Circumcision and HIV transmission

National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA.
Current Opinion in Infectious Diseases (Impact Factor: 5.01). 03/2007; 20(1):33-8. DOI: 10.1097/QCO.0b013e328012c5bc
Source: PubMed


To review the recent literature on male circumcision and its effect on HIV acquisition.
The report from the randomized clinical trial of male circumcision in South Africa demonstrating a 60% protective effect in preventing HIV acquisition provided the first clinical trial evidence of efficacy of male circumcision in protecting men against HIV infection. This protective effect was consistent with both ecological and epidemiologic studies which also show a protective effect of 50-70% in men at high risk for HIV infection. Biological studies also demonstrate an increased number of HIV receptor cells in the mucosa of foreskin providing additional evidence of HIV susceptibility in the uncircumcised male. Male circumcision may also have a beneficial effect in preventing HIV acquisition in women and lowering selected sexually transmitted infections in both sexes.
The results of two ongoing randomized clinical trials of male circumcision in Kenya and Uganda are awaited with interest, however male circumcision should be carefully considered as a potential public health tool in preventing HIV acquisition. If other trials confirm the results of the South African trial, implementation of this surgical procedure will need to be carefully scaled up and integrated into other prevention programs with emphasis on surgical training, aseptic techniques, acceptability, availability and cultural considerations.

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    • "Thus, it is urgent and imperative to develop prevention systems capable of stopping the spread of HIV in the most disadvantaged and vulnerable populations, especially during sexual intercourse (Anton, 2012; Stephenson, 2011). It is known that behavioral and structural interventions, such as the use of condoms or circumcision, are effective methods in the prevention of HIV sexual transmission (Padian et al., 2008; Quinn, 2007). Other pre-exposure prophylaxis (PrEP) HIV-preventive strategies, such as the oral administration of antiretroviral (ARV) drugs or topical microbicides, also seem to be feasible and effective approaches against the spread of HIV (Abdool Karim and Baxter, 2014; Balzarini and Van Damme, 2005; Buckheit et al., 2010; Granich et al., 2010). "
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    • "In addition, the inner foreskin is more susceptible to tears and abrasions which can facilitate infection with sexually transmitted diseases and subsequently HIV. Based on these factors, one possible explanation for the decreased susceptibility to HIV in circumcised men is the removal of the foreskin which results in the removal of the target cells for HIV infection (Quinn 2007; Weiss 2007). Furthermore, in circumcised men, the penis is thought to have a greater keratin barrier, thus providing additional protection from infection (McCoombe and Short 2006). "
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    ABSTRACT: Now that male circumcision has been shown to have a protective effect for men against HIV infection when engaging in vaginal intercourse with HIV-infected women, the research focus needs to shift towards the operational studies that can pave the way for effective implementation of circumcision programs. Behavioral research is needed to find out how people perceive the procedure and the barriers to and facilitators of uptake. It should also assess the risk of an increase in unsafe sex after circumcision. Social research must examine cultural perceptions of the practice, in Africa and beyond, including how likely uncircumcised communities are to access surgery and what messages are needed to persuade them. Advocates of male circumcision would benefit from research on how to influence health policy-makers, how best to communicate the benefits to the public, and how to design effective delivery models.
    Preview · Article · Mar 2009 · AIDS and Behavior
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    • "Topical oestrogen has been shown to hasten wound healing [16] and could also be used before and after circumcision to reduce the postoperative wound healing time. Furthermore, whilst male circumcision is undoubtedly effective [17], [18], implementing it is a daunting task, particularly in countries like India, China and most of South-East Asia where it is culturally unacceptable [15]. In such cases, topical oestrogen could provide a medical alternative to circumcision to reduce HIV infection. "
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    ABSTRACT: With the growing incidence of HIV, there is a desperate need to develop simple, cheap and effective new ways of preventing HIV infection. Male circumcision reduces the risk of infection by about 60%, probably because of the removal of the Langerhans cells which are abundant in the inner foreskin and are the primary route by which HIV enters the penis. Langerhans cells form a vital part of the body's natural defence against HIV and only cause infection when they are exposed to high levels of HIV virions. Rather than removing this natural defence mechanism by circumcision, it may be better to enhance it by thickening the layer of keratin overlying the Langerhans cells, thereby reducing the viral load to which they are exposed. We have investigated the ability of topically administered oestrogen to induce keratinization of the epithelium of the inner foreskin. Histochemically, the whole of the foreskin is richly supplied with oestrogen receptors. The epithelium of the inner foreskin, like the vagina, responds within 24 hours to the topical administration of oestriol by keratinization, and the response persists for at least 5 days after the cessation of the treatment. Oestriol, a cheap, readily available natural oestrogen metabolite, rapidly keratinizes the inner foreskin, the site of HIV entry into the penis. This thickening of the overlying protective layer of keratin should reduce the exposure of the underlying Langerhans cells to HIV virions. This simple treatment could become an adjunct or alternative to surgical circumcision for reducing the incidence of HIV infection in men.
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