title: Circumcision status and incident herpes simplex virus type 2 infection, genital ulcer disease, and HIV infection.
abstract: OBJECTIVE
  We assessed the protective effect of medical male circumcision (MMC) against HIV, herpes simplex virus type 2 (HSV-2), and genital ulcer disease (GUD) incidence.
  
  
  METHODS
  Two thousand, seven hundred and eighty-seven men aged 18-24 years living in Kisumu, Kenya were randomly assigned to circumcision (n=1391) or delayed circumcision (n=1393) and assessed by HIV and HSV-2 testing and medical examinations during follow-ups at 1, 3, 6, 12, 18, and 24 months.
  
  
  METHODS
  Cox regression estimated the risk ratio of each outcome (incident HIV, GUD, HSV-2) for circumcision status and multivariable models estimated HIV risk associated with HSV-2, GUD, and circumcision status as time-varying covariates.
  
  
  RESULTS
  HIV incidence was 1.42 per 100 person-years. Circumcision was 62% protective against HIV [risk ratio=0.38; 95% confidence interval (CI) 0.22-0.67] and did not change when controlling for HSV-2 and GUD (risk ratio=0.39; 95% CI 0.23-0.69). GUD incidence was halved among circumcised men (risk ratio=0.52; 95% CI 0.37-0.73). HSV-2 incidence did not differ by circumcision status (risk ratio=0.94; 95% CI 0.70-1.25). In the multivariable model, HIV seroconversions were tripled (risk ratio=3.44; 95% CI 1.52-7.80) among men with incident HSV-2 and seven times greater (risk ratio=6.98; 95% CI 3.50-13.9) for men with GUD.
  
  
  CONCLUSIONS
  Contrary to findings from the South African and Ugandan trials, the protective effect of MMC against HIV was independent of GUD and HSV-2, and MMC had no effect on HSV-2 incidence. Determining the causes of GUD is necessary to reduce associated HIV risk and to understand how circumcision confers protection against GUD and HIV.
authors.affiliation: Department of Epidemiology and Biostatistics, University of Illinois Chicago School of Public Health, Chicago, Illinois 60622, USA. supriyad@uic.edu
authors.forename: Supriya D
authors.initials: SD
authors.lastname: Mehta
authors.forename: Stephen
authors.initials: S
authors.lastname: Moses
authors.forename: Corette B
authors.initials: CB
authors.lastname: Parker
authors.forename: Kawango
authors.initials: K
authors.lastname: Agot
authors.forename: Ian
authors.initials: I
authors.lastname: Maclean
authors.forename: Robert C
authors.initials: RC
authors.lastname: Bailey
mesh_terms: D000293:Adolescent; D002944:Circumcision, Male; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D006558:Herpes Genitalis / Q000453:epidemiology / Q000517:prevention & control* / Q000821:virology; D018258:Herpesvirus 2, Human / Q000302:isolation & purification* / Q000472:pathogenicity; D006801:Humans; D015994:Incidence; D007630:Kenya / Q000453:epidemiology; D008297:Male; D012307:Risk Factors; D014456:Ulcer / Q000453:epidemiology / Q000517:prevention & control* / Q000821:virology; D055815:Young Adult