Association between male circumcision and women's biomedical health outcomes: a systematic review.

Jonathan M Grund,Sheng Zhou,Apollo Kivumbi,Tyler S Bryant,Kelly Curran,Sherri Pals,Naomi Bock,Jorge Martin Del Campo,Inimfon Jackson,Joanna Taliano,Carlos Toledo,Ling Yang,Peizi Li,Stephanie M Davis

doi:10.1016/s2214-109x(17)30369-8

Abstract

SummaryBackgroundMale circumcision reduces men’s risk of acquiring HIV and some sexually transmitted infections from heterosexual exposure, and is essential for HIV prevention in sub-Saharan Africa. Studies have also investigated associations between male circumcision and risk of acquisition of HIV and sexually transmitted infections in women. We aimed to review all evidence on associations between male circumcision and women’s health outcomes to benefit women’s health programmes.MethodsIn this systematic review we searched for peer-reviewed and grey literature publications reporting associations between male circumcision and women’s health outcomes up to April 11, 2016. All biomedical (not psychological or social) outcomes in all study types were included. Searches were not restricted by year of publication, or to sub-Saharan Africa. Publications without primary data and not in English were excluded. We extracted data and assessed evidence on each outcome as high, medium, or low consistency on the basis of agreement between publications; outcomes found in fewer than three publications were indeterminate consistency.Findings60 publications were included in our assessment. High-consistency evidence was found for five outcomes, with male circumcision protecting against cervical cancer, cervical dysplasia, herpes simplex virus type 2, chlamydia, and syphilis. Medium-consistency evidence was found for male circumcision protecting against human papillomavirus and low-risk human papillomavirus. Although the evidence shows a protective association with HIV, it was categorised as low consistency, because one trial showed an increased risk to female partners of HIV-infected men resuming sex early after male circumcision. Seven outcomes including HIV had low-consistency evidence and six were indeterminate.InterpretationScale-up of male circumcision in sub-Saharan Africa has public health implications for several outcomes in women. Evidence that female partners are at decreased risk of several diseases is highly consistent. Synergies between male circumcision and women’s health programmes should be explored.FundingUS Centers for Disease Control and Prevention and Jhpiego

Highlights

After the randomised controlled trials (RCTs), WHO and UNAIDS recommended that voluntary medical male circumcision should be implemented as an intervention for HIV prevention.[4]
WHO and UNAIDS noted in their recommendation that voluntary medical male circumcision programmes should promote improved health for women;[4] evidence exists that male circumcision is associated with protection from some diseases in women
Secondary analyses of the circumcision RCTs supported the data from observational studies, showing that male circumcision protected female partners from other sexually transmitted infections, including bacterial vaginosis, trichomonas,[14] and human papillomavirus (HPV).[9]

Summary

Introduction

Male circumcision has been shown to reduce the risk of HIV acquisition in men due to heterosexual exposure in three randomised controlled trials (RCTs).[1,2,3] Shortly after the RCTs, WHO and UNAIDS recommended that voluntary medical male circumcision should be implemented as an intervention for HIV prevention.[4]. WHO and UNAIDS noted in their recommendation that voluntary medical male circumcision programmes should promote improved health for women;[4] evidence exists that male circumcision is associated with protection from some diseases in women. Protection could either be direct (ie, decreased infectiousness of men with HIV or sexually transmitted infections) or indirect (ie, decreased susceptibility of men to infection and women’s exposure to infected partners). Secondary analyses of the circumcision RCTs supported the data from observational studies, showing that male circumcision protected female partners from other sexually transmitted infections, including bacterial vaginosis, trichomonas,[14] and HPV.[9]

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