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Circumcision Produces Eightfold Reduction in HIV Risk: Presented at IDSA

By Maury M. Breecher, PhD, MPH

SAN DIEGO, CA -- October 14, 2003 -- Uncircumcised men have 8 times the risk of being infected with HIV-1 compared with those who are circumcised, according to a large study of men from the subcontinent of India presented here October 11^th at the 41^st Annual Meeting of the Infectious Diseases Society of America.

"It's important that we offer measures to help curb the spread of AIDS, particularly in developing countries, where it continues to grow at an alarming rate," said study investigator Steven J. Reynolds, MD, MPH, post-doctoral fellow in the division of infectious diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States. "Condoms are protective, but they still are not being used consistently in some settings. This study suggests that circumcision, where safe and culturally acceptable, may offer the developing world another tactic in combating the spread of HIV."

The findings, if replicated, would be a compelling argument for circumcision of male babies in countries where the practice is not common," said Thomas Quinn, MD, a professor of medicine at Johns Hopkins University, who was not one of the study investigators, but who, as one of 14 members of the IDSA governing council, was familiar with the research.

"In this particular study circumcision reduced the risk 8-fold, a finding that has sparked the creation of three randomised, controlled studies currently being done on this subject," Dr. Quinn continued. "If those prospective studies show a reduction of HIV acquisition by 50%, then this one surgical procedure could reduce half of all HIV transmissions to men over subsequent years and that would be a compelling argument for circumcision of male babies in countries where the practice is not common."

In North America, 70% of adult men are circumcised.

"That explains why female-to-male transmission of HIV in the Americas is less efficient than male-to-female transmission," continued Dr. Quinn. "Because nearly 3 out of 4 men are circumcised, they are less susceptible.

"In Europe and in Africa it is the reverse -- 75% to 80% of all men are uncircumcised. So, if this study is replicated, that would be strong argument that this large body of susceptible men that could benefit from this procedure"

Dr. Quinn pointed out that in North America there is a movement to ban circumcision because "some people think it is cruel and unfair to infants." However, this research, if replicated, would take the wind from the sails of that movement, Dr. Quinn opined.

The study researchers also evaluated the risk of other STDs - including syphilis, gonorrhea and genital herpes - among circumcised and uncircumcised men. Although the incidence of these STDs was slightly higher among uncircumcised men compared to circumcised men, the difference was not statistically significant in this study, said Dr. Reynolds. This was in contrast to the reduced risk of HIV among circumcised men, which was highly statistically significant.

The research was part of a larger study investigating risk factors for HIV-1 infection based on men attending one of three STD clinics in Pune, India. Between 1993 and 2000, 2,298 men who tested negative for HIV-1 were enrolled in the study. During subsequent visits (an average of three visits in 11 months), 1.0% of 191 men who were circumcised and 7.8% of 2,107 who were uncircumcised tested positive for HIV.

Demographics, sexual risk behaviours (including having sex with a prostitute), and condom use were remarkably similar between both groups, said Dr. Reynolds. Despite the similarity in risk profiles, researchers determined the incidence rate of HIV-1 among circumcised men was 0.7%, whereas among uncircumcised men it was 5.5%, an 8-fold increase.

The findings suggest the benefit of circumcision may be biological rather than due to other factors, such as infection with another STD, or differences in behaviour between circumcised and uncircumcised men, said Dr. Reynolds.

"The inner surface of the foreskin is not as thickly "keratinised" as the outside or other surfaces of the penis, meaning it has less of a protective layer and may be more easily penetrated by HIV, he explained. Thus, the inner surface of the foreskin has higher numbers of the cells that HIV can infect, and that possibly contributes to the reduced risk of HIV infection observed when the foreskin is removed.

Circumcision is not totally protective so regular condom use is still the best way of protecting against HIV and other sexually transmitted diseases, said Dr. Reynolds. Condom promotion remains a key strategy in the current fight against the spread of AIDS, he said.


[Study title: Male Circumcision Is Protective Against HIV-1 But Not Other Common Sexually Transmitted Infections In India. Abstract LB-10]

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