Circumcision trial hailed as milestone, but caution also stressed

Thursday December 14, 12:31 PM

By Richard Ingham

PARIS (AFP) - Campaigners mixed joy with prudence after new trials, described as a watershed in the quarter-century-long tragedy of AIDS, showed circumcision nearly halves a man's risk of catching HIV.

They hailed it as a golden opportunity Thursday for braking a pandemic that has claimed 25 million lives, left another 40 million infected with HIV and for which there is no cure, only a costly, lifelong dependence on drugs.

Until now, the only prevention strategies have depended on condoms

But the campaigners also cautioned that circumcision -- while low-cost, one-off and effective -- was no silver bullet.

Circumcision would not provide complete protection for the man, nor would it protect his sex partner if he himself is infected, they said. And any circumcision campaign will need safe medical provision, counselling and cultural acceptance to be effective.

The news "is a milestone in the history of the AIDS epidemic," the AIDS Vaccine Advocacy Coalition (AVAC) declared. It warned, though, the benefits "will only be realised if male circumcision is included as part of a larger package of prevention services."

The two trials were conducted by US-led researchers among 2,784 uninfected young men in Kenya, and 4,996 men in Uganda. In Kenya, those who were circumcised showed a 53-percent reduction in HIV acquisition compared to those who were uncircumcised.

In Uganda, the risk of HIV infection was reduced by 48 percent.

The findings were so emphatic that the doctors called an early halt, saying it would have been unethical for the trials to continue.

Last year, a French-funded trial conducted in South Africa found a 60-percent fall in infection risk among circumcised men. Another trial is underway in Uganda to see whether male circumcision has any effect on the risk of infection for women.

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 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 the human immunodeficiency virus (HIV) to latch on to them.

According to figures cited by a UN Population Fund (UNFPA) expert, 3.7 million infections and 2.7 million deaths could be averted over the next 20 years if male circumcision is added to the meagre arsenal of preventive weapons.

"Circumcision is now a proven, effective prevention strategy to reduce HIV infections in men," said Robert Bailey, a professor of epidemiology at the University of Illinois at Chicago, who led the Kenyan study.

Zambian surgeon and university lecturer Kasone Bowa, speaking at a conference of the 14-nation Southern African Development Community (SADC), said male circumcision would cost only 15 dollars, "unlike AIDS drugs which cost 480 dollars per person per year, and it's a continued expense."

Bailey, Bowa and others strongly insisted that circumcision was not a stand-alone intervention.

It requires safe, hygienic operations carried out under anaesthetic by trained surgeons as well as safe-sex counselling and access to condoms.

"We can't expect to just cut off a foreskin and have the guy go on his merry way without addtional tools to fight against getting infected," said Bailey.

Governments and doctors also have to tread carefully in advising circumcision. In some cultures, circumcision is considered a rite of passage to adulthood and a symbol of manhood; in others, it is considered an emasculation.

"It is important that circumcision remains an individual choice and is not imposed on men," said Will Nutland of Britain's Terrence Higgins Trust.

Bernar Auvert of the France's National Agency for Research on AIDS, who led the South African trial, said any circumcision campaign also had to match medical resources.

If poor countries 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."