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Wednesday, August 19, 2009

Does Circumcision of HIV-Infected Men Prevent HIV Acquisition in Their Female Partners?

Risk for HIV transmission was highest among couples who resumed sexual activity before wound healing was complete.

Circumcision of HIV-negative men has emerged as one of the most effective methods for preventing HIV acquisition among men (JW AIDS Clin Care Mar 19 2007). Now, researchers have studied the effect of circumcision on HIV transmission from seropositive men to seronegative women in rural Uganda. In all, 922 uncircumcised HIV-seropositive men (age range, 15–49) were randomized to circumcision within 2 weeks (intervention group) or at 24 months (control group). Female partners were invited to participate, and, if they were HIV negative, they were followed for ≤24 months. Learning or disclosing one's HIV status was not a requirement for study entry.

The trial was stopped early because circumcision was unlikely to benefit women. In a modified intent-to-treat analysis, HIV acquisition was demonstrated in 18% of women whose partners underwent immediate circumcision and in 12% of women whose partners were uncircumcised (P=0.36). Compared with risk for HIV transmission among controls, risk was significantly higher among couples who resumed sexual activity before wound healing (rate ratio, 3.5; P=0.04) but not among couples who delayed resumption of sex (RR, 1.2). Condom use was low, even though condoms and counseling were provided.

Comment: Despite observational studies, which show that circumcised men are less likely than uncircumcised men to transmit HIV to their female partners, the present results do not support circumcision for preventing HIV transmission and indicate that sexual activity before wound healing is a particularly high-risk behavior. Further trials are probably not feasible; in the long run, however, women will benefit from male circumcision because fewer men will be HIV infected in populations that adopt this procedure routinely. As circumcision programs are introduced, the message must be clear — sexual activity before wound healing can raise risk for HIV transmission from men to women.

Anna Wald, MD, MPH

Published in Journal Watch Women's Health July 30, 2009


Wawer MJ et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: A randomised controlled trial. Lancet 2009 Jul 18; 374:229.

Baeten JM et al. Male circumcision and HIV risks and benefits for women. Lancet 2009 Jul 18; 374:182.