Circumcision May Prevent HIV Infection in Older Men -- and Some Gay Men -- but Complications Are Common in Resource-limited Settings

By Liz Highleyman

Recent research has shown that adult male circumcision can help lower the chances of men becoming infected with HIV, with a 50%-60% reduction in HIV incidence in 2 randomized studies of young heterosexual men in Kenya and Uganda.

Much remains to be learned, however, about which populations might benefit most from circumcision, and how to overcome potential drawbacks associated with providing the procedure on a large scale in resource-limited settings.

What Age Groups to Target?

As reported in the September 12, 2008 issue of AIDS, Richard White of the London School of Hygiene and Tropical Medicine and colleagues analyzed how the population-level impact of circumcision varies by target age group, coverage, time to scale-up, level of risk compensation (e.g., men foregoing use of condoms because they believe they are protected), and circumcision of men who are already HIV-infected.

The United Nations Joint Programme on HIV/AIDS (UNAIDS) currently recommends that circumcision should be offered in countries with high HIV prevalence and low circumcision rates, prioritizing HIV negative men aged 12-30 years.

The investigators used a mathematical model based on the characteristics of a typical high HIV prevalence population in sub-Saharan Africa to look at 3 scenarios of individual-level impact corresponding to the central and upper and lower estimates of benefit in the circumcision trial in Kisumu, Kenya.

The simulated intervention increased the rate of circumcision from 25% to 75% over 5 years in the targeted age groups. The impact and cost-effectiveness of the intervention were calculated over 2-50 years. Future costs and effects were discounted and compared with the present value of lifetime HIV treatment costs (estimated at U.S. $4043).

Results

• Initially, targeting men older than the UNAIDS recommended age group may be the most cost-effective strategy.

• However, targeting any adult age group would be cost-saving.

• Substantial risk compensation could negate the beneficial impact of circumcision, particularly if already circumcised men engage in riskier practices.

• If the rate of circumcision in HIV-uninfected men increases less because HIV-infected men are also circumcised, this would reduce impact of the intervention for men, but would have little effect on the population-level impact for women.

In conclusion, the study authors wrote, "Circumcision is a cost-saving intervention in a wide range of scenarios of HIV and initial circumcision prevalence, but the [UNAIDS]/WHO recommended target age group should be widened to include older HIV-uninfected men and counseling should be targeted at both newly and already circumcised men to minimize risk compensation."

To maximize infections averted, they added, "circumcision must be scaled up rapidly while maintaining quality."

Benefits for Men Who Have Sex with Men

To date, the large randomized studies of circumcision for HIV prevention have been carried out among men who have sex with women, primarily in high HIV prevalence countries in Africa.

It remains unclear whether adult circumcision might confer similar benefits for men who have sex with men (MSM) or for men in low HIV prevalence areas such as the U.S., Australia, and Europe. A study published last year, for example, found no difference in HIV infection rates between circumcised and uncircumcised black and Latino MSM in 3 U.S. cities.

Now, however, an analysis presented this month at the Australasian Sexual Health Conference 2008 offered evidence that circumcision might play a role in preventing HIV infection in some gay and bisexual men.

Researchers from the University of New South Wales studied 1400 HIV negative men, two-thirds of whom were circumcised. During 4 years of follow-up, a total of 53 men became infected with HIV. There was no evidence that circumcision reduced the risk of infection overall. Among men who mainly took the insertive role in anal intercourse, however, the risk of infection was 85% lower among circumcised men.

"We have shown for the first time that MSM who predominantly take on the insertive role in sex are less likely to contract HIV if they've been circumcised," said David Templeton of the National Center for HIV Epidemiology and Clinical Research in Sydney. "Most HIV infections are contracted in the receptive role, so what we're talking about is a risk reduction for a small group of men who didn't have a huge risk in the first place."

The study's mathematical model estimated that 5 of the 7 infections that occurred among insertive partners could have been prevented if the men had been circumcised. Taking a larger view, the model projected that if all Australian MSM were to be circumcised, 37 new infections per year would be prevented during the first decade, rising to 57 per year by 2030.

However, the researchers emphasized that these estimated represented only about 9% of all new infections -- "not enough to advocate throwing out condoms or advocating widespread circumcision," Dr. Templeton said.

High Rate of Complications

Another recent study focused on the risks of circumcision carried out in a resource-limited setting. As reported in the September 2008 Bulletin of the World Health Organization, Robert Bailey -- who led the Kisumu circumcision trial -- and colleagues analyzed circumcision outcomes in the Bungoma district of Western Kenya, where (unlike Kisumu) boys and young men are traditionally circumcised, usually as adolescents.

During the July-August 2004 circumcision season, the investigators interviewed 1007 men between 30 and 89 days after circumcision. Of these, 445 were circumcised by traditional practitioners and 562 were circumcised in a medical setting such as a clinic or hospital. Participants ranged in age from 5 to 21 years. The median age was about 14 years overall, but the men who underwent medical circumcision tended to be younger. About half were sexually active prior to circumcision.

A subset of 24 men were directly observed during the procedure and again at 3, 8, 30, and 90 days post-circumcision, while 298 men underwent clinical exams 45 to 89 days after the procedure.

Finally, 21 traditional practitioners and 20 clinical providers were interviewed to assess their experience and training, and inventories of health facilities were performed to assess the availability and condition of instruments and supplies necessary for performing safe circumcisions.

Results

• All clinical circumcisions, but none of the traditional procedures, were performed under local or general anesthesia.

• Circumcision wounds were usually sutured in clinical circumcisions, but not in the traditional procedures.

• 156 of 443 men who underwent traditional circumcision (35%) experienced an adverse event, compared with 99 of 559 men (18%) who underwent clinical circumcision (odds ratio 2.53).

• Among the medical procedures, those done in private facilities led to adverse events about twice as often as those done in government-run public facilities (23% vs 11%, respectively).

• Bleeding and infection were the most common adverse effects.

• Infections -- ranging from mild to life-threatening -- occurred in 50% of the traditional and 42% of the clinical procedures.

• Excessive pain, lacerations, torsion (curvature of the penis), erectile dysfunction, and incomplete foreskin removal necessitating additional surgery were also observed.

• About 6% of the men experienced potentially permanent adverse events including torsion and loss of sensitivity due to scarring.

• When examined 45-89 days post-procedure, only about 20% in the traditional circumcision group and 10% in the clinical circumcision group were fully healed (a rate considerably lower than that observed in clinical trials)

• About 6% of the traditionally circumcised men and 3% of those who underwent clinical circumcision engaged in sex an average of 60 days after circumcision, often before wounds had fully healed.

• Overall, the researchers reported, "practitioners lacked knowledge and training."

• In addition, "proper instruments and supplies were lacking at most health facilities," including sharp scalpels and autoclaves for sterilization of equipment.

"Extensive training and resources will be necessary in sub-Saharan Africa before male circumcision can be aggressively promoted for HIV prevention," the study authors concluded.

These findings have important implications as countries begin campaigns to scale up adult circumcision for HIV prevention, underlining the need for improved healthcare infrastructure and more trained providers.

Furthermore, the researchers emphasized, "Safety of circumcision in communities where it is already widely practiced must not be ignored."

9/26/08

Sources

R White, J Glynn, K Orroth, and others. Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when? AIDS 22(14): 1841-1850, September 12, 2008. (Abstract).

Australia Associated Press. 'Snip' protects some gay men from HIV: study. September 17, 2008.

R Bailey, O Egesah, and S Rosenberg. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bulletin of the World Health Organization 86(9): 657-736.
(Abstract).