Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia Version 2.5C (Jan08)
Randomized controlled trials to assess the efficacy of male
circumcision in reducing risk of HIV infection
• In July 2005 the results of the Orange Farm Intervention Trial in
South Africa were made public; they were subsequently published
in November 2005. 6 This was the first report from a randomized
controlled trial of male circumcision as a means to prevent HIV
infection. A total of 3274 uninfected men, aged 18–24 years, were
randomly assigned to undergo circumcision either immediately or
after 21 months. The incidence of HIV infection was found to be
60% lower among those who were circumcised. On the strength of
these results, the Independent Data Monitoring Committee
recommended that the men initially assigned to the delayed
circumcision group should be offered the procedure without further
delay, without waiting the full 21 months.
• Two further trials on male circumcision and HIV infection were
stopped in December 2006 and published in early 2007. Both trials
involved random allocation of HIV-negative volunteers to either
immediate circumcision, performed by trained medical
professionals in a clinic setting (intervention group), or
circumcision delayed for 2 years (control group). The first trial, in
Kisumu, western Kenya, was conducted among men aged 18–24
years, and showed a 53% reduction in HIV incidence. 7 The second
study was conducted in Rakai, Uganda, among men aged 15–49
years, and showed a 51% reduction in HIV incidence. 8 Following
release of the study results, circumcision was offered without
further delay to the men in both non-intervention groups.
• A further trial in Rakai is focusing on differences in transmission
from circumcised and non-circumcised men to their female
partners. Results are not expected before late 2008.
Possible biological explanations for the protective effect of male
circumcision
• The primary target cells through which HIV enters the body are
Langerhans cells. These cells are present in high density in the
epithelium of the inner foreskin, and are close to the surface
because the layer of keratin is thin.
Male circumcision and HIV infection Chapter 1-5
18, 19
• In an in vitro study, viral uptake by cells from the mucosal surface
of foreskin was 7 times more efficient than that by tissue from the
female cervix. 20 The inner mucosal surface of the foreskin lacks
the thick layer of keratin that covers most exposed skin. This
leaves numerous mucosal Langerhans cells and other immune cell
targets easily accessible to HIV infection. 21
• The highly vascularized foreskin mucosa, and in particular the
frenulum, is prone to tearing and bleeding during intercourse,
especially with “dry sex”, as practised in some parts of southern
Africa. These micro-injuries allow easy access of HIV to the
bloodstream.
• A further factor facilitating the entry of the virus is the presence of
an ulcerative STI, such as herpes simplex, chancroid or syphilis,
which tend to be more common in uncircumcised men. 5
Male circumcision under local anaesthesia Version 2.5C (Jan08)
Protection for women
• A study in Uganda observed lower rates of male-to-female
transmission of HIV if the man was circumcised. 13 Among 47
couples in which the circumcised male partner was infected with
HIV and whose viral load was below 50 000 copies per ml, none of
the female partners became infected in two years. By contrast, 26
of the 147 women whose HIV-infected partners were not
circumcised became infected.
Other health benefits of circumcision
• A multicountry study 22 found a lower prevalence of human
papillomavirus (HPV) infection in circumcised men than in
uncircumcised men. HPV infection is a necessary causal factor for
cervical cancer and is associated with an increased risk of cancer
of the vulva, vagina and anus in women, and of the penis and
anus in men.
• The incidence of invasive penile cancer is significantly lower in
circumcised men than in uncircumcised men, though this condition
23, 24
is extremely rare.
Acceptability of circumcision among African men
• Surveys and qualitative studies among young as well as older men
in six African countries have found that a considerable proportion
expressed interest in circumcision, ranging from 45% in Harare,
Zimbabwe, to over 80% in a large survey in Botswana. 25 These
studies indicate that many men would willingly undergo
circumcision if it could be performed safely and cheaply.
• In the surveys, the men reported that their main interest in
circumcision was related to hygiene, infection control and, for
some, a belief that condom use is easier for men who are
circumcised.
Male circumcision and HIV infection Chapter 1-6