Circumcision in men and the prevention of HIV infection: a 'meta-analysis'revisited

Citation
N. O'Farrell et M. Egger, Circumcision in men and the prevention of HIV infection: a 'meta-analysis'revisited, INT J STD A, 11(3), 2000, pp. 137-142
Citations number
49
Categorie Soggetti
Clinical Immunolgy & Infectious Disease
Journal title
INTERNATIONAL JOURNAL OF STD & AIDS
ISSN journal
09564624 → ACNP
Volume
11
Issue
3
Year of publication
2000
Pages
137 - 142
Database
ISI
SICI code
0956-4624(200003)11:3<137:CIMATP>2.0.ZU;2-Q
Abstract
There is debate on the role of male circumcision in HIV transmission. Most case-control and cohort studies from Africa have shown an association betwe en a lack of circumcision and an increased risk of HIV infection in men. Th e evidence is conflicting, however, with cross-sectional surveys from Tanza nia and Rwanda either showing no relationship or an association in the oppo site direction. A recent review and meta-analysis of the literature(1) conc luded that the risk of HN infection was lower in uncircumcised men (combine d odds ratio 0.94, 95% confidence interval 0.89 to 0.99). However, the anal ysis was performed by simply pooling the data from 33 diverse studies, whic h is an inappropriate method for combining studies. We re-analysed the data, stratifying by study, and found that an intact for eskin was associated with an increased risk of HIV infection: combined odds ratio 1.43 (1.32 to 1.54) with a fixed effect model and 1.67 (1.25 to 2.24 ) with a random effect model. There was significant between-study heterogen eity (P < 0.0001) which was partly explained by stronger associations in st udies in high-risk groups. The results from this re-analysis thus support t he contention that male circumcision may offer protection against HIV infec tion, particularly in high-risk groups where genital ulcers and other STDs 'drive' the HIV epidemic. A systematic review is required to clarify this i ssue. Such a review should be based on an extensive search for relevant stu dies, published and unpublished, and should include a careful assessment of the design and methodological quality of studies. Much emphasis should be given to the exploration of possible sources of heterogeneity. In view of t he continued high prevalence and incidence of HIV in many countries in sub- Saharan Africa, the question of whether circumcision could contribute to pr event infections is of great importance, and a sound systematic review of t he available evidence should be performed without delay.