U.S. considers endorsing circumcision to fight HIV

Public-health officials are considering promoting routine, universal circumcision for all baby boys born in the United States to reduce the spread of HIV, the virus that causes AIDS.

The topic has already sparked controversy, even though a formal draft of the proposed recommendations, due from the Centers for Disease Control by the end of the year, has yet to be released.

Experts are also considering whether the surgery should be offered to adult heterosexual men at high risk of infection.

But they acknowledge a circumcision drive in the United States would be unlikely to have a dramatic impact: The procedure does not seem to protect those at greatest risk in the U.S., men who have sex with men.

Recently, studies showed that in African countries hard hit by AIDS, men who were circumcised reduced their infection risk by half. But the clinical trials in Africa focused on heterosexual men at risk of getting HIV from infected female partners.

For now, the focus in this country appears to be on making recommendations for newborns, a prevention strategy that would only pay off many years from now.

Critics say it subjects baby boys to medically unnecessary surgery without their consent. But Dr. Peter Kilmarx, chief of epidemiology for the Centers for Disease Control's division of HIV/AIDS prevention, said any step that could thwart the spread of HIV must get serious consideration.

"We have a significant HIV epidemic in this country and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic," Kilmarx said. "What we've heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks."

He and other experts acknowledged that although the clinical trials 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, spreads through different routes and the health systems are so disparate as to be incomparable.

Circumcision is believed to protect men from infection with HIV because the mucosal tissue of the foreskin is more susceptible to HIV and can be an entry portal for the virus.

Observational studies have found that uncircumcised men have higher rates of other sexually transmitted diseases like herpes and syphilis, and a recent study in Baltimore found that heterosexual men were less likely to have become infected with HIV from infected partners if they were circumcised.

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 HIV over the course of the trials than those 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 effect in the United States is that some 79 percent of adult American men are already circumcised, health officials say.

But newborn circumcision rates have dropped off in recent decades, to about 65 percent of all newborns in 1999 from a high of 80 percent after World War II, according to CDC figures.

And blacks and Hispanics, who have been affected disproportionately by AIDS, are less likely than whites to circumcise their baby boys, according to the Centers.

Circumcision rates have fallen, in part because the American Academy of Pediatrics, does not endorse routine circumcision.

The academy is revising its guidelines, however, and will likely do away with the neutral tone in favor of a more encouraging policy stating that circumcision has health benefits beyond HIV prevention, like reducing urinary-tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics.

Circumcision will be discussed this week at the Centers for Disease Control's National HIV Prevention Conference in Atlanta.

Among the speakers is a physician from Operation Abraham, an organization named after the biblical figure who was circumcised when he was 99 years old, according to the Book of Genesis. The group trains doctors in Africa to perform circumcisions on adult men to reduce the spread of HIV.

Members of Intact America, a group that opposes newborn circumcision, have rented mobile billboards carrying their message that "circumcising babies doesn't prevent HIV," said Georganne Chapin, who leads the organization.