Important note: Information in this article was accurate in 2006. The state of the art may have changed since the publication date.
Bay Area Reporter - December 21, 2006
Bob Roehr
The findings were no surprise. Researchers have known for many years that rates of HIV infection in Africa generally are lower among populations where most of the men are circumcised. However, because most of the men who are circumcised are Muslim, they did not know whether it was because of the circumcision or because of other social or cultural practices associated with that religion.
The trials enroll volunteers who want to be circumcised and randomize them to receive the procedure immediately or after two years. All participants are educated to safer sex practices and the use of condoms.
The first randomized controlled trial to test circumcision as a prevention intervention was carried out in South Africa and was stopped in 2005 when interim analysis found that it reduced female-to-male transmission of HIV by at least 60 percent. Those results were so dramatic that it would have been unethical to delay circumcision for those volunteers who had been randomized to receive it at the conclusion of the trial.
Additional trials on circumcision were under way in Uganda and Kenya and were allowed to continue with periodic monitoring of the results by a data safety monitoring board. In December, the board determined that there was a reduction in risk of acquiring HIV of 48 percent and 53 percent respectively and advised that the trials be terminated early.
"These results indicate that adult male circumcision could be an important addition to an HIV prevention strategy for men," said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at NIH. "However, it is not completely protective and must be seen as a powerful addition to, not a replacement for, other HIV prevention methods."
Fauci explained the biology of how circumcision provides protection by removing the foreskin, which contains cells that are particularly vulnerable to HIV. The procedure also changes the physical characteristics of the head of the penis from that of a mucosal membrane, which the virus can easily enter, to a harder "kernatinized" surface that is more difficult to penetrate.
The World Health Organization began to develop activities around male circumcision after results of the South African trial became known last year, said Kevin De Cock, director of WHO's department of HIV/AIDS. It will offer guidance and training to countries that choose to make circumcision more widely available.
"This has the potential to prevent many tens of thousands, perhaps even millions, of infections over the coming years," said De Cock.
However, he warned that circumcision must be carried out under proper medical conditions. There is risk of common infection with any medical procedure, and improperly sterilized tools carry the added risk of HIV infection.
Circumcision is common in the United States, reaching a peak of about 85 percent of males born in 1965 but declining thereafter. Part of the decline is because medical associations decided that the procedure carries no medical benefit and have dropped their support for it. As a result, some insurance providers no longer provide reimbursement.
The results of these trials are likely to lead to reconsideration of what, if any, role circumcisions should play in the prevention of HIV transmission within different societies and groups of persons who are at risk.
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