AIDS Meeting Spotlight on Circumcision Despite Promising Research, it may be Trouble to Adopt

At a conference often dominated by high-tech research from the world’s most sophisticated labs, a medical practice dating back to biblical times is emerging as potentially the most powerful weapon available to curtail the modern scourge of AIDS.

Male circumcision – the surgical removal of the foreskin from the penis – has been shown in at least one major clinical trial in Africa to reduce the chance of female-to-male transmission of HIV by 60 percent, and policymakers and leaders as prominent as Bill Gates and Bill Clinton have begun to consider ways to vastly expand the practice in regions of the world hardest hit by AIDS.

“If research shows it saves lives, we have to be prepared to deal with it,” Clinton said to a packed hall of over 6,000 delegates at the 16th International AIDS Conference in Toronto, and to thousands of others who filled overflow rooms to watch him on video screens.

Clinton noted that definitive proof that circumcision works is still pending, but he said that if researchers give the procedure the green light, ways must be found to assure that it can be offered in “safe, rapid and comprehensive ways.” And he conceded that, because the decision to circumcise is often deeply rooted in cultural traditions, it is bound to be controversial. “Frankly, it’s going to be a lot of trouble to get it done,” he said.

At a session devoted to circumcision research, scientists reported that, if the 60 percent protective rate holds up, programs to offer safe circumcision in Africa could save thousands of lives and would be extremely cost-effective.

Although dozens of studies since the 1980s have shown that circumcised men in Africa and India appeared to have substantially lower HIV infection rates, agencies such as the World Health Organization and UNAIDS have refused to endorse the procedure until three large-scale, carefully controlled experiments combined prove that it works.

Last year, the first of the three studies found that the protective effect was about 60 percent — and possibly as high as 76 percent – in a group of South African men who were circumcised.

On Tuesday, Walter Reed Army Medical Center researcher Douglas Shaffer reported on a smaller study comparing infection rates of circumcised and uncircumcised men in rural Kenya, and found a 69 percent protective effect. Two remaining large-scale trials are expected to be completed next year in Kenya and Uganda. Results of the Ugandan study are expected in July, the Kenyan study in September.

In the meantime, the startlingly good results of the South African study are prompting researchers to contemplate just how to roll out a campaign to encourage circumcision – and to keep the potentially dangerous procedure safe. Professor James McIntyre of the University of the Witwatersrand in Soweto, South Africa, said hospitals are already reporting an increase in men seeking circumcision on their own.

However, the sensitivities surrounding the operation – which some view as sexual mutilation, others as emblematic of cultural identity – have made major payers such as private foundations and government agencies reluctant to promote it without ironclad scientific proof it is safe and lowers overall HIV risk. As a consequence, McIntyre said, a potentially lifesaving intervention is being held to an unreasonably high standard.

If, for example, a vaginal gel, or microbicide, were found to protect 60 percent of the women using it, “we’d be out promoting it,” he said. “I should think we should at least be planning how to do a scale-up (of circumcision).”

In Tuesday’s session, UCSF researcher James Kahn reported that adult circumcisions could be provided for about $55 per man, and that based on the South African study findings, that investment could save as much as $2,400 in future medical costs for every infection averted.

“As male circumcision is scaled up, it’s an important opportunity to study economics as well as effectiveness,” said Kahn.

Another study by Yale University researchers projected that a program that increased adult male circumcision rates in Soweto by 10 percent each year for five years could save 32,000 lives in that city over 20 years — 52,000 if that rate were doubled to 20 percent. Yale researcher Kyeen Mesesan told delegates that male circumcision “can confer substantial health benefits” and that programs offering even a modest expansion of the procedure should be “implemented immediately.”

French researcher Dr. Bertrand Auvert, who conducted the South African study, separately reported last month in the journal PLoS Medicine, that widespread adoption of circumcision in sub-Saharan Africa could save 3 million lives over 20 years.

At the conference, Auvert said in an interview that “people are reluctant to promote ‘low technology’ ” such as circumcision, and are enamored instead with high-tech treatments. Although he is frustrated that policymakers haven’t moved more quickly to promote circumcision since his study came out, Auvert acknowledged that there are challenges ahead. The surgery in the study was performed by doctors, but Africa faces an acute shortage of physicians. “A health priority is to find a simple, fast way for this to be done by nurses,” he said.