The Truth About Circumcision and HIV

By Gussie Fauntleroy
Issue 149, September/October 2005

Medical journals and mainstream publications caught the world's attention in recent years with headlines such as this one, from the December 24, 2007 issue of Time: "Circumcision Can Prevent HIV." The magazine honored this dramatic claim with the top spot on its annual list of "medical breakthroughs." The New York Times, the Manchester Guardian, Medical News Today, and scores of other newspapers, magazines, and online news and medical information sources echoed the news. The World Health Organization (WHO) used the phrase "compelling evidence" to describe the development.

The source of all the excitement was a pair of research studies from Africa whose results were reported in the British medical journal The Lancet in February 2007.^{1, 2} According to the researchers, randomized trials conducted in Kenya and Uganda, and a similar, earlier one from South Africa, indicated that circumcision of heterosexual men could reduce the risk of HIV infection by 53 to 60 percent.

This attention-getting assertion quickly resulted in action by WHO and the United Nations' AIDS advocacy organization, UNAIDS, both of which recommended expanding programs of male circumcision in sub-Saharan Africa, where HIV rates are highest. These recommendations represent a "significant step forward in HIV prevention," according to Dr. Kevin De Cock, director of WHO's HIV/AIDS Department.³

In the US, the national Centers for Disease Control and Prevention (CDC) concurred, stating that "several types of research have documented that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex."⁴ (At the same time, however, the CDC's own research has yielded contradictory results among American black and Latino homosexual men.⁵) In addition, the President's Emergency Plan for AIDS Relief (PEPFAR), established by Congress in 2003 to fund health initiatives in developing countries, last year asked beneficiary governments to draft policies encouraging male circumcision as part of their HIV prevention plans.⁶

What about American babies?

What does all this mean for American parents who may wonder whether to have their infant sons circumcised? How does the claim of HIV protection relate to neonatal circumcision in the US and the developed world?

The short answer: It doesn't. Short-term trials involving heterosexual adult males in Africa cannot be applied to babies in the US because the two populations have too little in common, experts say. In addition, a number of scientists and scholars are raising serious questions about the African studies themselves, in terms of methodology, statistical results, confounding factors, ethics, and other issues.

Marilyn Milos, founder of the National Organization of Circumcision Information Resource Centers (NOCIRC), addresses the question of HIV risk protection succinctly in a pamphlet designed to clear up confusion on the issue: "Circumcision cannot prevent the spread of HIV; circumcised men contract HIV, transmit HIV, and die from AIDS. Transmission of HIV infection is caused by risky behaviors, such as multiple sex partners, failure to use condoms, and contaminated instruments or needles. Anyone who engages in high-risk behavior, whether circumcised or intact, is in danger of contracting HIV and other sexually transmitted diseases."⁷

Milos goes on to point out that the US has the highest rate of medically unnecessary, non-therapeutic infant circumcision in the world—about 56 percent of male babies today undergo the procedure,⁸ down from almost 85 percent in the 1960s⁹—and yet the HIV infection rate in North America is twice the rate in Europe,¹⁰ where circumcision rates are low. Even in Africa, the correlation between circumcision and HIV in various countries and regions does not support the premise that intact men are more at risk for the infection. Some geographic areas where the practice is part of the culture have higher HIV rates than areas where circumcision is rare; in other places, the situation is reversed.^{11, 12}

Weighing in on circumcision in general for American babies, the American Academy of Pediatrics statement, reaffirmed in 2005, asserts that the data on the potential medical benefits of circumcision are "not sufficient to recommend routine neonatal circumcision."^{13, 14} Physicians' organizations and AIDS advocates in other countries, including Australia, have made similar statements.^{15, 16}

What's behind all the fuss?

The two randomized trials that have aroused so much discussion were initiated in Uganda and Kenya in early 2006, and were funded by the National Institute of Allergy and Infectious Diseases, which is part of the National Institutes of Health. Additional support for the Kenyan trial came from the Canadian Institutes of Health Research. Leading the Kenyan trial were Robert Bailey, PhD, of the University of Illinois, and Stephen Moses, MD, of the University of Manitoba, in Canada. The Ugandan study was headed by Ronald Gray, MD, of Johns Hopkins University. Both trials were similar in structure and outcome to one conducted the previous year in South Africa—which researchers brought to an early conclusion.^{17, 18}

In Uganda, researchers began with a total of 4,996 men and randomly divided them into two groups, medically circumcising one group (2,474 men) and leaving the other group (2,522 men) intact. After 24 months, both groups were tested for HIV infection. Of the circumcised men, 22 tested positive, while 45 in the uncircumcised group tested positive. Researchers derived a 55 percent risk-prevention figure from the difference in results between the two groups. Similarly, the Kenyan trials began with 2,784 men and randomly divided them, with 1,391 undergoing circumcision and 1,391 left intact. Two years later, testing showed 22 new infections among the circumcised men and 47 among those left intact. In both studies, the men were given extensive counseling on the use of condoms. Significantly, researchers made no attempt to determine the HIV status of any of the men's female partners, a startling omission that effectively negates the findings, critics say.