Circumcision, or the removal of the foreskin of the penis, is a common practice in the US. Although some people choose this procedure for religious reasons, others choose it for social or health-related reasons.
Some people are surprised to learn that research has found a link between circumcision and the risk of HIV. What is this link? Does foreskin protect against STDs like HIV, which would mean that circumcision would increase the risk? Or can being uncircumcised cause infections with HIV, meaning that circumcision is protective?
Circumcised vs uncircumcised HIV risk
In the 1980s, a series of studies was done to assess the impact of circumcision on the risk of acquiring HIV. The studies were done in communities in Kenya and Uganda, where there is a relatively high level of transmission of HIV.
For these studies, the men who signed up were divided into two groups. Half of them were circumcised right away, while the other half didn’t get their circumcision until later. During the period of the study, one group was circumcised, while the other wasn’t. The groups were then followed to see how many men in each group got HIV.
The results surprised even the researchers. In terms of acquiring HIV, uncircumcised risk was more than double the circumcised risk. The effect was so strong that all three trials were stopped early, so the uncircumcised men could get their procedure.
So what does circumcision prevent or cause, in order to reduce HIV risk? Researchers don’t have definite answers to this, but there are some theories. The inner surface of the foreskin is extremely thin and delicate, so it’s easier for the virus to penetrate. In addition, the foreskin has a high concentration of Langerhans cells, which are cells of the immune system that HIV targets. By covering the end of the penis, the foreskin makes the skin of this area more delicate, which leads to a higher risk of skin irritation during sex. HIV can more easily enter the body through irritated skin.
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Some researchers believe circumcision does not prevent HIV
The results of these three studies have resulted in large-scale circumcision campaigns in African countries by the World Health Organization, the Gates Foundation, and other groups. However, it’s important to note that these studies are not without their critics.
Some doctors have noted serious flaws with the design of these studies, and argue that they are not of high enough quality to justify widespread circumcision of males. For example, very large numbers of men dropped out of each study before it was completed. The trials were also not very long. Additionally, the circumcised men had to abstain from sex for a period of time after the procedure, while the uncircumcised ones did not. This could have meant that the uncircumcised men were exposed to more sex, and therefore more risk, than the circumcised men, which would explain their higher HIV rates. These issues cause some doctors to question whether it’s really been proven that circumcision reduces HIV risk.
Is circumcision recommended in the US?
The World Health Organization is currently actively seeking to circumcise as many males as possible in areas where HIV is highly prevalent. In terms of circumcision and AIDS, the WHO hopes that this could prevent deaths from HIV in these areas of the world. However, the mass circumcision campaign is highly controversial, and there are concerns that African boys are being coerced or even forced into getting circumcised.
In the US, health authorities have stopped short of recommending universal circumcision. This is largely because community transmission of HIV in the US is much less common. Factors like the availability of HIV testing (including home testing), the use of antiretroviral therapy, and widespread condom availability all contribute to keeping the risk of HIV relatively low. Because the baseline risk is lower, the benefit of circumcision is also reduced.
It should also be noted that, while circumcision is popular in the US, there are also many people who object to this procedure because it involves removing healthy tissue from a baby’s body. Given that HIV can also be prevented by using condoms, some people don’t consider a potential reduction in HIV risk to be a good enough reason for doing the procedure.
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Sources
Auvert B, Taljaard D, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005 Nov;2(11):e298. doi: 10.1371/journal.pmed.0020298.
Bailey RC, Moses S, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007 Feb 24;369(9562):643-56. doi: 10.1016/S0140-6736(07)60312-2.
Collier C. The studies that launched a thousand snips. CMAJ 2012 Jan 10; 184(1): E37–E38. doi: 10.1503/cmaj.109-4029.
Gray RH, Kigozi G, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007 Feb 24;369(9562):657-66. doi: 10.1016/S0140-6736(07)60313-4.
Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: recommendations and key considerations. World Health Organization (2020). https://www.who.int/publications/i/item/978-92-4-000854-0. Accessed 15 April 2022.
Trends in Circumcision for Male Newborns in U.S. Hospitals: 1979–2010. Centers for Disease Control and Prevention (2015). https://www.cdc.gov/nchs/data/hestat/circumcision_2013/circumcision_2013.htm. Accessed 15 April 2022.
