For simplicity, this page may be cited as www.circumstitions.com/hiv.

(The Roman senator Cato was in the habit of ending every speech on any subject with those words - it helped that "must be destroyed" was a single splendid Latin word, "delenda". Eventually the Senate agreed to destroy Carthage, with disastrous consequences for Rome.)

• Any link between circumcision and HIV is statistically quite slight, so the protection would be quite inefficient compared to education in safe-sex practices and a culture of protected or otherwise safe(r) sex.
• The studies are trumpetted by their Relative Risk Reduction (RRR), currently running about 50-60%, but the corresponding Number Needed to Treat (NNT) is much less impressive. (In the latest Uganda study it is 56 circumcisions to prevent one HIV infection per year. That corresponds to 380 circumcisions/infection/year in the US, where AIDS is less prevalent.)
• As each new study corrects the errors of its predecessors, the protection claimed is less. When all the errors are corrected, what effect will be left?

• While large numbers of men enter a trial, only a very small number are infected, making random errors high.
• The men were randomly assigned to be circumcised or left intact, but they were not a random sample of the population.
  • They were all HIV-negative, meaning they were more likely to have any natural immunity than the rest of the population
  • None were circumcised, meaning certain tribal groups had been selected out.
  • All were willing to be circumcised
  • They were significantly rewarded for taking part, skewing the socio-economic status of the sample
    It may have been impossible to correct for these (since humans are not lab rats), but they are issues none the less.
• Significant numbers of men dropped out of the trials (were "lost to study"). Only those who stay the distance should be counted.
• Those who are circumcised and contract HIV will be more likely to drop out than the others because
  1. they got what they came for but
  2. circumcision didn't protect them, so they would be disillusioned with the trial.
• The three RCTs were cut short: this has reduced their accuracy.
  • The control groups were then offered circumcision, making long-term follow-up impossible.
  • Ethical approval for better studies will be harder to get, making these studies the last word.
• The gold standard of medical testing is the double blind random controlled trial. Circumcision can not be concealed from the experimenter or the subject. The control groups were not given a placebo operation.
• The after-effects of the operation are likely to alter sexual behaviour.
• In an experimental environment, the subjects got counselling and safe-sex advice that would not be available in a mass circumcision campaign.
• The circumcised group had specific instructions to abstain from sex and use condoms that the intact control group does not.
  • Experimenter and circumcision advocate Robert Bailey has admitted that "repeated study visits and intensive behavioural counselling" of the circumcised men were needed to reduce risk behaviours.

• Protection, if any, would be extended to a population, but it would be impossible to convince the average man that circumcision did not confer significant protection on him personally.
• The temptation would be irresistible - especially if he had submitted to a painful operation in adulthood - for a man to say "I'm circumcised, I'm safe".
  • He would be more likely to lean on partners for unprotected sex
  • This disempowers women
• Transmission from man to woman is easier than from woman to man. Circumcision has not been shown to protect women directly.
• Since circumcision desensitises the glans, men circumcised in adulthood would be less willing to use condoms than before.
• If they combine mass circumcision with Abstinence, Be faithful, Condoms, campaigns, as they propose, it will be impossible to tell what is responsible for the outcome: circumcision will be given the credit for any reduction, but will not have to take the blame for any lack of reduction.

National Prevention Information Network
September 17, 2008

'Snip' Protects Some Gay Men from HIV: Study

Findings reported at the Australasian Sexual Health Conference 2008 shed new light on male circumcision’s role in preventing HIV infection.

“We have shown for the first time that [men who have sex with men] who predominantly take on the insertive role in sex are less likely to contract HIV if they’ve been circumcised,” said Dr. David Templeton from the National Center for HIV Epidemiology and Clinical Research in Sydney.

He went on to note, however, “Most HIV infections are contracted in the receptive role, so what we’re talking about is a risk reduction for a small group of men who didn’t have a huge risk in the first place.” In the study, University of New South Wales researchers recruited 1,400 HIV-negative men, two-thirds of whom were circumcised. During the four-year study, 53 men acquired HIV. There was no evidence that circumcision reduced the HIV risk among gay men in general. But in looking at the men who predominantly took the insertive role in intercourse, there was an 85 percent reduction in the risk of HIV infection if they were circumcised. Only seven of the 53 HIV infections occurred among insertive partners; the study’s model indicated that five of these infections could have been avoided if the men had been circumcised.

[No figure for how many of the seven HIV infections were among circumcised insertive men. That's pathetically few to be drawing any statistical conclusions from, and then only of correlation, not causation. Were any of these men circumcised for religious reasons? Factors like that might selectively influence their behaviour, putting them at less risk.]

Templeton was quick to note, however, “That’s only 9 percent of all HIV infections overall that can be attributed to being uncircumcised, not enough to advocate throwing out condoms or advocating widespread circumcision.”

Indeed, the study’s model projected [by multiplying by thousands] that circumcising all Australian gay men would prevent 37 infections a year in the first decade and 57 per year by 2030, at a cost of $196 million (US $153 million) in the first two years.

[No studies have been done of insertive-to-receptive transmission, cut vs intact, but it seems likely the keratinised circumcised penis is more likely to tear the receptive anus or rectum, and there is much anecdotal evidence - and visual evidence from US vs European gay porn - that cut men are rougher, because their fewer nerve-endings need more stimulation. So circumcising insertive men could readily increase HIV transmission to their partners. Yet already this study is being touted as a reason for gay men to get circumcised.]

The study (Gray R et al. Male circumcision and the risks of female HIV and sexually transmitted infections acquisition in Rakai, Uganda. Thirteenth Conference on Retroviruses and Opportunistic Infections, Denver, abstract 128, 2006.) was an attempt to find whether circumcised men were less likely to infect their female partners with HIV.

