[This introductory page links to other pages: Intact men have less HIV in many African countries! — Circ’ing and HIV outside Africa – Observed new HIV infections in intact vs. circumcised men – Critique of 3 trials of circ to protect men – Boys and men harmed by circ’ing — Impact of male circumcision on women’s HIV risk — Some anti-circ resources — Plans to circ millions, achievements falling short. But if you want to get circ’d, here’s how to ensure you don’t get HIV from the procedure.]
Bloodborne transmission drives Africa’s HIV epidemics
For more than 33 years, beginning with the first tests for HIV in Africa, evidence shows that healthcare likely infects as many or more Africans as does sex.[1,2] Public health agencies from WHO to Africa’s ministries of health have chosen to ignore the evidence, have not cleaned up health care, and have instead accused HIV-positive people of sexual misbehavior. As healthcare facilities continued to infect patients, Africa’s generalized epidemics raged on. Sexual transmission, is there, of course, but it is derivative; people who get HIV from unsafe healthcare can pass it to their sexual partners.
Africa’s continuing nosocomial epidemics opened the door to proposed solutions, even ones that made no sense. Circ’ing men is one such senseless response.
The US wants to circumcise millions of men in Africa
In 2007, WHO and UNAIDS recommended circumcising men in Africa to prevent HIV. The US leads the charge. WHO’s and UNAIDS’ 2012 “joint strategic” plan to circ men in 14 African countries lists 11 “stakeholders”: four US government agencies (Department of Defense, USAID, CDC, and the State Department’s global AIDS czar), the Gates Foundation, and three international organizations in which the US is the major funder (World Bank, UNAIDS, and WHO). No other government or organization in Europe or elsewhere signed the plan.
Why are so many US elected officials and health managers so excited to pay to circumcise men in Africa? At least part of the answer may be the unusual popularity of circumcision in the US. Across 35 rich countries (ie, OECD member countries), the average (median) percentage of circ’d men is 6%. Aside from Israel and Turkey, where religion promotes circ’ing, no other rich country has more than 33% of men circ’d – except the US (71%) and South Korea (77%).
Why circumcise? Relying on selected evidence from unethical trials
Outside Africa, less than one man in 1,000 gets HIV through their penis, and most men are intact (uncircumcised). Within Africa, intact men are less likely to be HIV-positive compared to circ’d men in more than half of the countries with available data, including 4 of 14 countries where the US targets men for foreskin removal.
The main excuse for circ’ing men in Africa – the excuse the US uses — comes from three partially reported and unethical trials that are widely believed to show that circumcision reduces men’s risk to get HIV from sex by about 60%. Even the reported evidence from these trials undermines that claim; and why did study teams withhold so much other relevant evidence?
Circ’ing millions of men
As a response to a nosocomial epidemic, circ’ing millions of men is dangerous. Circ’ing has been promoted with insufficient care — putting men at risk to get HIV, hepatitis B, hepatitis C, and other infections. These dangers are coming to the fore with recent reports of adverse events, including deaths from tetanus. Thankfully, the numbers circ’d have fallen far short of targets, but ambitious targets remain.
1. Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS. 2003; 14: 148-161. Available at: http://www.cirp.org/library/disease/HIV/gisselquist1/gisselquist1.pdf (accessed 18 April 2018).
2. Gisselquist D. Randomized controlled trials for HIV/AIDS prevention among men and women in Africa: untraced infections, unasked questions, and unreported data. Social Science Research Network 2011. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 21 May 2017).
3. WHO, UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. Geneva, WHO: 2007. Available at: http://apps.who.int/iris/bitstream/handle/10665/43751/9789241595988_eng.pdf;jsessionid=FBAEAFE7FB9E7D69C17004CF4BE9801E?sequence=1 (accessed 17 April 2018).
4. WHO, UNAIDS. Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa. Geneva: WHO, 2012. Available at: http://www.who.int/hiv/pub/strategic_action2012_2016/en/ (accessed 17 April 2018).’
5. Morris BJ, et al. Estimation of country-specific and global prevalence of male circumcision. Pop Health Metrics 2016; 14: DOI 10.1186/s12963-016-0073-5. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772313/pdf/12963_2016_Article_73.pdf (accessed 17 April 2018).