An interim analysis from the Rakai Health Sciences Program Data and Safely Monitoring Board indicates that there may be a heightened risk of HIV transmission to female partners of recently circumcised men if sexual activity takes place before the surgical wound is completely healed. It also calls into question whether circumcision indirectly benefits uninfected female partners of HIV-infected men.
This information was presented by researchers from the Rakai Health Sciences Program and Makerere University in Uganda and the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland at a multi-day meeting convened by the World Health Organization (WHO) and UNAIDS Secretariat to discuss policy and operational and ethical issues concerning circumcision as a weapon against HIV transmission. The preliminary data were released on March 6th at the meeting because of potential public health implications.
The trial involves 997 couples from the Rakai district of southern Uganda and the interim analysis looked at 124 discordant couples in which the man was HIV-positive. The risks, benefits, and safety of circumcision to the male partner were looked at, as was circumcision’s impact on HIV transmission to the female partner.
In 25% of the couples who engaged in sexual activity before a physician had “certified” the man as being healed, HIV transmission took place (3/12 women). In those couples who abstained from sexual activity until wound healing was complete, transmission took place in 11% (6/55 women). In those couples where the man was not randomised to undergo circumcision, ~9% of the women became HIV-infected in this six-month study period (4/46 women).
“Because the total number of men who resumed sex before certified wound healing is so small, the finding of increased transmission after surgery may have occurred by chance alone. However, we need to err on the side of caution to protect women in the context of any future male circumcision programme,” said Dr Maria Wawer, the study’s principal investigator and a researcher at the Johns Hopkins Bloomberg School of Public Health. “Women make up a majority of people living with HIV in Africa, and these results demonstrate that women need to be educated about the risks and benefits of male circumcision.”
Many studies undertaken in Africa have shown that the risk of acquiring HIV infection, or any other sexually transmitted disease, is lessened for men who have undergone circumcision. These preliminary results caution that circumcision may not be effective in preventing male-to-female disease acquisition and may even result in an increased risk of transmission, particularly in the first months after surgery.
Recent circumcision studies among HIV-negative men also suggest that wound healing might play a role in increasing the rate of new HIV infections post-surgery and that the benefits to circumcision are not seen until six to twelve months after the procedure. The question of whether circumcision might have an indirect protective benefit to women in the long term remains to be answered.
“While male circumcision has extraordinary potential to prevent HIV infection, these new findings remind us that we must proceed with thought and care in developing strategies to expand male circumcision in Africa,” said Dr Kevin De Cock, the head of the WHO’s HIV/AIDS department. “Circumcision of adult males is a surgical intervention that needs to be performed by trained medical personnel, and issues such as wound healing, condom use, other prevention approaches, and HIV testing must be considered very carefully. Even under the best of conditions, male circumcision must be implemented as part of a comprehensive programme for HIV/AIDS prevention, treatment and care.”