For well over two decades, Sub-Saharan Africans have been fighting the insidious spread of HIV with everything from latex condoms and faith-based programs to an array of drug cocktails, yet the disease has continued unabated. Now, an unorthodox prevention method shows promise. Health care providers and HIV experts are putting their hopes in a mundane and low cost, but powerful weapon against new infections: male circumcision.
Three trials in Kenya, Uganda and South Africa have demonstrated that male circumcision reduces the rate of HIV infection in heterosexual relationships by 50 to 60 percent.
According to the National Institutes of Health (NIH), among the 2,784 men who participated in the study in Kenya, some for over three years, 62 percent contracted HIV while uncircumcised and only 27 percent have acquired HIV after circumcision. It is estimated from the study data that circumcision cuts a man’s risk of HIV infection by 64 percent.
Experts are now expressing optimism. Consequently, the United Nations Joint Programme on HIV/AIDS (UNAIDS) has recommended that the provision of safe circumcision services be increased in communities with high HIV prevalence.
But the role male circumcision may play in decreasing the risk of HIV acquisition in the U.S. may not be the slam-dunk it appears to be in Africa.
A report from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) on employing circumcision to prevent sexually transmitted diseases (STDs), including HIV, has mixed results in the U.S., which has the highest rate of infant circumcision in the West. The CDC say American youth have the highest rate of STDs in any industrialized nation, even though two-thirds of young males have been circumcised.
In Minnesota, the Department of Health 2007 surveillance data showed that African-born and African American males account for 32 percent of new HIV diagnoses among males, although they make up less than five percent of the state’s male population. But when asked about introducing circumcision to curb the spread of the virus among blacks here, Dr. Richard White, an international HIV prevention researcher, was reluctant.
“There is no doubt that male circumcision is an exciting and important HIV prevention strategy, and is being successfully scaled up in many populations. But male circumcision is also sometimes associated with strong cultural and religious beliefs so it should never be imposed and, if it is promoted, must be done in a culturally sensitive way, and with ethnic communities that find the practice acceptable,” White said.
“Minnesota does not have a universal male circumcision policy, said Peter Carr, director of HIV/AIDS Division at MDH. If we identified a trend in a particular community, our approach would be to implement targeted promotion efforts, and consult with providers that service the African and other minority communities to find culturally-relevant solutions.”
“The objective here is to see male circumcision as part of a comprehensive prevention toolkit which includes the correct and consistent use of condoms, abstinence and the reduction of sexual partners”, said Melanie Bacon, a nurse consultant at the National Institute of Allergy and Infectious Diseases (NIAID), a division of the NIH.
In an interview from his office in London, White warned: “Male circumcision is not a vaccine. Even if you are circumcised, if you continue to have unprotected sex with an infected person, you are still likely to get HIV. Circumcised men should be encouraged to use other prevention choices available to them, such as condoms.”
Bacon, who is the medical officer for two of the male circumcision trials in Africa funded by NIAID, said HIV targets cells that are very close to the inner surface of the foreskin. Medical practitioners say taking out the foreskin reduces the potential of being vulnerable to HIV infection. The foreskin may trap the virus close to the vulnerable target cells, providing a greater chance for access.
When AIDS first began to surface as a pandemic in Africa, researchers noted that men who were circumcised seemed to be less likely to be at risk of being infected. Groups that circumcised boys tended to have lower HIV rates than those that did not. Africa’s Muslim countries, where circumcision is the norm, had fewer AIDS cases than predominantly Christian countries. However, it was difficult to tell if circumcision was the cause or other factors were responsible.
The first definitive evidence came in 2005 from French AIDS researchers, when a “randomized-controlled” trial was carried out in South Africa. One group of males was randomly assigned to be circumcised, and one group left uncircumcised. Then researchers waited while the men went about their normal lives. The trial was so successful that it was halted prematurely – the men who had been circumcised were 60 percent less likely to acquire have gotten HIV than the men who were uncircumcised.
White said male circumcision should also benefit women as well. “If the prevalence of HIV infection falls over time in men because more men are circumcised, then women will benefit because their partners will be less likely to be infected with HIV.”
The picture is not so clear for men who have sex with men. White said that circumcision is unlikely to protect against HIV during receptive anal sex, and therefore men who have sex with men are likely to benefit less.
Currently, a campaign to promote large-scale male circumcision in the U.S. may be premature, but a nationwide dialogue among various agencies to explore the benefits of the practice as a potential HIV intervention strategy is already underway at the CDC.
In a related development, today marks the 20th World AIDS Day (WAD). Since its inception in 1998, by the World Health Organization, WAD has helped raise awareness about the HIV/AIDS pandemic globally, fostering support for AIDS research, prevention, treatment and care worldwide.
"World AIDS Day gives us an opportunity to remember the 25 million people lost to AIDS since the pandemic began three decades ago. More importantly, it gives an opportunity to honor those working on the frontlines of the epidemic who ensure that the 33 million people living with HIV/AIDS, and the countless number impacted by the disease worldwide, receive the services they need to live healthier lives," said Paul A. Kawata, executive director of the National Minority AIDS Council, in a statement released today.
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