The largest and most comprehensive study to date of the HIV prevention benefits of male circumcision for men who have sex with men (MSM) found that circumcision reduced the odds of HIV infection among this group by 42 percent in low- and middle-income countries, and overall by 23 percent.

Based on this data, the study published in The Lancet Global Health asserts that campaigns promoting male circumcision should also include gay and bisexual men, as well as other men who have sex with men, to help fight HIV. This is particularly important in low- and middle-income countries with high rates of HIV infections.

“Gay, bisexual, and other men who have sex with men (MSM) have borne a disproportionate burden of the global HIV epidemic since its first recognition,” notes the study, published online for the journal’s April issue.

It further explains that MSM in low- and middle-income countries “are 19 times more likely to be HIV-infected compared with the general population,” and that HIV rates are actually rising among this at-risk group in countries with high HIV burden, in contrast with the global decline in HIV infections and burden of disease.

The study, “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,” was authored by Tanwei Yuan and Thomas Fitzpatrick of Sun Yat-sen University, Shenzhen, China, and Nai-Ying Ko of National Cheng Kung University, Tainan, Taiwan, among others.

“When the history of HIV control is one day written, the scale-up of voluntary medical male circumcision and the active provision of quality services to marginalised populations such as MSM will be core elements of that story,” concludes a companion article on the study, published in the same edition of The Lancet Global Health.

Argument to Include MSM in Voluntary Medical Male Circumcision Campaigns

Extensive studies of self-identified heterosexual men, including more than 40 observational studies and three randomised trials, previously found that voluntary medical male circumcision reduces the transmission of HIV among this population by approximately 60 percent, the companion article notes. These findings, it says, led to large-scale campaigns promoting male circumcision targeting heterosexual men.

“Between 2010 and 2017,” it recounts, “more than 18.6 million men became circumcised in 14 priority African countries with generalised HIV epidemics and low rates of male circumcision. Voluntary medical male circumcision procedures averted an estimated 230 000 new HIV infections by 2017 and are projected to prevent more than 1 million HIV infections by 2030.”

Men who have sex with men, however, had not been systematically included in these campaigns, which the study asserts is partly due to inconclusive evidence from previous studies regarding the benefits of male circumcision in preventing HIV infection among this at-risk group.

Those previous studies, it says, were based on insufficient data and lacked sources from low- and middle-income countries.

The new Lancet Global Health study aimed to address this gap through a systematic review and meta-analysis of 62 previous studies including a population of 119,248 men who have sex with men. The data reviewed included 24 studies from middle-income countries and nine from low-income countries.

While male circumcision reduced odds of HIV infection by abut 23 percent among men who have sex with men overall, the procedure was most protective for those living in low- and middle-income countries, reducing the odds of infection among this group by 42 percent.

This, the study asserts, can be partly attributed to the fact that male partners in low- and middle-income countries have greater role stability when engaging in anal sex.

“Although circumcision offers the most direct protection to MSM who primarily engage in insertive anal sex,” the study notes, “high coverage of circumcision among MSM overall could reduce HIV prevalence at a population level and, therefore, indirectly protect MSM who engage in receptive anal sex.”

Another reason for the apparently high rates of protection afforded by male circumcision may lie in the fact that proportionately more men in low- and middle-income countries who have sex with men also have sex with women, exposing the men to other sources of infection risks.

“Up to 70% of MSM also have sex with women (and up to 30% are married to women),” the study notes, adding that “this important contextual difference could streamline uptake of voluntary medical male circumcision for MSM who might want to seek the procedure from existing community programmes serving heterosexual men.”

Since voluntary medical male circumcision campaigns including MSM can target all men, regardless of sexual orientation, the study suggests that “MSM in countries of low and middle income seeking circumcision would most likely experience less stigma when accessing this service.”

The authors of the study argue “that the global HIV prevention response for MSM, particularly in countries of low and middle income, is already belated and needs rapid sustained commitment and action.”

“These new data,” it says, “should extinguish concerns that the benefits of voluntary medical male circumcision for MSM are too ambiguous to drive programmatic action.”

The authors suggest that “randomised controlled trials of circumcision among MSM in countries of low and middle income could confirm this protective effect,” however, they acknowledge that “evidence from this meta-analysis might not be strong enough to support development of a randomised trial.”

They note that the “protective effect of circumcision seen in countries of low and middle income could be accounted for by prevention of female-to-male HIV transmission among bisexual men rather than prevention of HIV transmission during anal sex.”

Due to this possibility, they recommend that “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.”

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