Circumcision and HIV
Recently, circumcision has been heavily promoted as a method of preventing HIV. The World Health Organization (WHO), now known to be corrupted, hasitly endorsed male circumcision as a form of HIV prevention in 2007, based on three studies (2005) & (2007) conducted in Africa (Kenya, South Africa, and Uganda) which claim that male circumcision is supposed to "reduce the risk of HIV transmission by 60%." This endorsement has lead to the institution of "mass circumcision campaigns" aimed at circumcising the majority of African men in a few countries, and the promotion of male circumcision as a HIV-prevention method by the Centers for Disease Control
- 1 Origin of the circumcision/HIV hypothesis
- 2 Early research
- 3 Confounding factors
- 4 African RCTs
- 5 Real world data
- 6 Findings
- 7 Follow-up studies
- 8 Real-world
- 9 Problems with promoting circumcision as HIV prevention policy
- 10 Increased risk to women
- 11 Effective prevention
- 12 See also
- 13 External links
- 14 References
Origin of the circumcision/HIV hypothesis
The idea that circumcision prevented HIV transmission was invented by Valiere Alcena, long before there was any "research" to substantiate the claim. In 1986, California urologist Aaron J. Fink, (1926-1994) adopted this idea, and vehemently promoted it, without any kind of proof whatsoever.
In 1986, Fink sent a letter to the New England Journal of Medicine titled "A possible Explanation for Heterosexual Male Infection with AIDS," where he argued that the hard and toughened glans of the circumcised male resisted infection, while the soft and sensitive foreskin and glans mucosa of the intact male were ports of entry. Fink proposed in his letter: "I suspect that men in the United States, who, as compared with those in Africa and elsewhere, have had less acquisition of AIDS, have benefited from the high rate of newborn circumcision in the United States," regardless of the fact that the United States has one of the highest circumcision rates, and one of the highest HIV rates, in the western (industrialized) world (compare with European countries, Canda, and Australia).
Fink's proposal appeared in media throughout the US and Canada. Asked about his idea by a United Press reporter, Fink replied "This is nothing I can prove." This didn't stop other physicians from conducting "research" leading to a steady stream of widely publicized articles arguing that circumcised men were less likely to contract HIV--with the result that prevention of HIV infection has now surpassed even cancer prevention as the most popular claim of circumcision advocates.
|“||Fink's Own Words |
This is nothing I can prove.
– Aaron J. Fink ("This Little Operation". Marked in Your Flesh. p.206-208)
Fink abandoned the circumcision/HIV controversy in 1991, and he died in 1994. He left behind an indelible legacy nonetheless; the circumcision/HIV hypothesis continues to be supported by researchers and scientists that are adopting his assertions and writing studies based upon them, and the campaign to establish a causal link between HIV infection and the presence of the foreskin continues to this day.
Carael et al. (1988) studied HIV transmission among heterosexual couples in Central Africa. No difference was found between couples in which the male was circumcised and in which the male was intact.
de Vincenzi & Mertens (1994) reviewed the literature regarding the alleged role of the foreskin in HIV transmission. They concluded:
The potential public-health benefits of male circumcision have been greatly discussed in the past 50 years, often in a passionate and emotional manner. However, relatively few studies have been carried out and those that have, present conflicting results. The major criticism of most of the studies preformed to date is the lack of attention given to potential confounding factors, which could be related to both circumcision status and risk of sexually transmitted infections, such as sexual behaviour or differences in hygienic practices, or differential use of specific health facilities. As Poland  noted, "We must remember that circumcision is not performed randomly."
Therefore, further efforts are still required to quantify the relative risk associated with the lack of male circumcision. Some of this can be achieved by using observational designs which better address the limitations discussed above. Laboratory and primate research might also continue to provide useful information.
As the safety, expected benefits, feasibility and acceptability of mass circumcision are all questionable, neither public-health interventions nor intervention studies appear to be defensible options before there is stronger evidence from observational studies in different settings that show lack of male circumcision may be a genuinely independent risk factor for the transmission of HIV.
Thomas et al. (2004) studied the incidence of HIV in circumcision and intact men in a United States Navy population. A slightly higher incidence of HIV infection was found in circumcised men (84.9%) as compared with intact men (81.8%). The authors concluded:
Although there may be other medical or cultural reasons for male circumcision, it is not associated with HIV or STI prevention in this U.S. military population.
