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Circumcision for MSM May Be Effective: New Debate Over Circumcision, HIV Reduction
By Catherine Guthrie Tuesday, Oct. 07, 2008
"male circumcision.....may prove to be one more tool in the toolbox...if you can add it to behavioral risk reduction, prompt diagnosis and access to care, it may be the combination needed to really knock the socks off the H.I.V. epidemic."
Male circumcision has been shown to protect men from acquiring H.I.V. infection during sex with women - it has reduced female-to-male transmission rates by 48% to 60% in sub-Saharan Africa - but that protective effect appears less reliable among men who have sex with men, according to a new meta-analysis published Oct. 7 in the Journal of the American Medical Association (J.A.M.A.).
The review is the most comprehensive analysis of the subject to date. It encompasses data from 15 studies conducted in seven countries, involving more than 53,000 men, most of whom were Caucasian and approximately half of whom were circumcised. The authors concluded that being circumcised reduced a man's risk of acquiring H.I.V. by 14%. That finding was statistically nonsignificant, but the authors say it should be regarded as a launching point for future trials. "This study gives us a more complete picture than we've ever had before," says Gregorio Millett, the study's lead author and a senior behavioral scientist at the Centers for Disease Control and Prevention (CDC). "The next step is to design better quality studies to see if there is an association we aren't detecting."
One such question, says Millett, is whether circumcision can reduce infection rates among the subset of men who have only insertive sex with other men, as opposed to those who have only receptive sex or both. Millett's review suggested that among the former group, circumcision lowered H.I.V.-infection risk by 29%, a finding that also showed statistical nonsignificance. But targeting that distinct population in future studies may prove useful for distilling the specific effect of circumcision - and perhaps for future public-health strategies. "For every insertive man who is protected, there might be a receptive man who isn't infected, for the same reason why women get other words, from a herd-immunity phenomenon," says Dr. Sten Vermund, director of the Institute for Global Health at Vanderbilt University School of Medicine, who co-authored an editorial in the current issue of J.A.M.A.
Circumcision is believed to lower H.I.V. transmission in several ways. The inner surface of the foreskin is rich with cells that are more vulnerable to H.I.V. than cells on other parts of the penis; because they are also closer to the epithelial surface and at higher risk for tears during intercourse, they increase susceptibility to infection. Removal of the foreskin further lowers men's odds of developing genital ulcers (from diseases such as syphilis), which in turn lowers their vulnerability to H.I.V. during intercourse. In theory, circumcision should be protective for all men who participate in insertive sex, including heterosexual men and men who have sex with men.
But researchers note that circumcision is no cure, and no substitute for safe-sex measures such as using condoms. Millett's analysis found that in studies conducted before 1996 - before the advent of highly active antiretroviral therapy - circumcision was associated with a statistically significant 53% reduction in H.I.V.-transmission risk, which is on par with the 48% to 60% reduction in infection rates reported by the 2007 trials in Kenya, South Africa and Uganda that studied heterosexual men. After 1996, however, when antiretroviral (ARV) drugs turned H.I.V. into a condition that people lived with rather than died from, the protective effect of circumcision became nonsignificant, Millett found. The widespread belief that ARVs could prevent H.I.V. transmission led to an increase in risky sexual behavior, outbreaks of sexually transmitted infections and increasing rates of H.I.V., which, the study's authors say, may have diminished the relative effectiveness of male circumcision.
"Nobody should frame male circumcision as some sort of panacea," says Vermund. "But it may prove to be one more tool in the toolbox...if you can add it to behavioral risk reduction, prompt diagnosis and access to care, it may be the combination needed to really knock the socks off the H.I.V. epidemic."

Can Circumcision Cut HIV in Gay Men?
Study Shows Weak Circumcision/HIV Benefit for Gay/Bisexual Men

