CUTTING HIV RISK: A new study suggests that bacterial changes following circumcision could help protect circumcised men from HIV infection.
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The World Health Organization declared three years ago that circumcision should be part of any strategy to prevent HIV infection in men. The organization based its recommendation on three randomized clinical trials in Africa that found the incidence of HIV was 60 percent lower in men who were circumcised. Although this "research evidence is compelling," wrote the WHO panel assigned to the topic, there was little evidence explaining how circumcision might reduce a man's risk of acquiring HIV.
Now comes an answer in a new study, published in the January 6 issue of PLoS ONE, which found that there are gross changes in the penis's microbiome following circumcision, suggesting that shifts in the bacterial environment could account, in part, for the differences in HIV infection. Families of anaerobic bacteria, which are unable to grow in the presence of oxygen, are abundant before circumcision but nearly disappear after the procedure. The researchers suspect that in uncircumcised men, these bacteria may provoke inflammation in the genitalia, thereby improving the chances that immune cells will be in the vicinity for HIV viruses to infect.
"We never knew that there were that many anaerobic bacteria on the uncircumcised penis before [this study]," says Ronald Gray, a reproductive epidemiologist at Johns Hopkins Bloomberg School of Public Health and one of the lead authors on the current study. According to a 2006 survey, 56.1 percent of boys in the U.S. are circumcised. In its recommendation, the WHO panel stated that circumcision efforts would be most beneficial in parts of the world where less than 20 percent of boys are circumcised.
Gray, who is also working with one of the three randomized clinical trials on which WHO based its recommendation, adds that, "If we can show that these anaerobic bacteria are associated with HIV, then one could develop microbicides—antiseptics or targeted antibiotics —that might provide protection."
In the current study Gray and his colleagues compared the microbiota of 12 HIV-negative Ugandan men ages 15 to 49 before and after they were circumcised. It was important to limit the study to HIV-negative participants because infection itself can throw off the bacterial environment of the penis, says Lance Price, a research director at the Translational Genomics Research Institute in Flagstaff, Ariz., and co-author on the study. The team collected swabs from an area between the head and shaft of the men's penises before and one year after circumcision. Then the researchers performed polymerase chain reaction analysis of a gene that is shared by, although not identical in, numerous bacterial families. The analysis allowed for identification of different bacterial families as well as abundance counts.
At 12 months after circumcision, the microbiome's predominant bacterial population had shifted fromanaerobic to aerobic, which require oxygen to grow. Whereas the researchers detected similar number of bacteria belonging to aerobic families in circumcised and uncircumcised samples, they found that the abundance of anaerobic family members plummeted after circumcision. As the authors wrote, this decrease makes sense because there is an oxygen-deprived area under the foreskin that is lost after circumcision.
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33 Comments
Add CommentCircumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms.
Reply | Report Abuse | Link to thisThe one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.
ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.
Everyone seems to be focusing on HIV risk reduction for men but ignoring what happens to women.
Reply | Report Abuse | Link to thisWhy is everyone focusing on the men's HIV rates and ignoring what happens to women?
There is a study that showed that women who have sex with circumcised HIV positive men have a greater than 50% increased risk of acquiring HIV. See <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60998-3/abstract">Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial</a>. This study has received little press and it would seem to offset the title of this article. Male circumcision benefits men but not women.
Interesting article, I'm sure the comment section is going to turn into another one of those Circumcision wars.
Reply | Report Abuse | Link to thisSeriously, I don't think the circumcision debate is something that will ever have an end. I think part of the problem is that researchers and debators are trying to pinpoint a vast majority of STD/STI contributing factors to a simple, miniscule piece of skin. Truly, sexual practices and a plethora of other major contributing factors play a much more immense role in the contraction of STD's/STI's regardless of whether one has a foreskin or not.
I think the best approach to the circumcision debate would be a neutral one. Parents and patients should be advised that both sides of the issue hold little to no significant measurable benefit. Regardless, I think aesthetics, and 'social' worries are the biggest contributing factor concerning alot of current decisions to have kids circumcised in the U.S.
