In recent years, many articles have appeared in the literature that have examined the relationship between circumcision status and the risk of contracting human immunodeficiency virus (HIV) infection. This page introduces abstracts, full text articles, and other material about this relationship. The materials are indexed in chronological order.
Whether circumcision status plays a role in HIV risk or not, it is important to recognize that HIV can be prevented through several known very effective means, such as condom use, and limiting exposure to multiple partners. Rather than advocating circumcision, given the existing evidence, it would be appropriate to advocate better public health education, so that individuals can make appropriate decisions regarding their own sexual behavior.
Furthermore, the consideration of circumcision with regard to STD and AIDS prevention does not apply to children. Kept intact from birth, they can weigh the issue for themselves when they are old enough to consent. A vaccine may even be available by the time they reach adulthood!
The debate over circumcision status and HIV in the medical literature was started in 1986, when the New England Journal of Medicine published a letter from the late Aaron J. Fink, MD.2 Fink was a California urologist, an outspoken advocate of circumcision who had self-published a book to promote his ideas about circumcision. Fink maintained that the foreskin increased infection by HIV. Fink claimed that the keratinization of the penis of the circumcised male reduced the chance of HIV penetration. There is little direct evidence to support this claim.
A flurry of studies have appeared in recent years concerning Fink's idea, many having contradictory conclusions. This has led to an ongoing debate in the medical literature that has yet to be resolved.
Studies from Africa
A number of studies from Africa point to the fact that the regions of Africa most troubled with HIV infection tend to overlap with the regions where male circumcision is rare. However, this does not imply a causal link: If the same argument were applied to the industrialized world, one would note that the United States has a high circumcision rate, and also has the highest prevalence of HIV.28,31,32,38 Circumcision alone cannot explain these differences. Furthermore, the applicability of data from Africa vis-à-vis the conditions in developed countries—where hygiene standards, prevalence of different STDs, and strains of HIV differ greatly—is questionable. Rather, these variances can be explained by looking at cultural differences andsexual practices.
Unfortunately, this subject has received an unbalanced treatment in the popular and scientific press. For example, in February 1996, Scientific American printed an article by two Australian researchers, JC Caldwell and P Caldwell, based on the apparent correlation between HIV infection and non-circumcised populations in Africa. Their retrospective analysis did not examine any patients. Furthermore, de Vincenzi and Mertens (AIDS, 1994) had, two years previously, criticized the design of such studies;17 and although this fact was pointed out in at least two letters to the editor, the magazine chose to edit the letters severely for publication. The Caldwells were also allowed a rebuttal that did not address the criticisms. See the original complete (unpublished) Fleiss and Hodges (1996) and Falk (1996).
A 2013 survey from Kenya indicates that mass circumcision programs in that country are in fact exacerbating the HIV situation instead of alleviating it, as many had hoped.
In one recent study, Baeten et al.75 reported a small increased risk of HIV-1 acquisition in intact vs. circumcised truck drivers in Kenya. This study followed a cohort of 745 long-distance truck drivers. Subjects self-reported their sexual behavior at quarterly intervals over a 1–2 year period. Commonly reported behaviors included multiple partnerships, failure to use condoms, and contact with prostitutes. This study concluded that circumcision status may explain the rapid spread of the HIV epidemic in settings, found throughout much of Africa, in which multiple partnerships and a lack of male circumcision are common.
Baeten et al. estimated that the rate of HIV-1 infection amongst prostitutes frequented by working-class men in Kenya is 60-65%.75 During the course of the study, 43 of the 745 men experienced seroconversion to HIV-1. It is important to point out that HIV can be prevented through several known very effective means, such as condom use, and limiting exposure to multiple partners. Rather than advocating universal circumcision (as some have done), it would be more appropriate to advocate better public health education in African countries regarding these issues.
Self-reporting is an unreliable means of collecting data on sexual behavior. For instance, Baeten et al.75 relied on self-reporting of sexual behavior in a group of 745 truck drivers in Kenya. This study was designed to investigate female-to-male HIV transmission. Over the study duration, none (0) of the subjects reported having had a sexual contact with another man. As this is rather implausible, given the size of the study group, studies based on self-reporting must be seen as questionable at best.
