Circumcision and HIV: Difference between revisions
→Misinformation about VMMC programs: this is improper synthesis, as the cited source does not refer to Trump's statement as false |
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Male [[circumcision]] reduces the risk of [[HIV transmission|human immunodeficiency virus (HIV) transmission]] from HIV positive women to men in high risk populations.<ref>{{Cite journal |last1=Sharma |first1=Adhikarimayum Lakhikumar |last2=Hokello |first2=Joseph |last3=Tyagi |first3=Mudit |date=2021-06-25 |title=Circumcision as an Intervening Strategy against HIV Acquisition in the Male Genital Tract |journal=Pathogens |volume=10 |issue=7 |pages=806 |doi=10.3390/pathogens10070806 |pmid=34201976 |pmc=8308621 |issn=2076-0817 |quote=There is disputed immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1.|doi-access=free }}</ref><ref name=":0">{{Cite book |last1=Merson |first1=Michael |title=The AIDS Pandemic: Searching for a Global Response |last2=Inrig |first2=Stephen |publisher=[[Springer Publishing]] |year=2017 |isbn=9783319471334 |pages=379 |quote=This led to a [medical] consensus that male circumcision should be a priority for HIV prevention in countries and regions with heterosexual epidemics and high HIV and low male circumcision prevalence.}}</ref> In 2020, the [[World Health Organization]] (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions.<ref name="WHO-PrevHIV">{{cite web|title=Preventing HIV Through Safe Voluntary Medical Male Circumcision For Adolescent Boys And Men In Generalized HIV Epidemics | Male [[circumcision]] reduces the risk of [[HIV transmission|human immunodeficiency virus (HIV) transmission]] from HIV positive women to men in high risk populations.<ref>{{Cite journal |last1=Sharma |first1=Adhikarimayum Lakhikumar |last2=Hokello |first2=Joseph |last3=Tyagi |first3=Mudit |date=2021-06-25 |title=Circumcision as an Intervening Strategy against HIV Acquisition in the Male Genital Tract |journal=Pathogens |volume=10 |issue=7 |pages=806 |doi=10.3390/pathogens10070806 |pmid=34201976 |pmc=8308621 |issn=2076-0817 |quote=There is disputed immunological evidence in support of MC in preventing the heterosexual acquisition of HIV-1.|doi-access=free }}</ref><ref name=":0">{{Cite book |last1=Merson |first1=Michael |title=The AIDS Pandemic: Searching for a Global Response |last2=Inrig |first2=Stephen |publisher=[[Springer Publishing]] |year=2017 |isbn=9783319471334 |pages=379 |quote=This led to a [medical] consensus that male circumcision should be a priority for HIV prevention in countries and regions with heterosexual epidemics and high HIV and low male circumcision prevalence.}}</ref> In 2020, the [[World Health Organization]] (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions.<ref name="WHO-PrevHIV">{{cite web|title=Preventing HIV Through Safe Voluntary Medical Male Circumcision For Adolescent Boys And Men In Generalized HIV Epidemics | ||
|year=2020|publisher=[[World Health Organization]]|url=https://www.who.int/publications/i/item/978-92-4-000854-0 |access-date=2021-05-24}}</ref> | |year=2020|publisher=[[World Health Organization]]|url=https://www.who.int/publications/i/item/978-92-4-000854-0 |access-date=2021-05-24}}</ref> | ||
Circumcision reduces the risk that a man will acquire HIV and other [[sexually transmitted infections]] (STIs) from an infected female partner through [[vaginal sex]].<ref name="CDCPrevHIV2018">{{cite report|title=Information for providers counseling male patients and parents regarding male circumcision and the prevention of HIV infection, STIs, and other health outcomes|publisher=[[Centers for Disease Control and Prevention]]|date=August 22, 2018|url=https://stacks.cdc.gov/view/cdc/58456|access-date=2021-05-26|archive-date=2021-05-06|archive-url=https://web.archive.org/web/20210506034452/https://stacks.cdc.gov/view/cdc/58456|url-status=live}}</ref> The evidence regarding whether circumcision helps prevent HIV is not as clear among [[men who have sex with men]] (MSM).<ref name="WHO-PrevHIV" /> The effectiveness of using circumcision to prevent HIV in the [[Developed country|developed world]] is not determined.<ref name="WHO-PrevHIV" /><ref name="kim_2010" /> | Circumcision reduces the risk that a man will acquire HIV and other [[sexually transmitted infections]] (STIs) from an infected female partner through [[vaginal sex]].<ref name="CDCPrevHIV2018">{{cite report|title=Information for providers counseling male patients and parents regarding male circumcision and the prevention of HIV infection, STIs, and other health outcomes|publisher=[[Centers for Disease Control and Prevention]]|date=August 22, 2018|url=https://stacks.cdc.gov/view/cdc/58456|access-date=2021-05-26|archive-date=2021-05-06|archive-url=https://web.archive.org/web/20210506034452/https://stacks.cdc.gov/view/cdc/58456|url-status=live}}</ref> The evidence regarding whether circumcision helps prevent HIV is not as clear among [[men who have sex with men]] (MSM).<ref name="WHO-PrevHIV" /> The effectiveness of using circumcision to prevent HIV in the [[Developed country|developed world]] is not determined.<ref name="WHO-PrevHIV" /><ref name="kim_2010" /><ref>{{Cite journal |last=Nayan |first=Madhur |last2=Hamilton |first2=Robert J. |last3=Juurlink |first3=David N. |last4=Austin |first4=Peter C. |last5=Jarvi |first5=Keith A. |date=2022-02 |title=Circumcision and Risk of HIV among Males from Ontario, Canada |url=https://pubmed.ncbi.nlm.nih.gov/34551593 |journal=The Journal of Urology |volume=207 |issue=2 |pages=424–430 |doi=10.1097/JU.0000000000002234 |issn=1527-3792 |pmid=34551593}}</ref> | ||