You can take the argument even further, because I imagine removing the entire penis and not just the foreskin would even be better at keeping HIV from occurring too.
Reply | Report Abuse | Link to thisIf it's possible to dramatically reduce men's risk, then automatically the risk to women is reduced as much.
Reply | Report Abuse | Link to thisEpidemics require, must have a "ping pong" effect between the infected and uninfected.
Stymie that and the epidemic slows to a crawl.
I don't get why they say this info is new. It's been known since the late 1980s. Perhaps they mean it's now backed up by research rather than just the common sense conclusion early on that noted men who had sex with men but were not passive partners and circumcised didn't sereoconvert even when sleeping with positive partners. Uncircumcised men enjoyed no such protection.
This article is another religous fantics attempt to butcher the boys like they did with the jews boys in ancient times. I think the most simple approach is to tell your new born boys not to have sex until they are at least a year old. In parts of Europe where it is rare to find a circumcised boy, HIV practically does not exist. The foreskin is a protective skin and the bacteria, all of them together, kills invading virsus and other harmful bacteria and it is a way the body rids itself of harmful invaders.
Reply | Report Abuse | Link to thisDon't listen to these backward religious idiots; leave your boys foreskin there and protect them from future infections. HIV is not a good reason to take the chance of the doctor messing up and killing your baby boy. It is a burtal procedure and should never be performed on anyone.
"If it's possible to dramatically reduce men's risk, then automatically the risk to women is reduced as much."
Reply | Report Abuse | Link to thisConversely, if the risk to women is increased, then automatically the risk to men is increased.
Perhaps this explains why there are no fewer than six African countries where men are *more* likely to be HIV+ if they've been circumcised. If male circumcision actually worked in the real world, then this simply should not happen.
Remember that many people who circumcise for religious reasons also have fewer sexual partners, and are less likely to have same-sex sexual encounters. That means you'd expect circumcised men to have lower rates of STI's for reasons others than the circumcision itself, and yet there are still six countries where circumcised men have higher rates of HIV than intact men.
You'll notice that the people promoting male circumcision haven't suggested leaving HIV+ men alone, even though circumcising them seems to make them more infective. It's hard to escape the conclusion that the people promoting male circumcision are more interested in promoting male circumcision (or sometimes anything-but-condoms), rather than fighting AIDS.
http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431</a>
"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."
http://apha.confex.com/apha/134am/techprogram/paper_136814.htm
"Results: … No consistent relationship between male circumcision and HIV risk was observed in most countries."
This 1993 study that found that "partner circumcision" was "strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates."
http://ije.oxfordjournals.org/cgi/content/abstract/23/2/371
So why is male circumcision being promoted in Africa?
I'm learning to expect no better of Scientific American. Just because bacteria are different after circumcision doesn't mean they are any better or that that has anything to do with HIV transmission. What do these researchers plan to do about vaginal bacteria? And "Bacterial vaginosis is not associated with circumcision status of the
Reply | Report Abuse | Link to thiscurrent male partner" is the title of a paper by J. M. Zenilman, A. Fresia, B. Berger, and W. M.
McCormack at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758232/
Ronald Gray is one of a small number of very active circumcision advocates who have published most of the recent flurry of studies claiming to show that circumcision is the best thing since sliced, um, bread. (The others include Daniel Halperin, Robert Bailey, Stefan Bailis, Stephen Moses, Malcolm Potts, Thomas Quinn, Helen Weiss, Brian Morris, Jeffrey Klausner, Edgar Schoen and Thomas Wiswell.) The motivation of some of them is less than scientific. Halperin is on record as thinking his descent from a ritual circumciser means "maybe I'm destined" to promote circumcision. Morris never saw a reason for circumcising he didn't like and thinks "The Bathroom Splatter" and zipper injuries are good reasons for circumcising. Schoen has written poetry in praise of circumcision. I wouldn't call it a "conspiracy", but many of them have authored papers jointly, and their common interest seems to be in promoting circumcision, rather than any particular benefit.
