"I just cannot live with my conscience... who would agree to having the most sensitive part of their body mutilated?"

Male Circumcision is Inappropriate for the Prevention of HIV

Last updated on 1st September 2008

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Recent research in Africa has claimed to provide proof that male circumcision confers protection against HIV/AIDS.[1][2][3]

NORM-UK, NOCIRC and ICGI consider male circumcision inappropriate as an intervention for three reasons: bioethical considerations, lack of real-world applicability and doubts about the science.

To summarise the research finding, men who were circumcised in the study were reported to be at a roughly 60% reduced relative risk of HIV compared to those who retained the normal foreskin. This amounted to an absolute risk reduction, during the two years of the study, of around 1.3%. Participants who were circumcised suffered a complication rate of up to 3% with complications including erectile dysfunction. Whether those who were circumcised will remain at lower risk during their remaining lives is purely speculative.

Bioethical implications

There are over-riding ethical reasons why circumcision of men for protection from HIV is inappropriate:-

It is not a proportionate intervention since it is in itself damaging to the normal appearance and function of the body[4]
A less invasive intervention - use of condoms - is proven to be effective and indeed is likely to be more effective [5][6]
Male circumcision does not decrease[7][8][9][10] and may increase the risk of male to female transmission[11]
Male circumcision in real-world African settings will be a vector for transmitting the virus and is likely to worsen the pandemic[12][13][14][15][16][17]

Everyone has a right to autonomy: the right to make an informed choice as an adult to decide the fate of their own body. While adult men have the right to be circumcised if they consider that it will protect them from HIV, they have a right to be realisticallly informed about the prospects of the treatment achieving the goal, the negative effects that will go along with it and the risks.

Informed consent to circumcision for HIV protection must disclose:-

The modest reduction in the absolute risk rather than the exciting apparent reduction in relative risk.
The doubt about whether the treatment will give any reduction over the person’s lifetime.
The risk of complications,[18] including the risk of transmitting HIV in an African setting.
The potential for the female partner to be put at risk.
Male circumcision removes the part of the penis most sensitive to fine touch.[19]

It is never appropriate to remove normal body parts from normal unconsenting children to prevent diseases of sexually promiscuous adults.

Real World Applicability

Several lines of enquiry suggest that the findings of the research do not translate into any meaningful reduction of HIV in the real world:-

Overall evidence of the relationship between circumcision and HIV in Africa is contradictory and does not show any overall reduction in HIV due to circumcision [20]
The US is the only country in the developed world to circumcise most of its boys for non-religious reasons but this has not prevented it from becoming the developed nation most burdened with HIV.[21]
More generally countries with a high level of circumcision compare badly in terms of HIV prevalence with European countries that have a low level of circumcision.
A British study of gay men found a higher rate of HIV among those who were circumcised than those who were normal.[22]
Any increase in male to female transmission due to male circumcision could negate the effect.
In reality, circumcision in Africa is performed in a dirty setting. Medical instruments have been
shown to contribute to the spread of HIV in Africa. Mandating circumcision can only make the HIV problem worse.

Review of the Science

The African HIV studies fall short of the gold-standard of proof of medical effectiveness. The lack of blinding in the studies makes them prone to "observer bias". The researchers were known to be biassed since they had previously published work advocating male circumcision for the prevention of HIV in Africa.

The studies recruited men who "wanted to be circumcised" because the participants believed that circumcision would protect them from HIV. Those who were circumcised in the studies had less sex than those who were not since they alone were told to abstain from sex for six weeks.

The number of study participants who were "lost to follow-up" from the studies far outweighed the number of participants who acquired the virus. This casts serious doubt on the validity of the research findings.[23]

The studies were terminated early. Research has shown that studies terminated early consistently overestimate the benefits of treatment.[24][25] In two well-documented cases a data-monitoring committee recommended that the study be terminated early because there was no possibility of the treatment being shown to be ineffective but the study nevertheless went on to its end.[26][27] The conclusion was that the treatment was not effective. It has been suggested that exciting finding in studies terminated early merely "reflect the prevailing bias" of the research community.