==Efficacy== | ==Efficacy== | ||
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{{blockquote|text=Although these results confirm that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing, counseling, and treatment.|author=World Health Organization|source=Joint WHO/UNAIDS Statement made in 2007.<ref name="WHOsec">{{cite press release | url = https://www.who.int/mediacentre/news/statements/2007/s04/en/index.html | title = WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk | access-date = 2007-02-23 | date = February 23, 2007 | publisher = World Health Organization | archive-date = 2007-02-26 | archive-url = https://web.archive.org/web/20070226135123/http://www.who.int/mediacentre/news/statements/2007/s04/en/index.html | url-status = dead }}</ref>}} | {{blockquote|text=Although these results confirm that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing, counseling, and treatment.|author=World Health Organization|source=Joint WHO/UNAIDS Statement made in 2007.<ref name="WHOsec">{{cite press release | url = https://www.who.int/mediacentre/news/statements/2007/s04/en/index.html | title = WHO and UNAIDS Secretariat welcome corroborating findings of trials assessing impact of male circumcision on HIV risk | access-date = 2007-02-23 | date = February 23, 2007 | publisher = World Health Organization | archive-date = 2007-02-26 | archive-url = https://web.archive.org/web/20070226135123/http://www.who.int/mediacentre/news/statements/2007/s04/en/index.html | url-status = dead }}</ref>}} | ||
In the United States, the [[American Academy of Pediatrics]] (AAP) led a 2012 task force which included the [[American Academy of Family Physicians]] (AAFP), the [[American College of Obstetricians and Gynecologists]] (ACOG), and the [[Centers for Disease Control]] (CDC). The task force concluded that circumcision may be helpful for the prevention of HIV in the United States.<ref name="AAP_2012">{{cite journal |author=American Academy of Pediatrics Task Force on Circumcision |title=Technical Report |journal=Pediatrics |volume=130 |issue=3 |year=2012 |pages=e756–e785 |issn=0031-4005 |pmid=22926175 |doi=10.1542/peds.2012-1990 | In the United States, the [[American Academy of Pediatrics]] (AAP) led a 2012 task force which included the [[American Academy of Family Physicians]] (AAFP), the [[American College of Obstetricians and Gynecologists]] (ACOG), and the [[Centers for Disease Control]] (CDC). The task force concluded that circumcision may be helpful for the prevention of HIV in the United States.<ref name="AAP_2012">{{cite journal |author=American Academy of Pediatrics Task Force on Circumcision |title=Technical Report |journal=Pediatrics |volume=130 |issue=3 |year=2012 |pages=e756–e785 |issn=0031-4005 |pmid=22926175 |doi=10.1542/peds.2012-1990 |doi-access=free }}</ref> The CDC 2018 position on circumcision and HIV recommended that circumcision should continue to be offered to parents who are [[informed consent|informed]] of the benefits and risks, including a potential reduction in risk of HIV transmission. The position asserts that circumcision conducted after sexual debut can result in missed opportunities for HIV prevention.<ref name="CDCPrevHIV2018" /> | ||
Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the [[Royal Dutch Medical Association]] (KNMG) questioned the applicability of those studies to developed countries. Circumcision has not been included in their HIV prevention recommendations. The KNMG circumcision policy statement was endorsed by several Dutch medical associations. The policy statement was initially released in 2010, but was reviewed again and accepted in 2022.<ref>{{Cite web|title=Non-therapeutic circumcision of male minors KNMG viewpoint|url=https://www.knmg.nl/advies-richtlijnen/dossiers/jongensbesnijdenis|date=31 March 2022}}</ref> | Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the [[Royal Dutch Medical Association]] (KNMG) questioned the applicability of those studies to developed countries. Circumcision has not been included in their HIV prevention recommendations. The KNMG circumcision policy statement was endorsed by several Dutch medical associations. The policy statement was initially released in 2010, but was reviewed again and accepted in 2022.<ref>{{Cite web|title=Non-therapeutic circumcision of male minors KNMG viewpoint|url=https://www.knmg.nl/advies-richtlijnen/dossiers/jongensbesnijdenis|date=31 March 2022}}</ref> | ||
==Mechanism of action== | ==Mechanism of action== | ||
While the biological mechanism of action is not known, a 2020 meta-analysis stated "the consistent protective effect suggests that the reasons for the heterogeneity lie in concomitant individual social and medical factors, such as presence of STIs, rather than a different biological impact of circumcision."<ref name="farley" /> | While the biological mechanism of action is not known, a 2020 meta-analysis stated "the consistent protective effect suggests that the reasons for the heterogeneity lie in concomitant individual social and medical factors, such as presence of STIs, rather than a different biological impact of circumcision."<ref name="farley" /> | ||
