Circumcision and HIV

Got an interesting reply with lots of medical references to my comment
on circumcision that I sent to Gaynet. Here it is.  I'll also post my reply.
----------------------------Original message----------------------------

I apologize for uploading this very long list of medical journal
references on cicumcision and the risk of HIV transmission but
unlike much of the discussion on this subject, HIV transmission is
very much a Gay Issue.  Please note that I am ambivalent on the
issue of circumcision (my girlfriend, who is a medical practitioner
(PA), and I have discussed it and can't decide on what to do if
we should have a son).  I certainly don't recommend circumcision
simply for the sake of HIV prevention (safer sex is much easier and
much more effective).  The search for these references were done as
objectively as possible through MedLine, the top searching facility
for medical people.  I also severely edited the results and
headings to only include the relevant passages.  Edited sections
are indicated by "..."  If my objectivity in editing is in doubt,
you can 1) look up the references yourself in the cited journal, 2)
do the same search in MedLine (many universities have it), 3) ask
me to upload the unedited list to you.  I'd be very curious to read
references to the contrary as well (my mind is not made up on
this), so please upload them if you know of any.  Happy reading.

> Date:         Thu, 24 Feb 94 23:55:39 EST
> From:         ALTENB@mitvma.mit.edu
> Subject:      circumcision
>
> The "study" that showed a relation between being "uncircumcised"
> and having a greater risk of HIV infection was flawed at best.
> Aaron Fink (a retired LA-area urologist who sounds, on talk
> shows, like he has an axe to grind) picked up some early raw
> statistics on something like 12 (twelve) men who
> were long-distance truck drivers in central Africa, and who
>           [ ... ]
> in evaluating sexual practices in the US.  A similar report out
> of theearly years of the AIDS epidemic in San Francisco was
> explained (anecdotally) thus: intact men are considered  more
> desirable as sexual partners, therefore have a more active sex
> life, therefore were more liable to contract HIV. The same
> anecdotal report said that the inequality disappeared as the
> epidemic progressed.

If possible, please provide a reference for this San Francisco
report.  I've never heard that uncut men were more desirable as sex
partners in the US, in the 70's or otherwise.  I encountered just
the opposite in a very informal and unscientific survey we did in
a grad course I took on sexuality (1987).  I'd be very interested
in reading this, and how they were able to reach their conclusions.
Thanks!  As for the inequality disappearing, please read the
following ...

Searches were done on "HIV and (CIRCUMCISION or CIRCUMCISED)"
through MEDLINE (1/87-2/94), HEALTH and the NYTIMES.  Only 1 study
concluded that that no correlation was found (it is listed last for
accessibility), while 13 disagreed with you, with 5 likely to
disagree (I will get the actual articles on Monday).  A search on
"FINK-A" yielded all kinds of studies on tumors, fertility,
geriatrics and healthcare policy, but nothing related to this.  The
study supposedly cited by Fink (someone who I've never heard of in
my years of working in AIDS), and discredited by you, was conducted
by Bwayo et al, but its verity hardly affects the positive
conclusions of the 12 other studies, which don't suffer from a
small sample size and are generally well-randomized.  Regardless,
despite your implication that there was only one study showing a a
positive relationship between having a foreskin and HIV
transmission, no one reputable I know of has used the Bwayo study
exclusively to support their case; I wasn't even aware of the study
when I did HIV counseling.  Many other much better studies exist.

13 of the following medical journal abstracts either directly
concluded that the lack of circumcision is a risk factor (most), or
otherwise mention it as a given risk factor.

5 search results had no abstracts although the titles suggest that
they too found a correlation.

1 study agreed with your assertion. (included at the end)

===========================

[This study is especially interesting because:  1) The sample is
English, which shares the same epidemiological pattern (Pattern I)
as the US (unlike most African countries which display Pattern II).
2) England has a large pool of uncircumcised men, making it ideal
to extrapolate to the US, which has relatively few.  3) "A
culmulative 43% of uncircumcised men who acquired an ulcer
seroconverted to HIV-1 after a single sexual exposure."]