299 couples where the man was intact were compared with 44 where the man was circumcised. After 30 months (if the pattern of the rest of the study was followed), infection rates were 7 per 100 person-years for the wives of circumcised men and 10 for the wives of intact men. This may look like a protective effect, but in statistical terms, p=0.22, meaning no statistical significance. In real terms, it can be back-calculated that 8 of the wives of circumcised men were infected. If 11 had been, the rate would be the same for both, and that difference of three infections in 30 months is too few to be considered significant.

But the study was widely reported (by Reuters) as showing that all 299 wives of intact men were infected, compared with only 44 wives of circumcised men, as if these were just the small (infected) samples of two much larger and equal samples. This makes the supposed protective effect look much greater.

See the garbled report and the relevant part of a more accurate report.

Why, one wonders, was the study ever published, and why in this very misleading form?

Male Circumcision and Risk of HIV Infection among Heterosexual African American Men Attending Baltimore Sexually Transmitted Disease Clinics

Lee Warner, Khalil G. Ghanem, Daniel R. Newman, Maurizio Macaluso, Patrick S. Sullivan, and Emily J. Erbelding

Background. Male circumcision has received international attention as an intervention for reducing HIV infection among high-risk heterosexualmen; however, few US studies have evaluated its association with the risk of HIV infection.

Methods. We analyzed visit records for heterosexual African American men who underwent HIV testing while attending sexually transmitted disease (STD) clinics in Baltimore, Maryland, from 1993 to 2000. We used multivariable binomial regression to evaluate associations between circumcision and the risk of HIV infection among visits by patients with known and unknown HIV exposure.

Results. Overall, 1096 (2.7%) of 40,571 clinic visits yielded positive HIV test results. Among 394 visits by [385] patients [fewer than 50 of whom were intact] with known HIV exposure, circumcision was significantly associated with lower HIV prevalence (10.2% vs. 22.0% [i.e. about 11 intact men compared to about 5 who might not have contracted HIV if they had been circumcised]; adjusted prevalence rate ratio [PRR], 0.49 [95% confidence interval [CI], 0.26–0.93]). [The question arises, how can you "adjust" {for age, STDs, year of visit, and clinic location} when you are dealing with only 385 men, and only 50 of them intact.] Conversely, among 40,177 visits by patients with unknown HIV exposure, circumcision was not associated with reduced HIV prevalence (2.5% vs. 3.3%; adjusted PRR, 1.00 [95% CI, 0.86 –1.15]), and age =>25 years old and diagnosis of ulcerative STD were associated with increased prevalence.

Conclusions. Circumcision was associated with substantially reduced HIV risk in patients with known HIV exposure, suggesting that results of other studies demonstrating reduced HIV risk for circumcision among heterosexual men likely can be generalized to the US context. [The suggestion does not follow from the evidence.]

[This study has generated a flurry of headlines like "Circumcision significantly cuts HIV infection risk in heterosexual men"]

A total of 2585 males over the age of 15 were administered questionnaires and provided specimens for HIV testing. 916 (35.4%) of them said they were circumcised. HIV prevalence among circumcised males was 10.7% and among uncircumcised males was 12.1%, p = 0.9 [i.e. no statistical significance]. Blacks were less likely to be circumcised (28.8%) compared to other racial groups, 42.6%, p = 0.002. When the data was stratified by racial group, circumcised Blacks showed similar rates of HIV as uncircumcised Blacks, (OR: 0.8, p = 0.4) however other racial groups showed a strong protective effect, (OR: 0.3, p = 0.01) [or rather, a correlation]. When the data are further stratified by age of circumcision, there is a slight protective effect [correlation] between early circumcision and HIV among Blacks, OR: 0.7, p = 0.4.
Conclusion In general, circumcision offers slight protection. The effect is much stronger in other racial groups than in blacks. This racial difference cannot be explained by age of circumcision.

HIV and circumcision in South Africa
C.A. Connolly, O. Shisana, L. Simbayi, M. Colvin.
Poster at the XV AIDS Conference in Bangkok [MoPeC3491]

South African Medical Journal, October 2008, Vol. 98, No. 10

Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002

Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo

Objective. To investigate the nature of male circumcision and its relationship to HIV infection. Methods. Analysis of a sub-sample of 3 025 men aged 15 years and older who participated in the first national population-based survey on HIV/AIDS in 2002. Chi-square tests and Wilcoxon rank sum tests were used to identify factors associated with circumcision and HIV status, followed by a logistic regression model.

Results. One-third of the men (35.3%) were circumcised. The factors strongly associated with circumcision were age >50, black living in rural areas and speaking SePedi (71.2%) or IsiXhosa (64.3%). The median age was significantly older for blacks (18 years) compared with other racial groups (3.5 years), p <0.001. Among blacks, circumcisions were mainly conducted outside hospital settings. In 40.5% of subjects, circumcision took place after sexual debut; two-thirds of the men circumcised after their 17th birthday were already sexually active. HIV and circumcision were not associated (12.3% HIV positive in the circumcised group v. 12% HIV positive in the uncircumcised group). HIV was, however, significantly lower in men circumcised before 12 years of age (6.8%) than in those circumcised after 12 years of age (13.5%, p=0.02). When restricted to sexually active men, the difference that remained did not reach statistical significance (8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for possible confounding.

Conclusion. Circumcision had no protective effect in the prevention of HIV transmission. This is a concern, and has implications for the possible adoption of the mass male circumcision strategy both as a public health policy and an HIV prevention strategy.

