Male Circumcision Helps to Prevent HIV Transmission?
By: Dr. Gary Bellman on January 2, 2014
The male foreskin, an unassuming flap of skin eagerly discarded in some cultures, has taken center stage in debates over HIV prevention. Although researchers now agree that its removal is a proved method to reduce HIV spread in heterosexual men, the picture still remains a bit unclear.
Male circumcision can be efficacious for men in reducing their risk of HIV acquisition through intercourse with women. Some experts predict that the impact of male circumcision as a biomedical intervention for HIV prevention in Africa could be large, and preparatory work has been done to establish male circumcision programs in Africa. The implications of African trials on circumcision for HIV prevention programs in the United States are less clear; despite the interest of the popular press in the idea.
The association between circumcision and reduced risk for HIV acquisition is biologically plausible; the foreskin contains high concentrations of superficial Langerhans cells and macrophages-- all target cells for HIV infection, some of which may also be close to the skin surface. There are also potential associations between lack of circumcision and HIV risk; for example, lack of circumcision is associated with increased risk of genital ulcer diseases, which in turn are associated with increased risk of HIV transmission.
Following infection, Langerhans cells not only serve as reservoirs for replicating virus, but also transport the virus to nearby lymph nodes where HIV spreads to other immune cells. In fact, the foreskin's anatomical function actually amplifies the risks. In uncircumcised men the foreskin covers and protects the tip of the penis, paradoxically making the skin there more delicate and prone to microscopic abrasions. These tiny injuries may promote inflammation, allowing the virus to come into closer contact with target immune cells.
Should adult male circumcision be recommended for HIV prevention in the US?
Circumcision may have a role for the prevention of HIV transmission in the US. However, because of the many differences between the underlying HIV epidemics in Africa and the US, differences in the prevalence of male circumcision in Africa and the US, and the considerable gaps in knowledge that exist regarding the potential impact of circumcision on HIV transmission by male–male sex, the extent of this role on a population basis is unknown. Further, the already high prevalence of circumcision among US men suggests some limitations in the potential impact of circumcision at a population level.
In order to understand the potential for male circumcision as an HIV prevention approach in the US, we believe that there are important questions that should be answered. These include questions that can be answered by basic science, by modeling, by surveys of acceptability, by considering ethical issues, and, perhaps, by clinical trials in the US.
The main take away should be that circumcision protects heterosexual men from HIV acquisition via sexual intercourse with the greatest benefits accruing in developing nations that are hardest hit by the epidemic.
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