Circumcision and HIV control in Australia

 

Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia.

In October 2010 the Medical Journal of Australia published an opinion piece by David Cooper, Alex Wodak and Brian Morris, calling for a significant “boost” in the incidence of infant circumcision in Australia in order to combat heterosexually acquired HIV infection. The editorial attracted much media attention, and so much criticism that the journal (eventually) published eight letters in reply. A much longer and detailed rebuttal of the editorial by medical historian Robert Darby and pediatrician Robert Van Howe has now been published in Australia’s leading journal of public health issues, the Australian and New Zealand Journal of Public Health. A summary of the article follows.

ABSTRACT

Objective: To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection.

Approach: These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia’s HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues.

Conclusion: Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia’s HIV epidemic and exaggerate the relevance of the African random controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a “surgical vaccine” is criticised as polemical and unscientific.

Implications: Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.

SUMMARY

1. A conservative position

To reject infant circumcision is to follow the policy of Australian medical authorities, which have discouraged routine circumcision since 1971. It was the suggestion in the Med J Aust that was radical, and far out of step with the policies of relevant medical authorities: Royal Australasian College of Physicians, British Medical Association, Canada Pediatric Society, Royal Dutch Medical Association, American Academy of Pediatrics. The timing of the editorial suggests that it was intended to influence or criticise the circumcision policy statement about to be released by the task force set up in 2007 by the Paediatric and Child Health Division of the Royal Australasian College of Physicians. This policy stated clearly that the evidence of the African circumcision trials were not relevant in developed countries and that routine circumcision was not warranted in Australia or New Zealand.

2. Doubts about the African clinical trials themselves

• only a small protective effect – somewhere between 38 and 66 per cent, and not the mythical 60 per cent reported everywhere;
• uncertainty about why: anatomy or behaviour? No convincing biological mechanism yet found that would explain greater vulnerability of uncircumcised men;
• high drop-out rate: in some of the trials more men dropped out than were infected with HIV;
• inconsistent with epidemiological evidence from population surveys, which show no consistent pattern in HIV infection between cut and uncut;
• we don’t know how much transmission is non-sexual, probably through non-sterile medical procedures;
• even advocates of circumcision solution insist that condoms must still be used: so what’s the point of getting circumcised, with all the cost, risks, and loss of both appearance and function necessarily entailed?
• evidence from African trials might justify a modest circumcision program in high prevalence countries with high female to male transmission, as one element of a broad range of preventive measures, but not the multi-billion dollar promotion of circumcision pretty much to the exclusion of other interventions. Criticism of excessive focus on circumcision by report published by German Development Bank; plus Bjorn Lomborg and other leading economists at Georgetown conference, that circumcision on this massive scale is not cost-effective and bad way to tackle the problem.
  

3. Not relevant to nature of Australia’s HIV problem

• The WHO recommendations apply to adult men in underdeveloped countries with high HIV prevalence and a high incidence of female to male transmission via unprotected intercourse. They do not apply to the developed world, and they do not apply to children anywhere.
• Africa: high prevalence; mostly heterosexual; female to male transmission;
• Australia: low prevalence; mostly homosexual, plus a few injecting drug users – these categories get no protection from circumcision;
• no evidence that hetero transmission is increasing: only 23 new cases in 2009;
• infection from prostitutes common in Africa, but in Australia there has never been a single example of a prostitute infecting a male client;
• Australia’s HIV prevention program (condoms and safe sex education) has worked very well, and we have one of the lowest rates of HIV infection in the developed world – much less than in USA.

4. Suggestion departs from principles of evidence-based medicine.

• Trials involved consenting, sexually active adult men and did not provide any evidence that circumcision in infancy would provide protection. The trials cannot therefore be cited to justify circumcision of infants.
• In any case, infants are not sexually active, not at risk, and cannot give consent.

5. Suggestion ignores harm of circumcision and underestimates level of complications.

• Circumcision is always harmful. The foreskin is a sensitive, functional body part that many men value highly; it cannot be dismissed as nothing more than a piece of surgical waste.
• Complications are under-reported, and we have no benchmarks for acceptable risk. The bar must be set higher in cases where the surgery is not immediately necessary, and even higher when it is not elected by the individual, but imposed on him by somebody else.

