Male
Circumcision Does Not Reduce Risk of HIV Transmission to Women
 | A
trial of adult male circumcision was recently halted after interim results showed
that the procedure -- which has previously been shown to reduce the rate of HIV
acquisition by circumcised men -- did not protect their female partners. Findings
were reported in the July
18, 2009 issue of The Lancet. |
By
Liz Highleyman
Randomized trials conducted in Africa over the past
several years have demonstrated that circumcision performed on adult men can
reduce the rate of HIV infection by as much as 60%. 
Some
observational data appeared to suggest that male circumcision may also protect
women from HIV infection. Maria Wawer and colleagues evaluated this hypothesis,
assessing whether circumcision of HIV positive men would reduce transmission of
the virus to their female sexual partners. The
study included 922 uncircumcised asymptomatic HIV-infected men aged 15-49 years
old in the Rakai district of Uganda (men included in the earlier circumcision
trials mentioned above). Participants had relatively well-controlled HIV disease,
with CD4 cell counts above 350 cells/mm3, and were not on antiretroviral therapy
(an intervention that itself has been shown to reduce the risk of HIV transmission A
total of 474 men were randomly assigned to undergo immediate circumcision, while
448 were assigned to a waiting list with circumcision delayed for 2 years.
HIV
negative female partners of these men were concurrently enrolled in the present
study (93 partners of immediately circumcised men, 70 partners of men in the deferred
circumcision group). Participants were followed up at 6, 12, and 24 months. Results 
| The
trial was halted early due to "futility," or no protective effect of
circumcision for the women. | |
| In
a modified intention-to-treat analysis, 18% of women in the immediate intervention
group and 12% in the deferred group became infected with HIV during follow-up,
not a statistically significant difference (P = 0.36). | |
| The
cumulative probability of HIV infection at 24 months among women whose partners
were immediately circumcised was 21.7%, compared with 13.4% among women in the
deferred group (adjusted hazard ratio 1.49; P = 0.37). |
"Circumcision
of HIV-infected men did not reduce HIV transmission to female partners over 24
months," the investigators concluded. "[L]onger-term effects could not
be assessed." Given
these findings, they emphasized, "Condom use after male circumcision is essential
for HIV prevention." However, they said it would not be "sensible"
to urge men to not get circumcised or to scale down recently implemented adult
circumcision programs. Even
if circumcision does not protect the female partners of specific circumcised men,
a lower prevalence of HIV infection among the men in a population would ultimately
benefit women as well. Johns
Hopkins University, Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins
Medical Institutions, Baltimore, MD; Rakai Health Sciences Program, Kalisizo,
Rakai District, Uganda; Makerere University School of Public Health, Kampala,
Uganda; Mulago Hospital, Department of Surgery, Urology Unit, Makerere University,
Kampala, Uganda; College of Health Sciences, Makerere University, Kampala, Uganda;
National Institute of Allergy and Infectious Diseases, National Institutes of
Health, Bethesda, MD; Bill & Melinda Gates Foundation, Seattle, WA. 7/21/09 Reference
MJ
Wawer, F Makumbi, G Kigozi, and others. Circumcision in HIV-infected men and its
effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled
trial. The Lancet 374(9685): 229-237. July 18, 2009.
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