Benefits of male circumcision for MSM: evidence for action
Authors: Jillian Pintye, Jared M Baeten
Journal: The Lancet Global Health (2019)

Voluntary medical male circumcision is a one-time, safe, highly cost-effective, biomedical, HIV prevention intervention supported by a robust evidence base of more than 40 observational studies and three randomised trials that showed circumcision reduces HIV acquisition in self-identified heterosexual men by approximately 60%, an effect that is sustained years after the procedure.1Tobian AA Kacker S Quinn TC Male circumcision: a globally relevant but under-utilized method for the prevention of HIV and other sexually transmitted infections.Annu Rev Med. 2014; 65: 293-306Crossref PubMed Scopus (59) Google Scholar Male circumcision also decreases the risk of heterosexual men acquiring other sexually transmitted infections (STIs), including genital ulcer disease, syphilis, herpes simplex virus type 2, and human papillomavirus (HPV).2Tobian AA Serwadda D Quinn TC et al.Male circumcision for the prevention of HSV-2 and HPV infections and syphilis.N Engl J Med. 2009; 360: 1298-1309Crossref PubMed Scopus (386) Google Scholar These STI prevention benefits extend to female partners, who have reduced rates of syphilis, HPV, bacterial vaginosis, and trichomoniasis.3Grund JM Bryant TS Jackson I et al.Association between male circumcision and women's biomedical health outcomes: a systematic review.Lancet Glob Health. 2017; 5: e1113-e1122Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar Between 2010 and 2017, more than 18·6 million men became circumcised in 14 priority African countries with generalised HIV epidemics and low rates of male circumcision.4WHOWHO progress brief: voluntary medical male circumcision for HIV prevention.https://afro.who.int/publications/voluntary-medical-male-circumcision-hiv-preventionDate: July 2018Date accessed: January 31, 2019Google Scholar Voluntary medical male circumcision procedures averted an estimated 230 000 new HIV infections by 2017 and are projected to prevent more than 1 million HIV infections by 2030.4WHOWHO progress brief: voluntary medical male circumcision for HIV prevention.https://afro.who.int/publications/voluntary-medical-male-circumcision-hiv-preventionDate: July 2018Date accessed: January 31, 2019Google Scholar Global goals are targeting 27 million more voluntary medical male circumcision procedures by 2021, translating to 90% of males aged 10–29 years being circumcised in priority settings.5UNAIDSA framework for voluntary medical male circumcision: effective HIV prevention and a gateway to improved adolescent boys' & men's health in eastern and southern Africa by 2021—policy brief.https://www.who.int/hiv/pub/malecircumcision/vmmc-policy-2016/en/Date: July, 2016Date accessed: January 31, 2019Google Scholar Gay, bisexual, and other men who have sex with men (MSM) have borne a disproportionate burden of the global HIV epidemic since its first recognition. In countries of low and middle income, MSM are 19 times more likely to be HIV infected compared with the general population, and HIV rates are rising among MSM in countries of low and middle income with high HIV burden, by contrast with global decreases in overall HIV incidence.6Beyrer C Sullivan P Sanchez J et al.The increase in global HIV epidemics in MSM.AIDS. 2013; 27: 2665-2678Crossref PubMed Scopus (239) Google Scholar, 7Baral S Sifakis F Cleghorn F Beyrer C Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000–2006: a systematic review.PLoS Med. 2007; 4: e339Crossref PubMed Scopus (535) Google Scholar Homophobia and stigma, manifesting as criminalisation of homosexuality and neglect in national planning,8Santos GM Makofane K Arreola S Do T Ayala G Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men.Sex Transm Infect. 2017; 93: 62-64Crossref PubMed Scopus (29) Google Scholar constrain both the provision and uptake of HIV prevention services among MSM in many settings, further fuelling the HIV epidemic among MSM. While the benefits of male circumcision against HIV and STIs among heterosexual men are clear, data for MSM have had conflicting results. Previous meta-analyses of observational data found some benefit but either with no or marginal statistical significance,9Millett GA Flores SA Marks G Reed JB Herbst JH Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis.JAMA. 2008; 300: 1674-1684Crossref PubMed Scopus (187) Google Scholar, 10Wiysonge CS Kongnyuy EJ Shey M et al.Male circumcision for prevention of homosexual acquisition of HIV in men.Cochrane Database Syst Rev. 2011; 6 (CD007496.)Google Scholar, 11Sharma SC Raison N Khan S Shabbir M Dasgupta P Ahmed K Male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition: a meta-analysis.BJU Int. 2018; 121: 515-526Crossref PubMed Scopus (26) Google Scholar and those inconclusive findings led some voluntary medical male circumcision programmes to primarily target heterosexual men without active promotion of circumcision for MSM. In all previous reviews, subanalyses were not undertaken among MSM in countries of low or middle income. In The Lancet Global Health, Tanwei Yuan and colleagues12Yuan T Fitzpatrick T Ko N-Y et al.Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data.Lancet Glob Health. 