Circumcision Status and HIV Infection among Black and Latino MSM in 3 US Cities Gregorio A Millett Centers for Disease Control Division of HIV/AIDS Prevention

Circumcision Status and HIV Infection among Black and Latino MSM

in 3 US Cities

Gregorio A Millett

Centers for Disease Control

Division of HIV/AIDS Prevention

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and

Prevention

Presentation Outline

• Description of male circumcision studies with heterosexuals

• Background on U.S. HIV epidemic and circumcision prevalence

• U.S.-based circumcision studies with MSM

• Brothers y Hermanos study purpose and methods

• Demographic and behavioral data of circumcised and uncircumcised Black and Latino MSM

• Circumcision status and HIV infection among Black and Latino MSM

• Discussion and implications

African Clinical Trial Results- HIV Incidence

Study Number of men

Incidence RR (95% CI)

Auvert B

PLoS Med, 2005

South Africa

3,520 0.40 (0.24-0.68)

Bailey RC

Lancet, 2007

Kenya

2,784 0.47 (0.28-0.78)

Gray RH

Lancet, 2007

Uganda

5,000 0.43 (0.24-0.75)

Summary RR (95% CI): 0.42 (0.31-0.57)

WHO Map MC Globally

Global Estimates of HIV Prevalence

Association between MC Prevalence HIV Prevalence

Country characteristics HIV prevalence in

countries w/ low MC (<20%)

HIV prevalence in

countries w/ high MC (>80%)

Sub-Saharan African countries 16.5%* 3%

Non sub-Saharan African countries:

heterosexual-driven epidemic

0.76%* 0.09%

*P<.0001 (Drain, 2006)

WHO/UNAIDS Recommendations for Further Study

• The risks and benefits of male circumcision for HIV-positive men

• The impact of male circumcision on sexual transmission from HIV-infected men to women

• Resources needed for, and most effective ways, to expand quality male circumcision services

• The impact of male circumcision on the health of women for reasons other than HIV transmission (e.g. lessened rates of cancer of the cervix)

• The protective benefit of male circumcision in the case of insertive partners engaging in heterosexual anal intercourse

• The protective benefit of male circumcision in the case of insertive partners engaging in homosexual anal intercourse

WHO/UNAIDS Recommendations for Further Study

• The risks and benefits of male circumcision for HIV-positive men

• The impact of male circumcision on sexual transmission from HIV-infected men to women

• Resources needed for, and most effective ways, to expand quality male circumcision services

• The impact of male circumcision on the health of women for reasons other than HIV transmission (e.g. lessened rates of cancer of the cervix)

• The protective benefit of male circumcision in the case of insertive partners engaging in heterosexual anal intercourse

• The protective benefit of male circumcision in the case of insertive partners engaging in homosexual anal intercourse

HIV/AIDS Diagnoses, 2006Sex of adults and adolescents with HIV/AIDS diagnosed

during 2006

HIV Prevalence and Incidence among Young MSM

• Initial dx of HIV among MSM ages 13-24– Black 16% ; Latino 13%;

White 9% (MMWR, 1/14/00)

Impact • Ages 15-22

– HIV Prevalence: Black 14%, Latino 7%, White 3% (MMWR, 6/1/01)

– HIV Incidence: Black 4%, Latino 1.8%, White 2.4%. (MMWR, 6/1/01)

• Ages 23-29– HIV Prevalence: Black 32%,

Latino 13%, White 7% (MMWR, 6/1/01)

– HIV Incidence: Black 14.7%, Latino 3.5%, White 2.5%. (MMWR, 6/1/01)

Age HIV Prevalence

15-22 15%

23-29 32%

Median age 32

46%

Circumcision Rates in the United States

• Prevalence in general population– White (81-88%)– Black (65-73%)

– Latino (42-54%) (Xu, 2007; Laumann, 1997)

