Circumcision and HIV: Difference between revisions

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>Fink, Aaron J. "A possible Explanation for Heterosexual Male Infection with AIDS." ''New England Journal of Medicine'' 315, 18 (1986): 1167</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

Despite circumcision being near-universal, HIV is an increasing problem in Israel.

<ref>http://www.haaretz.com/print-edition/opinion/failing-the-aids-test-1.249088</ref>

<ref>http://www.haaretz.com/print-edition/features/israeli-gays-shun-condoms-despite-worrying-rise-in-aids-1.249372</ref>

<ref>http://www.haaretz.com/news/has-the-aids-cocktail-worked-too-well-in-israel-1.258520</ref>

<ref>http://www.haaretz.com/print-edition/news/hiv-diagnoses-in-israel-climb-new-cases-among-gays-up-sharply-1.248651</ref>

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.

<ref>http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf</ref>

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>

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>Castilho EA, Boshi-Pinto C, Guimaraes MDG. Male circumcision and HIV heterosexual transmission. XIV World AIDS Conference. 2002.</ref><ref>Guimaraes MD, Vlahov D, Castilho EA. 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. Arch Intern Med. 1997; 157(12):1362-8.</ref><ref>Guimaraes M, Castilho E, Ramos-Filho C, et al. Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil. VII Intl Conf on AIDS. 1991.</ref><ref>Changedia SM, Gilada IS. Role of male circumcision in HIV transmission insignificant in Conjugal relationship. XIV World AIDS Conference. 2002.</ref><ref>Circumcision protects men from AIDS but might increase risk to women, early results suggest.International Herald Tribune, Tuesday, 6 March 2007.</ref>

Strong bias exists in the RCTs.<ref>Green LW et al. Male circumcision is not the HIV 'vaccine' we have been waiting for! Future HIV Ther. (2008) 2(3), 193–199.</ref><ref>Montori VM, Devereaux PJ, Adhikari NKJ, et al. Randomized trials stopped early for benefit: a systematic review. JAMA. 2005;294:2203-2209.</ref><ref>Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA. 2005;294:218-228.</ref><ref>Wheatley K, Clayton D. Be skeptical about unexpected large apparent treatment effects: the case of an MRC AML12 randomization. Control Clin Trials. 2003;24:66-70.</ref><ref>Slutsky AS, Lavery JV. Data safety and monitoring boards. N Engl J Med. 2004;350:1143-1147.</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

Concerns about the three randomized controlled clinical trials (RCCTs) in Africa (in South Africa, Uganda, and Kenya)<ref>Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2005;2(11):e298.</ref><ref>Bailey RC, Moses S, Parker CB, ''et al''. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 2007;369(9562):643–56.</ref><ref>Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. ''Lancet'' 2007;369(9562):657– 66.</ref>:

* 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>Gisselquist D. Points to consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean. London: Adonis and Abbey, 2008, chapter 7.</ref>

* 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>Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 2000;14:2361–70.</ref><ref>Siegfried N, Muller M, Deeks J, et al. HIV and male circumcision—a systematic review with assessment of the quality of studies. Lancet Infect Dis 2005;5:165–73.</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>Slutsky AS, Lavery JV. Data safety and monitoring boards. N Engl J Med. 2004;350:1143-1147.</ref>

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>Garenne M. Long-term population effects of male circumcision in generalized HIV epidemics in sub-Saharan Africa. Afr J AIDS Res 2008;7(1):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>Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: results of a national survey in 2002. S Afr Med J 2008;98:789 –94.</ref> When commercial sex worker patterns are controlled, male circumcision is not signifıcantly associated with lower HIV prevalence.<ref>Talbott JR. Size matters: the number of prostitutes and the global HIV/AIDS pandemic. PloS One 2007;2(6):e543. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0000543</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>Lima V, Anema A, Wood R, et al. The combined impact of male circumcision, condom use and HAART coverage on the HIV-1 epidemic in South Africa: a mathematical model. 5th IAS Conference on HIV Treatment, Pathogenesis and Prevention, Cape Town, abstract WECA105, 2009.</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>{{REFjournal

Circumcision in real-world African settings will likely be a vector for transmitting the virus and is as such likely to worsen the pandemic.<ref>Brewer DD, Brody S, Drucker E, Gisselquist D, Minkin SF, Potterat JJ, Rothenberg RB, Vachon F. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS. 2003; 14(3):144-7.</ref><ref>Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS. 2003; 14:148-61.</ref><ref>Gisselquist D, Potterat JJ, Brody S. Running on empty: sexual co-factors are insufficient to fuel Africa's turbocharged HIV epidemic. Int J STD AIDS. 2004; 15(7):442-52.</ref><ref>Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS. 2003; 14:162-73.</ref><ref>Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries. Br Med J. 2002; 324(7331):235.</ref><ref>Nyindo M. Complementary factors contributing to the rapid spread of HIV-I in sub-Saharan Africa: a review. East Afr Med J. 2005; 82(1):40-6.</ref>

A recent prospective study<ref>Turner AN, Morrison CS, Padian NS, et al. Men’s circumcision status and women’s risk of HIV acquisition in Zimbabwe and Uganda. AIDS 2007;21:1779–89.</ref> showed that male circumcision offered no protection to women, and an RCCT<ref>Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet 2009;374:229 –37.</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>Nyakairu F. Uganda turns to mass circumcision in AIDS fıght. Reuters Africa 2008, Aug 13. www.reuters.com/article/idUSLD 23235720080813</ref><ref>Irin, Swaziland: Circumcision gives men an excuse not to use condoms. UN Offıce for the Coordination of Humanitarian Affairs, 2008 Jul. www.irinnews.org/Report.aspx?ReportId�79557</ref>

* 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>Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A. Male circumcision and HIV prevention insufficient evidence and neglected external validity. Am J Prev Med. 2010 Nov;39(5):479-82. Department of Epidemiology and Biostatistics, University of California at San Francisco, USA. PMID: 20965388</ref>