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A CUT IN TIME? CIRCUMCISION & HIV INFECTION
SARID, December 17, 2006
The excitement generated by new data showing that circumcision can halve the rate of HIV infection in heterosexual men unfortunately trumped the UN’s more cautious response.
Two major trials were carried out among 4,996 HIV-negative men between 18 and 24 in Rakai, Uganda and 2,784 in Kisumu, Kenya. The results, announced on December 12 by the US National Institutes of Health (NIH), revealed a 48 per cent reduction in infection in the Ugandan study and 53 per cent in the Kenyan one.
Both trials were terminated early when preliminary data showed that medically performed circumcision — the surgical removal of the foreskin of the penis — to be safe and effective at reducing HIV infection.
This outcome confirms a South African study published last year that showed a 60 per cent reduction in HIV infection among circumcised men. The new numbers support what doctors and campaigners have suspected and hoped for several years.
Scientists say circumcision may decrease the transmissibility of HIV because removing the foreskin eliminates the type of immune cell that particularly attracts the virus.
Though these results have major implications for the fight against the AIDS pandemic raging in Africa and Asia, five UN agencies - the World Health Organization (WHO), UN Population Fund, Joint UN Programme on HIV/AIDS (UNAIDS), UN Children's Fund and the World Bank - said circumcision should never replace other known, effective preventive methods and should be considered as part of a comprehensive prevention package.
"Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners," they emphasized in a joint statement on December 14.
The UN points out that circumcisions were performed by skilled medical professionals during the trials, with those treated receiving aftercare in case of complications. The agency fears the new report will trigger a booming trade in adult male circumcision among those who have no medical qualifications, with potentially harmful consequences.
There is also evidence contradictory to the new data. Some researchers have found either no effect or more HIV in circumcised males. Negative reports on the circumcision-HIV link are less likely to be published mainly because journals regard studies with positive results "more interesting". Other factors contributing to HIV infection were the presence of other sexually transmitted diseases, female circumcision, viral load, socio-economic-cultural differences, and most importantly, unsafe health care.
The positive outcomes for circumcision in preventing HIV infection shown by the most recent trials does not explain the paradox of the United States of America (USA), where the HIV incidence rate is 3.5 times higher than that of the closest advanced industrialized nation. The high incidence of adult male circumcision (approximately 77 percent) in the US did nothing to prevent the spread of this infection.
These conclusions suggest that attempts to control HIV by imposing universal circumcision are unlikely to be successful and that advocating better public health education regarding these issues would be more appropriate.
“Whether circumcision status plays a role in HIV risk or not, it is important to recognize that HIV can be prevented through several known very effective means, such as condom use, and limiting exposure to multiple partners. Rather than advocating circumcision, given the existing evidence, it would be appropriate to advocate better public health education, so that individuals can make appropriate decisions regarding their own sexual behavior.” CIRP
UNAIDS announced that a further trial to assess the impact of male circumcision on the risk of HIV transmission to female partners is underway in Africa with results expected in 2008.
India has 5.7 million people living with the AIDS virus, the highest number in the world, though a recent study says it may be less than half of that.
Sources: Agencies, Circumcision Information & Research Pages (http://www.cirp.org/), Science & Development Network (http://www.scidev.net).