Background
Observational studies suggest that male
circumcision may provide protection against HIV-1 infection.
A randomized, controlled
intervention trial was conducted in a general population of South Africa to test this hypothesis.
Methods and Findings
A total of 3,274 uncircumcised men, aged 1824 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male
circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95 CI. Protection against HIV infection was calculated as 1 RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.021.0) when the data were analyzed. There were 20 HIV infections (incidence rate = 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95 CI: 0.240.68; p < 0.001). This RR corresponds to a protection of 60 (95 CI: 3276). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61 (95 CI: 3477).
Conclusion
Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.)