View source for Circumcision and HIV

This article discusses the relationship of male '''circumcision and HIV''' infection. For a discussion of [[circumcision]] and other sexually transmitted infections, see [[Circumcision and STDs]].

Recently, circumcision has been heavily promoted as a method of preventing [[HIV]]. The [[World Health Organization|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%."<ref>{{REFweb
 |url=http://www.who.int/hiv/topics/malecircumcision/en/
 |title=Male circumcision for HIV prevention
 |publisher=World Health Organization
 |date=2007
 |accessdate=2011-05-06
}}</ref> This endorsement has lead to the institution of "mass circumcision campaigns" aimed at circumcising the majority of African men in a few countries,<ref>{{REFnews
 |last=Mazzotta
 |first=Meredith
 |url=http://sciencespeaksblog.org/2011/03/04/swaziland-embarks-on-ambitious-plan-to-circumcise-80-percent-of-men-18-to-49-this-year/
 |title=Swaziland embarks on ambitious plan to circumcise 80 percent of men 18 to 49 this year
 |publisher=
 |work=Science Speaks: HIV & TB News
 |quote=The emphasis is on reaching 80 percent coverage with the Soka Uncobe campaign...
 |date=2011-03-04
 |accessdate=2011-05-06
}}</ref> and the promotion of male circumcision as a [[HIV]]-prevention method by the [[Centers for Disease Control|Centers for Disease Control]]<ref>{{REFweb
 |url=http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm
 |title=Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States
 |publisher=
 |date=2008-02
 |accessdate=2011-06-01
}}</ref><ref>{{REFweb
 |url=http://www.cdc.gov/botusa/Success-Stories/0307-MaleCircumcision-Botswana.htm
 |title=Success Stories: Male Circumcision: A Question and Answer Session
 |publisher=[[CDC]]
 |date=2007-03
 |accessdate=2011-06-01
}}</ref><ref>{{REFweb
 |url=http://www.cdcnpin.org/Display/FundDisplay.asp?FundNbr=4285
 |title=Funding
 |publisher=
 |date=2011-01-09
 |accessdate=2011-06-01
}}</ref>

== 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.<ref>{{REFjournal
 |last=Alcena
 |first=Valiere
 |init=V
 |author-link=Valiere Alcena
 |title=AIDS in Third World Countries
 |journal=N Y State J Med
 |volume=8
 |pages=446
 |pubmedID=3463895
 |DOI=10.1371/journal.pmed.0020298#r1326
 |date=2006-10
 |accessdate=2020-05-28
}}</ref> In 1986, California urologist [[Aaron J. Fink| Aaron J. Fink]], (1926-1994) adopted this idea,<ref>{{REFbook
 |last=Glick
 |first=Leonard B.
 |init=LB
 |author-link=Leonard B. Glick
 |year=2005
 |title=Marked in Your Flesh
 |url=
 |editor=
 |edition=
 |volume=
 |chapter="This Little Operation", Jewish American Physicians and Twentieth-Century Circumcision Advocacy
 |page=206
 |location=New York, NY
 |publisher={{UNI|Oxford University|Oxon}} Press
 |isbn=0-19-517674-X
 |quote=What if circumcision protected against infection with HIV...
 |accessdate=2011-02-19
 |note=
}}</ref> and vehemently promoted it,<ref>{{REFjournal
 |last=Weiss
 |first=Helen A.
 |init=HA
 |author-link=Helen Weiss
 |last2=Quigley
 |first2=Maria A.
 |init2=MA
 |last3=Hayes
 |first3=Richard J.
 |init3=RJ
 |title=Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis
 |journal=AIDS
 |volume=14
 |issue=15
 |pages=2361-2370
 |url=http://www.aidsonline.com/pt/re/aids/fulltext.00002030-200010200-00018.htm
 |pubmedID=11089625
 |DOI=10.1097/00002030-200010200-00018
 |date=2000-10
}}</ref> 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.<ref>{{REFjournal
 |last=Fink
 |first=Aaron J.
 |init=AJ
 |author-link=Aaron J. Fink
 |title=A possible Explanation for Heterosexual Male Infection with AIDS
 |journal=New England Journal of Medicine
 |volume=315
 |issue=18
 |year=1986
 |page=1167
 |url=https://www.nejm.org/doi/full/10.1056/NEJM198610303151818
 |pubmedID=3762636
 |}}</ref> 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).<ref>{{REFweb
 |url=http://www.who.int/hiv/facts/hiv2003/en/
 |title=A global view of HIV infection
 |last=WHO/UNAIDS
 |first=
 |publisher=[[World Health Organization]]
 |date=2004
 |accessdate=2011-02-27
}}</ref>

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."<ref>{{REFbook
 |last=Glick
 |first=Leonard B.
 |init=LB
 |author-link=Leonard B. Glick
 |year=2005
 |title=Marked in Your Flesh
 |url=
 |editor=
 |edition=
 |volume=
 |chapter="This Little Operation", Jewish American Physicians and Twentieth-Century Circumcision Advocacy
 |page=207
 |location=New York, NY
 |publisher={{UNI|Oxford University|Oxon}} Press
 |isbn=0-19-517674-X
 |quote=This is nothing I can prove.
 |accessdate=2011-02-19
 |note=
}}</ref> 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.
{{Citation
 |Title=Fink's Own Words
 |Text=This is nothing I can prove.
 |Author=[[Aaron J. Fink]]
 |Source="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.

==Early research==

Hrdy (1987) identified numerous African cultural practices other than circumcision or non-circumcision that would contribute to the spread of [[HIV]] infection. Such factors include:
* Female circumcision and [[infibulation]].
* Promiscuity.
* Homosexuality and anal intercourse.
* Practices resulting in exposure to blood.
* Practices involving the use of shared instruments.
* Contact with non-human primates.<ref name="hrdy1987">{{REFjournal
 |last=Hrdy
 |first=Danniel B
 |init=DB
 |etal=no
 |title=Cultural practices contributing to the transmission of human immunodeficiency virus in Africa
 |journal=Rev Infect Dis
 |date=1987-11
 |volume=9
 |issue=6
 |pages=1109-19
 |url=http://www.cirp.org/library/disease/HIV/hrdy1/
 |pubmedID=3321361 
 |DOI=10.1093/clinids/9.6.1109
 |accessdate=2021-05-12
}}</ref>

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.<ref name="carael1988">{{REFjournal
 |last=Carael
 |init=M
 |author-link=
 |last2=Van de Perre
 |init2=PH
 |author2-link=
 |last3=LePage
 |init3=PH
 |author3-link=
 |last4=Allen
 |init4=S
 |author4-link=
 |etal=yes
 |title=Human immunodeficiency virus transmission among heterosexual couples in Central Africa
 |journal=AIDS
 |location=
 |date=1988-06
 |volume=2
 |issue=3
 |pages=201-5
 |url=http://www.cirp.org/library/disease/HIV/carael/
 |pubmedID=3134914
 |accessdate=2020-05-28
}}</ref>

de Vincenzi & Mertens (1994) reviewed the literature regarding the alleged role of the [[foreskin]] in [[HIV]] transmission. They concluded:
<blockquote>
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 [48] 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]].<ref>{{REFjournal
 |last=de Vincenzi
 |first=Isabelle
 |init=I
 |author-link=
 |last2=Mertens
 |first2=Thierry
 |init2=T
 |author2-link=
 |etal=no
 |title=Male circumcision: a role in HIV prevention?
 |journal=AIDS
 |date=1994
 |volume=8
 |issue=2
 |pages=153-60
 |url=http://www.cirp.org/library/disease/HIV/vincenzi/
 |pubmedID=8043224
 |accessdate=2020-05-29
}}</ref>
</blockquote>

