Male Circumcision for Prevention of HIV
Male Circumcision for Prevention of HIV
In the United States in 2009, the Centers for Disease Control and Prevention (CDC) reported that 61% of the approximately 48,000 new HIV infections were among men who have sex with men (MSM); 9% were among those engaging in injection drug use; and 27% were among heterosexuals, of whom more than two thirds were women. These figures show that most new HIV infections in the United States occur through transmission routes other than the one for which circumcision has shown to be protective: namely, infection in men acquired through heterosexual sex. In 2009, an estimated 3600 new HIV infections occurred in heterosexual males (7.5% of new HIV infections), a small proportion of the US total.
With respect to MC and HIV prevention among MSM, to date no randomized clinical trials have been completed. A Cochrane review published in 2011 included 21 observational trials that corresponded to 71,693 participants. Although the main analysis found no significant association between MC status and HIV infection in MSM, the rate of HIV infection seemed to be lower among circumcised MSM who reported a predominantly or exclusively insertive role during anal sex. Biologically, this is plausible, because the probable portal of HIV entry with this type of exposure would be the foreskin, whereas in MSM who report receptive anal intercourse, the rectal mucosa would be the primary portal of entry. A randomized trial designed to investigate this question would require a large population of uncircumcised men with a high incidence of HIV infection who would be willing to be circumcised.
Despite the nature of the HIV epidemic in the United States, a study suggests that neonatal MC (about 10% of the cost of the procedure in older age groups) would reduce a US male's 1.87% lifetime risk for HIV infection by 16%. Furthermore, this intervention would be a cost-saving HIV-prevention intervention in the United States. Another study from the United States found that lack of Medicaid coverage for MC was associated with lower rates of circumcision. It has been pointed out that because poor families are the most likely to depend on Medicaid, lack of circumcision could lead to future health disparities in these populations, increasing the lifetime risk for HIV and other STIs.
The CDC offered this statement in 2008:
As CDC proceeds with the development of public health recommendations for the United States, individual men may wish to consider circumcision as an additional HIV prevention measure, but they must recognize that circumcision 1) does carry risks and costs that must be considered in addition to potential benefits; 2) has only proven effective in reducing the risk of infection through insertive vaginal sex; and 3) confers only partial protection and should be considered only in conjunction with other proven prevention measures (abstinence, mutual monogamy, reduced number of sex partners, and correct and consistent condom use).
Given the new longer-term data from the original study participants, some of the concerns about lack of durable effect may be put to rest: Studies have shown very consistent protective effect across study settings and over time. It also seems from these longer-term data that the fears about behavioral disinhibition have not been realized. Men have not significantly increased risky sexual behavior after MC. With respect to lack of direct benefit of MC to women, one must consider that at the population level, this intervention will eventually be of significant benefit to women. If a woman's partner has avoided HIV infection, he will not then infect her.
To quote a recent letter to the editor in reply to an article titled "Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity"
[The authors] continue to question its effectiveness and would deny millions of men -- and their female partners -- a proven, permanent, and inexpensive method to reduce their lifetime risk of HIV infection. Such denialism in the face of the ongoing pandemic are unethical and immoral...Deliberate misrepresentation of data, broad generalizations, and poor understanding of research methodology undermine efforts to prevent millions of premature deaths annually.
Implications for the United States
In the United States in 2009, the Centers for Disease Control and Prevention (CDC) reported that 61% of the approximately 48,000 new HIV infections were among men who have sex with men (MSM); 9% were among those engaging in injection drug use; and 27% were among heterosexuals, of whom more than two thirds were women. These figures show that most new HIV infections in the United States occur through transmission routes other than the one for which circumcision has shown to be protective: namely, infection in men acquired through heterosexual sex. In 2009, an estimated 3600 new HIV infections occurred in heterosexual males (7.5% of new HIV infections), a small proportion of the US total.
With respect to MC and HIV prevention among MSM, to date no randomized clinical trials have been completed. A Cochrane review published in 2011 included 21 observational trials that corresponded to 71,693 participants. Although the main analysis found no significant association between MC status and HIV infection in MSM, the rate of HIV infection seemed to be lower among circumcised MSM who reported a predominantly or exclusively insertive role during anal sex. Biologically, this is plausible, because the probable portal of HIV entry with this type of exposure would be the foreskin, whereas in MSM who report receptive anal intercourse, the rectal mucosa would be the primary portal of entry. A randomized trial designed to investigate this question would require a large population of uncircumcised men with a high incidence of HIV infection who would be willing to be circumcised.
Despite the nature of the HIV epidemic in the United States, a study suggests that neonatal MC (about 10% of the cost of the procedure in older age groups) would reduce a US male's 1.87% lifetime risk for HIV infection by 16%. Furthermore, this intervention would be a cost-saving HIV-prevention intervention in the United States. Another study from the United States found that lack of Medicaid coverage for MC was associated with lower rates of circumcision. It has been pointed out that because poor families are the most likely to depend on Medicaid, lack of circumcision could lead to future health disparities in these populations, increasing the lifetime risk for HIV and other STIs.
The CDC offered this statement in 2008:
As CDC proceeds with the development of public health recommendations for the United States, individual men may wish to consider circumcision as an additional HIV prevention measure, but they must recognize that circumcision 1) does carry risks and costs that must be considered in addition to potential benefits; 2) has only proven effective in reducing the risk of infection through insertive vaginal sex; and 3) confers only partial protection and should be considered only in conjunction with other proven prevention measures (abstinence, mutual monogamy, reduced number of sex partners, and correct and consistent condom use).
It's Time for Action
Given the new longer-term data from the original study participants, some of the concerns about lack of durable effect may be put to rest: Studies have shown very consistent protective effect across study settings and over time. It also seems from these longer-term data that the fears about behavioral disinhibition have not been realized. Men have not significantly increased risky sexual behavior after MC. With respect to lack of direct benefit of MC to women, one must consider that at the population level, this intervention will eventually be of significant benefit to women. If a woman's partner has avoided HIV infection, he will not then infect her.
To quote a recent letter to the editor in reply to an article titled "Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity"
[The authors] continue to question its effectiveness and would deny millions of men -- and their female partners -- a proven, permanent, and inexpensive method to reduce their lifetime risk of HIV infection. Such denialism in the face of the ongoing pandemic are unethical and immoral...Deliberate misrepresentation of data, broad generalizations, and poor understanding of research methodology undermine efforts to prevent millions of premature deaths annually.