Male circumcision called a “surgical vaccine”

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Over time, male circumcision would probably protect more African women, albeit indirectly, than nearly any other achievable strategy for preventing human immunodeficiency virus (HIV) transmission, write Malcolm Potts of the School of Public Health, University of California at Berkeley, et al. (Science, 2008;320(May 9):749-750).

In nine southern African countries, more than 12% of adults are said to be infected with HIV, and infection has spread outside of the accepted high-risk groups, creating a generalized, heterosexual epidemic. This has frequently been attributed to poverty, illiteracy, limited health services, war, and gender inequity.

HIV has, however, remained concentrated in high-risk groups in countries where male circumcision is common and multiple sexual partnerships, especially concurrent ones, are unusual. For example, Niger, a Muslim country where male circumcision is universal and sexual behavior relatively constrained, HIV prevalence is 0.7%, although it is the lowest ranking country on the Human Development Index.

Botswana, the second wealthiest country in sub-Saharan Africa, has an HIV rate of 25%. It has high levels of multiple concurrent sexual partnerships and lacks circumcision.

UNAIDS has spent nearly $1 billion on condom promotion, probably contributing to a decline in some generalized epidemics, but “there is no evidence of a primary role.” Potts et al. write: “[C]onsistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections.”

More than 45 studies have shown that male circumcision significantly reduces risk of heterosexual transmission. All three randomized controlled trials in Africa had to be stopped early for ethical reasons because of initial findings of at least a 60% reduction in HIV risk.

Modeling suggests that male circumcision could avert up to 5.7 million new HIV infections and 3 million deaths over the next 20 years in sub-Saharan Africa. Studies suggest that up to 80% of men in high-prevalence countries would accept the procedure if it were safe and inexpensive.

Educational efforts to reduce promiscuity have also proved effective. In Swaziland, the number of people reporting two or more partners in the preceding month was halved after a 2006 campaign focusing on the dangers of having a “secret lover.” HIV prevalence has declined significantly in Uganda and Kenya after similar campaigns.

At present less than 1% of requested funding is for this “surgical vaccine,” while large donor investments are made in interventions for which evidence of impact is weak.

An article in the Aug 6, 2008, issue of JAMA assesses risk factors for recent HIV conversion in Uganda. The adjusted odds ratio for being uncircumcised was 2.5 (P < .02), which was comparable to that for having more than two sex partners in the last year (2.9). For married men, the adjusted odds ratio for being uncircumcised was higher than for not using a condom with extramarital partners (4.1 compared to 3.2) (JAMA 2008;300:540-549).

Infant circumcision in the U.S. is a topic sparking tremendous interest on the www.SueEasy.com website, as pointed out by Medical Justice, Inc. One complainant said he would claim damages of $10 million.

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10 Comments

  1. good friend of mine was missionary doctor in Kenya. states there are no ‘heterosexuals’ in that country. come the full moon, he reports ‘one giant mongolian cluster-f***’. imagine the naivete of statistical data compiled without this consideration.

  2. Really? Male circumcision would protect more African women than using condoms would? Really? Even though male circumcision – if the 60% protective rate is assumed to be accurate – does NOT protect 40% of the time?

    Circumcising a man and claiming that it will protect him from HIV is just like giving a woman a birth control method that fails 40% of the time and saying it will protect her from unwanted pregnancies. Eventually, realistically speaking, a circumcised man will contract HIV and eventually that woman with the faulty birth control will get pregnant.

    How else do we explain the indisputable fact that America has both the highest circumcision rate and the highest HIV rate in the developed world? Obviously, in the real world, being circumcised didn’t protect American men from contracting HIV, how can anyone think that it will protect African men from contracting HIV in the real world outside of these studies?

  3. “How else do we explain the indisputable fact that America has both the highest circumcision rate and the highest HIV rate in the developed world?”

    Ummmm, the explanation is rather simple! A penis is not the only way that a man (or woman) can contract the HIV virus. The African RCTs focused on heterosexual transmission because, unlike the US, that is the primary mechanism of infection in that area of the world.

