HIV and Circumcision…in America

Over the next year, the Office of National AIDS Policy, led by Dr. Jeffery Crowley, will come up with a strategy for fighting HIV in the United States. That project is long overdue. While the Bush administration devoted unprecedented resources to combating HIV/AIDS in the developing world, it largely ignored the epidemic here at home. Over 1.1 million Americans live with HIV. In 2006, over 56,000 new infections were recorded. And the disease is increasingly associated with minority communities and the poor; in Washington, D.C., the major American city with the highest HIV/AIDS rate, 4.3 percent of all African Americans are infected. Among black men in D.C., 6.5 percent are HIV-positive.

Internationally, the HIV-prevention method gaining the most momentum — and attracting the most press — is male circumcision. A series of studies conducted in Africa found that circumcision decreases female-to-male HIV transmission by as much as 60 percent. That is because the cells of the foreskin are especially susceptible to infection. (Women though, aren't any less likely to contract HIV from circumcised men.) Since 2007, the World Health Organization has strongly recommended circumcision, calling the new research on the procedure "an important landmark in the history of H.I.V. prevention."

Considering this evidence, should circumcision-promotion be among the policy levers the Obama administration considers? As New York City Mayor Michael Bloomberg learned two years ago, when he created a maelstrom by asking the city health department to encourage the procedure, American public health efforts must tread carefully around this issue. The promising circumcision research was conducted entirely in Africa, largely among heterosexuals. In the United States, HIV continues to disproportionately affect the gay community. In 2005, half of all new cases were among men having sex with men, compared to 33 percent among heterosexuals engaged in what the CDC calls "high-risk" behaivor — a woman who has unprotected sex, for example, with a man who is also having unprotected sexual encounters with other men.

American HIV/AIDS advocates have worked for nearly three decades to send the message that condoms are the best way to protect against the disease. That messaging has been effective, and it's important to double down on it within the gay community: Clinical studies show that gay sex is much more likely to lead to HIV infection than hetero sex. Among men having sex with men, circumcision is likely to offer very little protection against the disease. But the truth is, we don't have good research on that question — and certainly not in an American context.

About 60 percent of American men are already circumcised. Those who aren't are more likely to be recent immigrants or first generation Americans, and to hail from cultures resistant to condom usage. For these men, a public health push on condoms is likely to reap far greater dividends than a pro-circumcision campaign, which is likely to be seen as even more radical and intrusive. What's more, condoms are far cheaper than circumcision. So when it comes to extrapolating American public health policies from the African circumcision research, we should proceed with caution. After all, the United States already has the highest circumcision rate in the developed world — and also the highest HIV infection rate.

cross-posted at TAPPED

7 thoughts on “HIV and Circumcision…in America

  1. Alec

    Well, don’t forget that most cases of HIV in the U.S. are caused by injection drug use, which circumcision obviously can’t protect against. Let’s also not forget that there are other health benefits to circumcision, such as reduced incidence of HPV: link to health.usnews.com

    Check out the other finding of the recent studies, as well: link to men.webmd.com

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  2. mike

    And I’m afraid that your first commenter has it wrong: Most cases of HIV in the U.S. are NOT attributable to injection drug use, unless you focus just on women. By and large, HIV is transmitted in the U.S. and places like Sub-Saharan Africa through unprotected sex. Not so in Eastern Europe, North Africa, the Middle East, etc. Check the CDC Fact Sheets.

    But s/he is right in pointing out that there are many potential benefits of male circumcision, not least of which is a decreased risk of female to male transmission via unprotected sex. Note that the converse is not true, according to the evidence. Nor is it true that MC protects against transmission among same sex partners.

    Reply
  3. franky

    Seriously circumcision doesn’t cure anything !

    Circumcision was introduced during 1870s to decrease sexual pleasure and masturbation. Then it was supposed to cure all sorts of diseases : hysteria, epilepsy, infections, hydrocephalus, cervical cancer, penile malignancy etc…
    All these myths have been debunked so far.
    Now it is said that it prevents AIDS.

    The funniest thing is people are still beliving all these myths. Circumcision is just a cure searching for a disease. The only people who have ever really benefited from circumcision are the American doctors who have treated the homegrown American foreskin as an annuity. Circumcision and foreskins used for cosmetic research have become a huge buiness.

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  4. Hugh7

    Brava Dana for your balanced coverage!

    The HPV studies seem to have been wheeled up to answer the objection that circumcision does not protect women from HIV (which has now been proved – in fact the recent study suggested it might put women at greater risk, but they cut it short before that could be determined).

    HPV is a common virus and there is now a vaccine for it. The claim that circumcising men will protect women from cervical cancer is speculative at this stage, though some highly biased studies have been given a lot of spin in that direction. (The one most often cited, that of Castellsagué et al., actually pooled people in five different countries, but only in one of them, the Philippines, were a significant number of the men circumcised, so there were a lot of demographic confounders. There was no significant difference in the countries taken individually.)

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  5. Rational Thinker

    > That is because the cells of the foreskin are especially susceptible to infection.

    This is conjecture that has never been proved, even 2-3 years after those statistical studies in Africa.

    America is the most circumcising industrial nation in the West, and yet it has an HIV incidence rate 3.5 times higher than that of the next most advanced nation (which doesn’t circumcise).

    That gay men are not protected by circumcision strongly suggests that sexual behavior is what is important.

    Reply
  6. Rational Thinker

    I should add that even if circumcision were to reduce the risk of STDs, it is important to note that children do *not* get sexually transmitted diseases (unless you consider those poor boys who contracted genital herpes after a mohel sucked on their bloody phalluses—go look it up).

    Reply

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