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Health

Circumcision to prevent HIV infection in America

Gene ExpressionBy Razib KhanAugust 25, 2009 11:11 AM

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Officials Weigh Circumcision to Fight H.I.V. Risk:

Public health officials are considering promoting routine circumcision for all baby boys born in the United States to reduce the spread of H.I.V., the virus that causes AIDS. ... 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, because it spreads through different routes and because 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 H.I.V. 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 of an impact in the United States is that some 79 percent of adult American men are already circumcised, public health officials say.

My first thought is that I really would like to see the cost vs. benefit analysis; the United States is not KwaZulu-Natal. The article notes white males tend to be circumcised already, which is interesting because American white male HIV prevalence rates seem to be somewhat higher than British rates (compare & contrast). This is important because while American men are mostly circumcised, most British men are not. The point is not that circumcision has no effect, but that on the margins its return is probably far less when you have a population which is already has low rates of infection. As I have noted before, circumcised South Korea and uncircumcised Japan have the same HIV infection rates, on the order of ~0.1%. In the United States non-Hispanic white men have the highest rates of circumcision, followed by black men, and then Hispanics. But here are the ethnic-racial proportions of HIV infected individuals in the United States:

prevalence3.gif

Hispanics are slightly overrepresented (as they are somewhat less than15% of the population), but blacks who are 12% of the population are heavily overrepresented. Around ~25% of HIV transmission in the USA occurs via high risk heterosexual sex, a far lower proportion than in Africa. This is really an issue with complex parameters. One-size-fits-all answers are frankly dumb and short-sighted. I've gotten some grief when I've offered that male circumcision may be part of the solution in regions where HIV infection rates are on the order of 1/3 of the population. The cost vs. benefit seemed to make this a plausible line of thinking, but in the United States I don't see it. As it happens American whites have higher HIV prevalence rates than many European populations, so in that case it isn't circumcision where the low hanging fruit is likely to be. In the United States there is a particular problem among homosexuals and blacks. As noted above most are skeptical about circumcision's ability to reduce risk when it comes to male-male sex, but it might have some benefit for black Americans. Look at the odds:

To date, over 225,000 African Americans have died of AIDS - nearly 40% of total deaths - and of the more than 1 million people living with HIV in the United States of America today, around half are black. And yet, as a racial group, African Americans represent just 13% of the US population. The estimated lifetime risk of becoming infected with HIV is 1 in 16 for black males, and 1 in 30 for black females, a far higher risk than for white males (1 in 104) and white females (1 in 588).

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