Circumcision could have a huge positive impact on the HIV pandemic in developing countries

A simple, outpatient procedure could potentially save millions of men and their partners from becoming infected with HIV, but health professionals have been reluctant to provide the needed information and resources, say the authors of an editorial published in the Lancet.

The procedure is circumcision, a practice widely accepted in the United States, but less common in many other parts of the world. Despite numerous epidemiological studies showing an association between lack of male circumcision and HIV transmission, training and resources for the procedure are lacking in the countries hit hardest by the AIDS pandemic, the authors said.

Daniel Halperin, PhD, UCSF assistant adjunct professor of community health systems and medical anthropology, and Robert Bailey, PhD, MPH, professor of epidemiology in the School of Public Health and of anthropology at the University of Illinois at Chicago, are co-authors of the Lancet editorial.

"The evidence is so compelling now, it shouldn't be ignored," said Bailey. "We have limited tools against the AIDS epidemic. Circumcision could have a huge impact on the HIV pandemic in many developing countries."

Researchers have put the relative risk of heterosexual HIV infection, the primary way AIDS is spread throughout Africa and Asia, at two to eight times higher for uncircumcised men. The authors point to 32 studies from eight countries that found a significant association between lack of male circumcision and HIV infection. Recent findings from three additional countries reported similar results.

In addition, dramatic discrepancies in regional HIV infection rates can be partially explained by circumcision practices, say the authors. In most West African countries, for example, where male circumcision is a widespread practice, HIV prevalence levels are between one and five percent. In comparison, many of the predominately non-circumcising East and South African nations have infection rates approaching 25 percent. Similar patterns exist in South and Southeast Asia.

Halperin and Bailey estimate that in countries like Nigeria and Indonesia, where no more than a fifth of the men are uncircumcised, roughly 25 percent of HIV infections can be explained by a lack of circumcision. This number jumps to 55 percent for countries such as Zambia and Thailand, where 80 percent or more of men are uncircumcised.

The increased risk of infection is attributable to the foreskin of the penis, which provides a vulnerable portal of entry to HIV and other pathogens. The foreskin is susceptible to small scratches and tears during intercourse and contains a high density of Langerhans cells - primary target cells for HIV. An intact foreskin also exposes a man to other sexually transmitted diseases such as syphilis, herpes, and chancroid that are known cofactors for HIV infection.

Anecdotal evidence suggests that circumcision could lead to better protection against HIV through an increased use of condoms as well, says Halperin. Uncircumcised men seem more likely to find condoms uncomfortable and prone to breakage, although further research is needed to substantiate these claims.

"The number of infections probably caused by lack of male circumcision already reaches into the millions," says Halperin. "We would expect the international health community to at least consider some form of action, but male circumcision remains largely unexplored as a tool against AIDS."

Perhaps the biggest argument for addressing the feasibility of male circumcision is that a majority of men and women in the countries besieged by AIDS may support the practice, say the authors. In a survey of 216 adults in Western Kenya, Bailey found that 60 percent of men would prefer to be circumcised and 62 percent of women would prefer to have circumcised partners, but only about 10 percent of men actually have the procedure done.

Many health professionals have been hesitant to integrate circumcision with other HIV prevention strategies, say the authors, perhaps because it is embedded in a complex web of deeply held cultural values and religious beliefs.

"Health workers may be biased by their own traditions and religious beliefs," said Bailey. "The practice is currently discussed in the context of culture and religion, but it needs to be brought into the context of health and disease prevention."

Men who seek circumcision have difficulty gaining access to trained professionals operating in safe settings, say the authors. Private clinics that specialize in male circumcision, many of which are run by people with minimum or no medical training, are sprouting up in many countries including Tanzania, western Kenya, Rwanda, and Uganda. When done properly, adult circumcision is a simple, outpatient procedure that allows most men to return to work the next day. In unsafe and unclean conditions, however, excessive bleeding or infections can disable a man for weeks.

"We need to provide communities with balanced information, training, and the resources needed to offer safe, voluntary male circumcision," says Halperin. "Everyone has the right to access safe services and to make informed decisions."

A preliminary analysis by Halperin and Malcolm Potts, MD, PhD, Bixby Professor of Population and Family Planning at the UC Berkeley School of Public Health, estimates that the practice of male circumcision has so far prevented at least eight million HIV infections in the 15 African and Asian countries cited in the Lancet editorial review alone.

The authors believe that in addition to proper training in the procedure itself, clinicians need training on how to counsel men and women on the risks, benefits, and care associated with circumcision. They also caution that advertising circumcision as a way to prevent HIV transmission could be counterproductive if men who opt for the procedure believe it will fully protect them from AIDS and other sexually transmitted diseases.


UCSF News Service