What Is the Potential Impact of Adult Circumcision on the HIV Epidemic Among Men Who Have Sex With Men in San Francisco?

Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
Sexually transmitted diseases (Impact Factor: 2.84). 11/2010; 38(4):353-5. DOI: 10.1097/OLQ.0b013e3181fe6523
Source: PubMed


With the help of a community-based survey, we assess the potential effect of circumcision on the HIV epidemic among men who have sex with men (MSM) in San Francisco. Only a small minority of MSM would both derive benefit from circumcision (i.e., were uncircumcised, HIV-negative, predominantly insertive, and reported unprotected insertive anal sex) and be willing to participate in circumcision trials (0.7%) or be circumcised if proven effective as a prevention strategy (0.9%). Circumcision would have limited public health significance for MSM in San Francisco.

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    • "Willingness is generally low (∼10%) in high-resource settings [23], [24], but higher (∼30%) in some resource-limited Asian settings [25]–[27]. One San Francisco study found moderate willingness (20%) among the target population (HIV-negative, predominantly insertive, uncircumcised MSM who have UAI); however, the proportion of the MSM sample found in the target population was so small (3.7% or n = 15) that the study anticipated limited public health benefits for MSM-MC [28]. In contrast, unpublished results from Peru and Ecuador suggest that around half (54.3%) of uncircumcised MSM would be willing to participate in an MSM-MC trial [29]. "
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    ABSTRACT: Background Three trials have demonstrated the prophylactic effect of male circumcision (MC) for HIV acquisition among heterosexuals, and MC interventions are underway throughout sub-Saharan Africa. Similar efforts for men who have sex with men (MSM) are stymied by the potential for circumcised MSM to acquire HIV easily through receptive sex and transmit easily through insertive sex. Existing work suggests that MC for MSM should reach its maximum potential in settings where sexual role segregation is historically high and relatively stable across the lifecourse; HIV incidence among MSM is high; reported willingness for prophylactic circumcision is high; and pre-existing circumcision rates are low. We aim to identify the likely public health impact that MC interventions among MSM would have in one setting that fulfills these conditions—Peru—as a theoretical upper bound for their effectiveness among MSM generally. Methods and Findings We use a dynamic, stochastic sexual network model based in exponential-family random graph modeling and parameterized from multiple behavioral surveys of Peruvian MSM. We consider three enrollment criteria (insertive during 100%, >80% or >60% of UAI) and two levels of uptake (25% and 50% of eligible men); we explore sexual role proportions from two studies and different frequencies of switching among role categories. Each scenario is simulated 10 times. We estimate that efficiency could reach one case averted per 6 circumcisions. However, the population-level impact of an optimistic MSM-MC intervention in this setting would likely be at most ∼5–10% incidence and prevalence reductions over 25 years. Conclusions Roll-out of MC for MSM in Peru would not result in a substantial reduction in new HIV infections, despite characteristics in this population that could maximize such effects. Additional studies are needed to confirm these results for other MSM populations, and providers may consider the individual health benefits of offering MC to their MSM patients.
    PLoS ONE 07/2014; 9(7):e102960. DOI:10.1371/journal.pone.0102960 · 3.23 Impact Factor
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    • "In studies of MSM, a US study found that 53% of participants were willing to be circumcised in one survey [95], whereas another, conducted in San Francisco, found 28% of the uncircumcised were willing to get circumcised if there was evidence of efficacy, but only 0.9% of those for whom MC would be a relevant intervention (mostly those who engaged in insertive anal intercourse not using condoms) were willing [116]. In Scotland, only 14% of MSM indicated their willingness to take part in a circumcision trial [117]. "
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    ABSTRACT: Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves. We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used. Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.
    BMC Pediatrics 02/2012; 12(1):20. DOI:10.1186/1471-2431-12-20 · 1.93 Impact Factor
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    ABSTRACT: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection. These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues. Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random-controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a 'surgical vaccine' is criticised as polemical and unscientific. Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.
    Australian and New Zealand Journal of Public Health 10/2011; 35(5):459-65. DOI:10.1111/j.1753-6405.2011.00761.x · 1.98 Impact Factor
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