1. 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

2. 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

4. African Clinical Trial Results- HIV Incidence StudyNumber 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)

5. WHO Map MC Globally

6. Global Estimates of HIV Prevalence

7. Association between MC Prevalence HIV Prevalence Country characteristicsHIV prevalence in countries w/ low MC (<20%) HIV prevalence in countries w/ high MC (>80%) Sub-Saharan African countries16.5%*3% Non sub-Saharan African countries: heterosexual-driven epidemic 0.76%*0.09% *P<.0001(Drain, 2006)

8. 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

9. 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

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

15. 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) AgeHIV Prevalence 15-2215% 23-2932% Median age 32 46%

16. 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

17. N=6174

19. 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)

20. 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)

21. Study Aims Examine 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)

22. 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 eligibility 1.Male 2.Black or Latino 3.> 18 years of age 4.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

23. 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

24. Results: Univariate Data

25. Circumcision Prevalence 74% 33% n=1079n= 957

26. 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

27. 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 more likely to Born in US Have a parent born in US Been in US for a longer time Borderline significant: Private health insurance

28. Univariate Results: Demographics Black MSM (n=1079)Latino MSM (n=957) Circumcised N (%) Uncircumcised N (%) PCircumcised N (%) Uncircumcised N (%) P Total794 (73.6)285 (26.4)317 (33.1)640 (66.9) Age, median43.741.1<0.01*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) 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 US747 (94.1)243 (85.3)<0.01*191 (60.3)231 (36.2)<0.01* Yrs in US, mean39.841.10.1223.818.4<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

29. 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

30. 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

31. Univariate Results: Substance Use (3 mos) Black MSM (n=1079)Latino MSM (n=957) Circumcised N (%) Uncircumcised N (%) PCircumcised N (%) Uncircumcised N (%) P Alcohol use522 (65.9)175 (61.6) 0.19 201 (63.4)435 (68.0) 0.16 Crystal meth use28 (3.5)7 (2.5) 0.38 51 (16.1)74 (11.6) 0.05 Cocaine use249 (31.4)103 (26.3) 0.14 46 (14.5)58 (9.1) 0.01 Crack use266 (33.6)102 (35.8) 0.50 23 (7.3)31 (4.9) 0.13 Marijuana use386 (48.7)113 (39.7) <0.01* 115 (36.3)209 (32.7) 0.27 Heroin use27 (3.4)12 (4.2) 0.53 11 (3.5)9 (1.4) 0.04 ‘Club’ drug + use28 (3.5)5 (1.8) 0.13 41 (12.9)76 (11.9) 0.64 Amyl nitrites use100 (12.6)18 (6.3) <0.01* 60 (18.9)120 (18.8) 0.96 + Includes ketamine, Ecstasy, GHB

32. Sexual Risk (3 mos), STD hx, HIV Status by Circumcision Status Circumcised black MSM more likely to 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

33. Sexual Risk (3 mos), STD hx, HIV Status by Circumcision Status Circumcised black MSM more likely to 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

34. Univariate Results: Sexual Risk (3 mos), STD, HIV Black MSM (n=1079)Latino MSM (n=957) Circumcised N (%) Uncircumcised N (%) PCircumcised 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 UAI296 (37.3)87 (30.5)0.04*103 (32.5)209 (32.7)0.95 Insertive UAI138 (17.4)52 (18.3)0.7443 (13.6)87 (13.6)0.99 STD Dx (ever)525 (66.1)177 (62.1)0.22131 (41.5)261 (40.9)0.87 HIV test (ever)727 (91.7)256 (89.8)0.34279 (88.0)539 (84.4)0.13 # HIV tests5.75.50.766.75.10.01 HIV test (past yr)342 (47.6)123 (49.2)0.67164 (59.0)255 (47.4)<0.01 HIV-positive425 (53.7)138 (48.8)0.16116 (36.6)232 (36.4)0.94

35. Results: Multivariable Analyses

36. Black MSM (n=1044) CovariatesAOR(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. Other3.67(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 Dx3.64(2.64, 5.02) Factors Associated with HIV-Positive Status (Full Sample)

37. Black MSM (n=1044)Latino MSM (n=923) CovariatesAOR(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. Other3.67(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 Dx3.64(2.64, 5.02)4.29(2.92, 6.30) Factors Associated with HIV-Positive Status (Full Sample)

