Male circumcision in some nations may be the best available HIV prevention tool
Evidence growing for safety, efficacy
Randomized clinical trials and other recent studies have confirmed earlier work showing a strong public health benefit for the use of male circumcision to prevent HIV infection in high-prevalence areas of the developing world.
Investigators who once were somewhat isolated in their pursuit of this question, and who have had to deal with nasty emails, phone calls, and even protests by fringe anti-circumcision groups, now can see the benefits of their research.
"We now have three clinical trials that show how male circumcision approximately cuts in half the risk of HIV infection," says Robert C. Bailey, PhD, MPH, a professor of epidemiology in the School of Public Health at the University of Illinois at Chicago.
Bailey is principal investigator of a clinical trial of more than 2,700 HIV-negative, uncircumcised men in Kenya, who were randomly assigned to groups that were circumcised or not circumcised. The trial was halted early because results within the first two years showed that the circumcised men had half as many HIV infections as the uncircumcised men.
"If we had a vaccine that was 50 to 60 percent effective, the world would be scrambling to make it available," Bailey notes. "Because circumcision is a surgical procedure, people are less enthusiastic about it."
Nonetheless, Bailey's research and other studies showing similarly positive results are expected to result in some changes in prevention strategies in parts of sub-Saharan Africa.
"I think the international public health community has been waiting for the results of these trials," Bailey says. "And now that they've arrived, the evidence is very compelling that circumcision has a protective quality against HIV infection."
At the same time the clinical trials have shown strong evidence of the protective effect of circumcision against HIV infection, there have been numerous other studies looking at psychosocial issues, cultural/religious issues, financial impact of circumcision, and whether circumcised men engage in more and riskier sex than uncircumcised men.
Another recent study shows that in sub-Saharan Africa, male circumcision is significantly associated with lower cervical cancer incidence and lower HIV prevalence, independent of whether participants were Christian or Muslim.1
"We found that male circumcision is strongly associated with less HIV prevalence in sub-Saharan African countries and in non-sub-Saharan countries that have primarily heterosexual transmission," says Paul Drain, MPH, MD-candidate, an investigator at the University of Washington in Seattle, WA.
"And male circumcision is associated with low cervical cancer incidence [among a population], and it's associated with lower herpes virus, type 2," Drain adds. "All three of those are sexually transmitted diseases [STDs]."
When investigators compared circumcision rates with diseases that are not sexually transmitted, such as tuberculosis and malaria, they found no such association, Drain says.
There are various other studies that have had results overwhelmingly positive with regard to employing circumcision as a prevention strategy. (See article in the "AIDS Alert International" section of the upcoming April 2007 issue of AIDS Alert, about the variety of research involving HIV infection and circumcision.)
For example, a study published in January 2007 in the Journal of Acquired Immune Deficiency Syndrome found that in the first year after being circumcised, men did not engage in more risky sexual behaviors than uncircumcised men.2
"The circumcised men did not assume they were insulated from HIV," says Kawango Agot, PhD, MPH, director of the Impact Research and Development Organization of Kisumu, Kenya.
While the circumcised men studied did not engage in risky sexual behaviors for HIV infection, this was a short study and the situation could be different with a longer follow-up, Agot notes.
Other research found that male circumcision is a cost-effective HIV prevention strategy in sub-Saharan Africa settings that have high or moderate HIV prevalence among the general population.3
Investigators studied the question of how many infections likely will be prevented if 1,000 men are circumcised, says James G. Kahn, MD, MPH, professor of health policy and epidemiology at the Institute for Health Policy Studies at the University of California, San Francisco.
"We compared what it costs to deliver the intervention to the potential savings when people aren't getting HIV infected and sick," Kahn says. "What we found is that if you circumcise 1,000 men over 20 years, using our epidemic modeling, you would avert an estimated 308 infections over 20 years."
The averted infections would include women partners, he notes.