• Rates declining

N=6174

U.S.-based Studies of Circumcision Status and HIV Infection among MSM

• Cross-sectional study (N= 595)– 83% circumcised (self-report)– MSM of color less likely to be

circumcised – Circumcised MSM less likely

to be HIV-positive (Kreiss, 1993)

• Prospective study- Vaccine Preparedness Trial (N=3257)– 88% circumcised (self-report)– Circumcised MSM less likely

to seroconvert– Circumcision unrelated to STD

infection (Buchbinder, 2005)

• Cross-sectional study of STD clinic attendees 1996-2005 (N= 58,598)– Enrolled 20,832 MSM– 73% circumcised (genital exam)– No protective effect of

circumcision against syphilis or HIV infection (Mor, 2007)

• Prospective study- Vaccine Preparedness Trial (N=1836)– 56% circumcised (self-report)– No association between

circumcision and HIV– Uncircumcised men in vaccine

group 4x more likely to seroconvert than uncircumcised men in placebo (Buchbinder, 2007)

U.S.-based Studies of Circumcision Status and HIV Infection among MSM

• Cross-sectional study (N= 595)– 83% circumcised (self-report)– MSM of color less likely to be

circumcised – Circumcised MSM less likely

to be HIV-positive (Kreiss, 1993)

• Prospective study- Vaccine Preparedness Trial (N=3257)– 88% circumcised (self-report)– Circumcised MSM less likely

to seroconvert– Circumcision unrelated to STD

infection (Buchbinder, 2005)

• Cross-sectional study of STD clinic attendees 1996-2005 (N= 58,598)– Enrolled 20,832 MSM– 73% circumcised (genital exam)– No protective effect of

circumcision against syphilis or HIV infection (Mor, 2007)

• Prospective study- Vaccine Preparedness Trial (N=1836)– 56% circumcised (self-report)– No association between

circumcision and HIV– Uncircumcised men in vaccine

group 4x more likely to seroconvert than uncircumcised men in placebo (Buchbinder, 2007)

Study AimsExamine• Prevalence of circumcision among black and Latino

MSM

• Demographic and behavioral differences between circumcised and uncircumcised black MSM and Latino MSM

• Association between circumcision and HIV status among black MSM and Latino MSM

• Association between circumcision and HIV status separately for MSM/W and MSM/only

• Whether circumcision affords a protective effect against HIV infection for men who only engage in insertive unprotected anal intercourse (UAI)

Methods• Brothers y Hermanos study in

response to YMS infection rates– 2 sites recruited Black MSM

(NY & Phil); 2 sites recruited Latino MSM (NY & LA)

• Study eligibility1. Male2. Black or Latino3. > 18 years of age4. Sex with male in past year

(mutual masturbation, oral, anal)

5. Resident of NYC, Philadelphia and LA

• No enrollment restrictions based upon HIV status

• Respondent driven sampling to recruit participants– 3 coupons per participant

• Audio Computer Assisted Survey Instrument

• HIV testing: Rapid oral fluid and Western blot assay

• Data collected between May 2005 and April 2006– Recruited 1154 black MSM

and 1091 Latino MSM

Methods

• Participants were asked “Is your penis circumcised or cut?”– 2106 (94%) men answered the question

• Examined demographics, substance use (3 mos), sexual risk (3 mos), and HIV/STD history

• Analyzed data in SAS 9.1– Univariate analyses

• Chi-square (categorical variables); t-tests (continuous variables)

– Multivariable analyses• Logistic regression

Results:Univariate Data

Circumcision Prevalence

0%

10%

20%

30%

40%

50%

60%

70%

80%

Black MSM Latino MSM

74%

33%

n=1079 n= 957

Demographics by Circumcision Status

Circumcised black MSM more likely to

• Older• Educated• Higher income• Born in US• Have a parent born in

US• Be gay-identified

Circumcised Latino MSM (n= 957) more likely to

• Born in US• Have a parent born in

US• Been in US for a longer

time

• Borderline significant: Private health insurance

Demographics by Circumcision Status


• Older• Educated• Higher income• Born in US• Have a parent born in

US• Be gay-identified

Circumcised Latino MSM more likely to

• Born in US• Have a parent born in

US• Been in US for a longer

time

• Borderline significant: Private health insurance

Univariate Results: DemographicsBlack MSM (n=1079) Latino MSM (n=957)

