Saturday, May 28, 2011

Where Circumcision Doesn't Prevent HIV

There's currently a lot of hype surrounding circumcision and the transmission of HIV. The word on people's lips is that "circumcision reduces HIV transmission by 60%." The claim is based on the result of three major "studies" that were carried out in Africa, but there are a few confounding factors that bring the validity of these so-called "studies" into question. One of the greatest confounding factors in these studies is empirical evidence to the contrary; real world data from countries where circumcision is already a widespread practice and studies with contrary results.

Countries in Africa
Let's begin with countries in Africa, where these "studies" would be relevant. According to demographic health surveys performed in other countries in Africa, HIV transmission was prevalent in circumcised men in at least 6 different countries. I go one by one, analyzing some of the commentary in these surveys, some of which seems to be revealing of the researchers' bias.

In Cameroon, where 91% of the male population is circumcised, the ratio of circumcised men vs. intact men who contracted HIV was 4.1 vs. 1.1. (See p. 17)

"...the vast majority of Ghanaian men (95 percent) are circumcised... There is little difference in the HIV prevalence by circumcision status..." (1.6 vs 1.4 See p. 13)

In Lesotho, 23% of the men are circumcised, and the ratio circumcised men vs. intact men who contracted HIV was 22.8 vs 15.2.

"The relationship between male circumcision and HIV levels in Lesotho does not conform to the expected pattern of higher rates among uncircumcised men than circumcised men. The HIV rate is in fact substantially higher among circumcised men (23 percent) than among men who are not circumcised (15 percent). Moreover, the pattern of higher infection rates among circumcised men compared with uncircumcised men is virtually uniform across the various subgroups for which results are shown in thetable. This finding could be explained by the Lesotho custom to conduct male circumcision later in life, when the individuals have already been exposed to the risk of HIV infection. (Additional analysis is necessary to better understand the unexpected pattern in Table 12.9.)" (p. 13)

What is disturbing here is that it seems researchers grope for a reason to dismiss these results because they are not what they are looking for; a positive result for circumcision. The above is an interesting defense of male circumcision, given the fact that the latest "studies," if they can even be called that, observed HIV trasmission in men circumcised as adults. Then again, this demographic health survey was conducted in 2004, BEFORE the newer "studies" in 2006. None the less, the unproven assertion that "circumcision is only effective in reducing the risk of HIV when done in infancy" persists in some circles.

In Malawi, 20% of the male population is circumcised. The ratio of circumcised vs. intact men who contracted HIV was 13.2 vs 9.5.

"The relationship between HIV prevalence and circumcision status is not in the expected direction. In Malawi, circumcised men have a slightly higher HIV infection rate than men who were not circumcised (13 percent compared with 10 percent). In Malawi, the majority of men are not circumcised (80 percent)(...where one would expect HIV to be the most rampant... note the "expected direction.") (p. 10)

According to a demographic health survey taken in 2005,  the ratio of circumcised vs. intact men who contracted HIV was 3.8 vs 2.1. (See p. 10)

In a recent demographic health survey (2006-2007), the ratio of circumcised vs. intact men who contracted HIV was found to be 22 vs. 20.

As Table 14.10 shows, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher HIV infection rate than men who are not circumcised (22 percent compared with 20 percent). (p. 256)

Here is that "expected direction" again. The majority of Swazi men are uncircumcised, and one would especially expect to see HIV prevalence here. HIV transmission was more prevalent in the circumcised men here, yet our (the US) government has decided to spend millions on a campaign to circumcise 80% of the men in Swaziland.

Other Countries Where HIV/Circumcision Rates Don't Correlate

According to Malaysian AIDS Council vice-president Datuk Zaman Khan, more than 70% of the 87,710 HIV/AIDS sufferers in the country are Muslims. In Malaysia, most, if not all Muslim men are circumcised, whereas circumcision is uncommon in the non-Muslim community. 60% of the Malaysian population is Muslim, which means that HIV is spreading in the community where most men are circumcised at an even faster rate, than in the community where most men are intact.

The Philippines
In the Philippines, the majority of the male population is circumcised, as it is seen as an important rite of passage. In the 2010 Global AIDS report released by UNAIDS in late November, the Philippines was one of seven nations in the world which reported over 25 percent in new HIV infections between 2001 and 2009, whereas other countries have either stabilized or shown significant declines in the rate of new infections. Among all countries in Asia, only the Philippines and Bangladesh are reporting increases in HIV cases, with others either stable or decreasing.

Despite circumcision being near-universal, it hasn't stopped HIV transmission in Israel.

The most obvious smoking gun: The United States of America
Circumcision hasn't stopped HIV in our own country.

And, it hasn't stopped other STDs either.

