Male Circumcision and HIV

Queereka recently received a comment through our “contact us” portal asking us to weigh in on this video https://www.youtube.com/watch?v=NwX5zfC0hgc about the recent evidence that’s been uncovered that HIV transmission can be reduced by circumcision and this article as a possible rebuttal to the point. The commenter further worried that “This is bad on many levels because it could also filter back to the gay community here in the US. I’ve heard guys tell me they’re safe because they always top or that they’re safe because they’re circumcised before and we’ll likely see a wave of that again.” To examine whether or not these fears are founded let’s examine how these claims fair when held against the scientific literature.

Does circumcision have an impact on HIV transmission? Yes. A series of three randomized clinical trials carried out in South Africa, Kenya and Uganda indicated that the HIV transmission rates for female to male transmission were reduced by between 50-60 percent. Further studies have replicated these findings and the meta-analysis of the studies (the statistical assessment of the findings of multiple studies) confirmed this risk reduction. The prevailing hypotheses are that the increased keratinization of the glans creates an inhospitable environment for the virus and that immune cells known as Lagrans cells, may serve as hosts. Removing the foreskin removes the initial host, reducing the risk of infection. In response, the WHO has called for male circumcision to be included as a strategy in the fight against HIV. However these recommendations apply only to regions where HIV infection rates among male heterosexuals are at or above 15% and the circumcision rate is below 20%. In response, many African nations, including South Africa and Kenya, have begun voluntary, mass, male circumcision programs.

You may have noticed that I emphasized female-to-male transmission. The few studies that have addressed this issue have not found evidence that male-to-female transmission is reduced in circumcised men. There is also no evidence to suggest that circumcision prevents male-to-male transmission, especially in penetrative sex. This makes sense given that the vectors male-to-female and male-to-male transmission are semen and pre-ejaculate. Circumcision doesn’t impact Semen and pre-ejaculate production which means that there is no benefit on an individual level to the penetrated partner. That’s problematic as transmission from men to women is about 2 times higher than the reverse. There is, however, a potential benefit for women and MSM if the levels of circumcision are high enough to confer “herd immunity” status on uninfected males, thus reducing the risk of transmission but this is a clinical and epidemiological picture that’s yet to appear.

Voluntary mass circumcision programs and circumcision as a strategy are not without controversy, ethical concerns or cost. The biggest problem, which I’ve already touched on, is that circumcision does nothing to prevent HIV transmission from an infected male to an uninfected partner and may also drive an increase in male-to-female transmission due to an increase in unprotected or multiple-partner sex. Marketing may also lead people to the erroneous conclusion that circumcised men directly protect women from HIV and other STIs. If adult circumcision is to be protective it must go hand-in-hand with HIV testing to eliminate HIV positive men from the circumcised pool to receive other medical attention. Finally, if circumcision is to be effective it must be carried out in a safe, medical setting. This presents a cost challenge to widespread circumcision efforts because of poor, rural healthcare coverage. This problem that has led some experts to call for increased reproductive health education and condom use as pro-circumcision zeal grows.

There are also cultural concerns at play. Male circumcision is thought to be most protective for men when they are circumcised in infancy, before the HIV infection. Informed consent and anti-circumcision advocates hold that this violates consent because an infant cannot consent to an optional, irreversible surgery. Circumcising infants would also only have an impact on the HIV epidemic more than a decade after circumcision which would not help prevent transmission now. Infant circumcision would also change the cultural context of circumcision for many African ethnic groups who currently practice it as a rite of passage into adulthood. It may not be tolerable for certain ethnic groups to change the meaning of the act of circumcision from a socio-religious one to a strictly medical one. Furthermore boys who undergo circumcision as a rite of passage are encouraged to have sex soon afterwards, often with sex workers to facilitate the transition. Intercourse with an unhealed, circumcised penis is riskier than circumcised sex because the virus has the opportunity to get into the bloodstream. The increase in pro-circumcision sentiment may also have a the spillover onto female genital mutilation. As the drive for male circumcision grows it may follow that the demand for female circumcisions will grow in the absence of evidence of any medical benefit whatsoever.

None of what I’ve said touches on the sensitive politics of circumcision in general and that’s intentional. This article isn’t about the body integrity debate so much as it is about what has been discovered about circumcision and when it is appropriate. In the US a mass circumcision strategy would be at best expensive and impractical due to the lower prevalence of HIV in the general public. 71% of HIV transmissions are between men who have sex with men which has been shown to not be protective by current studies. This is why the CDC and FDA have not called for mass circumcision in the US, opting for PrEP instead. In short, if you are a straight man who is HIV negative that lives in an area where you can safely get a circumcision in a region with high incidence rates of HIV then a circumcision might be a way to keep yourself safe from HIV and HIV only. You should probably still use condoms and refrain from sowing your wild oats across the countryside. If you live in the USA circumcision is not going to protect you from HIV and you should practice safe sex. If you’re a man who likes other men and you live in the USA circumcision is still not going to help and you should consider going on PrEP and safe sex. Circumcision is a valuable tool in the fight against HIV but it’s no magic bullet and has some large limitations. Practicing safe sex is cheaper and more reasonable for most people in developed nations