By David Brown
Washington Post Staff Writer
Wednesday, August 16, 2006; A03
TORONTO, Aug. 15 -- Circumcision, which lowers a man's risk of becoming infected with HIV, may soon join the growing arsenal of weapons against the AIDS epidemic. But to do so will require overcoming a unique set of obstacles, hazards, costs and enemies.
Wider use of the procedure would require convincing cultures that do not practice circumcision of its benefits at the same time that individual men would be advised not to count on it to protect them. It would require a massive training program for doctors and nurses, as well as for traditional healers who perform most circumcisions in most developing countries. It would also require drawing a clear distinction between that procedure and the misleadingly named "female circumcision," a form of ritual mutilation with no medical benefit.
Delegates to the 16th International AIDS Conference debated some of those issues on Tuesday, aware they will not have to confront this delicate matter until at least two more studies are completed.
AIDS researchers noticed as long ago as 1989 that tribes and communities practicing circumcision in Africa had lower rates of AIDS than non-circumcising ones, even when the two lived in the same area and intermingled. A randomized controlled trial in South Africa was stopped early, and its findings released last summer, when it found a 60 percent lower risk of HIV infection in the men who had undergone the procedure.
Two more randomized studies of circumcision are underway in Kenya and Uganda, with results expected in 2007 and 2008. Although many people here consider the evidence of circumcision's benefit already overwhelming, the big voices of public health advice on AIDS are keeping silent until those experiments are completed.
"Our position is that the evidence to date is compelling and persuasive, but it's generally unwise to base major policy decisions on the basis of one trial," said Kevin De Cock, head of the World Health Organization's AIDS office. "I think some guidance will be issued if the other two trials are protective." UNAIDS, the United Nations' AIDS program, has taken a similar stand.
Some AIDS activists, however, are happy for the delay. They foresee serious practical problems and decry what they view as naive enthusiasm for a procedure that has historically been a religious ritual and is freighted with issues of sexuality and self-image.
"I think it's scientists looking for a magic bullet," said Annabel Kanabus, the 58-year-old director of the English AIDS charity Avert, which runs a Web site offering AIDS information and has several village-based care programs in South Africa.
"It's not like you're just giving someone an injection. This will require an operation, and there's already a huge lack of health-care workers in Africa," she said. "You can't just say, 'Oh, never mind the traditional healers,' because they will be the cheapest. But HIV can actually be transmitted by traditional healers. It doesn't seem very well-thought-out."
Worldwide, circumcision is mostly practiced by Jews, Muslims, Americans of all religions, South Koreans, Filipinos, some African tribes and some peoples of the South Pacific. It appears to protect against HIV infection in several ways.
Circumcision removes skin rich in Langerhans cells, which are particular targets of the AIDS virus. The procedure promotes a drying and thickening of the skin of the end of the penis, and may also protect somewhat against genital ulcers.
A major issue involving circumcision as a public health tool is whether men who choose it will be less apt to take other precautions, such as using condoms or forgoing casual sex.
Data presented Tuesday suggest that this "risk compensation" is not taking place, at least over the short term.
The randomized study of about 2,800 men in Kenya, which is still underway, found that at the outset 20 percent of the men reported always using condoms. That has now increased to 35 percent. The proportion of men who reported paying for sex has fallen from 18 percent to 9 percent.
"Our behavioral counseling seems to have had some effect," one of the study leaders, Robert C. Bailey of the University of Illinois at Chicago, told the conference.
Another study from Kenya followed what happened to men who chose the procedure and compared them to men who did not. The circumcised men were no more likely to have liaisons outside marriage, to have multiple partners, or not to use a condom.
Two researchers reported on mathematical models that predicted the possible effects of greater circumcision in South Africa, a country with a rising rate of HIV infection.
One predicted that if current trends continue, 17 percent of men in the city of Soweto will be HIV-positive in 20 years, up from 12 percent now. That could be held to 13 percent if 20 percent of uncircumcised men underwent the procedure each year over the next five years. The other model predicted that widespread adoption of circumcision in South Africa could save the country's health system $2,411 in treatment costs for every HIV infection averted.
Whether male circumcision protects women from being infected by men is uncertain. Previous research suggested some benefit to women, but a study described Tuesday found that there was little or no protection in a group of Ugandan and Zimbabwean women when their regular partners were circumcised.
The studies presented Tuesday did not include any investigations of cultural beliefs about circumcision, although several studies did report that circumcised men and their female partners had no complaints after the procedure. The lack of cultural studies was severely criticized by several members of the audience.
One activist said, to scattered applause, that circumcision in adulthood could cause psychological trauma. An Australian anthropologist said the disregard of cultural issues "completely fetishizes this act."