Considerations in the Role of Male Circumcision in the Prevention of HIV Transmission in the USA

Abstract

Male circumcision (MC) has been associated with a reduced risk for female-male HIV transmission in observational and ecological studies, as well as clinical trials. Three recent randomized, controlled trials in sub-Saharan Africa demonstrated a 50-60% reduction in HIV incidence among men randomized to circumcision compared with uncircumcised men. In 2007, WHO/UNAIDS recommended that MC be recognized as an additional efficacious intervention to prevent sexual transmission of HIV from women to men. This article reviews information on the potential role of MC for HIV prevention in the USA where, compared with the African clinical trial countries, the prevalence of HIV infection is lower, the main route of HIV transmission is male-male sex rather than heterosexual sex and the prevalence of MC is higher.
Introduction

Male circumcision (MC) is the surgical removal of some or all of the foreskin, or prepuce, from the penis [1]. MC has long been associated with cultural rites and imbued with religious significance in many regions of the world. In some settings, hygiene and health consequences of MC have been factors in adopting the practice. In recent years the role of MC in preventing female-male HIV transmission has been demonstrated and MC is being implemented as an HIV prevention intervention, especially in sub-Saharan Africa.

Biological Plausibility of Male Circumcision for HIV Prevention

The foreskin can serve as a portal of entry for HIV infection, lending biological plausibility to the role of circumcision in preventing HIV acquisition through insertive sexual intercourse. The inner mucosa of the foreskin is less keratinized than the dry external skin of the penis shaft. It also has a higher density of target cells for HIV infection (Langerhans cells, CD4+ cells and macrophages) close to the skin surface.[2,3] Foreskin mucosal tissue has been shown to be more susceptible to HIV infection than cervical mucosa or the external foreskin surface in laboratory studies.[4] During sexual intercourse, the foreskin retracts from the glans of the erect penis and is inverted over the shaft of the penis, exposing the inner mucosal surface of the foreskin to the body fluids of the sex partner, and potentially to HIV infection (Figure 1).[2] It has also been argued that the foreskin may have greater susceptibility than dry epithelial tissue to traumatic small tears and disruptions during sexual intercourse, thereby providing a portal of entry for pathogens including HIV.[5] The micro-environment in the preputial sac between the unretracted foreskin and the glans penis may also be conducive to viral survival.[4] Finally, higher rates of sexually transmitted diseases (STDs), such as syphilis[6] and herpes simplex virus type-2 infection,[7] have been observed in uncircumcised men; these conditions may independently increase susceptibility to HIV infection.[8]

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Figure 1.

Position of the foreskin in the flaccid and erect uncircumcised penis.
(A) Flaccid uncircumcised penis. (B) Erect uncircumcised penis with the foreskin retracted, showing likely sites of HIV-1 entry. Reproduced with permission from [2].

Observational Studies of Male Circumcision & HIV Infection

Several types of research have suggested that MC reduces the risk of HIV acquisition by men during penile–vaginal sex, including ecological surveys, observational studies and randomized, controlled trials. Ecologic observations, or evaluations of HIV infection at the population level, initially suggested a link between MC and reduced risk of HIV infection. Although confounding owing to associations between circumcision, culture, religion and risk behavior may account for some of the differences in HIV infection prevalence, the countries in Africa and Asia with a prevalence of MC of less than 20% have HIV infection prevalence several times higher than countries in regions where more than 80% of men are circumcised.[9]

International observational studies have also suggested that MC is associated with lower rates of HIV infection. A systematic review and meta-analysis that focused on heterosexual transmission of HIV in Africa was published in 2000.[10] It included 19 cross-sectional studies, five case–control studies, three cohort studies and one study of discordant couples. A substantial protective effect of MC on risk for HIV infection was noted, along with a reduced risk for genital ulcer disease. After adjusting for confounding factors in the population-based studies, the relative risk for HIV infection was 44% lower in circumcised men. The strongest association was observed in high-risk men, such as patients at STD clinics, for whom the adjusted relative risk was 71% lower for circumcised men.

