From Our 2009 Archives
Circumcising Men With HIV Won't Protect Women
Study: Circumcision Doesn't Keep HIV-Positive Men From Infecting Female Partners
Daniel J. DeNoon
Reviewed By Louise Chang, MD
Definitive clinical trials in Uganda, South Africa, and Kenya show that men cut their HIV risk by 50% if they undergo circumcision. That can reduce a woman's odds of getting HIV, note Johns Hopkins researcher Maria J. Wawer, MD, and colleagues.
And there's an even better way to protect women.
"Condom use after male circumcision is essential for HIV prevention," Wawer and colleagues conclude.
Earlier observational studies offered a hint that circumcision might also cut men's risk of passing HIV infection to women. But that turns out not to be the case.
Circumcision programs have been popular in parts of Africa where HIV and AIDS are highly prevalent. But the WHO and the U.N. AIDS program do not require men to undergo HIV testing before offering them circumcision -- and do not refuse circumcision to men who are infected with the AIDS virus.
There are two reasons for this policy: to avoid stigmatizing men with HIV, and to keep circumcision from becoming an unreliable marker of being HIV-free.
Wawer and colleagues enrolled 922 uncircumcised, symptom-free men with HIV infection. About half the men were offered immediate circumcision, and half were asked to delay circumcision for two years. At regular intervals, the researchers checked the men's female sex partners for HIV infection.
But the study was stopped early when it became clear that circumcision wasn't protecting the women. Eighteen percent of the women with circumcised HIV-infected partners became infected, compared to 12% of those whose partners had not yet been circumcised.
About a quarter of the men in each group did not reveal to their female partners they carried the AIDS virus. And even though the men and women were given repeated AIDS education -- and free condoms -- no more than half the men consistently used condoms.
Despite the findings, Wawer and colleagues suggest that women do benefit when men participate in circumcision programs.
"Reductions in male acquisition of HIV attributable to circumcision are likely to reduce women's exposure to HIV infected men," they say. "Male circumcision programs are thus likely to confer an overall benefit to women."
In an editorial accompanying the Wawer study, University of Washington researcher Jared M. Baeten, MD, and colleagues stress the importance of male circumcision programs. They argue strongly for focusing more effort on people in relationships where one partner is HIV infected and the other is not.
"Prevention services for this population -- including HIV testing for couples, facilitated disclosure of HIV seropositivity, and ongoing counseling services -- should be a public health priority," they write. "Such services should be incorporated into male circumcision programs, thereby providing further protection to HIV uninfected women."
The Wawer study and the Baeten editorial appear in the July 18 issue of The Lancet.
SOURCES: Wawer, M.J. The Lancet, July 18, 2009; vol 374: pp 229-237. Baeten, J.M. The Lancet, July 18, 2009; vol 374: pp 182-184.
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