Some have suggested that MC may not be an effective HIV prevention strategy in the US, in part because the prevalence of MC is already high in this country.21 Our data indicate that MC prevalence is indeed common in the NYC populations described, both among heterosexual men and MSM, but that it differs considerably across race/ethnicity groups and place of birth. HIV prevalence in NYC MSM and Hispanic MSM15 is higher than the general adult population HIV prevalence in some African countries16,17 where MC is a recommended HIV prevention strategy. Though heterosexual sex is the primary mode of transmission in Africa, the similarities in the HIV and MC prevalence in the NYC MSM population and some African countries, such as Kenya,22 suggests that if the protective effect of MC for HIV acquisition via anal sex is confirmed, MC could be a potential strategy to reduce HIV in NYC MSM.
Before MC can be recommended as a strategy for preventing HIV infection among MSM, stakeholders will need to consider much more than the MC prevalence among populations at high risk of HIV. Foremost among the unanswered questions is whether the protective effect of MC observed for men practicing vaginal sex is similar for men practicing insertive anal sex. Though our findings suggest exclusive practice of receptive anal sex is not especially common, MSM who engage only in receptive anal intercourse would be unlikely to reduce their risk of HIV acquisition through circumcision of their insertive partners. Two US observational studies report a twofold increased risk of HIV among uncircumcised MSM.22,23 In contrast, a study in Australia found no association between HIV and MC.24 None of these studies has examined in-depth how specific sexual practices may alter the association between MC and HIV. Studies specifically designed to examine this issue are needed to better assess the relationship between MC and HIV among MSM and to estimate the expected population-level impact. Another unanswered question is whether a perception of decreased risk of HIV might accompany adult MC, resulting in sexual disinhibition and increased sexual risk-taking. Also, adult MSM who undergo the procedure may be more likely to engage in receptive anal intercourse during the postoperative healing phase, which could increase their risk of HIV. Though MC does not appear to negatively affect sexual function7,25,26 evidence as to whether MC affects pleasure26 is sparse. Consideration must also be given to social norms and the acceptability of MC27,28; 1 study found that only 54% of uncircumcised MSM would get circumcised if MC was demonstrated to reduce the risk of HIV in MSM in the US.27 Cost-effectiveness of adult MC also needs to be evaluated. Any circumcision recommendations will need to carefully balance all of these concerns.
Our findings indicate that certain population segments previously shown to be at high risk of HIV have a MC prevalence lower than the general population and that there may be groups in which MC could reduce the risk of HIV. However, we know of no estimates of the proportion of HIV that could be prevented by MC among MSM in the US. Such estimates will depend on a number of disease transmission dynamics, including risk of HIV transmission conferred by different types of sex. We hope our findings may be useful for policy makers, mathematical modelers and others considering the possible national impact of MC among MSM and heterosexual men in the US.
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