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Male Circumcision and Risk for HIV Transmission: Implications
for the United States
This fact sheet summarizes information in four areas of male
circumcision: 1) male circumcision and risk of HIV transmission; 2)
male circumcision and other health conditions; 3) risks associated
with male circumcision; and 4) status of HIV infection and male
circumcision in the United States.
What is Male Circumcision?
Male circumcision is the surgical removal of some or all of the foreskin
(or prepuce) from the penis
Male Circumcision and Risk for HIV Transmission
Biologic Plausibility
Compared to the dry external skin surface, the inner mucosa of the
foreskin has less keratinization (deposition of fibrous protein), a
higher density of target cells for HIV infection (Langerhans cells), and
is more susceptible to HIV infection in laboratory studies [3]. It has
also been argued that the foreskin may have greater susceptibility to
traumatic epithelial disruptions (tears) during intercourse, providing a
portal of entry for pathogens including HIV [4]. In addition, the micro-
environment in the preputial sac between the unretracted foreskin
and the glans penis may be conducive to viral survival [2]. Finally, the
higher rates of sexually transmitted genital ulcerative disease, such
as syphilis, observed in uncircumcised men may also increase
susceptibility to HIV infection
International Observational Studies
Multiple cross-sectional, prospective, and ecologic (population-level)
studies have identified lack of male circumcision as a risk factor for
HIV infection.
A systematic review and meta-analysis that focused on heterosexual
transmission of HIV in Africa was published in 2000 [6]. It included 19
cross-sectional studies, five case-control studies, three cohort
studies, and one partner study. A substantial protective effect of male
circumcision on risk for HIV infection was noted, along with a reduced
risk for genital ulcer disease. After adjusting for confounding factors
in the population-based studies, the relative risk for HIV infection was
44% lower in circumcised men. The strongest association was seen in
high-risk men, such as patients at sexually transmitted disease (STD)
clinics, for whom the adjusted relative risk was 71% lower for
circumcised men.
A review that included stringent assessment of 10 potential
confounding factors and was stratified by study type or study
population was published in 2004 [7]. Most of the studies were from
Africa. Of the 35 observational studies included in the review, the 16
in the general population had inconsistent results. The one large
prospective cohort study in this group showed a significant protective
effect, with the odds of infection being 42% lower in circumcised men
[8]. The remaining nineteen studies were conducted in high-risk
populations. These found a consistent, substantial protective effect,
which increased with adjustment for confounding. Four of these were
cohort studies: all demonstrated a protective effect, with two being
statistically significant.
Ecologic studies also indicate a strong association between lack of
male circumcision and HIV infection at the population level. Although
links between circumcision, culture, religion, and risk behavior may
account for some of the differences in HIV infection prevalence, the
countries in Africa and Asia with prevalence of male circumcision of
less than 20% have HIV-infection prevalences several times higher
than countries in those regions where more than 80% of men are
circumcised [9].
International Clinical Trials
Three randomized, controlled clinical trails have been undertaken in
Africa to determine whether circumcision of adult males will reduce
their risk for HIV infection. The study conducted in South Africa [10],
was stopped in 2005 and those in Kenya [11] and Uganda [12] were
stopped in 2006 after their interim analyses found that medical
circumcision reduced male participants’ risk of HIV infection.
In these studies, men who had been randomly assigned to the
circumcision group had a 60% (South Africa), 53% (Kenya), and 51%
(Uganda) lower incidence of HIV infection compared to men assigned
to the wait list group to be circumcised at the end of the study. In all
three studies, a few men who had been assigned to be circumcised
did not undergo the procedure, and vice versa. When the data were
reanalyzed to account for these deviations, men who had been
circumcised had a 76% (South Africa), 60% (Kenya), and 55%
(Uganda) reduction in risk of HIV infection compared to those who
were not circumcised. The Uganda study investigators are also
examining the following in an ongoing study: 1) safety and
acceptability of male circumcision in HIV-infected men and men of
unknown HIV-infection status, 2) safety and acceptability of male
circumcision in the men’s female sex partners, and 3) effect of male
circumcision on male-to-female transmission of HIV and other STDs.