The inner foreskin harbours an increased density of CD4 T-cells and releases increased levels of pro-inflammatory cytokines. Hence the sub-preputial space displays a pro-inflammatory environment, conducive to HIV infection.<ref>{{cite journal |last1=Prodger |first1=Jessica L. |title=The biology of how circumcision reduces HIV susceptibility: broader implications for the prevention field |journal=AIDS Research and Therapy |date=September 2017 |volume=14 |issue=1 |page=49 |doi=10.1186/s12981-017-0167-6|pmid=28893286 |pmc=5594533 |doi-access=free }}</ref> | The inner foreskin harbours an increased density of CD4 T-cells and releases increased levels of pro-inflammatory cytokines. Hence the sub-preputial space displays a pro-inflammatory environment, conducive to HIV infection.<ref>{{cite journal |last1=Prodger |first1=Jessica L. |title=The biology of how circumcision reduces HIV susceptibility: broader implications for the prevention field |journal=AIDS Research and Therapy |date=September 2017 |volume=14 |issue=1 |page=49 |doi=10.1186/s12981-017-0167-6|pmid=28893286 |pmc=5594533 |doi-access=free }}</ref> | ||
[[Langerhans cell]]s (part of the human immune system) under the foreskin may be a source of entry for HIV.<ref>{{cite journal | vauthors = Weiss HA, Dickson KE, Agot K, Hankins CA | title = Male circumcision for HIV prevention: current research and programmatic issues | journal = AIDS | volume = 24 | issue = Suppl 4 | pages = S61-9 | date = October 2010 | pmid = 21042054 | pmc = 4233247 | doi = 10.1097/01.aids.0000390708.66136.f4 | type = Randomized controlled trial }}</ref> Excising the foreskin removes what is thought to be a main entry point for the HIV virus.<ref>{{cite journal |vauthors=Szabo R, Short RV |title=How does male circumcision protect against HIV infection? |journal=BMJ |volume=320 |issue=7249 |pages=1592–4 |date=June 2000 |pmid=10845974 |pmc=1127372 |doi=10.1136/bmj.320.7249.1592 |type=Review}}</ref> | [[Langerhans cell]]s (part of the human immune system) under the foreskin may be a source of entry for HIV.<ref>{{cite journal | vauthors = Weiss HA, Dickson KE, Agot K, Hankins CA | title = Male circumcision for HIV prevention: current research and programmatic issues | journal = AIDS | volume = 24 | issue = Suppl 4 | pages = S61-9 | date = October 2010 | pmid = 21042054 | pmc = 4233247 | doi = 10.1097/01.aids.0000390708.66136.f4 | type = Randomized controlled trial }}</ref> Excising the foreskin removes what is thought to be a main entry point for the HIV virus.<ref>{{cite journal |vauthors=Szabo R, Short RV |title=How does male circumcision protect against HIV infection? |journal=BMJ |volume=320 |issue=7249 |pages=1592–4 |date=June 2000 |pmid=10845974 |pmc=1127372 |doi=10.1136/bmj.320.7249.1592 |type=Review}}</ref> | ||
==Advocacy campaigns== | |||
Sociologist Sarah Rudrum and colleagues have written that the communication of VMMC in Uganda is unethical and contradicts medical evidence. In their analysis of “Stand Proud, Get Circumcised”, a [[public health]] campaign promoting circumcision as an [[Prevention of HIV/AIDS|HIV-prevention]] strategy in [[Uganda]], Rudrum et al. “exploit male anxieties about appearance and performance, drawing on [[hegemonic masculinity]] to promote circumcision as an idealized body aesthetic”.<ref>{{cite journal |last1=Rudrum |first1=Sarah |last2=Oliffe |first2=John L. |last3=Benoit |first3=Cecilia |year=2017 |title=Discourses of masculinity, femininity and sexuality in Uganda's Stand Proud, Get Circumcised campaign |journal=Culture, Health & Sexuality |volume=19 |issue=2 |pages=225–239 |doi=10.1080/13691058.2016.1214748|pmid=27684495 }}</ref> In their work combining a [[transnational history]] of medicalised [[Circumcision|male circumcision]] and an analysis of International Organisations documents promoting VMMC, Alejandro and Feldman show that medicalised male circumcision “is represented as an enhancer of [[virility]], sexual pleasure and sexual performance”.<ref>{{cite journal |last1=Alejandro |first1=Audrey |last2=Feldman |first2=Jacob |year=2024 |title=The discursive process of resemantisation: how global health discourses turned male circumcision into an anti-HIV policy |journal=International Relations |volume=0 |doi=10.1177/00471178241249641}}</ref> | |||
==History== | ==History== | ||
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Valiere Alcena, in a 1986 letter to the ''New York State Journal of Medicine,'' noted that low rates of circumcision in parts of Africa had been linked to the [[List of countries by HIV/AIDS adult prevalence rate|high rate of HIV infection]].<ref name="taken">{{cite journal | type = Comment | vauthors = Alcena V | title = AIDS in Third World countries | journal = PLOS Medicine | date = 19 October 2006 | volume = 86 | issue = 8 | page = 446 | pmid = 3463895 | url = http://www.plosmedicine.org/annotation/listThread.action?root=15231 | access-date = 10 January 2014 | archive-date = 10 January 2014 | archive-url = https://web.archive.org/web/20140110204325/http://www.plosmedicine.org/annotation/listThread.action?root=15231 | url-status = dead }}</ref><ref>{{cite journal |type = Letter |vauthors = Alcena V |title = AIDS in Third World countries |journal = New York State Journal of Medicine |volume = 86 |issue = 8 |pages = 446 |date = August 1986 |pmid = 3463895 |url = http://www.popline.org/node/363663 |access-date = 2014-01-10 |archive-date = 2014-01-10 |archive-url = https://web.archive.org/web/20140110194304/http://www.popline.org/node/363663 |url-status = live }}</ref> Aaron J. Fink several months later also proposed that circumcision could have a preventive role when the ''[[New England Journal of Medicine]]'' published his letter, "A possible explanation for heterosexual male infection with AIDS," in October, 1986.