Sexually Transmitted Diseases:
Prevalence of Adult Male Circumcision in the General Population and a Population at Increased Risk for HIV/AIDS in New York City
McKinney, Christy M. PhD, MPH*; Klingler, Ellen J. MPH†; Paneth-Pollak, Rachel MPH†; Schillinger, Julia A. MD, MSc†‡; Gwynn, R Charon PhD§; Frieden, Thomas R. MD†
From the *Houston School of Public Health, University of Texas, Dallas, Texas; †New York City Department of Health and Mental Hygiene, New York, New York; ‡Division of STD Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia; and §Columbia University, New York, New York
Correspondence: Christy M. McKinney, PhD, MPH, Faculty Associate, University of Texas School of Public Health, Dallas Regional Campus, 5323 Harry Hines Blvd, V8.112, Dallas, TX 75390-9128. E-mail: firstname.lastname@example.org.
Received for publication December 17 2007, and accepted March 18, 2008.
NEWBORN MALE CIRCUMCISION IS the most common surgical procedure in the United States (US); approximately 80% of US men are circumcised.1 Male circumcision (MC) is associated with a decreased risk of infant urinary tract infections, penile cancer, and some sexually transmitted diseases (STDs) including HIV in adult men.2–8 However, citing the rarity of these conditions, potential complications of the newborn circumcision procedure, and inconclusive evidence linking MC to common STDs, current policy statements of the American Academy of Pediatrics and other professional bodies do not endorse newborn circumcision as medically indicated.8,9 Others oppose MC considering it genital mutilation.10
Since the latest (1999) American Academy of Pediatrics policy statement, 3 randomized controlled trials conducted in Africa3–5 have demonstrated that adult MC reduces HIV transmission in heterosexual men by more than half. Because of these trials, adult MC is now a recommended HIV prevention strategy by UNAIDS and the World Health Organization in settings where the heterosexual HIV incidence is high and MC prevalence is low.11 The implications of these findings for adult MC as an HIV prevention strategy in the US are currently being considered.12,13 In theory, at least, populations in the US with a high incidence of HIV and a low MC prevalence could potentially benefit from adult MC. However, in the US, male-to-male sexual exposure accounts for a substantial proportion of male HIV/AIDS cases (61%)14 and the protective effect of adult MC for transmission during anal sex is not yet confirmed. In New York City (NYC), the epicenter of the US HIV epidemic, HIV prevalence in MSM in the general population is 8.4%,15 which is slightly higher than HIV prevalence in the general adult population in Uganda (7.0%)16 and Kenya (7.4%).17 If MC proves protective against HIV transmission during anal sex, MC could be of value as an intervention among the MSM population in NYC and elsewhere.
The potential value of MC for heterosexual men in this country will also be a function of MC prevalence and HIV incidence in population subgroups at increased risk for HIV. STD clinic patients often have STDs that increase their risk for HIV.18 In NYC the HIV prevalence among male STD clinic patients is 2.1% (Klingler to McKinney, July. 25, 2007, personal communication), however little is known about MC prevalence in these populations. To provide data which could be used to elucidate the potential value of MC as an HIV prevention strategy in a city with both heterosexually transmitted HIV cases and high rates of HIV infection among MSM, we estimated MC prevalence in a population-based sample of men in the general population; in men presenting to publicly-funded STD clinics; and in MSM from both of these populations.
The NYC Health and Nutrition Examination Survey (HANES) was a 2004 population-based cross-sectional survey of the NYC noninstitutionalized population ≥20 years of age. Detailed information about the survey is published elsewhere.19 Briefly, NYC HANES included a personal interview that elicited health and demographic information. A private Audio Computer-Assisted Self-Interview collected self-reported data on sexual behavior and circumcision status. The Audio Computer-Assisted Self-Interview was administered in English or Spanish; those who did not understand either language were unable to respond and were not included in these analyses. To address this limitation, we adjusted our weights to account for nonresponse for foreign born status in addition to age and race/ethnicity. The household response was 84%; 64% of invited males participated.19 Of the 831 men who took part, we included the 661 study participants who responded definitively to the question, “Are you circumcised or uncircumcised?” A medical drawing of a circumcised and uncircumcised penis was made available to assist the respondent in determining his status.1 Race/ethnicity was self-reported and categorized as follows: first, persons reporting Hispanic ethnicity were classified as Hispanic of any race (“Hispanic”). Remaining study participants were classified on race as non-Hispanic white (“white”); non-Hispanic black (“black”); non-Hispanic Asian (“Asian”); or “other race.” We used self-reported country of birth to group study participants into world regions of birth.20 Sex was defined as vaginal, oral or anal sex; for those reporting ever having had sex, we asked number of sex partners in the last 12 months. Men who reported a history of ever having sex with a man were classified as MSM.
