The New York Times
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April 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.

While the Centers for Disease Control and Prevention in Atlanta is just beginning to convene meetings and design studies to help it formulate a national policy, New York City is moving ahead on its own.

In the United States, “New York City remains the epicenter of the AIDS epidemic,” Dr. Thomas R. Frieden, the city’s health commissioner, said in an interview. Referring to H.I.V., he said, “In some subpopulations, you have 10 to 20 percent prevalence rates, just as they do in parts of Africa.”

His department has started asking some community groups and gay rights organizations to discuss circumcision with their members, and has asked the Health and Hospitals Corporation, which runs city hospitals and clinics, to perform the procedure at no charge for men without health insurance.

A spokeswoman for the corporation said it was “having conversations” with the health department but had not reached a decision.

“As you know, the research on this is pretty recent,” the spokeswoman, Ana Marengo, said.

In three recent clinical trials in Africa, circumcision was shown to lower a man’s risk of contracting the virus from heterosexual sex by about 60 percent. On March 28, the World Health Organization officially recommended that countries adopt the procedure as part of their AIDS prevention plans.

No spontaneous outcry for circumcision has arisen in New York, Dr. Frieden conceded.

“This is not something that has a lot of buzz,” he said.

But he added that even 1,000 circumcisions in the right subgroups might slow the spread of AIDS.

For example, in Manhattan, 20 percent of all black men between 40 and 50 are infected with the virus that causes AIDS. About 10 percent of all gay men in the city are infected, and the rate rises to as high as 25 percent in the Chelsea neighborhood.

Dr. Frieden said black, Hispanic and foreign-born men were less likely to be circumcised than white Americans, and the percentage is smaller among men with lower incomes.

(About 65 percent of all male babies in the United States are circumcised, according to the National Center for Health Statistics, compared with about 30 percent of men worldwide, by W.H.O. estimates.)

Among men seeking treatment at the city’s clinics for sexually transmitted diseases — another risk group for AIDS infection because of genital sores — a large proportion are uncircumcised, Dr. Frieden said.

There are clear limitations, however, on extrapolating data from Africa to New York.

The studies, done in Uganda, Kenya and South Africa, enrolled men who said they had sex with women, while New York’s highest-risk groups are men who have sex with men, men who inject drugs and people who have sex with those men.

Nonetheless, Dr. Frieden said, it is logical to assume that circumcision would offer protection in some types of gay sex.

A man’s risk from performing penetrative anal sex is about the same as his risk from vaginal sex, Dr. Frieden said, so circumcision would presumably confer the same protection as it did in the African trials.

The risk from receptive anal sex is five times higher, he said, and circumcision would obviously not protect those men. Oral sex is much less risky.

Also, cutting down infections among bisexual men — some of whom do not admit to female partners that they participate in gay sex — would protect women, he said.

Dr. Frieden said he thought health insurance companies might agree to pay for preventive circumcisions since they already covered them for infections and urinary blockage. City hospitals also offer the operation in those cases, Ms. Marengo said.

Peter Staley, a longtime AIDS activist and co-founder of ACT-UP New York, the Treatment Action Group and AIDSmeds.com, said he was “intrigued” by the idea of offering circumcisions but worried because those in the studies supporting it bore little relation to New York’s risk groups.

“Should we proceed when we don’t have hard data yet on the population here?” he asked. “On the other hand, if we wait the three years it would take to answer that question, how many will be infected in the meantime?”

Also, after reading many postings on gay Web sites about the Africa trials, he said he feared a backlash among black and Hispanic men to endorsements of circumcision from white public health officials or gay activists.

“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.”

Tokes Osubu, executive director of Gay Men of African Descent, a 21-year-old gay rights organization, agreed.

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

He also said he thought circumcision was “not the answer to our problems” and doubted that it would lower infection rates.

Many black men who have sex with men, he said, already face discrimination, stigma and an inability to talk about their sex lives with family members and sometimes even with doctors.

“No amount of circumcision is going to change that,” he said.

Bric Bernas, manager of information and counseling for the Asian and Pacific Islander Coalition on H.I.V./AIDS, said his organization wanted to see studies done in the United States and among gay men before taking a position on the issue.

Circumcision is not common among Asian men, except those from Muslim countries and the Philippines, Mr. Bernas said, “and there might be cultural sensitivities around it.”