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HIV/AIDS and circumcision in Australia

Recent studies suggesting that male circumcision could reduce HIV transmission in Africa have been getting significant media attention. The implications of these studies are complex and controversial. Australia has a very different epidemic to that in Africa, and male circumcision is not a suitable strategy to prevent transmission here.

Summary of knowledge to date

Influence of male circumcision
on HIV transmission risk
In high prevalence areas (eg. sub-Saharan Africa)
Africa
In Australia
Australia
Heterosexual sex Male partner's risk Lower risk * No change
Female partner's risk No change * No change
Male-to-male sex Receptive partner's risk No change No change
Insertive partner's risk No change * No change *

What is circumcision and why is it done?

Male circumcision is a surgical procedure that involves the removal of all or part of the foreskin from the head of the penis. It has ritual significance in some cultures, and so its practice may be ceremonial, performed with non-surgical instruments by elders rather than doctors, and without anesthesia. It is an irreversible procedure.

Different cultures have performed the rite at different stages of life: commonly in preadolescence as part of a ritual of becoming a man; sometimes for older adult men as a sign of status; and in more recent history, in infancy. Cultural identity may also be entwined with non-circumcision.

In the twentieth century in industrialized countries such as Australia and the United States, circumcision became very popular for reasons that are not clear, but do not appear to be directly related to religious or specific ethnic affiliation. This trend was reversed in Australia in the 1980s and 90s due to increased acceptance that circumcision provided no medical benefit.

What is the recent research about circumcision in HIV/AIDS?

Recent data from three major trials in Africa challenges the notion that it is of no benefit. Adult male circumcision has been found to reduce the risk of acquiring HIV in men by around 55-60% in three randomised controlled studies.

These trials were conducted in African countries where HIV is endemic – Uganda, South Africa and Kenya. Heterosexual vaginal intercourse is the predominant mode of HIV transmission in these countries.

Circumcision did not provide complete protection against HIV, but researchers concluded that circumcision reduced the risk of HIV acquisition in the study groups. While there were high rates of HIV acquisition in both arms of these studies – the circumcised and the uncircumcised – rates were lower in the former group.

Does this mean men in Africa should be getting circumcised?

The issue is very complicated. The results of the studies do suggest that widespread circumcision in Africa could reduce HIV transmission by hundreds of thousands.

Mass circumcision programs are being proposed throughout the sub-Saharan region [PDF]. While consideration is being given to making such programs culturally sensitive, the proposed implementation of male circumcision raises complex moral problems relating to cultural practice, gender equity, informed consent, and the just allocation of limited resources.

There are some strong arguments against circumcision campaigns, including:

What about in Australia?

Parents in Australia should not consider the results of these studies as a reason to have their child circumcised. The results are not relevant in the Australian context.

Circumcision does not prevent HIV - in high prevalence areas it reduced the risk of female-to-male transmission only. Australia is not a high prevalence country for HIV. Further, male circumcision has been shown to have no effect on transmission through insertive anal sex, which is the most common risk activity for HIV transmission in Australia. Circumcision has no significant impact for heterosexual or homosexual transmission of HIV in Australia.

Condoms are still the most effective means of preventing sexual transmission of HIV and other sexually transmitted infections.

Conclusion

References and further reading

The randomised control studies in Africa:

Male circumcision and women's risk:

Effect of male circumcision on male-to-male transmission in Australia:

This article has been based on an AFAO Briefing Paper, Circumcision has no role in the Australian epidemic [PDF] (23/07/07).

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