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Does circumcising an HIV-positive man increase his risk to transmit HIV?

[return to first circumcision page]

Best evidence: Yes, circ’d men seem to transmit HIV faster

This answer comes from the one trial which looked at the issue.[1] During 2003-7, researchers in Uganda ran a study to “test whether male circumcision would reduce transmission of HIV…to their uninfected female sex partners.” The study recruited HIV-positive intact men and their HIV-negative partners (wives, steady partners), then on a random basis circumcised some men but not others, and then followed all partners, testing them from time-to-time to see which women got HIV (to be sure a woman’s HIV came from her man, the study confirmed that a couple’s HIV were similar).

The study found that circ’ing a man increased his risk to infect his partner’s: 18% (7 of 92) of  women with newly circ’d partners got HIV compared to only 12% (8 of 67) of women with intact partners. Women with circ’d partners were 1.58 times more likely to get HIV. But because the trial saw only 25 new infections, there was a 28% chance this was a statistical accident due to chance only.

Whether trial results showed real risk or were a matter of chance only, the relative risk with circ’ing increased with longer time after circ’ing: during the first 6 months partners of circ’d vs intact men were 1.46 times more likely to get HIV; from 6-24 months, they were 1.82 times more likely to get HIV.

But the study was stopped early…

By design, the trial was supposed to follow all women for 2 years, whether circ’ing men increased or decreased their partners risk to get HIV (in other words: “the female acquisition end point cannot be determined prior to the completion of the trial”; see p 38 in [2]). This trial design makes sense, because once men are circumcised to see what happens to their partners’ HIV risk, the foreskin cannot be reattached.

Despite the plan to follow women for 2 years, the research team stopped the trial early. The excuse was that the study was unlikely to show circ’ing an HIV-positive man was good for his partner (less likely to transmit).

Here’s Jim Thornton’s (former editor, British Journal of Obstetrics and Gynaecology) comment on stopping the trial early[3]: “Consider a treatment which affects husbands and wives. Treating one automatically treats the other. Evidence accumulates that it is good for the husband but results are unclear for the wife. It would be bonkers to stop when interim data showed a non-significant harmful trend for wives, on the grounds that the treatment was never going to be good for them, and then go ahead and implement it!   But that’s what the authors of the only trial ever to test the effect of male circumcision on HIV transmission to the woman did…”.

The trial was unethical (and illegal?)

The trial was unethical by design: Researchers recruited HIV-positive men even if they were not willing to learn their HIV status and to warn their partner. “[A]bout a quarter” of HIV-positive men did not tell their partners they were HIV-positive.[1]

Following women at risk without warning them is unethical. It may have been illegal as well. According to Ugandan law, “any person who unlawfully or negligently does any act…which he or she knows or has reason to believe to be likely to spread the infection of any disease dangerous to life commits an offence and is liable to imprisonment for seven years.”[4]

Researchers (and UNAIDS) disregard women’s risk to get HIV from circ’d men

The research team recommended “…circumcision for remaining HIV+…men who had completed their 2 year follow-up…”[5] From the trial’s own evidence, doing so would increase men’s HIV transmission to their partners by 1.58 times. Compounding the damage, researchers did not insist on couple counseling before circ’ing HIV-positive men, even though many women were not aware their partners had HIV.

Similarly, the research team recommended circ’ing men in Africa whether they are HIV-positive or not, and without insisting on prior HIV tests and couple counseling. UNAIDS offers the same anti-women advice: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative.”[6]

Don’t forget women’s non-sexual risks for HIV!

Discussions of women’s risk to get HIV from circ’d or intact men overlook their risks to get HIV from anything but sex. There’s a lot of evidence that much if not most HIV among women in Africa comes from healthcare and other bloodborne risks. For example:

A survey among students 5 high schools in Umgungundlovu District of KwaZulu-Natal found 135 HIV-positive girls of which 77 (35%) reported they were virgins.[7]

There’s a lot of evidence women have gotten HIV from pregnancy-related healthcare. Fifteen studies of new HIV infections in pregnant and early postpartum women in Africa – a group with limited sexual risks – report women getting new infections at rates from 6.1% to 19% per year.[8]

Sex? Nothing about sexual behavior can explain why women in Africa are 26 times more likely to be HIV-positive compared to women elsewhere in the world. As of end 2016, UNAIDS estimated 17.8 million women aged 15-49 in the world were HIV-positive — 3.6 million outside Africa and 14.2 million in Africa. Outside Africa, only 0.15% of women were HIV-positive (3.6 million out of about 2.4 billion women), whereas across Africa 3.9% were infected (14.2 million out of about 360 million women).

References

1. Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009; 374: 229-237. Available at: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)60998-3.pdf (accessed 25 April 2018).

2. Wawer MJ, Seerwadda D. Randomized trial of male circumcision: STD, HIV and behavioral effects in men, women and the community. Protocol. 2007. This document is provided as a supplement to: Kigozi et al. The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda. PLoS Med 2008. Available at: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050116 (accessed 26 April 2018).

3. Thornton J. This’ll turn you feminist. blog post on Ripe-tomato.org. Available at: https://ripe-tomato.org/2014/12/21/thisll-turn-you-feminist/ (accessed 18 April 2018).

4. Wesaka A. Lab technician arrested over falsification of HIV test results. Daily Monitor, 8 March 2018. Available at: http://www.monitor.co.ug/News/National/Lab-technician-arrested-falsification-HIV-test-results/688334-4334338-o0n96tz/index.html (accessed 23 April 2018).