Circumcised

N (%)

Uncircumcised

N (%)

P Circumcised

N (%)

Uncircumcised

N (%)

P

Total 794 (73.6) 285 (26.4) 317 (33.1) 640 (66.9)

Age, median 43.7 41.1 <0.01* 33.1 33.1 0.95

Education

<HS diploma

HS or GED

> College

162 (20.4)

439 (55.4)

192 (24.2)

85 (29.8)

146 (51.2)

54 (19.0) <0.01*

64 (20.2)

164 (51.7)

89 (28.1)

137 (21.4)

335 (52.4)

167 (26.1) 0.79

Income

<$5000

$5000-$9999

$10,000-$19,999

>$20,000

257 (33.0)

191 (24.6)

155 (19.9)

175 (22.5)

113 (40.8)

62 (22.4)

62 (22.4)

40 (14.4) 0.01*

85 (27.9)

68 (22.3)

58 (19.0)

94 (38.8)

194 (31.1)

131 (21.0)

136 (21.8)

163 (26.1) 0.35

Born in US 747 (94.1) 243 (85.3) <0.01* 191 (60.3) 231 (36.2) <0.01*

Yrs in US, mean 39.8 41.1 0.12 23.8 18.4 <0.01*

Any parent born in US

756 (95.5) 246 (86.3) <0.01* 169 (53.3) 165 (25.8) <0.01*

Sexual Identity

Gay

Bisexual

Heterosexual

Other

399 (50.5)

277 (35.1)

78 (9.9)

36 (4.6)

109 (38.3)

120 (42.1)

39 (13.7)

17 (6.0) <0.005*

229 (72.2)

71 (22.4)

7 (2.2)

10 (3.2)

483 (75.7)

109 (17.1)

13 (2.0)

33 (5.2) 0.14

Substance Use (3 mos) by Circumcision Status

Circumcised black MSM more likely to report using

• Marijuana• Amyl Nitrites

• No reported differences: alcohol consumption, crack/cocaine, marijuana, meth, club drugs

Circumcised Latino MSM (n= 957) more likely to report using

• Cocaine• Heroin• Meth

• No reported differences: alcohol consumption, marijuana, nitrites, crack, club drugs

Substance Use (3 mos) by Circumcision Status

Circumcised black MSM more likely to report using

• Marijuana• Amyl Nitrites

• No reported differences: alcohol consumption, crack/cocaine, marijuana, meth, club drugs

Circumcised Latino MSM more likely to report using

• Cocaine• Heroin• Meth

• No reported differences: alcohol consumption, marijuana, nitrites, crack, club drugs

Univariate Results: Substance Use (3 mos)Black MSM (n=1079) Latino MSM (n=957)

Circumcised

N (%)

Uncircumcised

N (%)

P Circumcised

N (%)

Uncircumcised

N (%)

P

Alcohol use 522 (65.9) 175 (61.6) 0.19 201 (63.4) 435 (68.0) 0.16

Crystal meth use 28 (3.5) 7 (2.5) 0.38 51 (16.1) 74 (11.6) 0.05

Cocaine use 249 (31.4) 103 (26.3) 0.14 46 (14.5) 58 (9.1) 0.01

Crack use 266 (33.6) 102 (35.8) 0.50 23 (7.3) 31 (4.9) 0.13

Marijuana use 386 (48.7) 113 (39.7) <0.01* 115 (36.3) 209 (32.7) 0.27

Heroin use 27 (3.4) 12 (4.2) 0.53 11 (3.5) 9 (1.4) 0.04

‘Club’ drug+ use 28 (3.5) 5 (1.8) 0.13 41 (12.9) 76 (11.9) 0.64

Amyl nitrites use 100 (12.6) 18 (6.3) <0.01* 60 (18.9) 120 (18.8) 0.96

+ Includes ketamine, Ecstasy, GHB

Sexual Risk (3 mos), STD hx, HIV Status by Circumcision Status


• Report any UAI• Report receptive UAI > 2

partners

• No reported differences: insertive UAI, # insertive UAI partners, HIV test (ever), HIV test (past yr), # HIV tests, STD dx (ever), HIV-positive status

