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circumcision (CIRCUMCISION)
Sep 5, 2006

Hello Doc,

Is it true that an uncircumcized male is at more risk for HIV? If so, why is that?

tks

Response from Dr. Frascino

Hello,

Before considering cutting off the business end of your meat thermometer, let's discuss this "to circ or not to circ" question!

Here's what we know so far. Epidemiological studies suggest rates of HIV infection are lower in populations in Africa that routinely circumcise males compared to regions where the practice is not common, such as Southern Africa, an area particularly hard hit by the AIDS epidemic. We also have evidence that some cells in the foreskin are especially vulnerable to HIV infection. Circumcision is also associated with a decreased risk of other STDs, which might also decrease the overall risk of contracting HIV.

A recent report estimates that routine circumcision of all men in Africa could prevent up to 2 million new HIV infections and avert 300,000 AIDS-related deaths over the next decade. However, these benefits might be offset if circumcised men subsequently changed their sexual behaviors and became less cautious. Additional studies are still in progress. It's important to note that proper use of a condom is a far more effective HIV-prevention strategy than routine circumcision.

I'll post some information from the archives below that addressed this topic.

Dr. Bob

prophylactic circumcision

Apr 15, 2006

I am an ob-gyn, and when my son was born 18 years ago, I did not have him circumcised. Recently he told me that he is gay, I have read the reports of 50-70% reduction in HIV transmission for MSM even if the circumcision is done as a young adult. I would like to convince my son to be circumcised. Do you have any advice? Are there any handouts I can give him that discuss this issue in laymen's terms? He's in college. I know he is drinking, and may be using drugs. He says he knows all about safe sex, but I am worried. Thanks for your help. Worried Mom

Response from Dr. Frascino

Hello Worried Mom,

You want to convince your 18-year-old gay son to have a prophylactic circumcision???? OUCHAMAGOUCHA! Gosh, I wish I could be there to witness what happens when you break the news that you've invited a Mohel to dinner next week.

Mom, despite what you may have read concerning the preliminary studies related to that age-old question, "to circ or not to circ," no one is recommending prophylactic circumcision for young gay men as an HIV-prevention measure at this time. What we do recommend is proper use of latex condoms. Talk to him about safe sex. He may well "know all about it," but then again, he may just think he knows all about it. There are a wide variety of resources that discuss safer sexual practices for MSM, many of which are available on this Web site and related links. Even if you could convince your son to trim his drapes (which I very strongly doubt), and if elective circumcision did reduce HIV transmission 50% (which we are still evaluating), this is still not nearly "safe enough." Effective HIV prevention requires that a latex condom be used properly whether someone has a foreskin or not. That is the message you should impart to your son. Elective circumcision may seem like cutting-edge (pun intended) HIV prevention, but in reality, even in best case scenarios, it's far inferior to condom use.

Dr. Bob

HENRY J. KAISER FAMILY FOUNDATION PREVENTION/EPIDEMIOLOGY Researchers, HIV/AIDS Advocates Debate Use of Circumcision as HIV Prevention Method in Developing Countries

August 16, 2006

Researchers and HIV/AIDS advocates and experts on Tuesday at the XVI International AIDS Conference in Toronto debated whether male circumcision is a safe and effective method for preventing or reducing the spread of HIV in developing countries, the Washington Post reports. Researchers discussed a completed study from South Africa and two ongoing studies in Kenya and Uganda that examine circumcision as an HIV prevention method (Brown, Washington Post, 8/16). The South Africa study -- which was published in the November 2005 issue of PLoS Medicine and discussed last year at the IAS Conference on HIV Pathogenesis and Treatment in Brazil -- was a randomized, controlled clinical trial involving more than 3,000 HIV-negative, uncircumcised men ages 18 to 24 living in the South African township of Soweto. Half of the men were randomly assigned to be circumcised and the other half served as a control group, remaining uncircumcised. For every 10 uncircumcised men who contracted HIV, about three circumcised men contracted the virus. The study was halted early when researchers determined that circumcision significantly reduced HIV transmission and that it was unethical to proceed without offering the option to all males in the study (Kaiser Daily HIV/AIDS Report, 6/29). According to researchers, if adult male circumcision rates are raised by 10% each year for five years, 32,000 lives could be saved, and if the rates were raised by 20% each year for five years, 52,000 lives would be saved (Russell, San Francisco Chronicle, 8/16).

Kenya, Uganda, Other Research

The ongoing Kenyan study involves 3,000 previously uncircumcised, HIV-negative men, half of whom underwent circumcision for the study. In September 2007, researchers will count the number of men in both groups who have contracted HIV. The Ugandan study, which involves 5,000 men and is being lead by researchers at Columbia University and Johns Hopkins University, is scheduled to be completed in July 2007 (Kaiser Daily HIV/AIDS Report, 6/29). The Kenya and Uganda studies are expected to have results similar to the South Africa study, according to the Toronto Star (Talaga, Toronto Star, 8/16). Other research discussed at the conference showed that women had little or no additional protection against HIV if their sexual partners were circumcised (Washington Post, 8/16). In addition, according to University of California-San Francisco researcher James Kahn, circumcision would cost about $55 per adult male, but that cost would be offset by savings of about $2,400 in future medical costs for every averted HIV infection (San Francisco Chronicle, 8/16).

Recommendations, Comments

According to the Post, conference attendees discussed the cultural implications, training and other issues related to widely implementing circumcision as a way to prevent HIV (Washington Post, 8/16). Many researchers at the conference said circumcision should be widely adopted as an HIV prevention method in developing countries, Toronto's Globe and Mail reports (Nolen, Globe and Mail, 8/16). Some conference attendees complained that the research discussed did not examine cultural beliefs about circumcision, the Post reports (Washington Post, 8/16). The World Health Organization and UNAIDS have "refused to endorse" circumcision until the Kenya and Uganda studies produce successful results, the San Francisco Chronicle reports (San Francisco Chronicle, 8/16). U.N. Special Envoy for AIDS in Africa Stephen Lewis said he thinks the two agencies will alter their stance if the studies are successful. "And they will (be)," he said, adding, "We shouldn't have waited 24 hours as soon as that South African study came out" (Toronto Star, 8/16). "Our position is that the evidence to date is compelling and persuasive, but it's generally unwise to base major policy decisions on the basis of one trial," Kevin De Cock, head of WHO's AIDS office, said, adding, "I think some guidance will be issued if the other two trials are protective" (Washington Post, 8/16) "The cultural meaning of this act is much more profound than this kind of research can take account of," Gary Dowsett, an Australian sociologist, said, adding that "social scientists have been deliberately excluded from this field because they know we'll mess up the field" (Smith, Boston Globe, 8/16).



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