A recent editorial in The New York Times heralded the conclusion, from 2 large sub-Saharan African studies, that male circumcision dramatically suppresses HIV acquisition rates as the "most important development in AIDS research since the debut of antiretroviral drugs."1 The editorial went on to state that while a "real [AIDS] vaccine is years away . . . we know its near equivalent [now] exists."1But Anthony Fauci, director of the National Institute for Allergy and Infectious Disease, was more circumspect. "These results could be negated by a small decrease in condom use or the addition of more sexual partners," he cautioned.2

In fact, that is just what at least some Africans at risk for HIV infection who are now lining up to undergo circumcision said they had in mind when they were interviewed last year after results from the first controlled trial of male circumcision were released. That study, a randomized controlled intervention conducted in a general population of 3274 uncircumcised men aged 18 to 24 years in South Africa, found 20 HIV infections in the intervention group compared with 49 among controls, representing a protection rate of 60% after a mean 18.1-month follow-up.3

These data paralleled numerous observational studies, some published more than 17 years ago, showing that uncircumcised men have higher rates of HIV infection than their circumcised counterparts.4,5 The data are also consistent with the fact that while cells with receptors for HIV are present in all penile epithelia, heavy keratinization of the glans penis makes this tissue an unlikely target for primary infection unless it has been compromised by lesions, inflammation, or trauma.6

However, superficial Langerhans cells on the inner aspect of the foreskin and frenulum are poorly keratinized and highly sensitive to HIV infection.6 These same cells may also be targets for other sexually transmitted viruses. For example, uncircumcised men infect women with human papillomavirus at a rate 3-fold higher than that of circumcised partners.7 Although formal trials have not yet addressed this issue, male circumcision may also help protect some women from HIV spread. This was suggested by a retrospective study of 300 Ugandan couples conducted last year: circumcised men were 30% less likely to transmit HIV to their female partners.8

The South African trial has now been replicated in Kenya and Uganda. The Kenyan study involved 2784 men aged 18 to 24 years, half of whom were randomly assigned to be circumcised. Forty-seven cases of HIV infection were found in the control group versus 22 among the circumcised men, a 53% reduction.2,8 In Uganda, 4996 men aged 15 to 49 years were studied; 43 cases of HIV infection occurred among the controls versus 22 among the circumcised men, for a 48% reduction in HIV transmission.2,8

Apart from concerns over a behavioral backlash that might ultimately increase the spread of HIV infection, as raised by Fauci, others have questioned the acceptability and safety of the procedure itself. Circumcision removes the "most erogenous tissue" of the male body, one nurse and anti-circumcision activist argued.2 As such, she questioned whether this diminished sensitivity might be an additional disincentive to use condoms. Male circumcision also does not diminish the spread of HIV through anal intercourse.8 And, "if performed by folk healers using dirty blades, as often happens in rural Africa," circumcision could conceivably accelerate the spread of HIV infection.8

This latter issue has become increasingly prominent in efforts to focus HIV prevention programs in the resource-poor world. Both traditional healers and medical clinics have been investigated as potential central sources for HIV transmission through needles. According to a recent interview with Edward Mills from McMaster University, who has investigated this issue in South Africa, "there is no doubt that traditional practices are spreading HIV. . . . UNAIDS [The Joint United Nations Programme on AIDS] has been ignoring it. I think it's because people think it's culturally insensitive to talk about."9


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