Circumcision: a surgical vaccine?

THREE leading Australian health professionals are calling for a change in public health policy that would see male infants routinely circumcised to combat the rise in heterosexual HIV transmission.

In an editorial in the Medical Journal of Australia that is likely to reignite debate on the controversial topic, the authors cited research which they said showed that male circumcision substantially reduces female-to-male HIV transmission.(1)

Their editorial also questioned the influential anticircumcision position taken by the Royal Australasian College of Physicians. Last week the College approved an updated neonatal circumcision policy that it said takes into account the latest research.

However the College said its official stance remains the same: there is no medical indication for routine neonatal circumcision.

The authors have criticised this stance as scientifically flawed and the major barrier to boosting the rate of circumcision in Australia.

Elective circumcision was also officially discouraged by a low Medicare rebate and the fact that public hospitals in most states do not perform them, according to the MJA editorial.

In January a petition was sent to the College with 47 signatories from Australia, New Zealand, the United States and the United Kingdom, that expressed concerns that the policy was not evidence-based or “reflective of the considerable and rapidly growing medical literature supporting the circumcision of males”.

The World Health Organization and other global groups have agreed that male circumcision has been proven beyond reasonable doubt to reduce female to male transmission of the disease, according to the editorial’s authors, Professor David Cooper, Director of the National Centre in HIV Epidemiology and Clinical Research, Dr Alex Wodak, Director of Alcohol and Drug Service at St Vincent’s Hospital, and Professor Brian Morris, Professor of Molecular Medical Sciences at the University of Sydney.

“A wealth of research has shown that the foreskin is the entry point that allows HIV to infect men during intercourse with an infected female partner.”

Further, the authors said that circumcision of males is now referred to by many as a “surgical vaccine” against a wide variety of infections and adverse medical conditions over a lifetime.

Professor Morris noted that large randomised controlled trials had shown that male circumcision also protected against human papillomavirus, some common sexually transmitted infections, penile cancer, cervical cancer and genital herpes as well as HIV.

Dr George Williams, a New South Wales paediatrician and the head of the anticircumcision group, Circumcision Information Australia, however, said the evidence on circumcision and HIV had been conducted in Africa and the results could not be translated to Western populations.

Med J Aust 2010; 193: 318-9.

Posted 20 September 2010