HIV Prevention Knowledge Base
Biomedical Interventions: Voluntary Medical Male Circumcision
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Longer-term Effects of Male Circumcision on HIV Incidence and Risk Behaviors during Post-trial Surveillance in Rakai, Uganda
In this study, the control group of a large randomized trial of male circumcision was offered the procedure after the original trial had closed, and four out of five accepted. The men were then followed up for over two years, and HIV incidence between the circumcised and uncircumcised participants was compared. In this group, HIV incidence was 0.53/100 person-years among the circumcised men and 1.65/100 person-years among those uncircumcised, which was almost identical to the outcome of the trial. Potential demographic confounders and sexual behavior traits such as condom use, number of partners, and alcohol use with sex were comparable in both the circumcised and uncircumcised controls, and any changes to sexual behavior during the course of the study were similar in both groups. Although both the circumcised and uncircumcised men reduced their use of condoms, the circumcised group did not do so more frequently.
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Adult Male Circumcision as an Intervention Against HIV: An Operational Study of Uptake in a South African Community (ANRS 12126)
Adult male circumcision (AMC) holds promise as an effective HIV prevention strategy, but detailed communication strategies are required to ensure that communities have an accurate understanding of what it is and the extent of HIV prevention it can confer, according to this paper. The authors conducted a cross-sectional survey and genital examination of almost 1,200 men aged 15 to 49 from Orange Farm, South Africa. Clinical examination revealed that almost half of the men who self-reported being circumcised had intact foreskins. One in five of respondents mistakenly believed that AMC fully protects men against HIV. The incidence of HIV infection was considerably lower among circumcised men, the study found, and among the 860 men who self-reported being uncircumcised who were offered AMC, over 80 percent said they would have the procedure if it was free and performed by a doctor.
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Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up
The cost of not scaling up efforts to implement voluntary male medical circumcision (VMMC) is now too high to ignore, according to this introduction to a series of articles on the costs and impact of VMMC as HIV prevention. If $1.5 billion is spent between 2011 and 2015 in 13 countries where VMMC is a priority in order to attain 80 percent coverage, future cost savings can reach $16.6 billion, by freeing up resources that would otherwise be used to provide antiretroviral treatment. Successful scale-up of VMMC relies on national-level factors such as strong political will and engagement of stakeholders, but it also requires community-level action in demand creation, mobilization, and deployment of human resources, the paper states.
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Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa
This study used the Male Circumcision: Decision Makers’ Program Planning Tool to predict both the cost and impact of scaling up voluntary male medical circumcision (VMMC) in 13 countries in eastern and southern Africa where VMMC is considered a priority (Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza province in Kenya). The calculations were based on epidemiologic and demographic data from each of the countries, and the cost of each procedure, which ranged from $65 to $95, was calculated according to World Health Organization supply-side models for optimal volume and efficiency. To attain 80 percent coverage in these countries requires over 20 million circumcisions between 2011 and 2015, and 8.4 million more in the subsequent decade to maintain coverage at that level. Modeling shows that if coverage at this level could be achieved, it would avert more than 3.3 million new HIV infections, with cost savings on care and treatment of $16.5 billion.
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Voluntary Medical Male Circumcision: A Cross-Sectional Study Comparing Self-Report and Physical Examination Findings in Lesotho
Self-reported male circumcision (MC) may not be an accurate measure of actual circumcision rates, according to this paper. Of 312 men aged 18 to 25 who applied to join the Lesotho Defence Force, 241 agreed to complete a survey and undergo physical examination. Although 64 men reported being circumcised, physical examination showed that only half were completely circumcised, a quarter were partially circumcised, and a quarter were not circumcised at all. Men who reported being circumcised by traditional circumcisers during the process of initiation were seven times more likely to report MC that physical examination showed was not complete. The low accuracy of self-reported circumcision could explain why data from the Lesotho Demographic and Health Surveys appear to contradict the findings of three clinical trials in support of MC as a means of HIV prevention. The authors recommend that service delivery and cost estimates for MC programs should be guided by data from physical examinations, and medical MC campaigns must include education about what constitutes complete circumcision.
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The Protective Effect of Adult Male Circumcision Against HIV Acquisition is Sustained for at Least 54 Months: Results from the Kisumu, Kenya Trial
This paper adds further support to the call for extensive scale-up of voluntary medical male circumcision (VMMC) by showing that the protective effects of the procedure to prevent HIV transmission extend for at least 54 months. The study followed up on the randomized controlled trial of over 2,800 men aged 18 to 24 years from Kisumu, Kenya, who were either offered immediate or delayed VMMC. The trial showed VMMC conferred 60 percent protection against HIV transmission. After the trial was unblinded, all the participants were offered immediate circumcision. Among the controls, those who did and did not choose VMMC had similar profiles in terms of age and number of sexual partners at baseline. The number of seroconversions among circumcised and non-circumcised trial participants during the follow-up period confirmed the level of protective effect found in the original trial, allaying fears that the protection may reduce over time.