Debunked ad-hoc hypotheses
Various hypotheses have been suggested in regards to the mechanism whereby circumcision prevents the tarnsmission of HIV. They have all been disproven, however, and all of the "studies" attempting to establish a causal link between circumcion and HIV transmission remain unsubstantiated by a working hypothesis.
Perhaps the oldest hypothesis on the mechanism whereby circumcision prevents the transmission of HIV is the theory that suggests that the keratinized surface of the penis in circumcised male resists infection, while the mucosa of the glans and inner of the intact male are ports of entry, which was purported by Aaron J. Fink.
Recent studies, however, disprove this hypothesis. One study found that there is "no difference between the keratinization of the inner and outer aspects of the adult male foreskin," and that "keratin layers alone were unlikely to explain why uncircumcised men are at higher risk for HIV infection." Another study found that "no difference can be clearly visualized between the inner and outer foreskin."
Langerhans cell hypothesis
Recent circumcision studies in Africa were conducted under the hypothesis that the Langerhans cells were the prime port of entry for the HIV virus. According to the hypothesis, circumcision was supposed to prevent HIV transmission by removing the Langerhans cells found in the inner mucosal lining of the foreskin.
deWitte found that not only are Langerhans cells found all over the body and that their complete removal is virtually impossible, but furthermore, deWitte found that Langerhans cells that are present in the foreskin produce Langerin, a substance that has been proven to kill the HIV virus on contact, acting as a natural barrier to HIV-1 transmission by Langerhans cells.
Bacterial environment hypothesis
This hypothesis attempts to identify the change in bacterial environment that results in the penis as a result of circumcision, as the mechanism whereby circumcision reduces the spread of HIV transmission. A desparate ad-hoc hypothesis, the explanation is rather farfetched. The argument is that the change in bacterial environment after circumcision makes it difficult for bacteria that cause diseases to live; there are less chances for penile inflamation, a condition that facilitates the transmission of viruses. The chances for penile inflamation are reduced, thereby reducing the chances of sexually transmitted viruses, such as HIV.
Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the randomized control trials were measuring frequency in HIV transmission, not for frequency in penile bacterial inflamation, and whether said inflamation facilitated sexually transmitted HIV. And secondly, circumcision advocates give themselves the new burden of proving the newly introduced hypothesis, that change in bacterial infection does indeed result in a significant reduction of HIV transmission. A new study is needed to measure HIV transmission in men who have been circumcised, uncircumcised men with constant penile inflamations, and uncircumcised men who don't suffer constant penile inflamation. Unless the randomized controlled studies were limited to only uncircumcised men who suffered constant penile inflamation.
Strong bias exists in the RCTs. "These trials, designed to detect a minimum 50 percent reduction in HIV risk, should provide definitive evidence regarding the efficacy and safety of MC within three to five years." By designing a trial to "detect" a minimum 50 percent reduction risk in HIV, these researchers might have artificially created the clinical setting to observe the effect they were looking to discover.
Boyle & Hill (2011) have shown these RCTs to be have significant methodological flaws and statistical errors that render their claims invalid. Although a 60 percent relative reduction in HIV was claimed, the absolute reduction was a statistically insignificant 1.3 percent.
- The three RCTs were terminated early because results had reached a signifıcent level showing reduced HIV infections in experimental compared with control groups; however, it was too soon to gauge long-term effectiveness.
- The results have no relevance for women or for men who have sex with men.
- Far more participants were lost to follow-up than were reported to have contracted HIV.
- A substantial number of participants appeared to have contracted HIV from nonsexual sources: 23 of the 69 infections reported in the South African trial and 16 of the 67 in the Ugandan study.
- Participants received continuous counseling, free condoms, and monitoring for infection, which was unlikely in real-world campaigns.
- The sanitary conditions of the surgeries would be diffıcult to replicate on a mass scale in many parts of Africa where HIV infection rates and prevalence are highest.
- Follow-up of any of these RCCTs is impossible. Study participants agreed to be circumcised when joining the study and were randomized into “circumcise now” and “circumcise later” groups.
