Male circumcision in HIV prevention [letter]

We agree with Robert Bailey and colleagues that a strategy to implement male circumcision will face many problems. A few years ago in the main sexually transmitted diseases (STI) clinic in Durban South Africa we started referring for circumcision people who we thought were at very high risk of acquiring HIV because of deep crevices in the coronal sulcus. We soon gave up because surgeons refused to undertake what they considered to be cosmetic surgery. This failure to promote circumcision led us to explore the role of poor genital hygiene as a risk factor for HIV and we have shown that penile wetness is associated with HIV in uncircumcised men. We believe that penile wetness is a marker for poor genital hygiene and varies significantly between different populations of uncircumcised men: in Durban penile wetness was identified in 49% of male STI clinic attenders compared with 8% in London. Although the circumcision trials in Kenya and Uganda were rigorous they did not seem to provide information about genital hygiene. The Uganda study did report asking questions about male genital hygiene but these results were not shown. Clearly undertaking mass male circumcision in selected populations in Africa will be a huge task. We therefore suggest that until any circumcision programme is successfully rolled out in addition to the usual package of other preventive measures uncircumcised men are advised to achieve good standards of penile hygiene by keeping the subpreputial space dry. (full text)