Circumcision reduces HIV infection co-factors

BOSTON (Reuters Health) - Circumcision appears to reduce the likelihood of men becoming infected with HIV, the virus that causes AIDS, and of passing it on to their female partners. However, among men who are already infected with HIV, circumcision does not seem to protect their partners from becoming infected, according to findings reported here at the Conference of Retroviruses and Opportunistic Infections. Circumcision protects men from acquiring genital herpes infections with HSV-2, and it also reduces the rates of genital and urinary disease (including bacterial vaginosis) in their female sex partners, Dr. Aaron Tobian of Johns Hopkins University in Baltimore reported Sunday. Because genital ulcer disease, HSV-2 infections and bacterial vaginosis are all co-factors for HIV infection, the findings of this study indicate a protective effect of male circumcision against HIV acquisition in these women, Tobian explained. Three previous African trials have shown that circumcision lowers the chances of a man becoming infected with HIV. "The effects of male circumcision on male and female sexually transmitted infections were much more equivocal," Tobian continued. To investigate, a two-part trial was undertaken. Tobian's team initially screened 6400 uncircumcised men and identified 3500 who were free of HIV and HSV-2. These men were randomly assigned to be circumcised or to just be followed for 2 years. "What we found was that there was a 25 percent reduction in HSV-2 acquisition - and those men were circumcised," Tobian reported. The second part of the trial enrolled the wives of the men. After 12 months, "those women who were married to circumcised men had a decrease in symptomatic genital ulcers by 25 percent." Rates of bacterial vaginosis were also reduced, by 20 percent, he announced. "This is, for us, one of the most heartening findings," Dr. Maria Wawer, also from Johns Hopkins, commented. "From our observation data, we had also hoped that male circumcision of (HIV) positive men might reduce the transmission of HIV to their female partners," she continued in the presentation. But this was not the case, in a trial conducted in Uganda. The researchers focused on discordant couples where the men were HIV-positive and the women were HIV-negative. Ninety-three of the men underwent circumcision while 63 did not. All of the participants were counseled about safe sex practices and were followed for up to 2 years. The HIV-positive men in the circumcision group had a 50 percent lower risk of developing genital ulcers, she said. However, this did not translate to a lower rate of HIV transmission among the women. Although the trial was small, "we did not see the trend toward protection that we expected and hoped for," she commented. There is also some evidence that circumcision may increase the rate of transmission in the short-term. This may be attributed to engaging in sexual activity before circumcision is completely healed, she speculated. More infections occurred sooner after circumcision than later, which supports this idea. "It is therefore imperative that men not resume sex in the post-operative period," for about 6 weeks after circumcision or until the wound is completely healed. This is also important because the researchers expect more men will now be circumcised. "Circumcision is the only HIV prevention modality that that leaves a physical mark on somebody," Wawer pointed out, making it "likely that more HIV-positive Ugandan men will seek circumcision in order not to be stigmatized as the only guy in the village who is still not circumcised - 'that means you must be HIV-positive'."