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Research Article

The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda

  • Godfrey Kigozi,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Ronald H Gray mail,

    To whom correspondence should be addressed. E-mail: rgray@jhsph.edu

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • Maria J Wawer,

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • David Serwadda,

    Affiliation: School of Public Health, Makerere University, Kampala, Uganda

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  • Frederick Makumbi,

    Affiliation: School of Public Health, Makerere University, Kampala, Uganda

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  • Stephen Watya,

    Affiliation: Department of Surgery, Urology Unit, Mulago Hospital, Makerere University, Kampala, Uganda

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  • Fred Nalugoda,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Noah Kiwanuka,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Lawrence H Moulton,

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • Michael Z Chen,

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • Nelson K Sewankambo,

    Affiliation: Department of Medicine, Makerere University, Kampala, Uganda

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  • Fred Wabwire-Mangen,

    Affiliation: School of Public Health, Makerere University, Kampala, Uganda

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  • Melanie C Bacon,

    Affiliation: National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America

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  • Renee Ridzon,

    Affiliation: Bill & Melinda Gates Foundation, Seattle, Washington, United States of America

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  • Pius Opendi,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Victor Sempijja,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Absolom Settuba,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Denis Buwembo,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Valerian Kiggundu,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Margaret Anyokorit,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • James Nkale,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Nehemia Kighoma,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Blake Charvat

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

    X
  • Published: June 03, 2008
  • DOI: 10.1371/journal.pmed.0050116

Reader Comments (2)

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Circumcising HIV-positive men: Ethical considerations

Posted by plosmedicine on 31 Mar 2009 at 00:27 GMT

Author: David Gisselquist
Position: independent consultant
Institution: independent consultant
E-mail: david_gisselquist@yahoo.com
Submitted Date: July 01, 2008
Published Date: July 8, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

In a recent paper, Kigozi and colleagues report similar low percentages of HIV-positive and HIV-negative men with adverse events after circumcision.[1] Based on that finding, the authors endorse WHO/UNAIDS’[2] recommendation that programs offering circumcision for HIV prevention should not require that men first take an HIV test.

Both the recommendation and the study raise ethical questions. The study of adverse events in men was linked to a randomized controlled trial that looked at the impact of circumcising HIV-positive men on HIV incidence in their wives. Over 2-years of follow-up, wives of circumcised men acquired HIV infection at the rate of 13.8 per 100 person-years (PYs) compared to 9.6 per 100 PYs for wives of uncircumcised men. Risk was greatest in the 1-2 months after circumcision; 5 of 18 wives of HIV-positive men who resumed intercourse prior to wound healing contracted HIV infections.[3]

Governments could protect women from these risks by requiring prior HIV tests for men applying to programs for subsidized circumcisions. Programs could agree to circumcise HIV-positive men who bring their regular partner(s) for counseling, so that partners are aware of risk. (Whether to extend such controls to unsubsidized circumcisions in the private sector brings up other questions, e.g., about interfering with personal choice.)

Finally, the study itself is ethically dubious, observing HIV incidence in spouses of HIV-positive partners, without ensuring that spouses are aware of their risk. The Rakai study has followed this practice from 1989. In 2000, when the New England Journal of Medicine published a paper from Rakai reporting HIV incidence in discordant couples,[4] the Journal’s editor criticized that “ethical standards…were indeed different from those that would govern research in developed countries.”[5] In this later study,[3] some HIV-positive men were not aware of their infection; and for men who were aware, the study did not ensure that they had informed their wives.

To ensure that wives of HIV-positive men in the study were aware of risks, the study could have refused to accept men who did not want to hear the results of their HIV tests (which is standard policy in research funded by the US government[6]) and who did not bring their wives for counseling (which would have brought the research into line with US practices for partner notification,[7] and which would be allowed but not required in Ugandan law).

1. Kigozi G, Gray RH, Wawer MJ, et al. The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda. PLoS Med 2008; 5: e116.

2. WHO, UNAIDS. New Data on HIV/AIDS and Circumcision: policy and programme implications. Geneva: WHO, 2007.

3. Wawer M, Kigozi G, Serwadda D, et al. Trial of male circumcision in HIV+ men, Rakai, Uganda: effects in HIV+ men and in women partners. 15th Conference on Retroviruses and Opportunistic Infections. 3-6 February 2008. Boston. Abstract 33LB.

4. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Eng J Med 2000; 342: 921-929.

5. Angell M. Investigators’ responsibilities for human subjects in developing countries. N Eng J Med 2000; 342: 967-968, p. 967.

6. Public Health Service (PHS). Policy on informing those tested about HIV serostatus. Washington, DC: PHS, 1988. Available at:
http://www.hhs.gov/ohrp/h... (accessed 9 September 2007).

7. MMWR. Perspectives in disease prevention and health promotion public health service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR 1987; 36: 509-515.

No competing interests declared.