Cutting the risk -- at last: Researchers have known for
almost two decades that circumcised men face lower HIV-infection
rates than uncircumcised ones. Why has it taken so long for anyone
to act?
The Ottawa Citizen
Sunday, August 13, 2006
Page: C9
Section: Special Section
Byline: Alex Hutchinson
Source: The Ottawa Citizen
Series: Aids in Africa

As countries across southern Africa prepare for an expected
surge in demand for adult male circumcision -- the result of reports
that the procedure may dramatically lower the risk of HIV infection
-- several questions arise: How effective is it? Can mass
circumcision be implemented safely? Will traditionally
non-circumcising tribes accept the practice?

For some researchers, however, the real question is simpler and
more troubling: Why has it taken almost 20 years for such a simple
intervention to gain acceptance?

"The initial clinical observations were made back in the late
1980s," says Dr. Stephen Moses, a professor at the University of
Manitoba who was working with a clinic for sexually transmitted
disease in Kenya at the time. Among men who visited the clinic, Dr.
Moses noticed, HIV-infection rates were much higher among
uncircumcised men than circumcised ones.

Since then, numerous studies have shown that countries -- or even
specific tribes within countries -- with high circumcision rates
have fared better in the battle against AIDS than comparable groups
where circumcision is less common. The inner side of the foreskin,
it turns out, lacks a protective layer of keratin and has a high
density of receptor cells through which HIV can enter the body.

But critics at the time pointed out that comparing different
populations doesn't prove that circumcision, rather than other
cultural differences, is what reduces HIV transmission.

It wasn't until last year that results from a randomized clinical
trial became available: 3,274 uncircumcised men in South Africa's
Gauteng Province were enlisted in 2003, and half of them were
circumcised. The trial was halted by an ethics board last year,
after just 17 months: the results were so clear, with a 60-per-cent
reduction in HIV infection among the circumcised group, that it was
deemed unethical to deny circumcision to the control group. Based on
those results, a study published last month estimated that a mass
circumcision program could prevent two million new infections and
300,000 deaths over the next 10 years in Africa.

Still, before taking any policy decision, the World Health
Organization is waiting for the results of two further clinical
trials, one in Uganda and another, co-led by Dr. Moses, in Kenya.
Those studies' reports are expected next year.

"A lot of people feel that the evidence really has to be
incontrovertible or indisputable before circumcision can be
recommended, so the bar has been raised quite high," Dr. Moses says.

"It's probably higher than I would like it to be raised. On the
other hand, you are dealing with a surgical procedure, something
that's irreversible."

Given the evidence in favour of circumcision and the lack of
effective alternatives, however, some researchers have questioned
why it wasn't pursued earlier. In 1999, Daniel Halperin of the
University of California, Berkeley, and Robert Bailey of the
University of Illinois published a paper in the medical journal The
Lancet titled "Male circumcision and HIV infection: 10 years and
counting." In it, they warned that "by avoiding this issue
altogether, medical professionals and public-health authorities may
inadvertently be harming the very individuals whom they are trying
to help."

The reasons for this hesitance may be related to the cultural
baggage that accompanies circumcision, says Ann Swidler, a
sociologist at the University of California, Berkeley.

As a member of the Canadian Institute for Advanced Research,
Swidler has been studying why it has taken so long for male
circumcision to be taken seriously as a preventive measure against
AIDS.

"The idea of a bunch of mostly white North Americans and Europeans
suddenly telling Africans, 'We want you all to circumcise' just
seems like right back to the old missionary, cultural imperialist
stance," she says.

This vague sense of unease is compounded by the nature of the
procedure -- "Men cross their legs and make jokes and dismiss the
whole thing," Swidler says -- and by the acrimonious debate in the
1990s that led the American Academy of Pediatrics and the Canada
Paediatric Society to stop recommending routine circumcision of
newborns.

The benefits are statistical -- 60-per-cent risk reduction --
rather than absolute, which makes results less immediately obvious.

"You don't come up to the man you circumcised five years ago and
say, 'You're HIV-negative! I saved your life!'" Swidler says.

Some critics have questioned whether mass circumcision would be
practical in tribes unused to the practice. But a series of
"acceptability studies" in countries across the continent has shown
a remarkable openness to the idea -- an indication, perhaps, that
people recognize the overriding importance of the fight against
AIDS.

"There really aren't these absolute cultural taboos against it,"
says Dr. Moses, who hasn't had any trouble recruiting men from the
Luo tribe in Kenya -- a traditionally non-circumcising group -- for
his study. And models developed by Dr. Moses's group show that even
if only 50 per cent of men in a population circumcise, it will have
a strong effect on preventing HIV.

Another concern noted by the WHO is that "men may wrongly believe
that once circumcised, they are fully protected against HIV, and
thus fail to use condoms."

This is true, Dr. Moses says, "but it would be true of any
HIV-prevention measure, even a vaccine." As a result, it will be
crucial to provide adequate counselling and followup along with the
operation.

In addition, the South African study already took that risk into
account: the 60 per cent reduction in HIV infections occurred
despite the fact that the circumcised men did in fact engage in more
high-risk behaviour, Swidler points out.

Even if the benefits of circumcision are accepted, the practical
difficulties remain. Any surgery, however minor, carries the risk of
complications -- especially if it's not performed under ideal
conditions.

"There are lots of horror stories of botched circumcisions, in
Africa and elsewhere, mostly ones that have been performed by
untrained or unqualified practitioners who are just trying to make
some money," Dr. Moses acknowledges.

While other HIV measures have benefited from existing
infrastructures -- family planning clinics were distributing condoms
throughout Africa long before AIDS, and drugs are backed by powerful
pharmaceutical companies -- the means of circumcising millions of
men will have to be created nearly from scratch.

In Swaziland, which at 33.4 per cent has the highest incidence of
HIV infection in the world, men aren't waiting on the niceties of
medical certainty.

The first Sunday in July was Circumcision Sunday at the Mbabane
Government Hospital, the latest in a series of efforts this year by
the Swazi government to respond to the demand for the procedure.
Drawn by newspaper ads targeting men between 20 and 30 years old,
hopeful patients started lining up at 5:30 in the morning.

Working in two operating theatres from 8 a.m. to 6 p.m., a team of
five doctors and three nurses managed to operate on 30 men, with at
least that many turned away. The marathon effort made only a small
dent in the hospital's waiting list, which already stretches to
December -- but it had the important benefit of training two more
doctors in the once-arcane art.

Men in Swaziland are not traditionally circumcised, so a program of
mass circumcision would require an estimated 40,000 circumcisions
per year for the next five years, says Dr. Adam Groeneveld, who was
hired by the Swazi government nine months ago to be the country's
first resident urologist.

"Forty-thousand is a staggering number, but that's the way it is,"
he says. "We must find ways and means to achieve it."