Male Circumcision Reduces HIV Infection Risk Equivalent to a High
Efficacy Vaccine
Over 3 million people died of AIDS in 2004 and about 5 million others
became infected with HIV, bringing the total number of people
living with the infection to nearly 40 million.
The continuing rise in the number of new cases makes it a priority
to investigate all possible measures that might reduce the risk
of infection, particularly—but by no means only—in Africa, which
has 10% of the world's population but two-thirds of the world's
people with HIV.
In many African tribal groups, men are circumcised, usually in late
childhood or as teenagers, and this is an important part of their
cultural identity. In other African ethnic groups, men are not
circumcised.
From observational studies dating back to the 1980s, it has become
clear that HIV infection rates are greater in those groups where
men were not circumcised.
It has, however, remained a matter of speculation as to whether it
is circumcision itself
or some other difference in behavior that has a protective effect.
What has been needed to settle this question is a randomized controlled
trial (RCT) of the use of circumcision as a preventive intervention.
Auvert et al. have completed the first such trial in the Orange
Farm area, a semiurban region close to Johannesburg, South Africa. This was a randomized, controlled intervention trial
conducted in a general population of South Africa to test this hypothesis.
Results
- A total of 3,274 uncircumcised men, aged 18–24 y,
were randomized to a control or an intervention group with
follow-up visits at months 3, 12, and 21.
- Male circumcision was offered to the intervention
group immediately after randomization and to the control group
at the end of the follow-up.
- The grouped censored data were analyzed in intention-to-treat,
univariate and multivariate, analyses, using piecewise exponential,
proportional hazards models.
- Rate ratios (RR) of HIV incidence were determined
with 95% CI.
- Protection against HIV infection was calculated
as 1 − RR. T
- The trial was stopped at the interim analysis, and
the mean (interquartile range) follow-up was 18.1 mo (13.0–21.0)
when the data were analyzed.
- There were 20 HIV infections (incidence rate = 0.85
per 100 person-years) in the intervention group and 49 (2.1
per 100 person-years) in the control group, corresponding
to an RR of 0.40; p < 0.001).
- This RR corresponds to a protection of 60%.
- When controlling for behavioural factors, including
sexual behaviour that increased slightly in the intervention
group, condom use, and health-seeking behaviour, the protection
was of 61%.
In
conclusion, the authors write, “Male circumcision provides a degree
of protection against acquiring HIV infection, equivalent to what
a vaccine
of high efficacy would have achieved.”
“Male
circumcision may provide an important way of reducing the spread
of HIV infection in sub-Saharan Africa.”
Hôpital Ambroise-Paré, Assitance Publique-Hôpitaux de
Paris, Boulogne, France, Saint-Maurice, France, University Versailles
Saint-Quentin, Versailles, France, Villejuif, France, Progressus,
Johannesburg, South Africa, National Institute for Communicable
Disease, Johannesburg, South Africa.
10/31/05
Reference
B
Auvert and others. Randomized, Controlled Intervention Trial of
Male Circumcision for Reduction of HIV Infection Risk: The ANRS
1265 Trial. SEARCH PLoS Medicine 2(11): e298. October 25, 2005.