Does anybody else see that circumcision is a violent act against a newborn? Stick a pin through your genitals. Then picture it times 1000. Sure, you can argue about anesthesia, but when it wears off, salty urine is hitting the wound.
Reply | Report Abuse | Link to thisHas anyone scientifically analyzed the difference in bacteria between a circumcised woman and an uncircumcised woman? Why would we care? Why should we care if it is a male? As others have said, why is the HIV infection rate so much lower in uncircumcised Europe, than in the mostly circumcised USA?
Why do doctors disregard their prime directive, "first, do no harm", when it comes to circumcision? Their ethics, removing healthy body parts from a non-consenting individual, also take a vacation. Why?
The choice for or against circumcision should lie with the owner of the penis, and no one else. He has to live with the repercussions, not his parents, and not the people who publish shoddy pseudo-scientific articles like this one.
60% reduction! and reduced infection of... 'that bacteria' in women's vagina. That's extremely good number... no wonder why WHO recommend circumsion.
Reply | Report Abuse | Link to thisWho cares about that extra skin. We even pull our teeth out, wheb was a kid, they forcefully drill my teeth and put some lead into it. Thank god that's the right thing, I feel so much better for my self now. Thanks the Ugandan people... it is a good discovery.
Let's circumcise the women, too. It has been proven by studies that circumcised women are less likely to contract HIV.
Reply | Report Abuse | Link to thisBesides, they have less bacteria. Thanks, African studies, and the people who manipulate them through defective design.
But, but... I thought we were made in gods image.
Reply | Report Abuse | Link to thisGod apparently has a foreskin, either clitoral or penile, and bacteria.
Reply | Report Abuse | Link to thisAlthough the study ignored women, it would seem logical to suppose that African women who have intercourse with circumcised partners would have a higher rate of HIV and other STDs. That is because of cultural preference of African males for "dry sex" in which the recipient female parts are wiped out to be made as dry as possible. Therefore, those African women are robbed of their natural mucosal protections and their tissues made receptive to pathogens. Theoretically, intercourse with males who are intact would be less insulting to the delicate vaginal tissues. (To illustrate, think of pulling on socks that have been rolled up first as opposed to socks that aren't.) Add to the situation that many African women have been subjected to FGM and their tissues all the more subject to tearing and scraping.
Reply | Report Abuse | Link to thisBTW, I am opposed to circumcision of infants.
The original research showing that circumcision prevents infection , when reviewed, has been condemned as bad science.
Reply | Report Abuse | Link to thishttp://www.davidwilton.com/files/potterattunexpectedrctsresults.pdf
There is also a very sinister conclusion in the paper discussion:
'Discussion
The criticism that this RCT was probably terminated
prematurely has been voiced previously
[101]. Wilton noted that there was a clear trend
towards much greater rates of HIV infection
among the female partners of circumcised men
and, Therefore, continued observation to the
scheduled completion date of the study could
only have yielded more and better data, possibly
rising to the level of statistical significance .
Wilton speculates that the investigators, committed
to circumcision owing to the success of
their principal RCT [2], may have been trying
to avoid contrary evidence [101].'
Has science in America sunk to such a low level that a publication called Scientific American published an article so lacking in actual science?
Reply | Report Abuse | Link to thisSince when has unwarranted SPECULATION acceptable in science?
Does science no longer expect that data be without KNOWN flaws such as in Gray's work.
Does science no longer require an hypothesis fulfill its prediction?
And empirical evidence in the real (actual rates of infections in US and Europe) contradicts Gray's speculation.
Gray desperately looks for any minor and inconsequential differences and pulls a facile speculation out of thin air and rushes to the media to tell them of his "great scientific break through.
As a REAL scientist, who understands the requirement of the process am frankly very disappointed in the publication of this nonsense.
I guess even SA has come to believe that merely HAVING evidence is sufficient, and does not have to be scientifically credible--and think they can convince those equally illiterate of the scientific process!
