Promoting infant male circumcision to reduce transmission of HIV: A flawed policy for the US
OpenForum | August 31, 2009 | 11 Comments
[Editor’s note: This is a guest post written by Sarah Bundick.]
On August 23, the New York Times reported that the CDC may recommend infant male circumcision as an HIV-prevention strategy. This article was followed by an editorial in the Boston Globe on August 26. The editorial states that infant male circumcision “makes sense [as a tactic] against a virus that infects more than 50,000 Americans each year” and that circumcision “deserves the CDC’s support.” These statements are based on the results of clinical trials in Africa showing that circumcised men were approximately 60% less likely to become infected with HIV than their uncircumcised counterparts. Unfortunately, the two numbers that the editorial cites — the 60% reduction in HIV transmission and the 50,000 new infections in the US every year — have very little to do with each other.
Let’s look first at the reduction in HIV transmission associated with male circumcision. In 2005, a group of French and South African researchers reported that adult male circumcision provided 60% protection (95% confidence interval: 32%–76%) from HIV infection to the circumcised men over a period of approximately 18 months in a South Africa-based trial. In 2007, two other studies completed in Africa, one in Uganda and one in Kenya, reported similar levels of reduction in the risk of HIV transmission. These clinical trials suggested that promoting adult male circumcision may be a way to reduce HIV transmission in certain contexts, particularly those in which HIV prevalence is high (as in the study areas, where prevalence estimates range from 5% to 30%) and where heterosexual transmission is the most common mode of transmission. The situation in the US, however, is markedly different: HIV prevalence is low (0.4%) and transmission of HIV is highest among injecting drug users and men who have sex with men. Thus, the applicability of the African trials to the American HIV epidemic is severely limited.
The second number cited in the Globe editorial is the number of new HIV infections in the US — 50,000 per year. This number is (apparently) based on a CDC estimate of all new HIV infections in 2006. The CDC also estimated the number of new infections for many different subgroups based on demographics and on mode of transmission. Looking at these data, it becomes immediately clear that the estimated 50,000 new infections every year are predominantly the result of injecting drug use and male-to-male transmission during sexual contact. Heterosexual contact is estimated to be responsible for only 5,250 new infections in men each year in the US — a far cry from the 50,000 infections cited by the Globe’s editorial team.
It is important to note that there is no strong evidence that circumcision reduces the risk of male-to-female or male-to-male transmission via sexual contact. (Although probably obvious, it is also important to note that male circumcision is not related to HIV transmission by injecting drug use.) Therefore, the current data suggest that the 5,250 female-to-male transmissions are the only ones likely to be prevented by male circumcision.
Now let’s factor in the efficacy of circumcision (approximately 60%), ignoring for a moment several important factors — the short time period used to determine efficacy in the clinical trials, the fact that the actual statistics gave ranges for the efficacy (from 22% to 77%), and the fact that the different infection profile in the US limits the trials’ relevance in the US context. If we assume that all 5,250 men who get HIV from a female sexual partner are not circumcised (though this is certainly not the case), the data suggest that about half of these infections — around 2,625 infections or ~5% of new infections — may have been prevented if the men had been circumcised. If we then factor in the number of men who are circumcised when they are infected (approximately 70-80% of American men are already circumcised), the number of infections that could have been prevented by circumcision drops considerably. Taken together, the data suggest that the number of HIV infections that could be prevented in the US by promoting infant male circumcision is likely to be only in the hundreds per year — a tiny fraction of the estimated 50,000 new HIV infections.
Why then are people pushing for infant male circumcision as an HIV-prevention measure here in the US? I can think of two possible explanations. First, proponents may have seen the same numbers that the Globe printed — protection of up to 60% and 50,000 new HIV infections per year — and erroneously concluded that male circumcision could significantly reduce HIV transmission in the US. Erroneous conclusions like this one are common when scientific literature is covered by the mainstream media, in which many important details are often lost. Second, proponents may be (consciously or unconsciously) using HIV prevention as a way to validate subjecting baby boys to medically unnecessary surgery done for cultural or religious reasons — it is a lot easier to defend genital modification (or mutilation depending on one’s viewpoint) if it prevents a deadly disease. (Please note that my argument here is not that circumcision should not be practiced for cultural or religious reasons — I am staying out of that debate here — my argument is that medical data from the African circumcision trials are being inappropriately used to defend and promote a practice done for cultural or religious reasons.)
But given that the majority of men in the US are circumcised anyway, some may ask why the CDC’s possible recommendation of infant male circumcision is such a problem. It is a problem because promoting infant male circumcision could have negative impacts with regard to HIV transmission by inadvertently promoting the idea that “circumcised sex” is safe sex. In the 2005 male circumcision trial in South Africa, men in the intervention (circumcision) group reported having more sexual partners than men in the control (uncircumcised) group. If circumcision is promoted as a way to reduce the risk of HIV transmission, there is a possibility that this disinhibition could happen in the US as well — men may incorrectly assume that they are protected from HIV if they are circumcised, and these men may therefore exhibit more risky behaviors (numerous sexual partners and limited condom use). Proponents are likely to counter this problem by calling for more education to prevent these misconceptions. The question then is why promote medically unnecessary surgery as an HIV-prevention strategy when it also increases the need for proper education on HIV transmission? Why not just educate people and leave out recommendations for surgical procedures of dubious medical value?
