Circumcision Reduces Risk of AIDS, Study Finds

December 13, 2006
By DONALD G. McNEIL Jr.Circumcising African men may cut their risk of catching AIDS in half, the National Institutes of Health said today as it stopped two clinical trials in Africa, when preliminary results suggested that circumcision worked so well that it would be unethical not to offer it to uncircumcised men in the trials.AIDS experts immediately hailed the result, saying it gave the world a new way to fight the spread of AIDS, and the directors of the two largest funds for fighting the disease said they would now consider paying for circumcisions. “This is very exciting news,” said Daniel Halperin, an H.I.V. specialist at Harvard’s Center for Population and Development, who has argued in scientific journals for years that circumcision slows the spread of AIDS in the parts of Africa where it is practiced.In an interview from Zimbabwe, Mr. Halperin added: “I have no doubt that, as word of this gets around, millions of African men will want to get circumcised and that will save many lives.”
But experts also cautioned that circumcision is no cure-all. It only lessens the chances that a man will catch the virus, it is expensive compared to condoms, abstinence or other methods, and the surgery has serious risks if performed by folk healers using dirty blades, as often happens in rural Africa. Sex education messages to young men need to make it clear that “this does not mean that you have an absolute protection,” said Dr. Anthony S. Fauci, an AIDS researcher and director of the National Institute of Allergy and Infectious Diseases, which sponsored the trials. Circumcision should be added to other prevention methods, not replace them, he said.The two trials were carried out among nearly 3,000 men in Kisumu, Kenya, and nearly 5,000 men in Rakai, Uganda. None were infected with H.I.V., the virus that causes AIDS; they were divided into circumcised and uncircumcised groups. They were given safe sex advice — although many presumably did not take it — and retested regularly. The trials were stopped by the National Institutes of Health’s Data Safety and Monitoring Board this week after data showed that the Kenyan men had a 53 percent reduction in new H.I.V. cases and the Ugandan men a 48 percent reduction.In Kenya, 22 of the 1,393 circumcised young men in the study caught the disease, compared with 47 of the 1,391 uncircumcised men.Those results echo the finding of a trial completed last year in the town of Orange Farm, South Africa, financed by the French government, which demonstrated a reduction of 60 percent among circumcised men.Two agencies, one under the State Department and the other financed by a number of countries, said they now would be willing to pay for circumcisions, which they have not before, citing a lack of hard evidence that it works. Dr. Richard G. A. Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said that if a country seeking money submitted plans to conduct safe, sterile circumcisions, “I think it’s very likely that our technical panel would approve it.”Ambassador Mark Dybul, executive director of the $15 billion President’s Emergency Plan for AIDS Relief in the State Department, said his agency “will support implementation of safe medical male circumcision for HIV/AIDS prevention.”He too warned that it was only one new weapon.“Prevention efforts must reinforce the ABC approach — abstain, be faithful and correct and consistent use of condoms,” he said. Uncircumcised men are thought to be more susceptible to AIDS because the underside of the foreskin is rich in Langerhans’ cells, which attach easily to the virus. The foreskin may also suffer small tears during intercourse, making it more susceptible to infection.Researchers have long noted that parts of Africa where circumcision is practiced — particularly in the Muslim countries of West Africa — had much lower AIDS rates. But it was unclear whether other factors, such as religion or polygamy, played important roles.Outside Muslim regions, circumcision is spotty. In South Africa, for example, the Xhosa people circumcise teen-age boys, while Zulus, whose traditional homeland abuts theirs, do not. AIDS is common in members of both tribes. In recent years, as word has spread that circumcision might be protective, many African men have sought it out. A Zambian hospital offered $3 circumcisions last year, and Swaziland trained 60 doctors to give them at $40 each after its waiting lists grew.“Private practitioners also do it,” Dr. Halperin said. “In some places, it’s $20, in others, much more. Lots of the wealthy elite have already done it. It prevents STD’s, it’s seen as cleaner, sex is better, women like it. I predict that a lot of men who can’t afford private clinics will start clamoring for it.”