Male circumcision and HIV/AIDS: challenges and opportunities.

On December 13, 2006, the National Institutes of Health (NIH) announced the early termination of two randomised controlled trials of male circumcision—in Kenya and Uganda—on the basis of interim evidence that male circumcision provided a protective benefi t against HIV infection of 53% among the 2784 Kenyan men and 51% among the 4996 Ugandan men enrolled in the respective studies. The Kenya and Uganda trials replicated the landmark fi ndings of the South African Orange Farm study, the fi rst randomised controlled trial to report a greater than 50% protective benefi t of male circumcision. Before the availability of data from these three African randomised controlled trials, multiple observational studies correlated male circumcision with reduced risk of HIV infection. Systematic reviews and meta-analysis of observational studies provide further evidence of the association of male circumcision with reduced risk of HIV infection and a plausible explanation for the biological mechanism for reduced risk of infection has been suggested. Recently released longitudinal evidence of the range of health benefi ts that male circumcision provides, modelling based on the South African trials, and cost-eff ectiveness data in both North America and Africa provide further evidence to support the health benefi ts of male circumcision. Male circumcision is also associated with reduced risk of urinary tract infections, genital ulcer diseases, penile cancer, and a possible reduction in transmission of human papillomavirus (HPV) exists. Yet enthusiasm generated from the three trials might not lead to accelerated scale-up. Regrettably, the global experience with access to antiretroviral drugs shows that strong science alone does not result in rapid, widespread rollout. Not until civil society, non-governmental organisations, and a chorus of advocacy groups successfully lobbied for universal access to antiretrovirals did widespread rollout in areas with a high burden of HIV areas begin in earnest. Rapid implementation of male circumcision will probably require a similar eff ort. In areas where HIV-1 prevalence constitute a generalised population epidemic, male circumcision could have dramatic life-saving eff ect at the population level. A recent article reported that 15-year-olds in South Africa now have a 56% chance of dying before turning 60; 10 years ago, the chance was 29%. The article continues, “A third of women between the ages of 25 and 29 years are infected, while 19% of the country’s workingage (age 20 to 64) population is HIV positive.” In South Africa, which has an estimated adult prevalence of about 19%, and in areas with similarly high prevalence, one could expect male circumcision to have a similar eff ect to the herd immunity seen with intensive immunisation programmes. Recent modelling by Williams and colleagues, based on the protective rates achieved in the South African trial, showed that the greatest eff ect would be in southern Africa, where circumcision rates are low and HIV prevalence is high. Williams and colleagues projected that large-scale implementation of male circumcision has the potential to avert about 2 million new HIV infections and 300 000 deaths over the next 10 years. Over the subsequent 10 years, an additional 3·7 million HIV infections and 2·7 million deaths could be averted. Furthermore, they report that combining male circumcision with prevention strategies known to reduce transmission rates—eg, use of antiretrovirals— would further reduce new infections. In communities with high HIV prevalence, cost analysis is not just limited to preventing HIV infections and the associated cost of treatment (if available), but the economic benefi ts gained by entire countries by maintaining the health of the most productive age-groups of their populations. In regions where HIV is not a generalised epidemic and access to antiretrovirals, condoms, and routine medical care is greater, male circumcision could have relevance for its other health benefi ts, and the associated risks should be considered in this context. For the general population, male circumcision might have populationlevel and cost benefi ts through decreasing urinary tract infections, HPV transmission (and thus cervical cancer), and incidence of genital ulcerative diseases. It could also have critical importance in specifi c segments of the population that are disproportionately burdened with sexually transmitted diseases, where circumcision rates are low, and HIV prevalence is high.