More data emerge on circumcision's impact

Data released at a recent international conference suggest that adult male circumcision, which has been seen as possibly reducing the risk of HIV transmission in Africa, could raise the risk for women there whose male partners seek the procedure after they are infected.1

In another study reviewed at the 15th annual Conference on Retroviruses and Opportunistic Infections (CROI) in Boston, researchers found that women whose male partners were circumcised while HIV-negative had a 25% lower rate of infection with genital herpes, a 50% reduction in trichomoniasis, and a 20% reduction in bacterial vaginosis.2

Interest in male circumcision as a possible preventive tool against HIV has been heightened after data from three randomized controlled trials undertaken in Kisumu, Kenya; Rakai District, Uganda; and Orange Farm, South Africa indicated that the procedure reduces the risk of heterosexually acquired HIV infection in men by about 60%.3-5 In light of the evidence, the World Health Organization (WHO) in March 2007 added the procedure to its list of recommended AIDS prevention measures.6

Wound healing key

If male circumcision reduces HIV acquisition in men, what impact does it have for their female partners? Scientists reporting at the CROI conference reviewed the results of their trial, conducted among HIV-positive men and designed to assess HIV transmission to their partners.1

Researchers randomized 1,015 HIV-positive African men to undergo immediate male circumcision or a delayed procedure 24 months later. Married men were asked to invite their spouses; 566 wives enrolled, with 43% of that group reporting HIV-negative status. Participants provided written consent; were given information on HIV prevention, wound care, and abstention from sex postoperatively; and were offered free condoms and couples counseling and testing.1

The annual HIV incidence rate in the wives of the men who were circumcised was 14.4% over two years of follow-up compared with 9.1% in women whose partners remained uncircumcised.

While the difference between these two groups was not statistically significant, scientists did not see a trend toward protection. The take-home message is that the data do suggest, but don't prove, that if couples undertake sexual intercourse before circumcision wound healing is complete, there is risk for transmission, says Maria Wawer, MD, MHS, professor in the Bloomberg School of Public Health at Johns Hopkins University (JHU). "In our trial of HIV-negative men, we found that the protective effect of HIV circumcision for men was really not particularly pronounced in the first period after circumcision; we started to see a significant effect six or more months after circumcision," says Wawer. "It suggests whether or not a man is positive or negative, it makes sense not to undertake intercourse before the wound is fully healed."

Plus for vaginal health

What is circumcision's role in prevention of herpes simplex 2 (HSV-2) in men and vaginal infections in women?

To determine the method's efficacy, researchers randomized men to undergo immediate male circumcision or delay circumcision for two years. A total of 2,787 HSV-2-negative men were followed for 24 months to determine HSV-2 acquisition. Married women were linked to enrolled men, with 825 wives of circumcised men and 783 wives of delayed-procedure men were followed at one year to assess genitourinary disease (GUD), bacterial vaginosis (BV), and trichomonas.2

Data indicate that male circumcision prevents HSV-2 acquisition in men and reduces rates of GUD, trichomonas, and BV in their female partners. These effects of circumcision may influence the protective effect of circumcision on HIV acquisition, the researchers conclude.2

What is the next step in research, given that scientists recorded a positive impact of circumcision in improving the vaginal health of women? "We will assess the effects of circumcision on female HPV infection and continue to monitor all female partners of trial participants to assess long-term HIV effects," says Aaron Tobian, MD, PhD, a member of the JHU Rakai research team and lead author of the paper.

References

  1. Wawer M, Kigozi G, Serwadda D, et al. Trial of male circumcision in HIV+ men, Rakai, Uganda: Effects in HIV+ men and in women partners. Presented at the 15th Conference on Retroviruses and Opportunistic Infections. Boston; February 2008.
  2. Tobian A, Serwadda D, Quinn T, et al. Trial of male circumcision: Prevention of HSV-2 in men and vaginal infections in female partners, Rakai, Uganda. Presented at the 15th Conference on Retroviruses and Opportunistic Infections. Boston; February 2008.
  3. Bailey C, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized controlled trial. Lancet 2007; 369:643-656.
  4. Gray H, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in young men in Rakai, Uganda: A randomized trial. Lancet 2007; 369:657-666.
  5. Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2005; 2:e298.
  6. World Health Organization/UNAIDS. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. Conclusions and Recommendations. Montreux, Switzerland; March 2007. Accessed at www.who.int.