The promotion of infant male circumcision also ignores the right of men to not be circumcised as infants — a right that many people and governments dispute. Despite the ongoing nature of the debate as to whether or not infant circumcision is a human rights violation, the fact that many people view infant circumcision as a human rights violation should make the CDC even more hesitant to promote the practice.
A consultant to the American Academy of Pediatrics, Dr. Michael Brady, has said that “families should be given an opportunity to know what [the benefits of male circumcision] are.” On this point, at least, everyone can agree. People in the US — and in all countries — should be educated about any potential benefits of circumcision, but the public should not be fed half-truths or statistics stripped of all meaningful context. Everyone should be told the whole story — a story that does not point to any significant reduction in HIV transmission as a result of promoting infant male circumcision in the US.
Given the problems with promoting infant male circumcision as an HIV-prevention strategy in the US — a low number of prevented infections and the possible misconception that “circumcised sex” is safe sex — the population-level health benefits of promoting infant male circumcision are not clear, and infant male circumcision does not make sense as a US HIV-prevention strategy. Instead of looking for the quick fix, we — and the CDC — should focus our attention on what will work: education.
Education and prevention of HIV transmission:
Journal of the American Medical Association: Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents
Comments
11 Responses to “Promoting infant male circumcision to reduce transmission of HIV: A flawed policy for the US”
Frank Inglis
Just read the Royal Australasian College of Physicians 2009 paper on Neonatal Circumcision in which they recommend not to circumcise for how ethical cost benefit science is conducted.
Robert Samson
let’s take a critical look at reality:
The USA with circumcision rates as high as 90% has an HIV and STD epidemic many times greater than intact Europe and Japan..how is this possible?
The surest sign of stupidity is to keep repeating the same mistake hoping for a different outcome.
S
A few points:
1. CDC recommendations don’t mandate anything, and they most certainly aren’t policy. They are general recommendations based on available research. In this case, the evidence points overwhelmingly to the effectiveness of infant male circumcision for HIV prevention, even if all of that evidence comes from Africa.
2. I can see the confusion with the numbers, but obviously we’re not going to avert 50,000 infections. Speaking of the infant procedure alone, I don’t see a rights-based problem unless you’re worried about the right of the boy to make that decision when he’s older (I think that’s negligible- since parents make a lot of decisions in the first weeks, months, years of life that children may one day have the potential disagree with).
3. Having said that, if HIV is the number 1 killer among African American heterosexual women age 25-44 in the US, and presuming that 90% (I’m being generous) are not injection drug users, then they’re getting HIV from heterosexual men (all 5,250 of them). You haven’t taken herd immunity into account at all in the number of infections you suppose to prevent. What about the next women these men could infect?
But 4, and most infuriating, is the fear that this procedure is going to make people more promiscuous. It’s the same reason people say girls shouldn’t get the HPV vaccine – girls might “get slutty” now that we have a better tool for prevention. Presuming we’ll always have to do education, that’s a shoddy reason not to perform a potentially life-saving procedure. We will ALWAYS need more education about STIs, regardless of what other medical interventions come along, and on this point we agree. Furthermore, it is irresponsible to draw from the 2005 study from South Africa since the men in this study were old enough to be sexually active when the procedure was performed. To my knowledge, and I could be wrong here, no one has studied the between group differences in number of sex partners between circumcised at birth and un-circumcised men in the US since it would require maybe 30 years of follow-up? For the record, I think the adult and infant procedures are entirely different issues, and would require very different recommendations.
Hugh7
If “families are to be told what the benefits of circumcision are”, then they should also be told what it actually entails, and what the possible risks and certain damage are. They should see a video of an actual circumcision right through, such as as this, from Stanford University or this. And they should see what can happen (rarely, but unnecessarily, and always a real tragedy) These are not for the squeamish – the last picture shows something like what happened to David Reimer of Ontario, who was unsuccessfully brought up as a girl.
But why should the decision be left to “families? As one circumcised man pointed out, his family has never had anything (else) to do with his genitalia – and rightly so. Through the Internet, more and more men are coming out as resentful that this choice was taken from them. In the wake of references to “mandatory” and “universal” circumcision, the CDC has issued a disclaimer, that circumcision should be “completely voluntary” and who can disagree with that? “Completely voluntary” can only mean at the option of the person most directly concerned, the man on the other end, when he is old enough to decide for himself.
