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An estimated 40 million people worldwide are currently infected with HIV. Africa has 10% of the world's population, but more than 65% of the world's HIV burden. Although the last 5 years have been marked by an increased investment in HIV treatment, the evaluation of both new and existing prevention strategies has also been under way. One promising preventive approach that is being investigated is male circumcision.
The focus on eliminating penile foreskin stems from previous immunologic studies demonstrating that it contains large concentrations of HIV-target cells, such as macrophages, Langerhans, and CD4+ cells. Therefore, it is plausible that the removal of these HIV-target cells could reduce the risk that exposure to the virus would result in transmission. Recently, the first randomized, single-blinded, controlled trial (RCT) to assess this strategy showed a significant reduction in rate of HIV infection. Findings from this trial have raised both hope and concern about use of the procedure.
In the late 1980s, observational researchers in Africa first noted a reduced prevalence of HIV in ethnic groups whose cultural practices included male circumcision. This was followed by a number of observational studies focused on the possible preventive effects of the practice. However, other researchers and policy-making bodies were skeptical of the quality of these data, and it became apparent that RCTs were needed.
The initial RCT (ANRS 1265 Trial) was conducted by Auvert and colleagues in a semiurban district near Johannesburg, South Africa, from 2002 to 2004. They enrolled 3274 men; 1617 underwent medical circumcision. All participants received a 20-minute sexually transmitted disease counseling session, and had access to condoms. Participants in the intervention group were asked to be abstinent for 6 weeks following circumcision to allow for adequate wound healing.
The trial was terminated following interim data analysis because of the overwhelming results: a 60% reduction in HIV infection in the circumcised group (20 new diagnoses in the intervention group vs 45 in the control group). The most common adverse events seen post circumcision were pain (0.8%) and swelling (0.6%). No increases in infection were detected at the first follow-up visit, indicating that the immediate postsurgical effects did not make the circumcised men more vulnerable to HIV.
Two similar RCTs are under way (in Kenya and Uganda); data from these investigations will help confirm or refute the ANRS findings. In the meantime, there is much to consider about the implications of the ANRS data, including possible effects and potential barriers to the promotion and implementation of male circumcision as a preventive strategy.
Opponents to encouraging widespread male circumcision have a number of concerns, including cultural considerations, the risk for increased infection if sterile circumcision techniques are not used, and the possibility of encouraging increased sexual promiscuity post procedure. With respect to concern about increased sexual promiscuity, data from Auvert and colleagues found an increased number of sexual partners in the circumcised group, despite which, there was still a decrease in HIV incidence compared with the controls. Previous data have demonstrated a false security associated with circumcision, with some men believing that the procedure conferred the ability to safely have sex with multiple partners. Whether the increase in number of sexual partners demonstrated in the ARNS Trial is generalizable requires data from other RCTs.
Concerns about cultural acceptability and feasibility are well founded. Experts have contended that circumcision may be least accepted in communities that need it most (groups in which male circumcision for any reason is currently nonexistent). However, studies of acceptability conducted in Africa have demonstrated acceptance among noncircumcised men of 51% to 61%. Anecdotally, clinicians and researchers have reported witnessing a fury of excitement and increased demand for circumcision when information about benefits spread by word of mouth throughout pockets of Africa.
Who performs circumcisions -- traditional healers or medical personnel -- could also affect the acceptability of circumcision in communities where certain types of practitioners are preferred, whereas others are greeted with skepticism. Moreover, recommended age(s), connection to religious/tribal affiliation(s), and conditions and pretenses under which circumcision is practiced will remain important variables as this approach is considered for widespread implementation.
Additionally, safety considerations associated with widespread adult male circumcision must also be addressed. To date, few studies have focused on complications of adult male circumcision. However, existing data have demonstrated variable rates of complications, primarily linked to whether trained or untrained personnel performed the procedure. Local general practitioners, using sterile techniques in a primary care setting, circumcised ANRS 1265 Trial participants. Although the rate of adverse events was low and self-limiting, these findings may not be generalizable to circumcision performed in less optimal conditions.
Sterile, single-use technologies would most likely contribute to best outcomes, but such technologies are not currently available in many parts of Africa. Additionally, because much of Africa lacks healthcare infrastructure, medical supplies and resources, and healthcare personnel, appropriate implementation of circumcision for HIV prevention would be challenging. Obviously, related needs should be assessed and addressed before any large-scale efforts to encourage circumcision are made.
Reactions to the findings from the first RCT demonstrating the preventive effects of adult male circumcision range from excitement to skepticism. Similar studies are currently ongoing, and more data should soon be available. If hurdles to providing male circumcision as a preventive strategy can be overcome, it is estimated that over the next 10 years, 2.0 million new HIV infections and 300,000 AIDS-related deaths can be avoided. In a time when the HIV epidemic continues unabated, especially in sub-Saharan Africa, despite current efforts to bring prevention and treatment to an ever increasing number of people, many hope to hasten the availability of new approaches, including male circumcision.
However, zeal about this promising prevention strategy must be counterbalanced with caution about the potential downfalls that could be encountered during implementation. Studies to evaluate cost-effectiveness, applicability to a variety of cultures and geographic settings, and the feasibility of widespread implementation are also needed.
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