2019; 7: e436-e447Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar present the largest and most comprehensive systematic review and meta-analysis to date of the association between male circumcision and HIV and other STIs among MSM. The investigators included 62 observational studies with a total of 119 248 MSM—a tremendous compilation of data. They found that male circumcision was associated with 23% reduced odds of HIV infection overall; the protective association was greater among MSM in countries of low and middle income, for whom circumcision had 42% reduced odds of HIV infection. These compelling results strongly suggest that voluntary medical male circumcision could be an effective strategy for helping to curb the HIV epidemic among MSM in some of the countries most burdened by HIV. The results extend beyond those of previous reviews by including 16 additional studies from countries of low and middle income. Several factors might contribute to a more pronounced association between circumcision and lower HIV rates among MSM in countries of low and middle income compared with other settings, including populations that have heterogeneity in male circumcision status (neither all circumcised or uncircumcised) and higher HIV rates, thus permitting potentially more robust analyses and higher stability in anal sex role segregation (because circumcision would biologically be expected to protect MSM during insertive but not receptive anal sex).13Whittles L Mitchell K Silhol R Dimitrov D Boily M Global variation in the impact of male circumcision in preventing HIV among MSM.Top Antivir Med. 2016; 24: 459-460Google Scholar Some previous reviews have concluded that a randomised clinical trial might be needed to answer definitively whether voluntary medical male circumcision prevents HIV acquisition among MSM.14Vermund SH Qian HZ Circumcision and HIV prevention among men who have sex with men: no final word.JAMA. 2008; 300: 1698-1700Crossref PubMed Scopus (22) Google Scholar We argue that the global HIV prevention response for MSM, particularly in countries of low and middle income, is already belated and needs rapid sustained commitment and action. These new data should extinguish concerns that the benefits of voluntary medical male circumcision for MSM are too ambiguous to drive programmatic action. The option for voluntary medical male circumcision should be a part of robust prevention services for MSM, along with high-quality HIV testing, antiretroviral therapy and pre-exposure prophylaxis, STI screening and treatment, counselling about prevention options, and provision of condoms and lubricant. In many countries in Africa, up to 70% of MSM also have sex with women (and up to 30% are married to women);15Smith AD Tapsoba P Peshu N Sanders EJ Jaffe HW Men who have sex with men and HIV/AIDS in sub-Saharan Africa.Lancet. 2009; 374: 416-422Summary Full Text Full Text PDF PubMed Scopus (248) Google Scholar this important contextual difference could streamline uptake of voluntary medical male circumcision for MSM who might want to seek the procedure from existing community programmes serving heterosexual men. Scale-up of voluntary medical male circumcision has been associated with reducing HIV burden at the population level16Grabowski MK Serwadda DM Gray RH et al.HIV prevention efforts and incidence of HIV in Uganda.N Engl J Med. 2017; 377: 2154-2166Crossref PubMed Scopus (115) Google Scholar and is a core component of the UNAIDS strategy for ending HIV by 2030.5UNAIDSA framework for voluntary medical male circumcision: effective HIV prevention and a gateway to improved adolescent boys' & men's health in eastern and southern Africa by 2021—policy brief.https://www.who.int/hiv/pub/malecircumcision/vmmc-policy-2016/en/Date: July, 2016Date accessed: January 31, 2019Google Scholar Moreover, high-quality prevention services for key populations who carry disproportionate HIV and intersectional burdens, such as MSM, are an essential part of the global epidemic response. When the history of HIV control is one day written, the scale-up of voluntary medical male circumcision and the active provision of quality services to marginalised populations such as MSM will be core elements of that story. The results of the work by Yuan and colleagues emphasise the opportunity for those two elements to come together and contribute to accelerating HIV prevention globally. JP and JMB are supported by the University of Washington and Fred Hutch Center for AIDS Research (National Institutes of Health/National Institute of Allergy and Infectious Diseases grant P30 AI027757). JMB has received personal fees for advisory work from Gilead Sciences, Merck, and Janssen, outside the area of research commented on; and has received study medication from Gilead Sciences and IPM, outside the area of research commented on. The content is solely the responsibility of the authors and does not necessarily reflect the views of the US National Institutes of Health. Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global dataWe found evidence that circumcision is likely to protect MSM from HIV infection, particularly in countries of low and middle income. Circumcision might also protect MSM from HSV and penile HPV infection. MSM should be included in campaigns promoting circumcision among men in countries of low and middle income. In view of the substantial proportion of MSM in countries of low and middle income who also have sex with women, well designed longitudinal studies differentiating MSM only and bisexual men are needed to clarify the effect of circumcision on male-to-male transmission of HIV and other STIs. Full-Text PDF Open Access