Circumcision Ineffective In HIV Prevention in MSM

The latest research results about the impact of circumcision on HIV prevention have been released. You may recall the "to cut or not to cut" controversy earlier in the year when the head of the New York City health department floated the idea of adult male circumcision as a reasonable HIV prevention strategy, to much derision and dismay from AIDS activists. The new research shows that uncut guys can maybe uncross their legs now...

Despite research showing circumcision can reduce a man's risk of HIV during heterosexual intercourse, a study published Wednesday in the Journal of the American Medical Association found that the procedure offers little protection against the virus for men who have sex with men, AFP/Yahoo! News reports. According to the study, there was minimal difference in HIV infections between those MSM who were circumcised and those who were not (AFP/Yahoo! News, 10/7).

For the study, researchers at CDC, led by Gregorio Millett, reviewed 15 previous studies on circumcision that included 53,567 MSM from Australia, Great Britain, Canada, India, the Netherlands, Peru, Taiwan and the U.S. Circumcised MSM were 14% less likely to be HIV-positive than those who were not, a rate that was not statistically significant, according to the researchers. Millett said, "You can't necessarily say with confidence that we're seeing a true effect there," adding, "Overall, we're not finding a protective effect associated with circumcision" for MSM (Dunham, Reuters, 10/7).

However, when examining studies carried out before the introduction of highly active antiretroviral therapy in 1996, the researchers found evidence that circumcision in the past had a protective effect for MSM, BBC News reports. The researchers said one explanation for the reduced effectiveness of circumcision among MSM following the introduction of HAART is that the efficacy of drugs diminished the perceived need to practice safer sex to avoid contracting HIV. In addition, the study noted that HAART might help reduce the risk of HIV transmission to a level that circumcision does not provide further benefits. The researchers also said that there may have been a smaller proportion of men in the pre-HAART trials who engaged primarily in receptive anal sex, which carries the greatest risk of HIV among MSM (BBC News, 10/7).

More Reports and Research On Uncircumsized Men and HIV

In Tuesday's New York Times there's an article ("Washing After Sex May Raise H.I.V. Risk") on a counter-intuitive result from a study on uncircumcised men in Uganda: immediate washing of the penis after vaginal sex increased the rate of HIV transmission from female to male sexual partners. A summary of the article by the invaluable Kaiser Daily HIV/AIDS Report says:

For the study, Fredrick Makumbi of the Makerere University Institute of Public Health and colleagues examined 2,552 uncircumcised, HIV-negative men ages 15 to 29 in the Rakai district of Uganda. Eighty-three percent of the participants said they washed their penises with all sex partners, the Times reports. The researchers asked the men when and how they washed their penises -- including if they washed with or without cloths -- after sex at the beginning of the study and at six, 12 and 24 months after the study began. According to Ronald Gray, a study co-author and professor of population and family planning at Johns Hopkins Bloomberg School of Public Health, the researchers did not ask details about how the washing was conducted or if soap was used because of an oversight. Some soaps used in Africa are more irritating than soaps used in other places, according to the Times.

The researchers found that men who washed within three minutes after sex had a 2.3% risk of HIV infection, compared with a 0.4% risk among men who delayed washing for 10 minutes or more. Makumbi and other AIDS experts said they do not know why washing might increase vulnerability to HIV, but they offered some explanations. One is that delaying washing and prolonging exposure to vaginal secretions might reduce viral infectivity. Another explanation is that the acidity of vaginal secretions might impair the ability of HIV to survive on the penis, the Times reports. In addition, the use of water, which has a neutral pH, might prolong viral survival and possible infectivity, according to the Times. HIV likely needs to be in a fluid to cross the mucosa and infect cells, Gray said, adding that if HIV-infected fluid dries, its infectivity could decrease. Adding water, therefore, could resuspend HIV and increase its infectivity, the Times reports.

This follows news reports that Bush Administration is going to start allocating some of the funds in PEPFAR (President's Emergency Plan for AIDS Relief) to provide adult male circumcision in African countries such as South Africa, Kenya and Uganda where studies have shown tha male circumcision can reduce HIV transmission rates by as much as 60 per cent among heterosexuals. The Black AIDS Institute sent out a rare statement praising an initiative by the Bush administration.

Meanwhile, public health must begin to make people aware of the dramatic difference circumcision appears to make in HIV risk. In doing so, however, the Bush administration must respect the justified concerns both communities and individuals may present. Too many years of abuse at the hands of pseudoscience have left communities of color around the world distrustful of health officials. Any outsider- driven, top-down campaign urging men to have skin removed from their penises will no doubt deepen that skepticism.

So as the Bush administration gears up its response to the compelling data on circumcision, it will be well advised to help local leaders do the leading, which is something its AIDS program has proven reluctant to do in the past. That includes investing in raising the HIV-science literacy among local leaders and supporting culturally appropriate venues where communities can develop the tools needed to interpret the science.