[[Robert Darby| Darby]] (2002) examined the claims that circumcision is preventive of infection with [[HIV]]. He tabulated the prevalence of circumcision and [[HIV]] infection in various nations.  He found no connection between the prevalence of circumcision and [[HIV]] infection. Darby also compared the nineteenth century British attempts to control syphilis (then a dreaded and incurable disease) with male circumcision, which was equally unsuccessful.<ref name="darby2002">{{REFjournal
 |last=Darby
 |first=Robert
 |init=R
 |author-link=Robert Darby
 |url=https://pool.intactiwiki.org/w/images/2002-09_Darby-BeenThereDoneThat.pdf
 |title=Been There, Done That: Thoughts on the proposition that yet more circumcision can save the world from AIDS
 |journal=Australian Quarterly
 |date=2002-09
 |volume=74
 |issue=5
 |pages=26-35
 |accessdate=2021-05-08
}}
</ref>

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:
<blockquote>
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.<ref name="thomas2004">Thomas AG, Bakhireva LN, Brodine SK, Shaffer RA. [http://www.cirp.org/library/disease/HIV/thomas1/ Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. Navy population]. Abstract no. TuPeC4861. Presented at the XV International [[AIDS]] Conference, Bangkok, Thailand, July 11-16, 2004.</ref>
</blockquote>

== Confounding factors ==

=== 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.

==== Keratinization hypothesis ====
Perhaps the oldest hypothesis on the mechanism whereby circumcision prevents the transmission of [[HIV]] is the theory that suggests that the [[Keratinization| 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."<ref>{{REFjournal
 |last=Dinh
 |init=MH
 |last2=McRaven
 |init2=MD
 |last3=Kelley
 |init3=Z
 |last4=Penugonda
 |init4=S
 |last5=Hope
 |init5=TJ
 |title=Keratinization of the adult male foreskin and implications for male circumcision
 |journal=AIDS
 |volume=24
 |issue=6
 |pages=899-906
 |url=http://www.ncbi.nlm.nih.gov/pubmed/20098294
 |quote=We found no difference between the keratinization of the inner and outer aspects of the adult male foreskin. Keratin layers alone are unlikely to explain why [[uncircumcised]] men are at higher risk for HIV infection.
 |pubmedID=20098294
 |pubmedCID=
 |DOI=
 |date=2010-03-27
 |accessdate=2011-06-28
}}</ref> Another study found that "no difference can be clearly visualized between the inner and outer foreskin."''<!-- <ref>{{REFcontribution
 |contribution=HIV-1 Interactions and Infection in Adult Male Foreskin Explant Cultures
 |quote=No difference can be clearly visualized between the inner and outer foreskin.
 |url=http://retroconference.org/2009/PDFs/502.pdf
 |title=16th Conference on Retroviruses and Opportunistic Infections
 |author=Minh H Dinh; Sheila M Barry, Meegan R Anderson, Scott G McCoombe, Shetha A Shukair, Michael D McRaven, Thomas J Hope
 |publisher=
 |place=Montreal, Canada
 |pages=
 |date=2009-12-06
 |accessdate=
}}</ref>-->

==== 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 [[mucosa]]l 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.<ref>{{REFjournal
 |last=de Witte
 |first=Lot
 |init=L
 |last2=Nabatov
 |first2=Alexey
 |init2=A
 |last3=Pion
 |first3=Marjorie
 |init3=M
 |last4=Fluitsma
 |first4=Donna
 |init4=D
 |last5=de Jong
 |first5=Marein A.W.P.
 |init5=MAWP
 |last6=de Gruijl
 |first6=Tanja
 |init6=T
 |last7=Piguet
 |first7=Vincent
 |init7=V
 |last8=van Kooyk
 |first8=Yvette
 |init8=Y
 |last9=Geijtenbeek
 |first9=Teunis B.H.
 |init9=TBH
 |title=Langerin is a natural barrier to HIV-1 transmission by Langerhans cells
 |journal=Nature Medicine
 |volume=13
 |issue=3
 |pages=367-71
 |url=http://www.circumcisionandhiv.com/files/de_Witte_2007.pdf
 |format=PDF
 |pubmedID=17334373
 |pubmedCID=10.1038/nm1541
 |DOI=10.1038/nm1541
 |date=2007-03-04
 |accessdate=2020-07-02
}}</ref>

==== 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 desperate 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 inflammation, a condition that facilitates the transmission of viruses. The chances for penile inflammation are reduced, thereby reducing the chances of sexually transmitted viruses, such as [[HIV]].<ref>{{REFjournal
 |last=Price
 |first=Lance B.
 |init=LB
 |last2=Liu
 |first2=Cindy M.
 |init2=CM
 |last3=Johnson
 |first3=Kristine E.
 |init3=KE
 |last4=Aziz
 |first4=Maliha
 |init4=M
 |last5=Lau
 |first5=Matthew K.
 |init5=MK
 |last6=Bowers
 |first6=Jolene
 |init6=J
 |last7=Ravel
 |first7=Jacques
 |init7=J
 |last8=Keim
 |first8=Paul S.
 |init8=PS
 |last9=Serwadda
 |first9=David
 |init9=D
 |last10=Wawer
 |first10=Maria J.
 |init10=MJ
 |last11=Gray
 |first11=Ronald H.
 |init11=RH
 |etal=yes
 |title=The Effects of Circumcision on the Penis Microbiome
 |journal=PLoS ONE
 |volume=5
 |issue=1
 |url=http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0015552
 |quote=The anoxic microenvironment of the subpreputial space may support pro-inflammatory anaerobes that can activate Langerhans cells to present HIV to CD4 cells in draining lymph nodes. Thus, the reduction in putative anaerobic bacteria after circumcision may play a role in protection from HIV and other sexually transmitted diseases.
 |DOI=10.1371/journal.pone.0008422
 |date=2010
 |accessdate=2011-06-29
}}</ref>

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, intact men with constant penile inflamations, and intact men who don't suffer constant penile inflammation. Unless the randomized controlled studies were limited to only intact men who suffered constant penile inflammation.

== The immunological function of the foreskin ==

The foreskin's inner fold and the glans of the penis are comprised of [[Preputial mucosa|mucous membrane]] tissue. These are also present in your eyes, mouth, and all other bodily orifices including the female genitals. These are the first line of immunological defense for the body's orifices. These mucous membranes perform many immunological and hygienic functions. 

