HIV in Canada: A primer for service providers

 

Penile circumcision

Key Points

  • Penile circumcision is the surgical removal of all or part of the foreskin of the penis.
  • Penile circumcision has the potential to reduce the risk of sexual HIV transmission in heterosexual men by up to 72%.
  • Penile circumcision is not recommended as an HIV prevention strategy in Canada.

Penile circumcision is the surgical removal of all or part of the penis foreskin. There are several biological explanations for why foreskin removal may reduce the risk of HIV infection:

  • The foreskin is vulnerable to small tears and/or inflammation that can happen during sex and can make it easier for HIV to pass through the skin into the body.
  • The inner part of the foreskin has a high concentration of the immune cells that HIV targets for infection.
  • HIV may be able to survive for longer when trapped under the foreskin.
  • Removing the foreskin lowers the chances of getting STIs that cause ulcers/sores (such as herpes or syphilis), which can facilitate HIV transmission.

An HIV-negative person with a circumcised penis has a lower chance of getting HIV through vaginal sex, compared to a person who is not circumcised. Meta-analyses have found that penile circumcision can reduce the risk of getting HIV by as much as 72% among heterosexual HIV-negative males, in countries where there is a high prevalence of HIV.

An HIV-negative person with a circumcised penis may also have a slightly lower risk of getting HIV when having insertive anal sex. One meta-analysis found a reduced risk of 20% for HIV-negative gay, bisexual and other men who have sex with men (gbMSM). This small risk reduction (much less than the 72% reduction for heterosexual males) likely reflects the fact that gbMSM may have both insertive and receptive anal sex. Circumcision only helps to protect HIV-negative males when they take the insertive role, which naturally carries a lower risk of HIV transmission, compared to receptive anal sex.

Circumcision of HIV-positive males does not reduce their risk of passing HIV to sexual partners.

The World Health Organization and UNAIDS recognize circumcision as an effective population-level intervention for the prevention of heterosexual HIV acquisition in men. Both agencies recommend voluntary adult penile circumcision in countries with a high prevalence of HIV throughout the population and where there is a low prevalence of circumcision in infancy. In Canada, circumcision is not recommended as a method of preventing HIV. 

Resources

Circumcision

Male circumcision for HIV prevention – World Health Organization

HIV and male circumcision – U.S. Centers for Disease Control and Prevention 

Voluntary medical male circumcision for HIV prevention: An introductory fact sheet – AVAC fact sheet

Sources

  1. Lei JH, Liu LR, Wei Q et al. Circumcision status and risk of HIV acquisition during heterosexual intercourse for both males and females: A meta-analysis. PLoS One. 2015 May 5;10(5):e0125436.
  2. Sharma SC, Raison N, Khan S, et al. Male circumcision for the prevention of HIV acquisition: A meta-analysis. BJU International. 2018 Apr;121(4):515–526.
  3. Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Medicine. 2005 Nov;2(11):e298.
  4. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet. 2007 Feb 24;369(9562):643–656.
  5. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet. 2007 Feb 24;369(9562):657–666.
  6. Wiysonge CS, Kongnyuy EJ, Shey M, et al. Male circumcision for prevention of homosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews Online. 2011;(6):CD007496.
  7. Anderson J, Wilson D, Templeton DJ, et al. Cost-effectiveness of adult circumcision in a resource-rich setting for HIV prevention among men who have sex with men. Journal of Infectious Diseases. 2009 Dec 15;200(12):1803–1812.