5. Wawer MJ. NCT00124878: Trial of male circumcision: HIV, sexually transmitted disease (STD) and behavioral effects in men, women and the community. Available at: https://clinicaltrials.gov/ct2/show/NCT00124878 (accessed 25 April 2018).

6. Quote from p. 7 in: UNAIDS, 2008. Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations. Available at: http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf (accessed 1 December 2011).

7.  Kharsany ABM, Buthelezi TJ, Frohlich JA, et al. HIV infection in high school students in rural South Africa: role of transmissions among students. AIDS Res Hum Retroviruses 2014; 30: 956-965. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179919/ (accessed 13 February 2018).

8. Gisselquist D. Missed signals: not investigating HIV incidence in pregnant women in Africa. SSRN, 17 April 2018. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3153795 (accessed 20 April 2018).]

 

 

HIV/AIDS experts don’t protect women in Africa from HIV

Women in Africa have much higher risk for HIV than women elsewhere in the world. The

infection An unethical and mismanaged trial rep

 

Whether or not your man is circ’d, bloodborne risks are likely a bigger risk 

 

 

Advocates for mass male circumcision have paid insufficient attention to protect women. Here are two ways these programs increase women’s risks for HIV.

Not protecting women from high risk to get HIV from a newly circumcised, HIV-positive partner

Only one study has followed wives of newly circumcised HIV-positive men to see what happens to their wives. That study, in Uganda, 2003-07, circumcised some HIV-positive men and left others intact, and then followed and tested their wives from time to time to see who got HIV. Over several years, wives of men circumcised for the study were 1.49 times more likely to get HIV than wives whose husbands remained intact (see Table below). Wives of circumcised men were at especially high risk if they resumed sex before their husbands’ circumcision wound healed – 5 (28%) of 18 who did so got HIV within 6 months after their husbands were circumcised.

Despite this risk, UNAIDS recommends: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative.”[i] Donors and governments follow this advice – circumcising men without requiring them to take an HIV first and, if found to be HIV-positive, to bring their wives for couple counseling before proceeding with the circumcision.

As mass circumcision programs have started, resuming sex before wound healing is common. In a 2009 survey among newly circumcised men in Kenya, 69% of married men resumed sex before wound healing (see page 28 in: WHO, Scaling up male circumcision programmes in the Eastern and Southern Africa Region). In another study about men circumcised in Zambia in 2010, 24% of men resumed sex early, before the end of the recommended 6 week period of abstinence after surgery (see Hewett et al, Sex with stitches…).

Allowing women (and men) to think sex without condoms with a partner who may be HIV-positive is safe

Disturbingly, many women think circumcised men are safe and/or are reluctant to ask them to use condoms. In recent surveys among women in Kenya, Namibia, South Africa, Swaziland, and Uganda, 37%-52% said they would be “not at all comfortable” asking partners to use a condom after circumcision (from: AVAC, Making Male Medical Circumcision Work for Women).

Such beliefs conflict with available evidence. According to three studies, even with healed wounds, circumcised men transmit HIV to women. Whether they do so faster or slower than intact men is unknown. Two out of 3 studies that followed discordant couples — with HIV-positive men and HIV-negative wives — report that intact men transmit faster than circumcised men. The third study reports the opposite: that circumcised men transmit faster than intact men — not only in the first 6 months after circumcision, but continuing for the next 18 months as well (when the study ended).

Faster or slower? The jury is out. But what is clear from these studies is that women who want to be safe — not just safer — need to continue to use condoms with men who may be HIV-positive, whether they are circumcised or intact.

Table: Rate of new HIV infections (incidence) in women with HIV-positive partners who are circumcised or intact

Countries, years New infections (%/year) in women whose partners are: Relative risk for HIV in women with circ’d vs intact partners
circ’ed intact
Uganda, 1994-98[ii] 5.2 13.2 0.39
Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, Zambia, 2004-08[iii] 2.04 3.47 0.61
Uganda, 2003-07[iv] 14.1 8.7 1.49

[i] Quote from p. 7 in: UNAIDS, 2008. Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations. Available at: http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf (accessed 1 December 2011).

[ii] Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. AIDS 2000; 14: 2371-2381.

[iii] Baeten JM, Donnell D, Kapiga SH, et al. Male circumcision and risk of male-to-female HIV-1 transmission: a multinational prospective study in African HIV-1-serodiscordant couples. AIDS 2010; 24: 737-744.

[iv] Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomized controlled trial. Lancet 2009; 374: 229-237.

Return to first circumcision page.

5 responses to “Does circumcising an HIV-positive man increase his risk to transmit HIV?

  1. Socks May 18, 2013 at 10:35 pm

    Can a circumcised man transmit HIV virus after 3 years of circumcision?

    • davidgisselquist May 19, 2013 at 12:09 am

      Hi Socks,
      Thanks for your question. The answer is: Yes.
      Even after the circumcision wound heals, a circumcised man who is HIV-positive transmits HIV through sex about as easily as an intact (uncircumcised) man.
      David

  2. Kermit July 28, 2014 at 3:29 pm

    It was hard to find your blog in google search results. I found it on 13 spot, you have
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  3. Mk June 21, 2018 at 6:31 pm

    Can a newly circumcised HIV negative man transit virus if he resume sex during healing period.

    • Anonymous June 29, 2018 at 9:34 pm

      Some confusion here? If the man is HIV-negative, he can’t transmit whether he is circ’ed or intact. If he’s HIV-positive, he could infect his sex partner if the wound has not healed, and he may have an increased risk to transmit even after the wound has healed.

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