Male Circumcision and Male-to-Female Transmission of HIV
In an earlier study of couples in Uganda in which the male partner was
HIV infected and the female partner was initially HIV seronegative, the
infection rates of the female partners differed by the circumcision
status and viral load of the male partners. If the male blood HIV viral
load was <50,000 copies/mL, there was no HIV transmission if the
man was circumcised, compared to a rate of 9.6 per 100 person-
years if the man was uncircumcised [8]. If viral load was not controlled
for, there was a non-statistically significant trend towards a reduction
in the male-to-female transmission rate from circumcised men
compared to uncircumcised men. Such an effect may be due to
decreased viral shedding from circumcised men or to a reduction in
ulcerative sexually transmitted infections acquired by female partners
of circumcised men [14].
Male Circumcision and Other Health Conditions
Lack of male circumcision has also been associated with sexually
transmitted genital ulcer disease, infant urinary tract infections, penile
cancer, and cervical cancer in female partners of uncircumcised men
[2]. The latter two conditions are related to human papillomavirus
(HPV) infection. Transmission of this virus is also associated with lack
of male circumcision. A recent meta-analysis included 26 studies that
assessed the association between male circumcision and risk of
genital ulcer disease. The analysis concluded that there was a
significantly lower risk of syphilis and chancroid among circumcised
men, while the reduced risk of herpes simplex virus-2 infection had a
borderline statistical significance [5].
Risks Associated with Male Circumcision
Reported complication rates depend on the type of study (e.g., chart
review vs. prospective study), setting (medical vs. nonmedical facility),
person operating (traditional vs. medical practitioner), patient age
(infant vs. adult), and surgical technique or instrument used. The
most common complications are minor bleeding and local infection. In
large studies of infant circumcision in the U.S., complications rates
range from 0.2 to 2.0% [2]. In the recently completed South African
study of adult circumcision by general medical practitioners in their
surgical offices, the overall complication rate was 3.8%. The most
commonly reported complications were pain (0.8%), followed by
swelling or hematoma, bleeding, and problems with appearance (each
0.6%). Damage to the penis (0.3%), infection (0.2%), and delayed
wound healing (0.1%) were uncommon. There were no reported
deaths or problems with urination [10].
HIV Infection and Male Circumcision in the United States
In 2004, men who have sex with men (MSM) (47%) and persons
exposed through heterosexual contact (33%) accounted for an
estimated 80% of all HIV/AIDS cases diagnosed in areas in the U.S.
with confidential name-based reporting. Blacks accounted for 49% of
cases and Hispanics for 18%. Infection rates in both groups were
several-fold higher than that in whites. An overall prevalence of about
less than 0.5% was estimated for the general population [15].
Although data on HIV infection rates are available since the beginning
of the epidemic, data on circumcision and risk for HIV infection in the
U.S. are limited. In one cross-sectional survey of MSM, lack of
circumcision was associated with a two-fold increased odds of
prevalent HIV infection [16]. In another, prospective study of MSM,
lack of circumcision was also associated with a two-fold increased risk
for HIV seroconversion [17]. In both studies, the results were
statistically significant and controlled statistically for other possible
risk factors. In one prospective study of heterosexual men attending
an urban STD clinic, when controlling for other risk factors,
uncircumcised men had a 3.5-fold higher risk of HIV infection than
men who were circumcised. However, this association was not
statistically significant [18].
Status of Male Circumcision in the United States
In a national probability sample of adults in 1992, the National Health
and Social Life Survey found that 77% of men reported being
circumcised including 81% of white men, 65% of black men, and 54%
of Hispanic men [19]. It is important to note that reported circumcision
status may be subject to misclassification. In a study of adolescents¸
only 69% of circumcised and 65% of uncircumcised young men
correctly identified their circumcision status as verified by physical
exam [20].
