delivery and impact while identifying the best methods of integrating safe male circumcision services into HIV prevention strategies and strengthening health systems.

The HIV Epidemic: High-Income Countries

“…Male circumcision is powerfully associated with reduced risk for HIV acquisition in both epidemiologic and experimental studies (Bongaarts et al 1989;Weiss et al 2000;Auvert et al 2005;Bailey et al 2007;Gray et al 2007;Sahasrabuddhe and Vermund 2007;Mills et al 2008;Siegfried et al 2009;Weiss et al 2010). Protection was more than 50% in three independent clinical trials from South Africa, Kenya, and Uganda.…”

CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants

“…There are several factors, which have to be considered when adopting findings from recent evidence as a basis for recommendation of neonatal circumcision in more developed countries [82][83][84][85][86][87]. The large sample size, magnitude of the effect, consistent results across the 3 trials and meta-analyses, and sound statistical methods to address…”

HIV Epidemiology and Prevention

“…In the 10 years thereafter, it could avert a further 3.7 million new infections and 2.7 million deaths, demonstrating the substantial public health benefits of male circumcision to lessen the transmission of HIV (Williams, et al, 2006). Many sub-Saharan African countries have begun taking steps to increase the availability of MMC services, with set targets of maximum coverage to be achieved over the next five years despite the concerns of risk compensation, the challenges of cultural and social acceptability, limited financial and human resources, poor infrastructure and systems for monitoring and evaluating circumcision programmes (Kim & Goldstein, 2009;Weiss, Dickson, Agot, & Hankins, 2010). Additionally, more research is needed to determine the side effects of poorly performed circumcision with a risk HIV acquisition from poorly healed procedures, serious bleeding, risk of cross infection and damage to the penis (Lagarde, Taljaard, Puren, & Auvert, 2009;Schackman, 2010).…”