Promoting infant male circumcision to reduce transmission of HIV: A flawed policy for the US

[Editor’s note: This is a guest post written by Sarah Bundick.]

On August 23, the New York Times reported that the CDC may recommend infant male circumcision as an HIV-prevention strategy. This article was followed by an editorial in the Boston Globe on August 26. The editorial states that infant male circumcision “makes sense [as a tactic] against a virus that infects more than 50,000 Americans each year” and that circumcision “deserves the CDC’s support.” These statements are based on the results of clinical trials in Africa showing that circumcised men were approximately 60% less likely to become infected with HIV than their uncircumcised counterparts. Unfortunately, the two numbers that the editorial cites — the 60% reduction in HIV transmission and the 50,000 new infections in the US every year — have very little to do with each other.

Let’s look first at the reduction in HIV transmission associated with male circumcision. In 2005, a group of French and South African researchers reported that adult male circumcision provided 60% protection (95% confidence interval: 32%–76%) from HIV infection to the circumcised men over a period of approximately 18 months in a South Africa-based trial. In 2007, two other studies completed in Africa, one in Uganda and one in Kenya, reported similar levels of reduction in the risk of HIV transmission. These clinical trials suggested that promoting adult male circumcision may be a way to reduce HIV transmission in certain contexts, particularly those in which HIV prevalence is high (as in the study areas, where prevalence estimates range from 5% to 30%) and where heterosexual transmission is the most common mode of transmission. The situation in the US, however, is markedly different: HIV prevalence is low (0.4%) and transmission of HIV is highest among injecting drug users and men who have sex with men. Thus,  the applicability of the African trials to the American HIV epidemic is severely limited.

The second number cited in the Globe editorial is the number of new HIV infections in the US — 50,000 per year. This number is (apparently) based on a CDC estimate of all new HIV infections in 2006. The CDC also estimated the number of new infections for many different subgroups based on demographics and on mode of transmission. Looking at these data, it becomes immediately clear that the estimated 50,000 new infections every year are predominantly the result of injecting drug use and male-to-male transmission during sexual contact. Heterosexual contact is estimated to be responsible for only 5,250 new infections in men each year in the US — a far cry from the 50,000 infections cited by the Globe’s editorial team.

It is important to note that there is no strong evidence that circumcision reduces the risk of male-to-female or male-to-male transmission via sexual contact. (Although probably obvious, it is also important to note that male circumcision is not related to HIV transmission by injecting drug use.) Therefore, the current data suggest that the 5,250 female-to-male transmissions are the only ones likely to be prevented by male circumcision.

Now let’s factor in the efficacy of circumcision (approximately 60%), ignoring for a moment several important factors — the short time period used to determine efficacy in the clinical trials, the fact that the actual statistics gave ranges for the efficacy (from 22% to 77%), and the fact that the different infection profile in the US limits the trials’ relevance in the US context. If we assume that all 5,250 men who get HIV from a female sexual partner are not circumcised (though this is certainly not the case), the data suggest that about half of these infections — around 2,625 infections or ~5% of new infections — may have been prevented if the men had been circumcised. If we then factor in the number of men who are circumcised when they are infected (approximately 70-80% of American men are already circumcised), the number of infections that could have been prevented by circumcision drops considerably. Taken together, the data suggest that the number of HIV infections that could be prevented in the US by promoting infant male circumcision is likely to be only in the hundreds per year — a tiny fraction of the estimated 50,000 new HIV infections.

Why then are people pushing for infant male circumcision as an HIV-prevention measure here in the US? I can think of two possible explanations. First, proponents may have seen the same numbers that the Globe printed — protection of up to 60% and 50,000 new HIV infections per year — and erroneously concluded that male circumcision could significantly reduce HIV transmission in the US. Erroneous conclusions like this one are common when scientific literature is covered by the mainstream media, in which many important details are often lost. Second, proponents may be (consciously or unconsciously) using HIV prevention as a way to validate subjecting baby boys to medically unnecessary surgery done for cultural or religious reasons — it is a lot easier to defend genital modification (or mutilation depending on one’s viewpoint) if it prevents a deadly disease. (Please note that my argument here is not that circumcision should not be practiced for cultural or religious reasons — I am staying out of that debate here — my argument is that medical data from the African circumcision trials are being inappropriately used to defend and promote a practice done for cultural or religious reasons.)

But given that the majority of men in the US are circumcised anyway, some may ask why the CDC’s possible recommendation of infant male circumcision is such a problem. It is a problem because promoting infant male circumcision could have negative impacts with regard to HIV transmission by inadvertently promoting the idea that “circumcised sex” is safe sex. In the 2005 male circumcision trial in South Africa, men in the intervention (circumcision) group reported having more sexual partners than men in the control (uncircumcised) group. If circumcision is promoted as a way to reduce the risk of HIV transmission, there is a possibility that this disinhibition could happen in the US as well — men may incorrectly assume that they are protected from HIV if they are circumcised, and these men may therefore exhibit more risky behaviors (numerous sexual partners and limited condom use). Proponents are likely to counter this problem by calling for more education to prevent these misconceptions. The question then is why promote medically unnecessary surgery as an HIV-prevention strategy when it also increases the need for proper education on HIV transmission? Why not just educate people and leave out recommendations for surgical procedures of dubious medical value?

The promotion of infant male circumcision also ignores the right of men to not be circumcised as infants — a right that many people and governments dispute. Despite the ongoing nature of the debate as to whether or not infant circumcision is a human rights violation, the fact that many people view infant circumcision as a human rights violation should make the CDC even more hesitant to promote the practice.

A consultant to the American Academy of Pediatrics, Dr. Michael Brady, has said that “families should be given an opportunity to know what [the benefits of male circumcision] are.” On this point, at least, everyone can agree. People in the US — and in all countries — should be educated about any potential benefits of circumcision, but the public should not be fed half-truths or statistics stripped of all meaningful context. Everyone should be told the whole story — a story that does not point to any significant reduction in HIV transmission as a result of promoting infant male circumcision in the US.

Given the problems with promoting infant male circumcision as an HIV-prevention strategy in the US — a low number of prevented infections and the possible misconception that “circumcised sex” is safe sex — the population-level health benefits of promoting infant male circumcision are not clear, and infant male circumcision does not make sense as a US HIV-prevention strategy. Instead of looking for the quick fix, we — and the CDC — should focus our attention on what will work: education.

Education and prevention of HIV transmission:

Lancet: Randomised, controlled, community-level HIV-prevention intervention for sexual-risk behaviour among homosexual men in US cities

AIDS: A peer-education intervention to reduce injection risk behaviors for HIV and hepatitis C virus infection in young injection drug users

Journal of the American Medical Association: Abstinence and Safer Sex HIV Risk-Reduction Interventions for African American Adolescents