Such a strategy would have a net savings of $2.4 million.3
Investigators conducted a sensitivity analysis, changing all of their assumptions, including changing the assumption that circumcision results in 50 to 60 percent fewer HIV infections to an assumption that it prevents only 40 percent, Kahn notes.
"We looked at what if the intervention costs more and if the area's HIV incidence is substantially lower," Kahn says. "But the bottom line is for the range of things we looked at, there never is a net cost — all of scenarios we looked at yielded net savings."
Bailey's research has looked into the acceptability of male circumcision as an HIV prevention tool, and the results have been promising.
In one review of acceptability studies, the median proportion of uncircumcised men who were willing to become circumcised was 65 percent, and 69 percent of women favored circumcision for their partners.4
"There now are 13 studies of acceptability from nine different countries in sub-Saharan Africa, and the general findings are that the main barriers for men in non-circumcising religions are cost, fear of pain, and fear of infection," Bailey says. "Adverse events, in other words."
This suggests that if the world's public health community was to make circumcision available at minimal or no cost in these non-circumcising areas, then many men who are not circumcised would consider the procedure, Bailey says.
Even before the HIV and circumcision clinical trial results were known, studies of male perceptions of circumcision in these areas showed that men considered circumcision a positive action to take for better hygiene, to prevent STDs, and to protect them from HIV infection, Bailey notes.
"About 50 percent of the men thought circumcision would protect them from HIV," Bailey says. "They could look around at tribal groups and see that the circumcised men were not infected."
Investigators also are studying the perceptions of newly circumcised men about their sexual pleasure and any changes, and so far the men haven't reported any differences in before and after circumcision, Bailey says.
The next step will be for the World Health Organization (WHO) of Geneva, Switzerland, to weigh in on the issue, and for medical experts to come up with a plan for providing male circumcision in a safe, affordable, voluntary setting within research-poor areas where medical training and resources are limited, Bailey adds.
Bailey has studied this issue since 1995 after reading an article about how the areas of Africa where HIV prevalence was the highest were areas where men do not traditionally get circumcised.
"That caught my attention, and I looked further into the literature, and there were quite a few studies where individuals who were not circumcised were at twice to eight times greater risk of HIV infection," Bailey says. "These were observational studies where both uncircumcised and circumcised men were observed."
As a biological anthropologist who also has trained in epidemiology, Bailey thought this would be the ideal topic to marry his experience in epidemiology and anthropology.
"This is a culturally and religiously loaded practice, and we also needed more information about the distribution of circumcision and HIV infection," Bailey says.
Bailey has experienced first-hand the controversy surrounding circumcision and any science that proves it is beneficial medically. People who are against circumcision demonstrated at one his talks, he says.
Kahn has received unpleasant emails from anti-circumcision groups.
"There is a bit of a backlash in this country against circumcision," Bailey says.
"A lot of nurses have been trained to advise against circumcision, and the American Pediatric Association says to do it out of religious or cultural preference, but not on a medical basis," Bailey says.
"I think their position is wrong," he adds. "I think there are a lot of medical and health benefits to circumcision, even beyond preventing HIV infection."
For example, circumcision results in a reduction in urinary tract infections in adults, and it results in lower rates of cervical cancer among sexual partners of circumcised men, Bailey says.
While this doesn't mean that it should be performed routinely on infants, there is evidence supporting voluntary circumcision among adult men, he adds.
References:
- Drain PK, Halperin DT, Hughes JP, et al. Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries. BMC Infect Dis. 2006;6:172.
- Agot KE, Kiarie JN, Nguyen HQ, et al. Male circumcision in Siaya and Bondo districts, Kenya: prospective cohort study to assess behavioral disinhibition following circumcision. J Aquir Immune Defic Syndr 2007;44(1):66-70.
- Kahn JG, Marseille E, Auvert B. Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting. PLoS Medicine 2006;3(12):e517; doi:10.1371/journal.pmed.0030517.
- Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behav 2006 Oct 20 [Epub ahead of print];PMID:17053855.
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