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The snip could save many lives
The snip could save many lives
New study shows that male circumcision could reduce HIV transfer October 31, 2005 By Thomas J Coates The Old Testament of the Bible prescribes circumcision as the mark of the covenant between God and Judaism. Circumcision is not mentioned in the Qur'an, but Islam adopted the practice for hygienic reasons. Early Christianity debated whether or not circumcision was necessary for conversion to the new faith. They decided not, and perhaps that was unfortunate. The HIV epidemic might have taken quite a different course if all Christians and Muslims in Africa were circumcised. A new French study completed in South Africa and released at the International Aids Society meeting in Rio de Janeiro shows that male circumcision could reduce the probability that a man will acquire HIV from an HIV-infected person by up to 70%. I have been working in HIV prevention since I moved to San Francisco in 1982, and have been working in Africa since 1990. This is the most important breakthrough in HIV prevention since the efficacy of the male condom was unequivocally demonstrated in laboratory and human studies. The only prevention strategy that is currently better than this is abstinence. This reduction in HIV infection is as much as we've hoped for with the elusive HIV vaccine, promised to us in 1985 but still decades away 20 years later. Some may question the results of this study by saying that many more men in the US, where male circumcision is practised, have HIV than in European countries where male circumcision is not widespread. But many HIV infections in the US and Europe are passed from male to male, and the primary risk is to the receptive partner in anal intercourse. Circumcision would not protect in that circumstance, nor would it protect when the mode of transmission is sharing of injection equipment. This current finding applies in situations where the male is the insertive partner in vaginal or rectal intercourse. The finding makes sense biologically. The foreskin can trap fluids, thus allowing HIV and other pathogens more time to infect. Further, the foreskin is rich in Langerhans cells that HIV can infect, further increasing the chances of infection. Male circumcision does have advantages over the male condom. Many men do not like condoms, and they can be expensive and unavailable just at the moment that they are needed. Further, they tend not to be used at the riskiest moments - when people are inebriated or high on drugs. Most important, they need to be used rather consistently to confer protection. Condoms require action every time; circumcision is a one-time irreversible event. But male circumcision does have disadvantages as well. The surgery cannot be done by just anyone. It requires sterile conditions and a good surgeon. The patient needs to refrain from any sexual activity until the surgical wound is healed - about three to four weeks - because the unhealed wound puts him at greater risk for HIV. Thus, one concern about widespread dissemination of these findings is that untrained or unqualified individuals will set up chop shops, not use sterile technique, and spread rather than prevent disease. Whether or not young men will come in droves to be circumcised remains to be seen. Men and women alike squirm at the thought of male circumcision, especially for adolescents and adults. I was at a medical conference last year when one of the male circumcision studies was presented, and the investigator showed a film of the surgery with an actual patient. It was easy to see everyone's face scrunch up and their legs close as they moaned softly in empathic agony with the patient. Male circumcision cannot be confused with female circumcision, and this is a real danger as well. Female circumcision is a mutilating technique, forced on unwilling young women, and it involves cutting the labia and often the clitoris. It has no medical benefits whatsoever, and fortunately it is declining in many parts of the world in which it is practised, due to worldwide pressure and the women's movement. Women bear the brunt of HIV infections in the world, but male circumcision can protect them as well. Women in subSaharan Africa are most likely to get infected with HIV between the ages of 14 and 25, while men get infected later, usually between the ages of 18 and 35. The women get their HIV infection from older men. Thus, women will benefit if we can prevent infections in men. There are many other important studies under way that are examining female-controlled protection methods. These include the use of the female diaphragm, acyclovir to suppress herpes (as herpes is highly associated with risk for HIV), and microbicides that can be placed in the vagina or rectum to kill HIV on contact. Finally, there is pre-exposure prophylaxis so that people might be able to take a pill prior to sex to prevent HIV infection from occurring, much as we currently do with malaria. There are two other clinical trials of male circumcision under way now, and they need to be examined to ensure that their findings are replicating, and not contradicting, this one. If the findings hold up, then studies need to start right away to determine the best ways to implement male circumcision on a broad scale without negative effects. It might be interesting if relatively small countries highly affected by HIV, like Lesotho or Swaziland, would try male circumcision on a broad scale to see if they can reduce HIV infection among men and women. The Botswana government has recently passed legislation indicating that all mothers need to be counselled on male circumcision for their male infants. It does not force circumcision on anyone - and that is important - but people need to be counselled about its potential benefits and disadvantages. The American Academy of Paediatrics in 1975 issued a statement indicating that there are no medical reasons for male circumcision, and the procedure has been dropping in the US ever since. It may need to rethink its position as well. This finding is good news in the fight against HIV. It will be controversial, and some individuals and countries may not want to do it. That is their choice, as no HIV prevention technique should be forced on anyone. But it does remind us that the pace of the fight against HIV is a hopeful one, and more good news is down the line. Thomas J Coates, Ph.D, is professor of medicine in the division of infectious diseases at the UCLA David Geffen School of Medicine, and associate director for international and health policy research at the UCLA Aids Institute. http://www.thestar.co.za/index.php?f...icleId=2973183 |
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