Circumcision for HIV prevention

March 30, 2009

Dr. Judith Wasserheit of the Center's Clinical Research Division and Vaccine and Infectious Disease Institute

Circumcision of adult and newborn males is an important tool for preventing HIV and other sexually-transmitted diseases and should be made widely available in areas of high disease prevalence around the world, according to a recent editorial in last week’s New England Journal of Medicine. Dr. Judith Wasserheit, of the Clinical Research Division and the Vaccine and Infectious Disease Institute, co-authored the widely-quoted editorial with Dr. Matthew Golden of the University of Washington Center for AIDS and STD and the Seattle-King County Public Health Department’s STD Control Program. Wasserheit also is a member of the departments of Global Health and Medicine at the University of Washington.

Citing a new study from Uganda published in the March 26 issue of the journal and summarizing previous research and observational studies, Golden and Wasserheit conclude that “evidence now strongly suggests that circumcision offers an important prevention opportunity and should be widely available.”
 
They call on professional organizations to take leadership roles in ensuring that medical providers actively educate all parents or guardians of newborn sons about the benefits and risks of circumcision.
 
Based on their review of newly- and recently-published studies, the authors conclude that:

• “In areas with a high prevalence of heterosexually-transmitted HIV, expanding access to safe circumcision, both for adults and neonates, is well justified, and new data related to HPV and HSV-2 add to already compelling arguments supporting circumcision.
• “In low-income and middle-income countries with a lower prevalence of heterosexually-transmitted HIV (particularly those with high rates of cervical cancer and limited infrastructure to perform safe circumcision), decisions should be made after estimating the costs and potential population-level benefits of the procedure.
• “In higher-income nations, such as the United States, the findings from studies of circumcision are a call to action for professional societies and providers. Given the frequency, morbidity and mortality that characterize the three most important sexually transmitted viral infections, widespread access to accurate information about circumcision and to safe procedures should be available. In the United States, rates of circumcision are declining and are lowest among black and Hispanic patients, groups in whom rates of HIV, herpes, and cervical cancer are disproportionately high. Medicaid, which insures many low-income persons in these populations, does not pay for routine neonatal circumcision in 16 states. This policy limits access to the procedure on the basis of economic circumstances, potentially exacerbating existing disparities.”
  

The Ugandan trial on the effect of circumcision on the prevalence of human papillomavirus (HPV) infection and the incidence of herpes simplex virus type 2 (HSV-2) infection and syphilis found that adult male circumcision decreased the prevalence of HPV by 35 percent, reduced HSV-2 acquisition by 25 percent, but had no effect on the incidence of syphilis “which probably reflected a limited power to detect an effect,” the authors wrote. Previous reports from this trial showed that male circumcision reduced the occurrence of genital ulcers in men and genital ulcers, bacterial vaginosis, and trichomoniasis in female partners. These findings agree with two recent studies from South Africa showing that circumcision reduced the prevalence of high-risk HPV and the incidence of HSV-2 by one third.

“These new data should prompt a major reassessment of the role of male circumcision, not only in HIV prevention but also in the prevention of other sexually transmitted infections,” the authors said.

The full text of the editorial, “Prevention of Viral Sexually Transmitted Infections – Foreskin at the Forefront,” can be found here: http://content.nejm.org/cgi/content/full/360/13/1349.