Male Circumcision as the Answer to the African AIDS Epidemic?

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July 10, 2000 (Durban, South Africa) -- Male circumcision -- for generations a standard operation for the vast majority of men in America -- is now being considered as a way to combat AIDS in Africa, the epicenter of the worldwide epidemic.

About 25 million Africans have AIDS or are infected with the HIV virus, which causes AIDS, and many of those men with the disease live in areas of Africa where circumcision is not performed regularly.

"Circumcision was once very common in Botswana," said Daniel Halperin, PhD. But missionaries discredited the practice, he said, and now few men in Botswana are circumcised -- and more than 30% of the adult population in that country has AIDS or is infected with HIV. Halperin is assistant professor of medical anthropology and HIV/STD Prevention at the University of California, San Francisco's AIDS Research Insitute.

During a symposium at the 13th International AIDS Conference here, researchers examined new research on male circumcision in Africa. Halperin asked during the session: "If you had a one-time intervention that could reduce the risk of becoming infected by more than 50%, wouldn't it be worth using that as an intervention?"

Other researchers said that dozens of studies on male circumcision indicated that the procedure, in which the foreskin of the penis is surgically removed, might be capable of reducing the risk of contracting the disease by as much as 57%. Robert Bailey, PhD, of the University of Illinois School of Public Health in Chicago, found that interestingly, circumcision was generally well accepted by men as well as women -- even in areas of Africa where it wasn't practiced.

However, there also were reports that raised the question of whether circumcision provided a biological safety net against HIV infection or if the reduced rate of infection among circumcised men was due to their cultural and religious activities.

Halperin said it could be argued that male circumcision -- especially in Western Africa -- already had protected more than eight million men from contracting the disease. "And if men aren't infected then woman are not infected by those men either," he added.

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He said that circumcision is rare in the "AIDS Belt" of southern Africa, but common in West Africa, where AIDS rates are considerably lower.

"The evidence is strong enough, at least in my mind, to start trying to use circumcision as an intervention in AIDS," said Anne Buve, MD, of the Institute of Tropical Medicine in Antwerp, Belgium. "Male circumcision should be seriously considered as a preventive strategy."

In her study, Buve reported that in two cities in West Africa -- Yaoundé, Cameroon, and Cotonou, Benin -- the prevalence of HIV among sexually active adult men was less than 4.5%. Almost all men in those cities are circumcised. In contrast, circumcision was less common in Kisumu, Kenya, and in Ndola, Tanzania. Only about 10 to 25% of men are circumcised in those cities, but up to 25 % of the men have contracted HIV.

Eugene McCray, MD, tells WebMD, "The question of using circumcision as an intervention against HIV infection is very community-specific. You have to demonstrate that the operation will be accepted in the community before it can be attempted." McCray is the head of the CDC's global initiative to fight AIDS based in Atlanta.

Addressing that concern, Bailey said he and his colleagues conducted a series of interviews about circumcision with Kenyan men and women. More than 90% of those interviewed were uncircumcised.

Bailey said the focus group discussions determined that those interviewed were interested in circumcision because they believed it made it easier for men to maintain sexual cleanliness; because uncircumcised men were perceived as being more likely to contract a sexually transmitted disease; and uncircumcised men were believed to enjoy sex less and give women less sexual satisfaction.

"Given a choice, 60% of uncircumcised men would prefer to be circumcised, and 62% of women would prefer a circumcised partner," Bailey said. He was surprised at the results because few, if any, of the 110 women interviewed had ever had sex with an uncircumcised man.

McCray says, "The CDC is willing to support pilot projects to look at circumcision as a way to combat AIDS." He said such studies might be difficult to establish due to ethical concerns.

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However, McCray said communities exist in Africa, particularly in Zimbabwe, where cultural norms and rituals circumcision would make controlled studies possible and medically ethical.

At the symposium, however, Ronald Gray, PhD, professor of population and family health sciences at Johns Hopkins School of Hygiene and Public Health in Baltimore, suggested that the differences seen between circumcised and uncircumcised men might have more to do with cultural and religious practices than a biological advantage to circumcision.

Almost all the circumcised men studied in a southwestern Uganda district by Gray and colleagues were Muslim. He suggested that Muslim religious prohibitions against alcohol and risky sexual behavior and religious mandates requiring cleansing of the genitals before prayer might play a role for lower risks of HIV infection.

McCray said researchers also need to study whether having a circumcision with its widely believed lower risk for suffering infection might lead to riskier sexual behavior that could wipe out gains of having the procedure performed. Controlled studies, he said, could also tease out questions of whether earlier circumcision -- before puberty or first sexual experience -- can have an effect on protection against HIV infection.

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