JANUARY 30, 2007


Circumcision/HIV trials disputed

WHO studies looked only at rarer female-to-male transmission

Circumcision "is, in fact, the real-world equivalent of an AIDS vaccine," trumpeted a January 14 New York Times editorial. The bold proclamation came in reaction to two recent clinical trials in Africa investigating circumcision's protective effects against HIV. The trials were halted early due to the procedure's apparent success in protecting men against contracting HIV from women. The Times opinion piece was typical of the ebullient international news media's reaction, but not everyone is convinced that ridding the world of prepuces will do much to diminish the HIV/AIDS epidemic.

The Seattle-based group Doctors Opposing Circumcision (DOC) released a statement condemning the early termination of the trials, which the investigators say was done on ethical grounds: "If the studies had continued for their scheduled time, it is probable that there would have been little difference between the circumcised group and the non-circumcised group."

Dr Stephen Moses, of University of Manitoba, was the principal investigator for the CIHR-funded Kenyan trial (the other study was in Uganda). He's quick to note that this particular trial did not look at man-to-woman transmission. "Our study only looked at the protection afforded to HIV uninfected men who are exposed to HIV through sex with HIV infected women," he said. "Circumcision reduced their risk of acquiring HIV by 53%."

The DOC statement also expressed concern that, despite the fact that rates of heterosexual woman-to-man transmission of HIV are low in developed countries, this trial might be used as an argument for routine neonatal circumcision in the US and Canada. Dr Moses, who favours routine neonatal circumcision, agrees.

"I think that it would be in order for the Canadian Paediatric Society (CPS) to revisit the issue of routine male circumcision, not just in the light of the findings of reduced risk for HIV infection, but in relation to other health benefits which have come to light in recent years," he told NRM.

Dr Robin Walker, Vice-President Medicine at the IWK in Halifax and a former president of the CPS, says that the CPS's official opposition to non-religious routine infant circumcision, based on years of study, isn't likely to change quickly.

"In this case there is growing evidence of a partial protective effect of circumcision on rates of transmission of HIV," he says. "But when our expert committee reviews the evidence it will not only have to determine if there is enough science of high enough quality to use for a recommendation, but also whether circumcising every male is justified by the degree of protection conferred."

"HIV is already preventable by other means that do not involve surgery, let alone surgery on every male," he stresses.

And indeed, besides condoms and safer sex, simply washing the penis after sex might help reduce the risk of female-to-male HIV transmission among uncircumcised men.

The CDC's fact sheet on circumcision trials noted the following: "The micro-environment in the preputial sac between the unretracted foreskin and the glans penis may be conducive to viral survival." It follows that improving access to clean water in endemic AIDS areas would be a good start.

Understanding local customs can also help when interpreting the results of the circumcision studies. For instance, in Kenya and other sub-Saharan African countries, a pervasive practice called "dry sex" is a major factor in heterosexual HIV transmission. In dry sex, women use a desiccant prior to intercourse to remove natural vaginal lubrication, which is often associated with promiscuity and uncleanliness. A 2000 Pulitzer Prize-winning report in the Village Voice described how drying agents like mutendo wegudo — soil with baboon urine — were widely used by women in Zimbabwe and Kenya prior to sex. Dry sex tends to cause vaginal lacerations and the inherent friction often shreds condoms.

When asked about the potential for dry sex to affect the results in the circumcision trials Dr Moses notes that this is indeed something that requires study. "We did ask the men questions about dry sex," he says. "But have not analysed those data yet. This will be done over the coming months."



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