Circumcision to prevent HIV infection in America

Officials Weigh Circumcision to Fight H.I.V. Risk:

Public health officials are considering promoting routine circumcision for all baby boys born in the United States to reduce the spread of H.I.V., the virus that causes AIDS.


He and other experts acknowledged that although the clinical trials of circumcision in Africa had dramatic results, the effects of circumcision in the United States were likely to be more muted because the disease is less prevalent here, because it spreads through different routes and because the health systems are so disparate as to be incomparable.

Clinical trials in Kenya, South Africa and Uganda found that heterosexual men who were circumcised were up to 60 percent less likely to become infected with H.I.V. over the course of the trials than those who were not circumcised.

There is little to no evidence that circumcision protects men who have sex with men from infection.

Another reason circumcision would have less of an impact in the United States is that some 79 percent of adult American men are already circumcised, public health officials say.

My first thought is that I really would like to see the cost vs. benefit analysis; the United States is not KwaZulu-Natal. The article notes white males tend to be circumcised already, which is interesting because American white male HIV prevalence rates seem to be somewhat higher than British rates (compare & contrast). This is important because while American men are mostly circumcised, most British men are not. The point is not that circumcision has no effect, but that on the margins its return is probably far less when you have a population which is already has low rates of infection. As I have noted before, circumcised South Korea and uncircumcised Japan have the same HIV infection rates, on the order of ~0.1%.

In the United States non-Hispanic white men have the highest rates of circumcision, followed by black men, and then Hispanics. But here are the ethnic-racial proportions of HIV infected individuals in the United States:


Hispanics are slightly overrepresented (as they are somewhat less than15% of the population), but blacks who are 12% of the population are heavily overrepresented. Around ~25% of HIV transmission in the USA occurs via high risk heterosexual sex, a far lower proportion than in Africa.

This is really an issue with complex parameters. One-size-fits-all answers are frankly dumb and short-sighted. I've gotten some grief when I've offered that male circumcision may be part of the solution in regions where HIV infection rates are on the order of 1/3 of the population. The cost vs. benefit seemed to make this a plausible line of thinking, but in the United States I don't see it. As it happens American whites have higher HIV prevalence rates than many European populations, so in that case it isn't circumcision where the low hanging fruit is likely to be. In the United States there is a particular problem among homosexuals and blacks. As noted above most are skeptical about circumcision's ability to reduce risk when it comes to male-male sex, but it might have some benefit for black Americans. Look at the odds:

To date, over 225,000 African Americans have died of AIDS - nearly 40% of total deaths - and of the more than 1 million people living with HIV in the United States of America today, around half are black. And yet, as a racial group, African Americans represent just 13% of the US population. The estimated lifetime risk of becoming infected with HIV is 1 in 16 for black males, and 1 in 30 for black females, a far higher risk than for white males (1 in 104) and white females (1 in 588).


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Recent field studies have not confirmed the earlier positive effects suggested for circumcision as a preventative measure.
Lancet. 2009 Jul 18;374(9685):229-37.
Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial.
Their conclusion was fairly blunt:
"INTERPRETATION: Circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months; longer-term effects could not be assessed. Condom use after male circumcision is essential for HIV prevention."
And furthermore if you really want a strong correlation between circumcision rates and low HIV rates I'm afraid the answer is somewhat unsettling - in East Africa the countries where Type 3 Female Genital Mutilation (yes, the most brutal and disgusting type) is prevalent have the lowest rates.

Have anyone checked the proportion of infections in prisons? I mean, the racial ratios seem similar to the incarceration rate.

The other side to this is the psychological effect - if people get the idea that circumcision protects them from HIV, they might be less inclined to use condoms, which are far more effective.
From what I've seen of arguments for circumcision in the US, protection from HIV seems to be offered as a justification for something parents were going to do anyway.

Comprehensive studies in the US have suggested that the reduced risk of HIV infection associated with circumcision is only about 20-30% - and that it's entirely obviated by the appropriate use of condoms.

The same studies also suggest that, once the proper corrections are made for SES and associated risk factors, circumcision significantly increases the risk of getting every other STI / STD. The 1940s-50s studies that claimed to demonstrate otherwise have been shown to be methodological nightmares.

I'm in agreement with you. Encouraging more circumcision of baby boys in the US is putting too much behind this one method of HIV control. There is also the question of whether it's really ethical to carry out an elective procedure on a nonconsenting patient, especially when we consider that by the time the patient is at risk of contracting the disease by intercourse, he'll be old enough to give or withhold consent.

