Circumcision may reduce HIV risk in men who have sex with men

Voluntary medical male circumcision (VMMC) appears to cut the risk of contracting HIV infection among men who have sex with men (MSM), particularly those who mainly practice insertive anal sex, as shown in a study from China presented at IAS 2023.

“This is the first randomized controlled trial to demonstrate the efficacy of VMMC in preventing HIV among MSM,” according to lead study author Prof Yanxiao Gao of Sun Yat-sen University, Shenzhen, China.

Gao and colleagues looked at a cohort of 247 uncircumcised, HIV-negative MSM in China and found no cases of HIV seroconversion over 116 person-years of follow-up among 124 participants in the intervention group who underwent circumcision. On the other hand, there were five cases of HIV infection documented over 117 person-years of follow-up among the 123 participants in the control group who remained uncircumcised. [IAS 2023, abstract 1002]

The corresponding HIV incidence rates were 0.00 per 100 person-years (95 percent confidence interval [CI], 0.00–3.18) in the intervention group vs 4.27 per 100 person-years (95 percent CI, 1.38–9.97) in the control group.

In both intention-to-treat and per-protocol analyses, circumcised participants were far less likely to catch HIV infection compared with uncircumcised participants (incidence rate ratio [IRR], 0.00, 95 percent CI, 0.00–1.08 and IRR, 0.00, 95 percent CI, 0.00–1.13).

“All adverse events related to VMMC were mild and resolved quickly,” Gao said.

In light of the findings, Gao believes that circumcision is very likely to be efficacious in preventing incident HIV acquisition among MSM who predominantly practice insertive anal sex.

Important HIV prevention option

“VMMC may protect men from HIV infection by reducing mucosal surface area and the concentration of HIV target cells in the penis,” Gao pointed out, adding that sexual position preference may have a crucial role in the protective effect of circumcision on HIV infection. [JMIR Res Protoc 2023;12:e47160; Am J Pathol 2002;161:867-873; Am J Pathol 2002;161:867-873]

“Men who practice insertive anal sex may benefit more from [circumcision] than those who practice receptive anal sex,” he said.

Meanwhile, current evidence-based HIV preventive measures for MSM including condoms and pre-exposure or postexposure prophylaxis are highly effective, although their use or uptake remains limited due to lack of awareness, limited availability of services, and poor adherence to medications and clinic follow-ups, especially in resource-limited settings. [Sex Health 2017;14:363-371; J Prim Prev 2018;39:619-645; Lancet HIV 2021;8:e502-e510; Lancet Public Health 2019;4:e494; AIDS Patient Care STDS 2020;34:193-204]

As such, Gao and colleagues are positive that VMMC has the potential to become an important HIV prevention option that will complement and expand existing prevention strategies among MSM in China, where 70 percent of MSM practice either exclusively insertive anal sex or both insertive and receptive anal sex. [Jiangsu J Prev Med 2015;26:33-35; Chinese J AIDS/STD 2012;18:306-309]

The study population were 18–49 years of age and predominantly practiced insertive anal sex and had two or more male sex partners in the past 6 months. Baseline characteristics of participants in the intervention and control groups were similar, and there was no difference in retention rates in both groups. All participants underwent repeated HIV testing at 3, 6, 9, and 12 months.