Universal Circumcision?

Circumcision cuts HIV risk in Africa; maybe U.S.?
By RONI CARYN RABIN
NEW YORK TIMES
08/23/2009

Public health officials are considering promoting routine, universal circumcision for all baby boys born in the United States to reduce the spread of HIV, the virus that causes AIDS.

The topic is a delicate one that has already sparked controversy, even though a formal draft of the proposed recommendations, due out from the Centers for Disease Control by the end of the year, has yet to be released.

Experts are also mulling whether the surgery should be offered to adult heterosexual men whose sexual practices put them at high risk of infection. But they acknowledge that a circumcision drive in the United States would be unlikely to have a dramatic impact: The procedure does not seem to protect those at greatest risk in the United States, men who have sex with men.

Recently, studies showed that in African countries hard hit by AIDS, men who were circumcised reduced their infection risk by half. But the clinical trials in Africa focused on heterosexual men who are at risk of getting HIV from infected female partners.

For now, the focus of public health officials in this country appears to be on making recommendations for newborns, a prevention strategy that would only pay off many years from now. Critics say it subjects baby boys to medically unnecessary surgery without their consent. But Dr. Peter Kilmarx, chief of epidemiology for the Centers for Disease Control’s division of HIV/AIDS prevention, said that any step that could thwart the spread of HIV must be given serious consideration.

“We have a significant HIV epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,” Kilmarx said. “What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.”

He and other experts acknowledged that although the clinical trials of circumcision in Africa had dramatic results, the effects of circumcision in the United States were likely to be more muted because the disease is less prevalent here, spreads through different routes, and the health systems are so disparate as to be incomparable.

Clinical trials in Kenya, South Africa and Uganda found that heterosexual men who were circumcised were up to 60 percent less likely to become infected with HIV over the course of the trials than those who were not circumcised. There is little to no evidence that circumcision protects men who have sex with men from infection. Another reason circumcision would have less effect in the United States is that some 79 percent of adult American men are already circumcised, public health officials say.

But newborn circumcision rates have dropped off in recent decades, to about 65 percent of all newborns in 1999 from a high of about 80 percent after World War II, according to CDC figures. And blacks and Hispanics, who have been affected disproportionately by AIDS, are less likely than whites to circumcise their baby boys, according to the Centers.

Circumcision rates have fallen, in part because the American Academy of Pediatrics, which sets the guidelines for infant care, does not endorse routine circumcision. Its policy says that circumcision is “not essential to the child’s current well-being,” and as a result, many state Medicaid programs do not cover the operation.

The academy is revising its guidelines, however, and will likely do away with the neutral tone in favor of a more encouraging policy stating that circumcision has health benefits beyond HIV prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics.

He said the academy would probably stop short of recommending routine surgery, however.

“We do have evidence to suggest there are health benefits, and families should be given an opportunity to know what they are,” Brady said. But, he said, the value of circumcision for HIV protection in the United States is difficult to assess, adding, “Our biggest struggle is trying to figure out how to understand the true value for Americans.”

Circumcision will be discussed this week at the Centers for Disease Control’s National HIV Prevention Conference in Atlanta, which will be attended by thousands of health professionals and HIV service providers.

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