A study from Orange Farm near Johannesburg in South Africa, the area that hosted the first-ever randomised controlled trial of male circumcision for HIV prevention, which concluded in 2005, has found evidence that women who are partners of circumcised men are less likely to have HIV themselves.
A 2009 meta-analysis (Weiss) of the benefits to women of circumcising men found no evidence that having sex with a circumcised, rather than an uncircumcised, man reduced the risk of HIV infection to women, though there have been studies that show that male circumcision reduces the risk of human papillomavirus (HPV) and genital herpes (HSV2) in women.
But this is the first study to provide convincing evidence that male circumcision offers a degree of protection to their female partners too – although the benefit is quite small, in the order of a 15% reduction in prevalence in women who only have sex with circumcised men.
A voluntary medical male circumcision (VMMC) centre called Bophelo Pele was set up in 2008, funded by the Bill and Melinda Gates Foundation, after the results from the Orange Farm randomised controlled trial were confirmed by two other large trials in Uganda and Kenya.
Since Bophelo Pele started, the proportion of local men who are circumcised has risen from 15% to 53% and a recent survey found that HIV prevalence in the area was 50% lower in circumcised than uncircumcised men.
Mathematical models show that circumcision will eventually benefit women through the general fall in HIV prevalence in the population, but a direct benefit has been hard to prove.
This is especially the case in an area like Orange Farm, where prevalence is very high in women. Although the survey of men last year found that HIV prevalence in uncircumcised men was 19% and circumcised men 7% (average was 12%), in women prevalence is 30%, and in the peak age of 30-34 rises to 38%.
Among women who report ever having had sex, 30.0% in the present study reported having had only circumcised partners.
HIV prevalence among these women was lower than among other sexually active women: it was 22.4% in the partners of circumcised men and 36.6% in women who said some or all of their partners were uncircumcised. This represents an unadjusted reduction in risk of 28%, but after adjusting for confounders (such as the fact that the partners of circumcised men tend to be younger, as indeed are circumcised men), the reduction in risk was 15%. This was still statistically significant (p = 0.004).
Circumcision appears to make no difference to the rate of condom use in what the researchers called ‘non-spousal’ sex. In extramarital sex, women reported using condoms 37.5% of the time with circumcised partners and 38.6% of the time with uncircumcised ones. Fifty-five per cent of women thought condom use was easier for circumcised men.
Of women who had had sex with both, 74.4% said they preferred circumcised men, precisely because they were seen to be less likely to have HIV, but a relatively low 9.6% thought that if they had sex with a man who did have HIV they would be fully or partly protected from HIV if he was circumcised. Nine out of ten women did understand that if a man was circumcised, he could still acquire HIV.
Between 2008 and 2012, the proportion of women willing to have their male children circumcised rose from 83.0% to 96.0%.
"This study is encouraging for the current roll-out of voluntary medical male circumcision," comment the researchers.
They believe, however, that rather than there being a direct protection for the woman, the findings on the association of women’s HIV prevalence with their sexual partners’ circumcision status are probably due to the lower HIV prevalence rate among circumcised men.
A longitudinal incidence study is needed to settle the question, they add.
Auvert B et al. Male circumcision: association with HIV prevalence, knowledge and attitudes among women: findings from the ANRS 12126 study. 21st Conference on Retroviruses and Opportunistic Infections (CROI), Boston, abstract 962, 2014.
Weiss HA, Hankins CA, Dickson K Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infect Dis. 9:669-77, 2009.