MALE CIRCUMCISION (MC) AND HIV

Adult male circumcision (MC) is a surgical procedure to remove the foreskin (prepuce) of the male penis. There are several proposed mechanisms for how male circumcision might reduce a man’s risk of HIV infection. The foreskin’s inner mucosal surface is more susceptible to HIV because it has more immune cells vulnerable to HIV infection than the external surface. Furthermore, the foreskin acts as a physical barrier, trapping HIV next to the mucosal surface of the penis for a longer period of time. In this moist environment, the virus can also survive longer, potentially increasing the risk of infection. Small tears in the foreskin as a result of intercourse could also promote entry of the virus. After circumcision the penile shaft and glans develops more epithelial keratinization, a process which makes the penis less susceptible to viral invasion.

Overall, studies have shown that 62% of adult males in Africa are circumcised. However, some studies in South Africa discovered that many men who thought had been circumcised during traditional initiation rites they still had intact foreskins, or were only partially circumcised. The 62% rate of circumcision differs with region and tribal groups. In particular, male circumcision is strongly tied to religious beliefs; almost all Muslim and Jewish men are circumcised. In Southern Africa, where the HIV epidemic is the most severe, rates of male circumcision are less than 20%.
MC as a surgical procedure has recognized risks if improperly performed such as serious infection, severe loss of blood, mutilation, penile amputation and death. Furthermore, the procedure requires some time for healing, and during that time there is a break in the epithelial (skin) surface of the penis. This incision site may be a portal for HIV entry and until fully healed, it may increase the risk of HIV infection.

Promoting circumcision for HIV-positive men is not recommended because trials showed no significant difference in HIV transmission from circumcised HIV positive men compared to uncircumcised HIV-positive men.

As with most prevention strategies, adult MC is not completely effective at preventing HIV transmission. Millions of circumcised men have become infected with HIV through heterosexual exposure to the virus. Men who receive adult MC may perceive that they are at decreased risk for transmission and, therefore, may not maintain other risk reduction strategies.

It is not known whether MC reduces the sexual transmission of HIV from men to women. Although a reduction in HIV incidence among men will eventually result in lower prevalence in men and therefore less likelihood that women will be exposed to HIV, currently there are insufficient data to know whether MC results in a direct reduction of transmission from HIV-positive men to women.

WHO recommends adult MC in settings where HIV is hyperendemic (HIV prevalence in the general population exceeds 15%), spread predominantly through heterosexual transmission, and where a substantial proportion of men (e.g. greater than 80%) are not circumcised.

Surveys conducted in Africa in both men and women have found that adult MC is acceptable (50 to 86 percent), provided that the procedure is safe, affordable and has minimal side effects or pain. Among the reasons cited include better hygiene, lower sexually transmitted disease rates, more modern/urban appearance, peer pressure and perceived attractiveness to women.

Accurate information about the intervention should be communicated; that MC provides only partial protection against the risk of acquiring HIV and that the reccommended procedure is done by trained medical personnel as opposed to fellow villagers which is the case in most African settings.