Circumcision for HIV Prevention in Men Who Have Sex With Men: An Updated Meta-Analysis.

BACKGROUND

Circumcision reduces HIV risk for men who have sex with women, but for men who have sex with men (MSM), prior meta-analyses were ambiguous because of inconsistent, highly confounded data suggesting regional differences. This has left the weight of evidence unclear even after a small 2024 trial in primarily insertive MSM (PI-MSM) in China showed protection. Any protection would be for PI-MSM and could have substantial impact given high incidence.

SETTING

No restrictions.

METHODS

We performed an updated literature search on the association of male circumcision with HIV among MSM. We conducted descriptive analyses, and a random-effects meta-analysis among PI-MSM. To isolate the protective effect of circumcision from confounders, we then performed a confounder-adjusted meta-analysis, comparing the effect of circumcision on HIV status among PI-MSM versus other MSM, testing for publication bias (funnel plot asymmetry) and regional heterogeneity (United States/Canada/Europe/Australia vs. Asia/Africa/Latin America).

RESULTS

Forty-nine studies were included in the descriptive analysis, 13 in the unadjusted meta-analysis, and 10 in the confounder-adjusted meta-analysis. In the unadjusted meta-analysis, circumcision was associated with a lower HIV risk among PI-MSM (odds ratio (OR) = 0.57, 95% CI: 0.33 to 0.98); publication bias and heterogeneity were present. In the confounder-adjusted analysis, the additional effect of circumcision in the PI-MSM group-a ratio of ORs-was 0.53 (95% CI: 0.34 to 0.83), a significant, substantial protective association. Regional heterogeneity ( P = 0.65) and publication bias ( P = 0.34) were not present.

CONCLUSIONS

Among PI-MSM, circumcision was protective against HIV. Findings support male circumcision as an effective HIV prevention method for PI-MSM.