A simple, outpatient procedure could potentially save millions of men and their
partners from becoming infected with HIV, but health professionals have been
reluctant to provide the needed information and resources, say the authors of a
Lancet editorial review.
The procedure is circumcision, a practice widely accepted in the United States
but less common in many other parts of the world. Despite numerous
epidemiological studies showing an association between lack of male
circumcision and HIV transmission, training and resources for the procedure are
lacking in the countries hit hardest by the AIDS pandemic, the authors said.
Daniel Halperin, PhD, UCSF assistant adjunct professor of community health
systems and medical anthropology, and Robert Bailey, PhD, MPH, professor of
epidemiology in the School of Public Health and of anthropology at the
University of Illinois at Chicago, are co-authors of the editorial.
“The evidence is so compelling now, it shouldn’t be ignored,” said Bailey. “We
have limited tools against the AIDS epidemic. Circumcision could have a huge
impact on the HIV pandemic in many developing countries.”
Researchers have put the relative risk of heterosexual HIV infection, the
primary way AIDS is spread throughout Africa and Asia, at two to eight times
higher for uncircumcised men. The authors point to 32 studies from eight
countries that found a significant association between lack of male
circumcision and HIV infection. Recent findings from three additional
countries reported similar results.
In addition, dramatic discrepancies in regional HIV infection rates can be
partially explained by circumcision practices, say the authors. In most West
African countries, for example, where male circumcision is a widespread
practice, HIV prevalence levels are between one and five percent. In
comparison, many of the predominately non-circumcising East and South African
nations have infection rates approaching 25 percent. Similar patterns exist in
South and Southeast Asia.
Halperin and Bailey estimate that in countries like Nigeria and Indonesia,
where no more than a fifth of the men are uncircumcised, roughly 25 percent of
HIV infections can be explained by a lack of circumcision. This number jumps
to 55 percent for countries such as Zambia and Thailand, where 80 percent or
more of men are uncircumcised.
The increased risk of infection is attributable to the foreskin of the penis
which provides a vulnerable portal of entry to HIV and other pathogens. The
foreskin is susceptible to small scratches and tears during intercourse and
contains a high density of Langerhans cells - primary target cells for HIV. An
intact foreskin also exposes a man to other sexually transmitted diseases such
as syphilis, herpes, and chancroid that are known cofactors for HIV infection.
Anecdotal evidence suggests that circumcision could lead to better protection
against HIV through an increased use of condoms as well, says Halperin.
Uncircumcised men seem more likely to find condoms uncomfortable and prone to
breakage, although further research is needed to substantiate these claims.
“The number of infections probably caused by lack of male circumcision already
reaches into the millions,” says Halperin. “We would expect the international
health community to at least consider some form of action, but male
circumcision remains largely unexplored as a tool against AIDS.”
Perhaps the biggest argument for addressing the feasibility of male
circumcision is that a majority of men and women in the countries besieged by
AIDS may support the practice, say the authors. In a survey of 216 adults in
Western Kenya, Bailey found that 60 percent of men would prefer to be
circumcised and 62 percent of women would prefer to have circumcised partners,
but only about 10 percent of men actually have the procedure done.
Many health professionals have been hesitant to integrate circumcision with
other HIV prevention strategies, say the authors, perhaps because it is
embedded in a complex web of deeply held cultural values and religious beliefs.
“Health workers may be biased by their own traditions and religious beliefs,”
said Bailey. “The practice is currently discussed in the context of culture
and religion, but it needs to be brought into the context of health and disease
Men who seek circumcision have difficulty gaining access to trained
professionals operating in safe settings, say the authors. Private clinics
that specialize in male circumcision, many of which are run by people with
minimum or no medical training, are sprouting up in many countries including
Tanzania, western Kenya, Rwanda, and Uganda. When done properly, adult
circumcision is a simple, outpatient procedure that allows most men to return
to work the next day. In unsafe and unclean conditions, however, excessive
bleeding or infections can disable a man for weeks.
“We need to provide communities with balanced information, training, and the
resources needed to offer safe, voluntary male circumcision,” says Halperin.
“Everyone has the right to access safe services and to make informed decisions.”
A preliminary analysis by Halperin and Malcolm Potts, MD, PhD, Bixby Professor
of Population and Family Planning at the UC Berkeley School of Public Health,
estimates that the practice of male circumcision has so far prevented at least
8 million HIV infections in the 15 African and Asian countries cited in the
editorial review alone.
The authors believe that in addition to proper training in the procedure
itself, clinicians need training on how to counsel men and women on the risks,
benefits, and care associated with circumcision. They also caution that
advertising circumcision as a way to prevent HIV transmission could be
counterproductive if men who opt for the procedure believe it will fully
protect them from AIDS and other sexually transmitted diseases.