Circumcised Latino MSM (n= 957) more likely to

• Have a greater # of previous HIV tests

• Be tested for HIV (past yr)

• No reported differences: Any UAI, insertive UAI, # insertive or receptive partners, HIV test (ever), STD dx (ever), HIV-positive status

Sexual Risk (3 mos), STD hx, HIV Status by Circumcision Status


• Report any UAI• Report receptive UAI > 2

partners

• No reported differences: insertive UAI, # insertive UAI partners, HIV test (ever), HIV test (past yr), # HIV tests, STD dx (ever), HIV-positive status

Circumcised Latino MSM more likely to

• Have a greater # of previous HIV tests

• Be tested for HIV (past yr)

• No reported differences: Any UAI, insertive UAI, # insertive or receptive partners, HIV test (ever), STD dx (ever), HIV-positive status

Univariate Results: Sexual Risk (3 mos), STD, HIV

Black MSM (n=1079) Latino MSM (n=957)

Circumcised

N (%)

Uncircumcised

N (%)

P Circumcised

N (%)

Uncircumcised

N (%)

P

# insertive UAI

0

1

> 2

583 (74.8)

7.2 (9.4)

124 (15.9)

218 (79.6)

21 (7.7

35 (12.8) 0.29

255 (81.0)

20 (6.4)

40 (12.7)

525 (83.2)

34 (5.4)

72 (11.4) 0.68

# receptive UAI

0

1

> 2

651 (83.1)

62 (5.8)

70 (8.9)

255 (91.7)

12 (4.3)

11 (4.0) <0.01*

268 (85.6)

21 (6.7)

24 (7.7)

547 (86.7)

43 (6.8)

42 (6.7) 0.85

Any UAI 296 (37.3) 87 (30.5) 0.04* 103 (32.5) 209 (32.7) 0.95

Insertive UAI 138 (17.4) 52 (18.3) 0.74 43 (13.6) 87 (13.6) 0.99

STD Dx (ever) 525 (66.1) 177 (62.1) 0.22 131 (41.5) 261 (40.9) 0.87

HIV test (ever) 727 (91.7) 256 (89.8) 0.34 279 (88.0) 539 (84.4) 0.13

# HIV tests 5.7 5.5 0.76 6.7 5.1 0.01

HIV test (past yr) 342 (47.6) 123 (49.2) 0.67 164 (59.0) 255 (47.4) <0.01

HIV-positive 425 (53.7) 138 (48.8) 0.16 116 (36.6) 232 (36.4) 0.94

Results:Multivariable Analyses

Black MSM (n=1044)

Covariates AOR (95 % CI)

Age (1 y) 1.05 (1.04, 1.07)

Education

> College

HS or GED

<HS diploma

1.00

1.26

1.20

-

(0.85, 1.85)

(0.75,1.93)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

2.27

2.08

1.15

-

(1.42, 3.64)

(1.32, 3.28)

(0.74, 1.77)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

0.24

0.09

0.52

-

(0.17, 0.34)

(0.05, 0.16)

(0.27, 1.00)

New York vs. Other 3.67 (2.71, 4.98)

Born in U.S. (yes vs no) 0.87 (0.51, 1.47)

Any recent UAI (yes vs no) 1.14 (0.81, 1.60)

Sexual position (top vs other) 0.75 (0.49, 1.15)

Previous STD Dx 3.64 (2.64, 5.02)

Factors Associated with HIV-Positive Status (Full Sample)


Covariates AOR (95 % CI) AOR (95%)

Age (1 y) 1.05 (1.04, 1.07) 1.10 (1.08, 1.12)