Certain components such as [[Langerhans cells]],<ref>{{REFjournal
 |last=Weiss
 |init=GN
 |last2=Sanders
 |init2=M
 |last3=Westbrook
 |init3=KC
 |url=http://www.circumstitions.com/Langerhans.html
 |title=The distribution and density of Langerhans cells in the human prepuce: site of diminished immune response?
 |journal=Isr J Med Sci
 |date=1993-01
 |volume=29
 |issue=1
 |pages=42-43
 |accessdate=2019-10-20
}}</ref> plasma cells,<ref name="flower1983">{{REFjournal
 |last=Flower
 |init=PJ
 |last2=Ladds
 |init2=PW
 |last3=Thomas
 |init3=AD
 |last4=Watson
 |init4=DL
 |url=https://journals.sagepub.com/doi/abs/10.1177/030098588302000206
 |title=An immunopathologic study on the bovine prepuce
 |journal=Vet Pathol
 |date=1983-03
 |volume=20
 |issue=2
 |pages=189-201
 |accessdate=2019-10-20
}}</ref> apocrine glands,<ref>{{REFjournal
 |last=Ahmed
 |init=A
 |last2=Jones
 |init2=AW
 |url=https://www.academia.edu/5687437/APOCRINE_CYSTADENOMA_A_REPORT_OF_TWO_CASES_OCCURRING_ON_THE_PREPUCE
 |title=Apocrine Cystadenoma: a report of two cases occurring on the prepuce
 |journal=Br J Dermatol
 |date=1969-12
 |volume=81
 |issue=12
 |pages=899-901
 |accessdate=2019-10-20
}}</ref> and sebaceous glands,<ref>{{REFjournal
 |last=Hyman
 |init=AB
 |last2=Brownstein
 |init2=MH
 |title=Tyson's "glands": ectopic sebaceous glands and papillomatosis penis
 |journal=Arch Dermatol
 |date=1969-01
 |volume=99
 |issue=1
 |pages=31-36
 |accessdate=2019-10-20
}}</ref><ref>{{REFjournal
 |last=Delbanco
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 |title=Über das gehäufte Auftreten von freien Talgdrüsen an der Innenfläche des Präputiums
 |trans-title=About the increased occurrence of free sebaceous glands on the inner surface of the prepuce
 |language=German
 |journal=Monatshefte für praktische Dermatologie
 |date=1904
 |volume=38
 |pages=536-538
 |accessdate=2019-10-20
}}</ref><ref>{{REFjournal
 |last=Piccinno
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 |last3=Menni
 |init3=S
 |etal=yes
 |title=sebacous glands mimicking molluscum contagiosum
 |journal=Acta Derm Venerol
 |date=1990
 |volume=70
 |pages=344-345
}}</ref><ref>{{REFjournal
 |last=Krompecher
 |first=St.
 |init=S
 |title=Die Histologie der Absonderung des Smegma praeputii
 |trans-title=Histology of allocation of a smegma praeputii
 |language=German
 |journal=Anatomischer Anzeiger
 |date=1932
 |volume=75
 |pages=170-176
}}</ref>, collectively secrete emollient lubricants.<ref name="parkash-jeykumar1973">{{REFjournal
 |last=Parkash
 |init=S
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 |last3=Subramanyan
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 |last4=Chaudhuri
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 |journal=J Urol
 |date=1973-08
 |volume=110
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}}</ref> Apocrine glands perform a crucial function by secreting enzymes such as lysosomal enzymes, cathepsin B, chymotrypsin, and neutrophil elastase.<ref>{{REFjournal
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 |last2=Shamburg-Lever
 |init2=G
 |last3=Klesses
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 |title=Immunelectron microscopic localization of cathepsin B in human apocrine glands
 |journal=J Cutan Pathol
 |date=1993-02
 |volume=20
 |issue=1
 |pages=54-60
}}</ref> 

There is also some research to suggest that lysozyme may protect against HIV infection.<ref>{{REFweb
 |first=George
 |last=Hill
 |author-link=George Hill
 |url=http://www.cirp.org/library/disease/HIV/hill1/
 |title=Summary of evidence that the foreskin and lysozyme may protect against HIV infection
 |date=2003-09-07
 |accessdate=2019-10-20
}}</ref> <ref name="fleiss-hodges-vanhowe1998" />

Apocrine glands also produce cytokine,<ref>{{REFjournal
 |last=Ahmed
 |init=AA
 |last2=Nordlind
 |init2=K
 |last3=Schultzberd
 |init3=M
 |last4=Liden
 |init4=S
 |url=https://link.springer.com/article/10.1007%2FBF01105803
 |title=Immunohistochemical localization of IL-1 alpha-, IL-1 beta-, IL-6- and TNF-alpha-like immunoreactivities in human apocrine glands
 |journal=Arch Dermatol Res
 |date=1995
 |volume=287
 |issue=8
 |pages=764-766
 |accessdate=2019-10-20
}}</ref> which is a very important non-antibody protein that generates immune response when in contact with specific agents. Plasma cells which increase in number in response to pathogens levels, secrete immunoglobulin.<ref name="flower1983"/>
It is also very important to note that [[Langerhans cells]] that are present in the foreskin produce ''Langerin'', a substance that has been proven to kill human immunodeficency virus ([[HIV]]) on contact.<ref>{{REFjournal
 |last=de Witte
 |init=L
 |last2=Nabatov
 |init2=A
 |last3=Pion
 |init3=M
 |etal=yes
 |url=http://www.cirp.org/news/healthday2007-03-05/
 |title=Langerin is a natural barrier to HIV-1 transmission by Langerhans cells
 |journal=Nat Med
 |date=2007-03
 |volume=13
 |issue=3
 |pages=367-371
 |accessdate=2019-10-20
}}</ref>

All of these function to sequester and “digest” foreign pathogens. All these substances play an important role in protecting the penis from viral and bacterial pathogens. The immunological functions of the human prepuce have been extensively documented by respected researchers for quite some time.<ref name="fleiss-hodges-vanhowe1998">{{FleissP HodgesF VanHoweRS 1998}}</ref>

Circumcision destroys the natural immunological protections of the foreskin and results in increased risk of contracting infection.

