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Evidence from circumcision trials says (a) only a minority of men’s infections came from sex and (b) intact (and circ’d) men can reduce their HIV risk by not washing their genitals immediately after sex. What messages do USAID and UNAIDS take from these trials? Their only message is that men should get circumcised. They don’t warn men about bloodborne risks or not to wash immediately after sex.
What we can see from such selective messaging is that: USAID and cooperating organizations such as UNAIDS, WHO, and the Gates Foundation are more committed to circumcise men than they are to protect men from HIV.
Washing immediately after sex increases men’s HIV risk
During two circumcision trials in Uganda (2003-08) researchers asked men whether and how they cleaned their genitals after sex. For both circumcised and intact men, those who did not wash or wipe after sex got HIV at the rate of 0.38% per year, whereas men who washed after sex got HIV more than three times faster at 1.35% per year. The study team explained this result as follows: “The increased HIV acquisition with penile washing may be due to the removal of acidic vaginal secretions or the addition of water with a neutral pH may assist HIV survival and infectivity.”
In a separate report from the same study, intact men who cleaned their genitals after sex, but waited at least 10 minutes to do so, got HIV at the rate of 0.39% per year. Those who wiped only, without water, got less HIV than men who used water. The study team explained: “…[T]he acid pH of vaginal secretions may impair viral survival. Use of water with a neutral pH may facilitate viral survival… Delayed cleansing may reduce viral infectivity by prolonged exposures to vaginal secretions.”
Natural protection against HIV in sexual fluids
Evidence that leaving vaginal fluids in place after sex protects men from HIV agrees with other evidence that vaginal fluids protect women.[3,4,5] From the evidence, researchers propose that “reducing vaginal washing could lower women’s risk of HIV infection.”
Moreover, some evidence suggests that semen also provides natural protection, that it “contributes…to the relative inefficiency of sexual transmission of HIV…”
Still advising men to wash immediately after sex…
Despite evidence from the trials – the above evidence was reported in 2007 and 2009 — HIV programs in Africa continued to advise men to wash after sex. For example, in 2009 the United States government gave the University of California more than $800,000 to teach men in South Africa to wash their genitals after sex to prevent HIV: “The aim of the proposed feasibility study is to evaluate the feasibility and acceptability of a post-coital male genital hygiene procedure, which participants will be asked to practice immediately post-coitus or at least 12 hours after.”
And men continue to wash after sex…
Furthermore, men in African continue to wash their genitals after sex, increasing their risk to get HIV. For example, in a follow-on study in 2006-11 in the same community that produced the evidence reported above, more than 90% of intact men in Rakai, Uganda, washed their genitals after sex. Washing was still dangerous: Intact men who washed got HIV at the rate of 1.35% per year, whereas the minority who did not wash got HIV at the rate of only 0.62% per year.
Somehow, men did not get the message that waiting to wipe was as good as circumcision. Managers in USAID, UNAIDS, etc, chose not to tell men – intact and circumcised – that washing more than doubled their risk to get HIV. Instead, intact men got persistent and repeated advise to circumcise. In other words, managers at USAID, UNAIDS, etc, chose to put more emphasis on circumcision rather than on HIV prevention.
But it’s not all sex
Both before and after the circ trials, some studies show intact men in Africa to have less risk for HIV compared to circ’d men, while other studies show them to have more risk. Why would results be so different in different populations?
The biggest factor to consider is that a lot of HIV infections in men in Africa do not come from sex, but rather from reused syringes and needles, unsterile dental instruments, and other contaminated skin-piercing instruments in healthcare and cosmetic services. Because not enough attention has been given to such risks, we can’t be more specific.
Don’t lose sight of condoms and partner testing…
As for sex, there isn’t much to worry about if someone uses condoms with untested partners – the chance for getting HIV from sex would be extremely low. But if someone wants to say circumcision protects men, it should not go without challenge. The evidence says immediate post-coital washing makes a bigger difference on men’s HIV risk than does circ’ing. Thus, differences in post-coital cleaning practices may help to explain why intact men have less HIV in some communities but more in others.
1. Tobian AAR, Ssempijja V, Kigozi G, et al. Incident HIV and herpes simplex virus type 2 infection among men in Rakai, Uganda. AIDS 2009; 23: 1589-1594. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2715553/ (accessed 3 May 2018).
2. Makumbi et al. Male post-coital penile clensing and the risk of HIV-acquisition in uncircumcised men, Rakai District, Uganda. Abstract WEAC1LB, 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Australia, 25 July 2007. Available at: http://www.abstract-archive.org/ (accessed 3 May 2018).
3. Fonck K, Kaul R, Keli f, et al. Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya. Sex Transm Inf 2001; 77: 271-275. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744330/ (accessed 6 May 2018).
4. Low N, Chersich MF, Schmidlin K, et al. Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. PLoS Med 2011; 8: e1000416. Available at: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000416 (accessed 6 May 2018).
5. Smith JA, Daniel R. Human vaginal fluid contains exosomes that have an inhibitory effect on an early step of the HIV-1 life cycle. AIDS 2016; 30: 2611-2616. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/27536982 (accessed 6 May 2018).
6. Masese L, McClelland RS, Gitau R, et al. A pilot study of the feasibility of a vaginal washing cessation intevention among Kenyan female sex workers. Sex Transm Infect 2013; 89: 217-222. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23002190 (accessed 6 May 2018).
7. Balandya E, Sheth S, Sanders KK, et al. Semen protects CD4+ target cells from HIV infection but promotes the preferential transmission of R5 tropic HIV. J Immunol 2010; 185: 7596-7604. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071682/pdf/nihms-283633.pdf (accessed 6 May 2018).
8. NIH. Project information: 3U01MH066701-07S1 [community-based HIV VCT: South Africa]. Available at: https://projectreporter.nih.gov/project_info_description.cfm?aid=7814411&icde=5021426 (accessed 6 May 2018).
9. Makumbi FE, Ssempijja V, Sekasanvu J, et al. Postcoital penile washing and the risk of HIV acquisition in uncircumcised men. AIDS 2016; 30: 1669-1673. Abstract available at: https://insights.ovid.com/pubmed?pmid=27243775 (accessed 6 May 2018).