At the same time, people of color around the world no longer have the luxury of allowing other folks' mistakes to hold us captive. If we're going to survive this epidemic, we must begin taking responsibility for our own lives. That means, no matter what the Bush administration does, and no matter what any local health department does here in the U.S., we must learn the facts about circumcision and HIV.

It is an entirely appropriate choice for any individual to opt against circumcision as a method of HIV prevention. But he must make that choice based on the facts, not as a self-defeating reaction to fears about government abuse.

Mad Professah has been following the ongoing debate(s) about HIV and circumcision quite closely and will continue to do so.

Circumcision Controversy Continues

Andrés over at Blabbeando and commenters over at Joe.My.God do a good job of following the "furor over foreskin" that Mad Professah has been blogging about for awhile now. Blabbeando links to a cool article at Vivir Latino which has a statement (via 20 Minutos) from Mariángela Simao, a technical advisor in the Health Ministry in Brazil (a country which probably has the world's largest supply of uncircumcized penises, and some would argue also the largest supply of world's largest uncircumcized penises) declaring that Brazil will not be considering circumcision as an HIV prevention tool anytime soon and lambasting the idea.

"I find the recommendations of the WHO and U.N. HIV/AIDS program a little surprising and even frightening," Simao told Agencia Brasil.

...This proposal gives a message of "false protection" because men might think that being circumcized means that they can have sex without condoms without any risk, which "is untrue", she said.

(English translation by Vivir Latino)

The always excellent Andrés has a copy of a Dear Community Member letter (and a link to the scanned-in full text by LifeLube) from often-controversial NYC Health Commissioner Thomas Frieden which was circulated to HIV/AIDS community leaders in New York City yesterday where he disputes statements attributed to him in the New York Times on April 5, 2007.

Dear Community Member:

Recent media reports misrepresent the Health Department’s response to recent studies showing that circumcision significantly reduces HIV transmission in some contexts. We do not yet know what impact circumcision could have on HIV transmission in New York City, and we have not suggested or planned any initiative or campaign. Quite to the contrary, I indicated in an interview with the New York Times (the source of the misrepresentation) that I very much doubted that even 1% of men at high risk in NYC would undergo the procedure.

As a result of rigorous studies, we now know that circumcision reduces risk of female-to-male spread of HIV by about 60%. There is some evidence, but no proof, that circumcision may reduce male-to-female transmission. There is also some evidence, but again no proof, that it may protect men who engage in insertive anal sex from male-to-male transmission.

[...]

The plot thickens!

New York City Seeks To Promote Circumcision Among Gay Men

Following up on a story Mad Professah discussed last week and recommendations from the World Health Organization about the beneficial prevention effects of adult male cicumcision, controversial New York City Health Commissioner Thomas Frieden announced today that he is interested in his department promoting the practice, the New York Times reported.

Mayor Mike Bloomberg and others called for caution in endorsing the measure. The current Mayor (and possible 2008 Presidential candidate?) was quoted saying:

“Whether it’s something that the government should be involved in, or just giving advice and making sure that people get educated, education in the end is the real tool to stop the spread of AIDS in our society. That may or may not be true elsewheres."

Founder of Treatment Action Group, AIDS activist Peter Staley said “Should we proceed when we don’t have hard data yet on the population here?” he asked. “On the other hand, if we wait the three years it would take to answer that question, how many will be infected in the meantime?”

Staley also pointed out the obvious cultural implications of several, predominantly white officials telling black and brown gay men that they should have surgery on their genitals. “I’m white, Frieden’s white,” he said. “It’s going to sound like white guys telling black and Hispanic guys to do something that would affect their manhood.”

Tokes Osubu, executive director of Gay Men of African Descent, agreed and declared that circumcision is "not the answer to our problems" and doubted that it would reduce alarmingly high HIV infection rates among gay men of color in New York City, currently estimated at at least 20%.

WHO recommends adult circumcision as HIV prevention measure

The United Nations Programme on AIDS (UNAIDS) announced this week in a joint press release with the World Health Organization the results of three clinical trials conducted in Africa which indicate that circumsized men are 50-60% less likely to contract HIV through heterosexual sex. The results were so striking that the trials were stopped and all participants offered the circumcision procedure.

This is very exciting news for HIV/AIDS prevention efforts in Africa, but as usual, the sticking point is money.

"Money is going to be the key. If additional resources brought to bear, we can have very substantial effects on the AIDS epidemic in East and Central Africa," Ronald Gray, MD [professor of reproductive epidemiology at Johns Hopkins University] says. "These are not cheap resources. There are the costs of training, the costs of equipment and supplies, the costs of all the complexities of providing surgeries and providing postsurgical care and managing any problems that arise."

If money is not forthcoming, the recommendations may do more harm than good. Men in areas with high HIV prevalence are very much aware of the news that circumcision lowers HIV risk.

"There is a lot of anecdotal evidence that men already are lining up asking for circumcision," Gray says. "And if we do not provide safe services, they will seek unsafe services."

Further trials are being conducted to see whether circumcision has a preventive effct on HIV transmission to women and the impact on men who have sex with men.