By Daniel J. DeNoon
WebMD Health News
Reviewed by Louise Chang, MD
Oct. 7, 2008 -- Circumcision offers little HIV protection to gay/bisexual men -- overall. But it might cut HIV risk in predominantly insertive partners.
It's now clear that circumcision reduces heterosexual men's risk of getting HIV from sexual intercourse. Can circumcision reduce HIV infection rates among men who have sex with men?
To find out, behavioral scientist Gregorio A. Millett, MPH, and colleagues at the CDC's division of HIV/AIDS prevention analyzed data on circumcision and HIV risk from 15 different studies of 54,000 men who had sex with men.
Overall, the data showed a weak effect: a 14% lower risk of HIV in circumcised gay/bisexual men. The finding was not statistically significant. That means even this small benefit could very well be due to chance.
But there was one highly significant finding. Back when AIDS was still a death sentence -- before the 1997 advent of highly effective HIV drugs -- circumcision cut men's risk of getting HIV by 53%.
"There has been an increase in sexual risk behavior in men who have sex with men since the availability of highly effective treatment for HIV," Millett tells WebMD. "If a man is engaged in unprotected sex or has lots of sex partners, that contributes more to his risk of HIV than being uncircumcised. So in recent years, the benefit of circumcision may have been overridden by the risks of unsafe sex."
Of course, that was yesterday. Today the world still struggles to control the spread of the AIDS virus. And there's another key finding from the Millett study.
In the few studies that looked specifically at men who predominantly engaged in insertive anal sex, circumcision seemed to offer more protection. This effect was much stronger in populations where relatively few men are circumcised.
It's a very important issue, says Sten Vermund, MD, PhD, director of Vanderbilt University's Institute for Global Health.
"The prospect that predominantly insertive men might derive considerably more benefit from circumcision is as logical as the day is long," Vermund tells WebMD. "What benefit is a predominantly receptive man going to gain from circumcision?"
Vermund notes that there is good evidence that, in many parts of the world, a high proportion of men who have sex with men are exclusively or predominantly insertive sexual partners. In areas where few men now are circumcised, circumcision could have a powerful effect on HIV transmission -- if it went hand-in-hand with safer sexual behavior.
"To add one more tool to our HIV prevention toolbox -- even if it affects only 40% of a risk group -- would be substantial," Vermund says.
Vermund and Millett agree that a clinical trial to test this approach is needed. Whether such a study can attract increasingly scarce funding is an open question.
The Millett study, and an accompanying editorial by Vermund and colleague Han-Zhu Qian, MD, PhD, appear in the Oct. 8 issue of The Journal of the American Medical Association.

Circumcision Benefit in AIDS Is Divided
Published: October 7, 2008
WASHINGTON (Reuters) - There is not enough evidence to show that circumcision reduces the risk of AIDS in sex between men, researchers are reporting, even though previous studies in Africa have shown its pronounced benefit in reducing AIDS from heterosexual sex.
"Over all, we're not finding a protective effect associated with circumcision for gay and bisexual men," said Gregorio A. Millett of the Centers for Disease Control and Prevention, the lead author of a report that appears Wednesday in The Journal of the American Medical Association.
The researchers based their conclusions on a review of 15 studies involving 53,567 gay and bisexual men in eight countries, including the United States, where nearly half of the 1.1 million people infected with the AIDS virus are men who have sex with men.
Circumcised men were 14 percent less likely to be infected with the human immunodeficiency virus, or H.I.V., than those who were uncircumcised, but the finding was not statistically significant, the researchers said.

Circumcision HIV impact doubted
There is no hard evidence that circumcision protects gay men from HIV, research shows.
African trials have shown circumcision cuts the likelihood of female to male HIV transmission by up to 60%.
But a US analysis of data on 53,567 men who have sex with other men found HIV rates were not significantly lower among those who were circumcised.
The Journal of the American Medical Association study stressed more work was needed to draw firm conclusions.
"This research adds weight to the evidence that circumcision isn't an effective method of HIV prevention for men who have sex with men" Will Nutland Terrence Higgins Trust
The US team, from the Centers for Disease Control and Prevention in Atlanta examined data on 53,567 men who have sex with men, of which 52% were circumcised.
HIV levels among those who were circumcised were lower - but not significantly so.
However, there was evidence that circumcision may have had a protective effect in studies carried out before the introduction of highly active antiretroviral therapy (HAART) in 1996.
The researchers said one possible explanation was that the advent of these more effective HIV drugs had encouraged higher levels of risk taking sexual behaviour, wiping out any marginal protective effect from circumcision.
Alternatively, the drugs may have helped lower the risk of transmission to the point where circumcision had no further benefit.
A third possibility is that there may have been a smaller proportion of men in the pre-HAART trials who primarily engaged in receptive anal sex, which carries the greatest risk for HIV infection among gay men.
Michael Carter, of the HIV information service NAM, said: "It's my sense that there has been a tempering of the excitement about circumcision, and researchers are now favouring a 'combination prevention' approach.
"Circumcision may have a place in this in some settings, but so too do good sexual health, consistent condom use, and there's real excitement and debate about the role of HIV treatment in prevention."
Will Nutland, of the HIV charity Terrence Higgins Trust, said: "This research adds weight to the evidence that circumcision isn't an effective method of HIV prevention for men who have sex with men.
"The majority of HIV infections in men who have sex with men are as a result of receptive anal intercourse and circumcision would make no difference in these cases.
"Rather than encouraging gay men to be circumcised, investment in prevention in the UK should focus on targeted education programmes, condom provision and easy access to testing."
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