Circumcised men have a significantly lower rate of HIV infection than uncircumcised men, according to recent studies conducted in Africa and India that have "given new impetus" to some HIV/AIDS experts who consider the procedure a possible prevention method, the Boston Globe
reports (Donnelly, Boston Globe
, 11/16). The association between circumcision and a decreased risk of contracting HIV previously has been suggested, as many scientists say that circumcision can provide protection from HIV for heterosexual men because the inner surface of the foreskin -- which is removed during circumcision -- has a large concentration of a type of white blood cell that HIV might use to enter the body (Kaiser Daily HIV/AIDS Report
, 9/7). New data from USAID
also suggests that the inner surface of the foreskin absorbs HIV nine times as effectively as cervical tissue.
According to an unpublished study conducted in Kenya by the Demographic and Health Surveys, HIV prevalence among uncircumcised men is 11 times the rate among circumcised men. Other studies have indicated that areas of Zambia and Ethiopia with higher rates of circumcision have lower HIV prevalence (Boston Globe, 11/16). The results of a recently published study also showed that uncircumcised men attending a clinic in India were eight times as likely to be HIV-positive as circumcised men who attended the same clinic (Kaiser Daily HIV/AIDS Report, 9/7). In the United States, previous studies have indicated that high rates of circumcision have a "protective benefit" against HIV infection among heterosexuals, the Globe reports.
Leaders in Swaziland and Zambia have said that while they require "more definitive" data linking circumcision to a decreased risk of HIV infection, the recent studies have "startled them," according to the Globe. "Watch this. There could be some breakthroughs coming out of this," Derek von Wissell, director of Swaziland's National Emergency Response Council on HIV/AIDS, said, adding, "If the evidence comes through, we could really look at this as a preventive measure. It's almost as effective as a vaccine. The effect would be massive." However, officials at the World Health Organization have said that ongoing clinical trials in Kenya, Uganda and South Africa need to be completed before circumcision is recommended as an HIV prevention method. The studies will be completed in one to three years, the Globe reports. "The numbers are striking, but we have to make sure that's really the effect from circumcision," Kevin O'Reilly, an HIV/AIDS treatment and prevention specialist at WHO, said, adding, "We don't know if the elevenfold increase we're seeing in Kenya is related to circumcision alone or differences in sex patterns, religious patterns and other things." He also "expressed concern" that some men might "abandon other safe-sex precautions" if they believe that circumcision prevents HIV infection, according to the Globe. "We have a long history in HIV/AIDS prevention learning time. ... There is no magic bullet," O'Reilly said.
Cultural, Religious Factors
Although researchers have "suspected" an association between circumcision and HIV prevention for about 15 years, many have not recommended the procedure because they believe that religious and cultural practices "might explain the link," according to the Globe. Most HIV/AIDS experts have attributed some countries' lower HIV prevalence rates to large Muslim populations, which normally practice "more conservative sexual behaviors" than Christian populations, the Globe reports. Even if circumcision is shown to decrease the risk of HIV infection, the "question is, what do you do with that information?" O'Reilly asked. "The preference for or against circumcision among different groups is a fairly strongly held conviction," he said, adding, "It has a lot to do with group identity. In tribal circumstances, it might be us versus them -- we circumcise and they don't." However, low HIV prevalence cannot be attributed to cultural and religious practices in all circumstances, according to the Globe. Almost 100% of boys in Madagascar are circumcised by puberty, and approximately 10% of the population is Muslim, 45% is Christian and 45% follow traditional beliefs. The country also has high rates of sexually transmitted diseases but relatively low HIV prevalence at 1.4%. "It's an intriguing question why HIV prevalence varies so dramatically across different parts of Africa as well as parts of Asia," Daniel Halperin, a USAID HIV prevention expert, said, adding, "The main, although not the only, factor explaining this appears to be male circumcision." Although USAID recently has begun funding a training session in Zambia for health care workers to perform voluntary circumcision, Halperin said that the agency will not recommend circumcision as a prevention method. '"It really needs to come from the Africans themselves," he said, adding, "They may be the ones to implement it on their own or ask for donor assistance. Maybe that's when things will change" (Boston Globe, 1/16).
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Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily HIV/AIDS Report, search the archives, or sign up for email delivery at www.kaisernetwork.org/dailyreports/hiv. The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, a free service of the Kaiser Family Foundation, by The Advisory Board Company. © 2004 by The Advisory Board Company and Kaiser Family Foundation. All rights reserved.