Cutting the HIV Rate?

A landmark study with major implications for the global AIDS epidemic, published this week by French and South African researchers, seems to confirm what scientists have long suspected: that circumcision cuts the risk of HIV infection dramatically, by as much as 60 percent. If similar studies now underway in Kenya and Uganda corroborate the results, circumcision could become a powerful weapon--with condom use and other measures-- in the fight against AIDS.

While more than 40 studies since 1989 have found lower HIV rates among circumcised men, this study, led by the French national agency for AIDS research and conducted in the Gauteng region of South Africa, is the first to test circumcision as an active intervention. Its publication, in the journal PLoS Medicine, was controversial: the authors announced their findings at an AIDS conference in Brazil in July, only to have their paper rejected by the British medical journal The Lancet over ethical concerns. (The researchers had not informed trial participants of their HIV status, even if it were positive, because treatment was unavailable at the time and discrimination was common.) Two review panels later OK'd the study for publication in PLoS, whose editors noted that "to not put this paper in the public domain quickly could be considered unethical in its own right," because the upside is that remarkable. A monitoring group even halted the experiment early because the results were so stark. More than 3,000 men were randomly assigned to be circumcised or left intact; only 20 men in the first group became infected, compared with 49 in the second.

News of the experiment arrives as U.S. anti-circumcision groups blossom on the Internet in a kind of phallic culture war, arguing that the practice is genital mutilation performed on unconsenting infants, with no medical benefits and risk of sexual harm. The American Association of Pediatrics last month reaffirmed its carefully hedged 1999 stance on circumcision, which neither endorses nor discourages the practice. And 16 states no longer offer Medicaid reimbursements for circumcisions, deeming it an unnecessary procedure. Despite all that, U.S. circumcision rates have remained relatively constant for 20 years, at nearly 80 percent of newborn boys.

That's compared with a global rate of only 15 percent. Will that number now rise? U.S. and international AIDS organizations are awaiting results from Kenya and Uganda, due in the summer of 2007, before they recommend circumcision to the developing world on a massive scale. Even then, there are practical considerations of cost and training; circumcisions performed with dirty tools by inexperienced health workers could expose men to more infections. And there is the "disinhibition" factor, which may lead newly circumcised men to engage in more risky behavior. "This doesn't replace the usual techniques that we know work, like condom use. That has to be loud and clear," says Dr. Jay Levy, one of the doctors who helped identify HIV in 1983. But the potential of reducing the global AIDS rolls by even a fraction could be measured in hundreds of thousands of lives.

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