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Neonatal Circumcision for HIV Prevention: Cost, Culture, and Behavioral Considerations

  • Seth C. Kalichman mail

    seth.k@uconn.edu

    Affiliation: Department of Psychology, University of Connecticut, Storrs, Connecticut, United States of America

    X
  • Published: January 19, 2010
  • DOI: 10.1371/journal.pmed.1000219

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Arguments against circumcision are serious

Posted by Hugh_Young on 03 Feb 2010 at 08:23 GMT

Seth Kalichman says: “Anticircumcision groups have long existed and are increasingly vocal as MC programs for HIV prevention are promoted. Anticircumcision groups resemble other antiscience and antimedicine extremists including AIDS denialists who refute public health realities to maintain entrenched belief systems.”[1]

This is simply argument ad hominem. Most Intactivists do not deny that circumcision may measurably reduce the incidence of certain diseases, but consider the protection to be exaggerated, the risks and harms to be underreported, the entrenched cultural nature and intimate character of circumcision to distort ostensibly scientific consideration, and the ethical barrier to circumcising the non-consenting to take precedence. Dr Kalichman would be better occupied answering the real ethical objections to the circumcising of non-consenting people (such an operation on healthy people is unique and anomalous), and the serious critiques of the claims of circumcision's benefits.

An enormous weight has been put on the results of the three RCTs. (A Cochrane review prior to them found “insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men.” [2]) The figure of “up to 60 percent protection” has been widely circulated, but it all rests on a total of 64 of the 5,400 circumcised volunteers and 132 of the control groups who contracted HIV in less than two years. Much hangs on 73 of the circumcised men who did not contract HIV, when the numbers of their partners, HIV status of those partners, numbers of acts of intercourse, numbers of those acts that were without condoms, and numbers of exposures to non-vaginal, non-heterosexual and non-sexual HIV transmission were unknown and uncontrolled. The studies, and the conclusions being drawn from them, assume without evidence that being circumcised had no effect on any of those factors.

A total of 327 of the circumcised men (and 376 controls) left the studies, their HIV serostatus unknown to the researchers, but not necessarily to themselves, since they were encouraged to be tested at clinics nearby. If knowledge of their HIV serostatus differentially affected the controls' and the experimental men's willingness to continue (for example if circumcised men who tested HIV seropositive felt they had been let down by the trials' failure to protect them), the significance of the findings could easily be overthrown.

Kalichman writes:
“While risk compensation following MC may occur, the evidence thus far is mixed. It is possible that boys who grow up circumcised will not experience compensatory behavior because they will not undergo reductions in risk perception. However, an increase in beliefs that a
man's circumcision status determines his vulnerability to HIV will likely shift social norms, with the potential for community-wide risk compensation. The contextualization and framing of MC must therefore be tailored to each individual culture to avoid adverse behavioral
ramifications of implementing neonatal MC.”

Yet he wrote in 2007:
“... It is difficult to imagine a convincing public health message that effectively influences men to undergo circumcision and continue to consistently use condoms.”[3]

It is not at all clear what has made him change his position. On the contrary, the 2009 National Communication Survey on HIV/AIDS found that 15% of people (up to 22% of men) in South Africa now believe that circumcised men do not need to use condoms.[4] This in spite of the fact that news items have usually mentioned that the protection circumcision offers is only partial: they have played up the “prevention”, and people have an inevitable tendency toward wishful thinking.

Seth Kalichman also wrote then:
“There is no evidence that circumcision increases or decreases the risk of HIV transmission by HIV-infected men. However, risk compensation by HIV-infected circumcised men will substantially increase the risk of
transmission to their sex partners. This suggests that, in the short term at least, circumcision would reduce the incidence of HIV among men, but increase the incidence among women, translating to increased prevalence
among women, which in turn translates to greater risk to men. Epidemiological models of MC should take this dynamic into account.”

That was a good argument then, and it is still. There is now evidence that circumcision does not decrease the risk of HIV transmission by HIV-infected men.[5] In fact if the trial had not been halted “for futility” before it reached statistical signficance, it might well have shown that circumcision itself increases the risk, since 18% of the partners of circumcised men contracted HIV, while only 12% of the partners of controls did. This does not seem to have been a possibility the experimenters were willing to entertain. (There was no ethical necessity to halt the trial.)

Mass circumcision campaigns could do more harm than good, even if circumcision does offer the protection to men that is claimed for it, and that not nearly as certain as its proponents claim.

Hugh Young BSc

1. http://www.plosmedicine.o... accessed February 4, 2010

2. 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. http://www.cirp.org/libra...

3. Kalichman S, Eaton L, Pinkerton S Circumcision for HIV Prevention: Failure to Fully Account for Behavioral
Risk Compensation PLoS Med 4(3): e138 doi:10.1371/journal.pmed.0040138
(2007) http://www.plosmedicine.o...

4. http://www.jhhesa.org/doc... p2 accessed February 3, 2010

5, Wawer, M, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial Lancet, 374, 9685, pp 229 - 237, 18 July 2009

No competing interests declared.