Male circumcision cited for differing HIV rates among Africans

By Kurt Shillinger, Globe Correspondent, 11/05/99

JOHANNESBURG - Male circumcision reduces the risk of HIV-infection by at least 50 percent and may explain the vast discrepancies in the prevalence of the AIDS virus from one region to another across Africa, according to new assessments of nearly 40 individual studies in Africa over the past decade.

That should be good news on a continent where more than 2 million people die each year from AIDS. In Africa, the disease is largely spread by heterosexual contact and transmission from mother to child.

But African governments remain skeptical about such high-cost interventions as antiretroviral drugs. From country to country, between 20 percent and 80 percent of African men are not circumcised. The procedure represents one of the most promising, low-cost ways of reducing the swift rate by which the epidemic is moving across the continent.

International organizations and health workers have been reluctant to push the procedure partly out of cultural sensitivities, although that reticence may be unfounded. While those ethnic groups that do circumcise males often attach deep significance to the practice, specialists say, the same does not apply to those that do not circumcise their men.

''The evidence is not 100 percent consistent, but more and more studies are out, and they show that men who are not circumcised are at least two times more at risk of infection than men who are circumcised,'' said Stephen Moses of the University of Manitoba in Canada.

The inconsistent spread of HIV in Africa has confounded experts for years. In the early 1990s, more than 30 percent of pregnant women attending prenatal clinics in Uganda were HIV-positive, while the national infection rate in Senegal has never gone above 3 percent. HIV has moved much more swiftly through South Africa's Kwa-Zulu/Natal Province than most of the nation.

An important part of the answer to this riddle may be male circumcision. Last month, UNAIDS, the joint program of the United Nations addressing the AIDS epidemic worldwide, released a comparative study of four cities in Africa. Two cities, Cotonou, Benin, and Yaounde, Cameroon, had low HIV infection rates of 3 percent and 4 percent, respectively, among men aged 15-49. The other two sites, Kisumu, Kenya, and Ndola, Zambia, had infection rates of 20 percent and 23 percent, respectively, for the same population group.

In Cotonou and Yaounde, nearly all the men in the study reported being circumcised. Only 10 percent of the men in Ndola and less than 30 percent of the men in Kisumu, meanwhile, had undergone the procedure. Furthermore, the study found, ''HIV prevalence was below 8 percent in men circumcised before their sexual debut and 25 percent in uncircumcised men.''

''We have to move carefully, but the time has come to stop holding meetings,'' said UNAIDS epidemiologist Michel Carael. ''This information should be given to the countries.''

The first study on the increased risk of HIV infection among uncircumcised men was published a decade ago. Since then, 37 scientific inquires have been conducted.

Among those, according to Robert Bailey, an epidemiologist at the University of Illinois at Chicago who has just completed a comparative analysis of existing studies, 27 papers from 8 countries found a significant link between HIV infection and lack of male circumcision. Five others found a trend toward such a link. In a separate review of 28 papers, Richard Hayes of the London School of Hygiene and Tropical Medicine observed a consensus finding that circumcision reduces the risk of HIV by 50 percent.

Despite this mass of evidence, Bailey said, research supporting an association between HIV infection and male circumcision has been met with resistance or silence.

''No one wants to be first to come out with a statement in support of male circumcision,'' Bailey said. ''In the US and Europe there are big anticircumcision movements now, so people don't want to promote something in Africa that is discouraged here. But when you have a 35 percent HIV prevalence rate'' - as is the case in parts of southern Africa - ''you have a very different situation.''

The difficulty lies in promoting male circumcision as an intervention against HIV in Africa. Resources and training are needed to make circumcision safe and more widely available at clinics. Ways must be found to make the procedure appealing to cultures that do not practice it.

The cultural obstacle looms largest. But the issue may not be as sensitive among noncircumcising ethnic groups as might be thought. In a study yet to be published, Bailey and his Kenyan colleagues assessed the feasibility of making circumcision more widely available to Luos, the predominant ethnic group in Kisumu. Luos do not circumcise their men, and have traditionally viewed their status as a characteristic distinguishing them from other Kenyans.

In 32 focus groups divided evenly among women and men, rural and urban dwellers, the majority of participants in all but one group favored promoting the procedure.

Making male circumcision more widely available through local clinics raises two immediate concerns. One is cost. The average price for the procedure with a general practitioner in South Africa is about $30, according to an assessment by the Progressus Research and Development Consultancy in Johannesburg. Bailey estimates it is possible to lower the cost per circumcision to about $4.50. Health workers in Namibia recently estimated that most citizens of that country would not be able to afford HIV testing and counseling if it cost more than $1.60.

The other problem is the risk of creating a perception of false security. ''If you promote male circumcision as a mechanism to decrease the risk of HIV, men ... may act as if they have a natural condom,'' Bailey said. ''It cannot be a stand-alone intervention.''

This story ran on page A02 of the Boston Globe on 11/05/99.
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