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In some countries, men are asking to be circumcised because they have
heard the procedure may reduce their risk of HIV infection. However, while
there is evidence to support their belief, promoting circumcision as a way
to prevent the spread of HIV may not be appropriate.
If health officials recommend circumcision to reduce HIV risks, some
men might incorrectly assume that circumcision offers excellent protection
against HIV. As a result, many of them may adopt risky sexual behaviors,
such as not using condoms, having multiple sexual partners, or having sex
with high-risk partners. The overall effect could increase the spread of
HIV.
Also, circumcision by unqualified individuals under unsanitary
conditions can lead to serious, long-term complications or even death. Men
who elect to undergo the surgical procedure to remove the foreskin of the
penis should have qualified medical personnel perform it under hygienic
conditions.
"Our current position is that the evidence for a protective effect
of male circumcision on HIV acquisition in high-risk settings is
reasonably convincing," says Dr. Timothy Farley of the World Health
Organization's Programme of Research, Development and Research Training in
Human Reproduction in Geneva. "But there is no evidence that
promoting circumcision among boys or men actually reduces the incidence of
HIV infection, and there is a genuine possibility that it may undermine
other HIV-preventive strategies."
Dr. Michel Caraël, HIV prevention team leader in Geneva with the Joint
United Nations Programme on HIV/AIDS, agrees. "While there is a need
for the international research community to be actively involved in
further investigating the association between circumcision and HIV
prevention," he says, "it is too early to make clear policy
recommendations about this matter."
Men in some African countries seem to be seeking circumcision to reduce
HIV risks. In Nigeria, "there is an increased demand for male
circumcision now as an HIV-prevention strategy," confirms Dr. Ernest
Ekong, a public health physician at Military Base Hospital in Yaba Lagos,
Nigeria. In South Africa, many men are going to local clinics or general
practitioners to be circumcised for health reasons, with their wives often
making the appointment for them.1
Globally, about 20 percent of men are circumcised for religious,
cultural, medical or other reasons.2
Throughout the developing world, only a small percentage of male
circumcisions are performed under sterile conditions by qualified medical
personnel. Morbidity rates from circumcision are high. In a prospective
study conducted in Nigeria and Kenya between 1981 and 1998, 11 percent of
249 circumcisions performed under sterile conditions by one qualified
surgeon resulted in complications, although no complication led to death
or amputation. In the same study, one of 50 patients treated for
complications following circumcision performed by other surgeons (mostly
medically untrained traditional circumcisers) died from infection. Another
seven of the 50 suffered complete or partial loss of the penis. Also,
Ugandan Muslims reported in a survey that the same unsterilized cutting
device was used for multiple male circumcision procedures, a major risk
factor for HIV transmission.3
Even health professionals may not be prepared to perform safe
circumcisions. An assessment of acceptability of male circumcision among
Luo men and women in Nyanza province, Kenya, and of the feasibility of
offering the procedure in hygienic conditions there showed that only one
of eight health centers had sufficient instruments and supplies to perform
a circumcision safely.4
Conflicting evidence
Some scientists argue that promoting circumcision for health reasons is
not only warranted, but overdue. Some 30 studies show that circumcised men
are less likely than uncircumcised men to become infected with HIV.5
One recent prospective study suggesting that circumcision protects against
HIV infection was conducted in Rakai, Uganda. For 187 couples where women
were HIV-positive and their male partners were not, there were no new
infections among 50 circumcised men over 30 months, but 40 new infections
occurred among 137 uncircumcised men.6 Another recent study
involving some 8,000 men and women found that in Yaoundé, Cameroon, and
Cotonou, Benin -- where HIV prevalence rates among sexually active men are
low at about 4 percent -- nearly all men are circumcised. In Kisumu,
Kenya, and Ndola, Zambia -- where HIV prevalence rates are very high at 22
percent and 26 percent respectively -- circumcision is far less common (27
percent and 8 percent, respectively).7 Another recent
prospective study of the effect of circumcision on the acquisition of HIV
and other sexually transmitted infections, conducted among some 750 Kenyan
truck drivers, found HIV infection rates to be four times greater among
uncircumcised men than circumcised men.8
Some observers also point out that variation in circumcision practices
may help explain why HIV rates in countries or regions differ. In areas
where circumcision is common, HIV infection rates tend to be low. In North
America, where about 80 percent of men are circumcised, only a fraction of
1 percent of the population is HIV-positive. In western Africa, another
area where circumcision is widely practiced, rates of HIV infection among
those ages 15 to 49 are just 1 percent to 5 percent. But in eastern and
southern Africa, where typically fewer than 20 percent of men are
circumcised, rates of HIV infection range from 15 percent to 25 percent.9
The spread of HIV in Thailand and Cambodia also has been largely
attributed to low male circumcision rates.10
However, other scientists point out that at least five studies have
found no protective role for circumcision and one has found that
circumcision increases risk of HIV infection. There are discrepancies.
