Non-randomized epidemiological studies have suggested that uncircumcised men may be exposed to a higher risk of infection with the HIV virus after sexual intercourse.

It has been suggested that circumcision may reduce the risk of infection by eliminating non-keratinized epithelium in the inner prepuce tissue and tissue with a high proportion of HIV target cells. The first randomized trial performed in sub-Saharan Africa was terminated early after showing a 60% reduction in the rate of HIV infection in men after circumcision.

In the February 24th issue of Lancet, Gray and colleagues from the Johns Hopkins University Bloomberg School of Public Health report the results of the second prospective randomized trial performed in sub-Saharan Africa to address this issue.

The cohort consisted of 4996 HIV-negative men ages 15 to 49 years from the Rukai district in Uganda. All men underwent testing and counseling and were randomized to an immediate circumcision arm (n=2474) or a delayed circumcision arm 2 years after enrollment (n = 2522). Circumcision was performed with a sleeve procedure in all men using a dorsal penile block. Patients were followed serially with repeat HIV testing, history, and physical examinations for 2 years thereafter. In the year before enrollment, approximately one third of participants reported intercourse with 2 or more sexual partners; 28% of patients reported inconsistent condom use and 14% no condom use.

Remarkably, over 90 percent of men in both arms completed the study at last follow-up. Using an intent-to-treat analysis, the incidence of HIV infection over a period of 2 years was 0.66 cases per 100 person-years in the surgery group and 1.33 cases per 100 person-years in the control group. The efficacy of circumcision in preventing HIV was 55%. (95% CI 16-72; p=0.006) after adjusting for sociodemographic, behavioral factors, and symptoms of sexually transmitted diseases.

This well-conducted, prospective, randomized trial is the second to show that circumcision may halve the risk of HIV infection as early as 2 years after surgery. The authors conclude by recommending circumcision as a public health measure to reduce the incidence of HIV infection now approaching 4 million per year.

Prof Ronald H Gray MD, Godfrey Kigozi MBChB, David Serwadda MBChB, Frederick Makumbi PhD, Stephen Watya MBChB, Fred Nalugoda MHS, Noah Kiwanuka MBChB, Prof Lawrence H Moulton PhD, Mohammad A Chaudhary PhD, Michael Z Chen MSc, Nelson K Sewankambo MBChB, Fred Wabwire-Mangen PhD, Melanie C Bacon MPH Carolyn FM Williams PhD, Pius Opendi MBChB, Steven J Reynolds MD Oliver Laeyendecker MSc, Prof Thomas C Quinn MD and Prof Maria J Wawer MD

Lancet 2007 Feb 24; 369(9562):657-66

Reported by UroToday.com Contributing Editor Ricardo Sanchez-Ortiz, MD

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