Circumcision of men may decrease STD risk in women

Male circumcision may not be associated with a reduced risk for HIV acquisition in women.

Issue: March 2008

Male circumcision intended to thwart HIV acquisition may have additional benefits in decreasing men’s risk for herpes simplex virus-2 acquisition and in preventing vaginal infections. Women, however, did not reap the HIV risk-reduction benefit of male circumcision, according to study data presented at the 15th Conference on Retroviruses and Opportunistic Infections, held recently in Boston.

One study was conducted to determine if male circumcision prevents other STDs, such as herpes simplex virus-2 (HSV-2) in men and vaginal infections in women. A second study was conducted to determine whether the HIV transmission benefits of male circumcision would also benefit women in HIV prevention. Wives of men enrolled in these trials, conducted in Uganda, participated in separate follow-ups.

The studies were conducted by researchers from the Johns Hopkins School of Public Health in collaboration with Makerere University School of Public Health in Kampala, Uganda and the National Institute of Allergy and Infectious Diseases.

The researchers from the first study found that rates of HSV-2 among men were reduced by 25% and rates of genitourinary disease, bacterial vaginosis and trichomonas infection among women declined after circumcision. However, no direct reduction in the risk for HIV acquisition among women was detected. HSV-2 acquisition may also increase HIV acquisition risks by three times, according to the researchers.

“We had also hoped that male circumcision of men with HIV might reduce transmission of HIV to their negative partners, but data from a parallel trial of male circumcision in men with HIV in our trial did not show reduced transmission in women,” Maria Wawer, PhD, a study researcher at Johns Hopkins University School of Public Health, said at a press conference. “Male circumcision does appear to have benefits for female vaginal health and reduced acquisition of HSV-2 in men who are also circumcised. But we did not see a trend toward protection in women that we expected and hoped for.”

Although disappointed with trial results for women and HIV in the study of HIV-discordant couples, the researchers found additional benefits for men and women.

The initial male circumcision study was stopped for efficacy last year after early benefits for HIV acquisition were seen in men assigned to the circumcision arm.

Women enrolled

In the initial study, men were assigned to the immediate circumcision intervention arm or to the control arm of delayed circumcision for two years. Men who were HSV-2 negative in the intervention arm (n=1,400) and in the control arm (n=1,387) were followed for 24 months to determine HSV-2 acquisition via Kalon HSV-2 ELISA.

Spouses of enrolled men in the intervention arm (n=825) and spouses of men in the control arm (n=783) were followed for one year. Data were collected for genitourinary disease, bacterial vaginosis via Nugent score and trichomonas by culture.

HSV-2 was acquired by 7.6% of men in the intervention arm and 10.1% of men in the control arm. Sixty-two men acquired HIV during the trial, and 58.1% had either prior HSV-2 infections or simultaneous HSV-2 and HIV seroconversion.

The rate of symptomatic genitourinary disease was 12.5% for women married to men in the intervention arm and 16.8% for women married to men in the control arm. No differences between women linked to either study arm were detected, however, in reported symptoms of vaginal discharge or dysuria.

Trichomonas prevalence was 5.9% in women linked to men in the intervention arm and 11.2% in women linked to men in the control arm. The prevalence of bacterial vaginosis was 40.3% in women married to men in the intervention arm and 50.6% in women married to men in the control arm.

The severe bacterial vaginosis rate was 2% in women linked to men in the intervention arm and 6.5% in women linked to men in the control arm. Women who had normal vaginal flora at enrollment had a reduced chance of progression to bacterial vaginosis if their husbands were in the intervention arm. Persistence was reduced in women who had bacterial vaginosis at enrollment.

Risk for married couples

In the second study, the researchers examined potential decreased risk of HIV for women linked to circumcised men. Married men with HIV (n=770) were asked to include their wives in the study. Among the women enrolled (n=566), 43% were HIV negative (n=245).

Men in the study were examined at one, six, 12 and 24 months, whereas women were examined at six, 12 and 24 months. Both partners enrolled concurrently in the intent-to-treat analysis.

At 24 months, the women’s cumulative HIV incidence was 13.8/100 person-years in the male circumcision arm vs. 9.6/100 person-years in the control arm. HIV incidence was highest in women in both arms at the zero to six months interval and declined at the six to 24 months interval. During the zero to six months interval, HIV transmissions were highest in couples in the circumcision arm who resumed intercourse five days or more prior to certified wound healing when compared with couples who waited until five days of certified wound healing or longer to resume intercourse.

“This suggests that the early preoperative period is a very important period where it is imperative that people not resume sex because of the potential for increased risk,” Wawer said.

Condom use, bacterial vaginosis, vaginal discharge, dysuria and genitourinary disease rates were comparable among women in both study arms at follow-up. Genitourinary disease rates were reduced in men who had HIV and were circumcised.

“In HIV-positive men, those in the circumcision group had about a 50% lower risk for having genital ulcers,” Wawer said. “This is a very positive effect for the men, given that genital ulceration is a serious health problem in HIV-positive men.” – Kirsten H. Ellis

For more information:

Tobian A, Serwadda D, Quinn T, et al. Trial of male circumcision: prevention of HSV-2 in men and vaginal infections in female partners, Rakai, Uganda. #28.

Wawer M, Kigozi G, Serwadda D, et al. Trial of male circumcision in HIV positive men, Rakai, Uganda: Effects in HIV⁺ men and in women partners. #33.

Both presented at: The 15th Conference on Retroviruses and Opportunistic Infections; Feb. 3-6, 2008; Boston.