A paper by Green et al.
1
questions the external validity of the three RCTs of medical male circumcision for
HIV prevention, all of which reported 50%–60% reduction of HIV acquisition in heterosexual
circumcised men. The trials differed in the age of participants, background HIV incidence,
and surgical techniques, and it is very encouraging that they achieved such similar
results. Here, we address the key points from that paper:To read this article in full you will need to make a payment
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References
- Male circumcision and HIV prevention: insufficient evidence and neglected external validity.Am J Prev Med. 2010; 39: 479-482
- Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meat-analysis.AIDS. 2000; 14: 2361-2370
- The association between lack of male circumcision and risk of HIV infection: a review of the epidemiological data.Sex Trans Dis. 1994; 21: 201-210
- The relationship between male circumcision and HIV infection in African populations.AIDS. 1989; 3: 373-377
- The protective effect of male circumcision is sustained for at least 42 months: results from the Kisumu, Kenya trialOral presentation at the XVII International AIDS Conference, Mexico City; August 7; Abstract 16237 (2008).
Kong X, Kigozi G, Ssempija V, et al. Male circumcision effects on HIV incidence and risk behaviors in post-trial surveillance, Rakai, Uganda. Submitted, 11th Annual Conference on Retroviruses and Opportunistic Infections, Boston, Feb 27–Mar 2, 2011.
- Trial of male circumcision in HIV-infected men: effects on HIV transmission to women partners.Lancet. 2009; 374: 229-237
- The effects of male circumcision on female partners' genital tract symptoms and vaginal infections in a randomized trial, Rakai, Uganda.Am J Obs Gyn. 2009; 42: e1-e7
Wawer MJ, Tobian AAR, Kigozi G, et al. Male circumcision reduces human papillomavirus transmission to HIV-negative female partners: a randomized trial in Rakai, Uganda. Lancet. In press.
- Male circumcision quality assurance: a guide to enhancing the safety and quality of services.
- Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: a systematic review.PLoS One. 2010; 4: e9628
Article Info
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- Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External ValidityAmerican Journal of Preventive MedicineVol. 39Issue 5
- PreviewRecent editorials have asked the global health community to scale up male circumcision for HIV prevention in regions with HIV epidemics following the publication of three randomized controlled clinical trials (RCCTs) in Africa (in South Africa, Uganda, and Kenya).1–5 One editorial concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”6 This “Current Issue” review questions not the internal validity of the studies, but their external validity, an issue that has been discussed more generally in two commentaries,7,8 an editorial,9 and a systematic review of research on prevention trials10 in this journal.
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- Author ResponseAmerican Journal of Preventive MedicineVol. 40Issue 3
- PreviewThe primary intent of our article1 was not to challenge the 50%–60% results obtained by the three RCCTs conducted to evaluate the efficacy of male circumcision at reducing HIV transmission. Rather, it was to challenge the public health benefit of extrapolating these results to general populations in real-world settings. Mass circumcision campaigns, both planned and underway, involve investing billions of dollars, as well as placing millions of males at risk for surgical complications,2 placing female partners at greater risk of HIV infection,3 and posing a myriad of informed consent and related ethical issues surrounding mass prophylactic surgical campaigns.
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