Public health experts are concerned about the effects of medicalized circumcision on women, given the concern for misinformation about the partial (rather than complete) protection and the overall status of women within resource-poor countries. These concerns for women’s health persist and are discussed infrequently as the latest global spotlight in public health surrounds a male-centered HIV prevention strategy. The Bill and Melinda Gates Foundation sponsored a trial among discordant couples to evaluate HIV and STI outcomes in Ugandan women who are partners of HIV-positive men (The Randomized Trial of Male Circumcision: STD, HIV, and Behavioral Effects in Men, Women, and the Community) to address such concerns. Conducted in Rakai, Uganda, the trial assessed male-to-female transmission of HIV and STIs, the societal impact of circumcision, and modification in sexual behavior. The latter includes a particular focus on risk compensation.
The results were disheartening. Circumcision of HIV-infected men did not directly reduce male-to-female HIV transmission. The 24-month HIV incidence rates for women partners of HIV-infected men were 13.8/100 person-years in the male circumcision arm and 9.6/100 person-years in the control arm (P
= 0.42). No reductions were noted in genitourinary symptoms among the women [43
]. Further, during the immediate postoperative period, there was an increased rate of transmission events to women by HIV-positive male partners who returned to sex at least 5 days before certified wound healing. As a result, the WHO and UNAIDS statement in March 2007 included an advisory that circumcision of HIV-infected men is not recommended for direct HIV prevention in women on an individual basis. Male circumcision will translate into protection for women in settings with high HIV prevalence and extensive circumcision coverage. In these settings, the population-level risk for HIV infection among women will decrease as the prevalence decreases among men, due to lower risk of a woman’s risk exposure to an HIV-infected man.
Despite the disappointing results of the study among HIV-infected men for prevention of male-to-female HIV transmission, there is optimism that circumcision of HIV-infected men does extend other benefits to women’s health. For example, the Rakai circumcision study found a reduction in the risk for GUD among female partners of circumcised men compared with uncircumcised HIV-infected men, which could indirectly reduce HIV acquisition in women. Until now, there had been few data about circumcision’s effect on STI risk in female partners, and no prospective studies had been conducted to date. One prior observational study suggested that there may be protection against some STIs for women [44
]. In an earlier study in Rakai, Uganda, 44 women with circumcised HIV-positive male partners and 299 women with uncircumcised HIV-positive partners were studied for HIV and STI transmission. Circumcision was associated with a reduced risk of prevalent trichomonas (prevalence RR [PRR] 0.65, 95% CI, 0.55–0.77), bacterial vaginosis (PRR 0.86, 95% CI, 0.8–0.93) and GUD (PRR 0.73, 95% CI, 0.53–0.98) among women with circumcised partners. Circumcision did not modify the risk of HIV, syphilis, chlamydia, or gonorrhea. A subsequent, larger study among almost 6000 African and Thai women (the HC-HIV Study) found no association between male partner circumcision status and the female risk of gonorrhea, chlamydia, or trichomonas [45
Both Rakai trials augment these earlier data. The concurrent circumcision trials showed protection against GUD among women partners of HIV-uninfected (RR 0.78, 95% CI, 0.63–0.97) and HIV-infected men (PRR 0.64, 95% CI, 0.49–0.85) randomized to immediate circumcision [26
]. Further, circumcision of HIV-negative men protected against trichomonas (RR 0.52, 95% CI, 0.05–0.98), incident bacterial vaginosis (BV) (PRR 0.8, 95% CI, 0.65–0.97), severe BV (Nugent scores 9–10; RR 0.39, 95% CI, 0.24–0.64), and persistent BV (PRR 0.82, 95% CI, 0.72–0.96). These results are consistent with the prior observational study findings reported by the Rakai investigators [43
The benefits of male circumcision to women’s health likely do not end here. Strong evidence suggests that circumcision also may reduce male prevalence of human papillomavirus (HPV) and thereby reduce male-to-female transmission of HPV types [46
]. Observational studies indicate a lower prevalence of oncogenic penile glans and coronal sulcus HPV infection [48
] and cervical cancer among women with circumcised partners [23
]. By decreasing women’s risk of oncogenic HPV type infection, circumcision may prevent cervical cancer.
In regions of high HIV prevalence, women’s health will likely benefit from male circumcision. Although circumcision of HIV-infected men seems unsuccessful in preventing direct male-to-female HIV transmission, women will find indirect protection as the population prevalence of HIV decreases with increasing coverage of medicalized circumcision services for men. New data indicate that circumcision of men, regardless of HIV status, protects women against GUD. Furthermore, results of prospective studies assessing circumcision’s effect on HPV infection in women are ongoing. Any measure to reduce HPV-related cervical disease will contribute considerably to improve women’s health in developing countries, where cervical cancer is the second most common cause of cancer-related death.