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Routine Male Circumcision Could Reduce a Man's HIV Transmission Risk by About 50 Percent, According to Studies Conducted in Kenya, Uganda

December 14, 2006

Routine male circumcision could reduce a man's HIV transmission risk through heterosexual sex by about 50%, according to data from two studies conducted in Kenya and Uganda released Wednesday by NIH, the New York Times reports (McNeil, New York Times, 12/14). Researchers monitored 4,996 men ages 15 to 49 living in Uganda and 2,784 men ages 18 to 24 living in Kenya -- half of whom were randomly assigned to be circumcised and the other half served as a control group -- to determine if circumcision reduced HIV transmission, the Los Angeles Times reports. According to the Times, all participants in both studies received counseling on HIV risk reduction and were advised to use condoms (Maugh, Los Angeles Times, 12/14). According to researchers, male circumcision eliminates the cells most vulnerable to HIV. In addition, a circumcised penis develops thicker skin that is resistant to HIV transmission, the Washington Post reports. Many African tribes used to perform ritual male circumcisions when adolescent boys became men, but the practice in recent years has declined, according to the Post. African countries with low male circumcision rates -- including Botswana, South Africa, Swaziland and Zimbabwe -- have the highest HIV prevalence, compared with West Africa, where male circumcision is a common practice and HIV prevalence is lower, the Post reports. The Uganda study found 43 cases of HIV among the uncircumcised men, compared with 22 among the circumcised men -- a 48% reduction of HIV transmission. The Kenya study found 47 cases of HIV among uncircumcised men, compared with 22 among the circumcised men -- a 53% reduction. According to the Post, the results of the studies were so overwhelming that NIH stopped the trials early and offered circumcision to all participants (Timberg, Washington Post, 12/14). The researchers also found no evidence that the circumcised men in the studies adopted higher-risk sexual behaviors, including sex with multiple partners and unprotected sex (Smith, Boston Globe, 12/13).

South Africa Study
The results of the Uganda and Kenya studies "echoed" similar results of a study conducted in South Africa in 2005, according to the Post (Washington Post, 12/14). The South Africa study was based on an analysis of findings from a previous study in the country that indicated that male circumcision significantly reduces HIV transmission. According to the South Africa study, which was published in the November 2005 issue of PLoS Medicine, male circumcision might reduce by about 60% the risk of men contracting HIV through sexual intercourse with women. The randomized, controlled clinical trial enrolled more than 3,000 HIV-negative, uncircumcised men ages 18 to 24 living in a South African township. Half of the men were randomly assigned to be circumcised and the other half served as a control group, remaining uncircumcised. For every 10 uncircumcised men who contracted HIV, about three circumcised men contracted the virus. Researchers believed the findings were so significant they deemed it was unethical to proceed without offering the option to all males in the study (Kaiser Daily HIV/AIDS Report, 7/12).

Implications, Reaction, Next Steps
The results of the Uganda and Kenya studies "appear to have tipped the balance," and UNAIDS and the World Health Organization on Tuesday announced that they will rapidly convene a panel of experts to ascertain how the findings can be implemented, according to the Los Angeles Times (Los Angeles Times, 12/14). Ambassador Mark Dybul, who serves as the U.S. global AIDS coordinator and administers the President's Emergency Plan for AIDS Relief, in a statement said PEPFAR "will support implementation of safe medical male circumcision for HIV/AIDS prevention" if world health agencies recommend it, the Times reports. In addition, Richard Feachem, executive director of the Global Fund To Fight AIDS, Tuberculosis and Malaria, said that if a country submitted plans to conduct sterile circumcisions, "I think it's very likely that our technical panel would approve it." The study results are "very exciting news," Daniel Halperin, an HIV specialist at the Harvard Center for Population and Development Studies, said, adding, "I have no doubt that as word of [the study] gets around, millions of African men will want to get circumcised, and that will save many lives." Kevin De Cock, director of the WHO's HIV/AIDS Department, said that male circumcision is "not a magic bullet, but a potentially important intervention." Sex education messages for young men must clarify that "this does not mean that you have an absolute protection," Anthony Fauci, director of NIH's National Institute of Allergy and Infectious Diseases, said. According to Fauci, male circumcision should be used along with other HIV-prevention methods, and the procedure does not reduce the spread of HIV through anal intercourse or injection drug use, two ways in which HIV is commonly spread in the U.S. (New York Times, 12/14). The Bill and Melinda Gates Foundation is funding a fourth study in Uganda on the link between male circumcision and HIV transmission that will examine whether women also benefit from male circumcision in terms of reduced risk of contracting HIV, the San Francisco Chronicle reports (Russell, San Francisco Chronicle, 12/14). A study conducted recently in Uganda estimated that circumcised men were 30% less likely to transmit HIV to their female partners (New York Times, 12/14).

Related Editorial
The results of the male circumcision studies might be "the most important development in AIDS research since the debut of antiretroviral drugs," and groups such as UNAIDS and WHO should "move as quickly as possible" to determine how best to promote the procedure in developing countries, a New York Times editorial says. Donors also should "work urgently to provide new financing to help high-risk countries train community workers to do safe circumcision," the editorial adds. According to the editorial, HIV prevention efforts until now have "largely failed" because they "requir[e] people to resolve every day either not to have sex or to use condoms"; however, circumcision is a "one-time procedure" that is "familiar and widely accepted" worldwide. The editorial notes that any campaign to promote circumcision must be "coupled with warnings" that the procedure offers "only partial protection against HIV and should not become a license for risky sex." For years, the "holy grail of AIDS prevention has been a vaccine," but with the release of the study, "we know [a vaccine's] near equivalent exists," the editorial says, concluding, "International donors and governments should join together to spread the good news about circumcision and make the procedure available everywhere" (New York Times, 12/14).

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