Tuesday, August 25, 2009

The Nuts and Bolts of HIV in the USA and Why Circumcision Won't Protect Men

By Jennifer Coias © 2009


With recent news reports of the CDC possibly becoming the first organization to advocate infant circumcision, I thought I would share the nuts and bolts of HIV in the USA. The following will demonstrate exactly why the African studies have little relevance to the USA. Please keep in mind that over 500.000 circumcised, American men have died of AIDS. AIDS is already well-established in this country where the majority of men are circumcised..

According to avert.org approximately 56,000 Americans are infected with HIV each year. Overall, about three-quarters of those infected were men, approximately 42,000.

When examined by gender, [men only] approximately 62% were infected via male-to-male sexual contact, 18% were infected via IV drug use, and about 8% were infected via either IV drug use or male-to-male sexual contact. The importance of this is that for 88% of men there is no demonstrated benefit since the African study only showed a reduction in female-to-male HIV transmission, not for male-to-male, or IV drug use which account for 88% of cases in men.

What remains is the 12% which were thought to be contracted heterosexually. 11% is considered high-risk heterosexual contact, while 1% must contain all other possible modes of transmission. According to Avert, the CDC defines high-risk sexual contact as:
The 'high-risk heterosexual contact' category comprises persons who report specific heterosexual contact with a person with, or at high risk for, HIV infection (e.g., an injecting drug user). This does not include adults and adolescents born in, or who had sex with someone born in, a country where heterosexual transmission was believed to be the main mode of HIV transmission, unless they meet the criteria stated in the previous sentence.
So of the 42,000 men infected, about 4620 (give or take (42000 * 0.11) were infected via high-risk heterosexual sex. Or about 5,040 (42000 * 0.12) if all heterosexual sex is considered.

The United States has a male population 15 - 64 of over 100,000,000. So given these percentages, in any given year a man has about a 0.005% or 1/20,000 chance of becoming HIV positive [via heterosexual sex both high and normal risk], 5,040/100000000. Over 60 years, the chances of turning up HIV positive would be 0.3% or 1/333 (0.005 * 60).

These are exceedingly low numbers for an individual (overall) however. This is for those who fall with in the high-risk heterosexual category, which according to the CDC would include those whose partner are known to be HIV+, suspected to be HIV+, or are at high-risk otherwise (an IV drug user for example). We know that most people will not fall within this category.

If instead we focus on the 1% categorized as 'other' we are only talking about 420 men, assuming their infections were all acquired sexually. If only 80% (80000000) of the population fit this category (the other 20% being high risk takers and or homosexual) then overall in any given year an American man has about a 0.000525% chance of being infected with HIV about (1/200,000). Over the course of 60 years the odds are about 0.03% (1/3333). Which is a very interesting figure (0.03%).

Not long after the circumcision and it's relationship with HIV was published, several national HIV/AIDS organizations reviewed the data, and there national situations, and within months published statements that said in essence what the WHO statement already said, while there may be some relationship between circumcision and HIV it is not a strategy that should be considered for countries where the HIV problem is focused in specific groups of low prevalence countries. The original statement from Australia can be seen here. Recently, in a response to rhetoric by Alex Wodac, published in a local paper's opinion piece, the AFAO published a second data sheet in February where they noted:

  • African data on circumcision is context-specific and cannot be extrapolated to the Australia epidemic.
  • The Australian HIV epidemic is driven primarily by male-to-male anal intercourse and social research has shown that men frequently practice both insertion and receptive anal intercourse.
  • Correct and consistent condom use, not circumcision, is the most effective means of reducing male-to-male transmission, female-to-male transmission, and male-to-female transmission.
  • An Australian-born man is estimated to have a 0.02% (0.0002) risk of HIV acquisition if he does not inject drugs or have sex with men. This very low risk means that the population health benefit of an intervention like generalized circumcision programs would be negligible.
So, if the typical American born male (who is not involved in high risk activity) has a lifetime chance of becoming HIV+ of 0.03%, an Australian born man under similar assumptions has a lifetime risk of 0.02%, and the AFAO notes that such a low risk means the population health benefit of generalized circumcision would be negligible. How this doesn't apply to Americans is beyond me.

Here are just a few of the numerous ways that Africa is different from the United States:

  • About 30% of women in Africa are raped at some point in their lives. Rapists don't wear condoms. Rape is seen as a sign of masculinity in these cultures and 1 in 4 South African men admit to having raped.
  • Most Africans believe that sex with a virgin will cure HIV and, as a result, many young girls are infected with HIV. 
  • Many Africans engage in sexual practices that include activities such as 'dry sex' where a woman's vagina is purposefully dried out. This increases friction, which men feel is a sign that they are more well-endowed. Dry sex increases the rate of transmission of HIV because the walls of the vagina typically tear and bleed (Fleiss, P. 2002 What Your Doctor May Not Have Told You About Circumcision).
  • Many Africans engage in other sexual rituals. For example if a woman's husband dies, she must have sex with another man to cleanse her soul.
  • Africans commonly circumcise both men and women with dirty utensils and in poor hygienic conditions, which increases the spread of the disease.
  • A recent study shows that if Africans were given clean water the spread of HIV would drop by about 60%.


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Also by Jennifer Coias:

For additional information and resources on the prepuce, intact care and circumcision, see Are You Fully Informed?

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5 comments:

  1. Well said, Jennifer! And of course there is also the empirical evidence, which clearly shows that the US has the 10th highest HIV rate in the world (1st highest among industrial nations) with a majority of circumcised men, while non-circing Europe and Japan have among the lowest HIV rates in the world.

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  2. The fact that the CDC even is considering universal circumcision means they never got this far with the math, or they don't have any serious actuarial scientists whose work is used to recommend policy. I fully expect the circumcised doctors at the CDC to recommend the amputation of sexual tissue from every baby boy born in the U.S. Yeah, that will stop AIDS!

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  3. I highly suspect HIV rates are more related to good sex education and condom use and not to the circumcision status of your partner(s).

    The United States would do better if they just talked to their kids about sex and condoms. Both circumcised and intact men are capable of wearing condoms. (Though in my experience as a woman I have found intact men to be more willing to wear a rubber...strange isn't it?)

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  4. @the last Anon - I have found the same to be true. Intact men are much more willing to wear condoms and it doesn't bother them or deter from their experience in sex. Not surprising as they haven't had 30+ years of callusing over of the glans... Sex is all around more pleasurable for them and their partners - condom or not - because they have all the parts they were meant to have.

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