Male circumcision: a role in HIV prevention?
Summary: Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and . These studies' systematic lack of control of important confounding factors makes the assessment of the association between male circumcision and HIV. There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Three randomized.
Some of this can be achieved by using observational designs which better address the limitations discussed above. Laboratory and primate research might also continue to provide useful information. As the safety, expected benefits, feasibility and acceptability of mass circumcision are all questionable, neither public-health interventions nor intervention studies appear to be defensible options before there is stronger evidence from observational studies in different settings that show lack of male circumcision may be a genuinely independent risk factor for the transmission of HIV.
Acknowledgement The authors wish to thank M. Brunet for their comments and suggestions on previous drafts of this paper. Geographical patterns of male circumcision practices in Africa: Int J Epidemiol The relationship between male circumcision and HIV infection in African populations. Risk factors for HIV infection among Ugandan couples. Florence, June [abstract MC].
Circumcision and HIV
Female-to-male transmission of HIV Does male circumcision prevent HIV infection? Harvard Univ Press Circumcision and heterosexual transmission of HIV infection to men. Genital transmission of SIV and localization of SIV in the reproductive tract of chronically infected rhesus macaques. Piot P, Laga M. Genital ulcers and other sexually transmitted diseases, and the sexual transmission of HIV. Epidemiological methods to study the interaction between HIV infection and other sexually transmitted diseases.
Male circumcision: a role in HIV prevention?
Circumcision may protect against the AIDS virus. Arch Dermatol7: Advances in the diagnosis and management of chancroid. Sex Trans Dis Factors influencing venereal infection in a war environment. Br J Ven Dis Heterosexual transmission of HIV Association of cervical ectopy with heterosexual transmission of HIV: Infect Dis HIV infection in urban Rwanda.
- Male circumcision and HIV infection among sexually active men in Malawi
- The relationship between male circumcision and HIV infection in African populations.
- Circumcision and HIV infection
Montreal, June [abstract TAP]. Genital trauma during sex is a risk factor for HIV infection in Uganda. Genital ulcers and male circumcision as risk factors for acquiring HIV-1 in Zambia. J Infect Dis Genital ulceration as a risk factor for HIV infection. Risk factors for HIV seropositivity in selected urban-based Rwandese adults.
Human immunodeficiency virus transmission among heterosexual couples in Central Africa. HIV infection and circumcision status.
Heterosexual transmission of HIV-1 associated with the use of smokable freebase cocaine crack. Analytical methodology in a cohort study of cofactors for sexual transmission of HIV. Duration of HIV infection before detection of antibody. Taylor PK, Rodin P: Herpes genitalis and circumcision. Med J Aust Yeasts and circumcision in the male. Circumcision as a risk factor for urethritis in racial groups. Am J Pub Health Rodin P, Kolator B: Carriage of yeasts on the penis.
An argument for circumcision: Nevertheless, male circumcision does not provide a complete prevention against HIV infection, and circumcised men can become infected, and can transmit the virus to their partners [ 2389 ]. However, there still remain gaps and unanswered questions relating to HIV transmission and circumcision.
Although not supported by literature, one major concern is the behavioral disinhibition where circumcised men could feel more protected against HIV infection and hence may engage in a riskier behavior.
Traditionally, and in some communities, young men are taken into seclusion and given advice touching on their responsibilities which includes their sexual behavior [ 14 ].
However, cluster randomized trials done in South Africa to assess the interventions that could prevent men from sexual risky behaviors after circumcision showed that social cultural values dictated how men should behave among traditionally circumcised men [ 22 ] and hence resistance to change; while among those medically circumcised, a focused counseling session had short term effects on reducing risky sexual behavior [ 23 ].
During male circumcision rituals, the period of seclusion constitutes the most significant part where new attitudes, practices and behaviours are learnt which includes sexual issues [ 14 ]. Whereas sexual reserve and inappropriateness of promiscuity after reintegration into society are emphasized, in other contexts, boys are encouraged to have sex to prove their manhood even during the seclusion period, often referred to as ritual sex [ 14 ].
Although ritual sex is conducted in some communities in Malawi, there is limited information regarding this practice. However, in Zambia, ritual sex is associated with traditional circumcision and use of condom is not emphasized [ 2425 ]. There is therefore a need to look at the association between type of circumcision and HIV infection in Malawi, as well as analyze the effect of ritual sex on HIV infection.
While some studies show that pre-pubertal circumcision is associated with reduced risk of HIV infection [ 2627 ], one study shows no significant association between age at circumcision and HIV infection [ 28 ].
Male circumcision in many African societies is done at puberty [ 29 ] ; however, there are communities that do not have a defined circumcision period and therefore some men are circumcised as infants, while others are circumcised at adulthood. When circumcised at old age, these men are already exposed to sexual activities for a long time, and have higher chances of being exposed to HIV as compared to younger men. Though recent indicators have shown some decline from a prevalence rate of The AIDS Response Progress Report shows that Malawi has registered progress in the areas of prevention; treatment, care and support; and impact mitigation [ 30 ].
However, the country has been criticized for being slow in the introduction of free male circumcision in public facilities and only recently, inthe Malawi government adopted a policy on medical male circumcision as part of its HIV prevention strategy, offering the service free at public hospitals [ 30 ].
But male circumcision has been in practice in Malawi for cultural and religious reasons [ 31 ] and only recently that men are embracing circumcision and mainly due to its medical advantage. Even though male circumcision is viewed as one of the key interventions on HIV prevention, no study has examined its effect within the Malawian context. This was a nationally representative survey whose sample design was tailored to provide specific indicators at national and regional levels.Can Circumcision Reduce a Man's Risk of Getting HIV?
Women who acquired infection outside of the partnership were censored at the time of seroconversion. Additional analyses censored women at the time the partners initiated ART. Results A total of couples were included in this analysis. The median age of female participants was 30 years and for their male partners was 37 years.
Six women reported sex outside of the partnership in the month before enrollment. In addition, the female partners of circumcised men were older. The baseline sexual behavior and CD4 counts and viral load levels were similar between the two groups. Median follow-up was 18 months but was shorter for partners of uncircumcised men 18 vs.
The number of sexual episodes decreased over time between both groups.