According to the National Hospital Discharge Survey (NHDS), 65% of
newborns were circumcised in 1999 and the overall proportion of
newborns circumcised was stable from 1979 to 1999 [21]. Notably, the
proportion of black newborns circumcised rose over this reporting
period (58% to 64%), while the proportion of white infants circumcised
remained stable (66%). In addition, the proportion of newborns who
were circumcised in the Midwest increased over the 20-year period
from 74% in 1979 to 81% in 1999, while the proportion of infants born
in the West who were circumcised decreased from 64% in 1979 to
37% in 1999. In another survey, the National Inpatient Sample (NIS),
circumcision rates increased from 48% during 1988-1991 to 61%
during 1997-2000. Circumcision was more common among newborns
born to families of higher socioeconomic status, in the Northeast or
Midwest, and who were black [22].
In 1999, the American Academy of Pediatrics (AAP) changed from
routinely recommending circumcision to a neutral stance on
circumcision, noting that: “It is legitimate for the parents to take into
account cultural, religious, and ethnic traditions, in addition to medical
factors, when making this choice.” [23] This position was re-affirmed
by the Academy in 2005. This change in policy may influence
reimbursement for and practice of neonatal circumcision. In a 1995
review, 61% of circumcisions were paid by private insurance, 36%
were paid for by Medicaid, and 3% were self-paid by the parents of
the infant [24]. Since 1999, 16 states have eliminated Medicaid
payments for circumcisions that were not deemed medically
necessary [25].
Considerations for the United States
There are a number of important differences that must be considered
in the possible role of male circumcision in HIV prevention in the U.S.
Notably, the overall risk of HIV infection is considerably lower in the
United States, changing risk-benefit and cost-effectiveness
considerations. Also, studies to date have focused on heterosexual,
penile-vaginal sex, the predominant mode of HIV transmission in
Africa, while the predominant mode of sexual HIV transmission in the
United States is by penile-anal sex among MSM. In addition, while the
prevalence of circumcision may be somewhat lower in racial and
ethnic groups with higher rates of HIV infection, most Americans are
already circumcised, and it is not known if men at higher risk for HIV
infection would be willing to be circumcised, nor if parents would be
willing to have their infants circumcised to reduce possible future HIV
infection risk. Lastly, whether the effect of male circumcision differs by
HIV-1 subtype, predominately subtype B in the U.S. and subtypes A,
C, and D in Africa, is also unknown.
Summary
Male circumcision has been associated with a lower risk for HIV
infection in international observational studies and in three
randomized, controlled clinical trials. Male circumcision could also
reduce male-to-female transmission of HIV to a lesser extent. It has
also been associated with a number of other health benefits. While
there are risks to male circumcision, serious complications are rare.
Accordingly, male circumcision, together with other prevention
interventions, may play an important role in HIV prevention in settings
similar to the clinical trials.
Male circumcision may also have a role for the prevention of HIV
transmission in the United States. With the results of three clinical
trials showing that male circumcision decreases the risk for HIV
infection, CDC is undertaking additional research and consultation to
evaluate the potential value, risks, and feasibility of circumcision as
an HIV prevention intervention in the U.S.
As CDC proceeds with the development of public health
recommendations for the U.S., individual men may wish to consider
circumcision as an additional HIV prevention measure, but must
recognize that circumcision 1) does carry risks and costs that must be
considered in addition to potential benefits; 2) has only proven
effective in reducing the risk of infection through insertive vaginal sex;
and 3) confers only partial protection and should be considered only
in conjunction with other proven prevention measures (abstinence,
mutual monogamy, reducing number of sex partners, and correct and
consistent condom use).
REFERENCE
CDC. HIV and AIDS: Are You at Risk?