Demographic assumptions. Many of the African studies did not directly verify the circumcision status of the study subjects. The circumcision status was guessed based on tribal or religious affiliation. Without actually examining the patients to determine their circumcision status, obviously, it is impossible to get valid results.
Statistical significance. Most of those studies that claimed a positive correlation between circumcision and reduced HIV incidence had a small sample size. If there had been only a small number of misclassifications of circumcision status (Demographic assumptions), the results of those studies are not statistically significant.
Publication bias. Studies claiming a positive link between circumcision and reduced HIV incidence are more likely to be published than studies that found no correlation. Publication bias is a common phenomenon across the medical literature: Studies finding a positive result are more interesting to journals and therefore more likely to be published. Publication bias unfairly distorts the true significance of circumcision vis-à-vis HIV infection.
Dry sex. Studies from Zimbabwe,9,19,25 Zaire,13, Malawi,20 Zambia,26 The Central African Republic,30 and South Africa40,46 have documented the popular practice of drying and/or tightening the vagina by various methods of douching and/or application of leaves and powders to absorb the vaginal lubrication. Dry sex is a pervasive practice in sub-Saharan Africa. This practice is purported to increase sexual pleasure.
Reports indicate that dry sex dramatically increases HIV infection risk. Several reports document that dry sex causes various problems with condom usage.19,20,26 Dry sex is associated with an increased report of STDs in men.48 Several studies report increased HIV incidence among women.9,13,30,39 Vaginal dryness is associated with increased lesions,13 lacerations,19 peeling of the vagina,25, chlamydial infection,43 and epithelial trauma in both male and female,13 thus creating a portal of entry forHIV.
Because of this increased risk, dry sex is an obvious confounding factor in any study of HIV seroconversion vs. circumcision in sub-Saharan Africa. However, all of the approximately forty existing studies have ignored this potential confounding factor.
Genital ulcer disease (GUD). Genital ulcer disease, endemic in parts of Africa, is a very strong risk factor for HIV infection.10,12,17,35Pépin reported that HIV positive males often have pre-existing genital ulcers of an untreated STD other than HIV.10 It is believed that these lesions may provide an entry point for the HIV virus. O'Farrell found that Zulu men with bleeding genital ulcers often continue to have sexual intercourse with women, including prostitutes.12Kaul et al. reported on the prevalence of GUD in female sex workers in Kenya, noting that many prostitutes continue to work despite having the disease.33 Therefore, the presence of GUD becomes a significant confounding factor in any study that attempts to make meaningful conclusions about the relationship between circumcision status and HIV susceptibility.
Female circumcision.Hrdy identified female circumcision as a possible contributing factor to the spread of HIV in 1987.4Brady has done the same in 1999.49 However, the effect of female circumcision, common in parts of Africa, on the reception and transmission of HIV has not been studied. Not one study (as far as we are aware) has been done to determine the effect of female circumcision on HIV transmission/reception; although more than 40 African studies of the effects of male circumcision have been carried out. All existing studies of the effects of male circumcision on HIV transmission/reception (as far as we are aware) lacked controls for the effects of female circumcision. Female circumcision is a potential confounding factor of unknown magnitude in the study of the effects of male circumcision on HIV transmission/reception. No published studies control for female circumcision.
Cross-cultural comparisons. Since circumcision status is a cultural marker,6 circumcising and noncircumcising tribes may differ markedly in cultural mores, sexual behavior and in other ways.17 These and other such confounding factors make meaningful cross-cultural comparisons essentially impossible.
Viral load. Recent studies report that viral load is a major factor in the transmission of HIV.50,51 This is in itself a major confounding factor.59 Most studies of HIV infection failed to control for viral load.59,68
High Risk populations. Many of the African studies used unrepresentative high-risk sample populations, such as clients of prostitutes, or visitors to a sexually-transmitted-disease clinic. Unfortunately, such groups do not represent a balanced sample of the population in terms of sexual behavior, general health and other factors.