The NYC Department of Health and Mental Hygiene operates 10 publicly-funded STD clinics (“STD clinics”) throughout NYC. Male patients born before 1985 and who received a physical examination at a STD clinic in 2006 (the first year all STD clinics maintained electronic medical records) were eligible. Circumcision status was ascertained via physical examination by a physician. Of 20,913 patients, we analyzed 17,187 participants who had a measure of circumcision status. STD clinic patients missing circumcision status were disproportionately MSM and white compared with those with circumcision status recorded. Because these subpopulations tend to have a high MC prevalence, STD clinic estimates of MC prevalence may be biased downward. Number of sex partners and type of sexual practices among MSM was based on self-report for 3 months preceding the visit at which circumcision status was ascertained. Race/ethnicity, world region of birth, and MSM were classified in the same manner as for NYC HANES.
NYC HANES estimates were weighted to adjust for the complex sampling design and survey and component nonresponse. For NYC HANES and STD clinics we computed MC prevalence estimates and corresponding 95% confidence intervals. For NYC HANES, we also computed relative standard errors; those >30% were considered unreliable and notated. We present unadjusted prevalence estimates which are most appropriate for public health planning purposes; age-adjusted estimates, which allow for comparisons between groups unbiased by age, were similar to unadjusted estimates (data not shown).
Our adult MC prevalence estimates reflect the diverse immigrant, racial, ethnic, and cultural make-up of NYC. The overall population-based NYC HANES estimate for MC prevalence, 56.1% (55.7% among non-MSM and 67.2% among MSM) (Table 1) was considerably lower than that reported nationally (79%) for a similarly aged population.1 This difference likely reflects the sizeable proportion of immigrants in NYC. The overall MC prevalence among STD clinic patients was 61.4% (60.6% among non-MSM and 66.4% among MSM) which was higher than the overall NYC estimate; this is due to the small proportion of foreign-born men and a large proportion of blacks in this group. Table 2 shows the prevalence of MC among MSM in the NYC HANES and attending the STD clinics, by select demographic and behavioral characteristics. Among STD clinic MSM who reported having anal sex in the 3 months before their clinic visit, 13% engaged in receptive anal sex only, 62% of whom were circumcised; 32% engaged in insertive anal sex only, 68% of whom were circumcised; and 55% engaged in both types of anal sex, 62% of whom were circumcised. In all samples, MC prevalence increased with decreasing age and notable differences in MC prevalence were observed by race/ethnicity: white males had the highest prevalence (>70%) followed by blacks (58%–68%); Hispanics had the lowest MC prevalence (≤40%). Likewise foreign-born men had a lower MC (<40%) prevalence than US-born men (>70%) in all samples. Men born in Latin America or the Caribbean had the lowest MC prevalence (<26%) among world regions of birth.
Some have suggested that MC may not be an effective HIV prevention strategy in the US, in part because the prevalence of MC is already high in this country.21 Our data indicate that MC prevalence is indeed common in the NYC populations described, both among heterosexual men and MSM, but that it differs considerably across race/ethnicity groups and place of birth. HIV prevalence in NYC MSM and Hispanic MSM15 is higher than the general adult population HIV prevalence in some African countries16,17 where MC is a recommended HIV prevention strategy. Though heterosexual sex is the primary mode of transmission in Africa, the similarities in the HIV and MC prevalence in the NYC MSM population and some African countries, such as Kenya,22 suggests that if the protective effect of MC for HIV acquisition via anal sex is confirmed, MC could be a potential strategy to reduce HIV in NYC MSM.
Before MC can be recommended as a strategy for preventing HIV infection among MSM, stakeholders will need to consider much more than the MC prevalence among populations at high risk of HIV. Foremost among the unanswered questions is whether the protective effect of MC observed for men practicing vaginal sex is similar for men practicing insertive anal sex. Though our findings suggest exclusive practice of receptive anal sex is not especially common, MSM who engage only in receptive anal intercourse would be unlikely to reduce their risk of HIV acquisition through circumcision of their insertive partners. Two US observational studies report a twofold increased risk of HIV among uncircumcised MSM.22,23 In contrast, a study in Australia found no association between HIV and MC.24 None of these studies has examined in-depth how specific sexual practices may alter the association between MC and HIV. Studies specifically designed to examine this issue are needed to better assess the relationship between MC and HIV among MSM and to estimate the expected population-level impact. Another unanswered question is whether a perception of decreased risk of HIV might accompany adult MC, resulting in sexual disinhibition and increased sexual risk-taking. Also, adult MSM who undergo the procedure may be more likely to engage in receptive anal intercourse during the postoperative healing phase, which could increase their risk of HIV. Though MC does not appear to negatively affect sexual function7,25,26 evidence as to whether MC affects pleasure26 is sparse. Consideration must also be given to social norms and the acceptability of MC27,28; 1 study found that only 54% of uncircumcised MSM would get circumcised if MC was demonstrated to reduce the risk of HIV in MSM in the US.27 Cost-effectiveness of adult MC also needs to be evaluated. Any circumcision recommendations will need to carefully balance all of these concerns.
Our findings indicate that certain population segments previously shown to be at high risk of HIV have a MC prevalence lower than the general population and that there may be groups in which MC could reduce the risk of HIV. However, we know of no estimates of the proportion of HIV that could be prevented by MC among MSM in the US. Such estimates will depend on a number of disease transmission dynamics, including risk of HIV transmission conferred by different types of sex. We hope our findings may be useful for policy makers, mathematical modelers and others considering the possible national impact of MC among MSM and heterosexual men in the US.
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