Systematic review of circumcision for prevention of HIV
Jon Deeks with Nandi Siegfried, Martie Muller, Jimmy Volmink (Cape Town), Matthias Egger, Nichola Low (Bristol), Helen Weiss, Sarah Walker (London) and Paula Williamson (Liverpool)
The findings of observational studies, reviews and meta-analyses, supported by biological theories, have contributed to the recent ground swell of support for considering male circumcision as a strategy for preventing sexually acquired human immunodeficiency virus (HIV) infection.
This Cochrane systematic review assesses the evidence for an interventional effect of male circumcision for preventing acquisition of HIV-1 and HIV-2 by men through heterosexual intercourse. It includes a comprehensive assessment of the quality of all included studies. The review included 37 observational studies: studies in high-risk populations comprised four cohort, 12 cross-sectional and three case-control studies; general population studies comprised one cohort, 16 cross-sectional and one case-control studies. There was evidence of methodological heterogeneity between studies and statistical heterogeneity was highly significant for both general population cross-sectional studies (and high-risk cross-sectional studies. Study quality was very variable and no studies measured the same set of potential confounding variables. It was therefore inappropriate to conduct a meta-analysis. Although most studies show an association between male circumcision and prevention of HIV these results may be limited by confounding which is unlikely to be adjusted for. Detailed quality assessment of observational studies can provide an innovative useful visual aid to interpreting findings.
The review concluded that caution is warranted in interpreting the results of existing observational studies evaluating the association between male circumcision and heterosexual acquisition of HIV in men, and that the results of three randomised trials currently underway need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.
Publications: 76, 128, 177