A 2001 study by Bertran Auvert et al (who also ran the 2005 Random Controlled Study) of HIV infection among youth in a South African mining town found it is associated with the Herpes simplex 2 virus

It was "a community-based, cross-sectional study" of a random sample of men (n = 723) and women (n = 784) living in a township in the Carletonville district of South Africa.
Risk factors associated with HIV were recorded by questionnaire and biological tests were performed on serum and urine.
It found that women were much more likely to have HIV (34%) than men (9%) and HSV-2 (53% vs 17%) Two thirds of the 24-year-old women had HIV. Of the men,

Thus, the circumcised men in the study were more likely to be HIV+, but the difference was not statistically significant (the 95% CI straddles 1.0 - in real terms, 10 of the 61 circumcised men had HIV, three more than would be expected if they had the same rate as the intact men) But it certainly casts doubts on the claim that circumcision protects against HIV infection. Typically, Auvert expresses this cautiously, in terms of the prevailing mythology - which he has done so much to promote: "No protective effect of circumcision on HIV prevalence was shown."

"Our finding that 17% of homosexual men with newly acquired HIV infection reported insertive UAI [unprotected anal intercourse] as their highest risk activity suggests that insertive UAI is an important means of HIV transmission in this population. However, we found no association between circumcision status and infection by insertive UAI. In addition, men who had seroconverted despite no reported event of UAI were also no more likely to be uncircumcised. These data strongly suggest that the foreskin is not the main source of HIV infection in homosexual men who become infected by insertive UAI, and that other sites, such as the distal urethra, must be important in HIV infection.

"Our data showing that there is no difference in the circumcision status of men infected by receptive or insertive UAI, in a population with a circumcision prevalence of approximately 75%, suggests that circumcision is not strongly protective against HIV infection in homosexual men. Larger studies, preferably of prospective design, are needed to confirm the absence of a relationship between circumcision and HIV infection risk in gay men. In the meantime, educational messages to homosexual men should continue to emphasize that insertive anal sex is a high-risk activity for HIV transmission whether or not the insertive partner is circumcised."

- Grulich AE, Hendry O, Clark E, Kippax S, Kaldor JM.
Circumcision and male-to-male sexual transmission of HIV.
AIDS 2001 Jun 15;15(9):1188-1189.

JAIDS
December 15, 2007

Circumcision Status and HIV Infection Among Black and Latino Men Who Have Sex With Men in 3 US Cities.

Millett, Gregorio A; Ding, Helen; Lauby, Jennifer; Flores, Stephen; Stueve, Ann; Bingham, Trista; Carballo-Dieguez, Alex; Murrill, Chris; Liu, Kai-Lih; Wheeler, Darrell; Liau, Adrian; Marks, Gary

Abstract:
Objective: To examine characteristics of circumcised and uncircumcised Latino and black men who have sex with men (MSM) in the United States and assess the association between circumcision and HIV infection.

Methods: Using respondent-driven sampling, 1154 black MSM and 1091 Latino MSM were recruited from New York City, Philadelphia, and Los Angeles. A 45-minute computer-assisted interview and a rapid oral fluid HIV antibody test (OraSure Technologies, Bethlehem, PA) were administered to participants.

Results: Circumcision prevalence was higher among black MSM than among Latino MSM (74% vs. 33%; P < 0.0001). Circumcised MSM in both racial/ethnic groups were more likely than uncircumcised MSM to be born in the United States or to have a US-born parent. Circumcision status was not associated with prevalent HIV infection among Latino MSM, black MSM, black bisexual men, or black or Latino men who reported being HIV-negative based on their last HIV test. Further, circumcision was not associated with a reduced likelihood of HIV infection among men who had engaged in unprotected insertive and not unprotected receptive anal sex.

Conclusions: In these cross-sectional data, there was no evidence that being circumcised was protective against HIV infection among black MSM or Latino MSM.

JAIDS Journal of Acquired Immune Deficiency Syndromes. 46(5):643-650, December 15, 2007.

Author: Turner AN | Morrison CS | Padian NS | Kaufman JS | Salata RA

Source: AIDS. 2007 Aug 20;21(13):1779-1789.

Abstract: The objective was to assess whether male circumcision of the primary sex partner is associated with women's risk of HIV. Data were analyzed from 4417 Ugandan and Zimbabwean women participating in a prospective study of hormonal contraception and HIV acquisition. Most were recruited from family planning clinics; some in Uganda were referred from higher-risk settings such as sexually transmitted disease clinics. Using Cox proportional hazards models, time to HIV acquisition was compared for women with circumcised or uncircumcised primary partners. Possible misclassification of male circumcision was assessed using sensitivity analysis. At baseline, 74% reported uncircumcised primary partners, 22% had circumcised partners and 4% had partners of unknown circumcision status. Median follow-up was 23 months, during which 210 women acquired HIV (167, 34, and 9 women whose primary partners were uncircumcised, circumcised, or of unknown circumcision status, respectively). Although unadjusted analyses indicated that women with circumcised partners had lower HIV risk than those with uncircumcised partners, the protective effect disappeared after adjustment for other risk factors [hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.69-1.53]. Subgroup analyses suggested a non-significant protective effect of male circumcision on HIV acquisition among Ugandan women referred from higher-risk settings: adjusted HR 0.16 (95% CI, 0.02-1.25) but little effect in Ugandans (HR, 1.33; 95% CI, 0.72-2.47) or Zimbabweans (HR, 1.12; 95% CI, 0.65-1.91) from family planning clinics. After adjustment, male circumcision was not significantly associated with women's HIV risk. The potential protection offered by male circumcision for women recruited from high-risk settings warrants further investigation. (author's)

Date Posted: 3 September 2007

Int J Epidemiol. 1994 Apr;23(2):371-80.

Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda.
National University of Rwanda-Johns Hopkins University AIDS Research Team.
Chao A, Bulterys M, Musanganire F, Habimana P, Nawrocki P, Taylor E, Dushimimana A, Saah A.
Department of Epidemiology, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205.

