These two scenarios raise the question of whether male circumcision should be used in the UK as a means to decrease HIV transmission. Lack of circumcision has long been recognised as a risk factor for HIV acquisition in heterosexual men.1 This makes biological sense because superficial Langerhans cells, which express HIV-1 receptors, are more prevalent in the male foreskin than in the remainder of the penis.2 In addition, decreased keratinisation of the foreskin increases susceptibility to minor trauma during intercourse, potentially aiding the passage of HIV.3 Finally, ulcerative sexually transmitted infections, found more commonly in uncircumcised men, are associated with increased rates of HIV transmission.4

The biological plausibility of adult male circumcision to reduce HIV transmission has now been shown to have clinical relevance in three recent large randomised controlled trials conducted in sub-Saharan Africa, in which male circumcision reduced the rate of female-to-male HIV transmission by at least 50%.5^–7 Overall, there was little evidence of increased risk-taking behaviour in circumcised men. Here we examine whether the results of the African trials are relevant in the UK.

THE ISSUE FOR THE UK

The yearly number of new HIV diagnoses in the UK has increased by 157% since 1997.8 Of the new diagnoses reported in 2006, 12% were in black African men, most of whom were thought to have been infected heterosexually in Africa, whereas 36% were in men who have sex with men (MSM). Indeed, 2006 saw the greatest yearly number of newly diagnosed HIV infections in MSM since the start of the epidemic. New prevention strategies for these groups are urgently needed.

SCENARIO 1

Based on …