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To cut or not to cut....... Medical Male Circumcision for HIV Prevention: Implications for MSM

James McIntyre

Does circumcision protect men against HIV infection ?

PHRU 2012

Medical Male Circumcision

Circumcision as an HIV prevention strategy

AVAC 2011

RCT Results on HIV acquisition Orange Farm, SA Sample size

Rakai, Uganda

Kisumu, Kenya




4664 PY







HIV+ in MC arm




HIV+ in control arm




% reduction with MC





(approx halving of HIV infection in circumcised men) P < 0.001

P < 0.005

P < 0.005 Auvert 2011

Features of Three MMC Clinical Trials Orange Farm, SA

Rakai, Uganda

Kisumu, Kenya




MC Rate




HIV incid.




Age Range

18-24 yrs

15-49 yrs

18-24 yrs

Sample size








Known MSM in study

Auvert, 2011

Does Circumcision protect MSM?

Does Circumcision protect MSM? Clinical trials have shown that male circumcision reduces menâ&#x20AC;&#x2122;s risk of acquiring HIV through vaginal sex. The effect of circumcision on male-to-male sexual transmission through anal intercourse (AI) is less well understood. Analysis of available data has shown insufficient evidence of a protective effect for MSM, but circumcision data from high-prevalence, resourcechallenged MSM communities are lacking.

Circumcision and transmission risk: Australia Estimated transmission rate for insertive UAI in participants: Circumcised - 0.11% (95% CI 0.02â&#x20AC;&#x201C;0.24), Uncircumcised - 0.62% (95% CI 0.07â&#x20AC;&#x201C;1.68) Health in Men (HIM) cohort study, Jin et al 2010

What is the potential impact of adult male circumcision on the HIV epidemic among men who have sex with men (MSM) in San Francisco?

Cross-sectional survey was conducted among MSM using time-location sampling in 2008

Of 521 MSM:

115 (21.1%) were HIV-positive 327 (62.7%) were already circumcised, leaving 69 (13.2%) for whom circumcision may have an additional preventive benefit. Fuchs et al 2010

Does Circumcision protect MSM? A systematic evidence review included information on three specific HIV and STI outcomes of interest: HIV infection (20 studies), syphilis (eight studies) and herpes simplex virus (HSV) infection (seven studies).

All of the evidence came from observational studies and was therefore rated Down. There are no similar studies on transgender persons. WHO 2011

Does Circumcision protect MSM? The overall relative effect of circumcision on HIV transmission among MSM was OR 0.86 (95% CI: 0.70–1.06), (but) differences were primarily based on predominant sexual roles in anal sex. Among males who practised primarily receptive anal sex, there was no relation between circumcision and HIV infection (OR: 1.20, 95% CI 0.63–2.29). Among those who engaged mostly in insertive anal sex, circumcision was associated with a protective effect for HIV infection (OR: 0.27, 95% CI: 0.17–0.44). The findings were similar for other STIs.

Does Circumcision protect MSM? Male circumcision was associated with a protective effect only in those MSM who practised insertive sex. No protective effect was seen among those who practised receptive sex. It is not clear if the benefits outweigh the risks at this point in time, as male circumcision, like any other operation, carries some risks.

What is the potential impact of adult male circumcision on the HIV epidemic among men who have sex with men (MSM) in San Francisco? Among those in whom circumcision may confer a protective effect, i.e., those who predominantly engaged in IAI (21.7% reporting â&#x2030;Ľ 80% insertive and unprotected sex at least some of the time with the most recent 5 partners): only 3 (0.5% of total) were willing to participate in an MSM circumcision trial and only 4 (0.7% of total) were willing to get circumcised if proven safe and efficacious.

Based on an estimated 65,733 MSM in San Francisco, this would mean 500 men. Fuchs et al 2010

Soweto Men’s Study: MMC and MSM The Soweto Men’s Study explored the association between insertive AI and HIV infection in a periurban South African MSM community with high background HIV prevalence among MSM (13.2%). Lane et al, 2008

Results RDS-adjusted HIV prevalence by circumcision status among MSM who are exclusively insertive with male sexual partners (N=363) 18 All MSM


16 14





10 Uncircumcised

8 Circumcised-insertive

6 4


2 0

5.8 3.9

Soweto Men’s Study: results • Most men were exclusive in their practice of either insertive or receptive AI with other men. • In multivariable analysis, controlling for age, sexual identity, income, number of partners, unprotected insertive and receptive anal intercourse, and unprotected vaginal intercourse, we found:

• Greater odds of HIV infection among uncircumcised insertive men compared to circumcised insertive MSM • A non-significant greater odds of infection among circumcised receptive men compared to circumcised insertive MSM.

Soweto Menâ&#x20AC;&#x2122;s Study: results In settings like Soweto where MSM practice a high degree of sexual role segregation with other men, male circumcision may be effective at reducing HIV transmission between men Additional data from similar resourced challenged emerging MSM communities are needed.

‘It ain’t what you do, it’s the way that you do it”



Infant circumcision and traditional young adult and adults

Circumcision may have complex meanings, values and repercussions in men’s lives ...circumcision is based on culture. That’s how we understand it, it’s a must because our forefathers did it, so that’s the way we understand it. It’s a culture. You have to go and do it. That’s how we understand it…. You have to go to the bush and become a man

Circumcision may have complex meanings, values and repercussions in men’s lives ...okay you can be a gay guy or be a bisexual guy, doesn’t mean you are not a guy, just that you different from other guys in your sexual health, in your sexual side. So, yeah… the man… so I proved that I am the man, I am a guy like everybody but I’m different. The way that I’m different is that I’m having sex with other men; that’s all

Circumcision may have complex meanings, values and repercussions in men’s lives “I just wanna make it clear that i don’t suck cock. But I think amongst the gay community, people prefer someone who is cut, basically is more sensitive, it like get to the core..” “I’ve had sex with people who aren’t circumcised, and I’ve enjoyed it, even more than circumcised people (They work harder)” Jobson, 2012

Circumcision may have complex meanings, values and repercussions in men’s lives “ust to make this clear, I don’t give head often...but I would prefer giving it to a circumcised penis

I just give head to anybody. Penis is penis, sometime circumcised one can be even dirtier than an uncircumcised one. It deserves head, i don’t discriminate.

Jobson, 2012


MMC demand : CHAPS/Anova Orange Farm Clinic

25 Nov 2011

Should MMC be part of prevention packages for MSM?

WHO Recommendation 5. Not offering adult male circumcision to MSM and transgender people for the prevention of HIV and STI is suggested over offering it. Conditional recommendation, very low quality of evidence

Combination Prevention for MSM PEPFAR defines the core elements of a comprehensive package of HIV-prevention services for MSM and their partners to be: • Community-based outreach; • Distribution of condoms and condomcompatible lubricants; • HIV counseling and testing; • Active linkage to health care and antiretroviral treatment (ART); • Targeted information, education and communication (IEC); and • Sexually transmitted infection (STI) prevention, screening and treatment.

Another suggested approach 1. MMC should be actively promoted and offered to all men who have sex with women, regardless of whether or not they also have sex with men 2. The potential benefits of MMC should be discussed, with and the procedure actively promoted and offered to all MSM who report predominantly insertive sexual behaviour 3. MMC should be available for all men who request it, without discrimination or prejudice to those men who are, or may be, MSM McIntyre, 2012, unconsulted !!

With thanks for the generous help from: • Kevin Rebe • Tim Lane • Dirk Taljaard • Bertrand Auvert • Helen Struthers • Geoff Jobson

To cut or not to cut....... Medical Male Circumcision for HIV Prevention: Implications for MSM