Abstract: This study evaluated risk factors associated with prevalent HIV-1 infection among pregnant women in a semi-rural but densely populated area surrounding the town of Butare in Rwanda. Overall seroprevalence was 9.3% in 5690 pregnant women who sought antenatal care at one of five health centres. Factors associated with higher seroprevalence of HIV-1 included history of multiple sexual partners, history of at least one sexually transmitted disease (STD), relatively high socioeconomic status (SES), being unmarried, young age at first pregnancy, and low gravidity. Women who had used oral contraceptives, smoked more than one cigarette per day, whose partners were circumcised, and had had sex to support themselves were also at higher risk of being infected. A history of blood transfusion in the past 5 years was not associated with HIV-1 infection. History of multiple sexual partners, history of STD, high household income, partner circumcision, and past oral contraceptive use remained strongly associated with HIV-1 infection even when simultaneously controlling for other covariates. Among legally married women who lacked sexual behaviour risk factors, history of STD, high SES, young age at first pregnancy, and low gravidity were significantly associated with HIV-1 seroprevalence.

PMID: 8082965 [PubMed - indexed for MEDLINE]

International AIDS Society

Prevalence of male circumcision and its association with HIV and sexually transmitted infections in a U.S. navy population
A G Thomas, L N Bakhireva, S K Brodine, R A Shaffer
Int Conf AIDS. 2004 Jul 11-16; 15: abstract no. TuPeC4861.

Background: Lack of male circumcision has been found to be a risk factor for HIV and sexually transmitted infection (STI) in several studies performed in developing countries. However, the few studies conducted in developed nations have yielded inconsistent results. Policy regarding circumcision of male infants as a prevention measure against HIV/STI remains a controversial topic. This study describes the prevalence of circumcision and its association with HIV and STI in a U.S. military population.

Methods: This is a case-control study of male HIV infected U.S. military personnel (n= 232) recruited from 7 military medical centers and male U.S. Navy controls (n=516) from a general aircraft carrier population. Cases and controls completed similar self-administered HIV behavioral risk surveys. Case circumcision status was abstracted from medical charts while control status was reported on the survey. Cases and controls were frequency matched on age. Multiple logistic regressions were constructed separately to evaluate the role of circumcision in the acquisition of HIV and STI.

Results: The proportion of circumcised men did not significantly differ between cases (84.9%) and controls (81.8%). Prevalence of circumcision among men born in the U.S. was higher (85.0%) than those born elsewhere (58.1%). After adjustment for demographic and behavioral risk factors lack of circumcision was not found to be a risk factor for HIV (OR = 0.9; 95% CI: 0.51, 1.7) or STI (OR = 1.08; 95% CI 0.52, 2.26). The odds of HIV infection were 2.6 higher for irregular condom users, 5 times as high for those reporting STI, 6.2 times higher for those reporting anal sex, 2.8-3.2 times higher for those with 2-7+ partners, nearly 3 times higher for Blacks, and 3.5 times as high for men who were single or divorced/separated.

Conclusions: Although there may be other medical or cultural reasons for male circumcision, it is not associated with HIV or STI prevention in this U.S. military population.

J Acquir Immune Defic Syndr. 2007 Aug 1;45(4):371-9.
The protective effect of circumcision on HIV incidence in rural low-risk men circumcised predominantly by traditional circumcisers in Kenya: two-year follow-up of the Kericho HIV Cohort Study.
Shaffer DN, Bautista CT, Sateren WB, Sawe FK, Kiplangat SC, Miruka AO, Renzullo PO, Scott PT, Robb ML, Michael NL, Birx DL.
US Army Medical Research Unit, Walter Reed Project HIV Program, Kericho, Kenya. dshaffer@wrp-kch.org

BACKGROUND: Three randomized controlled trials (RCTs) have demonstrated that male circumcision prevents female-to-male HIV transmission in sub-Saharan Africa. Data from prospective cohort studies are helpful in considering generalizability of RCT results to populations with unique epidemiologic/cultural characteristics.

METHODS: Prospective observational cohort sub-analysis. A total of 1378 men were evaluated after 2 years of follow-up. Baseline sociodemographic and behavioral/HIV risk characteristics were compared between 270 uncircumcised and 1108 circumcised men. HIV incidence rates (per 100 person-years) were calculated, and Cox proportional hazards regression analyses estimated hazard rate ratios (HRs).

RESULTS: Of the men included in this study, 80.4% were circumcised; 73.9% were circumcised by traditional circumcisers. Circumcision was associated with tribal affiliation, high school education, fewer marriages, and smaller age difference between spouses (P < 0.05). After 2 years of follow-up, there were 30 HIV incident cases (17 in circumcised and 13 in uncircumcised men). Two-year HIV incidence rates were 0.79 (95% confidence interval [CI]: 0.46 to 1.25) for circumcised men and 2.48 (95% CI: 1.33 to 4.21) for uncircumcised men corresponding to a HR = 0.31 (95% CI: 0.15 to 0.64). In one model controlling for sociodemographic factors, the HR increased and became non-significant (HR = 0.55; 95% CI: 0.20 to 1.49).

CONCLUSIONS: Circumcision by traditional circumcisers offers protection [That's not what "non-significant" means.] from HIV infection in adult men in rural Kenya. Data from well-designed prospective cohort studies in populations with unique cultural characteristics can supplement RCT data in recommending public health policy. PMID: 17558336 [PubMed - indexed for MEDLINE]

Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit

Mor Z, Kent CK, Kohn RP, Klausner JD (2007) Benefit. PLoS ONE 2(9):

The study objective was to describe male circumcision trends among men attending the San Francisco municipal STD clinic, and to correlate the findings with HIV, syphilis and sexual orientation.
Methods and Findings. A cross sectional study was performed by reviewing all electronic records of males attending the San Francisco municipal STD clinic between 1996 and 2005. The prevalence of circumcision over time and by subpopulation such as race/ethnicity and sexual orientation were measured. The findings were further correlated with the presence of syphilis and HIV infection. Circumcision status was determined by physical examination and disease status by clinical evaluation with laboratory confirmation.

