Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysis

Abstract

Background: Medical male circumcision (MMC) reduces HIV infection among heterosexual men. There are concerns MMC might prompt higher-risk sexual behaviours because of lower self-perceived risk of HIV infection. We reviewed the published literature to examine associations between MMC and both condom use and number of sex partners among heterosexual men.

Methods: In this systematic review and meta-analysis, we searched PubMed, Embase, and the Cochrane Library for studies published before Nov 15, 2020. Interventional and observational studies were included if they contained original quantitative data describing the association between MMC and condom use or number of sex partners among heterosexual men. We excluded data from men whose circumcisions were ritual or religious and data from men who have sex with men. We extracted odds ratios (ORs) and 95% CIs for the associations between MMC and condomless sex and MMC and multiple sex partners directly from the publications if available, selecting adjusted ORs when provided; when necessary, we calculated ORs and 95% CIs using original study data provided in the publication. We used the Mantel-Haenszel random effects model to calculate pooled ORs and 95% CIs.

Findings: Our search yielded 3035 results, of which 471 were duplicates and 2537 did not meet the inclusion criteria. From the remaining 27 eligible studies, we identified 99 292 men from 31 independent population samples. 24 studies were done in Africa. We found no statistically significant associations between MMC and condomless sex (OR 0·91, 95% CI 0·80-1·05; k=30; I²=88·7%) or multiple sex partners (1·02, 0·88-1·18; k=27; I²=90·1%). No associations between MMC and condomless sex or multiple sexual partners were found in any subgroup analyses by study design, income of country, age, recruitment setting, circumcision assessment, circumcision prevalence, and risk of publication bias.

Interpretation: The promotion of circumcision as an HIV preventive measure does not appear to increase higher-risk sexual behaviours in heterosexual men. Ongoing sexual health education should be maintained as a vital component of effective MMC programmes.

Funding: National Science and Technology Major Project of China, the Fundamental Research Funds for the Central Universities, and the Shenzhen Science and Technology Innovation Commission Basic Research Program.

Figure 1:

Flowchart of literature search

Figure 2:. Meta-analysis of the association between medical male circumcision and condomless sex among heterosexual men

OR=odds ratio. *Based on data from Auvert and colleagues’ 2007–08 study. †Based on data from Auvert and colleagues’ 2010–11 study. ‡Based on data from Kibira and colleagues’ 2004 study. §Based on data from Kibira and colleagues’ 2011 study. ¶Based on data from Westercamp and colleagues’ 2008–09 study. ||Based on data from Westercamp and colleagues’ 2011 study. **Based on data from Westercamp and colleagues’ 2013 study.

Figure 3:. Association between medical male circumcision and condomless sex or multiple sex partners among heterosexual men, stratified by follow-up time

Pooled OR less than 1·0 indicates reduction of outcomes in the circumcised group compared with the uncircumcised group. OR=odds ratio. *One of the reports is a follow-up visit at 21 months from a randomised controlled trial.

Figure 4:. Subgroup meta-analyses of the association between medical male circumcision and condomless sex among heterosexual men

OR=odds ratio. RCT=randomised control trial.

Figure 5:. Meta-analysis of the association between medical male circumcision and multiple sex partners among heterosexual men

OR=odds ratio. *Based on data from Auvert and colleagues’ 2007–08 study. †Based on data from Auvert and colleagues’ 2010–11 study. ‡Based on data from Kibira and colleagues’ 2004 study. §Based on data from Kibira and colleagues’ 2011 study. ¶Based on data from Westercamp and colleagues’ 2008–09 study. ||Based on data from Westercamp and colleagues’ 2011 study. **Based on data from Westercamp and colleagues’ 2013 study.

Figure 6:. Subgroup meta-analyses of the association between medical male circumcision and multiple sex partners among heterosexual men

OR=odds ratio. RCT=randomised controlled trial.