6. Suggestion totally ignores medical ethics and human rights.

• But all humans have an inherent right to bodily integrity that may be violated only with very good reason. Ethics should not be dismissed as an obstacle to the roll-out of circumcision programs: if we don’t have ethical principles we cannot regard ourselves as civilized, and we shall end up in a dog-eat-dog world, without values and without respect for individual rights.

7. Circumcision is not a surgical vaccine.

• The suggestion misrepresents both the nature of vaccines and the nature and level of protection given by circumcision. It is both exaggerated and mischievous in that it is likely to give a false sense of security and encourage high risk behaviour. Already there are reports from African countries of men saying that now they are circumcised they don’t need to use condoms.

8. Conclusion

It is generally accepted that the rapid spread of HIV in Africa was associated with a high level of sexual activity, involving numerous concurrent but often transient sexual partnerships, widespread prostitution, both formal and informal, various forms of polygamy, and reluctance to practise safe sex or use condoms. It is also probable that a significant proportion of HIV infections are the result of non-sexual transmission, such as non-sterile medical procedures. These conditions were aggravated by poorly developed health services, the co-presence of numerous other epidemic diseases, such as malaria, tuberculosis and other STIs, and the refusal of local authorities to take action until the disease had spread through the population, provoked by the misconception that AIDS was a “gay disease”, confined to decadent developed world. This crisis situation stands in dramatic contrast to that of a wealthy, developed nation such as Australia, where effective action was taken early on, based on respect for the autonomy and agency of those at greatest risk, and an emphasis on safe sex education, needle and syringe programs, and provision of condoms. This strategy has been strikingly successful: AIDS in Australia remains a relatively minor public health problem, largely confined to the sub-cultures where it has traditionally been found. There is no heterosexual epidemic that would justify a costly, authoritarian program of the type and scale that Cooper et al propose. There is every reason to think that the strategy that Australia has pursued so successfully since the 1980s will continue to protect the vast majority of the population from this disease.

Source (full text available through link): Robert Darby and Robert Van Howe, Not a surgical vaccine: There is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian and New Zealand Journal of Public Health, Vol. 35, October 2011.

Full text may be downloaded as PDF here: VaccineANZJPH

Figures on the incidence of HIV and other sexually transmitted infections in Australia are available from the Kirby Institute for Infection and Immunity in Society (formerly National Centre in HIV Epidemiology and Clinical Research), HIV/AIDS, Viral Hepatitis & Sexually Transmissible Infections in Australia, Annual Surveillance Reports

Argument confirmed by studies since paper written

Results of African trials not replicated in other countries.

1.   In the USA, study by Sansom showed that that the lifetime risk of HIV to Black men was 6.23% while 73% of Black men are circumcised, yet the lifetime risk to Hispanics was only 2.88% with a circumcision rate of only 42%. This suggests that there is no connection at all between circumcision and reduced susceptibility to HIV; or that circumcision increases the risk of HIV; or that being Black in the USA is a far greater risk factor for HIV than possessing a foreskin. (This last point may be related to the disproportionate number of Black men in American prisons, where unsafe sex is rampant.)

Stephanie L. Sansom et al, Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males, PLoS ONE 5(1): e8723. doi:10.1371/journal.pone.0008723. (And see comment by Circinfo.org)

2.   Study of HPV and HIV in Zambia (Heffron et al) found that uncircumcised men had slightly lower incidence of HIV infection – but did not discuss this finding in their paper:  Heffron R. et al, High prevalent and incident HIV-1 and herpes simplex virus 2 infection among male migrant and non-migrant sugar farm workers in Zambia. Sex Transm Infect 2011; 87: 283-8.

3.   Study by Brewer in Mozambique found that men circumcised as children had a higher incidence of HIV. Suggests that this is more evidence of non-sexual transmission:  Brewer D.D. Scarification and Male Circumcision Associated with HIV Infection in Mozambican Children and Youth. WebmedCentral EPIDEMIOLOGY 2011;2(9):WMC002206

Excessive focus on circumcision criticised by economists

Criticism of excessive focus on circumcision by report published by German Development Bank; plus Bjorn Lomborg and other leading economists at Georgetown conference, that circumcision on this massive scale is not cost-effective and bad way to tackle the problem. See news report at Circinfo.org.

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