Male-to-female transmission. Two studies report that partner circumcision is a risk factor for female sero-conversion.21,23
Rebuttals. Van Howe and Storms have raised a number of plausible arguments that imposing circumcision in Africa will increase the number of HIV infections by diverting attention and resources away from more effective interventions.95
Psycho-cultural factors. The AIDS researchers who propose that circumcision can prevent HIV transmission are overwhelmingly, white, male, and the products of English-speaking nations where male circumcision was once the usual practice. Females are seldom, if ever, represented. Male researchers from nations that do not practice male circumcision are usually not amongst those who advocate circumcision to prevent HIV transmission. There are few, if any, South American, Russian, Chinese, Japanese, European, or Scandinavian males amongst those who advocate male circumcision to prevent HIV transmission.
In a comparison of studies performed by European vis-à-vis those performed by white male English-speaking researchers, the studies by white male English-speaking ers have been more likely to report a protective effect for male circumcision. In the absence of another logical explanation for this effect, it is possible to conclude that the circumcision status of the researcher(s) may influence the conclusions of their studies.67
Male circumcision is common in North America, but uncommon in most of Europe. In a survey, Laumann reported that 77% of adult American men were circumcised.31Goldman explains why doctors from circumcising cultures may tend to overstate the purported benefits of circumcision.41 Goldman states:
Among physicians, support for circumcision has been based on supposed rational/q> factors, but as psychiatrist Wilhelm Reich wrote, Intellectual activity has often a structure and direction that it impresses one as an extremely clever apparatus precisely for the avoidance of facts, as an activity which distracts from reality./q> This appears to have been the case in those advocating circumcision. Science has been adopted as the great arbiter between fact and fiction. This systematic approach to evaluating experience is of value, especially as research has shown that a surprising number of adults do not reason logically. The scientific method is designed to help protect the scientific community and the public against flawed reasoning, but it is the flawed reasoning of supposedly reputable scientific studies that has contributed to the confusion on the circumcision issue.41
One reason that flawed studies are published is that science is affected by cultural values. A principal method of preserving cultural values is to disguise them as truths that are based on scientific research. This research can then be used to support questionable and harmful cultural values such as circumcision. This explains the claimed medical benefits/q> of circumcision.41
Goldman concludes:
Long-term psychological effects associated with circumcision can be difficult to establish because the consequences of early trauma are only rarely, and under special circumstances, recognizable to the person who experienced the trauma. However, lack of awareness does not necessarily mean that there has been no impact on thinking, feeling, attitude, behaviour and functioning, which are often closely connected. In this way, an early trauma can alter a whole life, whether or not the trauma is consciously remembered.
Defending circumcision requires minimizing or dismissing the harm and producing overstated medical claims about protection from future harm. The ongoing denial requires the acceptance of false beliefs and misunderstandings of facts. These psychological factors affect professionals, members of religious groups and parents involved in the practice. Cultural conformity is a major force perpetuating non-religious circumcision, and to a greater degree, religious circumcision. The avoidance of guilt and the reluctance to acknowledge the mistake and all that that implies help to explain the tenacity with which the practice is defended.41
The effect of birth-cultural factors on the HIV-prevents-circumcision literature should not be underestimated.59 The failure of the researchers to investigate the confounding effects of female circumcision, dry sex, and other African cultural practices is instructive.
A group of HIV researchers strongly argue that the major cause of HIV infection in Africa is unsafe health care, especially non-sterile injections. They have published letters and articles in the HIV/AIDS medical literature to build their case. Some are available on line.62-66 Three companion articles were published in the International Journal of STD & AIDS64-66 Only about 30 percent of the HIV epidemic in Africa would be attributed to heterosexual contacts.65 Most apparently is caused by unsafe medical procedures. If their hypothesis is correct, then a large number of studies (trying to prove that intact men with normal anatomy are the reason for the high incidence of HIV infection in Africa) would be invalidated. See the article Unsafe Health Care Drives Spread of African HIV at the Royal Society of Medicine website for more information. Even if the claims for circumcision to prevent the transmission/reception of HIV were true, a program of male circumcision could only affect a small portion of the one-third of infections caused by heterosexual contact. Introduction of a program of male circumcision in Africa in an effort to reduce the spread of HIV risks would expose African males to unsafe health care procedures and may actually increase the transmission/reception of the virus.
