The scientific case for circumcising men as a way to prevent HIV from spreading in Africa is compelling. The realizaton of this evidence is as dramatic as the discovery of HIV and AIDS in the first place.
However, now the science is done, the challenge is how to make it safe, affordable and accessible in countries already burdened with a range of healthcare programmes for tackling the HIV epidemic.
Three studies, two conducted in Kenya and Uganda recently, and an earlier one in South Africa, show that male circumcision reduces the risk of HIV infection in males by 50 to 60 per cent.
The two more recent trials are written up in today’s issue of The Lancet.
The Kenyan and Ugandan trials replicate the landmark findings of the South African study, known as the South African Orange Farm study, which was the first randomised controlled trial to show a greater than 50 per cent protective benefit of male circumcision.
The Kenyan trial involved 2,784 young men from Kisimu who were randomly assigned to circumcision (1,391) and non-circumcision groups (1,393). The researchers followed their progress for 2 years and then compared the results from the two groups.
Their analysis suggested there was a 53 to 60 per cent reduction in risk of getting HIV in those men who were circumcised compared with those who were not. The second improved figure was obtained when they took out the men who did not complete the trial and the men who were already HIV positive at the start.
The Ugandan trial involved 4,996 uncircumcised, HIV-negative men aged from 15 to 49 years living in Rakai, who were also randomly assigned to circumcision (2,474) and non-circumcision (2,522) groups. The risk reduction results were very similar to the Kenyan trial.
Both trials, which were sponsored by the US National Institutes of Health, were stopped early because the results were so definitive.
Scientists suggest that circumcision is effective in preventing the spread of HIV because cells inside the foreskin are an ideal breeding ground for the virus and allow it be passed on in sexual intercourse.
In an accompanying viewpoint article in the same edition of the journal, academics and policy advisers from the AIDS Policy Development Center at the David Geffen School of Medicine, University of California, the HIV Center for Clinical and Behavioral Studies at Columbia University, New York, and the Sonke Gender Justice, Cape Town, discuss the challenges and opportunities that this research presents for those who have the power to take this further.
In South Africa, where it is estimated that nearly 20 per cent of adults are infected with HIV, they say scientists expect that male circumcision could have a similar protective effective as that seen by intensive immunisation programmes.
They mention a modelling study that took the South African study results and projected that large scale implementation of male circumcision has the potential to prevent 2 million HIV infections and 300,000 deaths in the next ten years.
They say the scientific case for going ahead with male circumcision as a life-saving strategy for tackling HIV has been made. But it will only work if all the agencies involved, both government and non-government, multilateral and bilateral, work together to develop and promote a safe and affordable way to circumcise men in populations carrying the heaviest burden of HIV infection.
They list 13 areas that will present the main challenges and opportunities to those who now have to take the next step and make this happen. Their underlying principle is that all stakeholders should be engaged in the discussion of how to go forward, including those who disagree with male circumcision. Collaboration rather than confrontation and entrenchment is key to effective and speedy implementation.
They also stress the importance of viewing male circumcision as a complementary rather than a competing strategy for tackling HIV epidemics.
“Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial.”
Robert C Bailey, Stephen Moses, Corette B Parker, Kawango Agot, Ian Maclean, Prof John N Krieger, Carolyn FM Williams, Prof Richard T Campbell, and Jeckoniah O Ndinya-Achola.
The Lancet 2007; 369:643-656
DOI:10.1016/S0140-6736(07)60312-2
“Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial.”
Ronald H Gray, Godfrey Kigozi, David Serwadda, Frederick Makumbi, Stephen Watya, Fred Nalugoda, Noah Kiwanuka, Lawrence H Moulton, Mohammad A Chaudhary, Michael Z Chen, Nelson K Sewankambo, Fred Wabwire-Mangen, Melanie C Bacon, Carolyn FM Williams, Pius Opendi, Steven J Reynolds, Oliver Laeyendecker, Thomas C Quinn and Maria J Wawer.
The Lancet 2007; 369:657-666
DOI:10.1016/S0140-6736(07)60313-4
Written by: Catharine Paddock
Writer: Medical News Today