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Lack of Circumcision Coverage in U.S. Medicaid Programs Could Increase HIV Transmission Risk, Researchers Say

February 24, 2009

Utah's Medicaid program does not cover routine circumcisions for infant boys, which could put men in the state at a higher risk of HIV and other sexually transmitted infections, according to a recent study by researchers at the University of California-Los Angeles, the Salt Lake Tribune reports. The policy also could widen health disparities along socioeconomic lines, the researchers said. Utah officials in 2003 cut circumcision funding from the state's Medicaid program "because of the elective, non-therapeutic nature of the procedure rather than medical necessity," according to a Medicaid Information Bulletin published that year.

For the UCLA study, published in the American Journal of Public Health, researchers found that circumcision rates among infant boys were an average of 24 percentage points lower at hospitals in Utah and 15 other states where Medicaid does not cover the procedure. According to the researchers, this finding could be significant because studies conducted in Africa found that circumcision could reduce a man's risk of contracting HIV through heterosexual sex. In addition, HIV and STI transmission rates can be higher among low-income populations, therefore Utah's circumcision policy could create greater health disparities among children enrolled in public health programs, the researchers said. Arleen Leibowitz, an economics professor at UCLA and author of the study, said circumcision could be seen as analogous to vaccination. Leibowitz asked, "If you could save your child the trauma of all kinds of infectious diseases later in life for $350 or $300, wouldn't you think that's worthwhile?"

According to the researchers, circumcision rates in the U.S. have declined since the 1980s. The American Academy of Pediatrics estimates that 1.2 million newborns are circumcised annually, which costs between $150 million and $270 million. Although AAP traditionally has taken a neutral stance on the procedure -- recommending that "parents should determine what is in the best interest of the child" -- the group now is reconsidering its position in response to recent research. In addition, AAP in 2007 created a circumcision committee of 10 physicians to analyze data on the procedure. Douglas Diekema, pediatrics professor at the University of Washington, said the academy is "not there yet in terms of making a firm recommendation, or even having formulated tentative ones." He said researchers would need to determine whether the African studies have implications for risk reduction in the U.S., where HIV transmission is more likely to occur among men who have sex with men and injection drug users. Diekema said research on whether circumcision reduces HIV transmission among these groups is ambiguous. Although studies have demonstrated "more medical support for circumcision than there was 10 years ago," he said he is unsure whether the findings are "strong enough to make a firm recommendation that all children should be circumcised." In addition, although AAP's position on circumcision might become more nuanced, it should not determine insurance coverage, Diekema said. "Just because the academy makes a recommendation doesn't mean it shouldn't be paid for," he said.

However, opponents of circumcision argue that the procedure has unproven benefits and is invasive, risky and more painful than vaccination. Angela Chaudhari, assistant professor in the Department of Obstetrics and Gynecology at the University of Utah School of Medicine, said she considers circumcision a traumatic procedure that is not supported by sufficient data. Chuck Norlin, pediatrics professor and chief of the Division of General Pediatrics at the University of Utah, said only about 25% of his patients decline to have their sons circumcised. He said the procedure can reduce a man's risk of contracting STIs and urinary tract infections; however, he added that safer sex practices can minimize these risks. "I try to present a balanced view of the data," Norlin said.

Online An abstract of the study is available online.

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