Because the study subjects were not receiving antiretroviral therapy, the concentration of HIV-1 RNA in blood represents a balance between viral replication and host factors limiting replication. Circumcision appeared to prevent infection among the men. These results support hypotheses concerning risk factors for transmission put forward by other investigators using different methods. When HIV-1 infection was first recognized, the associated stigma limited the number of people who sought to determine their infection status. Effective antiretroviral therapy is available in developed countries and may become available in some developing countries as well.
Antiretroviral therapy reduces the viral burden in both blood and genital secretions.
But the results from the Ugandan study do not prove this point. Furthermore, antiretroviral therapy is currently too expensive and the treatment regimen is too complex for routine use in developing countries. The protection afforded by circumcision most likely reflects changes in cutaneous barriers after the procedure that reduce the prevalence of inflammation and genital ulcers and the access of HIV-1 to receptive cells. Countries where HIV-1 infection is endemic or epidemic might well consider promoting circumcision for its public health benefits. However, the promotion or institution of a procedure that has profound cultural implications, risks of complications, and benefits that are realized only decades later represents a formidable public health and political challenge.