Studies from developed countries
According to Laumann et al., (1997) data from the National Health and Social Life Survey in the United States indicate that, in 1992, of 1511 men surveyed who were between 18 and 59 years of age, 77 percent of U.S. born men were circumcised; this high percentage is unique among the industrialized nations. Laumann found no discernible differences with regard to STDs between circumcised and non-circumcised men.24
Dave et al. (2003) studied British males. Dave et al. found slightly more viral infection in circumcised males but the difference was not considered significant.72
Richters et al. (2006) studied Australian males. Although most Australian males born after 1980 in this study were non-circumcised, the incidence of HIV infection (0.1%) was too low to permit statistical analysis.76
The United States HIV incidence rate is 3.5 times higher than that of the closest advanced industrialized nation. Storms28 and Nicoll32 noted that the high incidence of male circumcision in the US did nothing to prevent the spread of this infection. Nicoll, in fact, states that the US is the industrialized country most burdened with HIV.32
These observations should not necessarily lead us to conclude that circumcision increases HIV risk. However, it does suggest that attempts to control HIV by imposing mass circumcision on populations are unlikely to be successful.
Sociocultural confounding factors.Poland makes it clear that circumcision is not performed at random. Circumcision is a socio-cultural marker that may indicate wide differences in social and cultural practices among different groups and tribes. For example, circumcision incidence in the U.S. is lower among poor and Hispanic people.6 Circumcision (and, conversely, intactness) are socioeconomic indicators that may relate to differences in sexual behavior, hygienic behavior, and access to medical care. Failure to control for these confounding factors is a frequent source of error in such studies.
Circumcision changes sexual behavior. Circumcised men have a greater tendency to engage in riskier, more highly elaborated sexual practices.31 Such behavior includes unsafe sex (less frequent use of condoms, which deaden sensation even more for circumcised men; anal sex, or sex with multiple partners). This may contribute to the high rate of HIV infection in the United States, where circumcision rates are still of epidemic proportions.
Other factors.Hooykaas reported more STDs amongst circumcised men in the Netherlands.8Pépin has identified pre-existing lesions from STDs as entry points for HIV.10
The protective effect of the natural anatomy
In 1982, Prakash and colleagues reported finding lytic material (lysozyme) in the sub-preputial wetness beneath the prepuce.1 Lysozyme is an enzyme secreted in human bodily fluids that acts to destroy bacteria, fungi, and other infectious agents. Bacteria are capable of producing lesions through which the HIV virus can enter the body. Lysozyme has long been known to destroy the cell walls of bacteria. Fleiss et al. have elaborated the natural protective properties of the prepuce. Compellingly, Lee-Huang and colleagues reported in 1999 that lysozyme is an effective agent for killing HIV directly in vitro.41Hill has prepared a summary of the evidence for the hypothesis that the intact prepuce may offer a protective effect against HIV infection.
The effectiveness of lysozyme at destroying HIV in or on the body has not been tested. More research is needed to establish what direct protection, if any, is afforded by the lysozyme found in the subpreputial wetness of the anatomically complete penis as designed by nature.
Fleiss, Hodges and Van Howe describe the immunological protections that the foreskin provides against infection.29 In another review, Van Howe found that men with circumcised penises were at statistically greater risk of acquiring HIV than a man with a non-circumcised penis.32 This is consistent with the results of Dezzutti, who discovered that intact epithelium (skin and mucosa) is resistant to penetration by HIV.28 The possible role of circumcision in the high rate of HIV infection in the US needs further study.
Meta-analyses
de Vincenzi and Mertens found that the existing evidence did not control sufficiently for confounding factors concerning the relationship between circumcision and HIV infection.17 They warned that caution was necessary: Implementing surgery as a strategy for controlling the spread of AIDS was not recommended based on the existing evidence.
Van Howe also concluded that circumcision could not be recommended to prevent HIV infection.44 This conclusion was based on a statistical analysis of all of the data from multiple published studies. In fact, the analysis indicated that circumcised men had a slightly greater chance of contracting HIV.
