Africans turn to circumcision as a way to limit risk of AIDS

By Sharon LaFraniere The New York Times


For well over a decade, southern Africans have battled the spread of AIDS with everything from condoms and abstinence campaigns to doses of anti-retroviral drugs for pregnant women - and generally found themselves losing.

Now a growing number of clinicians and policy makers in the region are pointing to a simple and possibly potent weapon against new infections: circumcision for men.

Armed with new studies suggesting that male circumcision can reduce the chance of HIV infection in men, and perhaps in women, health workers in two southern African nations are pressing to make circumcisions broadly available to meet what they call a burgeoning demand for them.

The validity of the approach is still being tested. But in Lusaka, the capital of Zambia, surgeons at the University Teaching Hospital began offering circumcisions for roughly $3 about 18 months ago and are urging the government to expand the service across the country.

Dr. Kasonde Bowa, a urologist at the hospital, says about 400 patients a month request the procedure - eight times as many as the surgeons can accommodate.

"One reason we decided to set up this service was the increasing evidence in the research in relation to reducing HIV," the virus that causes AIDS, he said. "The evidence is very strong."

In Swaziland, the Health Ministry backed a workshop in January to train 60 doctors in circumcision, citing a surge in demand for the procedure. Studies indicate that circumcision may protect against HIV, the ministry said, adding that the service should be more widely available.

"I've lost a cousin and an aunt," Nokuthula Sibandze said as she waited nervously with her 16-year-old son and 10-year-old nephew at a Swazi clinic offering free circumcisions in February. "I am trying to do the best for my children, and I have heard that if a male is circumcised there is less risk of infection."

Other policy makers in the region are holding back, waiting for direction from the World Health Organization. Officials there say the evidence so far, while intriguing, is not definitive enough to call for a shift in strategy on HIV prevention.

The most striking studies suggest that men can lower their own risk of infection by as much as 75 percent, and that infected men can reduce the odds of transmitting the virus to their partners by about 30 percent, simply by undergoing circumcision. Research suggests that the cells on the underside of the foreskin are prime targets for the virus and that tears and abrasions in the foreskin can invite the infection.

But World Health Organization experts say it would be premature to recommend circumcision until results come in from two randomized controlled trials involving nearly 8,000 people in Kenya and Uganda. Preliminary results could be released by late June.

Data from earlier studies is "excitingly tantalizing, and the potential effectiveness looks pretty good," said Kevin O'Reilly, who is in charge of HIV prevention for the health organization. But it must be confirmed, he said, "before we officially declare that circumcision is a policy that should be adopted by countries."

"We don't want to steer countries wrong," he said.

So far, southern Africa's HIV infection rate, the world's highest, has resisted a battery of efforts to lower it. Only three countries in sub-Saharan Africa - Kenya, Uganda and Zimbabwe - have shown declines in the prevalence of the virus among adults, according to Unaids, the United Nations agency devoted to curbing the epidemic.

Of the nearly five million people worldwide who became infected last year, 3.2 million live in sub-Saharan Africa, the agency said.

Daniel Halperin, an epidemiologist and HIV specialist in Africa for the U.S. Agency for International Development, argues that low rates of circumcision and high rates of multiple, concurrent sexual partners are the main reasons that the AIDS epidemic has raged in southern Africa but left western Africa mostly unscathed.

"Lack of circumcision and concurrent partnerships appears to be the lethal cocktail," he said in a speech last week to HIV clinicians in Johannesburg. According to a study Halperin published in 1999, seven southern African countries, where fewer than one in five men were circumcised, had HIV prevalence rates in adults of 14 percent to 26 percent in 1998.

In nine western African countries, where more than four in five men were circumcised, HIV prevalence rates were below 5 percent.

Researchers have suspected since the 1980s that such patterns are no coincidence, and while the topic has long been controversial, many of them say the bulk of studies suggest that circumcision has at least some protective effect.

Dr. Diana Dickinson, who has battled HIV for years from her private health clinic in Gaborone, Botswana, is one of many southern African clinicians in a quandary over how to react to such studies. On the one hand, she said, she wants her patients to be protected as much as possible. On the other, she worries that if circumcision is oversold, circumcised men may think they are free to engage in risky sex.

"I really worry about mixed messages," she said.

World Health Organization officials warn that even if studies now under way confirm the benefits of circumcision, it must be viewed as part of a much broader prevention strategy to promote testing, condom use, reduction in the number of sexual partners and abstinence.

"There never has been a magic bullet," O'Reilly of the UN health agency said, "and there never will be."