Male circumcision reduces risk of acquiring HIV

Three clinical trials conducted in East Africa have shown that male circumcision significantly reduces the risk of acquiring HIV in young African men.

However, some experts have suggested that circumcision, if promoted as an HIV preventive, may increase promiscuity or decrease condom use.

The new study, the first population-level longitudinal assessment of risk compensation associated with adult male circumcision, was conducted during the implementation of the national, voluntary medical circumcision programme in the East African country of Kenya.

From 2008 to 2010, 3,186 uncircumcised men from Nyanza Province participated in the study. Half were circumcised shortly after their baseline assessment, while half chose to remain uncircumcised.

The study is the first of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level Voluntary Medical Male Circumcision (VMMC) programme.

According to the study released by the World Health Organisation as part of the just ended World AIDS conference that took place in Melbourne, Australia, the men, between 18 and 35 years old, were assessed every six months for two years.

They were asked about their perceived risk of acquiring HIV, sexual behaviors, and condom use.

All participants, whether circumcised or uncircumcised, were encouraged to attend HIV testing and counseling services at clinics, where they were exposed to HIV educational videos playing in the waiting areas.

Participants did not receive direct risk-reduction counseling during visits.

“Sexual activity increased equally in the circumcised and uncircumcised men, particularly among the youngest, those 18-24 years old but despite an increase in sexual activity, all other sexual risk behaviors declined in both study groups, and condom use increased,” the study revealed.

Risky behaviors which included engaging in sex in exchange for money or gifts, sex with a casual partner or having multiple sex partners declined considerably among both groups.

Men who were circumcised often perceived they had lessened their risk of acquiring HIV, 30 per cent considered themselves high- risk before circumcision, while just 14 per cent considered themselves so after.

Among those who chose not to be circumcised, 24 per cent considered themselves high-risk at the beginning of the study and 21 per cent still did at the end.

However, the differences in perception of risk did not translate into differences in risky behavior over the two years of the study.

The study was funded by a grant to FHI 360 from the Bill & Melinda Gates Foundation to support the Male Circumcision Consortium, a partnership between FHI 360, Engender Health, and UIC, working closely with the Nyanza Reproductive Health Society.

Bailey received support from the Chicago Development Center for AIDS Research, an NIH funded programme (P30 AI 082151).

Voluntary medical male circumcision is a one-time procedure that has been shown to reduce female-to-male HIV transmission by 60 per cent, making it one of the most high-impact and cost-effective prevention tools available.

Despite this achievement, countries now face major challenges in maintaining momentum. Action is needed to close a looming resource gap of over US$700 million to ensure men at highest risk of HIV exposure have access.

Over the past five years an estimated 5.8 million men and boys in 14 priority African countries have chosen medical circumcision, according to new data from the World Health Organization, representing a dramatic increase in availability and acceptance of the procedure.

Three-quarters of these circumcisions were performed in the past two years, including 2.7 million in 2013.

Other countries like Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe have high rates of heterosexual HIV transmission and historically low levels of male circumcision coverage (nationally or sub-nationally), and are priorities for scale-up.

“The rapid increase in men and boys choosing medical circumcision in eastern and southern Africa demonstrates the feasibility of the procedure as an HIV prevention strategy.

“Social acceptance is growing, and countries are investing in medical infrastructure and capacity”, the study added.

To fully realize the HIV prevention promise of voluntary medical male circumcision, the study noted that countries were setting national targets for attaining high coverage.

Voluntary medical male circumcision is a one-time procedure with lifetime benefits, and its impact will be greatest if roll-out happens quickly.

Clinical studies have shown that voluntary medical male circumcision reduces female-to-male sexual HIV transmission by 60 per cent. When performed by a trained provider, the procedure is safe.

Reducing new HIV infections in men reduces their female partners’ exposure to HIV and men who choose medical circumcision can access HIV testing and other health screenings, and be linked to treatment and care if needed.