Content Source:
Divisions of HIV/AIDS Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
for the United States
This fact sheet summarizes information in four areas of male
circumcision: 1) male circumcision and risk of HIV transmission; 2)
male circumcision and other health conditions; 3) risks associated
with male circumcision; and 4) status of HIV infection and male
circumcision in the United States.
What is Male Circumcision?
Male circumcision is the surgical removal of some or all of the foreskin
(or prepuce) from the penis
Male Circumcision and Risk for HIV Transmission
Biologic Plausibility
Compared to the dry external skin surface, the inner mucosa of the
foreskin has less keratinization (deposition of fibrous protein), a
higher density of target cells for HIV infection (Langerhans cells), and
is more susceptible to HIV infection in laboratory studies [3]. It has
also been argued that the foreskin may have greater susceptibility to
traumatic epithelial disruptions (tears) during intercourse, providing a
portal of entry for pathogens including HIV [4]. In addition, the micro-
environment in the preputial sac between the unretracted foreskin
and the glans penis may be conducive to viral survival [2]. Finally, the
higher rates of sexually transmitted genital ulcerative disease, such
as syphilis, observed in uncircumcised men may also increase
susceptibility to HIV infection
International Observational Studies
Multiple cross-sectional, prospective, and ecologic (population-level)
studies have identified lack of male circumcision as a risk factor for
HIV infection.
A systematic review and meta-analysis that focused on heterosexual
transmission of HIV in Africa was published in 2000 [6]. It included 19
cross-sectional studies, five case-control studies, three cohort
studies, and one partner study. A substantial protective effect of male
circumcision on risk for HIV infection was noted, along with a reduced
risk for genital ulcer disease. After adjusting for confounding factors
in the population-based studies, the relative risk for HIV infection was
44% lower in circumcised men. The strongest association was seen in
high-risk men, such as patients at sexually transmitted disease (STD)
clinics, for whom the adjusted relative risk was 71% lower for
circumcised men.
A review that included stringent assessment of 10 potential
confounding factors and was stratified by study type or study
population was published in 2004 [7]. Most of the studies were from
Africa. Of the 35 observational studies included in the review, the 16
in the general population had inconsistent results. The one large
prospective cohort study in this group showed a significant protective
effect, with the odds of infection being 42% lower in circumcised men
[8]. The remaining nineteen studies were conducted in high-risk
populations. These found a consistent, substantial protective effect,
which increased with adjustment for confounding. Four of these were
cohort studies: all demonstrated a protective effect, with two being
statistically significant.
Ecologic studies also indicate a strong association between lack of
male circumcision and HIV infection at the population level. Although
links between circumcision, culture, religion, and risk behavior may
account for some of the differences in HIV infection prevalence, the
countries in Africa and Asia with prevalence of male circumcision of
less than 20% have HIV-infection prevalences several times higher
than countries in those regions where more than 80% of men are
circumcised [9].
International Clinical Trials
Three randomized, controlled clinical trails have been undertaken in
Africa to determine whether circumcision of adult males will reduce
their risk for HIV infection. The study conducted in South Africa [10],
was stopped in 2005 and those in Kenya [11] and Uganda [12] were
stopped in 2006 after their interim analyses found that medical
circumcision reduced male participants’ risk of HIV infection.
In these studies, men who had been randomly assigned to the
circumcision group had a 60% (South Africa), 53% (Kenya), and 51%
(Uganda) lower incidence of HIV infection compared to men assigned
to the wait list group to be circumcised at the end of the study. In all
three studies, a few men who had been assigned to be circumcised
did not undergo the procedure, and vice versa. When the data were
reanalyzed to account for these deviations, men who had been
circumcised had a 76% (South Africa), 60% (Kenya), and 55%
(Uganda) reduction in risk of HIV infection compared to those who
were not circumcised. The Uganda study investigators are also
examining the following in an ongoing study: 1) safety and
acceptability of male circumcision in HIV-infected men and men of
unknown HIV-infection status, 2) safety and acceptability of male
circumcision in the men’s female sex partners, and 3) effect of male
circumcision on male-to-female transmission of HIV and other STDs.
