Summary of research to date
| Influence of male circumcision on HIV transmission risk |
In high prevalence areas (eg. sub-Saharan Africa) |
In 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 | Limited proection* | Limited protection * | |
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:
- If more men decide not to use condoms because they have been circumcised, HIV transmission may increase.
- Male circumcision has no affect on women's HIV risk.
- Circumcision may reduce women's ability to negotiate condom use.
- Circumcision is a complex cultural practice, with identity and religious connotations in many cultures.
- Some people consider circumcision to be a form of genital mutilation.
- Circumcision is often performed outside clinical environments. There could be an increase in deaths due to complications from the circumcision procedure.
What about in Australia?
Parents in Australia should not consider the results of these studies as a reason to have their child circumcised.
Looking at heterosexual transmission in Australia, the protective factor for the male partner is very low (and again, male circumcision has no direct effect on female partners' risk). The National Centre in HIV Epidemiology and Clinical Research estimates an Australian heterosexual, non injecting drug user's risk of HIV infection at 0.02%.* These low rates of transmission and risk do not justify widespread circumcision in the general population in Australia.
Circumcision for men who have sex with men is slightly more controversial. HIV risk is highest for the receptive partner during male-to-male anal intercourse, and research shows that most men who have sex with men will be both a receptive and insertive partner. For the realtively small number of men who are only insertive partners and who engage in unprotected anal intercourse with casual partners, circumcision may have a protective effect.
Circumcision does not prevent HIV - it reduces the risk of female-to-male transmission only. Further, male circumcision has been shown to have no effect on transmission through receptive 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
- Widespread circumcision in high prevalence areas (eg. Africa) could reduce the number of HIV infections, but if people increased their risk behaviours because they are circumcised infections could further increase.
- Circumcision only reduces the risk of female-to-male transmission or receptive-to-insertive partner transmission. It has not been shown to reduce the risk of male-to-female transmission or insertive-to-receptive partner transmission.
- Circumcision is not an HIV risk-reduction strategy for men who have sex for men.
- On the basis of limited, and potentially conflicting, evidence there is no consensus to support the use of circumcision as a prevention strategy in the Australian epidemic. Australians should not use circumcision as an HIV risk reduction strategy.
- Condoms, safe sex campaigns, needle and syringe programs, and programs which empower women remain vital in reducing HIV transmission worldwide. These must remain the priority in HIV/AIDS prevention.
- Male circumcision is a complex cultural practice, and promoting widespread circumcision is highly controversial.
References and further reading
The randomised control studies in Africa:
- 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 Medicine, 2 (11) e298 doi:10.1371/journal.pmed.0020298.
- Gray H., Kigali G., Estrada D., et al. (2007) ‘Male circumcision for HIV prevention in young men in Racial, Uganda: a randomised trial’, Lancet, 369:657-66.
- Bailey C., Moses S., Parker CB., et al. (2007) ‘Male circumcision for HIV prevention in young men in Kyushu, Kenya: a randomised controlled trial’, Lancet; 369: 643-56.
Male circumcision and women's risk:
- Carter, M. (2007) 'Male circumcision doesn't affect women's HIV risk', Aidsmap.
Effect of male circumcision on male-to-male transmission:
- Carter, M. & McLay, D. (2007) IAS: Circumcision may be acceptable to some gay men, but study says no value for HIV prevention Aidsmap.
- Grulich, A., Hendry, O., Clarke, E., Kippax, S. & Kaldor, J. (2001) ‘Circumcision and male-to-male transmission of HIV’, [Research letter] AIDS; 15 (9): 1188-89.
- Millet G., et al. (2008) ‘Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men’, JAMA; 300 (14): 1674-84.
- Vermund SH, Qian HZ. (2008) ‘Circumcision and HIV prevention among men who have sex with men: no final word’, JAMA; 300 (14): 1698-700.
This article has been based on an AFAO Briefing Paper, Male circumcision and HIV [PDF] (09/02/09).