HIV Prevention with Male Circumcision

Clinical trials and epidemiological studies indicate that the surgical removal of the foreskin from the penis—male circumcision—can reduce the risk of an HIV infection by about 60 percent in heterosexual men.^{[1][2] [3][4][5]}

This observation has important implications for public health and HIV prevention. Increasing access to male circumcision services could limit the spread of HIV in regions with a high prevalence of heterosexual HIV transmission and a low prevalence of male circumcision.

Prevention of HIV and Other Diseases

Circumcision protects against the acquisition of HIV among sexually active men for at least 42 months after surgical removal of the foreskin.^[6] The relative risk of HIV infection in these circumcised men corresponds to a protective effect of approximately 60 percent. Because circumcision does not confer a 100-percent protective effect, adult men who undergo the procedure are counseled to use condoms during sexual activity and to avoid high-risk sex practices.

Although circumcision protects men from acquiring HIV from their female partners, it does not protect women from acquiring the virus from their circumcised male partners.^[7] Also, circumcision does not appear to protect men who have sex with men (MSM) from acquiring HIV.^[8] Most HIV infections among MSM are due to receptive anal intercourse, so transmission occurs across rectal tissue, not penile tissue.

Research suggests that male circumcision also protects heterosexual men against the acquisition of other sexually transmitted infections (STIs), including high-risk human papillomavirus (HR-HPV),^[9] Trichomonas vaginalis (TV),^[10] and herpes simplex virus type 2 (HSV-2).^[11] These findings help to explain why women with circumcised partners have a reduced risk of acquiring HR-HPV and TV infections.

Also, HIV-positive men who have been circumcised have reduced rates of genitourinary disease.^[12]

How It Works

Several biological mechanisms have been proposed to explain how male circumcision may help to prevent HIV infections:

(1) Circumcision removes cells in the foreskin that may be especially vulnerable to HIV

(2) Removal of the foreskin toughens the underlying skin, which may make it more difficult for the virus to penetrate this area

(3) Removal of the foreskin may reduce the risk of acquiring sexually transmitted infections that cause ulcers that facilitate HIV transmission

(4) Sexual activity may cause abrasions or inflammation of the foreskin that facilitate the passage of HIV

Scientists do not yet know which, if any, of these mechanisms account for the preventive effects of male circumcision.

Side Effects

Male circumcision carries few health risks when it is performed by well-trained providers with adequate instruments in sterile clinical settings. The main complications of male circumcision in adults and adolescents include delayed healing, infection, and bleeding. The complication rates are between 2 percent and 10 percent.^[13] The risks of the procedure are lower for infants than they are for adults.

Scientific studies on the effects of circumcision on a man’s sexual performance and sexual satisfaction offer mixed results. Some reports suggest that the glans of the penis loses some sensitivity to fine touch.^[14] A study of 138 Korean men after circumcision found that 20 percent reported a decrease in sexual pleasure, whereas 8 percent reported an increase in sexual pleasure.^[15] However, several large studies of men who have undergone adult circumcision have found that most men experience an improvement or no change in sexual function.^[16] For example, in an HIV-prevention trial of 2,684 men in Kenya, more than half reported greater penile sensitivity and enhanced ease in reaching orgasm; few men reported that sexual function was worse after circumcision.^[17]

Public Policy

In response to the African studies, which showed that circumcision can reduce a man’s risk of acquiring HIV, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended an urgent expansion of male-circumcision services in countries or regions with a high prevalence (greater than 15 percent) of heterosexually transmitted HIV infections and with low rates of male circumcision.

Because male circumcision provides only partial protection, WHO/UNAIDS suggests that male circumcision should only be one element of a comprehensive HIV-prevention package, which includes HIV testing and counseling, treatment for STIs, promotion of safer sex practices, and the use of male and female condoms.

The results of the African studies have also raised questions about male circumcision practices in the United States.^[18] However, the calls for change in U.S. policy have been tempered by significant differences between the U.S. and sub-Saharan Africa. Unlike many parts of southern and eastern Africa, where only a fraction of the men are circumcised, nearly 80 percent of American men are already circumcised. Also, HIV spreads mainly through heterosexual intercourse in Africa; in the United States, a relatively small proportion of HIV infections in men are due to heterosexual intercourse. Most HIV infections among U.S. men are among men who have sex with men—a population that does not appear to experience the preventive benefits of male circumcision.^[19]

The U.S. Centers for Disease Control and Prevention is now considering male circumcision recommendations for the United States; the recommendations are expected at the end of 2009.

Currently, the American Academy of Pediatrics does not endorse routine circumcision for male infants.