Male Circumcision and Male-to-Female Transmission of HIV
In an earlier study of couples in Uganda in which the male partner was
HIV infected and the female partner was initially HIV seronegative, the
infection rates of the female partners differed by the circumcision
status and viral load of the male partners. If the male blood HIV viral
load was <50,000 copies/mL, there was no HIV transmission if the
man was circumcised, compared to a rate of 9.6 per 100 person-
years if the man was uncircumcised [8]. If viral load was not controlled
for, there was a non-statistically significant trend towards a reduction
in the male-to-female transmission rate from circumcised men
compared to uncircumcised men. Such an effect may be due to
decreased viral shedding from circumcised men or to a reduction in
ulcerative sexually transmitted infections acquired by female partners
of circumcised men [14].
Male Circumcision and Other Health Conditions
Lack of male circumcision has also been associated with sexually
transmitted genital ulcer disease, infant urinary tract infections, penile
cancer, and cervical cancer in female partners of uncircumcised men
[2]. The latter two conditions are related to human papillomavirus
(HPV) infection. Transmission of this virus is also associated with lack
of male circumcision. A recent meta-analysis included 26 studies that
assessed the association between male circumcision and risk of
genital ulcer disease. The analysis concluded that there was a
significantly lower risk of syphilis and chancroid among circumcised
men, while the reduced risk of herpes simplex virus-2 infection had a
borderline statistical significance [5].
Risks Associated with Male Circumcision
Reported complication rates depend on the type of study (e.g., chart
review vs. prospective study), setting (medical vs. nonmedical facility),
person operating (traditional vs. medical practitioner), patient age
(infant vs. adult), and surgical technique or instrument used. The
most common complications are minor bleeding and local infection. In
large studies of infant circumcision in the U.S., complications rates
range from 0.2 to 2.0% [2]. In the recently completed South African
study of adult circumcision by general medical practitioners in their
surgical offices, the overall complication rate was 3.8%. The most
commonly reported complications were pain (0.8%), followed by
swelling or hematoma, bleeding, and problems with appearance (each
0.6%). Damage to the penis (0.3%), infection (0.2%), and delayed
wound healing (0.1%) were uncommon. There were no reported
deaths or problems with urination [10].
HIV Infection and Male Circumcision in the United States
In 2004, men who have sex with men (MSM) (47%) and persons
exposed through heterosexual contact (33%) accounted for an
estimated 80% of all HIV/AIDS cases diagnosed in areas in the U.S.
with confidential name-based reporting. Blacks accounted for 49% of
cases and Hispanics for 18%. Infection rates in both groups were
several-fold higher than that in whites. An overall prevalence of about
less than 0.5% was estimated for the general population [15].
Although data on HIV infection rates are available since the beginning
of the epidemic, data on circumcision and risk for HIV infection in the
U.S. are limited. In one cross-sectional survey of MSM, lack of
circumcision was associated with a two-fold increased odds of
prevalent HIV infection [16]. In another, prospective study of MSM,
lack of circumcision was also associated with a two-fold increased risk
for HIV seroconversion [17]. In both studies, the results were
statistically significant and controlled statistically for other possible
risk factors. In one prospective study of heterosexual men attending
an urban STD clinic, when controlling for other risk factors,
uncircumcised men had a 3.5-fold higher risk of HIV infection than
men who were circumcised. However, this association was not
statistically significant [18].
Status of Male Circumcision in the United States
In a national probability sample of adults in 1992, the National Health
and Social Life Survey found that 77% of men reported being
circumcised including 81% of white men, 65% of black men, and 54%
of Hispanic men [19]. It is important to note that reported circumcision
status may be subject to misclassification. In a study of adolescents¸
only 69% of circumcised and 65% of uncircumcised young men
correctly identified their circumcision status as verified by physical
exam [20].
