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The benefit of male circumcision in reducing HIV infection

Malcolm Potts, professor of population and family planning | December 16, 2009

One of the most important medical innovations of the 21st century- and one closely linked to UC Berkeley – is literally thousands of years old.

In the mid-90s a postdoctoral research fellow in anthropology at Berkeley, Daniel Halperin, asked if he could give a lecture in the course I teach on HIV/AIDS in the School of Public Health.  He talked about the evidence that male circumcision reduces the risk of HIV infection. I thanked him and invited him back next year. The third time Daniel spoke, I said ‘Wow!’  this person is saying something extremely important. Not long afterwards Daniel  published a landmark article in the Lancet called ‘Male circumcision in HIV infection: Ten years and counting”, where he and a co-author marshalled a compelling range of anthropological, clinical and epidemiological evidence supporting the protective nature of male circumcision.  I published a letter supporting the article, with a rough estimate that in those countries where men are circumcised there could have been as many as 8 million more HIV infections by the year 2000 if circumcision had not been practised. At about the same time, my colleague in Australia , Roger Short, published a paper on the presence of Langerhans cells in the male foreskin. These specialist cells are part of the immune system and HIV attaches to them directly. Removing the foreskin greatly reduces the risk of acquiring AIDS .

At the time, as a public health professional, I would have initiated programs telling men to use condoms, but also offering male circumcision. Unfortunately, no one was bold enough to do this, and even a thesis by one of my doctoral students on the acceptability of infant circumcision in Thailand if the parents knew about the relationship to HIV was rejected by all the journals she approached.

Dr. Halperin left the Bay Area and joined USAID in Washington. He organised a meeting on male circumcision, where experts from around the world agreed that if one of the random controlled trials then  taking place demonstrated a protective effect of male circumcision then UNAIDS, the WHO and others would put in place policies offering the operation.

Tragically, when the first random controlled trial was so successful that it had to be stopped prematurely (the results were so statistically powerful that it would have been unethical to continue it), the international organisations pussyfooted around and refused to initiate policies until a second trial was completed. This was also so successful that had to be stopped prematurely.

In case you are wondering how you do a random placebo-controlled trial of vasectomy – which after all is an operation the patient is likely to notice – it is done this way. Men at risk of HIV infection volunteer for trial and a coin is tossed. They are either circumcised  immediately or told to come back one year later. They also are told to use condoms. The rate of HIV infection in the two groups is then monitored.

I am on the board of Population Services International, a non-governmental organisation working around the world and using market forces to distribute contraceptives,  malaria bed-nets, oral rehydration tablets and working with health professionals in the private sector.  Using its own resources, PSI did start offering male circumcision in Africa, and recently the Bill and Melinda Gates Foundation has generously supported the expansion of this program.

Studies have shown that male circumcision reduces the risk of acquiring HIV by about 50%, every time a man is exposed to infection . Unlike a condom, circumcision once performed cannot be forgotten when the man goes away for the weekend, or omitted in a moment of sexual passion. Male circumcision has been called an ‘anatomical vaccine.’ Despite heavy investment, no vaccine exists but male  circumcision does.

Berkeley conducts world-class science. In this case common sense was used to pull together pieces of evidence. I am deeply disappointed in the way those working in HIV prevention were so slow to establish appropriate policy. I admit, like everybody else, that I was slow to see the potential of this intervention, but to delay action for so long when the evidence was so compelling simply condemned huge numbers of men to an otherwise preventable death.

Tragically, those controlling resources continue to learn slowly. Last year Daniel and I, along with other colleagues, published a Policy Forum in Science (320: 749, 2009) . We observed that the biggest investment in AIDS prevention prevention are targeted at those interventions where the evidence of a potential to slow a generalized heterosexual epidemic is weak – namely condoms, HIV testing, abstinence, and vaccines and microbicides – while the least investment is put in those strategies where the evidence of the powerful impact is strongest – namely male circumcision and reducing multiple concurrent sexual partners. Our article produced some defensive froth from international organisations, but it does not seem to have had the impact we hoped solid evidence in a premier journal might achieve.

Comments to “The benefit of male circumcision in reducing HIV infection

  1. There is compelling evidence that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.

  2. According to me that’s very important to precise to the men that it is asymmetrical, they can also transmit HIV to their sexual friend…

  3. Islam has ordered the circumcision of men 14 centuries ago, to be a religion of truth and when he came down from the Lord Almighty to isolate the Prophet peace be upon him. This is not a matter only, but much much more. All you need is to see more and more about Islam (not by the Western media of anti-Islam, originally, but try to find a neutral scientific sources do not have any political activities and you will find what you were not expecting.

  4. Is this procedure covered by health insurance? I am considering to have it done, but I don’t think that I can afford it. If anyone could help me out I would greatly appreciate it.

  5. You also have to take into consideration that if men think that they can’t spread HIV if they been circumcised, they might stop using protection.

    • I agree with you Joe, according to me that’s very important to precise to the men that it is asymmetrical, they can also transmit HIV to their sexual friend…

  6. There is something terrible about this: as you say, it decreases the probability to ACQUIRE HIV, but not the probability to TRANSMIT it. It is asymmetrical.