The studies have been supported by a massive publicity machine to drive home the conclusion. Publication of the studies was accompanied by pictures on the TV news of African boys being rushed into gleaming sterile operating theatres of a type that are thin on the ground in Africa. The reality is that African boys will be circumcised in the bush with a dirty knife that has just circumcised an HIV positive boy. As such, to promote circumcision in Africa is recklessly irresponsible.

The researchers have emphasised exciting reductions in relative risk while the findings in terms of absolute risk are less appealing. Even where the prevalence of HIV is very high, the risks of circumcision outweighed the benefits. In developed nations the risk to benefit ratio will be much higher.

That said, the researchers are to be complemented for being the first to use a Randomised Controlled Trial to prove that circumcision is actually effective in preventing a disease. Given this ground breaking finding, why will they not share their data with other researchers outside their closed group?

References

1 Auvert B, Taljaard D, Lagarde E, et. al. Randomized controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med. 2005;12: 298.

2 Gray RH and colleagues. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet,2007:369;657-666.

3 Bailey RC and colleagues. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet,2007:369;643-656.

4 Taves D. The intromission function of the foreskin. Med Hypotheses. 2002; 59(2):180.

5 Agot K, Ndinya-Achola JO, Kreiss JK, Weiss NS. HIV-1 prevalence in circumcised versus uncircumcised Luo men from African instituted churches in rural Kenya. XIV World AIDS Conference. 2002.

6 Wainberg MA. The cutting edge on circumcision: reducing the risk. Parkhurst Exchange, Jan 2001.

7 Castilho EA, Boshi-Pinto C, Guimaraes MDG. Male circumcision and HIV heterosexual transmission. XIV World AIDS Conference. 2002.

8 Guimaraes MD, Vlahov D, Castilho EA. Postcoital vaginal bleeding as a risk factor for transmission of the human immunodeficiency virus in a heterosexual partner study in Brazil. Rio de Janeiro Heterosexual Study Group. Arch Intern Med. 1997; 157(12):1362-8.

9 Guimaraes M, Castilho E, Ramos-Filho C, et al. Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil. VII Intl Conf on AIDS. 1991.

10 Changedia SM, Gilada IS. Role of male circumcision in HIV transmission insignificant in Conjugal relationship. XIV World AIDS Conference. 2002.

11 Circumcision protects men from AIDS but might increase risk to women, early results suggest.International Herald Tribune, Tuesday, 6 March 2007.

12 Brewer DD, Brody S, Drucker E, Gisselquist D, Minkin SF, Potterat JJ, Rothenberg RB, Vachon F. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS. 2003; 14(3):144-7.

13 Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS. 2003; 14:148-61.

14 Gisselquist D, Potterat JJ, Brody S. Running on empty: sexual co-factors are insufficient to fuel Africa's turbocharged HIV epidemic. Int J STD AIDS. 2004; 15(7):442-52.

15 Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS. 2003; 14:162-73.

16 Gisselquist D, Rothenberg R, Potterat J, Drucker E. Non-sexual transmission of HIV has been overlooked in developing countries. Br Med J. 2002; 324(7331):235.

17 Nyindo M. Complementary factors contributing to the rapid spread of HIV-I in sub-Saharan Africa: a review. East Afr Med J. 2005; 82(1):40-6.

18 Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993; 80:1231-1236.

19 Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine-touch pressure thresholds in the adult penis. BJU Int. 2007; 99(4):864-9.

20 Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008, 7(1): 1–8.

21 GW Dowsett, M Couch. Reproductive Health Matters 2007;15(29):33–44.

22 Reid D, Weatherburn P, Hickson F, Stephens M. Know the score. Findings from the National Gay Men’s Sex Survey 2001.

23 Green LW et al. Male circumcision is not the HIV 'vaccine' we have been waiting for! Future HIV Ther. (2008) 2(3), 193–199.

24 Montori VM, Devereaux PJ, Adhikari NKJ, et al. Randomized trials stopped early for benefit: a systematic review. JAMA. 2005;294:2203-2209.

25 Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA. 2005;294:218-228.

26 Wheatley K, Clayton D. Be skeptical about unexpected large apparent treatment effects: the case of an MRC AML12 randomization. Control Clin Trials. 2003;24:66-70.

27 Slutsky AS, Lavery JV. Data safety and monitoring boards. N Engl J Med. 2004;350:1143-1147.

John Dalton is NORM-UK's lead researecher and archiver
This page does not contain medical advice