Encouraging data from the recent clinical trials in Kenya, South Africa, and Uganda has raised the question regarding the implications for HIV prevention in the U.S. However, acceptability of routine neonatal circumcision in the U.S. is an issue at the intersection of medicine, public health, religion, culture, ethics, law, and human rights. Before neonatal circumcision can be recommended as a strategy to prevent the spread of HIV in the U.S., the applicability of the clinical trial data from Kenya, South Africa, and Uganda to this country must be carefully considered.
Assessment of the impact of male circumcision in the U.S. must consider exposures occurring during adolescence (because in the U.S. circumcision is generally performed at birth), differences in factors influencing HIV transmission dynamics, including the heterogeneity in HIV prevalence, as well as differences in other biological and behavioral factors that impact transmission. In addition, despite the widely recognized burden of HIV/AIDS-related diseases, resources available to combat the epidemic are limited (Marseille et al., 2002
). Comprehensive cost-effectiveness analysis considering the various elements of HIV transmission in the context of the United States will be instrumental in elucidating the potential cost, benefit, and risks of HIV prevention strategies.
Clearly, more research addressing the following questions would greatly inform the discussion regarding the utility of routine neonatal circumcision in HIV prevention in the U.S.: What is the effect on HIV transmission when circumcision is performed at birth? What is the effect on HIV prevention specifically in the context of the U.S. epidemic (particularly seroprevalence and predominant mode of transmission)? What is the magnitude of the impact of circumcision on reduction in male-to-female transmission? Whether it is cost-effectiveness to perform routine neonatal circumcision in preventing HIV transmission in the U.S. setting? These important questions must be answered before rational policy recommendations regarding neonatal circumcision can be made.