To the Editor:
The Cochrane Library review of male circumcision and HIV found that the numerous existent published studies all had severe methodologic problems, primarily caused by failure to adequately control for the many confounding factors associated with male circumcision, and that insufficient evidence exists to support a recommendation of a circumcision intervention.1 Subpreputial moisture contains lysozyme, an enzyme that attacks HIV, so the foreskin could have a protective effect.1
In his commentary, Franco2 argues the study by Agot and colleagues3 overcomes the difficulties associated with previous studies regarding protection by circumcision. However, it is highly unlikely that Agot et al. have succeeded where many others have failed.
Agot et al. report that 30% of uncircumcised men and 20% of circumcised men in their Kenyan population were HIV-positive, but between uncircumcised men with good genital hygiene and circumcised men, the ratio dropped to 26% as compared with 20%.
Genital ulcers provide portals of entry for HIV and are a major confounding factor.1 In the Kenyan study,3 24% of the circumcised men and 30% of the uncircumcised men in the study had a history of genital ulcer disease.3 It is, therefore, unclear to what extent the observed higher incidence of HIV infection in uncircumcised men is attributable to this preexisting disease, rather than to the existence of mucosal surfaces inside the foreskin.
Moore and Hogg4 collected data on the incidence of male circumcision in different groups in Eastern Uganda and Western Kenya. They found “a lack of effect of circumcision prevalence on HIV prevalence.” They also found that the incidence of HIV infection in Uganda was declining, whereas the incidence of HIV infection in Kenya remained high, which they attribute to the success of the behavior-changing education program of the Ugandan government. In Kenya, 75% to 85% of the men are circumcised, but the epidemic has not declined.4
The limited medical resources in developing nations should be expended in the most cost-effective manner. It is not clear that male circumcision can achieve a reduction in the incidence of HIV infection. The authors acknowledge that any potential value of male circumcision in reducing HIV infection is limited,3 and this is confirmed by the findings of Moore and Hogg.4
The high incidence of genital ulcers in the uncircumcised males reported by Agot et al.3 suggests that improved treatment of preexisting genital ulcers is indicated. Moreover, the Ugandan success4 indicates that behavior-changing education works. Epidemic control efforts should concentrate on proven methods.
George C. Denniston
Doctors Opposing Circumcision
1. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). The Cochrane Library
, issue 3. Oxford: Update Software; 2003.
2. Franco EL. Male circumcision in Africa: primum non nocere versus the collective good. Epidemiology
3. Agot KE, Ndinya-Achola JO, Kreiss JK, et al. Risk of HIV-1 in rural Kenya: a comparison of circumcised and uncircumcised men. Epidemiology
4. Moore DM, Hogg RS. Trends in antenatal human immunodeficiency virus prevalence in Western Kenya and Eastern Uganda; evidence of differences in health policies? Int J Epidemiol