Abstract
Publisher Summary The HIV epidemic in sub-Saharan Africa continues to grow despite prevention efforts, and there is an urgent need for preventive interventions to reduce transmission. Male circumcision has been shown to reduce HIV acquisition in men by over 50 percent in three randomized trials and is now recommended by WHO/UNAIDS as a component of HIV prevention strategies. The observational and randomized trial evidence documents the effects of male circumcision on HIV risk in men and women, and the mechanisms whereby circumcision might reduce HIV risk. The low prevalence of HIV in West Africa was associated with high rates of male circumcision, among both Muslims and non-Muslims, whereas in Eastern and southern Africa the high prevalence of HIV was associated with low rates of male circumcision. However, such ecologic analyses provide only a crude correlation, and cannot directly link circumcision status to HIV infection in individuals. Numerous individual-level observational studies have also shown an association between male circumcision and lower risks of prevalent or incident heterosexually acquired HIV in Africa, Asia, and the US. The possible effects of circumcision on HIV risk in men who have sex with men (MSM) are less well studied, and are complicated by varying practices of insertive or receptive anal intercourse. It is biologically plausible that circumcision can reduce male susceptibility to HIV. The foreskin is vulnerable to trauma during intercourse, and the presence of the prepuce increases the likelihood of genital ulceration and inflammatory conditions (such as balanitis) which may act as cofactors for HIV acquisition. The effects of circumcision on STIs are difficult to study because of the transient nature of many genital tract infections and the effectiveness of treatment for curable conditions.
Published Version
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