Can circumcision reduce HIV risk?
Living with AIDS # 264

KHOPOTSO: One listener wrote in with the following:

EXCERPT: ‘€œIf this study has any truth in it, then Jacob Zuma was right in saying that taking a shower after intercourse would reduce his chances of getting infected!’€¦ This study, I fear, will give people a reason to discard condoms ‘€“ all they will need to do is become circumcised’€.

KHOPOTSO: There are over 40 observational studies, most of which have been conducted in Africa, that suggest that circumcision could have a hand in how prevalence rates of HIV infection are distributed. For instance, compared to southern Africa where the epidemic is raging, central, eastern and western Africa have lower infection rates. Scientists ascribe the lower rates to, amongst others, a more common practice of male circumcision in those regions. But how does the removal of the fore-skin, a largely symbolic age-old practice, begin to matter in the equation of HIV prevention? Dr Adrian Puren is the Deputy Director of the National Communicable Diseases’€™ Virology Unit.

Dr ADRIAN PUREN: It’€™s only really in the 19th century that people started to give some sort of clinical basis for why one would do circumcision. And it’€™s a fact, it’€™s still controversial for some people as to why one would want to perform circumcision. But there seems to be evidence to show that circumcision can be protective in terms of acquiring particular sexually transmitted infections, and that includes HIV.  

KHOPOTSO: Puren was the Principal Investigator in the South African study conducted in Orange Farm, south of Johannesburg, which shows that circumcision has a 60% protective effect against HIV. Over 3000 men participated. These were divided into two equal groups ‘€“ the intervention and the control arm. Men in the intervention group were required to consent to circumcision, while those in the other group remained uncircumcised. After 21 months of follow-up, 69 had HIV – 20 from the intervention group and 49 from the control arm. Researchers say that the comparably fewer infections in the intervention group were as a direct result of being circumcised. Curiously though, 20 men still got infected. Why?                

Dr ADRIAN PUREN: When you do a circumcision you’€™re trying to remove the fore-skin as completely as possible’€¦

We want to remove that because when you look under a microscope and analyse what makes up that fore-skin, especially on the inner surface of the fore-skin’€¦ the cells that are able to bind HIV’€¦ there’€™s a high number of those – what we call target cells to be bound’€¦ So, by removing that fore-skin, we’€™re removing cells that HIV would usually bind to.

KHOPOTSO: Puren continues.

Dr ADRIAN PUREN: If the process is not complete it’€™s possible that there’€™s still residual cells, for example, that may still be there. Is there trauma in the area so that even though we’€™ve removed the fore-skin, and we argue, when you’€™re having sexual intercourse there may be micro-tears, for example, which will allow HIV to enter’€¦ So, these are some of the sort of speculative ideas that we have why those males may well still become infected despite being circumcised.

KHOPOTSO: In randomised trials such as the Orange Farm one, the two groups were treated equally and were given the same type of information to encourage safe sex practices and the reduction of sexual partners. However, there’€™s a concern that these were not followed, which could also explain why the men, in particular the 20 who were circumcised in the intervention group, contracted HIV.  

Dr ADRIAN PUREN: One of the concerns, of course, is that there can be what we call dis-inhibition. In other words, despite providing all this information to your participants ‘€“ use condoms regularly, partner reduction, treat STIs ‘€“ it’€™s still possible that they will say: ‘€œWell, actually, we’€™re gonna take that risk because we think we have some broad information that circumcision is protective. That’€™s what they tell us. And they’€™re testing this ‘€“ even though they would say to us we don’€™t know the answer to this’€. They may still well participate in high-risk behaviour that leads to them becoming infected.    

KHOPOTSO: Speaking at a discussion forum on male circumcision recently, Dr Daniel Halperin of the United States AIDS agency in southern Africa warned about the dis-inhibition Puren alludes to, saying if mass-scale male circumcision is promoted, some men could walk around as if they were having a natural condom on them.

Dr DANIEL HALPERIN: We want to be careful not to promote this as a way to fight HIV. We don’€™t want people to think that they’€™re immune because they are circumcised. One nice thing about circumcision is that there’€™s many other benefits. It reduces the chances of penile cancer, of cervical cancer, of various medical conditions and of certain sexually transmitted diseases, like syphilis and chanchroid. So, there are ways to promote circumcision for general overall male genital hygiene and health without focussing just on the HIV aspect.

KHOPOTSO: Tomas Lundstrom is the regional advisor for UNAIDS in eastern and southern Africa. The organisation also still needs to be convinced.

TOMAS LUNDSTROM: What we might be reluctant (about) is to promote male circumcision because there’€™s a whole range of things that need to be investigated further. We are seeing this as an extremely interesting development when it comes to preventing HIV. But many things need to be pursued. So, it’€™s dangerous if people see male circumcision as the magic bullet’€¦ Normally, we will have to wait for scientific facts. We don’€™t have that in a scientific meaning.  

KHOPOTSO: That scientific meaning lies in whether the results of two similar studies currently taking place in Kenya and Uganda confirm what the Orange Farm study found. These are expected to be known next year. For now, it’€™s up to you and I to decide: Can male circumcision reduce HIV risk in men? For me, being circumcised is not the reason to stop using a condom ‘€“ the safest method known to prevent HIV if sexually active.                                              



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