<ref>{{cite journal | vauthors = Fink AJ | title = A possible explanation for heterosexual male infection with AIDS | journal = The New England Journal of Medicine | volume = 315 | issue = 18 | pages = 1167 | date = October 1986 | pmid = 3762636 | doi = 10.1056/nejm198610303151818 | type = Letter }}</ref> By 2000, over 40 epidemiological studies had been conducted to investigate the relationship between circumcision and HIV infection.<ref name="Szabo">{{cite journal | vauthors = Szabo R, Short RV | title = How does male circumcision protect against HIV infection? | journal = BMJ | volume = 320 | issue = 7249 | pages = 1592–4 | date = June 2000 | pmid = 10845974 | pmc = 1127372 | doi = 10.1136/bmj.320.7249.1592 | type = Review }}</ref> A meta-analysis conducted by researchers at the [[London School of Hygiene & Tropical Medicine]] examined 27 studies of circumcision and HIV in sub-Saharan Africa and concluded that these showed circumcision to be "associated with a significantly reduced risk of HIV infection" that could form part of a useful public health strategy.<ref name="Weiss2000">{{cite journal | vauthors = Weiss HA, Quigley MA, Hayes RJ | s2cid = 21857086 | title = Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis | journal = AIDS | volume = 14 | issue = 15 | pages = 2361–70 | date = October 2000 | pmid = 11089625 | doi = 10.1097/00002030-200010200-00018 | url = https://www.aidsonline.com/pt/re/aids/pdfhandler.00002030-200010200-00018.pdf | url-status = dead | type = Meta-analysis | archive-url = https://web.archive.org/web/20140110151608/http://journals.lww.com/aidsonline/Fulltext/2000/10200/Male_circumcision_and_risk_of_HIV_infection_in.18.aspx | archive-date = 2014-01-10 }}</ref> A 2005 review of 37 observational studies expressed reservations about the conclusion because of possible [[confounding factor]]s, since all studies to date had been observational as opposed to [[randomized controlled trial]]s. The authors stated that three randomized controlled trials then underway in Africa would provide "essential evidence" about the effects of circumcision on preventing HIV.<ref name="Siegfried2005">{{cite journal | vauthors = Siegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, Walker S, Williamson P | display-authors = 6 | title = HIV and male circumcision--a systematic review with assessment of the quality of studies | journal = The Lancet. Infectious Diseases | volume = 5 | issue = 3 | pages = 165–73 | date = March 2005 | pmid = 15766651 | doi = 10.1016/S1473-3099(05)01309-5 | type = Review }}</ref> | Valiere Alcena, in a 1986 letter to the ''New York State Journal of Medicine,'' noted that low rates of circumcision in parts of Africa had been linked to the [[List of countries by HIV/AIDS adult prevalence rate|high rate of HIV infection]].<ref name="taken">{{cite journal | type = Comment | vauthors = Alcena V | title = AIDS in Third World countries | journal = PLOS Medicine | date = 19 October 2006 | volume = 86 | issue = 8 | page = 446 | pmid = 3463895 | url = http://www.plosmedicine.org/annotation/listThread.action?root=15231 | access-date = 10 January 2014 | archive-date = 10 January 2014 | archive-url = https://web.archive.org/web/20140110204325/http://www.plosmedicine.org/annotation/listThread.action?root=15231 | url-status = dead }}</ref><ref>{{cite journal |type = Letter |vauthors = Alcena V |title = AIDS in Third World countries |journal = New York State Journal of Medicine |volume = 86 |issue = 8 |pages = 446 |date = August 1986 |pmid = 3463895 |url = http://www.popline.org/node/363663 |access-date = 2014-01-10 |archive-date = 2014-01-10 |archive-url = https://web.archive.org/web/20140110194304/http://www.popline.org/node/363663 |url-status = live }}</ref> Aaron J. Fink several months later also proposed that circumcision could have a preventive role when the ''[[New England Journal of Medicine]]'' published his letter, "A possible explanation for heterosexual male infection with AIDS," in October, 1986.<ref>{{cite journal | vauthors = Fink AJ | title = A possible explanation for heterosexual male infection with AIDS | journal = The New England Journal of Medicine | volume = 315 | issue = 18 | pages = 1167 | date = October 1986 | pmid = 3762636 | doi = 10.1056/nejm198610303151818 | type = Letter }}</ref> By 2000, over 40 epidemiological studies had been conducted to investigate the relationship between circumcision and HIV infection.<ref name="Szabo">{{cite journal | vauthors = Szabo R, Short RV | title = How does male circumcision protect against HIV infection? | journal = BMJ | volume = 320 | issue = 7249 | pages = 1592–4 | date = June 2000 | pmid = 10845974 | pmc = 1127372 | doi = 10.1136/bmj.320.7249.1592 | type = Review }}</ref> A meta-analysis conducted by researchers at the [[London School of Hygiene & Tropical Medicine]] examined 27 studies of circumcision and HIV in sub-Saharan Africa and concluded that these showed circumcision to be "associated with a significantly reduced risk of HIV infection" that could form part of a useful public health strategy.