The New York Times is reporting on a new study to be published Wednesday in The Journal of the American Medical Association. The work reviewed the results of 15 separate studies conducted in eight countries which included nearly 54,000 men.
“Over all, we’re not finding a protective effect associated with circumcision for gay and bisexual men,” commented Gregorio A. Millett of the Center for Disease Control and the lead author of the study.
According to a report on this work by the BBC, researcher’s noticed that there seemed to be a protective effect in studies conducted prior to 1996 which has since then essentially eroded to non-statistical signifance, possibly due to three developments:
- The advent of more effective HIV drugs encouraged higher levels of sexual risk taking;
- The drugs lowered the risk of transmission to the point where circumcision had no further benefit;
- There may have been a smaller proportion of men in the pre-HAART trials who primarily engaged in receptive anal sex which is known to carry the greatest risk of HIV infection among gay men.
This makes for an interesting list but let’s consider each point individually.
Has the advent of more effective HIV drugs encouraged higher levels of risk taking? This would be an especially interesting issue to research since those encouraging circumcision have insisted that such an intervention would have no impact on risk-taking. If access to anti-retrovirals and the knowledge that HIV has moved from a deadly disease to a chronic, but manageable, condition fostered increased risk-taking, how could circumcision realistically be expected not to result in the same outcome? In a WebMd report, behavioral scientist Gregorio A. Millett noted:
“There has been an increase in sexual risk behavior in men who have sex with men since the availability of highly effective treatment for HIV.”
“If a man is engaged in unprotected sex or has lots of sex partners, that contributes more to his risk of HIV than being uncircumcised. So in recent years, the benefit of circumcision may have been overridden by the risks of unsafe sex.”
In both cases, we have an intervention which is purported to change the variables of HIV. To believe one may encourage risk-taking, but insist the other does not is simply contradictory. As a behavioral scientist, it should be clear to Dr. Millett that as people believe the dangers they face are receding, they are going to adjust their behavior accordingly. It is a predictable reaction that will result in poorly thought out, culturally motivated strategies, such as circumcision, costing vast sums of money and luring large numbers of men, and their unwitting partners, into a false sense of security.
Could the advent of anti-retrovirals decrease the rates of transmission? The evidence is fairly clear that it has. However, the larger challenge has been early detection. The high point of transmission is the first weeks of infection when viral load spikes. Swiss public health officials have even issued guidelines that sero-discordant partners may safely engage in unprotected sex when the positive partner is on a well monitored anti-retroviral regimen.
Whatever the fantasies of straight men who study gay men’s HIV risk factors, the proof, time and time again, is that exclusively top or bottom roles among gay men are consistently unpredictable. Identification with one preference or the other does not and never has translated into actual practice. While some researchers, such as Sten Vermund, director of Vanderbilt University’s Institute for Global Health, suggest that predominately insertive men make up as much as 40% of gay men in many locations, the indirect evidence seems to show that men switch roles, depending on factors not yet understood. It is probable that age, context, and timing all have more to do with which role is assumed in these encounters. This is precisely why social scientists must be included in HIV prevention studies.
As usual more temperate reaction comes from colleagues in Britain where Michael Carter, of Aidsmap, noted:
“It’s my sense that there has been a tempering of the excitement about circumcision, and researchers are now favouring a ‘combination prevention’ approach.
“Circumcision may have a place in this in some settings, but so too do good sexual health, consistent condom use, and there’s real excitement and debate about the role of HIV treatment in prevention.”
However, Aidsmap’s report also added this important finding.
Finally, the authors found no association between circumcision and reductions in any other STI. Indeed in post-1996 studies and in higher-quality studies, there was a nearly significant increase in HIV infection in circumcised men.
The investigators suggest that studies could be conducted in men who primarily have insertive sex or in resource-poor settings, though there would be considerable ethical issues in the latter case.
It isn’t clear how the authors believe the African RCTs avoided similar ethical issues.
Will Nutland, of the Terrence Higgins Trust, a British HIV charity, added:
“This research adds weight to the evidence that circumcision isn’t an effective method of HIV prevention for men who have sex with men.
“The majority of HIV infections in men who have sex with men
are as a result of receptive anal intercourse and circumcision would make no difference in these cases.
“Rather than encouraging gay men to be circumcised, investment in prevention in the UK should focus on targeted education programmes, condom provision and easy access to testing.”
Carter has it partially right. Nutland has it exactly right. Good sexual health and consistent condom use is the foundation of fighting HIV. Anything less is a flawed approach (and incomplete). That is the message that is getting lost. Next to these pillars of HIV prevention, circumcision adds nothing.
Nutland makes a point that is sure to be lost on the CDC. Programs that actually work must be developed. Conservatively speaking, more than half of the HIV infections in the US, and other first world countries, are among MSM. We know that broadly targeted programs waste resources and are responsible for vastly diluting the efforts among high risk groups.
Advocates for Youth recently pointed out that American youths use condoms less consistently than their European counterparts. The CDC needs to stop wasting time and money and dramatically increase the focus on education and condom use. This is what America needs. This is what at risk groups in America need.
Finally, the negative impact of circumcision cannot be discounted in this calculus. The next challenge is working the study of negative outcomes into the policy statements and over all conversation and debate on male circumcision and HIV.