Male circumcision to reduce sexual transmission of HIV

Three large trials among African heterosexual men in the last decade have confirmed that male circumcision reduces HIV acquisition. This review summarizes recent data regarding circumcision performed primarily to reduce HIV in high-prevalence settings.

Male circumcision more than halved the acquisition of HIV in the trials, and was associated with few adverse events and high levels of satisfaction. An additional trial found no direct reduction in HIV risk for female partners of circumcised men. Evidence for an HIV-protective effect of circumcision in men who have sex with men is weak and inconclusive. Acquisition of HSV-2 and high-risk human papillomavirus are both reduced in circumcised heterosexual men, whereas acquisition of common male urethral pathogens are not. Concerns exist that behavioural disinhibition could offset benefits of this intervention, and it remains to be seen whether the low rate of adverse events and adoption of safer sexual practices observed in the trials will be maintained in circumcision programmes outside trial settings.

The evidence that circumcision reduces HIV in African heterosexual men is clear. The impedance of political, cultural and logistic factors on expansion of much-needed African circumcision services requires urgent attention.