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Male circumcision and HIV risks and benefits for women - EDITORIAL
  The Lancet, 18 July 2009
Jared M Baeten a, Connie Celum a, Thomas J Coates b Departments of Global Health and Medicine, University of Washington, Seattle, WA 98104, USA b UCLA Program in Global Health, Division of Infectious Diseases, University of California Los Angeles, Los Angeles, CA, USA
In The Lancet today, Maria Wawer and colleagues,1 from the Rakai Health Sciences Program in Uganda, report the results of a clinical trial that examined whether circumcision of HIV-infected men reduces HIV transmission to their uninfected female sexual partners. HIV incidence was not statistically different for women whose HIV-infected partners were randomised to undergo circumcision compared with those whose partners remained uncircumcised. The Data and Safety Monitoring Board stopped the trial for futility at an interim analysis, because it was statistically unlikely that further accumulation of HIV transmission events would show a substantial benefit of circumcision on women's HIV risk.
Thus, the trial did not confirm earlier observational studies that showed that partners of circumcised HIV-infected men were less likely to acquire HIV.2 Additionally, the trial results suggested increased risk of HIV for some women: at the 6-month follow-up visit, the HIV acquisition rate in partners of circumcised men who resumed sexual activity before wound healing was 27·8%, compared with 9·5% in partners of men who underwent circumcision but delayed sex until healing and 7·9% in partners of uncircumcised men. This subgroup analysis was initiated after the trial was stopped and the results were unexpected; thus, the finding should be interpreted with some caution. No other trials of circumcision in HIV-infected men are underway. Lessons from Wawer and colleagues' study should be considered carefully to assess whether planning another such trial is now ethically and logistically feasible.
3 years ago, landmark randomised trials from Kenya, South Africa, and Uganda conclusively showed that circumcision reduces a man's risk of acquiring HIV by about 50%.3-5 WHO and UNAIDS recommend that men seeking circumcision be provided the procedure, irrespective of HIV status, including men who decline HIV testing.6 Despite Wawer and colleagues' results, we support this recommendation. Knowledge of an individual's HIV serostatus is a powerful tool for HIV prevention;7 however, HIV testing should not be a deterrent to receiving a proven HIV-prevention service. Provision of circumcision only to HIV-uninfected men might stigmatise those found to be infected or those refusing testing, and so potentially drive away the highest risk men from accessing HIV-prevention services. Importantly, male circumcision must not become a popular marker for lack of HIV infection; community messaging must emphasise this fact as well as the continued need for condom use and reduction in partner numbers to optimise HIV risk reduction after circumcision.
Circumcision provides a rare contact between young men in areas with a high prevalence of HIV and health-care providers. Circumcision programmes should make the most of the opportunity to provide condoms and risk-reduction counselling, and to offer voluntary HIV testing. Postprocedure counselling for men who undergo circumcision, especially if they are HIV-infected or do not know their serostatus, must emphasise the importance of delaying sexual activity until complete wound healing to avoid increased HIV risk to sexual partners. Because men might not be able to accurately assess healing, and because recently healed skin may be fragile, a window period of abstinence after circumcision (eg, 6 weeks) is advisable.
Although circumcision of HIV-infected men does not seem to directly reduce HIV risk for their female partners in the short term, women will benefit from male circumcision programmes. Wide-scale roll-out of male circumcision is expected to lead to decreasing HIV prevalence in communities over 10-20 years, in both men and women, by averting new infections in men and onward transmission to their partners.8 On a shorter timescale, a woman's HIV risk would be substantially reduced if circumcision prevents her male partner from acquiring HIV. Indeed, anecdotal reports suggest that interest in circumcision in young men in the first roll-out programmes in Africa is in part being driven by women's preference for circumcised partners. Finally, women with circumcised partners, irrespective of HIV serostatus, face decreased risk of sexually transmitted infections such as Trichomonas vaginalis, bacterial vaginosis, herpes simplex virus type 2, and human papillomavirus.1,9-12
One striking finding from today's trial was the high rate of HIV transmission.
At 24 months, the cumulative HIV probability was 13·4% for women in the control group, an incidence greater than that in high-risk cohorts of women who took part in recent trials of vaginal microbicides.13 High HIV risk for couples living in stable HIV-serodiscordant relationships is increasingly recognised.14 Prevention services for this population, including HIV testing for couples, facilitated disclosure of HIV seropositivity, and ongoing counselling services, should be a public health priority. Such services should be incorporated into male circumcision programmes, thereby providing further protection to HIV-uninfected women.
The results of today's study should in no way hinder programmes working to scale up circumcision services for men at risk for HIV. Involvement of women in decision making about circumcision offers an opportunity for enhanced messaging about the risks and benefits of circumcision, for men and for women, and for targeted risk-reduction counselling for HIV-serodiscordant couples.
JMB declares that he has no conflicts of interest. CC and TJC served as members of the trial's Data and Safety Monitoring Board.
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