Thursday, November 12, 2009

Part 1: Will Circumcision Prevent HIV?

Two steps forward, three steps back describes the direction circumcision is taking in the United States. We have seen the newborn circumcision rates gradually decrease over the years as parents have researched and discovered that there are benefits to keeping the foreskin intact. In many states, Medicaid, as well as many insurance companies, have stopped paying for circumcisions, declaring it "cosmetic" surgery. The American Academy of Pediatrics took the stand, essentially, to "leave it alone." Is all of this education and hard work about to be dismissed? The possibility is very real thanks to a couple of poorly-done studies. The CDC is said to have an official statement on mandatory circumcision for newborns by the end of this year.

Here's the fuss: The studies have concluded that circumcision reduces the risk of contracting HIV by 50-60% in heterosexual males only. First of all, this group is not the greatest at risk, which is -- no surprise -- men who have sex with other men. If it is truly an issue of a circumcised penis being protected from HIV , wouldn't he be greater "protected" no matter what, no matter who he is having sex with?

The reasons for contracting HIV in Africa are numerous. Heterosexual sex only accounts for about a third of cases. The rest is likely transmitted through unsafe medical procedures, including injections, transfusions, and other contact with infected blood. In fact, in the journal of the American College of Epidemiology, it has been suggested that some HIV infections are resulted from circumcisions themselves.

The Studies:
This is a lot of information and when you read so many numbers, I think a lot of us glaze over. I am going to try to make this as uncomplicated as possible.

Most people are aware that the area of the world hardest hit by the AIDS epidemic is Africa. It is important to note from the beginning that heterosexual sex is NOT the leading cause of contracting HIV in Africa. Conditions are very poor in many parts of the continent.

There were two studies done over a 24 month period, one in Uganda and the the other in Kenya. In Uganda, researches began with almost 5000 men and randomly divided them into 2 groups, circumcising one group and leaving the other group intact. For whatever reason, the intact group of men had almost 50 more men in its numbers than the circumcised group. The men were given extensive counseling on the use of condoms, but the researchers made no attempt to determine the HIV status of their female partners, which is a major flaw with both studies. After the 24 months, both groups were tested for HIV. The circumcised group had 22 positive results, while the uncircumcised group had 45 test positive. The researchers derived a 55% risk-prevention figure from the numbers.

The Kenyan study was very similar. They began with almost 2500 men and divided them evenly, circumcising half of the men. Two years later, 47 of the uncircumcised men and 22 of the circumcised men tested HIV positive.

Concerns with the Studies:
First of all, the number of men tested was such a small number to apply to large populations. In the Ugandan study, 0.8% of the circumcised men tested positive and 1.7% of the non-circumcised men tested positive. The numbers sound quite different when read in actualities. Plus, look at it from the flip-side: About 98% of the men remained HIV negative, possibly because of the extensive counseling about condoms. The actual numbers from the Kenyan study are: 1.5% circumcised men became infected, while 3.3% of the intact men became infected.

The timing of the release of these results is significant. They were released to the media in conjunction with UN World AIDS Day, 2 months before being released anywhere else. This unusual move "produced world-wide publicity that was heavy on eye-catching headlines and light on details because, in the absence of the published studies themselves, few journalists took the time to dig beyond the press releases made available to them."

Another concern is the short duration of the studies. Short time span and small numbers. The men who participated in the study were paid, which was significant, also, because more than half of them were unemployed when they signed up. They also received free health care for 2 years. For these reasons, it is impossible for their experience to reflect the larger population in other parts of Africa. In addition, there are more than 60 pre-existing conditions that can trigger an HIV false-positive result, including pregnancy, influenza, tuberculosis, hepatitis, and malaria.

There are other findings in the study. Circumcision does not appear to protect women. As mentioned earlier, it does not protect gay men either. Here's the reasoning behind believing that circumcision protects against HIV: "The mucosal tissue of the foreskin is more susceptible to HIV and can be an entry portal for the virus." More research has been done and has found the following: Langerhans cells in the foreskin have a protective effect against pathogens (including HIV) by secreting langerin. The original idea, stated earlier, believed these cells were an entrance point for viruses, and while this is partially true, the true mechanism at work is the cells set a trap for viruses in order to destroy them with langerin.

HIV infection is about behavior, not biology! Circumcision cannot prevent the spread of HIV. In fact, if men believe that they are safe because they are circumcised, that could make the problem worse! Circumcised men do contract HIV, they transmit HIV, and circumcised men die of AIDS. Anyone who participates in high-risk behavior, intact or not, carries a risk of contracting HIV and other STDs.


Stephanie said...

Thank you, Donna!

Anonymous said...

Yep. And if circ'd men think that circumcision has a protective effect, they may be more likely to engage in risky behavior, which would then increase their risk of contracting HIV. And spreading it to others.


Restoring Tally said...

Good analysis. One other point. Many advocate routine infant circumcision based on the Africa trials. But, babies don't have sex. If there is any efficacy to circumcision, it should only be available to adults who wish to engage in risky sex and desire it.

Donna Ryan said...

Part 2 will be about what these African studies mean for US babies. There's a whole lot more to say!

prashant said...

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Kendra said...

however small the overall rate of infection is which was quite small over the course of these studies there is still a marked difference in the rates of infection between the two groups. It s no matter how you slice it still a 50-60 % reduction in infection. Saying that it will only benefit a small amoutn of people is tantamount to saying seatbelts only save a small percentage of lives each year and cars ahve so many more safeties built in that we shouldn't really promote them. Or since breastfed and formula fed children often* socre similarly on certain* performance exams by adolesence women shouldn't bother with ther effort.
Both latter examples sound absurd. We know every little bit helps our children. We know seatbelts help save lives.
These studies show circumcised men contracted Hiv at 50% fwere rated than their intact counter parts.
No matter how small the total infection rate was this was an effective tool in lowers the rate of infection.