Safety, caution, and linkage to counselling and testing
Advocates and implementers alike have recognised the importance of delivering all HIV services in ways that are nonjudgmental and non-stigmatizing. Clearly, VMMC reduces HIV risk only in people who are HIV negative. Yet it is critical to offer services in a way that is welcoming to all people and that does not have adverse social outcomes for men living with HIV who seek VMMC or men who test HIV positive while seeking VMMC.
The March 2007 WHO/UNAIDS document, New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications, does not recommend circumcision for HIV-positive men. However, it states that HIV-positive men should not be denied male circumcision unless there is a medical reason to do so. This recommendation reflects concern that denying male circumcision on the basis of HIV status could 1) increase stigma experienced by HIV-positive men who are not circumcised, 2) lead to assumptions that circumcised men cannot have the virus, and 3) increase the chances that HIV-positive men will seek surgery from unsafe or poorly trained providers if they are turned away from medical points of service.
In 2016, WHO/UNAIDS introduced its new framework (VMMC2021) promoting male circumcision as an entry point into health systems. For men who test positive, circumcision services offer antiretroviral treatment or referral to these services. Those testing HIV negative are provided, at minimum, a package of services including HIV prevention methods such as condoms or pre-exposure prophylaxis (PrEP).
Research to date
Safety and wound healing in HIV-positive men
There have been three randomised controlled trials of male circumcision for HIV prevention. These studies enrolled HIV-negative men. A separate trial in Uganda's Rakai District enrolled HIV-positive men with CD4 cell counts above 350 and men who did not wish to know their status.1 This first study of HIV-positive men took place at the same site where circumcision was studied among HIV-negative men, so it was possible to compare rates of wound healing, adverse events, and sexually transmitted infections (other than HIV) between the two groups.
The results of the Rakai District study in 2008 showed male circumcision was safe for HIV-positive male volunteers. Overall rates of post-operative complications and adverse events were comparable between the two groups of volunteers. Circumcision also appeared to reduce HIV-positive men's risk of genital ulcer disease.
Further studies in 2013 and 2014 provided strong evidence that male circumcision in HIV-positive men can be safe. Studies in Kenya and Uganda found no statistically significant difference in the time period for wound healing to be complete regardless of HIV status2 or CD4 counts, indicating that HIV-positive men could be safely included in male circumcision rollout programmes.3
HIV transmission to women
Only one randomised trial, conducted in Uganda in 2009, examined whether male circumcision affects rates of HIV transmission to women.4 In this trial, which was stopped early because it would not have sufficient statistical power to answer the research question, VMMC did not reduce HIV transmission. However, the results suggest that the female partner of an HIV-positive man may be at increased risk of acquiring HIV if the couple resumes having sex before his circumcision wound has healed. These results underscore the need for abstinence during the six-week post-operative period.
Separate studies in Kenya and Uganda detected a temporary spike in penile HIV shedding in the first weeks after circumcision of HIV-positive men who had never taken antiretroviral drugs,5,6 but the viral shedding was reduced to pre-circumcision levels or lower by six weeks. This should pose no additional risk of HIV transmission if men adhere to six weeks of sexual abstinence post-circumcision. It was also found that lower viral load is associated with less viral shedding. Starting HIV treatment prior to circumcision should be considered to reduce the risk of male-to-female HIV transmission. Research is needed to assess the time on treatment required to decrease HIV penile shedding.
Reduced risk of sexually transmitted infections
Evidence from the Rakai District trial showed circumcised HIV-positive men have reduced rates of genital ulcer diseases, including chancroid, herpes, syphilis, and penile cancer. These infections can increase the viral shedding that could lead to HIV infection in a female partner.
Further studies confirm that male circumcision significantly reduces the incidence and prevalence of HPV infections in HIV-positive men, which reflects similar findings for HIV-negative men.7 HPV (human papillomavirus) can cause genital cancer; thus, circumcision may reduce the risk of penile cancer among HIV-positive men.However, studies among couples have found that when an HIV-positive individual also has HPV (known as co-infection), sexual partners are at much greater risk of acquiring HPV.8 A 2011 study showed that contrary to findings in HIV-negative men, male circumcision of HIV-positive men did not reduce HPV transmission to female partners.9
Modeling studies suggest that including males regardless of their HIV status in male circumcision programmes could greatly enhance a programme’s effectiveness if it increases the circumcision uptake of men at higher risk of HIV.10,11 Among HIV-positive men, VMMC can reduce the risk of some ulcerative sexually transmitted infections that increase HIV shedding and transmission to women. Importantly, VMMC services also serve as a valuable entry point to care, linking men who are tested and found HIV-positive to the antiretroviral treatment that suppresses viral load and reduces HIV risk.10
1. Kigozi G, Fray RH, Wawer MJ, et al. The safety of adult male circumcision in HIV infected and uninfected men in Rakai, Uganda. PLoS Med 2008;5(6):e116. doi: 10.1371/journal.pmed.0050116.
2. Rogers JH, Odoyo-June E, Jaoko W, et al. Time to complete wound healing in HIV-positive men following medical male circumcision in Kisumu, Kenya, a prospective cohort study. PLoS One 201315;8(4):e61725. doi: 10.1371/journal.pone.0061725.
3 Kigozi G, Musoke R, Kighoma N, et al. Safety of medical male circumcision in human immunodeficiency virus: infected men in Rakai, Uganda. Urology 2014;83(2):294-7. doi: 10.1016/j.urology.2013.08.038.
4. Wawer MJ, Makumbi F, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009;374(9685):229-37. doi: 10.1016/S0140-6736(09)60998-3.
5. Tobian AR, Kigozi G, Manucci J, et al. HIV shedding from male circumcision wounds in HIV-infected men: a prospective cohort study. PLoS Med 2015;12(4):e1001820. doi: 10.1371/journal.pmed.1001820.
6. Odoyo-June E, Rogers JH, Jaoko W, et al. Changes in plasma viral load and penile viral shedding among HIV-positive men in Kisumu, Kenya. J Acquir Immune Defic Syndr 2013;64(5):511–17. doi: 10.1097/QAI.0b013e3182a7ef05.
7. Serwadda D, Wawer MJ, Makumbi F, et al. Circumcision of HIV-infected men: effects on high-risk human papillomavirus infections in a randomized trial in Rakai, Uganda. J Infect Dis 2010;201(10):1463-9. doi: 10.1086/652185.
8. Mbulawa ZZ, Coetzee D, Marais DJ, et al. Genital human papillomavirus prevalence and human papillomavirus concordance in heterosexual couples are positively associated with human immunodeficiency virus coinfection. J Infect Dis 2009;199(10):1514–24. doi: 10.1086/598220.
9. Tobian AA, Kong X, Wawer MJ, et al. Circumcision of HIV-infected men and transmission of human papillomavirus to female partners: analyses of data from a randomised trial in Rakai, Uganda. Lancet Infect Dis 2011;11(8):604-12. doi: 10.1016/S1473-3099(11)70038-X.
10. Hankins C, Warren M, Njeuhmeli E. Voluntary medical male circumcision for HIV prevention: new mathematical models for strategic demand creation prioritizing subpopulations by age and geography. PLoS One 2016;11(10):e0160699. doi: 10.137/journal.pone.0160699.
11. Awad SF, Sgaier SK, Lau FK, et al. Could circumcision of HIV-positive males benefit voluntary medical male circumcision programs in Africa? Mathematical modeling analysis. PLoS One 2017;12(1):e0170641. doi: 10.1371/journal.pone.0170641.