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Will Circumcision Provide Even More Protection from HIV to Women and Men? New Estimates of the Population Impact of Circumcision Interventions.
This article is the first to note circumcision’s protective effect in male-to-female transmission. Using data from various studies in eastern and southern Africa, the authors assert circumcision confers a 46 percent reduction in male-to-female HIV transmission. The authors go on to posit that the impact of circumcision on HIV prevention is greater than originally estimated. These projections show a significant increase in infections averted by male circumcision: overall infections averted increased by 40 percent, which includes a doubling of infections averted among women. The authors also note that the increased risk during wound healing does not have a statistically significant impact at a population level.
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Male Circumcision and Risk of HIV Infection in Women: A Systematic Review and Meta-Analysis
Because male circumcision (MC) reduces the risk of HIV infection among heterosexual men, it also provides long-term, indirect protection to women. In this systematic review and meta-analysis, the authors looked at 19 epidemiological studies covering 11 populations, including one randomized controlled trial and six longitudinal studies to see what direct effect on HIV risk in women MC may have. The latter seven studies indicated that there was little evidence of a direct protective effect of MC against women becoming infected with HIV. It would require a randomized controlled trial of 10,000 serodiscordant couples to generate more definitive data, a task that is not logistically practicable. The authors recommend that with the scale-up of MC in high-prevalence settings, the maximum benefits for both men and women would be gained by integrating MC with other prevention strategies, and they urge rigorous monitoring for potential adverse effects for women.
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Effect of Male Circumcision on the Prevalence of High-risk Human Papillomavirus (HR HPV) in Young Men: Results of a Randomized Controlled Trial Conducted in Orange Farm, South Africa
Observational studies suggest that male circumcision (MC) may reduce transmission of high-risk human papillomavirus (HR HPV) strains, which can cause cervical cancer. This is the first randomized controlled trial to assess whether MC is protective against HR HPV. Over 1,200 men ages 18-24 in the Orange Farm township near Johannesburg provided urethral swab specimens 21 months after being randomized to the circumcision or control arm. HR HPV prevalence was 40% lower among men who had been circumcised, compared to those who had not been circumcised. Furthermore, HR HPV prevalence was significantly lower among the circumcised men. Study limitations include a lack of HR HPV testing prior to study inclusion (which can underestimate the true effect of MC), inability to blind the participants to the intervention (which can lead to changes in behavior), and urethral specimens (which are likely to miss HPV infection). Despite these limitations, this study provides additional evidence that MC can help reduce cervical cancer in developing countries.
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The Effects of Male Circumcision on Female Partners' Genital Tract Symptoms and Vaginal Infections in a Randomized Trial in Rakai, Uganda
Using the female partners of men enrolled in a male circumcision (MC) study, researchers investigated whether MC has an effect on their rates of bacterial vaginosis (BV), trichomonas vaginalis, and symptomatic genital ulcer disease. This study only included women who were not infected with HIV, nor whose partners were infected with HIV. Participants in the intervention arm had husbands who were randomized to immediate circumcision, while those in the control arm had husbands with delayed circumcision. Data were collected via interviews, and self-collected vaginal swabs provided samples for testing for BV and trichomonas. Compared to baseline data, one year after enrollment in the trial, women in the intervention arm had lower rates of BV, trichomonas, and self-reported genital ulcer disease than those in the control arm. The reduction of such infections among the partners of circumcised men was 18%, 45%, and 22%, respectively. Despite higher rates of BV among controls and more reported sexual partners among controls, the researchers believe these results are valid. Since reproductive tract infections can heighten the risk of HIV acquisition, MC can help reduce both primary and secondary HIV transmission among women.
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Risk Compensation is not Associated with Male Circumcision in Kisumu, Kenya: A Multi-Faceted Assessment of Men Enrolled in a Randomized Controlled Trial
This study assessed whether about 1,000 18-24 year-old men in Kisumu, Kenya in a male circumcision (MC) randomized, controlled trial adopted risky sexual behaviors after being circumcised. Participants were counseled that research about MC's protective effect against HIV was inconclusive. This study included a comprehensive, 18-point scale that was validated with serologic text results for sexually transmitted infections. Detailed sexual histories were collected at baseline, 6 months, and 12 months after randomization, with individualized HIV risk reduction counseling taking place at this time. The researchers found that sexual risk behaviors decreased one year after being randomized to either MC or to control. There was no difference between circumcised and uncircumcised men after one year of follow up in sexual risk propensity, or incidence of gonorrhea, chlamydia, and trichomoniasis. While this study indicates risk compensation may not be an issue with MC, study participants had risk reduction counseling and the support of a clinical trial—counseling and support that will be difficult to replicate when MC becomes widely available. Furthermore, changes in sexual behavior may take place more than one year after MC.