Among 58,598 male patients, 32,613 (55.7%, 95% Confidence Interval (CI) 55.2–56.1) were circumcised. Male circumcision varied significantly by decade of birth (increasing between 1920 and 1950 and declining overall since the 1960’s), race/ethnicity (Black: 62.2%, 95% CI 61.2–63.2, White: 60.0%, 95% CI 59.46– 60.5, Asian Pacific Islander: 48.2%, 46.9–49.5 95% CI, and Hispanic: 42.2%, 95% CI 41.3–43.1), and sexual orientation (gay/ bisexual: 73.0%, 95% CI 72.6–73.4; heterosexual: 66.0%, 65.5–66.5).

Male circumcision may [or, equally, may not] have been modestly protective against syphilis in HIV-uninfected heterosexual men (PR 0.92, 95% C.I. 0.83–1.02, P = 0.06) . [No correlations were found between circumcision and HIV or syphilis in any of the groups of men studied, but the paper tries its best to make it look as if they were]

From the Results:

Table 2. Percent circumcised in those with and without syphilis infection by HIV status and sexual orientation, as determined during male patient visits, San Francisco municipal STD clinic, 1996-2005.
Sexual orientation	Syphilis infection	HIV-infected				HIV-uninfected
		Circumcised %	(n/N)	PR*	(95% CI)	Circumcised %	(n/N)	PR	(95% CI)
Heterosexual	Yes	62.5	(10/16)	0.85	(0.40-1.56)	66.7	(384/576)	0.92	(0.83-1.02)
	No	73.8	(1,050/1,423)	Ref.		72.4	(36,290/50,128)	Ref.
Gay/ bisexual	Yes	75.8	(214/282)	1.0	(0.87-1.15)	72.7	(384/528)	0.98	(0.88-1.08)
	No	75.4	(15,910/21,090)	Ref.		74.6	(34,210/45,869)	Ref.
*PR = Prevalence ratio of circumcision status by syphilis infection (Yes/No) Table 2 shows the proportion of visits by circumcised men at the San Francisco municipal STD clinic from 1996 through 2005 by sexual orientation, syphilis and HIV infection status. There was a trend towards a protective effect of circumcision for syphilis infection in heterosexual HIV-uninfected men and in a lesser extent in HIV-infected men. Among gay/bisexual men, no such protective effect was seen and also no association was found between circumcision status and HIV infection (71.1% circumcised versus 72.2%, PR = 0.97, 95% CI 0.90-1.0, P =0.52).

Conclusions. Male circumcision was common among men seeking STD services in San Francisco but has declined substantially in recent decades. Male circumcision rates differed by race/ethnicity and sexual orientation. Given recent studies suggesting the public health benefits of male circumcision, a reconsideration of national male circumcision policy is needed to respond to current trends.

[And therefore Carthage must be destroyed. The conclusion does not follow at all from the data.

"A trend towards a protective effect" is weasel wording for no correlation.

However, none of the ratios is statistically significant.

Considering HIV, in every row except the first, the percentage on the right (circumcised men with HIV) is greater than the percentage on the left (intact men with HIV), and in the first row, there are only six intact (heterosexual) men with HIV (and syphilis). Here is a different presentation of the same data:

In all classes except the first, men with HIV are very slightly more likely to be circumcised than men without HIV, but in no class does the difference reach statistical significance. (And in the first class - because only six of the men with HIV were intact - if one more HIV+ man had been circumcised, that ratio would also have been greater than 1:1.)

There are other problems with this paper. According to its Table 1 there were 15,515 intact men, while according to Table 2 intact men paid only 14,409 visits to the clinic.

A published response to the paper

The Bagisu people of Eastern Uganda circumcise boys aged 12-18 years. The cultural practices associated with circumcision are a risk to HIV transmission. HIV transmission awareness programmes have been running in the local media but the message is mainly perceived by urban, literate people. The researchers found it is hard to change the attitude of the Bagisu towards their cultural circumcision practices despite the risks.

A. Kataami Moiti. Joint Clinical Research Centre, Kampala, Uganda
The Importance of education in addressing risk factors associated with cultural circumcision practices among Bagisu community, Uganda
Poster at the XV AIDS Conference in Bangkok, July 2004 [ThPeC7544]

Country

% of men
circumcised

% HIV prevalence in

Adults

Circumcised
men

Uncircumcised
men

Burkina Faso

88

1.8

1.8

2.9

Cameroon

93

5.5

4.1

1.1

Cote d'Ivoire

96

4.7

2.8

3.8

Ethiopia*

91

1.4

0.9

1.1

Ghana

95

2.2

1.6

1.4

Kenya

83

6.7

3.0

12.6

Lesotho

49

23.5

22.8

15.2

Malawi

20

11.8

13.2

9.5

Rwanda

9

3.0

3.5

2.1

Swaziland

8.1

25.9

21.8

19.5

Tanzania

69

7.0

6.5

5.6

Uganda

25

6.4

3.8

5.6

Source: National surveys, available at: www.measuredhs.com/countries/

"Circumcision status should be viewed as a proxy for other aspects of human behavior. Unless one can control for these aspects, one cannot draw reliable conclusions about the causative status of the presence or absence of a foreskin on the course of medical disease processes."