Angus Nicoll of the British Communicable Disease Surveillance Centre recommended that circumcision should not be used to control HIV infection.32
Medical Society Reports
The Fetus and Newborn Committee of the Canadian Paediatric Society examined the data, and concluded that more study would be necessary before a recommendation for circumcision could be made.27
The Task Force on Circumcision of the American Academy of Pediatrics examined the issue with the help of an epidemiologist. The task force concluded in its official Circumcision Policy Statement that behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status.45
The Council on Scientific Affairs of the American Medical Association has also examined the issue. The Council on Scientific Affairs stated, in a report titled Report 10: Neonatal Circumcision, that ...behavioral factors are far more important risk factors for acquisition of HIV and other sexually transmissible diseases than circumcision status, and circumcision cannot be responsibly viewed as protecting against such infections.53
Cochrane Review
The Cochrane Library established a protocol for the review of the HIV/Circumcision literature. That review notes the cultural bias of circumcision researchers. that review also expresses concern about the negative effects of circumcision on efforts to effect behavioural change.59 The systematic review reported a general failure to control for confounding factors and, in addition, found insufficient evidence to recommend male circumcision to control HIV infection and transmission.68
Conclusions
Confounding factors to the study of the relationship of HIV infection to male circumcision include:
female circumcision
dry sex
genital ulcer disease
other STDs
unsafe medical practices
viral load
religion
culture
education, occupation, and socio-economic status
condom use
migration status
age
location of the study
The Cochrane Review found that the existing studies fail to control for most of these confounding factors so the evidence produced is unreliable. After more than forty studies over a span of time greater than a decade, the Fink hypothesis that circumcision somehow reduces HIV infection remains unproven. Ntozi recognizes that this idea that circumcision can reduce HIV infection is only a hypothesis, but would like to see a controlled study carried out to see if circumcision would reduce the tragic epidemic that continues to rage in Africa.34
From time to time the popular press reports that one doctor or another recommends circumcision to reduce HIV infection. While it may be their personal opinion that circumcision prevents HIV transmission, since this has not yet been conclusively demonstrated, these opinions cannot be considered informed medical opinions. Frequently, the news item is based on a single study rather than the complete body of the medical literature. It would be foolish to base public health policy on such reports.
The conditions in Africa are very different from those in the developed world. It would be wrong to apply findings from Africa to the developed nations.
The Cochrane review of the medical literature found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men.68
Randomized Controlled Trials (RCT)
Despite the failure of observational studies to prove the alleged effect of male circumcision in preventing HIV infection, three randomized trials have recently been set up: One in South Africa (Orange Farm), one in Kenya, and one in Uganda. The first, conducted by Auvert, was published in 2005.77 The other two have been terminated but have not been published, except for a press release.
The Auvert study reported that young circumcised males in Orange Farm become infected more slowly than non-circumcised young males. This paper has received a large amount of attention in the worldwide media, but also was subject to extensive scientific criticism, which has been published at the PLoS website.
The other two studies, which were terminated in the fall of 2006, have not been published. The possible influence of researcher bias on the interpretation of the findings remains to be seen.
There is contradictory evidence. Some studies have found either no effect or more HIV in circumcised males.3,11,14,22,62,74,83
There remain serious medical ethical and human-rights issues around such studies. Non-therapeutic surgery on children or other incompetent individuals, who cannot give consent, falls under the definition of a human rights violation, so any circumcision programs and studies should be limited to adults who can personally grant consent.
