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."
WOMAN-TO-MAN
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.
CPS
STANDS FIRM
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.
THE
DRY SEX FACTOR
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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