Having been circumcised does not only protect you as they from getting AIDS but as a whole it does gives men a great and good hygiene. HIV kills the body’s immune systems. That is why the body becomes more susceptible to other opportunistic infections. Those with HIV/AIDS are also at an increased risk of developing certain cancers, neurological disorders, and a variety of other conditions.
Reply | Report Abuse | Link to thissource: http://simplestdtesting.com/resources/2009/07/the-importance-of-hiv-testing/
Why then do we not see this alleged reduction in the real world?
Reply | Report Abuse | Link to thisTHIS is the critical question that circumcision advocates need to answer. If they have no answer-- and they don't, then their claim cannot be considered credible
http://mysite.verizon.net/dortfay/science.html
Good Hygiene? Where have you been living? Even the pro-circ AAP calls this a myth. All one needs to do is retract, rinse, and replace.. ignorance is no valid excuse to amputate normal, healthy, FUNCTIONING body parts.
IF aerobic bacteria predisposes one to HIV, then females are more prone to getting HIV, so why are the authors only advocating removal of tissue from male genitals and not female genitals?
Reply | Report Abuse | Link to thisThere is no logic in even their idle speculations.
It appears that their obsession with male circumcision blinds them to simple logic and even common sense.
I am sorry, but unless there is credible evidence of some benefit to counter the proven harm , there is no neutral position for circumcision--it is NOT justified and parents should not rationally and ethically be allowed to harm their children.
Reply | Report Abuse | Link to thisA study in Rakai, Uganda found that male-to-female HIV transmission was 50% higher for circumcised males. In an astonishing display of cultural bias, researchers stopped the study early due to futility (since the results contradicted their pro-circ hypothesis). A study in Tanzania showed reduced HIV transmission rates for circumcised women. Should we advocate female genital cutting to curb the HIV problem, or at least research the issue? Of course not&its not ethical to cut healthy, functional tissue from non-consenting minors (current US law only protects females). True science must consider all the evidence Scientific American should be ashamed of this biased article. Whose body, whose rights?
Reply | Report Abuse | Link to this"60% reduction!" Yes, you can get an impressive relative risk reduction when the initial risk is tiny. In the trials, from 2.49% to 1.18%, a difference of 1.8% - or rather, less than two years after circumcising 5,400 men, "only" 64 of them had HIV, compared to 132 of a similar (but not, of course, identical) group left intact. This in three countries where more of the non-circumcised men happen to have HIV - there are at least six African countries where the reverse is true. Maybe if the trials had been carried out there, they would have found a different result.
Reply | Report Abuse | Link to thisAnd the study offers no evidence whatever that circumcision will have any effect on the bacteria in women's vaginas.
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1.The circumcision effect came up after a small study in a tiny country. all the jews and the muslims males are circumcised before puberty. Is there a world study what is the HIV % in them cf the comparable non circum groups of the globe? 2. properly performed circum is quite safe and atraumatic to the male and his fem. 3. but i see no reason why and how the prpuce attracts the viruses and other germs more than its absence. a few cells?
Reply | Report Abuse | Link to thisI assume uncircumcised people have access to soap and water in rich countries. But they don't in poor countries. The benefits of water and sanitation would be many times greater than the benefits of circumcision, don't you think?
Reply | Report Abuse | Link to thisI assume uncircumcised people have access to soap and water in rich countries. But they don't in poor countries. The benefits of water and sanitation would be many times greater than the benefits of circumcision, don't you think?
Reply | Report Abuse | Link to thisFirstly, there is a subtle medical view (female driven?) that the foreskin is a useless piece of skin - hence it can be removed. Pure rubbish!! The foreskin plays a fundamental role in good sexual function of a man (and thereby, their partner), to provide stimulation via friction to the penis, whether in sexual intercourse or masturbation. It is not a useless piece of skin. Any removal is abuse...period.
