Circumcision is a dangerous distraction in the fight against AIDS.  There are six African countries where men are *more* likely to be HIV+ if they’ve been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland.  Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men.  In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men.  If circumcision really worked against AIDS, this just wouldn’t happen.  We now have people calling circumcision a “vaccine” or “invisible condom”, and viewing circumcision as an alternative to condoms.  The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.

The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

ABC (Abstinence, Being faithful, Condoms) is the way forward.  Promoting genital surgery will cost African lives, not save them.

— Mark Lyndon on 2010-07-19

Thanks to Bob Davis for highlighting the Male Circumcision Clearinghouse at http://www.malecircumcision.org This WHO-managed website contains all the relevant scientific evidence related to male circumcision (MC), as well as tools for policy makers and program implementers. 

I would like to reassure Mark Lyndon that the MC community considers behavior change an important part of HIV prevention efforts. For this reason risk reduction counseling and condom promotion form part of the “minimum package” of MC services, along with HIV testing and counseling and STI screening and treatment.

Dozens of peer-reviewed scientific studies—including ecological, epidemiological and biological evidence—support MC for HIV prevention. More importantly, three randomized clinical trials enrolling more than 10,000 men in South Africa, Kenya and Uganda demonstrated definitively that MC reduces female to male HIV transmission by around 60%. Male circumcision’s protective effect was so strong (in other words, uncircumcised men were so much more likely to contract HIV) that the ethics committees governing these trials halted them early so that men in the control arms could access this lifesaving prevention intervention as soon as possible. Randomized clinical trials are the gold standard in clinical and public health research. As a result of these trials, WHO and UNAIDS said ”The efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt. This is an important landmark in the history of HIV prevention.” MC also provides important indirect benefits to women. As MC programs scale up and fewer men become HIV-infected, it is less and less likely that women will encounter an HIV positive partner. In fact, modeling data presented today in Vienna suggest that in the highest prevalence settings women will eventually benefit more than men in terms of reduced HIV incidence, since women after all bear the brunt of the pandemic in east and southern Africa. MC also reduces transmission of a number of other reproductive tract infections that can negatively affect women; these include HPV (which causes cervical cancer), herpes and bacterial vaginosis, which can cause pre-term labor in pregnant women. 

In most countries in east and southern Africa the highest prevalence provinces or regions are those where circumcision is uncommon (for example, Gambella, Ethiopia, Nyanza, Kenya, Iringa, Tanzania and Kwa-Zulu Natal, South Africa). In these settings HIV prevalence is double or even triple that of provinces where circumcision is the norm. There are rare cases, such as in Lesotho, where men who report that they are circumcised nonetheless have high HIV rates. In Lesotho traditional circumcision often involves the removal of only part of the foreskin, or sometimes just a ritual nick to draw blood. In this case men report that they have been circumcised but still have most or all of their foreskin which contains many target cells highly vulnerable to HIV infection.

— Kelly Curran on 2010-07-21

malecircumcision.org seems designed solely to promote male circumcision.  The one RCT into male-to-female transmission ( http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60998-3/abstract ) is simply glossed over.  The assumption (often unspoken) always seems to be that circumcised men are not more infective to women, when the available evidence simply does not back this up.  (see also this 1993 study which found that “partner circumcision” was “strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates.” 
http://ije.oxfordjournals.org/cgi/content/abstract/23/2/371 )

The figures in the first study mentioned were too small to show statistical significance, but there will be no larger scale study to find out if circumcising men increases the risk to women.  Somehow that would be considered unethical, yet it’s considered ethical to promote male circumcision whilst not knowing if the risk to women is increased (by 54%?, 0%?, 108%? - who knows?)

“WHO/UNAIDS advise against promoting male circumcision for HIV-positive men, but state that it should not be denied unless medically contra-indicated”.

Why would we be diverting medical resources towards circumcising men who are already HIV+, when the available evidence seems to suggest that it makes them more dangerous to women?

There are indeed very different forms of male circumcision, but I consider it unrealistic to expect that men who consider themselves to be circumcised will want to get circumcised again.  However the message of the circumcision campaign is that they have 60% protection anyway.  It seems implausible that there won’t be at least some risk compensation, especially as 15% of people in South Africa “believe that circumcised men do not need to use condoms” ( http://www.info.gov.za/issues/hiv/survey_2009.htm ).  If condom use drops by even a small amount, then there will almost certainly be a rise in new infections, amongst both men and women.

At the Vienna conference, we learned that only about 1 in 6 men being circumcised are agreeing to be tested for HIV first.  Even then, they are offered circumcision anyway, though it appears to increase their risk of transmitting HIV to women.  In Swaziland, 19.5% of intact men already have HIV (and 21.8% of circumcised men), so why is circumcision even being considered when one in five of the men being circumcised will already have HIV?

Female circumcision has also been linked to lower rates of HIV btw, but that would never be considered as a strategy:
( http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138 “In the final logistic model, circumcision remained highly significant [OR=0.60; 95% CI 0.41,0.88] while adjusted for region, household wealth, age, lifetime partners, union status, and recent ulcer.” )
There could be ten RCT’s showing a 90% protection rate, but even minor forms of female circumcision would never be considered an acceptable strategy of preventing the spread of HIV.

Promoting male circumcision is also likely to mean higher rates of female circumcision.  Even if some westerners see a fundamental difference, the people that cut girls don’t (and neither do I).

ABC, especially condoms is still the best way to fight HIV in Africa.  Promoting genital surgery is not only unethical (especially when practised on children), but may actually makes things worse, yet hundreds of millions of dollars of funding are being diverted towards circumcising up to 38 million males.

See also http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431
“Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs.”

http://apha.confex.com/apha/134am/techprogram/paper_136814.htm
“Results: … No consistent relationship between male circumcision and HIV risk was observed in most countries.”

French AIDS Council:
“Even though the WHO insists on the idea that, beyond male circumcision, the use of other forms of prevention remains essential, it is very likely that people who mistakenly believe themselves to be adequately protected will no longer use condoms.”
...
“Implementation of male circumcision as part of a draft of preventative measures could destabilize health care delivery and at the same time confuse existing prevention messages. The addition of a new tool could actually cause a result opposite to that which was originally intended.”
Rozenbaum W, Bourdillon F, Dozon J-P, et al. Report on Male Circumcision: An Arguable Method of Reducing the Risks of HIV Transmission. Conseil National du SIDA, 2007: 1-10.

and as this South African paper puts it:
“Those promoting circumcision argue that circumcision is an additional tool that will ultimately reduce infections more than just relying on condoms, monogamy and abstinence. However, African males are already lining up to be circumcised, thinking they will no longer need to use condoms. Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections.”
http://www.futuremedicine.com/doi/abs/10.2217/17469600.2.3.193

— Mark Lyndon on 2010-08-16