ArticlesCircumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial
Introduction
Three trials of male circumcision in HIV-negative men, including one undertaken in Rakai, Uganda, showed that circumcision reduced male acquisition of HIV by 50–60%;1, 2, 3 as a result, male circumcision is now a recommended strategy for HIV prevention in men.4 As these prevention programmes are scaled up, it is inevitable that men who are infected with HIV will also request to be circumcised, partly to avoid stigmatisation. We previously reported that male circumcision was safe and reduced rates of genital ulcer disease in asymptomatic HIV-infected men with CD4-cell counts 350 cells per μL or more.5, 6 In view of the social considerations and clinical findings, WHO and UNAIDS have recommended that surgery should not be denied to HIV-infected men who request the procedure unless there are medical contraindications.4
A previous observational study in HIV-discordant couples in Rakai suggested a lower rate of male-to-female HIV transmission from circumcised HIV-infected men, particularly if their viral load was below 50 000 copies per mL.7 Two other observational studies also reported an association between male circumcision and reduced risk of HIV infection in female sexual partners.8, 9
In parallel to the trial of male circumcision in HIV-uninfected men in Rakai,3 we undertook a randomised controlled trial of male circumcision in HIV-infected men and enrolled their female partners. Trial objectives were to assess the safety of circumcision in HIV-infected men and the efficicacy of male circumcision for the prevention of sexually transmitted infections (STIs) in HIV-infected men (reported elsewhere),5, 6 and to test whether male circumcision would reduce transmission of HIV and STIs from HIV-infected men to their uninfected female sexual partners. Here, we report the trial results from female partners of HIV-infected men, including frequency of HIV and rates of STI symptoms and vaginal infections.
Section snippets
Participants
The trial was done in Rakai District, Uganda, between 2003 and 2007. Trial procedures for HIV-infected men, including consent, randomisation, and data and sample collection, were the same as those previously reported in the trial of male circumcision in HIV-uninfected men.3 In brief, men received an explanation of study goals and provided written informed consent for screening and HIV testing. Before screening and throughout the trial, men were offered HIV results, counselling, and information
Results
Figure 1 shows the trial profile. The modified ITT population for the analysis of male-to-female HIV transmission comprised 92 couples from the intervention group and 67 couples from the control group. An additional 29 HIV-uninfected female partners of men in the intervention group and 30 HIV-uninfected partners of men in the control group entered the study 6 months or more after their husband's enrolment. These women were excluded from the primary analysis because we did not know their HIV
Discussion
In this trial, circumcision of HIV-infected men did not reduce transmission of the virus to uninfected female partners. Furthermore, we cannot exclude the possibility of higher HIV transmission in couples who resumed intercourse before complete healing of the surgical wound. Since the duration of the study was limited and not all female partners completed 24 months of follow-up, we could not assess the long-term benefits or risks of male circumcision for HIV transmission to women. The findings
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