Circumcision

Published Online First: 15 December 2008. doi:10.1136/sti.2008.032334
Sexually Transmitted Infections 2009;85:116-120

Copyright © 2009 by the BMJ Publishing Group Ltd.

EPIDEMIOLOGY

Male circumcision and Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis: observations after a randomised controlled trial for HIV prevention

J Sobngwi–Tambekou¹, D Taljaard², M Nieuwoudt³, P Lissouba¹, A Puren³ and B Auvert⁴

¹ INSERM U687, Hôpital Paul Brousse, Villejuif, France
² Progressus, Johannesburg, South Africa
³ National Institute for Communicable Diseases, Johannesburg, South Africa
⁴ INSERM U687, Assistance Publique-Hôpitaux de Paris, University of Versailles, France

Correspondence to:
Dr Bertran Auvert, INSERM U687, 12 avenue Paul Vaillant-Couturier, 94804 Villejuif Cedex, France; bertran.auvert@uvsq.fr

Objective: To assess the association between male circumcision and Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis using data from a male circumcision randomised controlled trial.

Methods: We used data collected during the male circumcision trial conducted in Orange Farm (South Africa) among men aged 18–24 years. Altogether, 1767 urine samples collected during the final follow-up visit were analysed using PCR. Prevalence of N gonorrhoeae, C trachomatis and T vaginalis was assessed as a function of male circumcision using odds ratios (OR) given by univariate and multivariate logistic regression.

Results: In an intention-to-treat analysis, prevalence of N gonorrhoeae, C trachomatis and T vaginalis among intervention and control groups were 10.0% versus 10.3% (OR 0.97; p = 0.84), 2.1% versus 3.6% (OR 0.58; p = 0.065) and 1.7% versus 3.1% (OR 0.54; p = 0.062), respectively. The association between T vaginalis and male circumcision remained borderline when controlling for age, ethnic group, number of lifetime partners, marital status, condom use and HIV status (AOR 0.48; p = 0.069). In the as-treated analysis, this association became significant (OR 0.49, p = 0.030; AOR 0.41, p = 0.030).

Conclusions: This study demonstrates for the first time that male circumcision reduces T vaginalis infection among men. This finding explains why women with circumcised partners are less at risk for T vaginalis infection than other women. The protective effect on T vaginalis is an additional argument to recommend male circumcision in Africa where it is acceptable.

Trial registration number: NCT00122525.

Circumcision reduced the incidence of human immunodeficiency virus (HIV), HSV 2, HPV infections

Male circumcision significantly reduced the incidence of HIV and herpes simplex virus type 2 (HSV-2) infection and the prevalence of human papillomavirus (HPV) infection, suggesting potential public health benefits, according to the results of a randomized controlled trial reported in the March 26 issue of the New England Journal of Medicine.

"Male circumcision significantly reduced the incidence of...HIV infection among men in three clinical trials," write Aaron A.R. Tobian, MD, PhD, from Bloomberg School of Public Health, Johns Hopkins University in Baltimore, Maryland, and colleagues. "We assessed the efficacy of male circumcision for the prevention of...HSV-2 and...HPV infections and syphilis in HIV-negative adolescent boys and men."

Two trials of male circumcision to prevent HIV and other sexually transmitted infections in a rural Ugandan population enrolled a total of 5534 HIV-negative, uncircumcised male subjects aged 15 to 49 years. Of 3393 subjects (61.3%) who were HSV-2 seronegative at enrollment, 1684 had been randomly assigned to undergo immediate circumcision (intervention group) and 1709 to undergo circumcision after 24 months (control group). Subjects were tested for HSV-2 and HIV infection and syphilis and underwent physical examinations and interviews at baseline and at 6, 12, and 24 months. A subgroup of subjects was also evaluated for HPV infection at baseline and at 24 months.

The cumulative probability of HSV-2 seroconversion by 24 months was 7.8% in the intervention group vs 10.3% in the control group. High-risk HPV genotypes were present at 24 months in 18.0% of the intervention group vs 27.9% of the control group.

"In addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection, findings that underscore the potential public health benefits of the procedure," the study authors write. "These findings, in conjunction with those of previous trials, indicate that circumcision should now be accepted as an efficacious intervention for reducing heterosexually acquired infections with HSV-2, HPV, and HIV in adolescent boys and men. However, it must be emphasized that protection was only partial, and it is critical to promote the practice of safe sex."

Points to remember

• Uncircumcised men may be at higher risk for sexually transmitted infection because of greater exposure of the lightly keratinized inner preputial mucosa during intercourse, a higher risk for microtears, and a favorable environment in the subpreputial cavity for incubation of infection.
• In the current study, circumcision reduced the risk for infection with HSV-2 and HPV

(ClinicalTrials.gov numbers, NCT00425984 [ClinicalTrials.gov] and NCT00124878 [ClinicalTrials.gov] .)

Aaron A.R. Tobian et al. Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis. New England Journal of Medicine. 360 (13) :1298-1309, March 26, 2009