Real world data
Countries in Africa
According to demographic health studies performed in other countries in Africa, HIV transmission was prevalent in circumcised men in at least 6 different countries:
In Cameroon, where 91% of the male population is circumcised, the ratio of circumcised men vs. intact men who contracted HIV was 4.1 vs. 1.1. 
In Ghana, the ratio is 1.6 vs 1.4 (95.3% circumcised). "...the vast majority of Ghanaian men (95 percent) are circumcised... There is little difference in the HIV prevalence by circumcision status..."
In Lesotho, the ratio is 22.8 vs 15.2 (23% circumcised). "The relationship between male circumcision and HIV levels in Lesotho does not conform to the expected pattern of higher rates among uncircumcised men than circumcised men. The HIV rate is in fact substantially higher among circumcised men (23 percent) than among men who are not circumcised (15 percent). Moreover, the pattern of higher infection rates among circumcised men compared with uncircumcised men is virtually uniform across the various subgroups for which results are shown in thetable. This finding could be explained by the Lesotho custom to conduct male circumcision later in life, when the individuals have already been exposed to the risk of HIV infection. (Additional analysis is necessary to better understand the unexpected pattern in Table 12.9.)"
- An interesting defense of male circumcision, given the fact that the latest "studies," if they can even be called that, observed HIV transmission in men circumcised as adults. Then again, this demographic health survey was conducted in 2004, BEFORE the newer "studies" in 2006. None the less, the unproven assertion that "circumcision is only effective in reducing the risk of HIV when done in infancy" persists in some circles.
DHS 2004 - 13.2 vs 9.5 (20% circumcised)
- "The relationship between HIV prevalence and circumcision status is not in the expected
direction. In Malawi, circumcised men have a slightly higher HIV infection rate than men who were not circumcised (13 percent compared with 10 percent). In Malawi, the majority of men are not circumcised (80 percent).
- ...where one would expect HIV to be the most rampant.
DHS 2005 - 3.8 vs 2.1 
Rosenberg et al. (2018) report that circumcised men in South Africa are more likely to be HIV infected than intact men.
DHS 2006-2007 - 22 vs 20
- "As Table 14.10 shows, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher HIV infection rate than men who are not circumcised (22 percent compared with 20 percent).
The prevalence of HIV infection among men aged 15-29 has not decreased despite several campaigns to perform male circumcision.
Garenne & Matthews (2019) report:
In a multivariate analysis, based on the 2013 DHS survey, circumcised men were found to have the same level of infection as uncircumcised men, after controlling for age, sexual behaviour and socioeconomic status. Lastly, circumcised men tended to have somewhat riskier sexual behaviour than uncircumcised men. This study, based on large representative samples of the Zambian population, questions the current strategy of mass circumcision campaigns in southern and eastern Africa.
According to Malaysian AIDS Council vice-president Datuk Zaman Khan, more than 70% of the 87,710 HIV/AIDS sufferers in the country are Muslims. In Malaysia, most, if not all Muslim men are circumcised, whereas circumcision is uncommon in the non-Muslim community. 60% of the Malaysian population is Muslim, which means that HIV is spreading in the community where most men are circumcised at an even faster rate, than in the community where most men are intact.
Interestingly enough, Malaysia is home to the TaraKlamp, a controversial circumcision device being marketed in KwaZulu Natal, Africa in the name of HIV prevention.
In the 2010 Global AIDS report released by UNAIDS in late November, the Philippines was one of seven nations in the world which reported over 25 percent in new HIV infections between 2001 and 2009, whereas other countries have either stabilized or shown significant declines in the rate of new infections. Among all countries in Asia, only the Philippines and Bangladesh are reporting increases in HIV cases, with others either stable or decreasing. 
The United States
In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact.
A common explanation given for this difference is the fact that sex education and instruction in the proper use of condoms is better executed in Europe than in the United States, where sex education is poor.
However, it is precisely these reasons given, that sex education and condoms aren't catching on in Africa, why circumcision advocates say "mass circumcision campaigns" should be promoted in Africa. What failed in the United States is somehow supposed to work miracles in Africa.
Studies with contrary conclusions
According to USAID, there appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher.
"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."