By Chem undergrad (not verified) on 25 Aug 2009 #permalink

We need to avoid junk science. The three Africa trials need to be closely examined for methodology. A cursory review reveals flaws in the methodology and renders the conclusions suspect.

As for the CDC evaluating routine infant circumcision, first, babies do not have sex. So, RIC is not relevant to reducing HIV. Let the adult man decide if he wishes to have a portion of his sex organ removed by circumcision. If the man is smart, he will wear a condom when having at-risk sex.

Second, having non-medically required surgery on an infant is a violation of that infant's human rights and bodily integrity. It is illegal to perform non-medically required genital surgery on infant girls in the US. Why is there a double standard that allows genital surgery on baby boys?

Many men are finding out that they miss their foreskin. They, like myself, are restoring their foreskin to regain what was taken from us at birth. See to read accounts of men who wish they had never been circumcised and are doing something about it.

I think what you're missing is the insurance side of the debate. The CDC, etc. are only discussing whether to RECOMMEND male circumcision (not make it mandatory) so that insurance companies will have to cover it IF the family decides to have it done. The issue is that the families that can least afford to pay for it out of pocket (disproportionately black and Hispanic families)are also at the highest risk of contracting HIV.

After studying this issue for quite a few years and closely analyzing all the major studies and published reports pertaining to the issue of circumcision and morbidity, I would like to propose an entirely different view. The foreskin actually protects against disease in several ways.

First, while some have hypothesized that "microabrasions" of the inner foreskin may be to blame for the results in the 3 African RCTs, this contradicts the medical evidence. The only published information on microtearing of the genitals found it to be true of circumcised males and their partners -- which makes sense, as the skin of the circumcised penis is generally less elastic and less mobile. Circumcised men are known to have rougher and more varied sex, which directly increases abrasion and the likelihood of disease transmission.

Second, the hypothesis that Langerhans cells attract HIV to the foreskin (and then what? HIV doesn't permeate intact tegument) also is faulty. When examined in vitro such attraction seems plausible, but looked at in vivo the langerin from such cells actually neutralizes virus, meaning both intact males and females have greater natural protection. This is consistent with several studies showing moist mucosal tissue to be a strong barrier to viral and bacterial infection. The dried mucosa of a circumcised penis lacks this important quality. Lysozymes present in small quantities of smegma from sloughed cells also aid in the fight against infection.

For these reasons, when populations of comparable demographic data and behaviors are examined, those that do not routinely practice circumcision consistently demonstrate better outcomes on all types of STIs, including HIV.

The results from the 3 recent African RCTs are markedly at odds with almost all data from other world regions regarding correlation between circumcision status and HIV acquisition, which in itself should raise a flag. This is likely due to researcher error and bias -- numerous significant questions remain about methodology and consistency. At least as disturbing is the follow-up result from these studies that circumcised males appear to transmit HIV up to 50% more often to female partners than do intact males, which shouldn't surprise anyone given the above information.

Ultimately, it would be irresponsible for any governmental health authority to recommend the circumcision of newborn males (and only males) on the basis of 3 controversial and related studies and without answering the very valid question of why, looking broadly at comparable populations (income, religion, education), circumcised males are consistently at higher risk for every single STI. Once again, nature knows best. The human body is clearly not in need of a redesign, but our priorities may be.

@ 8. This procedure should not be covered by insurance companies. Circumcising a baby boy is utterly unethical and should be illegal. Also, the evidence for circumcision as HIV control is questionable at best. One thing I find very interesting is that the populations in Africa with high circumcision rates happen to be Muslim, with tight restrictions on sexual activity. The best way to fight HIV is to ensure that people use condoms for risky sex.

I count myself fortunate that my parents did not go chopping off pieces of my genitals, and I have deep sympathy for those men who were not so lucky.

By Chem undergrad (not verified) on 26 Aug 2009 #permalink

You're absolutely right, Brant.

Unfortunately, there is little interest in abolishing the erroneous claims that were made about the supposed benefits of circumcision, and many people have a great deal of interest in supporting new excuses for the practice.

Australian and Canadian circumcision rates plummeted once it was recognized that there wasn't any justification for it, but American rates dropped only slightly.

I doubt that this is a battle which reason and common sense are going to win.

One thing I find very interesting is that the populations in Africa with high circumcision rates happen to be Muslim, with tight restrictions on sexual activity.

this is isn't really true. in much of west and east africa most populations are circumcised. e.g., in kenya the only group which doesn't practice male circumcision are the luo, with the exception of luo muslims of course. IOW, yes, muslims are necessarily circumcised, but in many nations there's minimal difference.

