Male circumcision and HIV/AIDS – link or co-incidence?
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Male circumcision may not be the answer to preventing the spread of HIV/AIDS in heterosexual men after all, say researchers at the South African Cochrane Centre, a unit of the SA Medical Research Council.

Previous studies have suggested that sufficient evidence exists to recommend male circumcision as a strategy in preventing heterosexual men from acquiring HIV.

“Not so”, says Dr Nandi Siegfried and her colleagues from the Universities of Cape Town, Oxford, Bristol, Liverpool and London, the Institute of Maritime Technology and the British Medical Research Council. The team have recently published a review on the subject in The Cochrane Library.

“We need to be very careful that we don’t send a message saying that if you’re circumcised you won’t get HIV. Circumcised men do get HIV. Results from current trials may well find that male circumcision is protective, but until we have that information, it would be irresponsible to promote it as a preventive strategy,” says Dr Siegfried.

The researchers conducted a systematic review of 35 studies using the high-quality research standards developed and promoted by the international group, the Cochrane Collaboration. Unlike previous reviews of this subject, the review included studies from all around the world regardless of their publication status or language.

“In this way, we attempted to capture all the evidence available, rather than only focusing on a specific geographic area or research published in English. We then went a step further than previous reviews and critically appraised the quality of all the included studies. Unfortunately, we found quality to be highly variable, limiting the conclusions that can be drawn from the data,” Dr Siegfried said.

A crucial finding of the review is that to date no actual Randomized Controlled Trials (RCTs) of circumcision have been conducted although three are currently underway. One of these is taking place in Gauteng, South Africa, where 1750 men will be circumcised and 1750 men will be left uncircumcised. The study participants will then be monitored for HIV over a period of 3, 12 and 21 months and the results in the two groups compared with each other. The other two trials are taking place in Kenya and Uganda.

RCTs are the most reliable method for determining whether a health intervention works or not. Given this fact, Dr Siegfried warns against the promotion of circumcision as an intervention for use in HIV/AIDS prevention programmes. None of the included studies looked at the possible adverse effects of circumcision – including the possibility that HIV might be passed on during circumcision itself.

The review will be published on the 21 July 2003 in The Cochrane Library and can be accessed free of charge, upon registration, by South African residents online at http://www.sahealthinfo.org/evidence/evidence.htm. This initiative is supported by The South African Cochrane Centre which aims to help people make informed decisions by disseminating up-to-date reviews on the effects of health care interventions.