== African RCTs ==
Strong bias exists in the RCTs.<ref>{{REFjournal
 |last=Green
 |init=LW
 |etal=yes
 |title=Male circumcision is not the HIV 'vaccine' we have been waiting for!
 |url=https://www.arclaw.org/wp-content/uploads/Green-Circumcision-not-HIV-Vaccine-2008.pdf
 |format=PDF
 |journal=Future HIV Ther
 |date=2008
 |volume=2
 |issue=3
 |pages=193–199
}}</ref><ref>{{REFjournal
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 |init2=PJ
 |last3=Adhikari
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 |etal=yes
 |title=Randomized trials stopped early for benefit: a systematic review
 |url=https://d1wqtxts1xzle7.cloudfront.net/57167251/Randomized_Trials_Stopped_Early_for_Bene20180810-22454-13zq2zz.pdf?1533940688=&response-content-disposition=inline%3B+filename%3DRandomized_Trials_Stopped_Early_for_Bene.pdf&Expires=1615121597&Signature=JYjNyliXY07z-v1JvMYVTVJG9IXinNjHYEsmuOy5GWAvqugfhsIwpf~gDfqgLbvyVwGpOQ-6~k05ckod-TeM~zo7Ja-fy1p-mg027mlh~MxWCjgQXWVFenwNqHV6liaq~8fVHQ5aZNRkQnu170vW4faves-pNadzVaRo0CgAtr2dvzQ4hA8dXYHKEuMXMyAsOTjErY-1Zgurz2mGdn99oya4~yAnUkj6QiYgVeDKiLJCTxRB6arwHJrIYDwcCh6vzkqZx7e23Faiiv6pXrB-plS1neoUQp5gE1UVt40YUiqpAlkAYmcxmsTJ~pPmZoIgRPLGcqN0rqpjPjlHwhycFw__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA
 |journal=JAMA
 |date=2005
 |volume=294
 |pages=2203-2209
}}</ref><ref>{{REFjournal
 |last=Ioannidis
 |init=JP
 |title=Contradicted and initially stronger effects in highly cited clinical research
 |url=https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.321.8200&rep=rep1&type=pdf
 |format=PDF
 |journal=JAMA
 |date=2005
 |volume=294
 |pages=218-228
}}</ref><ref>{{REFjournal
 |last=Wheatley
 |init=K
 |last2=Clayton
 |init2=D
 |title=Be skeptical about unexpected large apparent treatment effects: the case of an MRC AML12 randomization
 |url=https://www.sciencedirect.com/science/article/abs/pii/S0197245602002738
 |journal=Control Clin Trials
 |date=2003
 |volume=24
 |pages=66-70
}}</ref><ref>{{REFjournal
 |last=Slutsky
 |init=AS
 |last2=Lavery
 |init2=JV
 |title=Data safety and monitoring boards
 |journal=N Engl J Med
 |date=2004
 |volume=350
 |pages=1143-1147
}}</ref> "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."<ref>{{REFdocument
 |contribution=Male Circumcision: Current Epidemiological and Field Evidence
 |quote=designed to detect a minimum 50 percent reduction in HIV risk
 |url=https://path.azureedge.net/media/documents/HIV-AIDS_male-circ.pdf
 |title=Program and Policy Implications For HIV Prevention and Reproductive Health
 |publisher=USAID
 |format=PDF
 |date=2002-01
 |accessdate=2019-09-29
}}</ref> 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.<ref name="boyle-hill2011">{{BoyleGJ HillG 2011}}</ref>

Concerns about the [[HIV trials in Africa|three randomized controlled clinical trials (RCCTs) in Africa]] (in South Africa, Uganda, and Kenya)<ref>{{RCT Auvert et al 2005}}</ref><ref name="bailey2007">{{RCT Bailey et al 2007}}</ref><ref name="gray2007">{{RCT Gray et al 2007}}</ref>:
* 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.<ref>{{REFbook
 |last=Gisselquist
 |first=D.
 |init=D
 |year=2008
 |title=Points to consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean
 |url=
 |publisher=Adonis and Abbey
 |location=London
 |pages=
 |chapter=7
 |isbn=
 |accessdate=
}}</ref>
* 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.<ref>{{REFjournal
 |last=Weiss
 |init=HA
 |last2=Quigley
 |init2=MA
 |last3=Hayes
 |init3=RJ
 |title=Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis
 |journal=AIDS
 |date=2000
 |volume=14
 |pages=2361–2370
}}</ref><ref>{{REFjournal
 |last=Siegfried
 |init=N
 |last2=Muller
 |init2=M
 |last3=Deeks
 |init3=J
 |etal=yes
 |title=HIV and male circumcision — a systematic review with assessment of the quality of studies
 |journal=Lancet Infect Dis
 |date=2005
 |volume=5
 |pages=165–173
}}</ref>
* 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.<ref>{{REFjournal
 |last=Slutsky
 |init=AS
 |last2=Lavery
 |init2=JV
 |title=Data safety and monitoring boards
 |journal=N Engl J Med
 |date=2004
 |volume=350
 |pages=1143-1147
}}</ref>

== 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:

===== Cameroon =====
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. <ref>{{REFbook
 |last=Mosoko
 |first=Jembia J.
 |init=JJ
 |last2=Affana
 |first2=Gislaine A. N.
 |init2=GAN
 |year=2005
 |title=Prévalence du VIH et facteurs associés
 |url=http://www.measuredhs.com/pubs/pdf/FR163/16chapitre16.pdf
 |editor=Calverton, MD, USA
 |edition=Enquête Démographique et de Santé du Cameroun
 |volume=
 |chapter=16
 |page=309
 |location=Cameroon
 |publisher=DHS
 |isbn=
 |quote=Contrairement aux résultats trouvés dans d’autres pays, notamment le Kenya...
 |accessdate=2011-06-02
 |note=
}}</ref>

===== Ghana =====
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..."''<ref>{{REFbook
 |last=Marum
 |first=L.
 |init=L
 |last2=Muttunga
 |first2=J.
 |init2=J
 |last3=Munene
 |first3=F.
 |init3=F
 |year=Central Bureau of Statistics
 |title=HIV Prevalence and Associated Factors
 |url=http://www.measuredhs.com/pubs/pdf/FR152/13Chapter13.pdf
 |work=Kenya: Demographic and Health Survey 2003
 |editor=
 |edition=
 |volume=
 |chapter=13
 |pages=250-251
 |location=Nairobi, Kenya
 |publisher=Central Bureau of Statistics
 |isbn=
 |quote=...the vast majority of Ghanaian men (95 percent) are circumcised... There is little difference in the HIV prevalence by circumcision status...
 |accessdate=
 |note=
}}</ref>

===== Lesotho =====
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.)"''<ref>{{REFbook
 |last=
 |first=
 |year=2005
 |title=HIV Prevalence and Associated Factors
 |url=http://www.measuredhs.com/pubs/pdf/FR171/12Chapter12.pdf
 |work=Lesotho Demographic and Health Survey 2004
 |editor=
 |edition=
 |volume=
 |chapter=
 |page=13
 |location=Calverton, Maryland
 |publisher=Ministry of Health and Social Welfare
 |isbn=
 |quote=
 |accessdate=2011-06-02
 |note=
}}</ref>

::''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.''

===== Malawi =====
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).<ref>{{REFbook
 |last=Chipeta
 |first=John
 |init=J
 |last2=Schouten
 |first2=Erik
 |init2=E
 |last3=Aberle-Grasse
 |first3=John
 |init3=J
 |year=2005
 |title=HIV Prevalence and Associated Factors
 |url=http://www.measuredhs.com/pubs/pdf/FR175/12Chapter12.pdf
 |work=Malawi Demographic and Health Survey 2004
 |editor=
 |edition=
 |volume=
 |chapter=12
 |page=234
 |location=Calverton, Maryland
 |publisher=National Statistical Office
 |isbn=
 |quote=
 |accessdate=2011-06-02
 |note=
}}</ref>
::''...where one would expect [[HIV]] to be the most rampant.''

