Question:

Dear Sir,

I am making a web-site in Dutch about circumcision.

Here in the Netherlands most men are not circumcised, and it is quite difficult to get reliable (if any) information about the relationship between circumcision and HIV.

Therefore I would be very grateful if you could tell something about the relationship between circumcision and HIV in general, as well as the following questions:

• How reliable are the findings that circumcision makes men less susceptible to HIV?
• What are the possible explanations for the findings that circumcision makes men less susceptible to HIV?
• Does circumcision also protect against HIV when it is done post-infancy? Is there an age above which it is too late to be circumcised in order to gain the benefits related to the prevention of HIV?
• Does circumcision protect homosexual and bisexual men as much as heterosexual men?

Sincerely,
L. in the Netherlands

Answer provided by:

Rodger MacArthur, M.D.
Wayne State University
Division of Infectious Diseases

The data indicating that circumcised men are at decreased risk of acquiring HIV infection compared to non-circumcised men are compelling. For instance, in Cameroon and Benin, where the circumcision rates are 99%, HIV prevalence rates are < 5%. In Kenya and Zambia, where the circumcision rates are < 30%, HIV prevalence rates are between 20-30%. These data were summarized by Buve and colleagues at the World AIDS Conference in Durban in 2000. Similar data have been published previously.

However, none of these findings are from randomized clinical trials. That is, no study has ever randomized men to circumcision versus no circumcision and followed them for many years to determine HIV infection rates. Thus, it is possible that other explanations for the apparent protective effect of circumcision exist. For instance, it is possible (albeit unlikely), that the uncircumcised men in the high HIV prevalence countries have more frequent sexual encounters with HIV-infected women than the non-circumcised men in the low HIV-prevalence countries. There is no reason to believe that such differences in sexual practices exist, but data from observational, non-randomized, cohorts are considered less reliable, in general, than data from randomized clinical trials.

There are scientifically plausible reasons why circumcision is likely to decrease the risk of acquisition of HIV infection. The most likely explanation is that uncircumcised men have increased total duration of mucosal contact with HIV, as a result of the virus being "trapped" under the foreskin. Another explanation is that circumcision may protect against the acquisition of other sexually-transmitted diseases, the presence of which has been shown to increase the risk of HIV acquisition in other studies.

Circumcision typically is performed shortly after birth or in infancy. There are no data comparing HIV infection rates in men who were circumcised at birth with men who were circumcised as adults. Of course, the best way for adult men to prevent acquisition of HIV is to engage in "safe" (i.e., protected) sexual practices, which typically means wearing a latex condom. Uncircumcised adult men should not get a circumcision as a substitute for safe sexual practices.

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