HIV Rates Lower in Women With Circumcised Partners

Pam Harrison

August 06, 2014

MELBOURNE, Australia — Rates of new HIV infection are modestly lower in women who have sex with circumcised partners than in women whose partners are not circumcised, the first real-world evidence presented here at the 20th International AIDS Conference suggests.

"In the beginning, the thought was that circumcised men would feel fully rather than partially protected against HIV infection, and would therefore adopt riskier sexual behavior," said Kevin Jean, PhD, from the French Institute for Health and Medical Research (INSERM) in Paris. "But we did not observe this; circumcised men did not engage in riskier sexual behavior than uncircumcised men," he told Medscape Medical News.

The French National Agency for Research on AIDS and Viral Hepatitis has been funding research programs in Orange Farm, a township near Johannesburg in South Africa, where about 20% of adults are infected, which is among the highest prevalence of HIV in the world. In women 30 to 35 years of age, the prevalence is as high as 50%.

Early research in the township provided proof of concept that voluntary male medical circumcision halves the risk for HIV. From those early cohorts, investigators identified 2452 women 15 to 29 years of age who reported having sex only with circumcised partners.

"When accounting for other factors, such as age, we found that having circumcised partners corresponded to a 15% reduction in HIV prevalence, and this reduction was statistically significant," Dr. Jean told reporters attending a news conference.

When the researchers used a classic mathematical model to estimate new infections, the rate of HIV in women who had sex only with circumcised partners was lower than that in those who reported ever having had sex (17.8% vs 30.4%). "Among younger women, between 15 and 29 years of age, this reduction reached almost 20%," Dr. Jean reported.

High Uptake

Rates of circumcision in the township have increased from 12% at the outset of the project to 53%. This suggests that when circumcision is freely offered in a population, "uptake can be high, so it is feasible to have a real roll-out in this population," Dr. Jean explained.

Additional research suggests that women generally prefer circumcised men and are in favor of it.

In fact, compensating men with food vouchers led to a modest increase in circumcision rates, according to Kawango Agot, PhD, director of the Impact Research and Development Organization in Kisumu, Kenya, who presented results from a separate study, which were simultaneously published online in JAMA.

In the study, 1504 uncircumcised men 25 to 49 years of age, most of whom were married, were randomized to receive a food voucher in compensation for circumcision in the amount of 200 KES (US$2.50), 700 KES (US$8.75), or 1200 KES (US$15.00), or to receive no compensation.

For most of the men, 700 to 1200 KES represented 2 to 3 days' wages.

In the 2 months after study enrolment, uptake of circumcision increased 9.0% in those who received 1200 KES, 6.6% in men who received 700 KES, 1.9% in those who received 200 KES, and 1.6% in those who received no compensation.

"The absolute increase in circumcision was relatively modest," Dr. Agot acknowledged. "However, the actual increase is large given a prevalence among older men of approximately 35% after 5 years of roll-out."

Randomized trials evaluating male circumcision have been "incredibly clear," said Aaron Tobian, MD, from the Bloomberg School of Public Health at Johns Hopkins University in Baltimore, Maryland, who was asked by Medscape Medical News to comment on both studies.

Consistent Trial Results

There have been 3 trials in male circumcision, and all have shown "very clearly that male circumcision reduces HIV acquisition by 50% to 60%," Dr. Tobian reported. It also reduces genital herpes by about 30% and human papillomavirus (HPV) by about 30%."

In one of the trials, researchers showed that rates of HPV and several other sexually transmitted infections were approximately 30% lower in female partners of circumcised men, "so there were clear direct benefits of male circumcision in both men and women," Dr. Tobian added.

However, when female partners of HIV-positive men in one of the trials were assessed after circumcision, there was no reduction in transmission rates.

This is likely related to a problem with the healing period after male circumcision; the benefit to female partners is not seen if men have sex before wound healing is complete, Dr. Tobian explained.

"If female partners always have sex with circumcised men, there is an indirect benefit in terms of lower HIV acquisition rates among women" over the long term, he said.

"Any type of compensation or incentive that encourages male circumcision is extremely good," he added.

"Male circumcision is a one-time intervention for a lifetime of protection," Dr. Tobian explained. "If you can use financial incentives to increase male circumcision rates, it makes a lot of sense from a public health standpoint."

Dr. Jean and Dr. Tobian have disclosed no relevant financial relationships.

20th International AIDS Conference: Abstract MOPDC0104, presented July 21, 2014, and abstract FRAE0105LB, presented July 25, 2014.


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