Education

> College

HS or GED

<HS diploma

1.00

1.26

1.20

-

(0.85, 1.85)

(0.75,1.93)

1.00

0.71

0.78

-

(0.44, 1.15)

(0.43, 1.41)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

2.27

2.08

1.15

-

(1.42, 3.64)

(1.32, 3.28)

(0.74, 1.77)

1.00

2.50

5.51

5.92

-

(1.38, 4.52)

(3.02, 10.05)

(3.30, 10.64)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

0.24

0.09

0.52

-

(0.17, 0.34)

(0.05, 0.16)

(0.27, 1.00)

1.00

0.43

0.31

0.32

-

(0.27, 0.71)

(0.09, 1.03)

(0.10, 1.05)

New York vs. Other 3.67 (2.71, 4.98) 0.74 (0.64, 0.85)

Born in U.S. (yes vs no) 0.87 (0.51, 1.47) 0.52 (0.29, 0.95)

Any recent UAI (yes vs no) 1.14 (0.81, 1.60) 1.14 (0.76, 1.73)

Sexual position (top vs other) 0.75 (0.49, 1.15) 0.52 (0.29, 0.95)

Previous STD Dx 3.64 (2.64, 5.02) 4.29 (2.92, 6.30)




Circumcised (y vs. n) 1.23 (0.87, 1.74) 1.10 (0.73, 1.66)

Age (1 y) 1.05 (1.04, 1.07) 1.10 (1.08, 1.12)

Education

> College

HS or GED

<HS diploma

1.00

1.26

1.20

-

(0.85, 1.85)

(0.75,1.93)

1.00

0.71

0.78

-

(0.44, 1.15)

(0.43, 1.41)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

2.27

2.08

1.15

-

(1.42, 3.64)

(1.32, 3.28)

(0.74, 1.77)

1.00

2.50

5.51

5.92

-

(1.38, 4.52)

(3.02, 10.05)

(3.30, 10.64)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

0.24

0.09

0.52

-

(0.17, 0.34)

(0.05, 0.16)

(0.27, 1.00)

1.00

0.43

0.31

0.32

-

(0.27, 0.71)

(0.09, 1.03)

(0.10, 1.05)

New York vs. Other 3.67 (2.71, 4.98) 0.74 (0.64, 0.85)

Born in U.S. (yes vs no) 0.87 (0.51, 1.47) 0.52 (0.29, 0.95)

Any recent UAI (yes vs no) 1.14 (0.81, 1.60) 1.14 (0.76, 1.73)


Previous STD Dx 3.64 (2.64, 5.02) 4.29 (2.92, 6.30)


Black MSM/W (n=170) Black MSM/Only (n=551)


Age (1 y) 1.01 (0.96, 1.06) 1.08 (1.06, 1.11)

Education

> College

HS or GED

<HS diploma

1.00

4.18

7.85

-

(1.07, 16.37)

(1.63, 37.89)

1.00

1.58

1.25

-

(0.93, 2.69)

(0.64, 2.44)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

2.32

3.34

1.56

-

(0.59, 9.15)

(0.82, 13.68)

(0.43, 5.64)

1.00

2.07

1.89

0.84

-

(1.06, 4.06)

(1.01, 3.55)

(0.46, 1.52)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

2.18

1.80

0.50

-

(0.52, 9.16)

(0.31, 10.61)

(0.04, 7.21)

1.00

0.30

0.17

0.84

-

(0.18, 0.50)

(0.05, 0.66)

(0.29, 2.40)

New York vs. Other 5.97 (2.64, 13.50) 4.37 (2.76, 6.92)

Born in U.S (yes vs no) 0.12 (0.01, 1.48) 1.12 (0.51, 2.44)

.Any recent UAI (yes vs no) 0.92 (0.33, 2.53) 1.14 (0.71, 1.83)


Previous STD Dx 5.58 (2.10, 14.83) 3.93 (2.49, 6.20)