===== Rwanda =====
DHS 2005 - 3.8 vs 2.1 <ref>http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf p. 10</ref>

=====South Africa=====

Rosenberg et al. (2018) report that circumcised men in South Africa are more likely to be [[HIV]] infected than intact men.<ref name="Rosenberg2018">{{REFjournal
 |last=Rosenberg
 |first=Molly S.
 |init=MS
 |author-link=
 |last2=Gómez-Olivé
 |init2=FX
 |author2-link=
 |last3=Ronr
 |first3=Julia K.
 |init3=JK
 |author3-link=
 |last4=Kahn
 |first4=Kathleen
 |init4=K
 |author4-link=
 |last5=Bärnighausen
 |first5=Till W.
 |init5=TW
 |author5-link=
 |etal=no
 |title=Are circumcised men safer sex partners? Findings from the HAALSI cohort in rural South Africa
 |journal=PLOS ONE
 |date=2018-08-01
 |volume=13
 |issue=8
 |page=e0201445
 |url=https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201445
 |quote=
 |pubmedID=30067842
 |pubmedCID=6070310
 |DOI=10.1371/journal.pone.0201445
 |accessdate=2019-10-20
}}</ref>

===== Swaziland =====
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).<ref>http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf P. 256</ref>

=====Zambia=====
The prevalence of [[HIV]] infection among men aged 15-29 has ''not'' decreased despite several campaigns to perform male circumcision.

Garenne & Matthews (2019) report:
<blockquote>
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.<ref name="garenne-matthews2019">{{REFjournal
 |last=Garenne
 |init=M
 |author-link=
 |last2=Matthews
 |init2=A
 |author2-link=
 |etal=no
 |title=Voluntary medical male circumcision and HIV in Zambia: expectations and observations
 |journal=J Biosoc Sci
 |date=2019-10-14
 |volume=Epub ahead of print
 |pages=1-13
 |pubmedID=31608845
 |DOI=10.1017/S0021932019000634
 |accessdate=2019-10-19
}}</ref>
</blockquote>

==== Malaysia ====
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.<ref>http://www.mmail.com.my/content/39272-72-percent-aidshiv-sufferers-malaysia-are-muslims-says-council</ref>

Interestingly enough, Malaysia is home to the [[TARA KLamp]], a controversial circumcision device being marketed in KwaZulu Natal, Africa in the name of [[HIV]] prevention.

==== The Philippines ====
[[Tuli]] or male circumcision, a nearly compulsory cultural practice in the Philippine Islands, causes 93 percent of Filipino males to be circumcised.
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. <ref>http://globalnation.inquirer.net/news/breakingnews/view/20110102-312124/Philippines-HIVAIDS-problem-worries-UN</ref>

The statistics suggest that removal of the protective [[foreskin]] by circumcision increases the risk of contracting [[HIV]] infection.

==== Israel ====
Despite circumcision being near-universal, [[HIV]] is an increasing problem in Israel.<ref>{{REFweb
 |url=https://www.haaretz.com/1.4998790
 |title=Failing the AIDS Test
 |date=2008-07-04
 |accessdate=2020-01-05
}}</ref><ref>{{REFweb
 |url=https://www.haaretz.com/1.5000364
 |title=Israeli Gays Shun Condoms Despite Worrying Rise in AIDS
 |date=2008-07-09
 |accessdate=2020-01-05
}}</ref><ref>{{REFweb
 |url=https://www.haaretz.com/1.5067072
 |title=Has the AIDS Cocktail Worked Too Well in Israel?
 |date=2008-11-30
 |accessdate=2020-01-05
}}</ref><ref>{{REFweb
 |url=https://www.haaretz.com/1.4996895
 |title=HIV Diagnoses in Israel Climb; New Cases Among Gays Up Sharply
 |date=2008-06-27
 |accessdate=2020-01-05
}}</ref>

==== The United States ====
In America, the majority of the male population is circumcised, approximately 75%, 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.<ref>http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf</ref>

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.<ref>http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf</ref>

"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."<ref>http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431</ref>

Results: ...No consistent relationship between male circumcision and [[HIV]] risk was observed in most countries."<ref>"http://apha.confex.com/apha/134am/techprogram/paper_136814.htm</ref>

== Findings ==
Male circumcision has been found not to decrease the risk of [[HIV]] and may in fact increase the risk of male to female transmission<ref>{{REFconference
 |last=Castilho
 |first=E.A.
 |author-link=
 |coauthors=Boshi-Pinto C., Guimaraes M.D.G.
 |coauthors-link=
 |title=Male circumcision and HIV heterosexual transmission
 |url=
 |place=
 |source=XIV World AIDS Conference
 |date=2002
 |datefrom=
 |dateto=
 |accessdate=
}}</ref><ref>{{REFjournal
 |last=Guimaraes
 |init=MD
 |author-link=
 |last2=Vlahov
 |init2=D
 |last3=Castilho
 |init3=EA
 |title=Postcoital vaginal bleeding as a risk factor for transmission of the human immunodeficiency virus in a heterosexual partner study in Brazil (Rio de Janeiro Heterosexual Study Group)
 |journal=Arch Intern Med.
 |date=1997
 |volume=157
 |issue=12
 |pages=1362-1368
 |accessdate=
}}</ref><ref>{{REFconference
 |last=Guimaraes
 |first=M.
 |author-link=
 |coauthors=Castilho E., Ramos-Filho C., et al.
 |coauthors-link=
 |title=Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil
 |url=
 |place=
 |source=VII Intl Conf on AIDS
 |date=1991
 |datefrom=
 |dateto=
 |accessdate=
}}</ref><ref>{{REFconference
 |last=Changedia
 |first=S.M.
 |coauthors=Gilada I.S.
 |title=Role of male circumcision in HIV transmission insignificant in Conjugal relationship
 |source=XIV World AIDS Conference
 |date=2002
}}</ref><ref>{{REFweb
 |url=http://www.cirp.org/news/iht2007-03-06/
 |title=Circumcision protects men from AIDS but might increase risk to women, early results suggest
 |publisher=International Herald Tribune
 |date=2007-03-06
}}</ref>

== Follow-up studies ==

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]].<ref>{{REFjournal
 |last=Westercamp
 |init=M
 |last2=Bailey
 |init2=RC
 |last3=Bukusi
 |init3=EA
 |last4=Montandon
 |init4=M
 |last5=Kwena
 |init5=Z
 |etal=yes
 |title=Male Circumcision in the General Population of Kisumu, Kenya: Beliefs about Protection, Risk Behaviors, HIV, and STIs
 |journal=PLoS ONE
 |volume=5
 |issue=12
 |url=http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0015552
 |DOI=10.1371/journal.pone.0015552
 |date=2010
}}</ref>

