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Further study requirements to determine the benefits of circumcision to decrease the risk of HIV transmission, specifically in heterosexual relationships

How does male circumcision reduce the risk of HIV?
Circumcision is the removal of the foreskin. Past studies have proven that this decreases the rate of HIV-infection by 50-60% (Berezow, 2013).

By removing the foreskin of the penis, there is a dramatic change in the microbiome of the glans of the penis, as the increase of oxygen to the glans decreases the moisture in the area. This decreases the quantity and variety of microbiome, which needs moisture to survive (Berezow, 2013).

An uncircumcised male’s foreskin contains many Langerhans cells, a type of dendritic cell. Therefore, when the virus comes into contact with the foreskin, it needs to reach the CD4 T-cells in the blood or the lymph nodes. Researchers suggested that microbiome facilitates this process in two ways (Sciencedaily, 2013):

1. Due to inflammation caused by the altered microbiome, immune cells are recruited to the foreskin (Sciencedaily, 2013; Berezow, 2013) Therefore, the reduction of microbiome by removal of the foreskin would decrease the number of available immune cells for HIV to attack.
2. The microbiome triggers the Langerhans cells to deliver the virus to the T-cells. Therefore, without this trigger, the Langerhans cells would simply destroy the virus.

Previous African studies: What are the statistics?
To determine the effectiveness of male circumcision, three trials were conducted in sub-Saharan Africa with 1100 previously uncircumcised men. They were each assigned either to have their foreskin removed or to remain uncircumcised. The three studies took place in South Africa, Kenya and Uganda with the following results (AVERTingAIDS, 2013):

With these encouraging results, it was projected that full coverage of male circumcision could evade six million new HIV-infections and three million deaths over the next twenty years (AVERTingAIDS, 2013).

The need for further research
Further research is vital in developing male voluntary circumcision programmes.

• There is currently insufficient knowledge regarding the effect that circumcision has on HIV transmission from males to females. Currently no short-term effect has been shown; although long-term benefits have been established as potentially, reducing HIV-incidence by 46% as a result of fewer HIV-infected males (AVERTingAIDS, 2013).
• It is important to identify the physiological risks and advantages of circumcision for HIV-positive men (Visser, 2007)
• The benefits of circumcision for the receptive role in anal intercourse for both heterosexual and homosexual relationships (AVERTingAIDS, 2013)
• Studies which demonstrate that a change in the microbiome can assist in the reduction of HIV transmission (Sciencedaily, 2013)
• Exploring awareness and uptake of circumcision among different cultural groups (Kenyon et al, 2010)

Conclusion
By furthering these studies, the increased understanding of role of circumcision in preventing HIV holds potential to identify new HIV preventative interventions and improve existing ones, especially in populations where HIV-rates are high and where male circumcision is less acceptable. This research would lead to greater acceptability of circumcision and increased awareness on personal health and safer practices.

References

• AVERTingAIDS. (2013) Circumcision & HIV
• Berezow, A. B. (2013) Why does circumcision reduce HIV risk?
• Kenyon, C. Zondo, S. Badri, M. (2010) Determinants of Self-Perceived HIV Risk in Young South Africans Engaged in Concurrent Sexual Relationships. African Journal of Reproductive Health, 14(3), 171-181.
• ScienceDaily. (2013)  Dramatic changes in bacteria following mal circumcision
• Visser, P. J. (2007) Male circumcision and its links to HIV prevention [Online]

Author: Jodilee Erasmus (B.Soc Sci) 
Reviewed by: Hendra van Zyl (MPH) and Michelle Moorhouse (MBBCh, DA)
Contact: afroaidsinfo@mrc.ac.za
Date: May 2013

Preferred citation
Erasmus, J. (2013) Further study requirements to determine the benefits of circumcision to decrease the risk of HIV transmission, specifically in heterosexual relationships, AfroAIDSinfo. Issue 13 no. 5, Science (Open access).

Last updated: 2 May, 2013