Circumcision prevents HIV among men who have sex with men

Key takeaways:

• There were zero HIV seroconversions among MSM who underwent circumcision vs. five in uncircumcised MSM.
• Additional protective measures should also be used alongside circumcision, researchers said.

Voluntary medical male circumcision was effective in preventing HIV infection among men who have sex with men, or MSM, according to a randomized controlled trial recently published in Annals of Internal Medicine.

The CDC estimates that one in six MSM will develop HIV infection in their lifetime compared with one in 524 heterosexual men and one in 253 heterosexual women.

WHO and the Joint United Nations Programme on HIV and AIDs recommend voluntary medical male circumcision for HIV prevention in heterosexual men.

“While the benefits of voluntary medical male circumcision against HIV and sexually transmitted infections among heterosexual men are clear, data for MSM have had conflicting results,” Huachun Zou, MD, PhD, a professor in the department of epidemiology at Fudan University School of Public Health in China, told Healio.

Zou and colleagues filled this evidence gap by conducting a randomized controlled trial composed of 247 uncircumcised, HIV-seronegative men aged 18 to 49 years who self-reported practicing insertive anal intercourse and had two or more male sex partners in the past 6 months.

All participants received HIV counseling and testing. They were then randomly assigned to either an intervention group (n = 124) and immediately had a circumcision or a control group (n =123) where circumcision was delayed by 12 months.

The participants underwent rapid HIV testing at baseline and at 3, 6, 9 and 12 months. They also completed behavioral questionnaires and tests regarding sexually transmitted infections at baseline and at 6 and 12 months.

During the study, the researchers reported that there were zero HIV seroconversions (95% CI, 0-3.1) in the intervention group compared with five seroconversions (4.1%; 95% CI, 1.3-9.5) in the control group.

The HR for HIV was 0.09 (95% CI, 0-0.81), “indicating that voluntary medical male circumcision reduces HIV acquisition by 91%,” Zou said.

“This represents a phenomenal reduction,” he added.

Zou and colleagues noted that the incidence rates of herpes simplex virus type 2, syphilis and penile HPV were not significant between the two groups. There were, however, differences in sexual behavior because men in the intervention group were more likely to report consistent condom use at 6 and 12 months vs. those in the control group.

The findings warrant further large-scale randomized clinical trials with longer follow-up periods, “although the consistent observational and experimental findings of protection may raise ethical concerns for future trials,” the researchers wrote.

“We will continue to observe real-world data among our study participants to obtain a more precise point estimate and a tighter CI,” Zou said.

He explained that both global and national policymakers “should consider the importance of programmatic investments in HIV prevention among MSM using voluntary medical male circumcision,” and that MSM should be included in guidelines.

However, since circumcision does not offer complete protection and its efficacy can vary, additional HIV prevention measures should “include condom use, education to reduce the number of partners, regular HIV testing, and consideration of use of pre-exposure prophylaxis and post-exposure prophylaxis,” Zou and colleagues wrote.

For more information:

Huachun Zou, MD, PhDcan be reached at zouhuachun@fudan.edu.cn.

References:

• Gao Y, et al. Ann Intern Med. 2024;doi:10.7326/M23-3317.
• Men who have sex with men (MSM). https://www.cdc.gov/std/treatment-guidelines/msm.htm. Accessed May 22, 2024.