Johns Hopkins: The World Health Organization’s goal is to circumcise nearly 29
million men throughout sub-Saharan Africa to slow the spread of HIV and
other sexually transmitted diseases.
After medical circumcision, the number of HIV-positive men who were
shedding the HIV virus climbed for a few weeks while wounds healed, then
dropped to very low levels.
Men taking anti-HIV drugs were 90% less likely to shed the virus while their wounds healed.
In the midst of an international campaign to slow the spread of HIV in
sub-Saharan Africa, the World Health Organization recommends male
circumcision (the surgical removal of foreskin from the penis) which
reduces HIV acquisition by 50-60%. However, scientists report that a
new study of HIV-infected men in Uganda has identified a temporary, but
potentially troublesome unintended consequence of the procedure: a
possible increased risk of infecting female sexual partners while
circumcision wounds heal.
In a study by researchers from the Johns Hopkins University School of
Medicine, the Johns Hopkins University Bloomberg School of Public Health
and Rakai Health Sciences Program, 223 HIV-positive Ugandan men were
medically circumcised. Health workers poured 5 milliliters (about a
teaspoon) of saline solution over the circumcision site near the neck of
the penis and collected the solution for testing just before surgery,
during the operation, and once a week for 12 weeks.
Data showed that among the 183 men not taking anti-retroviral drugs,
less than 10 percent were shedding HIV before circumcision, but nearly
30 percent were shedding the virus two weeks after surgery. The
percentages dropped sharply as the men’s wounds healed, to less than
three percent at six weeks and less than two percent at 12 weeks.
Circumcision reduced the number of HIV-positive men who were shedding
the virus more than five-fold over the long term, but it had the
opposite effect in the weeks right after the surgery.
“There is a window of a few weeks after circumcision when the risk that
an HIV-infected man could transmit the virus to a female partner
actually increases,” says Aaron A.R. Tobian, M.D., Ph.D.,
an associate professor of pathology at the Johns Hopkins University
School of Medicine and the study’s first author. “During that time,
more HIV-infected men are shedding the virus, and on average they are
shedding greater amounts of it, than before circumcision,” he adds.
“We don’t know for certain if this increase in the amount of virus the
men are shedding actually leads to more cases of HIV transmission to
their female partners,” says co-author Ronald Gray, MD, MSc, a professor
of epidemiology at the Bloomberg School. “But we do know that
HIV-infected men who engage in sex before their circumcision wound heals
have higher rates of transmission to their partners. Also, the higher
an HIV-infected person’s viral load, the greater the risk of
transmitting the virus to a partner. So it is plausible that the risk
goes up during that time.”
A report on the study, published April 28 in PLOS Medicine,
cites two factors – the passage of time, and treatment with
anti-retroviral drugs - that dramatically reduced the virus’ prevalence
in HIV-positive, recently circumcised men.
Case by case, the likelihood of HIV transmission from a
newly-circumcised man to his female partner is less than one-tenth of
one percent, the researchers estimated. But with the World Health
Organization seeking to circumcise nearly 29 million men, the study
projects that this small increase could add up to 17,000 new infections
among female partners of newly circumcised HIV-infected men.
Medical circumcision has been shown to cut the odds of contracting HIV
by 50-60% in adult men; greatly reduce cases of genital herpes and human
papillomavirus; and reduce the prevalence of some sexually transmitted
infections in female partners. The World Health Organization has set a
goal of circumcising about four out of five men aged 15 to 49 in
southern and eastern Africa. Adolescent and adult circumcision programs
are ongoing, and include HIV testing and counseling. Studies show about
six percent of the men seeking circumcision are HIV-positive.
“All male circumcision programs are counseling men to abstain from sex
while their wounds are healing, “says co-author Dr. Godfrey Kigozi at
the Rakai Health Sciences Program. “But several programs have reported
that greater than 30% of the men have sex with female partners during
the healing period.”
“Although we’re counseling men not to have sexual intercourse while
their wounds are healing, we know that they are,” Tobian says, “and it’s
important to take steps to reduce the risk that they’ll transmit the
virus to their female partners during this time.”
The solution, he says, may lie in another one of the study’s findings.
“If the men are on anti-retroviral drugs, this reduces the risk of their
shedding the virus by about 90 percent,” Tobian says. “Thus, it is
logical for HIV-infected men to begin anti-retroviral therapy at the
time of circumcision. However, we will need further studies to find out
exactly which drugs and for how long.”