Why, for example, are HIV rates lower in Europe, where men typically are
uncircumcised? Why are they high in some places, like Ethiopia, where men
are usually circumcised?
"It would have been a happy coincidence if circumcision, which is
widely practiced in this country, had been protective against HIV
infection," says Dr. Asheber Gaym of Addis Ababa University,
Ethiopia. "Unfortunately, despite the nearly universal application of
this procedure, the HIV pandemic is rapidly spreading in our
country."
Some of these incongruities might be explained by behavior. Some
circumcised men, for example, may have hygienic, cultural or religious
practices that reduce their risk of HIV infection. This includes Muslim
men, whose religion forbids alcohol use (associated with high-risk sex
with commercial sex workers and failure to use condoms). Other Muslim
practices that may help reduce HIV transmission include polygamous
marriages (that limit sexual activity with women outside the family of
multiple wives) and postcoital genital washing before praying. Although
circumcision was strongly associated with reduced HIV acquisition in the
recent Ugandan study, the practice was not significantly protective among
non-Muslim men.11 The varying prevalence of sexually
transmitted infections among populations also likely plays a role.
Furthermore, many other factors besides circumcision may be responsible
for distinctly high or low HIV rates observed in specific populations.
Only rigorous, randomized, controlled studies will clearly determine the
roles biological and behavioral factors play in the matter, most experts
agree.
More research also is needed to determine whether male circumcision
reduces the risk of transmission of HIV from infected men to uninfected
female partners. The only study to address this issue found that
circumcision may reduce transmission from HIV-positive men with relatively
low viral loads.12
Further complicating the debate is evidence indicating that, to prevent
HIV infection, circumcision must be performed early. In a Ugandan study
among 6,821 men, HIV prevalence rates were 14 percent and 16 percent
respectively for uncircumcised men and men circumcised at age 21 and
older. But the prevalence rate fell to only 10 percent for men circumcised
between the ages of 13 and 20 years, and to 7 percent in men circumcised
at age 12 years or younger.13
These and other data suggest that circumcision as an HIV-prevention
strategy may be effective only when performed on prepubescent boys or
infants. Yet, such circumcisions would not be of immediate benefit in
terms of HIV prevention and would have to be done without informed
consent, raising ethical concerns that are far from being resolved.
Notably, neonatal circumcision has been found to protect against both
penile cancer in situ and invasive penile cancer.14
Uncircumcised men may be more likely to develop penile cancer because they
appear to be at greater risk of being infected with human papilloma virus
(HPV). In a study of 38 Argentinian men with penile cancer, most cancers
were related to HPV.15And in Bali, it has been estimated that
over 75 percent of genital cancers contain HPV. As of 1986, cervical
cancer, which is often associated with HPV infection, was the most
frequent cancer in Balinese women. Penile cancer was the second most
frequent cancer in Balinese men, who are rarely circumcised.16
-- Kim Best
References
- Taljaard R, Taljaard D, Auvert B, et al. Cutting it
fine: male circumcision practices and the transmission of STDs in
Carletonville. The XIII International AIDS Conference, Durban,
South Africa, July 9-14, 2000.
- Magoha GAO. Circumcision in various Nigerian and
Kenyan hospitals. East Afr Med J 1999;76(1):583-86.
- Magoha; Kagimu M, Marum E, Serwadda D. Planning and
evaluating strategies for AIDS health education interventions in the
Muslim community in Uganda. AIDS Educ Prev 1995;7(1):10-21.
- Bailey R, Muga R, Poulussen R. Trial intervention
introducing male circumcision to reduce HIV/STD infections in Nyanza
province, Kenya: baseline results. The XIII International AIDS
Conference, Durban, South Africa, July 9-14, 2000.
- Halperin DR, Bailey RC. Male circumcision and HIV
infection: 10 years and counting. Lancet 1999;354(192):1813-15;
Moses S, Plummer FA, Bradley JE, et al. Association between lack of
male circumcision and risk for HIV infection: review of the
epidemiological evidence, abstract no. We.C.452. Int Conf AIDS 1996;11(2):40;
Weiss H, Quigley M, Hayes R. Male circumcision and risk of HIV
infection in sub-Saharan Africa: a systematic review and
meta-analysis. AIDS 2000;14(15):2361-70.
- Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load
and heterosexual transmission of human immunodeficiency virus type 1. N
Engl J Med 2000;342(13):921-29.
- Buvé A, Auvert B, Lagarde E, et al. Male
circumcision and HIV spread in sub-Saharan Africa. The XIII
International AIDS Conference, Durban, South Africa, July 9-14,
2000.
- Lavreys L, Rakwaar JP, Thompson ML, et al. Effect of
circumcision on incidence of HIV and other STDs: a prospective cohort
study of trucking company employees in Kenya. J Infect Dis 1999;180(2):330-36.