According to the National Hospital Discharge Survey (NHDS), 65% of
newborns were circumcised in 1999 and the overall proportion of
newborns circumcised was stable from 1979 to 1999 [21]. Notably, the
proportion of black newborns circumcised rose over this reporting
period (58% to 64%), while the proportion of white infants circumcised
remained stable (66%). In addition, the proportion of newborns who
were circumcised in the Midwest increased over the 20-year period
from 74% in 1979 to 81% in 1999, while the proportion of infants born
in the West who were circumcised decreased from 64% in 1979 to
37% in 1999. In another survey, the National Inpatient Sample (NIS),
circumcision rates increased from 48% during 1988-1991 to 61%
during 1997-2000. Circumcision was more common among newborns
born to families of higher socioeconomic status, in the Northeast or
Midwest, and who were black [22].
In 1999, the American Academy of Pediatrics (AAP) changed from
routinely recommending circumcision to a neutral stance on
circumcision, noting that: “It is legitimate for the parents to take into
account cultural, religious, and ethnic traditions, in addition to medical
factors, when making this choice.” [23] This position was re-affirmed
by the Academy in 2005. This change in policy may influence
reimbursement for and practice of neonatal circumcision. In a 1995
review, 61% of circumcisions were paid by private insurance, 36%
were paid for by Medicaid, and 3% were self-paid by the parents of
the infant [24]. Since 1999, 16 states have eliminated Medicaid
payments for circumcisions that were not deemed medically
necessary [25].
Considerations for the United States
There are a number of important differences that must be considered
in the possible role of male circumcision in HIV prevention in the U.S.
Notably, the overall risk of HIV infection is considerably lower in the
United States, changing risk-benefit and cost-effectiveness
considerations. Also, studies to date have focused on heterosexual,
penile-vaginal sex, the predominant mode of HIV transmission in
Africa, while the predominant mode of sexual HIV transmission in the
United States is by penile-anal sex among MSM. In addition, while the
prevalence of circumcision may be somewhat lower in racial and
ethnic groups with higher rates of HIV infection, most Americans are
already circumcised, and it is not known if men at higher risk for HIV
infection would be willing to be circumcised, nor if parents would be
willing to have their infants circumcised to reduce possible future HIV
infection risk. Lastly, whether the effect of male circumcision differs by
HIV-1 subtype, predominately subtype B in the U.S. and subtypes A,
C, and D in Africa, is also unknown.
Summary
Male circumcision has been associated with a lower risk for HIV
infection in international observational studies and in three
randomized, controlled clinical trials. Male circumcision could also
reduce male-to-female transmission of HIV to a lesser extent. It has
also been associated with a number of other health benefits. While
there are risks to male circumcision, serious complications are rare.
Accordingly, male circumcision, together with other prevention
interventions, may play an important role in HIV prevention in settings
similar to the clinical trials.
Male circumcision may also have a role for the prevention of HIV
transmission in the United States. With the results of three clinical
trials showing that male circumcision decreases the risk for HIV
infection, CDC is undertaking additional research and consultation to
evaluate the potential value, risks, and feasibility of circumcision as
an HIV prevention intervention in the U.S.
As CDC proceeds with the development of public health
recommendations for the U.S., individual men may wish to consider
circumcision as an additional HIV prevention measure, but must
recognize that circumcision 1) does carry risks and costs that must be
considered in addition to potential benefits; 2) has only proven
effective in reducing the risk of infection through insertive vaginal sex;
and 3) confers only partial protection and should be considered only
in conjunction with other proven prevention measures (abstinence,
mutual monogamy, reducing number of sex partners, and correct and
consistent condom use).
REFERENCE
CDC. HIV and AIDS: Are You at Risk?
Content Source:
Divisions of HIV/AIDS Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
© 2007 Abesha Care Inc. All Right Reserved. office@abeshacare.org
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