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AAP reviews policy on circumcision
Current policy 'not where it should be'
A "flurry" of new studies suggesting that there is a link between sexually transmitted diseases and non-circumcision has led the American Association of Pediatrics (AAP) to undertake a new review of its policy on the procedure.
AAP President Jay Berkelhamer, MD, FAAP, told Medical Ethics Advisor that new evidence "has raised some concerns that the academy's current policy [on circumcision] is not positioned where it should be."
Drafted and adopted in 1999, then reviewed and reaffirmed in 2003 and 2005, the AAP's policy is to neither recommend nor discourage circumcision. The policy states:
"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child."1
Berkelhamer says the recent studies, including some studies in Africa that correlate non-circumcision with new cases of HIV, have prompted the AAP to revisit the policy about a year earlier than it would have.
"We generally review policies every three years, but because of the flurry of recent articles and heightened interest, we're going back and looking at the literature and publications — and there are hundreds of them, both proponents for and against — and reviewing both the body and quality of the evidence to determine if a change is needed," continues Berkelhamer.
The review process is expected to take about six months; at the time Medical Ethics Advisor was going to print in early May, the academy was about halfway through the review, Berkelhamer says.
"It won't change for a while, if at all, and in the meantime, families should continue to be well educated and well informed, and make their decision on circumcision based on what is best for their child," Berkelhamer says.
NIH studies show link to HIV
The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), announced in December 2006 that it was shutting down two clinical trials on adult male circumcision because an interim review of trial data revealed that medically performed circumcision significantly reduces a man's risk of acquiring HIV through heterosexual intercourse. The trial in Kisumu, Kenya, of 2,784 HIV-negative men, showed a 53% reduction of HIV acquisition in circumcised men relative to uncircumcised men,2 while a trial of 4,996 HIV-negative men in Rakai, Uganda, showed that HIV acquisition was reduced by 48% in circumcised men.3
Both trials involved adult, HIV-negative heterosexual male volunteers assigned at random to either intervention (circumcision performed by trained medical professionals in a clinic setting) or no intervention (no circumcision). All participants were extensively counseled in HIV prevention and risk-reduction techniques.
Both trials originally were designed to continue follow-up until mid-2007. However, at the regularly scheduled meeting of the NIAID study monitoring board in December, reviewers assessed the interim data and recommended the two studies be halted early due to the strength of the evidence and so that all study subjects who had been randomized into the non-circumcision group could be offered circumcision.
"Many studies have suggested that male circumcision plays a role in protecting against HIV acquisition," NIAID Director Anthony S. Fauci, MD, said in announcing the suspension of the trials. "We now have confirmation — from large, carefully controlled, randomized clinical trials — showing definitively that medically performed circumcision can significantly lower the risk of adult males contracting HIV through heterosexual intercourse. While the initial benefit will be fewer HIV infections in men, ultimately adult male circumcision could lead to fewer infections in women in those areas of the world where HIV is spread primarily through heterosexual intercourse."
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