Male Circumcision and HIV Risk Compensation Among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis.

Male circumcision (MC) has been shown to reduce the risk of HIV infection among men who have sex with men (MSM) in a recent randomised controlled trial. A question that remains unanswered is whether MC in MSM implies HIV compensation, i.e. condomless sex and/or multiple sex partners. We searched PubMed, Embase, and the Cochrane Library for relevant studies published before November 5, 2024 and reviewed references of included studies. We included interventional and observational studies reporting original quantitative data on the association between MC and condom use or the number of sex partners among MSM. Odds ratios (ORs) and 95% confidence intervals (CIs) were extracted directly from the studies or calculated from available data when necessary. A Mantel-Haenszel random effects model was used to calculate pooled ORs and CIs. The final analysis included 41,694 MSM from 15 eligible studies. No statistically significant association was found between MC and condomless sex (OR 1.02, 95% CI 0.91-1.14; k = 13; I² = 18%) or multiple sex partners (OR 1.03, 95% CI 0.94-1.12; k = 10; I² = 12%) among MSM. The lack of association persisted in the great majority of subgroup analyses, encompassing country income, age, recruitment setting, time length, year of recruitment, circumcision assessment, proportion circumcised, or risk of bias. In conclusion, MC among MSM was not found to be associated with either condomless sex or multiple sex partners. Nonetheless, standard minimum service packages, as per WHO guidelines, should be integrated and consistently provided within MC programs to better protect MSM from HIV infection.