Factors Associated with HIV-Positive Status (MSM/W vs. MSM/only)



Age (1 y) 1.01 (0.96, 1.06) 1.08 (1.06, 1.11)

Education

> College

HS or GED

<HS diploma

1.00

4.18

7.85

-

(1.07, 16.37)

(1.63, 37.89)

1.00

1.58

1.25

-

(0.93, 2.69)

(0.64, 2.44)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

2.32

3.34

1.56

-

(0.59, 9.15)

(0.82, 13.68)

(0.43, 5.64)

1.00

2.07

1.89

0.84

-

(1.06, 4.06)

(1.01, 3.55)

(0.46, 1.52)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

2.18

1.80

0.50

-

(0.52, 9.16)

(0.31, 10.61)

(0.04, 7.21)

1.00

0.30

0.17

0.84

-

(0.18, 0.50)

(0.05, 0.66)

(0.29, 2.40)

New York vs. Other 5.97 (2.64, 13.50) 4.37 (2.76, 6.92)




Previous STD Dx 5.58 (2.10, 14.83) 3.93 (2.49, 6.20)




Circumcised (y vs. n) 0.99 (0.41, 2.37) 1.44 (0.85, 2.44)

Age (1 y) 1.01 (0.96, 1.06) 1.08 (1.06, 1.11)

Education

> College

HS or GED

<HS diploma

1.00

4.18

7.85

-

(1.07, 16.37)

(1.63, 37.89)

1.00

1.58

1.25

-

(0.93, 2.69)

(0.64, 2.44)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

2.32

3.34

1.56

-

(0.59, 9.15)

(0.82, 13.68)

(0.43, 5.64)

1.00

2.07

1.89

0.84

-

(1.06, 4.06)

(1.01, 3.55)

(0.46, 1.52)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

2.18

1.80

0.50

-

(0.52, 9.16)

(0.31, 10.61)

(0.04, 7.21)

1.00

0.30

0.17

0.84

-

(0.18, 0.50)

(0.05, 0.66)

(0.29, 2.40)

New York vs. Other 5.97 (2.64, 13.50) 4.37 (2.76, 6.92)




Previous STD Dx 5.58 (2.10, 14.83) 3.93 (2.49, 6.20)


(n=925)


Age (1 y) 1.01 (0.99, 1.05)

Education

> College

HS or GED

<HS diploma

1.00

1.06

1.46

-

(0.50, 2.25)

(0.59, 3.60)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

4.31

4.20

1.59

-

(1.76, 10.57)

(1.69, 10.42)

(0.60, 4.22)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

0.46

0.53

0.31

-

(0.23, 0.93)

(0.19, 1.43)

(0.04, 2.43)

Latino vs. Black 0.79 (0.57

Born in U.S. 2.25 (0.94, 5.42)

Any recent UAI 1.36 (0.72, 2.56)


Previous STD Dx 1.47 (0.82, 2.62)

Factors Associated with New HIV Diagnoses Among Self-Reported HIV-Negative Men

(n=925)


Circumcised (yes vs. no) 1.61 (0.84, 3.07)

Age (1 y) 1.01 (0.99, 1.05)

Education

> College

HS or GED

<HS diploma

1.00

1.06

1.46

-

(0.50, 2.25)

(0.59, 3.60)

Income

>$20,000

$10,000-$19,999

$5000-$9999

<$5000

1.00

4.31

4.20

1.59

-

(1.76, 10.57)

(1.69, 10.42)

(0.60, 4.22)

Sexual Identity

Gay

Bisexual

Heterosexual

Other

1.00

0.46

0.53

0.31

-

(0.23, 0.93)

(0.19, 1.43)

(0.04, 2.43)

Latino vs. Black 0.79 (0.57

Born in U.S. 2.25 (0.94, 5.42)

Any recent UAI 1.36 (0.72, 2.56)


Previous STD Dx 1.47 (0.82, 2.62)

