HIV, Circumcision, and the Primary Care Physician’s Role

Newly released guidelines on circumcision from the American Academy of Pediatrics (AAP) include a substantial shift in the Academy’s previous stance on the procedure, clearly stating that circumcision protects against sexually transmitted diseases such as HIV, the human papillomavirus (HPV), and herpes.

The guideline changes were necessary, said Michael T. Brady, MD, a pediatric infectious disease specialist at Nationwide Children’s Hospital in Columbus, Ohio who chairs the AAP’s Committee on AIDS, because the last update in 1999 prevaricated on the benefits of circumcision. “They ‘suggested’ there were potential health benefits to circumcision,” he said, “and I think subsequent to that, even at the time of publication, most of us believed there were benefits.”

Without a clear recommendation, 18 state Medicaid programs felt empowered to stop covering newborn circumcision, he said, creating “what we think is a potential problem with access.”

Thus, he said, “we felt it was important to make sure we modified the statement about health benefits in an effort to ensure that families receive the appropriate information and, hopefully, influence state Medicaid programs so there is no financial barrier to circumcision.” This is particularly important, he said, because Medicaid recipients represent those groups at highest risk of HIV infection.

Three seminal studies on the preventive benefits of circumcision influenced the new recommendations:

•    Uganda. Nearly 5,000 uncircumcised, HIV-negative men ages 15 to 49 were randomized to immediate circumcision or circumcision in two years. After 24 months, the incidence of HIV infection in the intervention group was half that in the control group (.66 cases per 100 person years versus 1.33 cases per 100 person-years, P=0.006), regardless of sociodemographic, behavioral and STD symptom subgroups. Complications, all of which resolved with treatment, occurred in 3.6% of the intervention group.
•     Kenya.  This study randomized 2,784 men ages 18 to 24 to circumcision or delayed circumcision. It was stopped early after a median follow up of 24 months when interim results showed an HIV incidence of 2.1% in the intervention group versus 4.2% in the control group (P=0.006), resulting in a 53% relative risk reduction of HIV in the intervention group.
•    South Africa.  This study randomized 3,247 uncircumcised men ages 18 to 24 years to immediate circumcision or circumcision at 21 months. The intervention group demonstrated a relative risk reduction of 61%, even after controlling for behavioral factors such as condom use, health-seeking behavior, and slightly increased sexual activity.

“Because they were randomized, controlled trials, they are the cleanest studies verifying the benefit of circumcision in reducing the acquisition of HIV,” Dr. Brady said.

The application of the studies in the US, however, is often questioned because these were conducted in sub-Saharan Africa, said Dr. Brady. Yet a cost-effectiveness study of HIV and circumcision http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0008723 from the Centers for Disease Control used US data on a man’s lifetime risk of HIV and found newborn circumcision reduced the lifetime risk of HIV infection by about 16%, with a greater reduction in black males (21%). It also found that the net cost of circumcision per quality of life year saved was $87,792 for white males, with discounted HIV-related healthcare savings of $427.
 
Declining Rates of Circumcision in the United States

The AAP statement comes at a time when newborn circumcision rates have plummeted, from 79% in the 1970s and 1980s to about 55% today. In Europe, rates are as low as 10%.

There are two reasons for the decline, Dr. Brady said: lack of reimbursement from state Medicaid

programs and the influx of immigrants from countries where circumcision is not the norm.

The decline has significant health and economic costs, according to a recently published article in the Archives of Pediatrics and Adolescent Medicine. The authors used estimates of lifetime costs for diseases that could be reduced through circumcision (HIV, HPV, and the resulting cervical and penile cancers; bacterial vaginosis; trichomoniasis; and pediatric urinary tract infections) to determine that the declining rate of circumcision has already cost the US an estimated $2 million in healthcare expenses. If US rates fall as low as those in Europe, they predicted additional lifetime medical costs of $407 per male and $43 per female.

Clarifying the Guidelines

Dr. Brady stressed that the AAP guidelines do not recommend routine neonatal circumcision. Instead, the goal is to educate pediatricians and obstetricians so they can provide accurate, unbiased information about the benefits and risks. The risks, by the way, are very small when a qualified physician performs the procedure.

Which brings up another issue. Who does the circumcision? In some areas, it’s pediatricians; in others, obstetricians. One concern, said Dr. Brady, is that pediatricians trained in a region where the obstetricians do all circumcisions do not receive training in the procedure; while the opposite is true for obstetricians trained in regions where pediatricians perform all circumcisions.

“What happens when they move to another area and find they now have to perform circumcisions?” he asked.