Circumcision reduces HIV risk

Updated: 2007-02-23 08:45
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LONDON - Scientists say conclusive data shows there is no question circumcision reduces men's chances of catching HIV by up to 60 percent — a finding experts are hailing as a major breakthrough in the fight against AIDS. Now, the question is how to put that fact to work to combat AIDS across Africa.

The findings first were announced in December, when initial results from two major trials — in Kenya and Uganda — showed promising links between circumcision and HIV transmission. However, those trials were deemed so definitive that the tests were halted early.

The full data from the trials, carried out by the United States' National Institutes of Health, were published Friday in The Lancet.

"This is an extraordinary development," said Dr. Kevin de Cock, director of the World Health Organization's AIDS department. "Circumcision is the most potent intervention in HIV prevention that has been described."

Circumcision has long been suspected of reducing men's susceptibility to HIV infection because the cells in the foreskin of the penis are especially vulnerable to the virus.

A modeling study done last year projected that in the next decade, male circumcision could prevent 2 million AIDS infections and 300,000 deaths. Last year, 2.8 million people in sub-Saharan Africa became infected with HIV, and 2.1 million people died.

Experts say the breakthrough is a significant one on par with the identification of the virus and the use of lifesaving combination drug therapy.

The two US studies confirm similar results from an earlier trial in South Africa. Given the recent failure of a microbicide trial in Africa and India, and the ongoing difficulties in developing an AIDS vaccine, the potential of circumcision as a new weapon against HIV has become even more significant.

But they caution solid evidence is not justification for mass circumcisions.

African health systems are already overburdened. Circumcision requires much more planning than, for example, an immunization campaign.

"It's a tricky one, but it's something we're going to have to move on," said Dr. Catherine Hankins, a scientific adviser at UNAIDS.

"Male circumcision is such a sensitive religious and cultural issue that we need to be careful," she said.

Several African countries have already met with UN agencies to explore new strategies for increasing circumcision services. Swaziland, for instance, recently experimented with a series of "Circumcision Saturdays," where existing health care facilities, normally closed on weekends, were opened by local doctors to circumcise approximately 40 men a day on certain Saturdays.

Providing circumcisions across Africa would not be the first time surgical procedures have been adopted by public health campaigns.

"Cataract surgeries have been carried out extremely efficiently to prevent blindness worldwide," said Dr. Richard Hayes, an AIDS expert at the London School of Hygiene and Tropical Medicine. In some places, the cataract surgeries are performed by trained paramedics.

In recent years, the fight against the AIDS pandemic has focused on the provision of lifesaving drugs. The circumcision data gives prevention, rather than treatment, renewed emphasis.

"Treating people with antiretrovirals is completely unsustainable unless we can turn off the tap of infection," said Hayes.

While circumcision may offer new hope, it is not a cure for the epidemic.

"This is an additional tool, and it must not replace other interventions," said de Cock, who added that there will be no push for universal circumcision. "There is no one size fits all solution for AIDS."

Together with the United Nations AIDS agency, WHO is convening a meeting in Switzerland in early March to evaluate the circumcision data, and to decide on the next steps in slowing the AIDS pandemic.

In the Kenyan study, 1,391 circumcised men were compared to 1,393 who were not. And in Uganda, 2,474 circumcised men were compared to 2,522 men who were not. After tracking the men for two years, scientists found that circumcised men were 51 to 60 percent less likely to contract HIV than their uncircumcised counterparts. Since the studies were stopped, all the men have been offered the opportunity to be circumcised. And all the men were warned not to lapse into sexually risky behavior, such as abandoning condom use.

Scientists theorize that women would benefit indirectly from lower HIV prevalence in men, and a study is currently ongoing in Uganda to determine this.

In areas where HIV is spread primarily through heterosexual sex, such as sub-Saharan Africa, male circumcision could theoretically slash the infection rate in half.

It is unknown whether circumcision would be equally effective in concentrated AIDS epidemics, as in Asia and eastern Europe, where AIDS primarily strikes gay men and drug users.