<ref name="Weiss2000">{{cite journal | vauthors = Weiss HA, Quigley MA, Hayes RJ | s2cid = 21857086 | title = Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis | journal = AIDS | volume = 14 | issue = 15 | pages = 2361–70 | date = October 2000 | pmid = 11089625 | doi = 10.1097/00002030-200010200-00018 | url = https://www.aidsonline.com/pt/re/aids/pdfhandler.00002030-200010200-00018.pdf | url-status = dead | type = Meta-analysis | archive-url = https://web.archive.org/web/20140110151608/http://journals.lww.com/aidsonline/Fulltext/2000/10200/Male_circumcision_and_risk_of_HIV_infection_in.18.aspx | archive-date = 2014-01-10 }}</ref> A 2005 review of 37 observational studies expressed reservations about the conclusion because of possible [[confounding factor]]s, since all studies to date had been observational as opposed to [[randomized controlled trial]]s. The authors stated that three randomized controlled trials then underway in Africa would provide "essential evidence" about the effects of circumcision on preventing HIV.<ref name="Siegfried2005">{{cite journal | vauthors = Siegfried N, Muller M, Deeks J, Volmink J, Egger M, Low N, Walker S, Williamson P | display-authors = 6 | title = HIV and male circumcision--a systematic review with assessment of the quality of studies | journal = The Lancet. Infectious Diseases | volume = 5 | issue = 3 | pages = 165–73 | date = March 2005 | pmid = 15766651 | doi = 10.1016/S1473-3099(05)01309-5 | type = Review }}</ref> | ||
Experimental evidence was needed to establish a causal relationship, so three [[randomized controlled trial]]s (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in [[South Africa]], [[Kenya]] and [[Uganda]].<ref name=":1">{{cite journal |vauthors=Siegfried N, Muller M, Deeks JJ, Volmink J |date=April 2009 |title=Male circumcision for prevention of heterosexual acquisition of HIV in men |journal=The Cochrane Database of Systematic Reviews |issue=2 |pages=CD003362 |doi=10.1002/14651858.CD003362.pub2 |pmid=19370585 |veditors=Siegfried N|pmc=11666075 }}</ref> All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV incidence than the control group, and hence it was seen as unethical to withhold the procedure, in light of strong evidence of efficacy.<ref name=":1" /> In 2009, a [[Cochrane Library|Cochrane review]] which included the results of the three [[randomized controlled trial]]s found "strong" evidence that the acquisition of HIV by a man during sex with a woman was decreased by 54% ([[95% confidence interval]], 38% to 66%) over 24 months if the man was circumcised. The review also found a low incidence of adverse effects from circumcision in the trials reviewed.<ref name="Cochrane2009">{{cite journal |last1=Siegfried |first1=Nandi |last2=Muller |first2=Martie |last3=Deeks |first3=Jonathan J |last4=Volmink |first4=Jimmy |title=Male circumcision for prevention of heterosexual acquisition of HIV in men |journal=Cochrane Database of Systematic Reviews |date=15 April 2009 |issue=2 |pages=CD003362 |doi=10.1002/14651858.CD003362.pub2|pmid=19370585 |pmc=11666075 }}</ref> WHO assessed the trials as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results.<ref name="WHO-PrevHIV" /> In 2020, a review including post-study follow up from the three randomized controlled trials, as well as newer observational studies, found a 59% relative reduction in HIV incidence, and 1.31% absolute decrease across the three randomized controlled trials, as well as continued protection for up to 6 years after the studies began.<ref>{{cite journal |last1=Farley |first1=Timothy MM |last2=Samuelson |first2=Julia |last3=Grabowski |first3=M Kate |last4=Ameyan |first4=Wole |last5=Gray |first5=Ronald H |last6=Baggaley |first6=Rachel |title=Impact of male circumcision on risk of HIV infection in men in a changing epidemic context – systematic review and meta-analysis |journal=Journal of the International AIDS Society |date=June 2020 |volume=23 |issue=6 |pages=e25490 |doi=10.1002/jia2.25490|pmid=32558344 |pmc=7303540 |doi-access=free }}</ref> | Experimental evidence was needed to establish a causal relationship, so three [[randomized controlled trial]]s (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in [[South Africa]], [[Kenya]] and [[Uganda]].<ref name=":1">{{cite journal |vauthors=Siegfried N, Muller M, Deeks JJ, Volmink J |date=April 2009 |title=Male circumcision for prevention of heterosexual acquisition of HIV in men |journal=The Cochrane Database of Systematic Reviews |volume=2013 |issue=2 |pages=CD003362 |doi=10.1002/14651858.CD003362.pub2 |pmid=19370585 |veditors=Siegfried N|pmc=11666075 }}</ref> All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV incidence than the control group, and hence it was seen as unethical to withhold the procedure, in light of strong evidence of efficacy.<ref name=":1" /> In 2009, a [[Cochrane Library|Cochrane review]] which included the results of the three [[randomized controlled trial]]s found "strong" evidence that the acquisition of HIV by a man during sex with a woman was decreased by 54% ([[95% confidence interval]], 38% to 66%) over 24 months if the man was circumcised. The review also found a low incidence of adverse effects from circumcision in the trials reviewed.