Another review that included stringent assessment of ten potential confounding factors, which was stratified by study type or study population, was published in 2003.[11] Most of the 35 observational studies were from Africa. A total of 19 of the studies were conducted in high-risk populations. These found a consistent, substantial protective effect, which increased with adjustment for confounding variables. Four of these studies in high-risk populations were cohort studies; all demonstrated a protective effect, with two being statistically significant. The 16 studies in the general population had inconsistent results. The one large, prospective cohort study in this group showed a significant protective effect, with the odds of infection being 42% lower in circumcised men.[12]

International Clinical Trials of Male Circumcision for HIV Prevention

Three randomized, controlled trials (Male Circumcision and HIV Rates in Kenya; Effect of Male Circumcision on HIV Incidence [ANRS 1265]; and Male Circumcision for HIV Prevention in Rakai, Uganda) have been undertaken in predominately heterosexual populations in sub-Saharan Africa to determine whether circumcision of adult males will reduce their risk for HIV infection. The controlled follow-up period in all three was stopped early and the control group offered circumcision when interim analyses found that medical circumcision significantly reduced male participants' HIV infection risk. The controlled follow-up period in the study in South Africa[13] was stopped in 2005 and those in Kenya[14] and Uganda[15] were stopped in 2006. In intent-to-treat analyses, men who had been randomly assigned to the circumcision group had a 60% (South Africa), 53% (Kenya) and 51% (Uganda) lower incidence of HIV infection compared with men assigned to the group to be circumcised at the end of the study. In all three studies, some men who had been assigned to be circumcised did not undergo the procedure, and vice versa. When the data were re-analyzed to account for these deviations in per-protocol analyses, men who had been circumcised had a 76% (South Africa), 60% (Kenya) and 55% (Uganda) reduction in risk of HIV infection compared with those who were not circumcised. In 2008, results of longer-term follow-up from the Kenya study were reported, indicating that the protective effect of circumcision was durable – with 42 months of follow-up, a 64% reduction in HIV infection risk was seen in circumcised men compared with uncircumcised men.[16] Although these results may not be generalizable to the USA, in general, risk compensation was not observed in the circumcised men,[17] and MC was not associated with sexual dysfunction.[18] Similarly, MC did not adversely affect sexual satisfaction or function in the Ugandan trial.[19]

Male Circumcision and Female-Male HIV Transmission in the USA

Two published observational studies have reported on the association between circumcision and risk of HIV infection in heterosexual men in the USA. In one prospective study of heterosexual men attending an urban STD clinic, when other risk factors were controlled, uncircumcised men had a 3.5-fold higher risk for HIV infection than men who were circumcised. However, this association was not statistically significant.[8] In an analysis of clinic records for African–American men attending STD clinics in Baltimore (MD, USA), circumcision was not associated with HIV infection status overall, but among men with known HIV exposure to an HIV-infected female partner, circumcision was associated with a statistically significant 51% reduction in risk for HIV infection.[20]

Male Circumcision and Male-Female HIV Transmission

Studies have not conclusively demonstrated an effect of MC on the risk of HIV transmission from infected men to their female partners. Data from Uganda on male–female transmission demonstrated a somewhat higher rate of HIV acquisition among initially HIV-negative women whose HIV-infected male partners were circumcised compared with women whose HIV-infected male partners remained uncircumcised, although this was not statistically significant.[21] The effect was greatest among couples who resumed sexual relations at least 5 days prior to certified postsurgical wound healing, suggesting an increased risk of HIV acquisition with early resumption of sex.

In an earlier study of couples in Uganda in which the male partner was HIV-infected and the female partner was initially HIV-negative, the infection rates of the female partners differed by the circumcision status and viral load of the male partners. If the male blood HIV viral load was less than 50,000 copies/ml, there was no HIV transmission if the man was circumcised, compared with a rate of 9.6 per 100 person-years if the man was uncircumcised.[22] If viral load was not controlled for, there was a nonstatistically significant trend towards a reduction in the male–female transmission rate from circumcised men compared with uncircumcised men. Such an effect may have been due to decreased viral shedding from circumcised men or to a reduction in ulcerative sexually transmitted infections acquired by female partners of circumcised men.[23]