Factors Associated with New HIV Diagnoses Among Self-Reported HIV-Negative Men

HIV infection, Circumcision and Insertive UAI

• Nonsignificant interaction between circumcision status and insertive UAI for

– Latino MSM (P= 0.12)

– Black MSM (P= 0.42)

– Black MSM/W (P= 0.78)

– Black MSM/Only (P= 0.95)

– New HIV diagnoses (P= 0.63)

Discussion

Discussion

• Circumcision status was not associated with HIV infection – among black MSM or Latino

MSM

– among black MSM/W or Black MSM/Only

– among black or Latino MSM with new HIV diagnosis

• Discrepant with 2 of 3 U.S.-

based studies that found protective effect– Protective effect of

circumcision is moderate

Strengths

• One of the largest observational studies of black and Latino MSM

• First U.S. study to examine circumcision among black MSM and Latino MSM separately– Comparable estimates to population-based studies – Demographic, substance use, sexual differences by

circumcision status

• Delineated between MSM/W and MSM/only

• Report data on men who had only engaged in insertive unprotected sex

Limitations

• Network-based sampling method

• Circumcision status based upon self-report

• No data of when men were circumcised

• Sexual risk behavior limited to past 3 months

• Cross-sectional study

Association between MC Prevalence HIV Prevalence

Country characteristics HIV prevalence in

countries w/ low MC (<20%)

HIV prevalence in

countries w/ high MC (>80%)

Sub-Saharan African countries 16.5%* 3%

Non sub-Saharan African countries:

heterosexual-driven epidemic

0.76%* 0.09%

Non sub-Saharan African countries: IDU or

homosexual-driven epidemic

0.41% 0.06%

*P<.0001 (Drain, 2006)

MSM Circumcision Studies Outside the U.S.

• Peru: Cross-sectional study in 3 cities (N=2048)– 3.7% circumcised (genital

exam)– No association between

circumcision and HIV infection– Insertive men less likely to be

HIV-positive (Guanaria, 2007)

• Australia: Cross-sectional study in Sydney (N=63) – HIV-positive men – 73% circumcised (self-report)– Circumcision status not

associated with HIV infection among men who engaged in insertive sex (Grulich, 2001)

• Australia: Prospective study in Sydney (N= 1427)– 66.6% circumcised (self-

report)– No association between

circumcision and incident HIV infection in overall sample

– No association between circumcision and incident HIV infection among men who only reported insertive UAI (Templeton, 2007)

(Buchbinder, 2005)

Tally of MSM Circumcision Studies

• 8 studies– 3 prospective studies

• 2 found no effect• 1 found a protective effect

– 5 cross-sectional studies• 3 found no effect• 1 found a protective effect• 1 found no overall effect, but found protective

effect for insertive MSM

Recommendations from the experts

• “There are few observational studies and no RCT of the impact of circumcision on HIV transmission among MSM…Definitive evidence may come only from an RCT.”– Helen Weiss

• “Observational studies of MSM also are limited by confounding factors. Because of these limitations and the difficulty of extrapolating trial results from heterosexual men to MSM, randomized trials among MSM are urgently needed.”– Ronald Gray

• “To determine definitively whether circumcision could play a role in HIV prevention for MSM, a clinical trial is needed.”– Harold Jaffe

MistrustApril 5, 2007

New York City Plans to Promote Circumcision to Reduce Spread of AIDS By DONALD G. McNEIL Jr. New York City’s Department of Health and Mental Hygiene is planning a campaign to encourage men at high risk of AIDS to get circumcised in light of the World Health Organization’s endorsement of the procedure as an effective way to prevent the disease.

“I’m white, Frieden’s white,” he said. “It’s going to sound like white guys telling black and Hispanic guys to do something that would affect their manhood.”

-Peter Staley, AIDS activist

“There will always be conspiracy theorists. That’s par for the course.”