<ref name="Cochrane2009">{{cite journal |last1=Siegfried |first1=Nandi |last2=Muller |first2=Martie |last3=Deeks |first3=Jonathan J |last4=Volmink |first4=Jimmy |title=Male circumcision for prevention of heterosexual acquisition of HIV in men |journal=Cochrane Database of Systematic Reviews |date=15 April 2009 |volume=2013 |issue=2 |pages=CD003362 |doi=10.1002/14651858.CD003362.pub2|pmid=19370585 |pmc=11666075 }}</ref> WHO assessed the trials as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results.<ref name="WHO-PrevHIV" /> In 2020, a review including post-study follow up from the three randomized controlled trials, as well as newer observational studies, found a 59% relative reduction in HIV incidence, and 1.31% absolute decrease across the three randomized controlled trials, as well as continued protection for up to 6 years after the studies began.<ref>{{cite journal |last1=Farley |first1=Timothy MM |last2=Samuelson |first2=Julia |last3=Grabowski |first3=M Kate |last4=Ameyan |first4=Wole |last5=Gray |first5=Ronald H |last6=Baggaley |first6=Rachel |title=Impact of male circumcision on risk of HIV infection in men in a changing epidemic context – systematic review and meta-analysis |journal=Journal of the International AIDS Society |date=June 2020 |volume=23 |issue=6 |pages=e25490 |doi=10.1002/jia2.25490|pmid=32558344 |pmc=7303540 |doi-access=free }}</ref> | ||
== Society and culture == | == Society and culture == | ||
| Line 58: | Line 62: | ||
{{POV section|date=June 2025 |talk="Misinformation about VMMC programs"}} | {{POV section|date=June 2025 |talk="Misinformation about VMMC programs"}} | ||
{{close paraphrasing|article|source=https://www.cgdev.org/blog/brief-look-president-trumps-list-appalling-aid-projects|free=no|talk="Misinformation about VMMC programs"|date=June 2025}} | {{close paraphrasing|article|source=https://www.cgdev.org/blog/brief-look-president-trumps-list-appalling-aid-projects|free=no|talk="Misinformation about VMMC programs"|date=June 2025}} | ||
Misinformation about circumcision has been spread by [[United States]] President [[Donald Trump]], {{failed verification span|text= many members of the [[Republican Party (United States)|Republican Party]], and other Western [[Right-wing populism|right-wing populists]] and [[National conservatism|national conservatives]], who have falsely alleged that it is ineffective in reducing HIV transmission, portrayed it as a threat to [[masculinity]], or an ineffective use of the dollars of taxpayers.|date=June 2025}} The scientific consensus positions of major medical organizations, including that of the [[World Health Organization]], is that circumcision is one of the most effective methods of preventing HIV transmission in high-risk locations.<ref name="WHO-PrevHIV" /><ref name=":2">{{Cite web |last=Uribe |first=Grace Abels, Maria Ramirez |title=The facts behind the 19 programs Trump described as | Misinformation about circumcision has been spread by [[United States]] President [[Donald Trump]], {{failed verification span|text= many members of the [[Republican Party (United States)|Republican Party]], and other Western [[Right-wing populism|right-wing populists]] and [[National conservatism|national conservatives]], who have falsely alleged that it is ineffective in reducing HIV transmission, portrayed it as a threat to [[masculinity]], or an ineffective use of the dollars of taxpayers.|date=June 2025}} The scientific consensus positions of major medical organizations, including that of the [[World Health Organization]], is that circumcision is one of the most effective methods of preventing HIV transmission in high-risk locations.<ref name="WHO-PrevHIV" /><ref name=":2">{{Cite web |last=Uribe |first=Grace Abels, Maria Ramirez |title=The facts behind the 19 programs Trump described as 'waste' |url=https://www.politifact.com/article/2025/mar/12/the-facts-behind-the-19-programs-president-donald/ |access-date=2025-05-22 |website=@politifact |language=en-US}}</ref><ref>{{Cite news |last=Roldan |first=Bec |date=2025-03-06 |title=Trump says 'male circumcision in Mozambique' is a 'scam.' What's the program about? |url=https://www.npr.org/sections/goats-and-soda/2025/03/06/g-s1-52361/trump-says-male-circumcision-in-mozambique-is-a-scam-whats-the-program-about |access-date=2025-05-22 |work=NPR |language=en}}</ref><ref>{{Cite journal |last=Bendana |first=Christopher |date=2025-05-20 |title=Trump's cuts to international aid are stifling Africa's HIV research |url=https://www.nature.com/articles/d41586-025-01424-1 |journal=Nature |language=en |doi=10.1038/d41586-025-01424-1 |pmid=40394388 |issn=1476-4687|url-access=subscription }}</ref><ref name=":3">{{Cite web |last=Kenney |first=Charles |date=2025-03-06 |title=A Brief Look at President Trump's List of "Appalling" Aid Projects |url=https://www.cgdev.org/blog/brief-look-president-trumps-list-appalling-aid-projects |access-date=2025-05-22 |website=Center For Global Development |language=en |quote=This is potentially referring to a grant to an organization in the country. It is worth noting how powerful a tool male circumcision is in the fight against AIDS. Reaching targeted male circumcision rates in Mozambique would have prevented 220,000 HIV infections 2011–2025.