Male Circumcision for HIV and STI Prevention: A Reflection

Circumcision is one of the oldest surgical procedures, dating from the Neolithic age (Fig. 1). It is widely practiced throughout the world for religious reasons (e.g., Muslims and Jews), as part of traditional cultures among tribal groups in Africa (e.g., Kikuyu in Kenya) and in Melanesia, and for medical reasons both preventive and therapeutic. The majority of procedures are performed in infancy or childhood, but in some cultures circumcision is part of initiation rituals marking the transition from adolescence to adulthood (e.g., Xhosa of South Africa). Since the 1990s, the Rakai Health Sciences Program has worked on male circumcision for prevention of HIV and other sexually transmitted infections (STIs) through a series of studies conducted in rural Rakai district of south-central Uganda. This reflection summarizes our work, progressing from observational studies, clinical trials, assessment of effectiveness in programmatic settings, and implementation science to improve efficiency and cost-effectiveness. To better understand the biologic effects of circumcision, we also assessed penile histopathology, immunology, and the microbiome. These and other studies have established circumcision as a major component of HIV prevention strategies in sub-Saharan Africa (1) and have affected policies in the US (2).