Male circumcision should be actively encouraged to fight the spread of HIV/AIDS in Africa, a non-profit group urged the XVIIth annual International AIDS Conference this past week. The conference, which took place in Mexico City, focused on current trends in HIV/AIDS prevention and treatment. The non-profit organization Population Services International, which investigates and advocates on behalf of the health needs of low-income populations in the developing world, presented new evidence in favor of circumcision programs, particularly for sub-Saharan Africa, where two-thirds of the world's 33 million HIV+ people live. The information once again puts the focus on a controversial and emotional area of HIV/AIDS prevention.
Circumcision is a controversial procedure even in the U.S., where roughly 60 percent of newborns are circumcised. In Africa, rates are much lower. Web sites like the Circumcision Resource Center have sprung up to voice a growing chorus of concerns that the practice of circumcision constitutes unnecessary genital mutilation; that it traumatizes infants; and that it reduces sexual pleasure for adult men. Over time, even American rates of circumcision, though still high, have fallen off somewhat as parents see less need for the procedure.
Yet for some time, it has also been clear that circumcision substantially lowers the risk of HIV infection. The World Health Organization asserts that, "There is now strong evidence from three randomized controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda and Orange Farm, South Africa that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%." Yet with regard to Africa, the list of concerns about circumcision broaden beyond the medical to the cultural and logistical, including questions about identifying safe practitioners to perform the procedure, the potentially subordinate social status of circumcised men, and the suspicious reactions of governments that see no purpose in the procedure. Last month, for example, the Elders of Kenya's Luo community chose to reject a Kenyan Ministry of Health program to encourage male circumcisions, citing doubt about the procedure's effectiveness and an unwillingness to disturb their traditional cultural practices, which did not include male circumcision.
PSI's presentation at the AIDS Conference attempted to overwhelmingly counter these concerns. Citing evidence amassed from several different studies, Dvora Joseph, Acting Director of PSI's HIV Department, and Dr. Robert Bailey of the University of Illinois, Chicago, who co-authored some of the relevant research, offered a host of reasons to press governments and communities—like the Luo of Kenya—to join circumcision programs. One major concern involves access to safe circumcisions. A program initiated by PSI in Zambia has, according to Joseph, had overwhelming success training low-level health workers to perform male circumcisions as part of a comprehensive prevention and education program. The idea is to create a broad base of qualified practitioners for the procedure, without putting strain on the existing medical system. "As news gets out about the efficacy of male circumcision, we need to meet that demand with quality services and a comprehensive HIV prevention approach, and scale up male circumcision as an ethical, human rights issue," Joseph said, pointing out that in Zambia there are waiting lists of up to two months for the procedure. This can lead to potentially dangerous procedures—a problem that will grow as the demand increases. "Just by word of mouth, the demand is so great that already men are going to unqualified practitioners and experiencing serious complications," Joseph said. "We must scale up our response rapidly to meet the demand for safe circumcision services."
Dr. Bailey, a researcher at the University of Illinois, Chicago, presented research related to the physical and social effects of circumcision. His research group in Kenya is presenting a report to the conference demonstrating the results of a study of 2,784 participants, comparing sexual function between circumcised and uncircumcised men over a two-year period. His conclusions are likely to be controversial. The research reports that, "Circumcision status was not associated with any sexual dysfunction or with specific sexual dysfunctions (premature ejaculation, pain during intercourse, erectile dysfunction) at follow-up visits." As Dr. Bailey elaborated at a press conference, "And in fact, circumcised men did report greater penile sensitivity after circumcision," countering the oft-reported decrease in sensitivity on the part of circumcised men. Bailey's research on sexual function post-circumcision comes on the heels of his research, reiterated at the PSI event, demonstrating that there is no increase in sexual risk-taking by men who have been circumcised. In a study published in the Public Library of Science, Bailey and his colleagues found that, after intensive counseling to warn them that they were still able to contract HIV, there was no increase in risk-taking among 1,319 recently circumcised men. When circumcision is accompanied by education and other forms of support, Bailey said, "the results of this study suggest that HIV risk behaviors are unlikely to increase. They may even decline as we saw in our study."
PSI emphasizes that circumcision should be part of a broad-based prevention program, and should be encouraged in the hardest-hit parts of the world. "Based on the existing body of evidence, and our experience implementing male circumcision to strengthen our prevention efforts, we are asking the international community to help national governments and their partners to introduce male circumcision wherever HIV prevalence is greatest and circumcision rates are lowest—in the nations of eastern and southern Africa," said Joseph. Widespread use of male circumcision in sub-Saharan Africa could, the researchers estimate, prevent two million infections in the next 10 years and save as many as four million lives over the next 20 years.
The implications of the circumcision discussion for gay men and the West remain unclear. As the Centers for Disease Control and Prevention report, "Studies to date have demonstrated efficacy only for penile-vaginal sex, the predominant mode of HIV transmission in Africa, whereas the predominant mode of sexual HIV transmission in the United States is by penile-anal sex among MSM [men who have sex with men]." The American Foundation for AIDS Research complained about a gay-straight HIV information gap at the conference this week, pointing out that 44 percent of countries worldwide have failed to provide any statistical data on AIDS and gay men, despite the fact that gay men are 19 times more likely to contract HIV than their heterosexual counterparts. For gay men, the current research indicates that the efficacy of circumcision will depend in part on the sex practices each man engages in. According to the CDC, "Receptive anal sex is associated with a substantially greater risk of HIV acquisition than is insertive anal sex. It is more biologically plausible that male circumcision would reduce HIV acquisition risk for the insertive partner rather than for the receptive partner, but few MSM engage solely in insertive anal sex." Given the lower infection rates in the U.S., and the demographic concentration of infections in the gay community, calls for widespread circumcisions are likely to continue to focus on Africa for the time being.