== Real-world ==

An analysis of [[HIV]] prevalence compared to circumcision status in sub-Saharan Africa concluded that male circumcision is not associated with reduced [[HIV]] prevalence.<ref>{{REFjournal
 |last=Garenne
 |init=M
 |title=Long-term population effects of male circumcision in generalized HIV epidemics in sub-Saharan Africa
 |url=http://www.circumstitions.com/Docs/garenne-2.pdf
 |format=PDF
 |journal=Afr J AIDS Res
 |date=2008
 |volume=7
 |issue=1
 |pages=1-8
}}</ref> Another study on circumcision prevalence compared to [[HIV]] in the general South African population concluded: “Circumcision had no protective effect on [[HIV]] transmission.”<ref>{{REFjournal
 |last=Connolly
 |init=C
 |last2=Simbayi
 |init2=LC
 |last3=Shanmugam
 |init3=R
 |last4=Nqeketo
 |init4=A
 |title=Male circumcision and its relationship to HIV infection in South Africa: results of a national survey in 2002
 |url=http://artemide.bioeng.washington.edu/connolly_nqeketo_male_samj_2008_98_10.pdf
 |format=PDF
 |journal=S Afr Med J
 |date=2008
 |volume=98
 |pages=789-794
}}</ref> When commercial sex worker patterns are controlled, male circumcision is not signifıcantly associated with lower [[HIV]] prevalence.<ref>{{REFjournal
 |last=Talbott
 |init=JR
 |title=Size matters: the number of prostitutes and the global HIV/AIDS pandemic
 |url=http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0000543
 |journal=PloS One
 |date=2007
 |volume=2
 |issue=6
 |page=e543
}}</ref> 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.”<ref>{{REFconference
 |last=Lima
 |first=V.
 |author-link=
 |coauthors=Anema A., Wood R., et al.
 |coauthors-link=
 |title=The combined impact of male circumcision, condom use and HAART coverage on the HIV-1 epidemic in South Africa: a mathematical model
 |url=
 |place=Cape Town
 |source=5th IAS Conference on HIV Treatment, Pathogenesis and Prevention (abstract WECA105)
 |date=2009
 |datefrom=
 |dateto=
 |accessdate=
}}</ref> 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]].<ref name="Green etal 2010">{{REFjournal
 |last=Green
 |init=LW
 |last2=Travis
 |init2=JW
 |last3=McAllister
 |init3=RG
 |author3-link=Ryan McAllister
 |last4=Peterson
 |init4=KW
 |last5=Vardanyan
 |init5=AN
 |last6=Craig
 |init6=A
 |title=Male circumcision and HIV prevention insufficient evidence and neglected external validity
 |url=https://www.arclaw.org/wp-content/uploads/Green-Circ-HIV-Prev-Insufficient-AmJPrevMed-2010.pdf
 |format=PDF
 |journal=Am J Prev Med
 |publisher=Department of Epidemiology and Biostatistics, {{UNI|University of California|UCSF}} at San Francisco, USA
 |date=2010-11
 |volume=39
 |issue=5
 |pages=479-482
 |pubmedID=20965388
}}</ref>

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.<ref>{{REFdocument
 |contribution=Levels and spread of HIV seroprevalence and associated factors: Evidence from national household surveys
 |title=DHS Comparative Reports 22
 |url=http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf
 |page=103
 |publisher=Measre DHS
 |format=
 |date=
 |accessdate=2019-09-29
}}</ref> Furthermore, [[HIV]] prevalence was found to be higher amongst circumcised males and females for virgins and adolescents in Kenya, Lesotho, and Tanzania.<ref>{{REFjournal
 |last=Brewer
 |first=Devon D.
 |init=DD
 |last2=Potterat
 |first2=John J.
 |init2=JJ
 |last3=Roberts Jr
 |first3=John M.
 |init3=JM
 |last4=Brody
 |first4=Stuart
 |init4=S
 |title=Male and Female Circumcision Associated With Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania
 |url=https://www.orchidproject.org/wp-content/uploads/2019/03/Male_Female_Circumcision_Prevalent_HIV_Infection_Virgins_Adolescents_Kenya_Lesotho_Tanzania.pdf
 |format=PDF
 |journal=Annals of Epidemiology
 |volume=17
 |issue=3
 |pages=217.e1-217.e12
 |note=Annals of Epidemiology
 |accessdate=2011-06-02
}}</ref>

[[David Gisselquist]], {{PhD}}, who has studied health care practices in sub-Saharan Africa, finds that much of health care, especially injection practices, in Africa is non-sterile, and is likely the cause of the high incidence of [[HIV]] infection. He notes that the consensus to make sex the primary cause of infection was determined in the 1980s  and is likely to be inaccurate, because it does not give sufficient weight to medical transmission of [[HIV]] infection.<ref name=”gisselquist2002”>{{REFjournal
 |last=Gisselquist
 |init=D
 |last2=Rothenberg
 |init2=R
 |last3=Potterat
 |init3=J
 |last4=Drucker
 |init4=E
 |title=Non-sexual transmission of HIV has been overlooked in developing countries
 |url=https://europepmc.org/article/med/11809652#free-full-text
 |journal=Br Med J
 |date=2002
 |volume=324
 |issue=7331
 |page=235
}}</ref> Gisselquist et al. argue strongly that statistical evidence indicates that 5/6s of the [[HIV]] infection in Africa is non-sexual.<ref name=”gisselquist2003”>{{REFjournal
 |last=Gisselquist
 |init=D
 |last2=Potterat
 |init2=JJ
 |title=Heterosexual transmission of HIV in Africa: an empiric estimate
 |url=http://www.cirp.org/library/disease/HIV/gisselquist2/gisselquist2.pdf
 |format=PDF
 |journal=Int J STD AIDS
 |date=2003
 |volume=14
 |pages=162-73
}}</ref><ref>{{REFjournal
 |last=Gisselquist
 |init=D
 |last2=Potterat
 |init2=JJ
 |last3=Brody
 |init3=S
 |title=Running on empty: sexual co-factors are insufficient to fuel Africa's turbocharged HIV epidemic
 |url=https://www.researchgate.net/profile/John-Potterat/publication/8479267_Running_on_empty_Sexual_co-factors_are_insufficient_to_fuel_Africa%27s_turbocharged_HIV_epidemic/links/00b7d529d10fbac5c9000000/Running-on-empty-Sexual-co-factors-are-insufficient-to-fuel-Africas-turbocharged-HIV-epidemic.pdf
 |format=PDF
 |journal=Int J STD AIDS
 |date=2004
 |volume=15
 |issue=7
 |pages=442-52
}}</ref> Male circumcision has been proposed to reduce the incidence of sexual transmission of [[HIV]]. In reality, it actually increases the sexual transmission of [[HIV]].  Even if it did work, it would be ineffective against non-sexual transmission by unsafe health care. Furthermore, non-sterile health care could mean that the circumcision operation could transmit the [[HIV]] infection to the patient.<ref>{{REFjournal
 |last=Nyindo
 |init=M
 |title=Complementary factors contributing to the rapid spread of HIV-I in sub-Saharan Africa: a review
 |url=https://www.ajol.info//index.php/eamj/article/view/9293
 |journal=East African Medical Journal
 |date=2005
 |volume=82
 |issue=1
 |pages=40-46
}}</ref>

== 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 [http://www.who.int/hiv/topics/malecircumcision/en/ 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.