As Frank Inglis implies, the Royal Australasian [Australia and New Zealand] College of Physicians says, “ethical concerns have focused on recognition of the functional role of the foreskin, the non-therapeutic nature of the operation, and the psychological distress felt by some adult males circumcised as infants. The possibility that routine circumcision contravenes human rights has been raised because circumcision is performed on a minor for non-clinical reasons, and is potentially without net clinical benefit for the child. … the RACP does not recommend that routine circumcision in infancy be performed, but accepts that parents should be able to make this decision with their doctors. One reasonable option is for routine circumcision to be delayed until males are old enough to make an informed choice.” This is a step forward, and it may be only legal caution that stops them from moving directly to total condemnation.
Robert Samson
” They are general recommendations based on available research. In this case, the evidence points overwhelmingly to the effectiveness of infant male circumcision for HIV prevention, even if all of that evidence comes from Africa.”
This assumption needs to have an explanation for the discrepancy I posted above–I have yet to have ANYONE provide solid evidence for this discrepancy.
Especially in light of this MUCH larger experiment:
Reality studies:
Duration 30 ys
subjects: >300M
Total conversions: millions
ratio 1/6 intact/cut
African studies:
Duration 2 yrs
subjects–10,000
total conversions <200
ratio: 2/1 intact/cut
Which is logically more credible?
Robert Samson
“no one has studied the between group differences in number of sex partners between circumcised at birth and un-circumcised men in the US since it would require maybe 30 years of follow-up?”
So, it would require 30 years HERE, but require only 2 years in Africa?
How exactly does this compute? Where is the logic?
S
Hugh7 – I don’t think it’s a reasonable option to wait until men are mature/already sexually active to perform the procedure, especially in light of new evidence published recently in the Lancet from the Uganda trials indicating that men did not wait the full time to heal before resuming sexual activity. Thus their female, previously HIV-negative, partners got HIV at a much higher rate than the partners in the control group. This is great evidence for performing the procedure at birth, and proof of the damage caused by waiting.
Samson – your second point is a fair one. I meant a longitudinal RCT where randomization occurs at birth (intact/cut) then follow up with lifetime number of sex partners would take a long time, instead of retrospective analysis of natural groups. To my knowledge, there hasn’t been any study anywhere (US or Africa) that has done that… so the potential for an increase in the number of sex partners (”promiscuity”) shouldn’t be used as fuel for people opposed to the recommendations.
Robert Samson
“Samson – your second point is a fair one. I meant a longitudinal RCT where randomization occurs at birth (intact/cut) then follow up with lifetime number of sex partners would take a long time, instead of retrospective analysis of natural groups. To my knowledge, there hasn’t been any study anywhere (US or Africa) that has done that… so the potential for an increase in the number of sex partners (”promiscuity”) shouldn’t be used as fuel for people opposed to the recommendations.”
This HAS been done–in the real world and with ALL variables inherent in the study groups:
Reality studies:
Duration 30 yrs
subjects: >300M
Total conversions: millions
ratio 1/6 intact/cut
African studies:
Duration 2 yrs
subjects–10,000
total conversions <200
ratio: 2/1 intact/cut
Again I have to return to the efficacy of re-doing a study that has failed so miserably in the real world. I think logic CAN be used by people opposed to infant circumcision.
Robert Samson
“I don’t think it’s a reasonable option to wait until men are mature/already sexually active to perform the procedure, especially in light of new evidence published recently in the Lancet from the Uganda trials indicating that men did not wait the full time to heal before resuming sexual activity. Thus their female, previously HIV-negative, partners got HIV at a much higher rate than the partners in the control group. This is great evidence for performing the procedure at birth, and proof of the damage caused by waiting.:
Gee, yet ANOTHER flaw in the African studies? Started too early, ended too early–the known flaws keep piling up.
Talk about “GREAT” evidence–NOT!
Frank OHara
“S,” you are making the mistake of taking the African studies at face value without critical review. The evidence clearly points to them not only being false but intentionally deceptive.
If male circumcision had the protective effect claimed, HIV would be conspiciously absent from The US and any country/locale where male circumcision is the dominant practice. Consider the polio epidemic of the first half of the 20th century. The vaccine was only 70% effective against a disease that is far, far more contagious yet managed to eliminate the infection in a single generation. If male circumcision had the protective effect claimed, we would see a similar situation. Instead, The US has the highest infection rate among the developed nations and among the demographic groups, the one with the highest circumcision rate also has by far the highest infection rate. African American males have both the highest circumcision rate and are estimated to represent 48% of infected males and African Amercan females represent 80% of all infected females. Why has circumcision so miserably failed African Americans? The answer is simply that circumcision provides no significant protection if any against HIV.
To understand the deception, you have to look into the history of the perpetrators. The two leaders in the promotion of male circumcision and the HIV studies, Bailey and Halperin have both been rabid promoters of male circumcision for more than 25 years, well before anything was known about HIV. It appears that these studies are simply a continuation of their agenda and an effort to raise their activities to a higher level.
.
P Hoath
This is second hand testimony with no corroborating evidence but it does agree with the facts:
http://www.youtube.com/watch?v=4AfPajxmfbE