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Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial.
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A.
PLoS Med
2005 Nov;2(11):e298.
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Reviewed by
Susa Coffey, MD
Abstract
BACKGROUND: Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted in a general population of South Africa to test this hypothesis. METHODS AND FINDINGS: A total of 3,274 uncircumcised men, aged 18-24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95% CI. Protection against HIV infection was calculated as 1 - RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0-21.0) when the data were analyzed.
There were 20 HIV infections (incidence rate = 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95% CI: 0.24%-0.68%; p < 0.001). This RR corresponds to a protection of 60% (95% CI: 32%-76%).
When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%-77%). CONCLUSION:
Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved.
Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.).
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Comment
This important randomized controlled study demonstrated that circumcision of HIV-uninfected South African adult men significantly decreased their risk of HIV acquisition, at least in the short term. Data from other studies suggest that male circumcision also may decrease the risk of HIV transmission from an HIV-infected male to his female partner(s).(1,2) Taken together, these and other data suggest that male circumcision may be an important means of reducing the spread of HIV in certain populations, including parts of sub-Saharan Africa.
However, little is known about the long-term efficacy of adult male circumcision in preventing HIV acquisition or transmission, or about the safety and acceptability of the practice outside research settings. It seems likely that many factors may mitigate the protective benefit offered by male circumcision. In particular, risky sexual behaviors (which, in this study, increased significantly among the circumcised men during the follow-up period, despite risk-reduction counseling) or sexually transmitted infections may counteract the beneficial effect of circumcision. Whereas these and other concerns about adult male circumcision must be addressed, the findings of this study and others show that male circumcision must be considered carefully as an HIV prevention modality.
The full text of this article is available on the Internet without charge at
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020298
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See also: Auvert B, Sobngwi-Tambekou J, Taljaard D, et al.
Authors' reply
. PLoS Med. 2006 Jan;3(1):e67.
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