TI: Female to male transmission of human immunodeficiency virus
type 1: risk factors for seroconversion in men [see comments] CM:
Comment in: Lancet 1989 Oct 21;2(8669):977-8. Comment in: Lancet
1989 Nov 11;2(8672):1157 AU: Cameron-DW; Simonsen-JN; D'Costa-LJ;
Ronald-AR; Maitha-GM; Gakinya-MN; Cheang-M; Ndinya-Achola-JO; Piot-
P; Brunham-RC; et-al AD: Department of Medical Microbiology,
University of Nairobi, Kenya. SO: Lancet. 1989 Aug 19; 2(8660):
403-7 CP: ENGLAND
AB: To determine the frequency and risk factors for female to male
sexual transmission of human immunodeficiency virus type 1 (HIV-1),
a prospective study was carried out in 422 men who had acquired a
sexually transmitted disease (STD) from a group of prostitutes with
a prevalence of HIV-1 infection of 85%. ...  No man without a
genital ulcer seroconverted. A cumulative 43% of uncircumcised men
who acquired an ulcer seroconverted to HIV-1 after a single sexual
exposure. These data indicate an extremely high rate of female to
male transmission of HIV-1 in the presence of STD and confirm a
causal relation between lack of male circumcision, genital ulcer
disease, and susceptibility to HIV-1 infection.

===========================

[This study concludes "Uncircumcised men were more frequently
infected with HIV, regardless of a history of genital ulcers]

TI: Human immunodeficiency virus infection among men with sexually
transmitted diseases. Experience from a center in Africa. AU:
Simonsen-JN; Cameron-DW; Gakinya-MN; Ndinya-Achola-JO; D'Costa-LJ;
Karasira-P; Cheang-M; Ronald-AR; Piot-P; Plummer-FA AD: Department
of Medical Microbiology, University of Nairobi, Kenya. SO: N-Engl-
J-Med. 1988 Aug 4; 319(5): 274-8 CP: UNITED-STATES
AB: ... HIV antibody was detected in 11.2 percent of 340 men who
enrolled in the study. Reports of nonvaginal heterosexual
intercourse and homosexuality were notably rare. Recent injections
and blood transfusions were not associated with HIV infection. ...
Men who were uncircumcised were more likely to have HIV infection
(odds ratio, 2.7; P = 0.003), as were those who reported a history
of genital ulcers (odds ratio, 7.2; P less than 0.001). ...
Multivariate analysis revealed an independent association of
genital ulcers with HIV infection in both circumcised and
uncircumcised men. Uncircumcised men were more frequently infected
with HIV, regardless of a history of genital ulcers. ...

============================

TI: The relationship between male circumcision and HIV infection in
African populations. AU: Bongaarts-J; Reining-P; Way-P; Conant-F
AD: Research Division, New York City, New York 10017.
SO: AIDS. 1989 Jun; 3(6): 373-7
CP: ENGLAND
AB: The relationship between HIV seroprevalence and the proportion
of uncircumcised males in African countries is examined to
determine whether circumcision practices play a role in explaining
the large existing variation in the sizes of African HIV epidemics.
A review of the anthropological literature yielded estimates of
circumcision practices for 409 African ethnic groups from which
corresponding national estimates were derived. HIV seroprevalence
rates in the capital cities were used as indicators of the relative
level of HIV infection of countries. The correlation between these
two variables in 37 African countries was high (R = 0.9; P less
than 0.001). This finding is consistent with existing clinic-based
studies that indicate a lower risk of HIV infection among
circumcised males.

===========================

TI: Geographical patterns of male circumcision practices in Africa:
association with HIV seroprevalence. AU: Moses-S; Bradley-JE;
Nagelkerke-NJ; Ronald-AR; Ndinya-Achola-JO; Plummer-FA AD:
Department of Medical Microbiology, University of Nairobi, Kenya.
SO: Int-J-Epidemiol. 1990 Sep; 19(3): 693-7 CP: ENGLAND
AB: To ascertain whether male circumcision might explain some of
the geographical variation in human immunodeficiency virus (HIV)
seroprevalence in Africa, we investigated the association between
the practice of male in Africa, we investigated the association
between the practice of male circumcision at a societal level and
HIV seroprevalence. Male circumcision practices for over 700
African societies were identified, and HIV seroprevalence in
general adult populations from 140 distinct locations in 41
countries was obtained. In locations where male circumcision is
practised, HIV seroprevalence was considerably lower than in areas
where it is not practised. This study supports the hypothesis that
lack of circumcision in males is a risk factor for HIV
transmission. ...

==========================


[I believe this study took place in Africa, but I am unsure]

TI: Human immunodeficiency virus, genital ulcers and the male
foreskin: synergism in HIV-1 transmission. AU: Jessamine-PG;
Plummer-FA; Ndinya-Achola-JO; Wainberg-MA; Wamola-I; D'Costa-LJ;
Cameron-DW; Simonsen-JN; Plourde-P; Ronald-AR AD: University of
Manitoba, Winnipeg, Canada.
SO: Scand-J-Infect-Dis-Suppl. 1990; 69: 181-6
CP: SWEDEN
AB: ... Uncircumcised men had an increased risk of seroconversion
which was independent of their risk of genital ulcer disease. Over
95% of attributable risk in men with STD was either genital
ulceration or the presence of a foreskin. ...

