Wawer, M. J. et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 374, 229–237 (2009).

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The conclusion drawn from several observational studies—that circumcision reduces the risk of HIV transmission from infected men to their uninfected female partners—has been contradicted by the results of a controlled trial. The trial was stopped early owing to futility.

HIV-positive adults in Uganda who volunteered to have their foreskin removed were randomized to either immediate surgery or to circumcision 2 years after enrollment. Despite intensive effort to educate all participants about the need to practice safe sex regardless of circumcision status, 10–20% of HIV-naive female partners of the enrolled men acquired the virus. Worryingly, the data indicate that the risk of transmission might actually be increased by circumcision.

The researchers detected viral load spikes in antiretroviral-naive men after circumcision. They suggest that the stress of surgery might heighten infectivity.

Further subanalysis showed that resumption of intercourse prior to complete wound healing might also increase the likelihood of transmission. A companion study of the preventive potential of circumcision in HIV-negative men showed that failure to abstain during the postoperative period was associated with higher rates of surgical adverse events. According to lead author Maria Wawer, “the message ... to both HIV-negative and HIV-positive men (and their partners) must be that it is imperative to wait until full wound healing (generally about 6 weeks) before resuming sex.”

“As male circumcision ... programs scale up, it is inevitable that HIV-positive men will request the procedure, partly to avoid stigmatization,” says Wawer. Ensuring that condom use increases concomitantly, beyond the maximum 50% use rate in this study population, is a challenge that must be met.