Non-therapeutic male circumcision in infancy or childhood and risk of human immunodeficiency virus and other sexually transmitted infections: national cohort study in Denmark

Morten Frisch,Jacob Simonsen

doi:10.1007/s10654-021-00809-6

Abstract

Whether male circumcision in infancy or childhood provides protection against the acquisition of human immunodeficiency virus (HIV) or other sexually transmitted infections (STIs) in adulthood remains to be established. In the first national cohort study to address this issue, we identified 810,719 non-Muslim males born in Denmark between 1977 and 2003 and followed them over the age span 0–36 years between 1977 and 2013. We obtained information about cohort members’ non-therapeutic circumcisions, HIV diagnoses and other STI outcomes from national health registers and used Cox proportional hazards regression analyses to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status (i.e., circumcised v. genitally intact). During a mean of 22 years of follow-up, amounting to a total observation period of 17.7 million person-years, 3375 cohort members (0.42%) underwent non-therapeutic circumcision, and 8531 (1.05%) received hospital care for HIV or other STIs. Compared with genitally intact males, rates among circumcised males were not statistically significantly reduced for any specific STI. Indeed, circumcised males had a 53% higher rate of STIs overall (HR = 1.53, 95% CI: 1.24–1.89), and rates were statistically significantly increased for anogenital warts (74 cases in circumcised males v. 7151 cases in intact males, HR = 1.51; 95% CI: 1.20–1.90) and syphilis (four cases in circumcised males v. 197 cases in intact males, HR = 3.32; 95% CI: 1.23–8.95). In this national cohort study spanning more than three decades of observation, non-therapeutic circumcision in infancy or childhood did not appear to provide protection against HIV or other STIs in males up to the age of 36 years. Rather, non-therapeutic circumcision was associated with higher STI rates overall, particularly for anogenital warts and syphilis.

Highlights

The World Health Organization (WHO) has endorsed voluntary medical male circumcision (VMMC) for adult men and boys above 15 years of age as an “efficacious human immunodeficiency virus (HIV) prevention option (...) in settings with generalized epidemics to reduce the risk of heterosexually acquired HIV infection” [1]
8531 cohort members were diagnosed in a Danish hospital with any STI, with the rate being 53% higher among circumcised than intact males (HR = 1.53; 95% confidence intervals (CIs): 1.24–1.89) (Table 1)
We examined whether the hazard ratios (HRs) for any STI and for anogenital warts differed according to the age at which the non-therapeutic circumcision took place

Summary

Introduction

The World Health Organization (WHO) has endorsed voluntary medical male circumcision (VMMC) for adult men and boys above 15 years of age as an “efficacious HIV prevention option (...) in settings with generalized epidemics to reduce the risk of heterosexually acquired HIV infection” [1]. This policy rests on the finding of overall 58%. Questions surrounding VMMC’s real-world effectiveness, combined with increasing knowledge about more effective and less invasive means of HIV prevention, reports of negative sexual consequences among some men undergoing the procedure at various ages [15,16,17,18,19], and bioethical concerns [20] may be among the relevant factors in explaining such reluctance

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