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Adult circumcision prevents HIV transmission in sub-Saharan African men

Clinical Question:
What are the benefits and harms from nontherapeutic circumcision?

Bottom Line:
This limited systematic review reveals that the benefits and harms of nontherapeutic neonatal circumcision are not adequately studied. However, nontherapeutic circumcision in adults in sub-Saharan Africa prevents HIV infection. These authors found no data on circumcising adults in other parts of the world. (LOE = 1a-)

Reference:
Perera CL, Bridgewater FH, Thavaneswaran P, Maddern GJ. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 2010;8(1):64-72.  [PMID:20065281]

Study Design:
Meta-analysis (randomized controlled trials)

Setting:
Various (meta-analysis)

Synopsis:
These authors systematically searched several databases for randomized trials of nontherapeutic circumcision published since 1997 (with the excuse that a comprehensive review occurred in 1996 and they didn't want to duplicate that summary). Since the goal of a meta-analysis is to look at the totality of evidence on a specific topic, this argument only holds up if the 1996 study did not assess outcomes included in this review. The authors don't report if the decision to include a study or if assessment of study quality was independently made by 2 or more reviewers. They also don't discuss searching for unpublished studies. Ultimately, they found 8 randomized trials, 2 of neonatal circumcision (138 infants) and 6 of adults (with approximately 11,000 patients). One of the 2 neonatal circumcision studies assessed maternal bonding and the other assessed subsequent pain at the time of vaccinations. Neither study reported any adverse events. Both of these studies were really about the role of analgesia at the time of circumcision and were not designed to assess circumcision versus no circumcision on other outcomes such as urinary tract infections, sexuality, and so forth. Curiously, the authors report no data from the one study that included an uncircumcised group. In the 3 studies reporting adverse events, approximately 5% of patients had bleeding, infection, or wound problems, or the patients complained about difficulty voiding, had concerns about appearance, or experienced erectile dysfunction. Three studies in sub-Saharan Africa reported on the rate of developing HIV infection, with HIV occurring in approximately 1% of circumcised men and 2.6% of uncircumcised men. One would need to circumcise 71 men (95% CI, 52 - 109) to prevent 1 HIV infection.

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