-Tokes Osubu, Executive Director, GMAD

http://topics.nytimes.com/top/reference/timestopics/people/m/donald_g_jr_mcneil/index.html?inline=nyt-per



http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/aids/index.html?inline=nyt-classifier

http://topics.nytimes.com/top/reference/timestopics/organizations/w/world_health_organization/index.html?inline=nyt-org

MSM of color and mistrust

HIV/AIDS Conspiracy Belief

Black MSM (n=239)

%

Latino MSM (n=152)

%

White MSM (n=111)

%

Pharmaceutical companies hiding cure for HIV/AIDS because of profits

58* 50 42

HIV/AIDS drugs harm you more than help you

56* 48* 41

HIV does not cause AIDS 54* 48 27

HIV is a man-made virus 50* 41 35

(Hutchinson, 2007) *P<.05 versus White MSM

Circumcision willingnessGay Pride events in 7 U.S. cities 2006

(Begley, 2007)N=127

Guanira Willingness slide 10

(Guanira, 2007)N=2048

(Guanira, 2007)

Future Research

• Confirm circumcision self-report estimates via physical examination

• Examine sexual position over time

• Examine association among insertive MSM exposed to positive partners

• Determine sexual risk differences between circumcised men and uncircumcised men

Future Research, contd

• Association between circumcision and HIV by – HIV prevalence or circumcision prevalence in

population

• Willingness to be circumcised among HIV-negative MSM

• Relative protective effect of circumcision compared to behavioral interventions

Future Research, contd

• Cost analysis of circumcision vs. benefit – Infections averted– Impact on MSM epidemic

• Male circumcision and STI risk– Viral – Bacterial

• Syphilis: No association (Mor); Protective (Kriess, Templeton)

Acknowledgments

• Co-authors– Helen Ding– Jennifer Lauby– Stephen Flores– Ann Stueve– Trista Bingham– Alex Carballo-Dieguez– Chris Murrill– Kai-Lih Liu– Darrell Wheeler– Adrian Liau– Gary Marks

• Community Advisory Board members

• ByH Staff– LA County Dept of Public

Health– NYC Dept of Mental Health

and Hygiene– Educational Development

Center, Inc– Philadelphia Health

Management Corporation

• CDC– Peter Kilmarx– Dawn Smith – Richard Wolitski

• Participants

• Additional information on ByH circumcision study

• Greg Millett, MPH• [email protected]• 404-639-1902

• CDC circumcision workgroup information

• Peter Kilmarx, MD• [email protected]• 404-639-8998

mailto:[email protected]

mailto:[email protected]

Extra slides

Non-gay ID/ DisclosureNon-gay ID/ Disclosure

SubstanceSubstance useuse

Sexual Risk behaviorSexual Risk behavior

HIV

Noncontributors to Racial Disparities in Noncontributors to Racial Disparities in HIV prevalence in MSMHIV prevalence in MSM

(Millett et al., 2006 & 2007)

STDsSTDs

Unrecognized HIV Unrecognized HIV infectioninfection

HIV

(Millett et al., 2006 & 2007)

Contributors to Racial Disparities in HIV Contributors to Racial Disparities in HIV prevalence in MSMprevalence in MSM

Sexual Sexual NetworksNetworks

Non-gay ID/ DisclosureNon-gay ID/ Disclosure

SubstanceSubstance useuse

STDsSTDs

Unrecognized HIV Unrecognized HIV infectioninfection

Sexual Risk behaviorSexual Risk behavior

Sexual Sexual NetworksNetworks

Incarceration?Incarceration?

Biology/ Genetics?Biology/ Genetics?

HIV

Hypotheses for Greater HIV Hypotheses for Greater HIV

Prevalence among Black MSMPrevalence among Black MSM

(Millett et al., 2006 & 2007)

Circumcision?Circumcision?Healthcare Healthcare Access?Access?

Sex w/ Known HIV+ Sex w/ Known HIV+ partners?partners?

HIV meds HIV meds adherence?adherence?

Documents

Circumcision Status and HIV Infection among Black and Latino MSM in 3 US Cities Gregorio A Millett Centers for Disease Control Division of HIV/AIDS Prevention