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.
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.
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
3. Not relevant to nature of Australia’s HIV problem
4. Suggestion departs from principles of evidence-based medicine.
5. Suggestion ignores harm of circumcision and underestimates level of complications.
6. Suggestion totally ignores medical ethics and human rights.
7. Circumcision is not a surgical vaccine.
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
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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