}}</ref><ref name=":4">{{Cite news |author=N. P. R. Staff |date=2025-03-04 |title=Read NPR's annotated fact check of President Trump's address to Congress |url=https://www.npr.org/2025/03/04/g-s1-50488/trump-congress-joint-address-fact-check |access-date=2025-05-22 |work=NPR |language=en}}</ref> In the [[2025 Donald Trump speech to a joint session of Congress|2025 speech to a joint session of Congress]], President Trump {{Synthesis span|text=falsely|date=June 2025}} cited a circumcision grant to [[Mozambique]] as a supposed example of government waste.<ref name=":3" /> It also marked the first time circumcision has ever been mentioned or criticized in a [[State of the Union]] or [[Joint session of the United States Congress|speech to a joint session of Congress]].<ref>{{Cite news |last1=Keating |first1=Dan |last2=Mourtoupalas |first2=Nick |last3=Dormido |first3=Hannah |date=2025-03-05 |title=You've never heard that in a presidential address to Congress before |url=https://www.washingtonpost.com/politics/2025/03/05/trump-speech-words-compared-state-of-the-union/ |archive-url=https://web.archive.org/web/20250307060750/https://www.washingtonpost.com/politics/2025/03/05/trump-speech-words-compared-state-of-the-union/ |archive-date=2025-03-07 |access-date=2025-05-22 |newspaper=The Washington Post |language=en}}</ref> Reaching targeted male circumcision rates in Mozambique would have prevented 220,000 HIV infections 2011–2025.<ref name=":3" /> | ||
== See also == | == See also == | ||
{{Portal|Human sexuality}} | {{Portal|Human sexuality}} | ||
* [[Reproductive health]] | * [[Reproductive health]] | ||
* [[Female Circumcision]] | |||
* [[Prevalence of circumcision]] | |||
* [[Circumcision controversies]] | |||
== References == | == References == | ||
Latest revision as of 12:09, 1 July 2025
Template:Short description Script error: No such module "about". Male circumcision reduces the risk of human immunodeficiency virus (HIV) transmission from HIV positive women to men in high risk populations.[1][2] In 2020, the World Health Organization (WHO) reiterated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions.[3] Circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner through vaginal sex.[4] The evidence regarding whether circumcision helps prevent HIV is not as clear among men who have sex with men (MSM).[3] The effectiveness of using circumcision to prevent HIV in the developed world is not determined.[3][5][6]
Efficacy
Heterosexual men
Template:As of, past research has shown that circumcision reduces the risk of HIV infection in heterosexual men, although these studies have had limitations.[7]
The WHO Expert Group on Models To Inform Fast Tracking Voluntary Medical Male Circumcision In HIV Combination Prevention in 2016 found "large benefits" of circumcision in settings with high HIV prevalence and low circumcision prevalence. The Group estimated male circumcision is cost-saving in almost all high priority countries. Furthermore, WHO stated that: "While circumcision reduces a man’s individual lifetime HIV risk, the indirect effect of preventing further HIV transmissions to women, their babies (vertical transmission) and from women to other men has an even greater impact on the population incidence, particularly for circumcisions performed at younger ages (under age 25 years)."[8]
Newly circumcised HIV infected men who are not taking antiretroviral therapy can shed the HIV virus from the circumcision wound, thus increasing the immediate risk of HIV transmission to female partners.[3] This risk of post-operative transmission presents a challenge, although in the long-term it is possible the circumcision of HIV-infected men helps lessen heterosexual HIV transmission overall. Such viral shedding can be mitigated by the use of antiretroviral drugs.[9] Additional research is needed to ascertain the existence and potential risk of viral shedding from circumcision wounds.
Men who have sex with men
The WHO does not recommend circumcision as protection against male to male HIV transmission, as evidence is lacking in regards to receptive anal intercourse. The WHO also states that MSM should not be excluded from circumcision services in countries in eastern and southern Africa, and that circumcision may be effective at limiting the spread of HIV for MSM if they also engage in vaginal sex with women.[3]
Regional differences
Whether circumcision is beneficial to developed countries for HIV prevention purposes is undetermined.[3][5] It is not known whether the effect of male circumcision differs by HIV-1 variant. The predominant subtype of HIV-1 in the United States is subtype B, and in Africa, the predominant subtypes are A, C, and D.[10]
Recommendations
The most recent WHO review of the evidence reiterates prior estimates of the impact of male circumcision on HIV incidence rates. In 2020, WHO again concluded that male circumcision is an efficacious intervention for HIV prevention and that the promotion of male circumcision is an essential strategy, in addition to other preventive measures, for the prevention of heterosexually acquired HIV infection in men. Eastern and southern Africa had a particularly low prevalence of circumcised males. This region has a disproportionately high HIV infection rate, with a significant number of those infections stemming from heterosexual transmission. The WHO has made voluntary medical male circumcision (VMMC) a priority intervention in that region since their 2007 recommendations.[3]
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Although these results confirm that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing, counseling, and treatment.