Male Circumcision and HIV Transmission in Men Who Have Sex With Men

The HIV risk reduction benefit demonstrated in the randomized trials in Africa accrued to men engaging predominately in insertive penile–vaginal sex. The presumed protective mechanism is decreased HIV entry and infection through target cells on the foreskin. Thus, any potential biologic benefit of circumcision for men who have sex with men (MSM) engaged in penile–anal sex is likely to accrue only to insertive partners and not to receptive partners. However, the risk for HIV acquisition among MSM engaging in penile–anal sex is substantially greater for the anal receptive partner than for the insertive partner.[24,25] In addition, although it is not well studied, it seems that in many settings many or most MSM practice both insertive and receptive sex. In the limited studies in the USA, approximately half of men self-identify as versatile partners, one quarter each identify as either predominately insertive or predominately receptive and substantial proportions of ‘tops', men who are predominately insertive, also report practicing receptive anal intercourse.[26,27] Therefore, any potential benefit of MC in reducing HIV infection risk from insertive anal sex is diluted both at the individual level, as most men remain at higher risk from receptive sex and at the population level because chains of HIV transmission through receptive anal intercourse would persist even if circumcision reduced risk of transmission through insertive sex.

Some observational studies have shown higher rates of HIV acquisition among uncircumcised MSM compared with circumcised MSM. When controlling for the number of male sex partners and unprotected sex with an HIV-positive partner, circumcision was associated with decreased odds of incident HIV infection (OR: 0.5, 95% CI: 0.25–21.0) in a vaccine preparedness cohort followed from 1995 to 1997.[28] However, other observational studies have failed to show a significant benefit (or risk) of circumcision. In a cross-sectional survey of Black and Latino MSM in three USA cities, there was no evidence that being circumcised was protective against HIV infection, even among men who had engaged in unprotected insertive but not unprotected receptive anal sex.[29] Similarly, no association was found in an Australian study of MSM,[30] although a subsequent study of MSM in Australia did report a significantly reduced HIV infection risk in circumcised men who were predominately insertive.[31] The study authors noted that because more infections were associated with receptive intercourse, lack of circumcision accounted for only 9% of the infections in the study overall.

A recent meta-analysis of unpublished as well as published data from 15 studies that quantitatively examined the association between circumcision and HIV infection among MSM found little overall effect, with a weighted overall odds ratio of 0.95 (95% CI: 0.81–81.11) among a total of 53,567 MSM participants, 52% of whom were circumcised.[32] The association remained nonsignificant when stratified by study type (cross-sectional and prospective) or when limited to MSM who engaged exclusively in insertive anal sex.

Some have advocated for randomized, controlled clinical trials to assess whether circumcision reduces HIV infection risk in MSM.[33,34] Designing such a trial would be challenging. Enrollment could be limited to populations of men who practice predominately insertive sex, which would exclude substantial proportions of MSM. Alternatively, the trials could be designed to be large enough to detect what would be a relatively small prevention benefit if men who also practice and remain at risk from receptive sex were enrolled. In the absence of clinical trial data, public health guidance based on the best available observational data is needed to inform men's choices.

Other Potential Health Benefits of Male Circumcision

Studies indicate that MC is associated with other health benefits as well,[1] such as reduced rates of some sexually transmitted infections,[6,7,35-37] penile cancer,[38,39] cervical cancer in female partners [35] and infant urinary tract infections.[1,40,41].

Risks and Adverse Effects Associated With Male Circumcision

Any potential benefit of circumcision must be weighed against the risks. Reported rates of immediate complications from circumcision in the neonatal period range from 0.2 to 2%[1,42,43] and vary by type of study, setting, operator and surgical technique or instrument used. The most common surgical complications reported have been bleeding and infection, usually minor and easily managed. Other reported complications are rare, including dehiscence, unsatisfactory cosmesis, skin bridges, urinary retention, meatal stenosis and retained surgical devices. These studies probably underestimate the rate of postcircumcision complications since patients were not followed after discharge from the hospital. A longitudinal study found rates of penile problems after 1 year of 5% in circumcised boys and 1% in uncircumcised boys. However, after 8 years the rates were 11 and 19%, respectively. Most of these problems were penile inflammation including balanitis, meatitis and inflammation of the prepuce.[44] At least one case of fatal complications of circumcision in North America has been reported.[45]

Complication rates reported for adult circumcisions in the three African clinical trials were of similar magnitude and severity and ranged from 2 to 4%, most commonly pain, bleeding, infection and unsatisfactory cosmesis.[46] There were no reported deaths or long-term sequelae documented. More recently, higher complication rates were documented for circumcisions performed outside the clinical trial setting in Kenya; 35.2% in men circumcised by traditional practitioners and 17.7% in clinical settings, underscoring the need for better training and resources in those settings.[47]

Effect of Male Circumcision on Sexual Function & Penile Sensation

The foreskin is a highly innervated structure,[48] and decreased sensitivity of the glans penis to fine touch can occur following circumcision, leading some authors to express concern that its removal may compromise sexual sensation or function.[49] In one survey of 123 men following medical circumcision in the USA, men reported worsened erectile function and decreased penile sensitivity, but reported no change in sexual activity and improved sexual satisfaction.[50] Other studies conducted among men after adult circumcision have found that relatively few men report that their sexual functioning is worse after circumcision; most report either improvement or no change[18,19,51-53].