==========================

[the sample size for this study was 1169 patients]

TI: HIV-1 and HIV-2 infections in men attending sexually
transmitted disease clinics in Abidjan, Cote d'Ivoire. AU: Diallo-
MO; Ackah-AN; Lafontaine-MF; Doorly-R; Roux-R; Kanga-JM; Heroin-P;
De-Cock-KM AD: Projet RETRO-CI, Institut d'Hygiene, Treichville.
SO: AIDS. 1992 Jun; 6(6): 581-5
AB: ... The highest prevalence, 46%, was in men with genital ulcer
disease. Risk factors associated with HIV-1 as well as with HIV-2
infection after multivariate analysis were a history of sex with
prostitutes, lack of circumcision, being unskilled, and a history
of prior genital ulcer ...

==========================

TI: The situation in Africa.
AU: Miotti-PG; Chiphangwi-JD; Dallabetta-GA
SO: Baillieres-Clin-Obstet-Gynaecol. 1992 Mar; 6(1): 165-86 CP:
ENGLAND
AB: ... Increasing evidence shows that STDs play a major role in
spreading the HIV epidemic. ... The role of non-ulcerative STDs
such as gonorrhoeal, chlamydial and trichomonal infections needs
further elucidation. Lack of circumcision, traditional healing
practices and oral contraceptives may affect the risk of viral
transmission, but may not be major or modifiable risk factors...

==========================

TI: Association between HIV-2 infection and genital ulcer diseases
among male sexually transmitted disease patients in The Gambia. AU:
Pepin-J; Quigley-M; Todd-J; Gaye-I; Janneh-M; Van-Dyck-E; Piot-P;
Whittle-H AD: Medical Research Council Laboratories, Fajara, The
Gambia.  SO: AIDS. 1992 May; 6(5): 489-93
CP: UNITED-STATES
AB: OBJECTIVE: To investigate whether genital ulcer diseases are
cofactors which enhance the transmission of HIV-2 in West Africa.
DESIGN: A cross-sectional study of 435 men presenting with a
sexually transmitted disease (STD). ...  RESULTS: ... Circumcised
patients with residual foreskin were more likely to be HIV-2
infected than patients with complete circumcision.  CONCLUSIONS:
Our data suggest that genital ulcerative diseases, such as syphilis
and chancroid, are probably cofactors that increase the
transmission of HIV-2 in West Africa ...

==========================

TI: HIV prevalence in patients with sexually transmitted diseases
in Yaounde, (Cameroon) in 1989 and 1990: necessity of an STD
control programme.  AU: Zekeng-L; Yanga-D; Trebucq-A; Sokal-D;
Salla-R; Kaptue-L  AD: Service National de Lutte Contre le Sida,
Yaounde, Cameroon. SO: Genitourin-Med. 1992 Apr; 68(2): 117-9 CP:
ENGLAND
AB: OBJECTIVE--To monitor HIV seroprevalence among STD clinic
attenders as part of a sentinel surveillance programme. ...
PATIENTS--1161 randomly selected patients. ... RESULTS-- ... There
was no association between HIV seropositivity and sex, marital
status, or educational level. Genital ulcer disease did not
correlate with HIV seroprevalence. ... CONCLUSIONS--Compared with
the findings among the same groups in metropolitan areas of various
other African countries, the HIV seroprevalence is still low; this
could be due to many reasons, such as the recent introduction of
the virus in the country, a different spectrum of STDs, the high
level of circumcision of males. ...

==========================

TI: Long distance truck-drivers: 1. Prevalence of sexually
transmitted diseases (STDs). AU: Bwayo-JJ; Omari-AM; Mutere-AN;
Jaoko-W; Sekkade-Kigondu-C; Kreiss-J; Plummer-FA AD: Department of
Medical Microbiology, College of Health Sciences, University of
Nairobi. SO: East-Afr-Med-J. 1991 Jun; 68(6): 425-9
CP: KENYA
AB: A cross section study was conducted among long distance truck
drivers to determine the prevalence of sexually transmitted
diseases (STDs) and antibodies to human immunodeficiency virus
(HIV). A total of 8 drivers and their assistants en route from port
of Mombasa to countries in East and Central Africa were enrolled
into the study. ... Lack of circumcision, past history of GUD and
urethritis were significantly associated with HIV seroconversion.

