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This article '''{{FULLPAGENAME}}''' 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 |quote=

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

|last= |first= |publisher=[[CDC]]

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

|first=LeonardB. |init=LB

|location=New York, New YorkNY |publisher={{UNI|Oxford University |Oxon}} Press

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

|}}</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=LeonardB. |init=LB

|location=New York, New YorkNY |publisher={{UNI|Oxford University |Oxon}} Press

}}</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]]

Alcena and Fink lacked a hypothesis to explain why the foreskin would be an entry point for HIV infection, but this was supplied by circumcision promoter [[Gerald N. Weiss]] and two colleagues. Weiss et al. (1993) produced the plausible but incorrect hypothesis that [[Langerhans cells]] attracted HIV. A medical journal in [[Israel]] was willing to publish the paper by Weiss et al.<ref name="weiss1993">{{REFjournal |last=Weiss |first=Gerald N. |init=GN |author-link=Gerald N. Weiss |last2=Sanders |first2= |init2=M |author2-link= |last3=Westbrook |first3= |init3=KC |author3-link= |etal=no |title=The distribution and density of Langerhans cells in the human prepuce: site of a diminished immune response? |journal= Isr J Med Sci |location= |date=1993-01 |volume=20 |issue=1 |article= |page= |pages=42-3 |url= |archived= |quote= |pubmedID=8454447 |pubmedCID= |DOI= |accessdate=2022-10-28}}</ref>. 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:* Female circumcision and [[infibulation]].

* Homesexuality Homosexuality and anal intercourse.

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 [[circumcised]] 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 [[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=DeWitte etal 2007-03-04 |accessdate=2020-07-02}}</ref>

This hypothesis attempts to identify the change in [[microbiome| bacterial environment ]] that results in the [[penis ]] as a result of [[adult circumcision]], as the mechanism whereby circumcision reduces the spread of [[HIV ]] transmission. A desparate 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 inflamationinflammation, a condition that facilitates the transmission of viruses. The chances for penile inflamation inflammation are reduced, thereby reducing the chances of sexually transmitted viruses, such as [[HIV]].<ref>{{REFjournal

|url=httphttps://wwwjournals.plosoneplos.org/plosone/article/info%3Adoi%2F10?id=10.1371%2Fjournal/journal.pone.00155520008422

Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the discredited randomized control trials were measuring frequency in [[HIV ]] transmission, not for frequency in penile bacterial inflamationinflammation, and whether said inflamation inflammation 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 inflamationsinflammations, and [[intact ]] men who don't suffer constant penile inflamationinflammation. Unless the randomized controlled studies were limited to only [[intact ]] men who suffered constant penile inflamationinflammation. == 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 |init=E |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 |init=R |last2=Carrel |first2=Ch.-F. |init2=CF |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 |last2=Jeykumar |init2=S |last3=Subramanyan |init3=K |last4=Chaudhuri |init4=S |url=http://www.cirp.org/library/anatomy/parkash/ |title=Human subpreputial collection: its nature and formation |journal=J Urol |date=1973-08 |volume=110 |issue=2 |pages=211-212 |accessdate=2019-10-20}}</ref> Apocrine glands perform a crucial function by secreting enzymes such as lysosomal enzymes, cathepsin B, chymotrypsin, and neutrophil elastase.<ref>{{REFjournal |last=Frohlich |init=E |last2=Shamburg-Lever |init2=G |last3=Klesses |init3=C |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 and protective function of the foreskin| immunological protections of the foreskin]] and [[preputial sac]], so it results in increased risk of contracting [[infection]].

}}</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>

Concerns about the [[HIV trials in Africa|three randomized controlled clinical trials (RCCTs) in Africa ]] (in South Africa, Uganda, and Kenya)<ref>{{REFjournal |last=RCT Auvert |init=B |author-link=Bertran Auvert |last2=Taljaard |init2=D |last3=Lagarde |init3=E |last4=Sobngwi-Tambekou |init4=J |last5=Sitta |init5=R |last6=Puren |init6=A |title=Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial |journal=PLoS Med |date=et al 2005 |volume=2 |issue=11 |page=e298}}</ref><ref name="bailey2007">{{REFjournal |last=RCT Bailey |init=RC |last2=Moses |init2=S |last3=Parker |init3=CB |etal=yes |title=Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial |journal=Lancet |date=et al 2007 |volume=369 |issue=9562 |pages=643–656}}</ref><ref name="gray2007">{{REFjournal |last=RCT Gray |init=RH |last2=Kigozi |init2=G |last3=Serwadda |init3=D |etal=yes |title=Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial |journal=Lancet |date=et al 2007 |volume=369 |issue=9562 |pages=657-666}}</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:

===== 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

===== 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

===== Lesotho =====

''"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 thetablethe table. 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.''

