Controversy Over Male Circumcision and HIV Transmission in Developing World

 Should the international healthcare community provide male circumcision information and services to help prevent heterosexually transmitted HIV in the developing world?

by Ronald Baker, PhD

In a commentary in the British medical journal the Lancet (November 20, 1999), researchers Daniel Halperin and Robert Bailey recommend widespread prophylactic male circumcision in parts of Africa where it is not already commonly practiced. They point out that several studies, most notably a prospective study by D.W. Cameron in 1989, show a greater than eight-fold increased risk of HIV infection for uncircumcised men. Halperin and Bailey urge the international health community to add male circumcision services to the current list of AIDS prevention measures in countries with a high prevalence of heterosexually transmitted HIV and sexually transmitted diseases (STDs). "The hour has passed for the international community to recognize the compelling evidence that show a significant association between lack of male circumcision and HIV infection."

Since the Halperin/Bailey editorial appeared in the Lancet last year, the magazine has received correspondence in favor and in opposition to their recommendations. Several of these letters appear in the current issue of the Lancet (March 11, 2000). Following is a summary of the major arguments presented for and against the Halperin/Bailey editorial in those letters.

Justin Pittas-Giroux

In his leter to the Lancet, Justin Pittas-Giroux in the Department of English at the College of Charleston, South Carolina criticizes the University of California at San Francisco (Halperin's institution) for issuing a press release with the "alarmist" headline, "Male Circumcision could Prevent Millions of HIV Infections." To read the text of that press release, CLICK HERE.

Giroux makes the argument that the Halperin/Bailey viewpoint leaves "unasked questions," such as why does Europe (where most men are uncircumcised) have one of the lowest HIV rates in the world, while in the US, where most men are circumcised, has one of the highest HIV rates? Giroux also laments remarks made by Halperin in an interview with the Bay Area Reporter, specifically, "If I were a top [insertive partner in anal intercourse], and I didn't like to use condoms, I would consider getting circumcised." Giroux says this statement contradicts Halperin's own caveat in his Lancet editorial that "male circumcision interventions must not be perceived by individuals or communities as a substitute for other HIV and STD prevention strategies."

Dennis Harrison

In his correspondence, Dennis Harrison (Vancouver BC, Canada) emphasizes that Haperin and Bailey acknowledge in their editorial that five studies found no association between male circumcision and HIV infection, and that one study even reported an increased risk of infection in circumcised men. Harrison raises the question of whether circumcision should be promoted because there is some evidence that this operation might reduce the risk of HIV infection as well as evidence to the contrary? Commenting on Halperin's and Bailey's comparison of circumcision to other HIV prevention methods, such as condom use and the promotion of safe sex, Harrison notes that, unlike circumcision, the latter prevention strategies are safe and effective, and don't require the "amputation of healthy erogenous tissue."

Malcolm Potts

Malcolm Potts of the School of Public Health, University of California at Berkeley, poses the question of how many HIV infections have been prevented by male circumcision in developing countries with all the "classic risk factors" for a heterosexual AIDS epidemic? He maintains that most of west Africa, where male circumcision is widespread, has high levels of STDs, sex work, multiple sexual partnering, and generally low levels of condom use. In support of the Halperin/Bailey position, he notes that in eastern and southern Africa, where non-circumcision predominates, the rate of HIV infection is relatively high, about 25 percent, while in western Africa, HIV infection rates are relatively low (1-5 percent). Potts argues that without the widespread practice of circumcision, the rate of HIV infection in Pakistan and Bangladesh might now be half that found in India (about 0.4 percent), and in Indonesia and the Phillipines it might be around 1 percent. He says that in Thailand and Cambodia, the low rate of male circumcision is believed to be a significant factor driving the spread of HIV in those countries. Potts theorizes that male circumcision has prevented 8 million or more adult HIV infections in 15 African and Asian countries, and he recommends that circumcision services should be more widely available in these areas.

Robert Bailey and Daniel Halperin

In defense of their 1999 commentary in the Lancet, Halperin and Bailey point out that Giroux is incorrect in asserting that North America has one of the highest HIV rates in the world, although he is correct to note that HIV rates in North America are higher than in most of Europe. However, it is important to recognize, they say, that in North America and Europe most HIV infections occur through receptive anal sex and injection drug use, not through heterosexual transmission, which was the focus of their 1999 article. The lack of male circumcision contributes most to female-to-male HIV transmission. This route of HIV transmission accounts for only a small amount of HIV infections in Europe and North America. There is compelling evidence that female-to-male HIV transmission is much higher in Europe than in the US, according to Halperin and Bailey. This would be expected, given the fact that there is a greater prevalence of uncircumcised men in Europe.

More than 35 epidemiological now studies show an increased risk of HIV infection for men who are not circumcised, say Halperin and Bailey. In view of this large body of evidence, they stand by their assertion that it is time for the international health community to take note of this fact and to begin to formulate strategies for introducing male circumcision information and services in regions where they are not available.

3/15/00

References:
Bailey RC, Green EC, Harrison DC, Halperin DT, Pittas-Giroux JA, Potts M. Male circumcision and HIV infection . Lancet 355: 9207. March 11, 2000. 926-934.

Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 354: 9192. November 20, 1999. 1813-15.

Kluge EH. Male circumcision in Canada. Journal of the Canadian Medical Association 50: 1542. 1994.

Moses S and others. Analysis of the scientific literature on male circumcision and risk for HIV infection. International Journal of Sexually Transmitted Diseases and AIDS 10: 626-28. 1999.

Quinn TC and others. Viral load and risk of heterosexual transmission of HIV-1 among sexual partners. Abstract 193. 7th Conference on Retroviruses and Opportunistic Infections. San Francisco. Jan 30, 2000.