- Dr Anne Laumann
in a letter to Archives of Dermatology

Australian Doctor
November, 2005

Circumcision equal to a vaccine for HIV

by Rebecca Jenkins

CIRCUMCISION offers the same level of protection against HIV infection in heterosexual men as a highly effective vaccine, according to a landmark study. In the first randomised controlled trial of its kind, researchers found circumcision provided 60% protection against the virus, confirming the results of a large body of observational studies.

A vaccine of high efficacy is expected to offer long-term protection of 95% or above. Smallpox was eradicated with such a highly efficient vaccine. If control of tetanus, measles, and poliomyelitis has been largely achieved in the world, it has been a result of high-efficacy vaccines. ... A 96%-efficient measles vaccine means that 96% of vaccinated persons exposed to measles are indeed protected against infection. Protection lasts for many years, and revaccination permits dealing with loss of immunity over time. What Auvert and colleagues show is ... a 60% reduction in disease incidence over an 18-month period among circumcised men compared with uncircumcised men with similar exposure. To our knowledge, this does not mean that those men are really "protected" against HIV, especially in the case of repeated exposure. It simply means "reduced risk," or reduced probability of contamination.

- Michel Garenne, Male Circumcision and HIV Control in Africa

In a text for upper division and/or graduate study of immunology, a table gives the percentage of reduction obtained by vaccines for the diseases modern societies associate with successful immunization programs.

Smallpox, diphtheria, and polio vaccinations resulted in 100% reduction of incidence. Vaccination against measles, Mumps, and rubella (German measles) resulted in >99% reduction of incidence. Tetanus (lockjaw) was reduced by more than 98%; Pertussis (whooping cough) by more than 87%.

(No vaccines that reduced incidence by as little as 70% were included in the table.)

- Kindt, Thomas J, Goldsby, R.A., and Osborne, B.A.
(Kuby) Immunology (6th Ed), New York: W.H. Freeman, 2007.
[Kindt - NIH, Goldsby - Amherst College, Osborne - UMass, Amherst]

"...even assuming that reducing the risk of HIV transmission could be a justification for infant male circumcision, this justification would not be available until it became at least more likely than not that circumcision would reduce the risk of HIV transmission.

"...even assuming that circumcision could help to protect against HIV infection, it would not be necessary to carry it out on unconsenting infants. One could wait until the person was about to become sexually active and could decide for himself.

"...one is ethically required to use the least harmful, least invasive means of achieving a good, the achievement of which involves harm. Consequently, a surgical intervention aimed at preventing the spread of HIV could only be justified if there were no other reasonable way to achieve this. And, even if circumcision helped to protect people in developing countries from the spread of HIV, we would not be justified in carrying this out for this purpose in developed countries, where other, better means of protection are much more readily available."

- The Gazette, Montreal, October 24, 1998, pB6

Abstract: Female circumcision and HIV infection in Tanzania: for better or for worse? Stallings R.Y, Karugendo E. (PowerPoint)

Introduction: ...The authors sought to explain an unanticipated significant crude association of lower HIV risk among circumcised women [R{isk} R{atio}=0.51; 95% C{onfidence} I{nterval} 0.38,0.70] in a recent survey by examining other factors which might confound this crude association.

Methods: Capillary blood was collected ... from a nationally representative sample of women age 15 to 49 during the 2004 Tanzania Health Information Survey. Eighty-four percent of eligible women gave consent for their blood to be anonymously tested for HIV antibody. Interview data was linked ... to final test results for 5753 women. The chi-square test of association was used to examine the bivariate relationships between potential HIV risk factors with both circumcision and HIV status. Restricting further analyses to the 5297 women who had ever had sexual intercourse, logistic regression models were then used to adjust circumcision status for other factors found to be significant.

Results: By self-report, 17.7 percent of women were circumcised. Circumcision status varied significantly by region, household wealth, age, education, years resident, religion, years sexually active, union status, polygamy, number of recent and lifetime sex partners, recent injection or abnormal discharge, use of alcohol and ability to say no to sex. In the final logistic model, circumcision remained highly significant [O{dds} R{atio}=0.60; 95% C{onfidence} I{nterval} 0.41,0.88] while adjusted for region, household wealth, age, lifetime partners, union status, and recent ulcer.

Conclusions: A lowered risk of HIV infection among circumcised women was not attributable to confounding with another risk factor in these data. Anthropological insights on female circumcision as practiced in Tanzania may shed light on this conundrum.

Will there be Randomised Controlled Trials of 3000 HIV-negative women, where 1500 are circumcised and they see how many seroconvert - followed by calls for mass circumcision of women to prevent the spread of HIV? Of course not.

Remarkably, there is consistent evidence that female-to-male HIV transmission, compared with male-to-female transmission, is much higher in Europe than in the USA . . . Data from the European Multicenter Partners Study and comparable research from the USA suggest that the ratio of female-to-male transmission (compared with male to female transmission) is about 10 fold higher in Europe.³

[3 De Vincenzi I. Heterosexual transmission of HIV. JAMA 1992; 267: 1919.]

"Russian Roulette with two bullets rather than three"

Male circumcision and HIV infection

For several years, researchers have been debating the relationship between male circumcision and HIV. Several studies have indicated that circumcised men are less likely to become infected with HIV than uncircumcised men. However, because circumcision is usually linked to culture or religion, it has been argued that the apparent protective effect of the procedure is likely to be related not to removal of the foreskin but to the behaviours prevalent in the ethnic or religious groups in which male circumcision is practised. In addition, some researchers have assumed that any association between circumcision and HIV must be complicated by the presence of other sexually transmitted infections, which have been found to be more common among uncircumcised men.

