Circumcision may not cut HIV spread among gay men
A man points at an artwork at a conceptual art exhibition about HIV/AIDS in Tehran December 2, 2007.
Credit: Reuters/Morteza Nikoubazl
NEW YORK |
NEW YORK (Reuters Health) - Although studies in Africa have shown that circumcision can lower the spread of HIV among heterosexuals, it may not do much to prevent infections among gay and bisexual men in Western countries, a new study suggests.
A number of studies in African nations have found that circumcised heterosexual men were up to 60 percent less likely than uncircumcised men to contract HIV during the study periods.
But it is unclear whether circumcision could have an impact on HIV transmission in the U.S. or other Western countries, where much of the transmission is among men who have sex with men. There has so far been no good evidence that circumcision lowers HIV risk among these men.
In the new study, researchers at the U.S. Centers for Disease Control and Prevention (CDC) looked at HIV infection rates among nearly 4,900 men in the U.S., Canada and the Netherlands who took part in a clinical trial of an HIV vaccine.
They found that circumcised and uncircumcised men showed no difference in the risk of HIV infection over three years.
Moreover, while having unprotected sex with an HIV-positive partner increased a man's risk of infection, there was no evidence that circumcision altered that risk.
The findings, reported in the journal AIDS, come as the CDC is developing new recommendations on circumcision for reducing HIV transmission. The agency says it is considering whether to recommend circumcision for heterosexual men at elevated risk of HIV, and whether there is enough evidence to make any recommendations for men who have sex with men.
With regards to infant circumcision, the CDC says on its Web site, "many options are still being considered in this process, including simply recommending that health-care providers educate parents about the potential benefits and risks to ensure that parents have the information they need to make an informed decision."
Circumcision is thought to protect men from HIV infection because foreskin tissue appears particularly susceptible to the virus, and may serve as an entry point for it.
But circumcision may not make much difference in transmission among men in Western countries for a number of reasons, according to Deborah A. Gust and her colleagues at the
CDC.
One factor could be the fact that many HIV-positive people in developed countries are on powerful HIV drugs that reduce the chances of transmission, and may outweigh any effects of circumcision. In addition, Gust and her colleagues point out, circumcision would not affect HIV risk from receptive anal sex -- and that, again, could outweigh any protective effect of circumcision during insertive sex.
The findings are based on data from 4,889 men who took part in an HIV vaccine trial begun in 1998; 86 percent had been circumcised. During the three-year study, 7 percent of the men became HIV-positive.
When the researchers accounted for other factors -- including demographics, and HIV risk factors like drug use and having unprotected sex -- circumcision showed no effect on the odds of HIV transmission.
Still, Gust and her colleagues point to some limitations of their study, including the relatively small number of uncircumcised men overall and the small number of uncircumcised men who became HIV-positive during the study -- 43.
They say that future studies, with larger samples of uncircumcised men, should continue to look at the question of circumcision and HIV transmission among men who have sex with men.
The researchers also note, however, that other CDC scientists have concluded, based on their own studies, that circumcision would likely have only a "limited" impact on HIV transmission in the U.S.
SOURCE: AIDS, 2010.
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“I must confess, at the outset, my initial reservations about the enthusiastic, and sometimes irrational, adoption of adult male circumcision as a strategy against the worldwide threat, especially the threat in our country, Zimbabwe, posed by HIV infection.
For a start, it confuses some of the messages we have painfully and intensely propagated over many years. The “ABC” of abstinence, being faithful, and using a condom is somehow muddied, because young men, in particular, go for circumcision in order to avoid the messy business of having to use a condom.
Secondly, the widely publicised experiments at Orange Farm in Gauteng, South Africa, Rakai in Uganda and Kisumu in Kenya were not, by any ordinary definition, “gold standard” randomised controlled trials. In fact, they were not random controlled trials at all, and even the experiment was uncompleted.
The only thing which was randomised, and this was not fully blinded, was the allocation of the volunteers to the two groups (circumcision or delayed circumcision). It is obvious to anyone that both the volunteer and the researcher knew immediately to which group the volunteer belonged, raising the strong probability of the Hawthorne effect, i.e. the bias introduced by multiple changes occurring at the same time, only one of which is recorded as being responsible for the effect seen. This, of course, was the effect that the funders of the experiment wanted to see. A moment’s thought will impress the objective observer that circumcision with enforced abstinence for 42 days is probably the most dramatic “behaviour change” a sexually active young man can ever experience as an individual!
Thirdly, if money for health initiatives is available, there are many more urgent and beneficial initiatives which cry out for funding in this region, in particular. One has only to see the disastrous effects, and, indeed, downstream consequences on both the family and the health worker of the deteriorating statistics and causes of maternal mortality and perinatal death and disability in our country. This quantum of money could have been more profitably used in preventing and treating cervical cancer, from which almost nobody now dies in rich countries. And I’ve only touched on reproductive health. Many initiatives in the broad spectrum of health could produce better and more permanent improvements in our social setting.
Fourthly, the question of gender balance has to be raised. Even the most ardent enthusiast will admit that this initiative will benefit men, exclusively, in the initial phase at least, though I’ve seen some fanciful medical modelling claiming that it will lead to benefits for women (on the HIV incidence) eventually. It is, however, an initiative totally targeted at benefiting young men.”
The study was ‘bad science’ done by culturally bias researchers and there never has been a protective effect for circumcision.
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