Kevin de Cock, head of the WHO Department of HIV/AIDS, is recommending circumcision to prevent HIV infection.

Credit: WHO

Related articles

• Circumcision is even more effective against HIV
• Circumcision reduces HIV infections by 60%
• Battle lines drawn against AIDS pandemic
• HIV infections surging in Asian gays and bisexuals
• Senegal winning battle against AIDS

TORONTO, 18 August 2006: Circumcision could be a highly effective way of braking the AIDS pandemic, experts said on Thursday, cautioning though that before surgeons everywhere reached for their scalpels, major questions had to be answered.

Interest in circumcision surged among AIDS researchers last year after a French-funded trial, conducted in South Africa, found that men who had had their foreskin removed were around 60 per cent less likely to be infected by HIV than uncircumcised counterparts.

Two similar trials, one in Uganda and the other in Kenya, are currently underway, the 16th International AIDS Conference heard. The trials are due to end in June and September 2007 respectively.

If their data confirm the astonishing outcome of the South African trial, the world's top agencies fighting AIDS will move to recommend male circumcision as one of a panoply of methods to prevent HIV infection, they said.

The U.N.'s World Health Organisation (WHO) is already drafting technical recommendations, which could be implemented if circumcision gets the green light.

Advocating circumcision "seems a pretty dramatic thing to suggest, or at least a few years ago it seemed so," said Kevin de Cock, director of the WHO's HIV/AIDS Department, admitting that the South African trial had had a resounding impact.

But he also sounded a loud warning, pointing out that circumcision may reduce the risk but was only a partial protection.

So it was essential that circumcised men do not become complacent and start to practise unsafe sex in the belief that they could not contract the human immunodeficiency virus (HIV).

"It is not a silver bullet," stressed Catherine Hankins, senior advisor to the specialist U.N. agency UNAIDS.

Hankins also said agencies, governments and doctors had to tread carefully in advising circumcision. In some cultures, circumcision was considered a rite of passage to adulthood and a symbol of manhood; in others, it was considered an emasculation.

"In some cultures if you're not circumcised, you are not a man, and in other cultures if you are circumcised, you are not a man. I think it goes very to the heart of masculinity and what that means in the cultures."

There are even some anti-circumcision organisations, which are lobbying fiercely against what they call "male genital mutilation," said de Cock.

Scientists started to take a close interest in the circumcision question in the late 1980s, when they realised that in East and West Africa, where the rate of circumcision is high, the rate of HIV infection was low, whereas in southern Africa, HIV rates were very high but the rate of circumcision was very low: less than 20 per cent of men.

The theory behind circumcision's protective effect is that the foreskin has a very thin epithelium, or lining, and easily suffers minor abrasions during intercourse.

These microscopic cuts make it easier for the AIDS virus to enter into the man's bloodstream.

Another mooted reason is that the foreskin is rich in so-called Langerhans cells whose surface configuration makes it easy for HIV to latch on to them.

If circumcision joins condoms in the meagre arsenal of weapons to prevent HIV, it could have a mighty effect, according to a study presented at the conference.

Taking into account information on HIV infection rates and the prevalence of male circumcision across Africa, it calculated that if all men were circumcised over the next 10 years, some two million new African infections and around 300,000 deaths could be avoided.

After 20 years, the number of lives saved would be somewhere in the range 1.6-5.8 million, it estimated.

Bernar Auvert of the France's National Agency for Research on AIDS, who led the South African trial, said circumcision was a low-cost option: the operation would cost only between 50 and 60 dollars, less than two months' of the cost of antiretroviral treatment for people who get infected with HIV.

But he stressed that circumcision was also a relatively complex operation, lasting around 30 minutes, that had to be carried out under anaesthetic by a surgeon working in hygienic conditions.

If poor countries with overstretched health services were unable to cope with demand, "males will then be circumcised by traditional circumcisers, with potential complications including death and permanent genital damage," he said.

"It will be a nightmare. The effect of AMC [adult male circumcision] will be the reverse of the expected effect. It will lead to harm instead of good."

A trial funded by the Bill and Melinda Gates Foundation is underway in Uganda to assess whether male circumcision has any impact on the risk of HIV transmission to females.