Over the next year, the Office of National AIDS Policy, led by Dr. Jeffery Crowley, will come up with a strategy for fighting HIV in the United States. That project is long overdue. While the Bush administration devoted unprecedented resources to combating HIV/AIDS in the developing world, it largely ignored the epidemic here at home. Over 1.1 million Americans live with HIV. In 2006, over 56,000 new infections were recorded. And the disease is increasingly associated with minority communities and the poor; in Washington, D.C., the major American city with the highest HIV/AIDS rate, 4.3 percent of all African Americans are infected. Among black men in D.C., 6.5 percent are HIV-positive.
Internationally, the HIV-prevention method gaining the most momentum -- and attracting the most press -- is male circumcision. A series of studies conducted in Africa found that circumcision decreases female-to-male HIV transmission by as much as 60 percent. That is because the cells of the foreskin are especially susceptible to infection. (Women though, aren't any less likely to contract HIV from circumcised men.) Since 2007, the World Health Organization has strongly recommended circumcision, calling the new research on the procedure "an important landmark in the history of H.I.V. prevention."
Considering this evidence, should circumcision-promotion be among the policy levers the Obama administration considers? As New York City Mayor Michael Bloomberg learned two years ago, when he created a maelstrom by asking the city health department to encourage the procedure, American public health efforts must tread carefully around this issue. The promising circumcision research was conducted entirely in Africa, largely among heterosexuals. In the United States, HIV continues to disproportionately affect the gay community. In 2005, half of all new cases were among men having sex with men, compared to 33 percent among heterosexuals engaged in what the CDC calls "high risk" behaivor -- a woman who has unprotected sex, for example, with a man who is also having unprotected sexual encounters with other men.
American HIV/AIDS advocates have worked for nearly three decades to send the message that condoms are the best way to protect against the disease. That messaging has been effective, and it's important to double down on it within the gay community: Clinical studies show that gay sex is much more likely to lead to HIV infection than hetero sex. Among men having sex with men, circumcision is likely to offer very little protection against the disease. But the truth is, we don't have good research on that question -- and certainly not in an American context.
About 60 percent of American men are already circumcised. Those who aren't are more likely to be recent immigrants or first generation Americans, and to hail from cultures resistant to condom usage. For these men, a public health push on condoms is likely to reap far greater dividends than a pro-circumcision campaign, which is likely to be seen as even more radical and intrusive. What's more, condoms are far cheaper than circumcision. So when it comes to extrapolating American public health policies from the African circumcision research, we should proceed with caution. After all, the United States already has the highest circumcision rate in the developed world -- and also the highest HIV infection rate.
--Dana Goldstein