[[Robert S. Van Howe|Van Howe]] & Boyle (2018) pointed out numerous reasons that one should doubt the published results of the randomised clinical trials (RCTs)<ref name= "vanhowe2018">{{REFjournal
 |last=Van Howe
 |first=Robert S.
 |init=RS
 |author-link=Robert S. Van Howe
 |last2=Boyle
 |first2=Gregory J.
 |init2=GJ
 |author2-link=Gregory J. Boyle
 |etal=no
 |title=Meta-analysis of HIV-acquisition studies incomplete and unstable 
 |journal=BJU Int
 |location=
 |date=2018-10-31
 |volume=
 |issue=
 |pages=
 |url=https://www.bjuinternational.com/letters/meta-analysis-circumcision-incomplete-unstable/
 |archived=
 |quote=Given the effectiveness of condoms, the lack of consistent findings on national levels, the methodologically flawed RCTs, the lack of translational research, and the impressive potential uptake and effectiveness of pre-exposure prophylaxis, circumcision as an intervention to prevent HIV infection should be treated with greater scepticism.
 |pubmedID=
 |pubmedCID=
 |DOI=
 |accessdate=2020-09-05
}}</ref>

[[George C. Denniston]], {{MD}}, {{MPH}}, the president of [[Doctors Opposing Circumcision (D.O.C.)| Doctors Opposing Circumcision]], in a letter to Ambassador Deborah L. Birx, {{MD}}, {{MPH}}, (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 and protective function of the foreskin| immunological protections]] of the [[foreskin]], and to focus on the provision of anti-retroviral therapy and condoms.<ref name="denniston2020">{{REFdocument
 |title=World Health Organization, HIV, and male circumcision
 |url=https://pool.intactiwiki.org/images/2020-06-15b_LettertoPEPFAR.pdf
 |contribution=
 |last=Denniston
 |first=George C.
 |publisher=Doctors Opposing Circumcision
 |format=
 |date=2020-06-29
 |accessdate=2020-09-02
}}</ref>

Fish et al. (2020), speaking for the [[VMMC Experience Project]], published an article that described the PEPFAR program to circumcise African men, as racist and neo-colonialist.<ref name="fish2020">{{REFjournal
 |last=Fish
 |first=Max
 |init=
 |author-link=
 |last2=Shavisi
 |first2=Arianne
 |init2=
 |author2-link=
 |last3=Gwaambuka
 |first3=Tatenda
 |init3=
 |author3-link=
 |last4=Tangwa
 |first4=Godfrey B.
 |init4=
 |author4-link=
 |last5=Ncayiyana
 |first5=Daniel
 |init5=
 |author5-link=
 |last6=Earp
 |first6=Brian D
 |init6=
 |author6-link=Brian D. Earp
 |etal=no
 |title=A new Tuskegee? Unethical human experimentation and Western neocolonialism in the mass circumcision of African men
 |trans-title=
 |language=English
 |journal=Developing World Bioeth
 |location=
 |date=2020-09-09
 |volume=00
 |issue=
 |article=
 |page=
 |pages=1-16
 |url=http://www.circumcisionharm.org/images-circharm.org/Fish%20Earp%20New%20Tuskegee%20Dev%20World%20Bioeth%202020.pdf
 |archived=
 |quote=
 |pubmedID=32909369
 |pubmedCID=
 |DOI=
 |accessdate=2021-04-07
}}</ref>

===September 2021===
September 2021 saw the publication of two huge population studies on the relationship of circumcision and [[HIV]] infection.

Mayan et al. (2021) carried out a massive empirical study of the male population of the province of Ontario, [[Canada]] (569,950 males), of whom 203,588 (35.7%) were circumcised between 1991 and 2017. The study concluded that circumcision status is not related to risk of [[HIV]] infection.<ref name="mayan2021">{{REFjournal
 |last=Mayan
 |first=Madhur
 |init=
 |author-link=
 |last2=Hamilton
 |first2=Robert J.
 |init2=
 |author2-link=
 |last3=Juurlink
 |first3=David N.
 |init3=
 |author3-link=
 |last4=Austin
 |first4=Peter C.
 |init4=
 |author4-link=
 |last5=Jarvi
 |first5=Keith A.
 |init5=
 |author5-link=
 |etal=no
 |title=Circumcision and Risk of HIV Among Males From Ontario, Canada
 |trans-title=
 |language=
 |journal=J Urol
 |location=
 |date=2021-09-23
 |volume=
 |issue=
 |article=
 |page=
 |pages=
 |url=https://www.auajournals.org/doi/pdf/10.1097/JU.0000000000002234
 |archived=
 |quote=We found that circumcision was not independently associated with the risk of acquiring HIV among men from Ontario, Canada.
 |pubmedID=34551593
 |pubmedCID=
 |DOI=10.1097/JU.0000000000002234
 |accessdate=2021-10-02
}}</ref>

[[Morten Frisch]] and Jacob Simonsen (2021) carried out a large scale empirical population study in [[Denmark]] of 855,654 males regarding the alleged value of male circumcision in preventing [[HIV]] and other sexually transmitted infections in men. They found that circumcised men have a higher rate of STI and [[HIV]] infection overall than [[intact]] men.<ref name="frisch2021">{{FrischM SimonsenJ 2021}}</ref>

There now is credible evidence that the massive, expensive African circumcision programs have ''not'' been effective in preventing [[HIV]] infection.

== Increased risk to women ==
A recent prospective study<ref>{{REFjournal
 |last=Turner
 |init=AN
 |last2=Morrison
 |init2=CS
 |last3=Padian
 |init3=NS
 |etal=yes
 |title=Men’s circumcision status and women’s risk of HIV acquisition in Zimbabwe and Uganda
 |journal=AIDS
 |date=2007
 |volume=21
 |pages=1779–1789
}}</ref> showed that male circumcision offered no protection to women, and an RCCT<ref>{{REFjournal
 |last=Wawer
 |init=MJ
 |last2=Makumbi
 |init2=F
 |last3=Kigozi
 |init3=G
 |etal=yes
 |title=Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial
 |journal=Lancet
 |date=2009
 |volume374
 |pages=229-237
}}</ref> 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.<ref>{{REFweb
 |last=Nyakairu
 |first=F.
 |title=Uganda turns to mass circumcision in AIDS fıght
 |publisher=Reuters Africa
 |date=2008-08-13
 |url=https://www.reuters.com/article/idUSLD23235720080813
}}</ref><ref>{{REFweb
 |title=Circumcision gives men an excuse not to use condoms
 |publisher=UN Offıce for the Coordination of Humanitarian Affairs
 |website=The New Humanitarian (formerly IRIN News)
 |url=http://www.thenewhumanitarian.org/news/2008/07/31/circumcision-gives-men-excuse-not-use-condoms
 |date=2008-07
 |accessdate=2020-01-05
}}</ref>

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.<ref name="Green etal 2010"/>