38. Black MSM (n=1044)Latino MSM (n=923) CovariatesAOR(95 % CI)AOR(95%) 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. Other3.67(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 Dx3.64(2.64, 5.02)4.29(2.92, 6.30) Factors Associated with HIV-Positive Status (Full Sample)

39. Black MSM/W (n=170)Black MSM/Only (n=551) CovariatesAOR(95 % CI)AOR(95%) 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. Other5.97(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) Sexual position (top vs other)0.79(0.28, 2.24)0.54(0.30, 0.95) Previous STD Dx5.58(2.10, 14.83)3.93(2.49, 6.20) Factors Associated with HIV-Positive Status (MSM/W vs. MSM/only)

40. Black MSM/W (n=170)Black MSM/Only (n=551) CovariatesAOR(95 % CI)AOR(95%) 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. Other5.97(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) Sexual position (top vs other)0.79(0.28, 2.24)0.54(0.30, 0.95) Previous STD Dx5.58(2.10, 14.83)3.93(2.49, 6.20) Factors Associated with HIV-Positive Status (MSM/W vs. MSM/only)

41. Black MSM/W (n=170)Black MSM/Only (n=551) CovariatesAOR(95 % CI)AOR(95%) 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. Other5.97(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) Sexual position (top vs other)0.79(0.28, 2.24)0.54(0.30, 0.95) Previous STD Dx5.58(2.10, 14.83)3.93(2.49, 6.20) Factors Associated with HIV-Positive Status (MSM/W vs. MSM/only)

42. (n=925) CovariatesAOR(95 % CI) 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. Black0.79(0.57 Born in U.S.2.25(0.94, 5.42) Any recent UAI1.36(0.72, 2.56) Sexual position (top vs other)1.15(0.54, 2.45) Previous STD Dx1.47(0.82, 2.62) Factors Associated with New HIV Diagnoses Among Self-Reported HIV-Negative Men

43. (n=925) CovariatesAOR(95 % CI) 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. Black0.79(0.57 Born in U.S.2.25(0.94, 5.42) Any recent UAI1.36(0.72, 2.56) Sexual position (top vs other)1.15(0.54, 2.45) Previous STD Dx1.47(0.82, 2.62) Factors Associated with New HIV Diagnoses Among Self-Reported HIV-Negative Men

44. 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)

45. Discussion

46. 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

47. 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

48. 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

49. Association between MC Prevalence HIV Prevalence Country characteristicsHIV prevalence in countries w/ low MC (<20%) HIV prevalence in countries w/ high MC (>80%) Sub-Saharan African countries16.5%*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)

50. 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)

51. (Buchbinder, 2005)

52. 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

54. 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

55. Mistrust 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.DONALD G. McNEIL Jr.AIDSWorld Health Organization “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

56. 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*5042 HIV/AIDS drugs harm you more than help you 56*48*41 HIV does not cause AIDS54*4827 HIV is a man-made virus50*4135 (Hutchinson, 2007) *P<.05 versus White MSM

57. Circumcision willingness Gay Pride events in 7 U.S. cities 2006 (Begley, 2007)N=127

58. Guanira Willingness slide 10 (Guanira, 2007) N=2048

59. (Guanira, 2007)

60. 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

61. 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

62. 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)

63. 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

64. Additional information on ByH circumcision study Greg Millett, MPH GMillett@cdc.gov 404-639-1902 CDC circumcision workgroup information Peter Kilmarx, MD PKilmarx@cdc.gov 404-639-8998

65. Extra slides

66. Non-gay ID/ Disclosure Substance use Sexual Risk behavior HIV Noncontributors to Racial Disparities in HIV prevalence in MSM (Millett et al., 2006 & 2007)

67. STDs Unrecognized HIV infection HIV (Millett et al., 2006 & 2007) Contributors to Racial Disparities in HIV prevalence in MSM Sexual Networks

68. Non-gay ID/ Disclosure Substance use STDs Unrecognized HIV infection Sexual Risk behavior Sexual Networks Incarceration? Biology/ Genetics? HIV Hypotheses for Greater HIV Prevalence among Black MSM (Millett et al., 2006 & 2007) Circumcision? Healthcare Access? Sex w/ Known HIV+ partners? HIV meds adherence?