Cost of Male Circumcision

The medical costs of circumcision must also be accounted for in considering the role of MC for HIV prevention in any setting. While MC has been shown to be a cost-saving HIV-prevention intervention in sub-Saharan Africa,[54,55] the calculus is different in the USA where medical costs are higher and the risk of HIV infection is lower. In the USA, the estimated cost of infant circumcision ranges from US$200 to as much as $900.[56,57,75] According to Medicaid reimbursement rates, the cost of MC in the USA after the neonatal period is at least $1700 and could be considerably higher in the private sector.[76] Cost-effectiveness analyses of male infant circumcision, circumcision for high-risk heterosexual men and circumcision for MSM are being conducted by the CDC to help guide recommendations for the USA.

Ethical Considerations in Infant Male Circumcision

Ethical concerns have been raised in asking parents to make decisions about elective surgery during infancy, particularly when it is done primarily to protect against risks of HIV infection and other health outcomes that do not occur until young adulthood or laterr.[58] By the time an infant has reached the age of sexual debut, the HIV epidemic may have changed substantially, both in terms of prevalence and risk groups, and the introduction of other modalities may have overtaken circumcision as a preventive strategy. Although infant circumcision is less expensive and has fewer associated adverse outcomes than adult circumcision, the choice by parents to circumcise an infant primarily for a distant prevention goal denies the infant the right of autonomy in medical decision-making. However, other ethicists have found this to be an appropriate parental proxy decision.[59,60]

HIV Infection in the USA

In 2006 in the USA, there were an estimated 56,300 new HIV infectionsr.[61] Of these, 73% were in males, 45% were in Black people and 53% were in MSM. A total of 5250 cases in men were attributed to high-risk heterosexual contact (or ~10% of all infections [in both sexes] attributed to female-male transmission[62]). This proportion differed by race and ethnicity; in White people, 5% of all cases were attributable to female-male transmission, compared with 13% in Black people and 10% in Hispanics. An overall HIV infection prevalence of 0.45% was estimated for the general population age greater than 13 years in the USA in 2006. The prevalence in Black people (1.7%) was nearly eight-times as high as in White people (0.22%), while the prevalence in Hispanics (0.58%) was more than twice as highr.[63]

Status of Male Circumcision in the USA

Nonreligious MC was introduced to the USA in the late 1800s,[64] and by the 1940s, an increasing proportion of male children in the USA were born in hospitals and were circumcised.[65] The proportion of newborns that were circumcised annually reached 80% after World War II, peaked in the mid-1960s and has subsequently decreased.

According to the National Hospital Discharge Survey, which documents circumcisions performed in hospitals but does not ascertain circumcisions performed outside of the hospital (e.g., for religious reasons), 65% of newborn boys were circumcised in 1999, and the overall proportion of newborns circumcised has remained stable from 1979 to 1999.[77] The proportion of Black newborns who were circumcised rose over this period to approximately 65%, while the proportion of White newborns who were circumcised remained stable at 66%. Significant discrepancies in rates of circumcision exist between regions. While the proportion of newborns born in the Midwest who were circumcised increased from 74 to 81% between 1979 and 1999, the proportion of infants born in the West who were circumcised decreased over the same period, from 64% in 1979 to 37% in 1999, reflecting the increased proportion of Hispanic births. In another hospital discharge survey with different methodology (Healthcare Cost and Utilization Project National Inpatient Sample), newborn circumcision rates reportedly increased from 48% in 1988-1991 to 61% in 1997-2000. Circumcision was more common among newborns born to families of higher socioeconomic status, in the Northeast or Midwest, and among newborns who were Black.[66]

