In response to:
God and the Fight Against AIDS from the April 28, 2005 issue
To the Editors:
Helen Epstein has fallen into a trap for the unwary. There are a multitude of confounding factors that affect the transmission-reception of HIV, so research in this area is fraught with difficulty. All studies published so far have been unable to adequately control for confounding factors.
While HIV infection may be lower in Muslim nations where almost all men are circumcised, the confounding factor of Islamic moral values regarding sexual behavior is inseparable from circumcision, so no conclusions may be drawn regarding the efficacy of circumcision to prevent transmission-reception of the virus.
The leading work is the Cochrane Review. The Cochrane Review reports that, due to failure to adequately control for confounding factors, there is inadequate evidence to recommend circumcision to prevent HIV transmission.1
Doctors Opposing Circumcision
Helen Epstein replies:
The evidence for the importance of male circumcision in reducing HIV risk is overwhelming, as the Cochrane Review referred to by Dr. Hill shows. Male circumcision, safely carried out, may well turn out to be a powerful weapon against the heterosexual HIV epidemic in Africa.2 Yes, the Cochrane Review states that it is premature to recommend circumcision as a public health measure; but that may well change when the results of randomized trials of male circumcision for HIV prevention in Africa are completed in the near future.
Unfortunately, there is a vigorous anti– male circumcision lobby in the US, of which Dr. Hill is a member. We can expect that this lobby will do all it can to discredit the results of these trials if they turn out to show that male circumcision effectively reduces HIV risk. No doubt this lobbying will prove to be yet another lethal distraction in the world’s wayward response to the AIDS epidemic.
N. Siegfried et al., “Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men” (Cochrane Review), in The Cochrane Library, Issue 3 (2003). It can be found on line at www.cochrane.org/ cochrane/revabstr/ab003362.htm. ↩
Daniel T. Halperin and Robert C. Bailey, “Male Circumcision and HIV Infection: 10 Years and Counting,” Lancet, Vol. 354 (November 20, 1999), pp. 1813–1815. The mucosal surface of the foreskin is rich in Langerhans cells that are easily infected by HIV and rapidly transmit the virus to other cells of the immune system. This explains why foreskin removal is likely to be protective. ↩