In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. Despite these facts, our country does poorly.

In fact, AIDS rates in some US Cities rival hotspots in Africa. In some parts of the U.S., they're actually higher than those in sub-Saharan Africa. According to a 2010 study published in the New England Journal of Medicine, rates of HIV among adults in Washington, D.C. exceed 1 in 30; rates higher than those reported in Ethiopia, Nigeria or Rwanda.

The Washington D.C. district report on HIV and AIDS reported an increase of 22% from 2006 in 2009.

"[Washington D.C.'s] rates are higher than West Africa... they're on par with Uganda and some parts of Kenya."
Shannon L. Hader, HIV/AIDS Administration, Washington D.C., March 15, 2009.
She once led the Federal Centers for Disease Control and Prevention's work in Zimbabwe.

One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact. It is telling that the HIV epidemic struck in our country in the 1980s, 90% of the male population was already circumcised. Somehow, we're supposed to believe that what didn't worked in our own country, or anywhere else, is going to start working miracles in Africa.

Studies With Contrary Conclusions

According to USAID, "there appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher."

"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."

Results: ...No consistent relationship between male circumcision and HIV risk was observed in most countries.

"Conclusions: ...[M]ale circumcision... is not associated with HIV or STI prevention in this U. S. military population."

One study which aimed at measuring male to female HIV transmission was ended early, because the results were not looking favorable. The Wawer study showed a 54% higher rate of male-to-female transmission in the group where the men had been circumcised. The figures were too small to show statistical significance, but there will be no larger scale study to find out if circumcising men increases the risk to women. Somehow that's considered unethical, yet it's considered ethical to promote male circumcision while not knowing if the risk to women is increased (by 54%?, 25%?, 80%? - who knows?)

The latest study in Kenya finds no association between male circumcision and lowered HIV rates:
'Using a population-based survey we examined the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.'

A few select studies show a prevalence of HIV transmission in uncircumcised men, but real world empirical data shows that circumcision hasn't stopped HIV in countries where there is already a prevalence of the practice of circumcision, nevermind the United States. Yet, for whatever reason, leaders at the WHO continue to endorse it as HIV prevention policy and millions are being spent on so-called "mass circumcision campaigns," even in countries where HIV transmission was shown to be prevalent among the circumcised.

As if the waste of money weren't bad enough, reports are showing that these "mass circumcision" campaigns are actually proving to be disastrous, as they are confusing African citizens, and many now believe to be fully protected by circumcision.

Something must be done to alert our world leaders. Millions of precious funds are being used to promote a worthless surgical procedure that leaves men with permanently altered organs, and they are no better protected. The false security that the promotion of circumcision creates is actually helping to facilitate the spread of HIV. Funds are already scarce, and they could be better spent promoting cheaper, less invasive modes of prevention that have actually been proven to be conclusively effective, such as condoms and education. In light of the real-world evidence, promoting a worthless surgical procedure is an impertinent disservice in the fight against HIV/AIDS and governments need to be told to stop. Africans deserve better.

Related Post:
80% of American men were circumcised from birth. Yet, the United States has a higher prevalence rate than 53 countries where circumcision is rare or not practiced. The United States has more HIV than Mexico, its neighbor to the south. Read about this and more in the sequel post linked below.


  1. Hi, you might be interested to know your article has been linked to in reddit and the comments are here:
    Just in case you aren't the OP of that thread... and I see you've got 0 comments on here.

  2. Thanks for the heads up; it is me.

    And uh... yeah... does get kind of lonesome...

    Thanks for adding your comment! :-)

  3. THIS IS INCREDIBLY GREAT! Please publish it! You could send it to all the medical journals which have run stuff about HIV or HIV/ circumcision, ie, as a "response letter". I think there is a good chance one will accept it and publish it, AT LEAST as a letter, and possibly as an opinion piece or even an article. (I'm not sure what the policy is, however, if MORE than one wants to publish it... perhaps you should stagger the submissions, starting with the most widely read journals.) Surely the British Journal of Urology (which published the Sorrells study) ought to be on our side. THANK YOU!

  4. I wish I had had this wonderful compilation of data handy a few years ago when I attended a community hearing held by the New York City Department of Health & Mental Hygiene on the topic of circumcision as a preventive strategy for HIV/AIDS. The panel - including Thomas Frieden, now director of the CDC - never blinked the veracity (or credibility) of the African studies from Auvert, Bailey and the usual pro-circumcision camp. More than once they even use the term "men who 'lack' circumcision", as though intact men were to be pitied (and "corrected"). Hardly the sort to rely on for objective scientific inquiry -- yet they are exactly the ones who determine HIV/AIDS policy in this country. It was a classic exhibition of the "circumcised mind": they reached around all of this freely accessible data to reach the figures that supported their cultural and personal bias toward male genital cutting. I will be sure to have your compiled data at the ready for any such meetings in the future. Thank you for posting!! - JWP

  5. Thanks for the comments.

    Unfortunately, I am not a "scientist" or an "expert" by any stretch of the imagination.

