Circumcision and HIV: Difference between revisions

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

}}</ref> and the promotion of male circumcision as a HIV-prevention method by the [[Centers for Disease Control|Centers for Disease Control]]<ref>{{REFweb

  |publisher=

The idea that [[circumcision]] prevented HIV transmission was invented by [[Valiere Alcena]], long before there was any "research" to substantiate the claim.<ref>{{REFjournal

  |}}</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

  |first=Leonard

  |location=New York, New York

}}</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.

  |Author=Aaron J. Fink

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.

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:

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

de Vincenzi & Mertens (1994) reviewed the literature regarding the alleged role of the [[foreskin]] in HIV transmission. They concluded:

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

[[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

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.<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>

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 [[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

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.<ref>{{REFjournal

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

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.

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

}}</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

}}</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>

* 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.

* 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

* 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

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. <ref>{{REFbook

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

''"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

::''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.''

:"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

::''...where one would expect HIV to be the most rampant.''

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

:"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>

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

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.

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.

Despite circumcision being near-universal, HIV is an increasing problem in Israel.<ref>{{REFweb

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>

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>{{REFconference

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

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

}}</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

}}</ref> When commercial sex worker patterns are controlled, male circumcision is not signifıcantly associated with lower HIV prevalence.<ref>{{REFjournal

}}</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

}}</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

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

}}</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

[[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

}}</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

}}</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

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.

[[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

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

[[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">{{REFjournal

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

}}</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

|+ Estimated per act risk for acquisition<br/>of HIV by exposure route (US only) <ref name=MMWR3>{{REFjournal

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

}}</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" />