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Male circumcision and risk of male-to-female HIV-1 transmission: a multinational prospective study in African HIV-1-serodiscordant couples

Baeten, Jared Ma; Donnell, Deborahb; Kapiga, Saidi Hd,e; Ronald, Allanf; John-Stewart, Gracea; Inambao, Mubianac; Manongi, Rachele; Vwalika, Bellingtonc; Celum, Conniea; for the Partners in Prevention HSV/HIV Transmission Study Team

doi: 10.1097/QAD.0b013e32833616e0
Epidemiology and Social

Objective: Male circumcision reduces female-to-male HIV-1 transmission risk by approximately 60%. Data assessing the effect of circumcision on male-to-female HIV-1 transmission are conflicting, with one observational study among HIV-1-serodiscordant couples showing reduced transmission but a randomized trial suggesting no short-term benefit of circumcision.

Design/methods: Data collected as part of a prospective study among African HIV-1-serodiscordant couples were analyzed for the relationship between circumcision status of HIV-1-seropositive men and risk of HIV-1 acquisition among their female partners. Circumcision status was determined by physical examination. Cox proportional hazards analysis was used.

Results: A total of 1096 HIV-1-serodiscordant couples in which the male partner was HIV-1-infected were followed for a median of 18 months; 374 (34%) male partners were circumcised. Sixty-four female partners seroconverted to HIV-1 (incidence 3.8 per 100 person-years). Circumcision of the male partner was associated with a nonstatistically significant approximately 40% lower risk of HIV-1 acquisition by the female partner (hazard ratio 0.62, 95% confidence interval 0.35–1.10, P = 0.10). The magnitude of this effect was similar when restricted to the subset of HIV-1 transmission events confirmed by viral sequencing to have occurred within the partnership (n = 50, hazard ratio 0.57, P = 0.11), after adjustment for male partner plasma HIV-1 concentrations (hazard ratio 0.60, P = 0.13), and when excluding follow-up time for male partners who initiated antiretroviral therapy (hazard ratio 0.53, P = 0.07).

Conclusion: Among HIV-1-serodiscordant couples in which the HIV-1-seropositive partner was male, we observed no increased risk and potentially decreased risk from circumcision on male-to-female transmission of HIV-1.

aUniversity of Washington, USA

bFred Hutchinson Cancer Research Center, Seattle, USA

cRwanda-Zambia HIV Research Group, Ndola and Lusaka, Zambia

dLondon School of Hygiene and Tropical Medicine, London, England

eKilimanjaro Christian Medical Centre, Moshi, Tanzania

fUniversity of Manitoba, Winnipeg, Canada.

*The Partners in Prevention HSV/HIV Transmission Study team members are listed in the Acknowledgements.

Received 3 October, 2009

Revised 23 November, 2009

Accepted 3 December, 2009

Correspondence to Jared Baeten, University of Washington, 901 Boren Avenue, Suite 1300, Seattle, WA 98104, USA. Tel: +1 206 520 3808; fax: +1 206 520 3801; e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.