Scientists have suspected, but there is now enough evidence to prove, that circumcision reduces a man’s chances of contracting the HIV virus through heterosexual contact by a wapping 50 per cent. The findings, from two large studies conducted recently, offers some real hope that the deadly virus’s relentless attack on sub-Saharan Africa can be slowed.
“It does have the potential to prevent many tens of thousands, many hundreds of thousands and perhaps millions of infections over coming years, ” said Dr. Kevin De Cock, director of the World Health Organization’s department of HIV-AIDS, on Wednesday after announcing the findings.
While these trials only looked at infection rates for men, the hope is that fewer infected men would lead to lower HIV rates among women as well. A study currently being conducted, funded by the Bill and Melinda Gates Foundation, is expected to shed some light on that question in the fall of 2008 when the results are revealed.
The two clinical trials, in Kenya and Uganda, were halted prematurely by their primary supporter, the U. S. National Institute of Allergy and Infectious Disease, when a review showed enough conclusive proof that circumcision works to lower the risk of infection.
“While the HIV-AIDS research community will continue to strive for a prevention technique that safely protects everyone all of the time, we are pleased to find a strategy that has the potential to significantly reduce new HIV infections in sub-Saharan Africa, ” said the institute’s director Dr. Anthony Fauci. The Kenyan study found a 53 per cent reduction among circumcised men aged 18 to 24. The Ugandan trial revealed a 48 per cent reduction for circumcised men aged 15 to 49.
“There’s no real doubt anymore about the magnitude of the effect of male circumcision in reducing risks for HIV acquisition, ” University of Manitoba’s Dr. Stephen Moses said in an interview.
Moses was a joint-investigator in the Kenyan trial, which was partially funded by the Canadian Institute of Health Research.
These reports confirm an earlier South African study showing a 60 per cent reduction in new HIV cases in circumcised men when compared to uncircumcised. Additionally, they support the observations many in Africa have made for years, that infection rates are significantly lower among circumcised men.
Dr. Frank Plummer, director of Canada’s National Microbiology Laboratory in Winnipeg, and co-author of the first scientific paper in the New England Journal of Medicine in 1986, says these recent trials are a definite step in the right direction.
“I think this proves this can be a major strategy for HIV reduction, ” he said from Winnipeg. As Fauci explained, it’s believed a foreskin left intact raises the risk of HIV infection because it is full of a cell-type called Langerhans, perfect targets for the virus. Additionally, the delicate mucosal tissue of the foreskin is subject to “micro tears, ” which would allow easy access for the infection. As promising as these findings are, there are potential pitfalls.
For one, health care systems in Africa are not all equipped to perform medically safe circumcisions on a mass scale.
“The cost of doing that is unlikely to be borne by these mostly poor countries themselves. So it would have to be subsidized from outside, by outside donors, ” Moses said.
But Dr. Alan Bernstein, the president of the Canadian funding agency, noted that if faced with the choice of funding treatment or prevention, prevention is the way to go.
“Treatment is extremely expensive — the antiretrovirals — and at the moment it’s only available to treat a very, very small proportion of individuals, particularly in Africa, ” Bernstein said. “The best approach would be prevention. ”
“If circumcision is as effective as the trial results suggest, and it’s available now and it certainly is cheap, then it offers, I think, a very powerful strategy for preventing the spread of this virus anywhere in the world, but particularly in Africa, ” he concluded.
Fauci, however, also noted that there is a concern that men will rely on circumcision as the number one prevention tool against HIV and will subsequently let their guards down in other areas of protection, such as the use of condoms.
“It is possible that the 48 to 53 per cent reduction in HIV transmission could be negated by small decreases in condom use, or the addition of more *** partners, ” he said.
Fauci also stated that male circumcision will have no protective impact on injecting drug users or people who have receptive anal intercourse.
De Cock also expressed concerns, citing possible cultural resistance to circumcision in some parts of the globe. Plummer addressed these concerns and said that observations have been made of some
African ethics groups, traditionally against circumcision, have come to the conclusion themselves that it is beneficial, “and in many incidences have started to get their kids circumcised just on their own. ”
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