San Anselmo, California,
September 2003.

Introduction. Few issues are more central to the ongoing debate about elective non-therapeutic neonatal circumcision in the United States than concerns about HIV and AIDS. The recent developments in our understanding of HIV have led to the implementation of medical guidelines that include recommendations for reducing the risk of transmission. Advocates of elective non-therapeutic neonatal male circumcision have been attempting to have male circumcision included in the list of HIV infection-preventing strategies.

The National Organization of Circumcision Information Resource Centers (NOCIRC) recognizes that cost, safety, effectiveness, and health are integrally related, and that it is possible to reduce HIV infection risk without resorting to circumcision. The purpose of this statement is to help healthcare providers interpret, evaluate, and understand the conflicting medical studies that seek a possible causal relationship between normal male genital anatomy and HIV infection risk.

History. Circumcision as a measure to reduce the transmission of HIV was proposed in the mid-1980s by the late Aaron J. Fink, MD,¹ who had extreme views about male circumcision, which he vigorously promoted. Fink had no scientific basis for his hypothesis that circumcision could reduce the transmission of HIV, nevertheless, certain scientists tried to show that his hypothesis was valid. They carried out a number of poorly designed studies in Africa, which purported to "prove" that male circumcision could prevent the transmission of HIV. AIDS researchers de Vincenzi and Mertens examined 23 of the studies in 1994.² They concluded that these studies suffered from a "lack of attention given to potential confounding factors" to the extent that the data was unreliable, and stronger evidence was needed before a program of "public health intervention" could be instituted.²

Later, in 1999, Robert Van Howe, MD, subjected the data from 35 articles to rigorous statistical analysis. Van Howe found that, based on the combined data, "a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis."³Van Howe concluded: "[B]ased on the studies published in the scientific literature, it is incorrect to assert that circumcision prevents HIV infection."³

Male to Female. Chao et al. reported that a circumcised partner is a risk factor for male-to-female transmission of HIV infection.⁴

Discordant Couples The Rakai project in Uganda has studied the heterosexual transmission/reception of HIV. Viral load, not circumcision status, was reported to be the most important determining factor.⁵ The Rakai project determined that studies of HIV infection and circumcision status are confounded by religion and cultural practices⁶ and that, when these are properly controlled, circumcision status is not a significant factor in preventing HIV transmission or reception amongst discordant couples (one partner is HIV-positive, the other HIV-negative).⁷

Male to Male. An Australian study found no relationship between circumcision status and HIV infection in men who have sex with men.⁸

Female to Male. Many studies have been carried out in Africa in an attempt to show that male circumcision reduces the incidence of female-to-male transmission of HIV. Confounding factors include female circumcision, viral load, genital ulcer disease, the African practice of "dry sex," sexual practices, socio-economic factors, and others. The studies are plagued with a general failure to adequately control the confounding factors. See "Cochrane Review" below for the conclusions of its systematic review of the evidence for the use of male circumcision to reduce HIV infection in heterosexual males.

Medical Society Reports. The Fetus and Newborn Committee of the Canadian Paediatric Society (CPS) examined the data (1996) but refrained from recommending circumcision to prevent HIV transmission because it believed that further study was necessary.⁹ The American Academy of Pediatrics Task Force on Circumcision (March 1999) also examined the data and concluded that the evidence was conflicting and behavioral factors are more important than circumcision status.¹⁰ The American Medical Association (December 1999) has examined the data and concluded that "circumcision cannot be responsibly viewed as 'protecting' against such infections."¹¹

Governmental and International Agencies. The U.S. Centers for Disease Control (CDC) has not endorsed the use of male circumcision to prevent HIV infection. Nicoll of the British Communicable Disease Surveillance Centre (BCDSC) says that the introduction of circumcision would lead to young men continuing their unsafe sex practices and would fail a cost-benefit analysis.¹² The BCDSC is opposed to the use of male circumcision to reduce HIV infection.¹²

The Joint UN Programme on HIV/AIDS (UNAIDS), with headquarters in Geneva, issued a statement on the use of circumcision to prevent HIV transmission/reception.¹³This statement was issued at a time when available data showed a small protective effect. The UNAIDS said that the use of circumcision to prevent HIV infection was to be compared to playing Russian roulette with two bullets in the revolver rather than three,¹³ UNAIDS does not support the use of circumcision to prevent HIV infection because it would convey a false sense of security.¹³

HIV in America. The great majority of the male population in the United States is circumcised, more so than any other advanced industrialized (first world) nation. Laumann, et al., reported that 77 percent of U.S.-born men in the National Health and Social Life Survey were circumcised.¹⁴ Both Nicoll (1997)¹² and Van Howe (1999)³ remarked that the United States has the highest rate of HIV infection amongst the advanced industrialized (first world) nations. Clearly, male circumcision has not been effective in protecting Americans from HIV infection.