== Effective prevention ==

{| class="wikitable" border="1" style="float:right; font-size:85%; margin-left:15px;"
|- style="background:#efefef;"
|+ Estimated per act risk for acquisition<br/>of [[HIV]] by exposure route (US only) <ref name=MMWR3>{{REFjournal
 |last=Smith
 |init=DK
 |last2=Grohskopf
 |init2=LA
 |last3=Black
 |init3=RJ
 |etal=yes
 |title=Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States
 |journal=MMWR
 |volume=54
 |issue=RR02
 |pages=1-20
 |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm#tab1
 |quote=
 |pubmedID=
 |pubmedCID=
 |DOI=
 |date=2005
 |accessdate=2009-03-31
}}</ref>
|- style="background:#efefef;"
! style="width: 100px" abbr="Route" | Exposure Route
! style="width: 130px" abbr="Infections" | Estimated infections<br/>per 10,000 exposures<br/>to an infected source
|-
! style="text-align:left"| Blood Transfusion
| 9,000<ref name=Donegan>{{REFjournal
 |last=Donegan
 |init=E
 |last2=Stuart
 |init2=M
 |last3=Niland
 |init3=JC
 |etal=yes
 |title=Infection with human immunodeficiency virus type 1 (HIV-1) among recipients of antibody-positive blood donations
 |journal=Ann. Intern. Med.
 |volume=113
 |issue=10
 |pages=733-739
 |url=
 |quote=
 |pubmedID=2240875
 |pubmedCID=
 |DOI=
 |date=1990
 |accessdate=
}}</ref>
|-
! style="text-align:left"| Childbirth <small>(to child)</small>
| 2,500<ref name=Coovadia>{{REFjournal
 |last=Coovadia
 |init=H
 |title=Antiretroviral agents&mdash;how best to protect infants from HIV and save their mothers from AIDS
 |journal=N. Engl. J. Med.
 |volume=351
 |issue=3
 |pages=289-292
 |url=
 |quote=
 |pubmedID=15247337
 |pubmedCID=
 |DOI=10.1056/NEJMe048128
 |date=2004
 |accessdate=
}}</ref>
|-
! style="text-align:left"| Needle-sharing injection drug use
| 67<ref name=Kaplan>{{REFjournal
 |last=Kaplan
 |init=EH
 |last2=Heimer
 |init2=R
 |title=HIV incidence among New Haven needle exchange participants: updated estimates from syringe tracking and testing data
 |journal=J. Acquir. Immune Defic. Syndr. Hum. Retrovirol.
 |volume=10
 |issue=2
 |pages=175-176
 |url=
 |quote=
 |pubmedID=7552482
 |pubmedCID=
 |DOI=
 |date=1995
 |accessdate=
}}</ref>
|-
! style="text-align:left"| Percutaneous needle stick
| 30<ref name=Bell>{{REFjournal
 |last=Bell
 |init=DM
 |title=Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview
 |journal=Am J Med
 |volume=102
 |issue=5B
 |pages=9-15
 |url=
 |quote=
 |pubmedID=9845490
 |pubmedCID=
 |DOI=10.1016/S0002-9343(97)89441-7
 |date=1997
 |accessdate=
}}</ref>
|-
! style="text-align:left"| Receptive anal intercourse<sup>*</sup>
| 50<ref name=ESG>{{REFjournal
 |last=European Study Group on Heterosexual Transmission of HIV
 |first=
 |title=Comparison of female to male and male to female transmission of HIV in 563 stable couples
 |journal=BMJ
 |volume=304
 |issue=6830
 |pages=809-813
 |url=
 |quote=
 |pubmedID=1392708
 |pubmedCID=1881672
 |DOI=10.1136/bmj.304.6830.809
 |date=
 |accessdate=
}}</ref><ref name=Varghese>{{REFjournal
 |last=Varghese
 |init=B
 |last2=Maher
 |init2=JE
 |last3=Peterman
 |init3=TA
 |last4=Branson
 |init4=BM
 |last5=Steketee
 |init5=RW
 |title=Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use
 |journal=Sex Transm Dis
 |volume=29
 |issue=1
 |pages=38-43
 |url=
 |quote=
 |pubmedID=11773877
 |pubmedCID=
 |DOI=
 |date=2002
 |accessdate=
}}</ref>
|-
! style="text-align:left"| Insertive anal intercourse<sup>*</sup>
| 6.5<ref name=ESG /><ref name=Varghese />
|-
! style="text-align:left"| Receptive penile-vaginal intercourse<sup>*</sup>
| 10<ref name=ESG /><ref name=Varghese /><ref name=Leynaert>{{REFjournal
 |last=Leynaert
 |init=B
 |last2=Downs
 |init2=AM
 |last3=de Vincenzi
 |init3=I
 |title=Heterosexual transmission of human immunodeficiency virus: variability of infectivity throughout the course of infection. European Study Group on Heterosexual Transmission of HIV
 |journal=Am J Epidemiol
 |volume=148
 |issue=1
 |pages=88-96
 |url=
 |quote=
 |pubmedID=9663408
 |pubmedCID=
 |DOI=
 |date=1998
 |accessdate=
}}</ref>
|-
! style="text-align:left"| Insertive penile-vaginal intercourse<sup>*</sup>
| 5<ref name=ESG /><ref name=Varghese />
|-
! style="text-align:left"| Receptive oral intercourse<sup>*§</sup>
| 1<ref name=Varghese />
|-
! style="text-align:left"| Insertive oral intercourse<sup>*§</sup>
| 0.5<ref name=Varghese />
|- style="background:#efefef;"
! colspan=5 style="border-right:0;"| <sup>*</sup> assuming no condom use <br /> <sup>§</sup> source refers to oral intercourse<br/>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.<ref>{{REFweb
 |url=http://www.avert.org/aids.htm
 |title=Facts about AIDS & HIV
 |last=
 |first=
 |publisher=avert.org
 |date=
 |accessdate=2007-11-30
}}</ref> Anti-retroviral treatment (ART) 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.<ref>[http://www.npr.org/templates/story/story.php?storyId=128495103 NPR.org]</ref> <ref name="denniston2020" />

{{SEEALSO}}
* [[Foreskin]]
* [[Immunological and protective function of the foreskin]]
* [[PEPFAR]]
* [[World Health Organization]]
* [[Bill & Melinda Gates Foundation]]

{{LINKS}}
* {{REFweb
 |url=http://www.nocirc.org/publish/11-HIV.pdf
 |title=Answers To Your Questions About Circumcision and HIV/AIDS
 |trans-title=
 |language=
 |last=Milos
 |first=Marilyn
 |author-link=
 |publisher=NOCIRC
 |website=
 |date=2007-09
 |accessdate=2019-12-07
 |format=PDF
 |quote=
}}
* {{REFweb
 |url=https://www.doctorsopposingcircumcision.org/for-professionals/alleged-medical-benefits/hivaids/
 |archived=
 |title=HIV/AIDS
 |trans-title=
 |language=English
 |last=
 |first=
 |author-link=
 |publisher=Doctors Opposing Circumcision
 |website=
 |date=2016
 |accessdate=2020-06-11
 |format=
 |quote=
}}
* {{REFweb
 |url=https://www.vmmcproject.org/
 |title=The VMMC Experience Project
 |last=
 |first=
 |accessdate=2021-03-07
}}
* {{REFweb
 |url=https://foregen.webflow.io/commentarium-articles/international-contractors-are-profiteering-from-new-circumcision-devices
 |archived=
 |title=International Contractors are Profiteering from New Circumcision Devices
 |trans-title=
 |language=English
 |last=Foregen Staff
 |first=
 |author-link=
 |publisher=Foregen
 |website=
 |date=2021-03-08
 |accessdate=2021-03-08
 |format=
 |quote=
}}

{{ABBR}}
{{REF}}

[[Category:Immunology]]
[[Category:Disease]]
[[Category:Sexually transmitted disease]]
[[Category:Circumcision in Africa]]
[[Category:From Intactipedia]]
[[Category:From IntactWiki]]

[[de:Beschneidung und HIV]]