===== Malawi =====

:"The relationship between [[HIV ]] prevalence and circumcision status is not in the expecteddirection. 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.''

===== Rwanda =====

=====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

===== Swaziland =====

:"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 [[Intact| not circumcised ]] (22 percent compared with 20 percent).<ref>{{REFweb |url=http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf P. 256 |title=Swaziland Demographic and Health Survey |last= |first= |date=2006 |accessdate=2022-06-15}}</ref>

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

[[Michel Garenne |Garenne]] & Matthews (2019) report:

In a multivariate analysis, based on the 2013 DHS survey, [[circumcised ]] men were found to have the same level of infection as [[uncircumcised]] men, after controlling for age, sexual behaviour and socioeconomic status. Lastly, circumcised men tended to have somewhat riskier sexual behaviour than [[uncircumcised]] men. This study, based on large representative samples of the Zambian population, questions the current strategy of mass circumcision campaigns in southern and eastern Africa.<ref name="garenne-matthews2019">{{REFjournal

|author-link=Michel Garenne

==== 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>{{REFweb |url=http://www.mmail.com.my/content/39272-72-percent-aidshiv-sufferers-malaysia-are-muslims-says-council |title= |last= |first= |date= |accessdate=2022-06-15}}></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 ====

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

==== The United States ====In America, the majority of the male population is [[circumcised]], approximately 7562%, <ref name="moore2015">{{REFweb |url=https://today.yougov.com/topics/lifestyle/articles-reports/2015/02/03/younger-americans-circumcision |title=Young Americans less supportive of circumcision at birth |last=Moore |first=Peter |date=2015-02-03 |accessdate=2022-06-15}}</ref> 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>

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>

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]].<refname="Green etal 2010">{{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]], Ph. D.{{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 discredited RCT 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

[[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

|publisher=[[Doctors Opposing Circumcision(D.O.C.)]]

Mayan et al. (2021) carried out a Threre now is credible evidence that the 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 expensive African circumcision status is programs have ''not related to risk of '' been effective in preventing [[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>

}}</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

* 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>{{REFjournal |lastname="Green |init=LW |last2=Travis |init2=JW |last3=McAllister |init3=RG |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-etal 2010.pdf |format=PDF |journal=Am J Prev Med (Department of Epidemiology and Biostatistics, University of California at San Francisco, USA) |date=2010-11 |volume=39 |issue=5 |pages=479-482 |pubmedID=20965388}}<"/ref>

|+ 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" /> == Population-based studies =={{Population-based studies}} ==Two African surveys==The previously reported studies were from developed Western nations. Now we have information from Sub_Saharan Africa. French scientist [[Michel Garenne]], Ph.D. has published two reports in 2022 comparing the incidence of HIV infection in [[circumcised]] and [[intact]] men. In his first report, Garenne presented the findings from a study in Lesotho, the enclave in South Africa. He reported:<blockquote>In couple studies, the effect of circumcision and VMMC on HIV was not significant, with similar transmission from female to male and male to female. The study questions the amount of effort and money spent on VMMC in Lesotho.<ref name="garenne2022A">{{REFjournal |last=Garenne |first=Michel |init=M |author-link=Michel Garenne |title=Changing relationships between HIV prevalence and circumcision in Lesotho |url=https://pubmed.ncbi.nlm.nih.gov/35373731/ |date=2022-04-04 |journal=J Biosoc Sci |volume=online ahead of print |pages=1-16 |DOI=10.1017/S0021932022000153 |pubmedID=35373731 |accessdate=2022-10-28}}</ref> </blockquote>  In his second report, Garenne (2022) presented information from six Sub-Saharan African nations (Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe). He reported:<blockquote> "Results matched earlier observations made in South Africa that [[circumcised]] and [[intact]] men had similar levels of HIV infection."<ref name="garenne2022B">{{REFjournal |last=Garenne |first=Michael |init=M |author-link= |etal=no |title=Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa |trans-title= |language= |journal=J Biosoc Sci |location= |date=2022-10-26 |season= |volume= |issue= |article= |page= |pages=1-13 |url=https://www.cambridge.org/core/journals/journal-of-biosocial-science/article/abs/ageincidence-and-prevalence-of-hiv-among-intact-and-circumcised-men-an-analysis-of-phia-surveys-in-southern-africa/CAA7E7BD5A9844F41C6B7CC3573B9E50 |archived= |quote= |pubmedID=36286328 |pubmedCID= |DOI=10.1017/S0021932022000414 |accessdate=2022-10-27}}</ref></blockquote>

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