Clearly, the correlations are not straightforward. In the higher income countries, the rates of HIV infection among men who have sex with men do not vary greatly even though the circumcision rates do: few men in Europe and Japan but four-fifths of men in the United States are circumcised. In Africa, however, circumcision seems to confer some protection. A study in Nyanza Province, Kenya, among men from the same ethnic group, the Luo, found that one-quarter of uncircumcised men were infected with HIV, compared with just under one-tenth of circumcised men. The protective effect remained even after other factors, such as sexual behaviour and sexually transmitted infections, had been taken into account. A study of over 6800 men in rural Uganda has suggested that the timing of circumcision is important: HIV infection was found in 16% of men who were circumcised after the age of 21 and in only 7% of those circumcised before puberty. A recent review of 27 published studies on the association between HIV and male circumcision in Africa found that, on average, circumcised men were half as likely to be infected with HIV as uncircumcised men. When African men with similar socio-demographic, behavioural and other factors were compared, circumcised men were nearly 60% less likely than uncircumcised men to be infected with HIV.

Even though the weight of evidence increasingly suggests that circumcising men before they become sexually active does provide some protection against HIV, the practical implications for AIDS prevention are not obvious. Circumcision, where it is practised, usually has links to religious or ethnic identities and life-cycle ceremonies, and may customarily be done after puberty. If the same scalpel were used without sterilization on a number of boys, this could actually contribute to the transmission of HIV. Finally, if circumcision were promoted as a way of preventing HIV infection, people might abandon other safe sexual practices, such as condom use. This risk is far from negligible - already, rumours abound in some communities that circumcision acts as a "natural condom". A sex worker interviewed in the city of Kisumu in Kenya summed up this misconception, saying: "I can sleep with circumcised men without a condom because they don't carry a lot of dirt on their penis". While circumcision may reduce the likelihood of HIV infection, it does not eliminate it. In one study in South Africa, for example, two out of five circumcised men were infected with HIV, compared with three out of five uncircumcised men. Relying on circumcision for protection is, in these circumstances, a bit like playing Russian roulette with two bullets in the gun rather than three. [...assuming the gun has only five chambers - or, if it had the more usual six, 2.4 bullets rather than 3.6.]

- Report on the global HIV/AIDS epidemic
UNAIDS, June 2000
A large file, >275KB.

In the wake of three incomplete Random Controlled Tests of circumcision, the head of UNAIDS, Dr Peter Piot, has chosen to forget these wise words.

The survey found no evidence to support the adoption of ‘the proportion of HIV uninfected men who are not circumcised’ as a population level target for HIV prevention programmes for gay and bisexual men. [... let alone evidence to support the promotion of circumcising anyone]

[The only possible confounder remaining is selection bias. The results would not reflect the actual position if circumcised men who have HIV (and know it), or intact men who don't, are more likely to take the survey than intact men who have HIV (and know it) or circumcised men who don't, but it is very hard to see why that might be.

Only a small proportion of these men with HIV would have been infected trans-penilely, compared to the proportion infected tran-anally, so the small surplus of those HIV-positive men who are circumcised should not be taken as suggesting that circumcision makes HIV-infection more likely.]

"Scientists must constantly be on guard against this sort of self-deception [picking and choosing data to agree with the preconception that electromagnetic fields, as from power lines, cause leukaemia]. Unless studies are carefully designed to avoid it, the biases of the epidemiologist have a way of creeping into the results. To minimize the opportunity for bias, scientists rely on double-blind studies. An independent researcher might be given a list in­cluding both the homes of victims of childhood leukemia and an equal number of addresses of nonvictim children matched in age, gender, race, family income, etc., but without any indication of which are which. Without knowing which were the homes of vic­tims and which were "controls," the researcher would rate them by whatever criteria were used to estimate the field strength. Some­one else would then apply the key after the judgments were made.

[Double-blinding a study involving circumcision is hardly practicable, but much more could have been done to make the circumcised experimental groups and the intact control groups equivalent.]

But even if the study had been double blind, a "risk ratio" of only three for a rare disease such as childhood leukemia would be regarded by many epidemiologists as barely credible. The risk ratio for lung cancer from smoking, for example, is well over thirty^ that is, a 3,000 percent increase in the incidence of lung cancer among smokers. Yet it took years of checking and rechecking the figures, as well as a highly plausible mechanism in terms of known carcinogens in tobacco smoke and, finally, confirming laboratory studies on animals before the cancer link was firmly nailed down."

- "Voodoo Science" by Robert Park, pp 150-1

"The estimated reduction in the relative risk of infection with HIV [between circumcised and intact men in the Kenyan and Ugandan trials] was 51% (unadjusted modified intention-to-treat analysis) to 55% (as-treated analysis)."

Editorial comment in The Lancet.

To the Editor:

Largely ignored in the report by Quinn et al. of their study of the heterosexual transmission of human immunodeficiency virus type 1 (HIV-1) in Uganda (March 30 issue) (1) is the finding that of 137 uncircumcised men who were negative for HIV-1, 40 seroconverted, whereas 0 of 50 circumcised men seroconverted. This finding suggests that male circumcision is at least as protective against female-to-male transmission of HIV-1 as low viral load in the female partner. Yet the authors do not consider male circumcision among their list of possible strategies for the prevention of HIV-1 infection.

There are now more than 30 epidemiologic studies from sub-Saharan Africa dating back to 1987 that report a significant protective effect of male circumcision against HIV-1 infection. (2) Is it not time for those in Rakai, Uganda (where Quinn et al. conducted their study), as well as others, to benefit from these studies? The feasibility of offering information on voluntary male circumcision and circumcision services to this community with a high prevalence of HIV-1 infection could at least be investigated. Justice and scientific evidence demand it.