==========================

TI: Documented male-to-female transmission of HIV-1 after minimal
vaginal exposure in the absence of other cofactors for infection.
AU: Henry-K
AD: HIV/AIDS Clinic and Programs, St. Paul-Ramsey Medical Center.
SO: Minn-Med. 1991 Oct; 74(10): 32-4 CP: UNITED-STATES
AB: ... Major cofactors that possibly increase the efficiency of
heterosexual transmission of HIV-1 include genital ulcer disease,
multiple sexual exposures, lack of male circumcision, and primary
and advanced stages of HIV-1 disease. I report the case of a 33-
year-old woman who was recently infected with HIV-1 after one to
three nontraumatic episodes of vaginal intercourse ... Her partner
was immunologically intact, HIV-1 antigen negative, and
circumcised. ...

==========================

TI: Sexual behaviour, AIDS and poverty in Sub-Saharan Africa
[editorial]  AU: Prual-A; Chacko-S; Koch-Weser-D
SO: Int-J-STD-AIDS. 1991 Jan-Feb; 2(1): 1-9
CP: ENGLAND
AB: ... Prostitution, though poorly understood in the African
context, unstable family structure, lack of male circumcision,
aversion to, and high cost of, condom use, and risky sexual
behaviour, including multiple sexual contacts and partners, are
causal and facilitating factors in the rapid spread of HIV
infection. Virtually all of these factors are related to poverty.
...

==========================

TI: Genital ulceration as a risk factor for human immunodeficiency
virus infection. AU: Greenblatt-RM; Lukehart-SA; Plummer-FA; Quinn-
TC; Critchlow-CW; Ashley-RL; D'Costa-LJ; Ndinya-Achola-JO; Corey-L;
Ronald-AR; et-al AD: Department of Medicine, University of
Washington, Seattle. SO: AIDS. 1988 Feb; 2(1): 47-50 CP: ENGLAND
AB: Among 115 heterosexual men who presented with genital ulcers to
a sexually transmitted disease clinic in Nairobi, Kenya, the
prevalence of serum antibody to HIV was 16.5%. A past history of
genital ulcers was reported by 12 (63%) of 19 men with antibody to
HIV versus 30 (31%) of 96 without antibody (P = 0.008). HIV
infection was also positively associated with lack of circumcision,
but was not associated with the etiology of the current genital
ulcer.

==========================

[No abstract available through MedLine]

TI: Circumcision and heterosexual transmission of HIV infection to
men [letter] SO: N-Engl-J-Med. 1987 Jun 11; 316(24): 1545-7
CP: UNITED-STATES

==========================

[No abstract available through MedLine]

TI: A link between HIV infection and circumcision.
SO: RN. 1990 Feb; 53(2): 101
CP: UNITED-STATES


==========================

[No abstract available through MedLine]

TI: [AIDS. Less risk for the circumcised]
TO: AIDS. Beschnittene weniger gefahrdet.
AU: Piechowiak-H
SO: Fortschr-Med. 1988 Nov 20; 106(33): 8-9
CP: GERMANY,-EAST

==========================

[No abstract available through Medline]

TI: Genital ulcers and male circumcision as risk factors for
acquiring HIV-1 in Zambia [letter] AU: Hira-SK; Kamanga-J;
Macuacua-R; Mwansa-N; Cruess-DF; Perine-PL SO: J-Infect-Dis. 1990
Mar; 161(3): 584-5 CP: UNITED-STATES

==========================

[No abstract available through Medline]

TI: Transmission of HIV: genital ulceration, sexual behaviour, and
circumcision [letter; comment] CM: Comment on: Lancet 1989 Aug
19;2(8660):403-7
AU: O'Farrell-N
SO: Lancet. 1989 Nov 11; 2(8672): 1157
CP: ENGLAND

==========================

[This is the only study I found that supported your contention]

TI: The epidemiology of HIV-1 infection in urban areas, roadside
settlements  and rural villages in Mwanza Region, Tanzania. AU:
Barongo-LR; Borgdorff-MW; Mosha-FF; Nicoll-A; Grosskurth-H;
Senkoro-KP;  Newell-JN; Changalucha-J; Klokke-AH; Killewo-JZ; et-al
AD: National Institute for Medical Research, Mwanza, Tanzania. SO:
AIDS. 1992 Dec; 6(12): 1521-8
CP: UNITED-STATES
AB: OBJECTIVE: To determine the prevalence of HIV-1 infection and
to identify the most important risk factors for infection. DESIGN:
A cross-sectional population survey carried out in 1990 and 1991 in
Mwanza Region, Tanzania. METHODS: Adults aged 15-54 years were
selected from the region (population, 2 million) by stratified
random cluster sampling: 2434 from 20 rural villages, 1157 from 20
roadside settlements and 1554 from 20 urban wards. ... CONCLUSION:
This study confirms that HIV-1 infection in this region in East
Africa is more common in women than in men. The results are
consistent with the spread of HIV-1 infection along the main roads.
There is no evidence that lack of circumcision is a risk factor in
this population.
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