How Effective Is Male Circumcision at Preventing Sexually Transmitted Infections?

Adult male circumcision is being pushed as the latest magic bullet for the HIV pandemic. There is good reason for the enthusiasm about a new use for the world's oldest surgical intervention. But let's be clear about what circumcision will and will not offer a man and his partner or partners.

Circumcision programs have captured the attention and funding of governments in East and Southern Africa, global funders, and policymakers. Job postings for "male circumcision specialists" are circulating, and the Bill and Melinda Gates Foundation and the President's Plan for AIDS Relief (PEPFAR), two of the largest funders of global HIV/AIDS programs, have incorporated male circumcision work into their efforts.

First, the good news: Three recent trials have shown that circumcised men are about half as likely to contract HIV from unprotected vaginal intercourse as their uncircumcised counterparts. Circumcision also protects against some other sexually transmitted infections (STIs).

But the reality is that circumcision offers only partial protection. A circumcised man still has a significant risk of contracting HIV and other STIs if he engages in unprotected sex with an infected partner. Circumcision does not offer the man's current female partners any protection from contracting HIV.

On a larger scale, the predictive models that show a significant reduction in the number of new HIV infections assume that between that 80 to 100 percent of men are circumcised. Currently approximately 30 percent of men worldwide are circumcised, although this varies widely between different communities and countries.

Surveys have shown that many men are willing to be circumcised, and the promise of surgical prevention may bring throngs of men into local clinics that do not routinely use health services. It would be shortsighted not to couple circumcision services with education on HIV prevention and safe sex, provider-initiated HIV counseling and testing, and referrals to HIV/AIDS care and treatment.

But given the protection that circumcision provides, men may assume and assert that they are "safe" and insist on having sex without condoms. There are questions about whether newly circumcised men will be willing to abstain from sex for the six weeks necessary for the wound to heal so as to not possibly increase their or their partner(s) risk of contracting HIV or other STIs.

In the communities where the demand for circumcision is high and resources are scarce, unqualified circumcisers may begin offering the surgery to meet men's demands. It would take only a very few unqualified safe surgeons to taint the safety and acceptability of these programs. We cannot allow this to happen.

Clearly, circumcision is an imperfect solution to HIV prevention. Even so, it promises to be one of the most effective strategies we currently have to curb new HIV infections in men.

So, what about those of us who never had a foreskin?

By the most optimistic predictions, male circumcision will not translate into fewer HIV infections in women for decades. The reality of HIV and the epidemic is that women account for the majority of people living with HIV in the most affected region, Sub-Saharan Africa. For biological reasons, a woman is between two to eight times more likely than a man to contract HIV during vaginal intercourse with an HIV-positive partner.

On top of women's biologic predilection to infection, gender inequalities have sustained and feminized the epidemic by limiting women's abilities to negotiate safe sex, refuse unwanted sex, and ask their partners to be monogamous. We must be cautious about how male circumcision may change these realities.

Too often women are blamed for bringing HIV into the household. They are cast out of their homes, subjected to discrimination and violence, and shunned by their communities. Will circumcised men be more likely to blame their female partner(s) if either of them becomes HIV-positive? As fewer men contract HIV, will it increasingly be seen as a women's disease and become more stigmatized? Will women living with HIV become more vulnerable to violence and abandonment than they already are?