Robert C. Bailey, Ph.D., M.P.H.
University of Illinois School of Public Health
Chicago, IL 60302

References

1. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med 2000;342:921-9.

2. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999;354:1813-5.

[...a letter on another topic here...]

The authors reply:

To the Editor:

Bailey comments on the association between circumcision and reduced rate of acquisition of HIV-1 in male subjects in our study of couples discordant for HIV-1 status. Although circumcision was strongly associated with reduced acquisition of HIV-1 in these highly exposed couples, additional analyses suggest that generalization to the whole population is complicated by confounding. (1) In our representative population in Rakai, we found that circumcision was associated with a reduced rate of HIV-1 acquisition; this was particularly true for circumcision performed before puberty. However, this effect was mainly due to the lower incidence of HIV-1 among Muslims, who constitute the largest group of circumcised males. Circumcision was not significantly protective among non-Muslim men or in couples in which both partners were HIV-1-negative. (1) The 30 African epidemiologic studies mentioned by Bailey are mainly cross-sectional investigations with inconsistent findings and inadequate control for potential confounding. These observational data are difficult to interpret, and clinical trials are needed before circumcision can be promoted as a means of preventing HIV infection.

[...]

Thomas C. Quinn, M.D.
National Institute of Allergy and Infectious Diseases
Bethesda, MD 21205

Maria J. Wawer, M.D.
Columbia University
New York, NY 10032

Nelson K. Sewankambo, M.B., Ch.B.
Makerere University
Kampala, Uganda

References

1. Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. AIDS (in press).

[...]

4. Urassa M, Todd J, Boerra JT, et al. Male circumcision and susceptibility to HIV infection among men in Tanzania. AIDS 1997;11:73-80. [study 1]

http://ije.oupjournals.org/cgi/reprint/dyh127v1.

Int J Epidemiol. 2004 Mar 24 [Epub ahead of print]

Trends in antenatal human immunodeficiency virus prevalence in Western Kenya and Eastern Uganda: evidence of differences in health policies?

Moore DM, Hogg RS.

Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC, Canada.

OBJECTIVE: To observe recent trends in human immunodeficiency virus (HIV) prevalence in antenatal clinic attendees to determine if previously noted falls in HIV prevalence are occurring on both sides of the Kenyan-Ugandan border. Design An ecologic study was conducted at the district level comparing HIV prevalence rates over time using data available through reports published by the Kenyan and Ugandan Ministries of Health and UNAIDS.

METHODS: Sentinel sites were compared with respect to population, ethnicity, language group, and the prevalence of circumcision practice. The prevalence of HIV found at each sentinel site was recorded for the years 1990-2000 and analysed visually and by conducting bivariate correlations.

RESULTS: Ethnographic analysis revealed a wide mix of ethnic and language groups and circumcision rates on both sides of the border. All sentinel surveillance sites in Uganda showed trends towards decreasing HIV prevalence, with three of five sites showing statistically significant declines (r = -0.87, -0.85, -0.86, P < 0.05). In contrast, all of the surveillance sites in Kenya showed trends toward increasing HIV prevalence, with two of the five sites showing statistically significant increases (r = 0.62, 0.84, P < 0.05).

CONCLUSIONS: The declines in HIV prevalence occurring in Uganda are not being seen in geographically proximal districts of Kenya. No obvious differences in ethnic groupings or their associated prevalence of circumcision appeared to explain these differences. This suggests that decreasing HIV prevalence in Uganda is not due to the natural course of the epidemic but reflects real success in terms of HIV control policies.

PMID: 15044420 [PubMed - as supplied by publisher]

http://www.ias2007.org/pag/Abstracts.aspx?SID=55&AID=2465

Circumcision status and risk of HIV seroconversion in the HIM cohort of homosexual men in Sydney
Presented by David James Templeton, Australia.

Templeton D.J.1, Jin F.1, Prestage G.P.1, Donovan B.1, Imrie J.2, Kippax S.C.2, Kaldor J.M.1, Grulich A.E.1
1National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Darlinghurst, Australia, 2National Centre in HIV Social Research, University of New South Wales, Randwick, Australia

Objectives: Circumcision substantially lowers the risk of HIV acquisition among heterosexual African men, but there are few data addressing circumcision status as a risk factor for HIV among homosexual men. We examined circumcision status as an independent risk factor for HIV seroconversion in the community-based Health in Men (HIM) cohort of homosexual men in Sydney, Australia.
Methods: Between 2001 and 2004, 1,427 initially HIV-negative men were enrolled. Circumcision status was self-reported at baseline and was validated by clinical examination during study visits in a sub-sample of participants. All participants were tested annually for HIV and offered testing for other sexually transmitted infections (STIs). Demographic information was collected at baseline and detailed information on sexual risk behaviours was collected every 6 months. Results: At baseline, 66% of participants reported being circumcised; mostly as infants. There were 49 HIV seroconversions through 2006, an incidence of 0.80 per 100PY. On multivariate analysis controlling for non-concordant unprotected anal intercourse (UAI), anorectal STIs and age, being circumcised was not associated with HIV seroconversion (RR = 0.88, 95% CI 0.45-1.74). Among men who reported no receptive UAI, there were nine seroconversions, an incidence of 0.35 per 100PY. When analyses were restricted to this group, there was also no association with HIV seroconversion (RR = 0.99, 95% CI 0.25-3.96).
Conclusion: Circumcision status was not associated with HIV seroconversion in this cohort. Although statistical power was limited, among men who were more likely to acquire HIV by insertive UAI, there was also no relationship. As most HIV infections in homosexual men occur after receptive anal sex, circumcision is unlikely to be an effective HIV prevention intervention in Australian gay men. However, further research in populations where there is more separation into exclusively receptive or insertive sexual roles by homosexually active men is warranted.