External Links

AVAC (2007) A New Way to Protect Against HIV? Understanding the Results of Male Circumcision Studies for HIV Prevention. http://www.aidsvaccineclearinghouse.org/pdf/MC/understanding_the_results_mc_sept.2007.pdf

Clearinghouse on Male Circumcision for HIV Prevention http://www.malecircumcision.org

WHO/UNAIDS (2007) New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. http://www.unaids.org/en/KnowledgeCentre/Resources/PolicyGuidance/Techpolicies/Male_Cir_Technical_policies.asp

WHO. Male circumcision for HIV prevention. http://www.who.int/hiv/topics/malecircumcision/en/index.html

References

1. ↑ 1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Medicine. 2:e298. http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0020298
2. ↑ Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. (2007) Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 396:643–656.
3. ↑ Gray RH, et al. (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 369:657–666.
4. ↑ Bongaarts J, Reining P, Way P, Conant F. (1989) The relationship between male circumcision and HIV infection in African populations. AIDS 3:373–377.
5. ↑ Moses S, Bradley JE, Nagelkerke NJ, Ronald AR, Ndinya-Achola JO, Plummer FA. (1990) Geographical patterns of male circumcision practices in Africa: association with HIV seroprevalence. Int. J. Epidemiol. 19:693–697.
6. ↑ Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CG, Ndinya-Achola JO. (2008) The protective effect of male circumcision is sustained for at least 42 months; results from the Kisumu, Kenya trial. XVII International AIDS Conference, Mexico City, August 3–8, 2008.
7. ↑ Wawer MJ, Makumbi F, Kigozi G, Serwadda D, et al. (2009) Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. The Lancet 374(9685):229–237. http://dx.doi.org/10.1016/S0140-6736(09)60998-3
8. ↑ Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. (2008) Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 300(14):1674–84.
9. ↑ Auvert B, Sobngwi-Tambekou J, Cutler E, Nieuwoudt M, Lissouba P, Puren A, and Taljaard D. (2009) Effect of Male Circumcision on the Prevalence of High-Risk Human Papillomavirus in Young Men: Results of a Randomized Controlled Trial Conducted in Orange Farm, South Africa. The Journal of Infectious Diseases 199:14–19. http://dx.doi.org/10.1086/595566
10. ↑ Auvert B, Sobngwi-Tambekou J, Cutler E, Nieuwoudt M, Lissouba P, Puren A, and Taljaard D. (2009) Effect of Male Circumcision on the Prevalence of High-Risk Human Papillomavirus in Young Men: Results of a Randomized Controlled Trial Conducted in Orange Farm, South Africa. The Journal of Infectious Diseases 199:14–19. http://dx.doi.org/10.1086/595566
11. ↑ Joelle Sobngwi-Tambekou J, Taljaard D, Lissouba P, Zarca K, Puren A, Lagarde E, and Auvert B. (2009) Effect of HSV-2 Serostatus on Acquisition of HIV by Young Men: Results of a Longitudinal Study in Orange Farm, South Africa. The Journal of Infectious Diseases 199:958–964.
12. ↑ Wawer MJ, Makumbi F, Kigozi G, Serwadda D, et al. (2009) Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. The Lancet 374(9685):229–237. http://dx.doi.org/10.1016/S0140-6736(09)60998-3
13. ↑ Weiss HA, Halperin D, Bailey RC, et al. (2000) Male circumcision for HIV prevention; from evidence to action? AIDS 14(15):2361–2370. Ben-Chaim J, Livne PM, Binyamini J, et al. (2006) Complications of circumcision in Israel: a one-year multicenter survey. Israeli Med Assoc Journal 7(6):368–370.
14. ↑ Masood S, Patel HRH, Himpson RC, et al. (2004) Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly? Urol Int. 75:62–6.
15. ↑ Kim DS, Pang MG. (2007) The effect of male circumcision on sexuality. BJU International 99(3):619–22.
16. ↑ Kigozi G, Watya S, Poli CB, et al. (2008) The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU International 101(1):65–70. Krieger JN, Mehta SD, Bailey RC, et al. (Abstract only) Adult male circumcision: effects on sexual function and sexual satisfaction in Kisumu, Kenya. J Sex Med 2008;5(11):2610–22. Senkul T, Iseri C, Sen B, et al. (2004) Circumcision in adults: effect on sexual function. Urology 63:155–8. Collins S, Upshaw J, Rutchik S, et al. (2002) Effects of circumcision on male sexual function: debunking a myth? J Urol. 167:2111–2.
17. ↑ Kigozi G, Watya S, Poli CB, et al. (2008) The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU International 101(1):65–70.
18. ↑ Sullivan PS, Kilmarx PH, Peterman TA, Taylor AW, Nakashima AK, Kamb ML, Warner L, Mastro TD. Male circumcision for prevention of HIV transmission: what the new data mean for HIV prevention in the United States. PLoS Medicine. 2007;4(7):e223.
19. ↑ Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. (2008) Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 300(14):1674–84.