Male Circumcision As a Component of Human Immunodeficiency Virus Prevention

      A paper by Green et al.
      • Green L.W.
      • Travis J.W.
      • McAllister R.G.
      • Peterson K.W.
      • Vardanyan A.N.
      • Craig A.
      Male circumcision and HIV prevention: insufficient evidence and neglected external validity.
      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:
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      Linked Article

      • Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity
        American Journal of Preventive MedicineVol. 39Issue 5
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          Recent 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 Response
        American Journal of Preventive MedicineVol. 40Issue 3
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          The 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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