Van Howe and Garenne have commented on the extensive promotion that has accompanied these allegedly scientific inquiries.77,79
Ntozi predicted that the raging AIDS epidemic in Africa would generate extensive political pressure on governments to do something—anything—to fight the epidemic.34 It is likely, therefore, that some African governments will institute programs of mass circumcision in Africa for political, not medical, reasons, although mass circumcision seems as likely to worsen the epidemic as improve it.82
These studies assume that heterosexual transmission of HIV is the dominant disease vector. That may not be case.63 HIV infection in children points to health care as a source of HIV infection.67 There are indications that homosexual activity in Africa is much higher than western researchers believe.69 Also, circumcision itself seems to transmit HIV infection.83
These studies are limited to heterosexual female-to-male transmission in Africa. They are not applicable to developed nations. The CDC has never recommended circumcision for Americans.81
de Witte et al. report that the Langerhans cells (found in the foreskin) produce Langerin, a substance that blocks the uptake of HIV.87
Talbott reports that the percentage of females engaged in prostitution that determines the percentage of the population that is infected. When the RCTs are adjusted for the prostitute population, circumcision ceases to be effective at preventing HIV infection.88
Highlights of the Medical Literature
Prakash finds lysozyme in the sub-preputial wetness.1
Carael reported that seropositive couples were similar to seronegative couples in the circumcision status of the husband.3
Hrdy identifies various African cultural practices that contribute the transmission of HIV. He suggests that female circumcision, group circumcisions, contact with non-human primates, ritual scarification, and other such practices are contributing to the epidemic of AIDS.4
Surick et al. (cited in Vincenzi (1994)) found that 17.7% of uncircumcised men and 8.4% of circumcised men misclassified their circumcision status, throwing serious doubt on any study relying on self-reporting, especially where the number of men in either category is small.5
Poland reports that circumcision does not occur randomly. Circumcision is associated with culture. The cultural diversity of circumcising and non-circumcising groups are important confounding factors.6
Guimares7 found circumcised and uncircumcised HIV infected males to be equally infectious to their female partners.
Hooykaas reports increased incidence of risky sexual behavior and increased incidence of STDs amongst circumcised immigrant men.8
Barongo found no evidence that lack of circumcision was a risk factor.11
O'Farrell reports that men with bleeding genital ulcers still engage in sexual intercourse.12
Brown reports on the cultural practice of dry sex in Zaire. Brown reports damage to the epithelium of both men and women that may contribute to infection with HIV.13
Chao et al. found partner circumcision to be a risk factor for HIV-1 infection for a pregnant woman in Rwanda.14
Malamba reports that sexual behavior is the predominant risk factor for infection.15
de Vincenzi and Mertens concluded n a 1994 review of the literature that ...lack of distinction between susceptibility and infectivity, inadequate control for confounding variables, potential selection bias and misclassification of exposure, inappropriate choice of a comparison group, and publication bias, may lead to under- or over-estimation of the association [between circumcision and HIV status]. It is difficult to predict the net effect of these sources of bias. Furthermore, the magnitude of the association varies strongly between studies and its crude measure is overestimated in some reports.17
Runganga reports on the use of herbs to dry, contract, and heat the vagina for increased sexual pleasure in Zimbabwe.19
Grosskurth et al. found more HIV in circumcised men and no protective effect for circumcision,.21
Civic et al. report that condoms break frequently when used in conjunction with dry sex practices.26
Marck identifies cultural influences that may cause variations in the rate of HIV infection in circumcised and intact males in sub-equatorial Africa.29
Laumann et al. report that circumcised men tend to have more elaborated sexual practices. Some of these practices involve high risk behavior.31
Angus Nicoll of the British Communicable Disease Surveillance Centre discusses the role that circumcision may play in the transmission of HIV. He concludes that universal circumcision would not be an effective or advisable way to try to reduceHIV rates.32
Kaul reports on genital ulcers (GU) and STDs in female sex workers.33
Ntozi reviews the circumcision hypothesis. He wants a controlled trial of circumcision versus non-circumcision to see if circumcision would help to control the HIV epidemic.34
Dezzutti of the US Communicable Disease Center reports that intact epithelium is resistent to HIV infection. Circumcision removes the intact epithelium and replaces it with scar tissue, However, the resistence of circumcision scar tissue to HIV infection is not known.35
Fleiss, Hodges and Van Howe review the immunological functions of the prepuce. The prepuce contains Langerhans cells. The sub-preputial wetness contains lytic material. These protections may help to prevent infection with human immunodeficency virus, although more study is needed.37