Reply | Report Abuse | Link to thisHaving been involved in development programmes in East Africa, especially Southern Uganda and Northwestern Tanzania, I am more than aware of this issue. The evidence, at best, for circumcision is highly debatable in terms of HIV transmission. Clearly there are multiple factors in transmission and focusing on male circumcision as some sort of panacea in morally flawed and, sadly, ideologically driven. Why is the medical world trying to promote male circumcision when we have been trying to eliminate the female equivalent? There is about as much evidence to suggest that FGM has a similar, highly variable, effect on HIV transmission as male circumcision - yet I do not see the promotion of FGM as a means of 'prevention' (and rightly so). Given the weak evidence, one has to wonder the ideology behind this campaign.
Also, I agree with a previous comment that it would be better to spend money on water, sanitation and hygenie issues, such as cleaning of the penis and under the foreskin after sex.
Perhaps this magazine should be renamed Pseudo-scientific American. Religious dogma, fetishistic perversion, ignorance, and the greed of doctors are the main motivators behind the genital mutilation of boys! HIV is just the latest excuse for this money-making scam. Circumcision is an outrageous human rights violation committed against boys. There is a casual disregard for the proper sexual functioning of males, where most of the sensitivity in the penis is in the foreskin, and circumcision is a form of emasculation! This stands in stark contrast to the concern shown for females who have been genitally mutilated.
Reply | Report Abuse | Link to thisI think that the genital mutilation of boys should be illegal just as it is in many countries for girls. No exemptions should be made for religion. If adults want to be mutilated they can do so for themselves, but they do not own the genitals of their sons. Doctors who carry out unnecessary circumcisions, should be sent to prison for at least ten years for aggravated assault! I view this as more serious than the rape of a grown woman. Americans may find this a strange perspective. But that is only because they have been lied to consistently for many years by their medical profession.
I say mother nature knows best (the prepuce is there for a reason) and the important thing is to keep promoting what has been shown to truly prevent HIV infection, which is condom use and a thorough, science-based sex education. When there are people who think they can get HIV through a plate of pasta (oh yes) a piece of forekin doesnt seem like such a big determining factor.
Reply | Report Abuse | Link to thisAhem, why female driven? The practice of circumsision has its origins in patriarcal society/religions and most men get it when they are babies because its less "traumatic", never mind that they are denied the right to choose what happens to their bodies. I dont know if there are any girlfriends/wives out there who expressly ask their partner to get cirumcised for some shallow "aesthetic" reason and if there are, quite frankly, shame on you. Female and male circumsicion is equally wrong. I think the problem is that it has become something as mainstream as it is for a girl to get her ears pierced. Guys, your genitalia is fine just the way it is.
Reply | Report Abuse | Link to thishttp://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA458066 -US Navy finds circumcision does not prevent HIV.
Reply | Report Abuse | Link to thishttp://physics.georgetown.edu/~rmca/Elephant_in_the_Hospital/Circumcision_and_HIV_Prevention_2010_Green_AJPM.pdf
Male Circumcision and HIV Prevention
Insufficient Evidence and Neglected External Validity
I don't have a dog in this fight, but it would seem to me that the best protection against HIV infection in women is to be non-infected men at which point whether they are circumcised or not makes no difference. So I would assume (aside from condoms) that there would be a benefit to women for circumcision if it lowers the HIV rate in men.
Reply | Report Abuse | Link to thisMost recent non-biased studies show that circumcised men are actually more prone to HIV and other STD infections, this correlates with the US having higher HIV infections than Europe where genital cutting of boys is rare. The old studies that claimed there is a HIV prevention were likely biased and only show that in Southern Africa where water is scarce, likely being dirty may increase risk of disease. Which is totally irrelevant to most of the world.
Reply | Report Abuse | Link to thisHaving a scientific mind means you have the ability of critical thinking, you simply should not accept a study's findings if the people involved have monetary reasons for a specific outcome, that is a conflict of interest. The people who tout these pro-circumcision studies often profit of it, there is over $1,000,000,000 that has come from the US and much of it is spent promoting circumcision in Africa... Why not promote Condoms? That is the logical, scientifically supported method to prevent HIV... not amputation of a perfectly healthy body part that likely has no if not a negative impact on the HIV epidemic.