HIV and CIRCUMCISION

Background: In the last decade, three randomized controlled studies done in Africa were published which showed, during the study period, a reduction in heterosexually acquired HIV of 50-60% , in circumcised men compared to intact men (South Africa 2005, Kenya 2007, Uganda 2007). The actual number of men who became infected was small, for example, in one of the studies, 1.8% of circumcised men compared to 3.6% of intact men. Based on the apparent significance of the early results, all three studies were ended early (none went longer than 24 months), preventing further study of the trends over time of HIV rates after circumcision. In March 2007, due to the pressing nature of the HIV epidemic in Africa, the World Health Organization issued recommendations to implement male circumcision programs in areas where HIV prevalence is high (greater than 15% of the population) and circumcision rates are low (under 20%).1 The WHO has not, at any point, recommended circumcision for American males.

POINTS TO CONSIDER

Circumcision is not a “magic bullet”: Circumcised men can and do get HIV.

Circumcision has not prevented HIV in the US: The high circumcision rate in the US has not prevented it from having the highest HIV rate in the developed world. There are numerous examples of countries with high circumcision and high HIV rates, and others with low circumcision and low HIV rates.

The studies: Ending the studies early could have potentially biased the results toward showing an interventional effect of circumcision on HIV acquisition, because the men who were circumcised were unable to have sex for some period of time and were told they had to wear a condom during healing. Also, because the results were obtained under research conditions — sanitary conditions, intensive monitoring, education, and full access to condoms — it is not yet clear whether these results will play out "in real life."

Condoms work: All men, circumcised or not, and their partners, need to use condoms and practice safer sex or they will be at risk for HIV. When used consistently and correctly, condoms are highly effective in preventing the transmission of HIV and other STDs.

Risk compensation: Circumcised men may feel they are protected against HIV and therefore may feel less need to practice safe sex. Loss of sensation from circumcision may also lead to reluctance to use condoms.

Behavior is the key: Behavior is more important than anatomical differences in preventing sexually transmitted diseases.

Public health: The US situation is very different from Africa. If the African studies are to be believed, the effects of circumcision would have the most impact in situations of very high HIV prevalence; where HIV transmission is predominantly through heterosexual sex; and where circumcision rates are very low – none of which is the case in the US.

Personal risk: The WHO says only that circumcision might be a reasonable suggestion for adults at high-risk of contracting HIV through heterosexual sex, for example, those in a relationship with an HIV+ person or those who have had other STDs.

The studies only apply to female-to-male heterosexual transmission: Circumcision has not been shown to protect female partners of circumcised men, or men who have sex with men, and of course has no effect on HIV acquired through IV drug use, health-care contamination, or maternal-child transmission.

Ethics: It is important to distinguish between circumcision of consenting, informed adults, and routine circumcision of non-consenting infants. Infants are not at risk for sexual transmission of HIV. The ethical presumption against interfering with the bodily integrity of another dictates that children should be allowed to make their own decisions about circumcision, when they are old enough to weigh the evidence and implications for themselves.

Other “health benefits” of circumcision: Other alleged benefits of circumcision have been shown to be false or insignificant, and have never been sufficient to recommend routine circumcision.

The foreskin is a normal, protective, sexually functional body part: The value of the foreskin must be given weight in any risk-benefit calculation. Recent studies have found that the foreskin is the most sensitive part of the penis,2 and that its Langerhans cells have the capacity to destroy HIV.3

Circumcision is not cost-free or pain-free: Circumcision carries the risks of multiple short- and long-term complications, some catastrophic, in addition to the loss of the foreskin's protective and sexual functions.

For further reading:

Darby R, Van Howe RS. Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Austr NZ J Pub Health. 2011;35(5):459-465. http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2011.00761.x/full

Boyle GJ, Hill G. Sub-Saharan African randomized clinical trials into male circumcision and HIV transmission: Methodological, ethical, and legal concerns. 2011; 19 JLM 316. http://xa.yimg.com/kq/groups/23477339/1441224426/name/JLM_boyle_hill.pdf

Green LW, Travis JW, McAllister RG, et al. Male circumcision and HIV prevention: Insufficient evidence and neglected external validity. Am J Prev Med 2010;39(5):479-482. http://tinyurl.com/7fuybmm

Green LW, McAllister RG, Peterson KW, Travis JW. Medicaid coverage of circumcision spreads harm to the poor. Am J Pub Health. 2009;99(4):584. http://ajph.highwire.org/cgi/content/full/99/4/584

Male circumcision: A dangerous mistake in the HIV battle Rev.7-11 http://www.intactamerica.org/dangerousmistake

References:

1. WHO/UNAIDS Technical Consultation. Male Circumcision and HIV Prevention: Research Implications for Policy and Programming: Conclusions and Recommendations. March 2007  

2. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:864-9.

3. de Witte L et al. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med 2007;13:367-371.  

This handout was developed by the Colorado chapter of the National Organization of Circumcision Information Resource Centers, www.ColoradoNOCIRC.org, Revised February 2012