Male Circumcision for Prevention of HIV Transmission: What the New Data Mean for HIV Prevention in the United States

PLoS Medicine, Jul 2007

Recent clinical trials in Africa found that male circumcision reduces the risk of acquiring HIV from heterosexual sex--what are the implications of these studies for the United States?

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Male Circumcision for Prevention of HIV Transmission: What the New Data Mean for HIV Prevention in the United States

et al. (2007) Male circumcision for prevention of HIV transmission: What the new data mean for HIV prevention in the United States. PLoS Med 4(7): e223. doi:10.1371/journal.pmed.0040223 Male Circumcision for Prevention of HIV Transmission: What the New Data Mean for HIV Prevention in the United States Patrick S. Sullivan 0 Peter H. Kilmarx 0 Thomas A. Peterman 0 Allan W. Taylor 0 Allyn K. Nakashima 0 Mary L. Kamb 0 Lee Warner 0 Timothy D. Mastro 0 0 Patrick S. Sullivan, Peter H. Kilmarx, Allan W. Taylor, Allyn K. Nakashima, and Timothy D. Mastro are with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. Thomas A. Peterman and Mary L. Kamb are with the Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. Lee Warner is with the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. The findings and conclusions in this commentary are those of the authors, and do not necessarily represent the views of the Centers for Disease Control and Prevention - Tclinical trials in South Africa, hree randomized, controlled Kenya, and Uganda were recently unblinded early because interim analyses concluded that circumcision of HIV-negative adult males reduced their risk for acquiring HIV infection through penilevaginal sex [13]. In each trial, men who had been randomly assigned to an intervention group receiving circumcision had a lower incidence of HIV infection in up to two years of follow up, compared to men who were assigned to a control group not receiving circumcision. The estimated reduction in the risk of HIV infection ranged from 51% to 60%; per-protocol estimates of risk reduction ranged from 55% to 76%. It is now clear that male circumcision can be efficacious for men in reducing their risk of HIV acquisition through sex with women [4]. Some experts predict that the impact of male circumcision as a biomedical intervention for HIV prevention in Africa could be large [5,6], and preparatory work has been done to establish male circumcision programs in Africa. The implications of African trials on circumcision for HIV prevention programs in the United States are less cleardespite the interest of the popular press in the idea [7]. Here, we consider the differences between the HIV epidemics in Africa and the US, the current status of male circumcision in the US, and the knowledge gaps that will need to be addressed as we consider whether male circumcision should be evaluated or implemented as a biomedical intervention to reduce sexually acquired HIV infections domestically. The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies. Epidemiological Differences The results of any trial must be interpreted with the caution that inference not be extended to populations differing from the study participants in important ways. The HIV epidemics in Africa are substantially different from the US epidemic. Generalized HIV epidemics exist in many areas of Africa, and the population prevalence of HIV among adult Kenyans, Ugandans, and South Africans ranges from 6%19% [8]. The predominant mode of HIV transmission in Africa is malefemale sex. In contrast, the US has a concentrated epidemic, with most sexual transmission occurring among men who have sex with men (MSM). The general population prevalence of HIV is about 0.4% in the US [9], and only 15% of men diagnosed with HIV infection during 2005 were reported to have acquired HIV through male female sex [10]. Biological Plausibility of Circumcision to Prevent HIV Acquisition The association between circumcision and reduced risk for HIV acquisition is biologically plausible: the foreskin contains high concentrations of superficial Langerhans cells, CD4+ T cells, and macrophages [11]all target cells for HIV infection, some of which may also be close to the skin surface [12,13]. In addition, the preputial sac may serve as a reservoir for HIVcontaining secretions, resulting in prolonged contact time after exposure to secretions, and the foreskin may present less of a physical barrier to HIV entry than the more heavily keratinized skin of the shaft of the penis [12], and may have more frequent epithelial disruption. There are also potential indirect mechanisms of association between lack of circumcision and HIV risk; for example, lack of circumcision is associated with increased risk of genital ulcer diseases, which in turn are associated with increased risk of HIV transmission and acquisition [14]. Considerations for Prevention of HIV Transmission by Penile Vaginal Sex in the US Epidemic differences are important because, on a population basis, the impact of circumcision as an intervention to prevent HIV infection among men who have sex with women will depend on th (...truncated)


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Patrick S Sullivan, Peter H Kilmarx, Thomas A Peterman, Allan W Taylor, Allyn K Nakashima, Mary L Kamb, Lee Warner, Timothy D Mastro. Male Circumcision for Prevention of HIV Transmission: What the New Data Mean for HIV Prevention in the United States, PLoS Medicine, 2007, Volume 4, Issue 7, DOI: 10.1371/journal.pmed.0040223