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In the United States, the American Academy of Pediatrics (AAP) led a 2012 task force which included the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the Centers for Disease Control (CDC). The task force concluded that circumcision may be helpful for the prevention of HIV in the United States.[12] The CDC 2018 position on circumcision and HIV recommended that circumcision should continue to be offered to parents who are informed of the benefits and risks, including a potential reduction in risk of HIV transmission. The position asserts that circumcision conducted after sexual debut can result in missed opportunities for HIV prevention.[4]
Because the evidence that circumcision prevents HIV mainly comes from studies conducted in Africa, the Royal Dutch Medical Association (KNMG) questioned the applicability of those studies to developed countries. Circumcision has not been included in their HIV prevention recommendations. The KNMG circumcision policy statement was endorsed by several Dutch medical associations. The policy statement was initially released in 2010, but was reviewed again and accepted in 2022.[13]
Mechanism of action
While the biological mechanism of action is not known, a 2020 meta-analysis stated "the consistent protective effect suggests that the reasons for the heterogeneity lie in concomitant individual social and medical factors, such as presence of STIs, rather than a different biological impact of circumcision."[7]
The inner foreskin harbours an increased density of CD4 T-cells and releases increased levels of pro-inflammatory cytokines. Hence the sub-preputial space displays a pro-inflammatory environment, conducive to HIV infection.[14]
Langerhans cells (part of the human immune system) under the foreskin may be a source of entry for HIV.[15] Excising the foreskin removes what is thought to be a main entry point for the HIV virus.[16]
Advocacy campaigns
Sociologist Sarah Rudrum and colleagues have written that the communication of VMMC in Uganda is unethical and contradicts medical evidence. In their analysis of “Stand Proud, Get Circumcised”, a public health campaign promoting circumcision as an HIV-prevention strategy in Uganda, Rudrum et al. “exploit male anxieties about appearance and performance, drawing on hegemonic masculinity to promote circumcision as an idealized body aesthetic”.[17] In their work combining a transnational history of medicalised male circumcision and an analysis of International Organisations documents promoting VMMC, Alejandro and Feldman show that medicalised male circumcision “is represented as an enhancer of virility, sexual pleasure and sexual performance”.[18]
History
Valiere Alcena, in a 1986 letter to the New York State Journal of Medicine, noted that low rates of circumcision in parts of Africa had been linked to the high rate of HIV infection.[19][20] Aaron J. Fink several months later also proposed that circumcision could have a preventive role when the New England Journal of Medicine published his letter, "A possible explanation for heterosexual male infection with AIDS," in October, 1986.[21] By 2000, over 40 epidemiological studies had been conducted to investigate the relationship between circumcision and HIV infection.[22] A meta-analysis conducted by researchers at the London School of Hygiene & Tropical Medicine examined 27 studies of circumcision and HIV in sub-Saharan Africa and concluded that these showed circumcision to be "associated with a significantly reduced risk of HIV infection" that could form part of a useful public health strategy.[23] A 2005 review of 37 observational studies expressed reservations about the conclusion because of possible confounding factors, since all studies to date had been observational as opposed to randomized controlled trials. The authors stated that three randomized controlled trials then underway in Africa would provide "essential evidence" about the effects of circumcision on preventing HIV.[24]
Experimental evidence was needed to establish a causal relationship, so three randomized controlled trials (RCT) were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda.[25] All three trials were stopped early by their monitoring boards because those in the circumcised group had a substantially lower rate of HIV incidence than the control group, and hence it was seen as unethical to withhold the procedure, in light of strong evidence of efficacy.[25] In 2009, a Cochrane review which included the results of the three randomized controlled trials found "strong" evidence that the acquisition of HIV by a man during sex with a woman was decreased by 54% (95% confidence interval, 38% to 66%) over 24 months if the man was circumcised. The review also found a low incidence of adverse effects from circumcision in the trials reviewed.[26] WHO assessed the trials as "gold standard" studies and found "strong and consistent" evidence from later studies that confirmed the results.[3] In 2020, a review including post-study follow up from the three randomized controlled trials, as well as newer observational studies, found a 59% relative reduction in HIV incidence, and 1.31% absolute decrease across the three randomized controlled trials, as well as continued protection for up to 6 years after the studies began.[27]
Society and culture
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The WHO recommends VMMC, as opposed to traditional circumcision. There is some evidence that traditionally circumcised men (i.e. who have been circumcised by a person who is not medically trained) use condoms less often and have higher numbers of sexual partners, increasing their risk of contracting HIV.Template:R Newly circumcised men must refrain from sexual activity until the wounds are fully healed.[3]
The prevalence of circumcision varies across Africa.[29][30] Studies were conducted to assess the acceptability of promoting circumcision; in 2007, country consultations and planning to scale up male circumcision programmes took place in Botswana, Eswatini, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Uganda, Tanzania, Zambia and Zimbabwe.[31]
Programs
In 2011, UNAIDS prioritized 15 high HIV prevalence countries in eastern and southern Africa, with a goal of circumcising 80% of men (20.8 million) by the end of 2016.[32] As of 2020, WHO estimated that 250,000 HIV infections have been averted by the 23 million circumcisions conducted in the 15 priority countries of eastern and southern Africa.[3]
Misinformation about VMMC programs
Script error: No such module "Labelled list hatnote". Script error: No such module "Unsubst". Template:Close paraphrasing Misinformation about circumcision has been spread by United States President Donald Trump, Template:Failed verification span The scientific consensus positions of major medical organizations, including that of the World Health Organization, is that circumcision is one of the most effective methods of preventing HIV transmission in high-risk locations.[3][33][34][35][36][37] In the 2025 speech to a joint session of Congress, President Trump Template:Synthesis span cited a circumcision grant to Mozambique as a supposed example of government waste.[36] It also marked the first time circumcision has ever been mentioned or criticized in a State of the Union or speech to a joint session of Congress.[38] Reaching targeted male circumcision rates in Mozambique would have prevented 220,000 HIV infections 2011–2025.[36]
See also
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References
Template:Circumcision series Template:AIDS
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- ↑ Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa, 2012-2016. Template:Webarchive WHO. 2014.
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