Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data

Abstract

Background Men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. Previous reviews investigating the role of circumcision in preventing HIV and other STIs among MSM were inconclusive. Many new studies have emerged in the past decade. To inform global prevention strategies for HIV and other STIs among MSM, we reviewed all available evidence on the associations between circumcision and HIV and other STIs among MSM.Methods In this systematic review and meta-analysis, we searched PubMed, Web of Science, BioMed Central, Scopus, ResearchGate, Cochrane Library, Embase, PsycINFO, Google Scholar, and websites of international HIV and STI conferences for studies published before March 8, 2018. Interventional or observational studies containing original quantitative data describing associations between circumcision and incident or prevalent infection of HIV and other STIs among MSM were included. Studies were excluded if MSM could not be distinguished from men who have sex with women only. We calculated pooled odds ratios (ORs) and their 95% CIs using random-effect models. We assessed risk of bias using the Newcastle-Ottawa scale. (0·99, 0·90-1·09; k=20; I²=40%). Circumcision was associated with reduced odds of herpes simplex virus (HSV) infection among MSM overall (0·84, 0·75-0·95; k=5; I²=0%) and penile human papillomavirus (HPV) infection among HIV-infected MSM (0·71, 0·51-0·99; k=3; I²=0%). Findings We identified 62 observational studies including 119 248 MSM. Circumcision was associated with 23% reduced odds of HIV infection among MSM overall (OR 0·77, 95% CI 0·67-0·89; number of estimates [k]=45; heterogeneity I²=77%). Circumcision was protective against HIV infection among MSM in countries of low and middle income (0·58, 0·41-0·83; k=23; I²=77%) but not among MSM in high-income countries Interpretation We found evidence that circumcision is likely to protect MSM from HIV infection, particularly in countries of low and middle income. Circumcision might also protect MSM from HSV and penile HPV infection. MSM should be included in campaigns promoting circumcision among men in countries of low and middle income.In view of the substantial proportion of MSM in countries of low and middle income who also have sex with women, well designed longitudinal studies differentiating MSM only and bisexual men are needed to clarify the effect of circumcision on male-to-male transmission of HIV and other STIs.

Critical evaluation of arguments opposing male circumcision: A systematic review

“…250 A more recent metaanalysis, involving 62 observational studies and 119 248 MSM, found MC was associated with a significant, overall 23% reduced risk of HIV infection among MSM (OR 0.77; 95% CI 0.67-0.89). 251 the implications of which were further discussed in an accompanying editorial. 252 Each meta-analysis referred to the highly significant 89% risk reduction conferred by MC to insertive MSM in Sydney, Australia, 253 and called for more studies of MSM who adopt the insertive role during anal intercourse, as well as more studies of bisexual men because of the risk of STI transmission they pose to women.…”

“…A Cochrane meta‐analysis concluded that, “ Current evidence suggests that male circumcision may be protective among MSM who practice insertive anal sex, but the role of male circumcision overall in the prevention of HIV […] among MSM remains to be determined .” The meta‐analysis found a 73% decrease in HIV infection risk in studies of MSM reporting an insertive role during anal intercourse, but no significant difference in studies of men reporting a receptive role . A more recent meta‐analysis, involving 62 observational studies and 119 248 MSM, found MC was associated with a significant, overall 23% reduced risk of HIV infection among MSM (OR 0.77; 95% CI 0.67‐0.89) . the implications of which were further discussed in an accompanying editorial .…”

“…A 2011 Cochrane meta‐analysis examined syphilis, HSV‐1, and HSV‐2 in MSM and found no overall significant association with MC status . A more recent meta‐analysis found MC was associated with reduced odds of HSV infection among MSM overall (OR 0.84, 95% CI 0.75‐0.95), and of penile HPV infection among HIV‐infected MSM (OR 0.71, 95% CI 0.51‐0.99) . The Australian group found that MC protected against incident syphilis (HR 0.35; 95% CI 0.15‐0.85), particularly in the one‐third of MSM in the study who engaged predominantly in insertive anal intercourse (HR 0.10; 95% CI 0.01‐0.81) .…”

Prevalence and Genotype distribution of Human Papillomavirus Infection in Different Anatomical Sites among Men Who Have Sex with Men (MSM): A Systematic Review and Meta-Analysis

“…It has been revealed that circumcision is associated with remarkably reduced odds of penile HPV infection among MSM. Male circumcision leads to a decreasing number of host cells for HPV to infect, removing microenvironments that support the replication and survival of HPV, and decreasing the risk of microabrasions during sexual intercourse that facilitates the entry of HPV into the body [169]. The estimated prevalence rate of male circumcision is approximately 38.7% across the world [170], and it is a routine practice for Muslims and Jews [171].…”

ART is key to clearing oncogenic HPV genotypes (HR-HPV) in anal mucosa of HIV-positive MSM

“…Preventive measures against HPV acquisition include circumcision in males [5], use of condom [6], and HPV vaccination [7]. Utilization of the condom is deficient among MSM [8], especially since the availability of pre-exposure prophylaxis to reduce the risk of HIV transmission [9].…”