The unequal benefits of male circumcision against HIV

The publication last August in the Lancet (Aaron A R Tobian, Ronald H Gray et al.) of findings from one of the two randomized control studies undertaken 2004-9 by the Rakkai Health Sciences Program (RHSP), Uganda, on the health impacts of circumcision to reduce HIV/STI transmission, has generated further comment in the Lancet from researchers engaged in the South African context (A R Giuliano, A G Nyitray et al.).  The findings of the initial paper indicate the inefficacy of circumcision of HIV-infected males as means of preventing the transmission of Human Papilloma Virus (HPV) to long-term partners.  The issue of HPV transmission has its own importance, given high levels of oncogenic HPV in African countries (4 in 10,000).  But their public health significance becomes fully apparent when taken in conjunction with the findings of a parallel study within RHSP indicating the same inefficacy in relation to the transmission of HIV (by infected males to partners) (M J Wawer, F Makumbi  & G Kigozi).  Altogether, this amounts to indicating no discernible benefits in the case of HIV-infected males – a result which has to be viewed against the background of earlier studies demonstrating the efficacy of circumcision of non-HIV infected males.  So it seems the balance of benefits and disbenefits of circumcision could vary substantially for different groups of the population, with the net effect of circumcision of HIV-infected males being inefficacious, or even harmful.

The findings raise interesting issues for the circumcision programs now under way in Uganda (as from 2010) and elsewhere in sub-Saharan Africa.  The authors of the initial paper plainly envisage the possibility of HIV-infected males demanding circumcision in contexts where this intervention is being promoted as a means of HIV prevention.  Against whatever limited benefit – if any – circumcision may actually confer in such cases, there evidently needs to be balanced the possible impact on the sexual behaviour of HIV-infected males who believe that their circumcision will minimise the risk of their transmitting the infection.  So what if – as the study would suggest – circumcision confers little or no benefit?  Tobian & Gray recommend that circumcision should still not be refused – on the grounds that this might stigmatize.  But they emphasize that “wherever possible, circumcision should be offered with HIV counselling, condoms, and education about HIV prevention”.

The second issue concerns “the ideal time for male circumcision to optimise prevention of infection and disease”.  Here Giuliano & Nyitray corroborate the conclusion from the trial data that “the greatest population benefit is likely to be achieved if done before sexual debut and first exposure to HIV and HPV”.

These are clearly pressing issues in the context of government-backed HIV prevention through circumcision in Uganda and beyond.  The Rakkai Health Sciences Program, which is involved in the provision of circumcision and the training of circumcision providers who operate throughout Uganda, is well placed to conduct a range of research projects that may contribute to the formation of public policy.  Linked with John Hopkins Bloomberg School of Public Health, the program began in 1987 at the initiative of a group of scientists from Makerere University, Kampala.  It has benefited since then from US and International grants, and has hosted two major, randomized, control trials: one, funded by the NIH, to investigate the efficacy of circumcision for HIV prevention; the other, funded by the Gates Foundation, to investigate circumcision and its behavioural impact in men, women and communities.

A R Giuliano, A G Nyitray et al., “Circumcised HIV-infected men and HPV transmission”, The Lancet Infections Diseases, August 2011, vol 11

A A R Tobian, Ronald H Gray et al., “Circumcision of HIV-infected men and transmission of human papillomavirus to female partners: analyses of data from a randomised trial in Rakai, Uganda”, The Lancet  Infectious Disease, August 2011, vol 11

M J Wawer, G Kigozi et al., “Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial”, The Lancet 2009: 374: 229-37

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