Results: ...No consistent relationship between male circumcision and HIV risk was observed in most countries."
Using a population-based survey, Westercamp et al. (2010) examined the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with the belief that circumcised men are less likely to become infected with HIV.
An analysis of HIV prevalence compared to circumcision status in sub-Saharan Africa concluded that male circumcision is not associated with reduced HIV prevalence. Another study on circumcision prevalence compared to HIV in the general South African population concluded: “Circumcision had no protective effect on HIV transmission.” When commercial sex worker patterns are controlled, male circumcision is not signifıcantly associated with lower HIV prevalence. Mathematical impact modeling of circumcision, antiretroviral therapy (ART), and condom use for South Africa concluded: “Male circumcision was found to have considerably lower impact than condom use or anti-retroviral therapy on HIV infection rates and death rates.” Both the U.S. and sub-Saharan Africa have relatively high incidence rates of HIV infection, considering that about 75% of U.S. men and about 70% of sub-Saharan African men are circumcised—higher percentages than in most other regions or countries with lower prevalence of HIV.
There is no clear pattern of association between male circumcision and HIV prevalence. In 10 out of 18 countries, HIV prevalence is higher amongst circumcised men. Furthermore, HIV prevalence was found to be higher amongst circumcised males and females for virgins and adolescents in Kenya, Lesotho, and Tanzania.
Problems with promoting circumcision as HIV prevention policy
The fact that the World Health Organization is corrupt is now well-established:
Circumcision advocates use the latest African studies and WHO's endorsement based on them as proof "beyond reasonable doubt" that circumcision "reduces the risk of HIV." However, there are problems with the WHO's endorsement, as the studies on which it is based on suffer various flaws and confounding factors that bring their credibility in to question, many of which will be discussed in this article.
On their website, the WHO acknowledges that, "[m]ale circumcision provides only partial protection," and that it should be part of a "comprehensive HIV prevention package" that includes HIV testing and counseling services, treatment for STD infections, the promotion of safer sex practices and the provision of condoms and the promotion of their correct and consistent use.
Van Howe & Boyle (2018) pointed out numerous reasons that one should doubt the published results of the randomised clinical trials (RCTs)
George C. Denniston, M. D., M. P. H., the president of Doctors Opposing Circumcision, in a letter to Ambassador Deborah L. Birx, M.D., M. P. H., (2020), the head of the President’s Emergency Plan for AIDS Relief (PEPFAR) has called on PEPFAR to suspend the provision of male circumcision because it is ineffective and may increase the reception of HIV infection due to the loss of immunological protections of the foreskin, and to focus on the provision of anti-retroviral therapy and condoms.
Increased risk to women
A recent prospective study showed that male circumcision offered no protection to women, and an RCCT found that male circumcision actually increased the risk to women. Women also are placed at greater risk from unsafe sex practices when they, or their circumcised male partners, wrongly believe that with circumcision they are immune to HIV and therefore they choose not to use condoms.
There are legitimate additional concerns about:
- How male circumcision programs, or being circumcised, will influence human behavior.
- The sidelining of women when considering male circumcision as a prevention method.
- The tendency of both men and women to ascribe undue power to a technical fıx for what must remain a matter of human control, as in the use of condoms and other safe sex practices.
|Exposure Route||Estimated infections|
per 10,000 exposures
to an infected source
|Childbirth (to child)||2,500|
|Needle-sharing injection drug use||67|
|Percutaneous needle stick||30|
|Receptive anal intercourse*||50|
|Insertive anal intercourse*||6.5|
|Receptive penile-vaginal intercourse*||10|
|Insertive penile-vaginal intercourse*||5|
|Receptive oral intercourse*§||1|
|Insertive oral intercourse*§||0.5|
|* assuming no condom use |
§ source refers to oral intercourse
performed on a man
The three main transmission routes of HIV are sexual contact, exposure to infected body fluids or tissues, and from mother to fetus or child during perinatal period. It is possible to find HIV in the saliva, tears, and urine of infected individuals, but there are no recorded cases of infection by these secretions, and the risk of infection is negligible. Anti-retroviral treatment of infected patients also significantly reduces their ability to transmit HIV to others, by reducing the amount of virus in their bodily fluids to undetectable levels. 
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