Immunology. Several authorities have described protective immunological functions of the prepuce.¹⁵ More investigation of these immunological functions is needed to determine their effectiveness in preventing HIV infection.¹⁶ Circumcision defeats those immunological functions.

Recent Developments. Several recently published articles strongly argue that the principal pathway for HIV transmission in Africa is unsafe health care.^17-19 If that is the case, then male circumcision, even if it were 100 percent effective in preventing sexual transmission—which no one believes, would have no effect in preventing transmision by non-sterile injections, transfusion of contaminated blood, and so forth.

Cochrane Review. There have been numerous studies carried out to determine if male circumcision has a protective effect against female-to-male transmission of HIV. These studies are all noted for their methodological flaws. The Cochrane Library has carried out a comprehensive review of the data regarding circumcision as a protective factor for female-to-male transmission of HIV. The Cochrane review concluded:

We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.²⁰

Conclusion. The National Organization of Circumcision Resource Centers (NOCIRC) finds that, based on currently available data, male circumcision is not effective in preventing the transmission or reception of any sexually transmitted disease, including HIV.²¹ Male circumcision may increase male-to-female transmission.⁴ Furthermore, the promotion of circumcision to prevent HIV transmission/reception is likely to provide a false sense of security in circumcised males¹³ and to divert attention and resources from effective proven measures of disease control.³

Prior to the institution of any medical or surgical procedure, the adverse effects and risks must be considered and the advantages and disadvantages must be weighed. Male circumcision is not a benign procedure. Male circumcision is painful and traumatic.^9-11 Circumcision removes functional erogenous tissue from the penis²² and results in a lifelong irreversible injury to the penis and loss of function.¹⁶ Even if circumcision was warranted—which it is not—aseptic surgery cannot be guaranteed in many developing nations and, therefore, would be dangerous.^{3,12, 20} Male circumcision has a high rate of complications,²³ especially in the developing nations, where infections from tuberculosis and tetanus infections, other severe complications, and fatalities following male circumcision are alarmingly common.³ Moreover, male circumcision has many adverse physical, sexual, and psychological effects.²⁴ In view of these adverse effects and lack of efficacy, the use of male circumcision as a disease control measure is contraindicated and inappropriate.

References:

1. Fink AJ. A possible explanation for heterosexual male infection with [letter]. N Engl J Med 1986;315:1167.
2. de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS 1994;8(2):153-60.
3. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16.
4. Chao A, Bulterys M, Musanganire F, et al. National University of Rwanda-Johns Hopkins University AIDS Research Team. Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. Int J Epidemiol 1994; 23(2):371-80.
5. Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda . Lancet 2001; 357: 1149-53.
6. Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team. AIDS 2000;14(15):2371-81.
7. Quinn TC, Wawer MJ, Sewankambo N, et al, for the Rakai Project Study Group. Viral load and heterosexual transmission of human immunodefficiency virus type 1. N Engl J Med 2000; 342:921-9.
8. Grulich, AE, Hendry O, Clark E, et al. Circumcision and male-to-male sexual transmission of HIV. AIDS 2001; 15(9):1188-1189.
9. Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996; 154(6):769-80.
10. American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement . Pediatrics 1999;103(3):686-693.
11. Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.
12. Nicoll A. Routine male neonatal circumcision and risk of infection with HIV-1 and other sexually transmitted diseases . Arch Dis Child 1997;77:194-5.
13. UNAIDS. Report on the global HIV/AIDS epidemic. Geneva: UNAIDS, June 2000: p.71.
14. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States. JAMA 1997;277(13):1052-7.
15. Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Inf 1998;74:364-367.
16. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44.
17. Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS 2003;14:144-7.
18. Gisselquist D, Potterat JJ, Brody S. Let it be sexual: how health care transmission of HIV was ignoredPDF. Int J STD AIDS 2003;14:148-61.
19. Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimatePDF. Int J STD AIDS 2003;14:162-73.
20. Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Walker S, Williamson P. Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software
21. Van Howe RS. Does circumcision influence sexually transmitted diseases?: A literature review . BJU Int 1999; 83 Suppl 1; 52-62.
22. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996;77:291-5.
23. Williams N, Kapila L. Complications of Circumcision . Brit J Surg 1993; 80: 1231-6.
24. Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychology 2002;7(3):329-43.

Statement released 18 September 2003.