    And, unfortunately, that's what it takes to question anything these days...

    I only hope this gets around to researchers and scientists in the field who are actually impartial and objective, and have no axe to grind when it comes to circumcision.

    I think it's a sad day in history when basic human anatomy is placed in the position of "guilty until proven innocent."

    From what I can tell, circumcision "researchers" are not actually interested in public health or stopping the spread of HIV; they're interested in spreading circumcision.

    It's what it's always been about; they like to pretend as if circumcision were this "new and innovative" procedure they only "just" discovered yesterday, as if circumcision hadn't been this historically controversial and ethically problematic surgery through the centuries.

    Look to see who's behind all this "research" and you'll find "scientists" who come from backgrounds where circumcision has been a constant struggle to defend (IE, Americans, Jews, Muslims, older commonwealth members, etc.).

    The validation of circumcision is and always has been their ultimate goal, and they have managed to hijack the HIV movement to this end...

    It's frustrating because, even if the "research" were 100% accurate, circumcision falls short, being outperformed by condoms. Circumcised men would still need to use condoms, to which one would ask, well then what is the point? Why must we spend millions of dollars to circumcise these men, only to tell them that all they have to do is wear a condom?

    Word on the African street is that "we circumcised guys can't get AIDS." The promotion of circumcision is already leading to more unsafe sex and this is resulting in the SPREAD AIDS, not its reduction.

    Even if the research were valid, and as I present, there is plenty of reason to question it, promoting a dubious alternative to condoms is a terrible mistake, and it's already having terrible consequences. We're effectively bankrolling the spread of HIV.

  6. You say "I only hope this gets around to researchers and scientists in the field"... well this is how you get it there! Have you ever tried to have this information (be sure to include the evidence that circumcision is backfiring) published in a scientific journal? Seriously, no one is asking you to be an expert, so you don't have to feel bad that you don't have degrees etc. You are just gathering public data in one place, as you've said. Isn't it worth giving it a try?

  7. At least one paper has already been written:

    It includes resources I provide here and more. I can only dream of writing something like this...

  8. Thank you for pointing us at Van Howe's terrific article. It would be really great to have your information in additional journals -- the more the merrier -- but at least his is out there.

    Thanks again for all your work, Joseph!

  9. I agree that you should try to get your blogs published. I've read a lot of what people have to say about circumcision and you're one of the best. What you say needs to be heard!

  10. Thanks for the article. I am going to spread it around. Did you happen to read scientific Americans article in this topic?

  11. Yes, though I must say it was more American than it was scientific...

  12. Hello.
    My local newspaper has been tossing around the 60% statistic and I have decided to write a letter to the editor on the matter. Would you mind if I used some of the data presented here?

  13. This is public knowledge available to anyone who searches for it. I claim no credit for it whatsoever. You should feel free to take whatever you want from this blog and use it how you see fit.

  14. Ronald said......Thanks Joseph i am a doctor from Uganda where one of the "trials" that claimed a protective effect of circumcision on HIV was carried out.I totally agree with you that these trial were flawed and are at variance with empirical evidence. For example in Uganda only 2 tribes out of the over 40 tribes in the country traditionally circumcise and yet the areas where these tribes come from have higher HIV prevalence rates than the national average.
    It therefore makes be sad when i see all the millions of dollars being spent on mass circumcision in my country at the expense of other proven interventions. In Uganda promotion of condom use and advocating behavior change has taken a back seat as the circumcision brigade take over!!
    But as some one knowledgeable on the goings on here i know it is all about the money..our so called researchers and policy makers have all been attracted by the huge amounts of money being poured in to this mass circumcision debacle despite knowing well that it is not going to deal with the epidemic but will probably worsen it

  15. Thanks Joseph. So our US has gall to mess with the sexual health of other countries, when its own youth are not as healthy compared to Germany, France, and the Netherlands.

  16. The pie chart has one typo in it. Under Kenya, it says 11.5% instead of 1.5%

  17. See the USAID document this is based on:

    In section 9.4 (table 9.3) on page 110 (or P124 of the PDF) they do have 11.5% for Kenya.

    There is no typo.

  18. Of course, the naysayers will either ignore this article, or feebly try to countermand it. We can but try to get the truth out - thank you!

    1. It's not the naysayers that I want reading this article...

      "Be who you are and say what you feel, because those who mind don't matter and those who matter don't mind." ~Dr. Seuss

      Someone will understand. Someone must.