Circumcision to Prevent HIV: A Promising Strategy Raises Provocative
Circumcision in high-risk adult males lowers their rate of HIV infection,
but will this procedure be culturally acceptable?
As access to antiretroviral therapy for HIV-infected people slowly
penetrates the developing world, preventing new HIV infections remains a
high priority. Unfortunately, efforts to lower transmission rates through
behavior change and use of vaginal microbicides generally have been
disappointing, and an HIV vaccine remains only a distant hope.
In December 2006, the NIH announced the early termination of two randomized
controlled studies of adult male circumcision in Kenya and Uganda after
interim analyses showed that, in each trial, HIV incidence was halved among
men who had been circumcised compared with those who had not. In both trials
researchers randomized uncircumcised, HIV-negative men to surgical
circumcision either immediately or after a delay of 24 months; all
participants were given risk-reduction counseling and condoms. No
differences in risk behaviors were observed between groups in either study
nor were severe complications of surgery seen (Journal Watch Mar 13 2007).
Based on these studies, an editorialist called male circumcision "the most
compelling evidence-based [HIV] prevention strategy to emerge since the
results from mother-to-child transmission clinical trials." Epidemiologic
modeling suggested that, in southern Africa alone, widespread male
circumcision could prevent 2 million new HIV infections and 300,000 deaths
in the next decade. The huge potential benefits of this strategy immediately
brought forth new questions: What might be the direct and indirect effects
on male-to-female transmission? What is the optimal age for circumcision?
How can resources be deployed to maximize benefits and minimize risks? Will
circumcision be accepted in different cultures? How can circumcision be
promoted without undermining education about condom use and campaigns
against female genital mutilation?
Finally, what are the implications of these findings for advice on newborn
circumcision in developed countries? In a study published in 2006,
uncircumcised men in a New Zealand birth cohort were more than three times
as likely as circumcised men to have sexually transmitted infections between
age 18 and age 25 (Journal Watch Dec 7 2006). Other evidence suggests that
circumcision lowers risk for urinary tract infections, genital ulcer disease
penile cancer, and, perhaps, transmission of human papillomavirus. The
perceived benefits of newborn circumcision in any setting will depend on the
perceived risks for these negative outcomes. The new data on HIV and
sexually transmitted diseases could shift the discussion perceptibly toward
advocacy for circumcision in the developed world, particularly among groups
perceived to be at greatest risk for HIV infection.
Bruce Soloway, MD
Published in Journal Watch General Medicine December 28, 2007
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