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Recently, circumcision has been heavily promoted as a method of preventing HIV. The [[cl:World Health Organization|World Health Organization]] (WHO) has endorsed male circumcision as a form of HIV prevention, based on three recent studies 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=
| url=http://www.who.int/hiv/topics/malecircumcision/en/
| first=
| publisher=World Health Organization
| websitework=
| date=2011
| accessdate=2011-05-06
| date=2011-03-04
| accessdate=2011-05-06
}}</ref> and the promotion of male circumcision as a HIV-prevention method by the [[cl:Centers for Disease controlControl|Centers for Disease Control]] <ref>{{REFweb
| quote=
| url=http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm
| first=
| publisher=
| websitework=
| date=February 2008
| accessdate=2011-06-01
| first=
| publisher=
| websitework=
| date=March 2007
| accessdate=2011-06-01
| first=
| publisher=
| websitework= | date=9/1/2011-01-09
| accessdate=2011-06-01
}}</ref>
== Origin of the Circumcisioncircumcision/HIV Hypothesis 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
| date=October 2006
| accessdate=
}}</ref> In 1986, California urologist [[cl: Aaron J. Fink| Aaron J. Fink]], (1926-1994) adopted this idea,<ref>{{REFbook
|last=Glick
|first=Leonard
|title=Marked in Your Flesh
|url=
|editor=
|edition=
| url=http://www.who.int/hiv/facts/hiv2003/en/
| title=A global view of HIV infection
| last=WHO/UNAIDS
| first=
| publisher=[[World Health Organization]] | websitework=WHO/UNAIDS
| date=2004
| accessdate=2011-02-27
|title=Marked in Your Flesh
|url=
|editor=
|edition=
|volume=
|chapter="This Little Operation", Jewish American Physicians and Twentieth-Century Circumcisoin Circumcision Advocacy
|pages=207
|location=New York, New York
|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.
== Confounding Factors factors ==
=== Debunked Adad-hoc Hypotheses 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.
==== Hardened Skin Hypothesis ====
Perhaps the oldest hypothesis on the mechanism whereby circumcision prevents the transmission of HIV is the theory that suggests that the keratinized surface of the penis in circumcised male resists infection, while the mucosa of the glans and inner of the intact male are ports of entry, which was purported by Aaron J. Fink.
| 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 (2009) | author=Dinh, 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=2011-06-28}}</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 mucosal lining of the foreskin.
==== Bacterial Environment Hypothesis ====
This hypothesis attempts to identify the change in bacterial environment that results in the penis as a result of circumcision, as the mechanism whereby circumcision reduces the spread of HIV transmission. A desparate ad-hoc hypothesis, the explanation is rather farfetched. The argument is that the change in bacterial environment after circumcision makes it difficult for bacteria that cause diseases to live; there are less chances for penile inflamation, a condition that facilitates the transmission of viruses. The chances for penile inflamation are reduced, thereby reducing the chances of sexually transmitted viruses, such as HIV.<ref>{{REFjournal
| last=Price
Presenting this hypothesis presents a two-fold problem. First, it presents an irrelevant conclusion; the randomized control trials were measuring frequency in HIV transmission, not for frequency in penile bacterial inflamation, and whether said inflamation facilitated sexually transmitted HIV. And secondly, circumcision advocates give themselves the new burden of proving the newly introduced hypothesis, that change in bacterial infection does indeed result in a significant reduction of HIV transmission. A new study is needed to measure HIV transmission in men who have been circumcised, uncircumcised men with constant penile inflamations, and uncircumcised men who don't suffer constant penile inflamation. Unless the randomized controlled studies were limited to only uncircumcised men who suffered constant penile inflamation.
=== Real World Data 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.
|last2=Affana
|first2=Gislaine A.N.
|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
===== 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
|last3=Munene
|first3=F.
|year=2003Central Bureau of Statistics
|title=HIV Prevalence and Associated Factors
|url=http://www.measuredhs.com/pubs/pdf/FR152/13Chapter13.pdf
|isbn=
|quote=...the vast majority of Ghanaian men (95 percent) are circumcised... There is little difference in the HIV prevalence by circumcision status...
|accessdate=2011-06-02
|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=Ministry of Health and Social Welfare; Bureau of Statistics
| first=
| year=2005
===== 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
|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>
===== 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>
==== 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>
==== 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>
==== Israel ====
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>
==== The United States ====
In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact.
<ref>http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf</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>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>
== African RCT's RCTs == Strong bias exists in the RCT'sRCTs.<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> "Thesetrials, 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>{{REFcontribution | contribution=Male Circumcision: Current Epidemiological and Field Evidence | quote=designed to detect a minimum 50 percent reduction in HIV riskREFdocument
| url=http://www.path.org/publications/detail.php?i=1048
| format=
| title=Program and Policy Implications For HIV Prevention and Reproductive Health
| publisher=USAID
| place= | pagespostscript= | date=September 18 and + 19, September 2002 | accessdate=20112019-0709-0729 | contribution=Male Circumcision: Current Epidemiological and Field Evidence | quote=designed to detect a minimum 50 percent reduction in HIV risk
}}</ref> By designing a trial to "detect" a minimum 50 percent reduction risk in HIV, these researchers might have artifically created the clinical setting to observe the effect they were looking to discover.
== 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>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. wwwhttp://journals.plosoneplos. org/plosone/article/info%3Adoi%2F10?id=10.1371%2Fjournal/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>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>
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>{{REFcontribution | contribution=Levels and spread of HIV seroprevalence and associated factors: Evidence from national household surveys | quote=REFdocument
| url=http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf
| format=
| title=DHS Comparative Reports 22
| publisher=Measre DHS
| placepostscript= | date= | accessdate=2019-09-29
| pages=103
| datecontribution= | accessdate= | format = PDFLevels and spread of HIV seroprevalence and associated factors: Evidence from national household surveys}}</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, PhD
| first=Devon D.
| pubmedCID=
| DOI=
| date=March 2007Annals of Epidemiology
| accessdate=2011-06-02
}}</ref>
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>
== Problems with promoting circumcision Promoting Circumcision as HIV prevention policy Prevention Policy ==
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 indorsment, 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.
Even if the recent trials were accurate, circumcision would only reduce the relative risk of acquiring HIV between circumcised and uncircumcised men by 60% over a period of about one year. Circumcision is outperformed by condoms, which have an absolute reduction risk of acquiring HIV that's over 95% (closer to 100% when used properly). Even if a man is circumcised, he would still need to use condoms, and even the authors of the latest studies cannot stress this enough.
== Increased risk Risk to women Women ==
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>
| pubmedCID=
| DOI=10.1056/NEJMe048128
| date=2004
| accessdate=
}}</ref>
| 30<ref name=Bell>{{REFjournal
| last=Bell
| first=D.M.DM
| coauthors=
| title=Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview
| volume=148
| issue=1
| pages=88-96
| url=
| quote=
| pubmedID=966340888-969663408
| pubmedCID=
| DOI=
| accessdate=2007-11-30
}}</ref> Anti-retroviral treatment of infected patients also significantly reduces their ability to transmit HIV to others, by reducing the amount of virus in their bodily fluids to undetectable levels.<ref>[http://www.npr.org/templates/story/story.php?storyId=128495103 NPR.org]</ref>
{{REF}}
[[Category:Sexually Transmitted Disease]]
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