    From a purely macho point of view, this is great. But if you consider the global population, is the impact really positive? Imagine all those circumcised males, who think they are immune to the virus, and who stop using condoms, or use them less? Some of them will get the virus, and will infect women (or other men – anal transmission active to passive is the most efficient one).
    In the real world, I would guess that promoting circumcision to prevent AIDS will INCREASE the infection rate of women.

    And I don’t even comment on the risk of badly done circumcision in many countries.

  7. I saw a call-in television show out of Austin concerning these African random controlled trials. The caller said a long-time physician friend of his was sent to Africa to work on one of them. The doc said it was clear from the beginning that they were there to prove circumcision reduced HIV infection, not to disover it if would or not. He said the reason the study he worked on was stopped short wasn’t because of ethics, but that the data began to come in that disproved their desired result. Made me wonder what the real reason the other two were stopped short, too.

  8. “Dr. Halperin left the Bay Area and joined USAID in Washington. He organised a meeting on male circumcision, where experts from around the world agreed …” So Halperin chose the experts? (Who were they?) How surprising that they agreed! Halperin is on record as saying that because his grandfather was a ritual circumcisor, “maybe in some small way I’m ‘destined’ to help pass along [circumcision] to people in [other] parts of the world … .” (Cover Story: The Case for Circumcision. By Gordy Slack. The East Bay Express Online. May 19-24, 2000.) Whatever else that it, it’s not science.

    Neither of the two trials were run to completion (nor a third that Potts doesn’t mention). This reduces their accuracy, which was never very good, because the event they were looking for is still relatively rare. They circumcised a total of 5,400 men in the three trials and left a similar number intact. 64 circumcised men got HIV in less than two years, while 132 non-circumcised men did. The difference of 73 men is the sole basis of the “50% protection”. Meanwhile 327 circumcised men (and a similar number of controls) dropped out of the trials, their HIV status unknown, so who knows what the real effect is, if any? (Finding you were HIV+ – and they were encouraged to be tested independently – after a painful and marking operation to prevent it would be a powerful incentive not to go back.)

    “In case you are wondering how you do a random placebo-controlled trial of vasectomy [circumcision] – which after all is an operation the patient is likely to notice – it is done this way. Men at risk of HIV infection volunteer for trial and a coin is tossed. They are either circumcised immediately or told to come back one year later.” That is NOT how you do a placebo-controlled trial. You give the control group an operation that looks like vasectomy (easy) or circumcision (not so easy – but they could have made a shallow circular incision and then sutured it closed again, which would have fooled some and made the two groups considerably more equivalent for other factors such as abstinence after wound healing). The trials were simply not placebo-controlled at all. And they were not a random sample of the population, but (paid – quite handsomely by local standards) volunteers for circumcision.

    “They also are told to use condoms.” – but giving some a painful and marking operation at the same time could reinforce that message in an unpredictible way.

    Langerhans cells, along with other classes of dendritic cells, are universally found in all skin,. There is minimal variation between parts of the body in their content of Langerhans cells. They are found in all genital tissue including the glans, foreskin, shaft, scrotum, clitoris, clitoral hood, labia, and vagina.

  9. @Joel

    “That being said, there are certainly a number of other factors to consider when advocating widespread elective surgery.People should have the right to make decisions about their behavior”

    Exactly, and that is the problem with infant circumcision. It isn’t elective. The infant who will one day be a man and have his own opinion about whether or not he would like to keep or lose his foreskin isn’t able to speak up and say no. This is why infant circumcision is ethically wrong and why it should be made illegal. It is the right of every human being to their own body. There is a limit to decisions parents can make about their children. They can not have a tiny incision made on the vagina of an infant girl. Yet they can have 1/3 the penile skin amputated from a son?

  10. Hi Simone – when the treatment being studied in a “random controlled trial” is so clearly effective, it is highly unethical to continue withholding that treatment from the control group.

    Unless one is accusing highly respected researchers and agencies of collusion to falsify data, the data speak strongly about the protective effect of male circumcision for males in the tested populations. That being said, there are certainly a number of other factors to consider when advocating widespread elective surgery. We are lucky to have simple answers for some of life’s problems (e.g. stop eating red meat, stop smoking, stop heavy drinking). People should have the right to make decisions about their behavior – we have the responsibility to provide them with as much information as possible so they can make responsible decisions.

  11. Question 1 (granted, I do not have a clinical background, unfortunately): I don’t understand how a “random controlled trial” can be so successful that it would have to be stopped prematurely. Also, were the subjects followed long enough to see if the occurences of infection in circumcised males caught up with the occurences of infection in the non-circumcised males?

    Question 2 (following Paul’s line of argument a bit): how can cultural biais be accounted for in such studies?

    Thank you for your article.

    Simone

  12. Caucasion Americans – who are overwhelmingly circumcised – have higher rates of sexually transmitted disease than Europeans – who are mostly not circumcised. Malcom Potts declines to mention this because it doesn’t fit his agenda. He also refuses to acknowledge the ethical conflict inherent in the practice of infant circumcision. He is a defender of an American cultural norm that is steadily declining in popularity everywhere in the country – but nowhere like on the west coast where he teaches.

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