Surgery may reduce AIDS incidence in African
Last Updated: 2006-11-29 10:49:07 -0400 (Reuters Health)
By Andrew Quinn
MAPUTO - With almost 25 million Africans infected with HIV -- 2.8 million new infections last year and 2.1 million deaths -- the statistics are as grim as ever as Africa readies for World AIDS Day on December 1. But after years of negative news, African health experts hope that at long last there may be a simple step doctors can take to fight the epidemic -- male circumcision.
"This would be the first intervention shown by the highest levels of science to prevent HIV infection," Dr. Daniel Halperin, an AIDS expert at the Harvard School of Public Health, told a U.N. AIDS seminar in Maputo, Mozambique's capital.
"We're not saying don't do condoms. But there is a missing element, and part of that appears to be circumcision."
The rising interest in circumcision as a tool against AIDS is based primarily on one study conducted in Orange Farm, a poor township outside Johannesburg, that found circumcised men were about 60 percent less likely to contract HIV.
Doctors say the most likely explanation is that cells on the inside of the foreskin, the part of the penis removed in circumcision, are particularly susceptible to HIV infection.
The Orange Farm study was so conclusive that it was halted ahead of time and all participants offered circumcision on the grounds that it would be unethical to deny them surgery which could save their lives.
Two more studies are now under way in Kenya and Uganda. Officials say they may stop as early as December if early results are as persuasive as those from Orange Farm.
UNAIDS, the United Nations organization devoted to the global fight against AIDS, says publicly it must await the results of the two studies before launching a campaign to promote circumcision among African men.
But U.N. officials are laying the groundwork for just such a campaign, quizzing African doctors and government officials on exactly what would be needed to roll out a major drive on male circumcision across the continent.
MIXED MESSAGES?
On the surface, male circumcision would appear to be an almost tailor-made defense against Africa's AIDS pandemic: a cheap, simple one-off surgery which makes it more difficult to contract and pass on HIV, the virus which causes AIDS.
A World Health Organization study said circumcision could prevent nearly 6 million new HIV infections and save 3 million lives in sub-Saharan Africa over the next 20 years -- making it one of the most promising interventions against a disease for which there remains no cure and no imminent hope of a vaccine.
African officials hope circumcision may help stop new infections, which continue to outpace the delivery of anti-retroviral drugs that remain expensive and difficult to monitor despite their growing use across Africa.
"Treatment has arrived. But treatment is not sustainable unless we can halt new infections," said Innocent Modisaotsile, who coordinates HIV/AIDS work for the Southern African Development Community (SADC) secretariat.
But there are also fears that any widespread campaign to promote circumcision may undercut other HIV/AIDS prevention messages, chief among them telling people to use condoms and have fewer sexual partners.
"Being circumcised does not mean men are wholly protected from HIV," the Treatment Action Campaign, South Africa's most vocal AIDS activist group, said in a statement.
"Even if circumcision reduces the risk of infection during any one sexual encounter, risky behavior such as sex with multiple partners without using a condom is likely to lead to HIV infection."
THE KINDEST CUT?
Any circumcision campaign in Africa would also have to navigate complicated ethnic terrain. Some tribal groups use traditional circumcision to mark the transition to manhood, others reject it.
In Lesotho, where traditional circumcision is widespread but AIDS is rampant, some doctors worry that traditional surgeries are not thorough enough to convey the medical benefits of modern hospital procedures.
In South Africa, dozens of young men die in traditional circumcision schools every year because of unhygienic equipment and botched surgeries.
Nevertheless, the hopeful news about medical circumcision is beginning to spread.
Swaziland, with no tribal tradition of circumcision, has seen a leap in the number of men requesting the operation which local doctors attribute to the news from Orange Farm.
Dr. Martin Smith, chief of surgery at Soweto's Chris Hani Baragwanath Hospital outside Johannesburg, said they had thus far not seen any major increase in requests for circumcision but would expect to do so if UNAIDS begins publicly promoting it as an AIDS strategy.
"We would have to put systems in place, and I think we would have to be quite pro-active about it. Does circumcision have to be done by a doctor, or can it be done by a trained nurse or medical associate? Those are questions we are starting to ask," he said.
UNAIDS has started canvassing selected African countries to find out how they would handle a major campaign on circumcision and what technical assistance they would need.
"Some people say it is too slow, let's do it now. Others said we had to wait until there is more scientific data," said Chiwene Chimbwete, a Malawian demographer at UNAIDS who has helped coordinate the preliminary work.
But Chimbwete said as far as he was concerned, the evidence was overwhelming. "I've been so convinced about it I myself was circumcised about two months ago."
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