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Acceptability of Male Circumcision for Prevention of HIV/AIDS in sub-Saharan Africa: A Review
As epidemiologic data mounted regarding the effectiveness of male circumcision (MC) in reducing heterosexual HIV transmission, acceptability of MC becomes a pressing question. As such, these researchers reviewed studies on the acceptability of MC among traditionally non-circumcising areas of sub-Saharan Africa. Thirteen studies met the inclusion criteria, representing nine countries. While willingness of uncircumcised men to become circumcised varied considerably, at least half of men in the studies “appear to be receptive, if not eager, to become circumcised.” Cost, fear of pain, and concern for safety were the three most consistent barriers to acceptability of MC. Furthermore, in every study Africans equated circumcision with improved hygiene. There is a widespread belief that circumcision leads to fewer sexually transmitted infections. Some studies indicated that circumcision was becoming an issue of personal choice rather than ethnic identity. The authors concluded that “acceptability of MC is likely to be high enough to have a significant impact on HIV prevalence in these communities.” Because existing acceptability studies are consistent in support for MC, the authors recommend moving into pilot interventions for MC without the need for further acceptability studies.
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Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomized Controlled Trial
Researchers stopped this study prior to completing because the positive results among study participants in the intervention arm were clear during interim analyses: male circumcision (MC) was protective of HIV infection. Nearly 2,800 men aged 18-24 in Kisumu, Kenya were randomized to immediate circumcision or delayed circumcision at 24 months. Researchers provided HIV counseling and testing, genital examination, and asked participants about their sexual activity; collected blood and urine for sexually transmitted infection (STI) testing, and used a comprehensive questionnaire about sexual function and HIV risk behaviors. Individual risk reduction counseling took place with every visit, free condoms were given to participants, those with STIs were treated and counseling, and those testing positive for HIV were referred to free HIV treatment and care along with a post-test counseling and support group. When the study was halted, MC had a protective effect of 53% compared to the control arm, which increased to 60% when the analysis was statistically adjusted. Men in both study arms reported a reduction in HIV sexual risk behaviors. Uncircumcised men reported decreasing rates of having two or more sex partners over the study period, while this percentage remained stable after month 6 for men who had been circumcised. Furthermore, men with MC were more likely to have unprotected sexual intercourse with any partner in the previous 6 months and less likely to use condoms consistently at 24 months of follow up. The researchers attribute this difference to “increases in safer sexual practices in the control group rather than to riskier behavior patterns in the circumcision group, indicating that risk compensation did not occur” during the study.
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Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomized Trial
This study confirmed the results of the first randomized, controlled trial clearly indicating a protective effect of male circumcision (MC) on HIV acquisition among men. As with the other studies, this one was also stopped early when interim analysis showed a benefit in the intervention arm. Among nearly 5,000 men in Rakai, Uganda, who were enrolled in the study, men who had been circumcised were 51% to 60% less likely to become infected with HIV than the uncircumcised men. (The protective effect varies due to the type of analysis.) This study also shows high acceptability of MC, with 80% of the controls completing 24 months of follow up agreeing to MC. There was no difference in the sexual behavior of the two study arms, which may have been a result of the “intensive health education provided during the trial to minimize risk compensation.” Moderate to severe adverse events were similar to those found in other studies, at about 4%. The authors conclude that while the epidemiological evidence shows a clear benefit of MC, studies that are stopped early could overestimate effectiveness of an intervention. They recommend that long-term surveillance take place to assess the effect of MC on HIV prevalence, and whether any risk compensation takes place.
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Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial
This landmark study was the first randomized, controlled trial to confirm the results of observations studies: that male circumcision (MC) reduced the rate of heterosexual HIV transmission. In fact, this protection was evident partway through the trial, and this was stopped early. Among 3,274 HIV-negative men aged 18-24 in Orange Farm, South Africa, those who had been circumcised were 60% less likely to be infected with HIV than those who had not been circumcised over an 18-month period. This level of protection was evident when using statistical techniques to control for other factors, such as condom use and non-marital sexual partnerships. Because the trial was stopped early, the long-term protective effects of MC on HIV acquisition are unknown. Furthermore, the men who had been circumcised were more likely to have risky sexual behaviors than uncircumcised men, raising concerns about behavioral disinhibition among circumcised men.
