HIV-positive men who have sex before circumcision wounds are healed could increase female partners' infection risk

HIV-positive men undergoing circumcision might be more likely to transmit the virus to their female partners if they have sex before the circumcision wounds have healed, according to preliminary results from a study being conducted in Uganda and presented on Tuesday to 75 officials from the World Health Organization and UNAIDS at a meeting in Montreux, Switzerland, the Washington Post reports (Brown, Washington Post, 3/7).

According to final data from two NIH-funded studies conducted in Uganda and Kenya published in the Feb. 23 issue of the journal Lancet, routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65% (Kaiser Daily HIV/AIDS Report, 2/28). According to the Post, some researchers have said they hoped male circumcision also might indirectly protect female partners because circumcised men are less likely to have genital ulcers, which increase the risk of HIV transmission. In addition, if circumcision reduces HIV prevalence in an entire population, both men and women would benefit. To examine the effect of male circumcision on their female partners, researchers from Uganda and the Johns Hopkins University Bloomberg School of Public Health enrolled about 1,000 HIV-positive men and randomly assigned half to be circumcised. The researchers followed 124 couples in which the men's regular female partner was HIV-negative when the man was circumcised. They found that among 70 partners including circumcised men, 11 women contracted HIV. In addition, among the 54 partners including men who were not circumcised, four women contracted HIV, according to the researchers. The researchers found that almost all new cases occurred within the first six months of the study. Among 12 partners including men who began having sex before the circumcision had healed, which takes about one month, three women contracted HIV. Among the 55 partners including men who waited until the wound had healed to resume sex, six women contracted HIV. An independent panel of scientists overseeing the study recommended that no new participants be enrolled (Washington Post, 3/7). The researchers said the increased risk might be because intercourse could cause small tears in the circumcision wound, transmitting HIV-infected blood into the women's vagina, Reuters South Africa reports (Dunham, Reuters South Africa, 3/7). Researchers said that the findings are too small to be statistically significant and that it is possible the HIV incidence rates were coincidental. However, researchers added that the findings suggest the increased HIV transmission was due to men having sex before their circumcision wounds healed. The men and women involved in the study received frequent HIV prevention education and free condoms, the AP/Houston Chronicle reports (Cheng, AP/Houston Chronicle, 3/6). The study is expected to be completed in two years, Reuters South Africa reports (Reuters South Africa, 3/7).

Reaction, Next Steps
Maria Wawer, a Johns Hopkins researcher who is leading the study, said the findings show the need to "err on the side of caution to protect women in any future male circumcision program" (AP/Houston Chronicle, 3/6). The researchers said that circumcision programs should include messages targeted to women that warn of increased HIV transmission risk before the wound has healed. Kevin De Cock, director of WHO's HIV/AIDS Department, said that the data do not "derail (the potential usefulness of circumcision) by any means," adding, "What it does do is provide a little more insight about the complexities that face us." Wawer added that the study shows that "the need for extreme precaution and abstinence from sex in the post-procedure period cannot be overemphasized" (Washington Post, 3/7). Jennifer Kates, HIV policy director and a vice president at the Kaiser Family Foundation who was not involved in the study, said, "Women are already so vulnerable in this epidemic. We need to be particularly careful about anything that could put them at even greater risk (AP/Houston Chronicle, 3/6). According to the Post, researchers plan to examine if some women in the study acquired HIV from someone other than their regular partners by conducting genetic analyses on both men's and women's viruses (Washington Post, 3/7). In addition, some experts have said that the study's findings are dependent on other factors, such as condom use, and demonstrate the difficulties associated with utilizing circumcision as an HIV prevention method in sub-Saharan Africa, the AP/Chronicle reports (AP/Houston Chronicle, 3/6).