Finally, in a series of national probability samples of adults surveyed during 1999-2004 as part of the National Health and Nutrition Examination Surveys, the overall prevalence of circumcision among adult males in the USA was 79% and varied by race/ethnicity (88% in non-Hispanic White men, 73% in non-Hispanic Black men, 42% in Mexican-Americans and 50% in men of other races/ethnicities).[67] The prevalence of circumcision among USA-born men decreased from the 1970s to the 1980s in all racial/ethnic categories. It should be noted that circumcision status may be subject to misclassification. In a study of adolescents¸ only 69% of circumcised and 65% of uncircumcised young men correctly identified their circumcision status as verified by physical exam.[68]

In 1999, the American Academy of Pediatrics (AAP) issued a policy statement asserting that the available data at the time were insufficient to recommend routine neonatal MC. The Academy also stated "It is legitimate for the parents to take into account cultural, religious and ethnic traditions, in addition to medical factors, when making this choice".[69] This position was reaffirmed by the Academy in 2005 following the report of the results of the first African clinical trial.[70] This policy has influenced reimbursement for and the practice of neonatal circumcision. In a 1995 review, 61% of circumcisions were paid for by private insurance, 36% were paid for by Medicaid and 3% were self-paid by the parents of the infant. Compared with infants of self-pay parents, those covered by private insurance were 2.5-times as likely to be circumcised.[71] Since the 1999 AAP policy statement was issued, several states have eliminated Medicaid payments for circumcisions that were not deemed medically necessary and, when controlling for other factors, hospitals in states in which Medicaid covers routine MC had circumcision rates that were 24% higher than hospitals in states without such coverage.[72] However, the AAP has recently (2008) convened a panel to reconsider its circumcision policy in light of the African clinical trials and other data now available. The American Urological Association modified their previously neutral recommendation in 2007 and concluded that "While the results of studies in African nations may not necessarily be extrapolated to men in the USA at risk for HIV infection, the American Urological Association recommends that circumcision should be presented as an option for health benefits".[78]

Acceptability of Male Circumcision for HIV Prevention in the USA

It is not well understood whether American men at higher risk for HIV infection would be willing to undergo circumcision for partial HIV prevention, nor whether parents would be willing to have their infants circumcised for the purpose of reducing possible future HIV infection risk.

In an analysis of interview data with self-reported HIV-negative MSM at gay pride events in 2006, uncircumcised respondents were asked about their willingness to be circumcised if it were proven to reduce risk of HIV infection among MSM.[73] Over half of uncircumcised MSM who were surveyed and 70% of Black MSM expressed willingness to be circumcised. The most commonly reported concerns about circumcision were postsurgical pain and wound infection.

Further research regarding acceptability and feasibility of MC for high-risk heterosexual men is needed. To this end, a demonstration project of circumcision of men in the USA at high risk for heterosexual HIV acquisition is being funded by the CDC. In this study, acceptability of MC, HIV infection risk behaviors before and after circumcision, and other relevant attitudes and behaviors are being assessed. Surveys of medical providers, insurance payers and end-consumers (parents and adult men) are also being conducted by the CDC to assess acceptability and feasibility of MC for prevention of HIV infection and other adverse health conditions in the USA.

Considerations in the Role of Male Circumcision for HIV Prevention in the USA

In March 2007, shortly after publication of the final two clinical trial reports, the WHO and UNAIDS recommended that MC be recognized as an additional important intervention to reduce heterosexual acquisition of HIV infection among men in settings with high HIV prevalence and low circumcision rates.[79]

For several reasons, however, the WHO/UNAIDS recommendations are not directly applicable to the USA.[74] Policy on MC needs to be considered in light of the domestic USA HIV epidemic, prevailing norms regarding MC, feasibility, policy issues and cost-effectiveness while addressing relevant ethical concerns.

The epidemiology of HIV infection in the USA differs considerably from that of regions prioritized by the WHO/UNAIDS recommendations and the sub-Saharan African areas where the randomized, circumcision trials were conducted. Most notably, the overall risk of HIV acquisition and the prevalence of HIV infection (0.45%)[63] is considerably lower in the USA than in the African clinical trials countries where the general population prevalence of HIV infection is 5-18%.[80]. With regard to the risk for female-male transmission, the prevalence of HIV infection in women in the USA is only 0.22%,[64] whereas in the African clinical trial countries, the prevalence is equal or higher in women as compared with men.[80]

While circumcision has only been proven to be effective in preventing female-male HIV transmission, only approximately 10% of transmission in the USA is attributed to this transmission route. Most transmission, an estimated 53% of incident cases in 2006, was through male-male sex,[61] for which circumcision could have, at best, only a limited impact as noted previously.