    Furthermore, a direct comparison of circumcision and HIV infection rates between different global regions is woefully flawed. Consider that such an analysis would only be meaningful if sexual contact were the sole mechanism of transmission and if condom compliance were identical in both areas. Obviously, these requirements can never be fulfilled.

    Correlation does not equal causation! It’s one of the most basic principles of statistics, yet people just don’t seem to get it….

  4. Most of the US men who have died of AIDS were circumcised at birth.

    In Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Tanzania, it is the circumcised who have markedly higher incidence of HIV infection.

    HIV is more rare in Japan where almost nobody is circumcised than it is in Israel where 95% are cut.

    African virgin boys are more likely to already have HIV if they have been circumcised.

    The supposed 60% improvement in HIV resistance has bearing only for an insertive male and has no bearing on his partner. Since it costs a man penile sensitivity and comes with these ridiculous associations with the word vaccine, it will surely make a man’s partner less safe as that man is less likely to don a condom.

    The three large trials were halted for ethical reasons? If ethics was a consideration they wouldn’t have been started. Non-double-blinded, non-placebo-controlled human amputation experiments overseen by long-time circumcision justifiers; how they get press is the mystery.

    Foreskin feels REALLY good. How disrespectful of the West to offer an inferior costly desensitizing form of protection when proven and less destructive prophylactics are just a matter of will. The UN can give condoms away for about 3 cents each.

  5. I find it fascinating that instead of noting the good news that circumcision and fidelity lower the rate of AIDS, some of you seem offended. Why? Isn’t this good news? Isn’t lowering AIDS a good thing? But you apparently feel that some deeply held but irrational belief including hatred for western civilization is more important than saving lives and preventing disease? No wonder we’re so screwed up.

    How does a virgin get HIV? You don’t even make sense in your objections. Did you even bother to read that the people aren’t using the condoms? And a condom has to be used each and every time. And picking a characteristic of a population that has a low incidence of HIV has nothing to do with that characteristic. There is a low incidence of HIV in Japan because there is a low incidence of HIV in Japan. That means it rarely is transmitted. You might as well say that speaking Japanese protects against AIDS. What is wrong with you people? If circumcision and fidelity save lives, then this is a good thing – never mind your twisted logic.

  6. “Isn’t lowering AIDS a good thing?”

    It would be if that was the outcome of circumcision in the real world. But if the cost of circumcision sucks resources out of the local health care system, gives men the false sense that they can abandon condoms, and/or does nothing directly to protect women while disempowering them from refusing sex without condoms, then circumcision may not lower AIDS even if it has that effect in controlled studies.

    “Did you even bother to read that the people aren’t using the condoms?”
    Where the campaigns are properly funded and managed, they use them, and the AIDS rate goes down – more effectively than with circumcision.

    “And picking a characteristic of a population that has a low incidence of HIV has nothing to do with that characteristic. There is a low incidence of HIV in Japan because there is a low incidence of HIV in Japan. That means it rarely is transmitted. You might as well say that speaking Japanese protects against AIDS.”
    Exactly the problem with Potts’ comparision of Niger with Botswana.

  7. “How does a virgin get HIV?”
    Through infected needles, largely. In parts of Africa there are “needle men” on every corner offering an injection for every ailment – with the same needles. (And the idea that a disease requires a needle is prevalent. They probably work, too, by the placebo effect. Pain is good like that.)

  8. Gotta agree with Baxter. If we could reduce HIV infection by 10% through any means that you support you would shout it from the roof tops, if it is by a means that you don’t like all you can do is complain.

  9. In Bangladesh MC is widely practiced culturally by the Moslem population through traditional practitioner who are doing the job for hundreds of years without any major problem. We believe that this wide practice of MC before adolesence protects the population from STDs including HIV/AIDS though the neibouring Myanmar and Calcutta (India) are significantly affected with AIDS. Bangladesh still HIV infection rate is less than 1% among the CSW.
    However, NGOs and AIDS prevention programme do not recognise it and the importance MC is not discussed. Why?
    Is it a bisedness?
    Is it an intelectual corruption?