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Male Circumcision and Risk of HIV Infection in Sub-Saharan Africa: A Systematic Review and Meta-Analysis
This review focused specifically on research available through 1999 on male-to-female transmission of HIV in sub-Saharan Africa. The authors included 28 observational studies from eight countries in their analysis, including studies among the general populations and high-risk populations. When the data were pooled, circumcision reduced the risk of HIV infection by about one-half compared to non-circumcised men. Those at high risk of HIV tended to experience a greater protective effect of the procedure, although men in the general population also experience a significant protective effect. Despite the limitations of observational studies, the authors concluded that compelling evidence exists for additional studies on “the, acceptability, feasibility, and safety of introducing male circumcision as an HIV prevention strategy in high prevalence areas where men are not traditionally circumcised.”
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Acceptability of Early Infant Male Circumcision as an HIV Prevention Intervention in Zimbabwe: A Qualitative Perspective
In this qualitative study, the authors say that early infant male circumcision (EIMC) is safer and more cost-effective than adult circumcision and find that barriers related to perceptions of safety and low levels of knowledge about male circumcision—rather than individual beliefs—are more likely to impede EIMC uptake. In a 2009 survey, 60 percent of Zimbabwean women and 58 percent of men reported a willingness to have their sons circumcised. The study found similar acceptability rates but low levels of knowledge about the procedure. The authors encourage the creation of community awareness and mobilization campaigns aimed at women as well as men to spread information on male circumcision beyond clinics. They also underscore the importance of understanding cultural and religious beliefs attached to male circumcision among certain groups and of involving religious and traditional leaders in EIMC campaigns. Finally, they stress that, although fathers often learn about EIMC from mothers (who themselves learn about the procedure at health centers), it’s important to provide information directly to fathers in workplaces and beer halls. Concerns for the child’s safety, such as the belief that a newborn’s penis is “too fragile” to undergo circumcision, must also be addressed. The authors encourage the use of quality assurance methods to ensure a cosmetically acceptable result and to prevent adverse effects. They also encourage increased education for nurses and midwives to improve their ability to safely perform EIMC skills.
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The Effectiveness of Male Circumcision for HIV Prevention and Effects on Risk Behaviors in a Posttrial Follow-Up Study
Male circumcision (MC) can provide protection from HIV over an extended period, according to a follow-on study that examined long-term effectiveness data from a trial in Rakai, Uganda—one of the three completed randomized controlled trials that proved the efficacy of MC for HIV prevention in men. The Uganda trial, involving 4,996 HIV-negative uncircumcised men aged 15 to 49, was closed early on December 12, 2006, after it demonstrated the efficacy of MC. Subsequently, 4,145 HIV-negative men were enrolled in a post-trial surveillance study that ended December 15, 2010. According to the authors, there were no statistically significant differences in socio-demographic characteristics or sexual risk between men who accepted circumcision and those who remained uncircumcised. Moreover, the authors found no significant risk compensation or increased risk behavior following circumcision. Analysis of the findings of the follow-on trial showed that MC’s high effectiveness (adjusted effectiveness of 73 percent) was maintained for slightly less than five years. These results are similar to those from a recent study in Kenya, which found efficacy rates of 64 percent over 4.5 years following the closure of a comparable MC trial. The results also mirror observational studies demonstrating reduced HIV incidence among adult men who had been circumcised during infancy or childhood.
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Sex with Stitches: The Resumption of Sexual Activity During the Post-Circumcision Wound Healing Period in Zambia
Approximately 25 percent of men who have undergone medical male circumcision in Zambia reported resuming sex prior to full healing of their wounds. This observational study, focusing on early resumption of sexual behavior following circumcision, included 225 men aged 15 to 29. Men undergoing circumcision are generally counseled to avoid sexual activity until six weeks post-circumcision. Of the men in the study, most (82 percent) reported at least one unprotected sex act before the end of the six-week recovery period, and close to 40 percent reported having sex with multiple partners. Using a regression model, the authors calculated that of the 61,000 men circumcised in one year, early resumption of sex leads to 69 additional HIV infections (32 in men and 37 in women), while circumcision averts 230 HIV infections in one year, predominantly among men. The authors caution that an increase of only 5 percent in early resumption of sex (from 25 to 30 percent) may lead to more new HIV infections in women than HIV infections averted overall. They associate early resumption of sex after circumcision with reported risky sexual behavior just prior to circumcision and with a reported higher number of lifetime sexual partners. The authors recommend targeting counseling at men who are identified as engaging in sexual behavior that puts them at high risk of acquiring HIV infection as well as investigating the costs and impact of interventions to drive down sexual behavior in the wound-healing period, particularly interventions targeting women.
Related Pages
Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa (PDF, 275 KB)- USAID Global Health e-Learning Course on Male Circumcision
- PloS Medicine VMMC Collection
- Clearinghouse on Male Circumcision
- M-CHIP Website on VMMC