I too agree with Brant and Caledonian, and see this as yet another silly reason to recommend circumcision, which is after all an ancient tribal mutilation ritual, with no proven health benefits!!.

In regards to Muslims, circumcision and HIV in Africa, I attended a meeting over a year ago at GMHC in NYC, where the speaker was the then Health Commissioner Dr. Thomas Frieden, now head of the CDC, who strongly advocated circumcision for all men - based on these studies. An attendee pointed out that he had studies to show that in East Africa, in countries where there are Animists and Muslims and there is conversion to the Muslim faith, often young Animist men will fool around and "sow their wild oats", then later become Muslims and become more sexually conservative, and these factors were not considered in the studies. It was felt by most attendees that these studies had no bearing on the 2 highest at risk New York populations for HIV; Men who have sex with men (MSM) and heterosexual Blacks.

@ 12. My reference is Marked in Your Flesh by Leonard Glick, page 274 in my edition (ISBN: 0-19-531594-4). What's your's?

By Chem undergrad (not verified) on 26 Aug 2009 #permalink

Razib: "check out the rates per county" [country?] That will only give you a rough correlation. The National Demographic and Health Surveys sampled individuals in each country, and found higher HIV rates among the circumcised men in at least six countries (Cameroon, Ghana, Lesotho, Malawai, Rwanda, Swaziland, Tanzania and parts of Uganda).

I'm reading Ben Goldacre's "Bad Science" and finding the research promoting circumcision to be very similar to the "research" promoting dietary supplements and quack cures.

foreskin in men = labia minor in women. Foreskin has most sensitive sexual zone on penis. For those who have foreskin, test it with small object. For those without foreskin, you never know what you missed (a lot of sexual pleasure) in sex.

Even better: check out the arguments and studies that were historically used to justify circumcision, and then see how well time has treated them.

They were eventually realized to be either incorrect, procedurally botched, or both. And whenever one reason had been discredited widely enough to no longer serve, other, new claims were brought up and supported with new studies. Those would eventually be debunked... but the cycle continued.

If there is a long history of conclusion-seeking on a matter, any new claims made to support that conclusion ought to be treated even more skeptically than normal. When it's known that people are irrational about a subject, their arguments need to be scrutinized and doubted rigorously.

I wonder if any health claims really have much to do with this, ah, perseveration in the USA. My intuition is that it has more to do with conformism and a superior appearance. But really, y'all, the thing was never meant to look good.

By Eric Johnson (not verified) on 27 Aug 2009 #permalink

Telling people that anything other than using condoms will prevent HIV infection is just plain dangerous. All of the insane anti-condom rhetoric that is being preached right now in the US and abroad is causing a spike in new infections. Giving people another mythical reason to think they can't get infected when having unprotected sex is unconscionable.

And why on earth should insurance cover circumcision when in the US it is typically considered either cosmetic or religious? I had lasic surgery on my eyes because glasses were a terrible nuisance, contact lenses didn't stay in my eyes, and I needed to be able to see. This surgery is considered cosmetic by insurance companies and I had to pay for it out of pocket. Yet infant genital mutilation for looks or religious beliefs should be covered?

I don't see how one could conclude that circumcision would have some benefit for black men in the USA without knowing the rate of circumcision among this population. The rates for African Americans are only slightly less than that of the white population. Hispanics, who truly do have vastly lower rates of circumcision, seem to also have fairly low rates of HIV among heterosexuals.

@Nador I tend to agree. I don't recall the exact estimate for prevalence in the prison population but it's a few times higher than the general population. I was surprised to read (I think at that proposals to perform mandatory testing of the prison population and possibly segregation based on status is considered inhumane by the UNAIDS and similar groups. Which seems odd to me because this would allow people to start treatment and prevent infections of non-infected individuals in prison. As well as protect them after release, since knowing your status has been correlated with decreased transmission.

@Lee this is no doubt an insurance scam in progress. There are a lot of people in American public health sectors that are just aching to find a reason to force Medicare to pay for circumcision again (16 states have dropped it). Cultural familiarity seems to be driving this decision, rather than rational thinking.

As an aside, the Royal Australasian College of Physicians have released a new summary statement on this issue, read it here. This position seems reasonable, it is not in anyway necessary to the health of boys in first world countries.

IF the CDC is trying to justify infant circumcision WHY did they permit "Operation Abraham"-an Israeli circumcision activist group give a propaganda presentation denigrating the normal, intact male?

It seems the Obama administration is continuing the Bush policy of subverting science to cater to religious and special interest groups.

By Robert Samson (not verified) on 03 Sep 2009 #permalink