Most men in the USA are already circumcised.[68] whereas in the African clinical trial sites, the prevalence of MC was 10-25%. Therefore, much of any possible prevention benefit has already been realized. However, it should be noted that the prevalence of MC is somewhat lower in USA racial and ethnic groups with higher rates of HIV infection. Moreover, to the extent that there is a prevention benefit to MC, that benefit is decreasing with the declining trend in infant circumcision.

Taken together, the lower risk for female-male HIV transmission, the higher pre-existing prevalence of MC and the higher cost of MC indicate that efforts to increase MC for HIV prevention would have less of an impact and be less cost effective in the USA than in sub-Saharan Africa.

In April 2007, the CDC held a consultation with clinicians, academics, community advocates and public health practitioners to solicit external expert advice on the potential role of male circumcision in the prevention of HIV infection and other health conditions in the USA. Views on the benefits of MC, as well as risks and downsides, were presented. Consultants suggested that the CDC consider that:

* Sufficient evidence exists to propose that adult/adolescent heterosexually active men in the USA be informed about the significant but partial efficacy of circumcision in reducing risk for HIV acquisition and be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services;
* Information about the potential health benefits and risks of MC should be presented to parents considering infant circumcision, and financial barriers to accessing MC should be removed;
* Insufficient data exist about the impact (if any) of MC on HIV acquisition by homosexually active men and additional research is warranted.

In formulating recommendations for the USA, the CDC is coordinating with academic medical societies (e.g., AAP, which, as mentioned previously, is reconsidering its circumcision policy) and other federal agencies. A rigorous systematic literature review on the clinical risks and benefits (including surgical outcomes, changes in penile sensation and sexual function, rates of other STDs, penile cancer, cervical cancer in female partners and urinary tract infection) is also being conducted. Draft recommendations are being published for public comment and peer review before being finalized.

As health authorities move forward in determining what role circumcision may play from a public health perspective, individual men may wish to consider circumcision as an additional HIV prevention measure, but must recognize that circumcision:

* Has only proven effective in reducing female-male HIV transmission in predominately heterosexual populations;
* Confers only partial protection and should be considered only in conjunction with other proven prevention measures, such as condom use;
* Does carry risks and costs that must be considered in addition to potential benefits;
* May result in increased risk for either male-female or female-male HIV transmission before wound healing is complete.

Conclusion

MC has been shown to substantially reduce the risk of female-male transmission of HIV and is being implemented as a HIV prevention intervention in sub-Saharan African countries where MC prevalence is low and the risk of female-male HIV transmission is high. In the USA, however, the role of MC as an HIV prevention intervention will be limited because the risk of female-male HIV transmission is lower and most men are already circumcised. Additionally, there is not good evidence that MC prevents HIV transmission through male-male sex, the most common transmission mode in the USA.

As the CDC, AAP and other organizations formulate recommendations for men and parents of newborn boys in the USA, it should be kept in mind that MC offers only partial protection for female-male HIV transmission and does carry risks and costs as does any surgical procedure. However, as discussed in this paper, there are other health benefits associated with MC, including prevention of sexually transmitted infections other than HIV. Future research, programmatic and surveillance activities should ensure access to accurate information to make evidence-based individual and policy decisions about MC, access to safe and affordable MC services when appropriate, and optimal use of MC to maximize health benefits while minimizing costs and risk.

Future Perspective

Since only a minority of HIV transmission in the USA is attributable to insertive sex, MC is unlikely to play a major role in HIV prevention in this country. The CDC and relevant professional societies such as the AAP and the American Urological Association have issued or are developing recommendations for MC for prevention of HIV infection and other adverse health conditions. Parents will consider these recommendations, together with advice from healthcare providers and others, in weighing the risk and benefits in deciding whether or not to circumcise their male newborns. Cultural, religious and family factors are likely to continue to play a significant role in parents' decision-making, and public and private healthcare reimbursement policies will influence overall infant circumcision rates. Uncircumcised heterosexual men at high risk for HIV infection may chose to be circumcised as an additional partially protective HIV prevention measure. Randomized, controlled clinical trials of MC for HIV prevention in MSM have been proposed which, if feasible, would provide specific guidance for that population in the future.

Source : http://cme.medscape.com/viewarticle/702029