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Male circumcision for prevention of HIV acquistion in heterosexual men: updated Cochrane systematic review provides best evidence
N. Siegfried1, M. Muller2, J. Deeks3, J. Volmink1
1Medical Research Council, South African Cochrane Centre, Cape Town, South Africa, 2Institute for Maritime Technology, Simons Town, South Africa, 3University of Birmingham, Department of Public Health and Epidemiology, Birmingham, United Kingdom
Background: In March 2007 UNAIDS advocated that male circumcision (MC) be included in national HIV/AIDS prevention programmes. Yet concerns around sexual disinhibition following MC and the early stopping of the trials, remain. This Cochrane review provides a rigorous evaluation of the efficacy and safety of MC for HIV prevention.
Methods: We used standard comprehensive Cochrane systematic review methods. We combined survival estimates at 12 and at 21 or 24 months in a random effects model meta-analysis. Detailed quality analysis of each trial was performed.
Results: The trials were conducted in South Africa (N = 3 274), Uganda (N = 4 996) and Kenya (N = 2 784) between 2002 and 2006. The resultant incidence risk ratio (IRR) was 0.50 at 12 months (95% confidence interval (CI): 0.34 to 0.72) in favour of MC; and IRR = 0.46 at 21 or 24 months (95% CI: 0.34 to 0.62). Meta-analysis of sexual disinhibition following MC for the Kenyan and Ugandan trials showed no significant differences between circumcised and uncircumcised men. In South Africa, mean number of sexual contacts at 12 months was 5.9 in the circumcision group versus 5 in the controls (p < 0.001), remaining significant at 21 months (7.5 versus 6.4; p = 0.0015). No other significant differences were observed. Incidence of adverse events following MC was low across trials. Reporting of methodological quality was variable across trials, but given the large sample sizes, the balance of possible confounding variables in randomised groups at baseline, and the use of acceptable statistical early stopping rules, the potential for significant biases was judged to be low to moderate.
Conclusions: Medical MC reduces HIV acquisition by heterosexual men by between 38% and 66% over 24 months. Adverse event rate and sexual disinhibition is low following MC with trial methodological quality of an acceptable standard.
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