Tanne reports on the epidemic of sexually transmitted diseases, including HIV in the United States where most men are circumcised.38
Baleta describes the practice of dry sex/q> in South Africa, raising concern about its effect on the transmission of HIV. HIV incidence is highest where dry sex is practiced.40
Goldman reports on the tendency of circumcised male doctors to misuse the medical literature to overstate the benefits of male circumcision.41
Laruche reports that women who douche with antiseptics have twice the rate of HIV infection.43
Van Howe produced a meta-analysis and review of the medical literature. Van Howe's meta-analysis concludes that a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with anon-circumcised penis.44
Fleming reports on the need for effective control of STD in a program of control of HIV infection.46
Beksinska reports that dry sex practices are prevalent in South Africa.48
Brady suggests that female genital mutilation plays a significant role in the transmission of HIV.49
Gray and associates report that control of STDs is important in reducing HIV transmission.50
Gray and colleagues report that religion and washing practices are a significant confounding factor in the study of the influence of circumcision status in HIV transmission.52
Gray and colleagues report a study of discordant couples in Uganda. The most important factors in transmission of HIV were GUD and viral load. Male circumcision status was found to not be a significant factor.54
Grulich and colleagues report a study of HIV transmisssion between homosexual males in Australia. Circumcision status was determined to not be a significant factor in male-to-male transmission of HIV.57
Brewer and others identify unsafe health care as a major vector for the transmission of HIV in Africa. This is an additonal confounding factor in the HIV-circumcision studies.63
The Cochrane Systematic Review finds insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men.67
de Witte et al. report that the Langerhans cells (found in the foreskin) produce Langerin, a substance that blocks the uptake of HIV.87
Talbott reports that the percentage of females engaged in prostitution that determines the percentage of the population that is infected. When the RCTs are adjusted for the prostitute population, circumcision ceases to be effective at preventing HIV infection.88
In October 2008, the South African Medical Journal published three papers that reject male circumcision as a control method for HIV infection.92-94
Library Holdings
Documents are indexed in the approximate chronological order of publication.
Surick I, McLaughlin M, Chaisson M. HIV infection and circumcision status. [New York City Department of Health, NY, NY, USA.] Int Conf AIDS, Montreal, June 4-9 1989, 5:113 [abstract TAP89].
Guimaraes M, Castilho E, Ramos-Filho C, et al. Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil. VII International Conference on AIDS. Florence, June 1991 [abstract MC3098].
Grosskurth H., Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9(8):927-934.
Sandala L, Lurie P, Sunkutu MR, et al. Dry sex and HIV infection among women attending a sexually transmitted diseases clinic in Lusaka, Zambia. AIDS 1995; 9 Suppl 1:S61-8.
Foxman B, Aral SO, Holmes KK. Interrelationships among douching practices, risky sexual practices, and history of self-reported sexually transmitted diseases in an urban population. Sex Transm Dis 1998;25(2):90-9.
Van Howe RS. Neonatal Circumcision and HIV Infection. In: Male and Female Circumcision: Medical, Legal, and Ethical Considerations in Pediatric Practice. George C Denniston, Frederick Mansfield Hodges, Marilyn Fayre Milos (eds). New York, Boston, Dordrecht, London, Moscow: Kluwer Academic/Plenum Publishers, 1999. (ISBN 0-306-46131-5)
Baeten JM, Richardson BA, Lavreys L, Rakwar JP, Mandaliya K, Bwayo JJ, Kreiss JK. Female-to-male infectivity of HIV-1 among circumcised and uncircumcised Kenyan men. J Infect Dis 2005;191:546-553.
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2:e298. [Full Text]
Green LW, McAllister RG, Peterson KW, Travis JW. Male circumcision is not the HIV vaccine we have been waiting for! Future HIV Therapy 2008;2(3):193-9. doi:10.2217/17469600.2.3.193 [Full Text]
The Circumcision Information and Resource Pages are a not-for-profit educational resource and library. IntactiWiki hosts this website but is not responsible for the content of this site. CIRP makes documents available without charge, for informational purposes only. The contents of this site are not intended to replace the professional medical or legal advice of a licensed practitioner.
Unsafe Health Care Drives Spread of African HIV at the Royal Society of Medicine website for more information. Even if the claims for circumcision to prevent the transmission/reception of HIV were true, a program of male circumcision could only affect a small portion of the one-third of infections caused by heterosexual contact. Introduction of a program of male circumcision in Africa in an effort to reduce the spread of HIV risks would expose African males to unsafe health care procedures and may actually increase the transmission/reception of the virus.
. Int J STD AIDS 2003;14:148-61. [PDF file]