- Halperin.
- Weniger BG, Brown T. The march of AIDS through Asia.
N Engl J Med 1996;335(5):343-45.
- Quinn TC, Wawer MJ, Sewankambo NK, et al. A study in
rural Uganda of heterosexual transmission of human immunodeficiency
virus [authors' reply to letters]. N Engl J Med 2000;343(5):364-65.
- Gray RH, Kiwanuka N, Quinn TC, et al. Male
circumcision and HIV acquisition and transmission: cohort studies in
Rakai, Uganda. AIDS 2000;14(15):2371-81.
- Kelly R, Kiwanuka N, Wawer MJ, et al. Age of male
circumcision and risk of prevalent HIV infection in rural Uganda. AIDS
1999;13(3):399-405.
- Schoen EJ, Oehrli M, Colby CD, et al. The highly
protective effect of newborn circumcision against invasive penile
cancer. Pediatrics 2000;105(3):E36; Maden C, Sherman KJ,
Beckmann AM, et al. History of circumcision, medical conditions and
sexual activity and risk of penile cancer. J Natl Cancer Inst 1993;85(1):19-24.
- Picconi MA, Eijan AM, Distefano, et al. Human
papillomavirus (HPV) DNA in penile carcinomas in Argentina: analysis
of primary tumors and lymph nodes. J Med Virol 2000;
61(1):65-69.
- Boon ME, Susanti I, Tasche MJ, et al. Human
papillomavirus (HPV)-associated male and female genital carcinomas in
a Hindu population. The male as vector and victim. Cancer 1989;64(2):559-65.
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Removing Specialized
Cells May Explain Protective Effect
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How might male circumcision protect against HIV infection?
There is some evidence of a biological explanation. Most cases
of primary HIV infection in women are thought to occur when HIV
binds to receptors of specific cells in the vagina, called
Langerhans' cells. Similar cells are abundant in the inner surface
of the foreskin and urethra of men.
Langerhans' cells are likely to be sites where HIV enters the
male body during intercourse,1 when the foreskin is
pulled down the shaft of the penis and its inner surface is
exposed to vaginal secretions. Langerhans' cells have been shown
to be the major surface cell type involved in transmission of HIV
infection to lymph tissue,2 where it eventually leads
to a fatal infection. In addition, the highly vascular frenulum
(the thin band connecting the inner foreskin to the underside of
the tip of the penis in uncircumcised men) is particularly
susceptible during intercourse to tears and abrasions that
facilitate entry of HIV into the body.
Without proper hygiene, bacteria and viruses can accumulate
under the foreskin. Although little is known about the association
between penile hygiene and HIV infection, accumulation of sexually
transmitted pathogens under the foreskin may explain in part why
uncircumcised men are at greater risk of acquiring an infection
and related lesions than are circumcised men. Having a sexually
transmitted infection increases one's risk of acquiring HIV.
Studies in Africa have shown that HIV-infected men are more
likely to have a history of genital ulcers than uninfected men. In
one study, men with chancroid were five times more likely to
become infected with HIV than men without chancroid.3Another
study, in which 24 of 293 men (8 percent) became HIV-infected,
found that nearly all infections occurred in men who were
uncircumcised or had genital ulcer disease.4 Some
experts believe that uncircumcised men with genital ulcers may be
the core group spreading the epidemic in some populations.5
-- Kim Best
References
- Szabo R, Short R. How does male circumcision
protect against HIV infection? BMJ 2000;320:1592-94;
Hussain LA, Lehner T. Comparative investigation of Langerhans'
cells and potential receptors for HIV in oral, genitourinary
and rectal epithelia. Immunology 1995;85(3):475-84.
- Blauvelt A, Glushakova S, Margolis LB.
HIV-infected human Langerhans' cells transmit infection to
human lymphoid tissue ex vivo. AIDS 2000;14(6):647-51.
- Jessamine PG, Plummer FA, Ndinya Achola JO,
et al. Human immunodeficiency virus, genital ulcers and the
male foreskin: synergism in HIV-1 transmission. Scandinavian
J Infect Dis Supplementum 1990;69:181-86.
- Cameron DW, Simonsen JN, D'Costa LJ, et al.
Female to male transmission of human immunodeficiency virus
type 1: risk factors for seroconversion in men. Lancet 1989;2(8660):403-7.
- O'Farrell N, Egger M. Circumcision in men
and the prevention of HIV infection: a 'meta-analysis'
revisited. Int J STD AIDS 2000;11(3):137-42; O'Farrell
N, Hoosen AA, Coetzee KD, et al. Genital ulcer disease:
accuracy of clinical diagnosis and strategies to improve
control in Durban, South Africa. Genitourin Med 1994:70(1):7-11.
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