In a real-world setting, a program of voluntary male circumcision was widely accepted and was associated with a community-wide reduction in HIV prevalence, researchers reported.
Over a 3-year period in the South African community of Orange Farm, a free program increased the prevalence of circumcision by more than a factor of four -- from 12% to 53%, according to Bertran Auvert, MD, PhD, of the University of Versailles in Versailles, France, and colleagues.
And without those circumcisions, Auvert and colleagues reported online in PLoS Medicine, the HIV prevalence rate in the community would have been 19% higher than it is.
Importantly, Auvert and colleagues found, there was no sign that circumcision was accompanied by increases in risky sexual behavior, such as not using condoms or having multiple partners.
Taken together, the evidence suggests that voluntary male medical circumcision "should be an international priority and needs to be accelerated to effectively combat the spread of HIV," the researchers argued.
The findings "confirm the efficacy of the circumcision practiced on a population scale in reducing HIV transmission appreciably among the men of this population," Auvert said in a statement.
And, he added, "they show that it is possible to achieve this result in just a few years, including in populations where circumcision is not a common practice."
Three major randomized trials -- one of them conducted in Orange Farm by the same researchers -- have shown that male circumcision reduces the risk of men acquiring HIV through heterosexual sex by between 50% and 60%.
(Interestingly, however, circumcision didn't prevent them passing on the infection to female partners if they became HIV-positive.)
But it had not been clear, Auvert and colleagues noted, whether those results would hold up outside the confines of a controlled trial. To find out, they rolled out a community program in Orange Farm, home to an estimated 110,000 adults, where circumcision is not a local norm.
Starting in 2008, men over age 15 were offered free circumcision, along with education on the procedure, HIV risk reduction counseling, and treatment of symptomatic sexually transmitted infections. They were also offered HIV testing.
Interim results, presented in Rome in 2011, showed a direct impact on HIV prevalence and incidence. The final results confirm both the acceptability of the program and the HIV-prevention benefits, Auvert and colleagues reported.
All told, some 18,000 men were circumcised during the 3 years of the project, starting in 2008. The researchers derived outcomes from analysis of two surveys -- one conducted in 2007 and early 2008, before the project rollout, and another three years later in 2010 and early 2011.
Before the project started, Auvert and colleagues reported, the prevalence of male circumcision among men ages 15 through 49 was 12%, which grew to 53% in 2010-2011. Among younger men -- those 15 through 29 -- the rate grew to 58%.
Auvert and colleagues estimated that -- in the absence of the circumcisions -- HIV prevalence in Orange Farm would have been 14.7% in 2010-2011. Instead, they reported, it was 12.3%.
Importantly, circumcision was not associated with an increase in risky behavior, they found.
The proportion of circumcised and uncircumcised men who reported consistently using condoms with nonspousal partners was 44% and 45.4%, respectively and the difference did not reach significance.
Similarly, the proportion having two or more nonspousal partners was 50.4% for circumcised men and 44.2% for the noncircumcised, and again the difference was not significant.
Auvert and colleagues cautioned that the study was not randomized, so a cause-and-effect relationship can't be established. And, they added, it's possible that some unmeasured factors affected the outcomes.
Nonetheless, they concluded, the study "gives hope that the epidemic can be reduced in settings where most men are uncircumcised."
The study was supported by the French Agency for AIDS and Viral Hepatitis Research, the Bill and Melinda Gates Foundation, and PEPFAR.
Auvert made no disclosures
- Reviewed by F. Perry Wilson, MD, MSCE Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner