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. Last Updated: 07/27/2016

Circumcision May Slow HIV Spread




DURBAN, South Africa -- Millions of cases of AIDS around the world might have been avoided if circumcision of men were more customary in sub-Saharan African countries where the disease is prevalent. On the other hand, it may simply be that circumcision is more common in populations at low risk for AIDS for different reasons.


Those were the possibilities pondered Monday by AIDS researchers who heard provocative f although far from definitive f information about the links between male circumcision and infection with HIV, the virus that causes AIDS.


Papers presented at the 13th International AIDS Conference here noted that while circumcision is common in broad swaths of Africa, it is uncommon in precisely those parts of the continent where HIV infection is most prevalent and the epidemic is spreading most rapidly.


"If there were a vaccine announced at this conference that could be given in one procedure, no booster needed, that was safe and culturally acceptable, and which was effective 50, 75 or 100 percent of the time, would that be news or not?" said Daniel Halperin, an AIDS researcher at the University of California at San Francisco.


His question suggested circumcision might be the equivalent of such a treatment but has been overlooked. Only a controlled experiment could prove or disprove that idea, and delegates appeared to agree that one is urgently needed.


At the level of national populations, circumcision is highly associated with relatively low rates of HIV infection. Southern Africa contains six countries in which at least 20 percent of adults are HIV-positive and less than 20 percent of men are circumcised. In such West African countries as Nigeria, Liberia and Benin, however, infection with HIV, the human immunodeficiency virus, is only one-fourth as common, while the circumcision rate is four times as high.


In various studies, HIV has infected uncircumcised men two to eight times as readily as those who are circumcised. If even the low end of that range is correct, nearly half the infections in men in such high-prevalence countries as Zambia may be "attributable" to lack of circumcision, Halperin said.


But data presented at the conference Monday demonstrated how tricky such conclusions may be.


In the Rakai District of Uganda, 17 percent of men are circumcised. Among Moslems, the rate is 99 percent; among non-Moslems, 4 percent. Overall, the infection rate among circumcised men is about half that among the uncircumcised. But in the subgroup of circumcised non-Moslems, it has virtually no effect on risk.


Those findings suggest that religion, not circumcision, may be the protective characteristic. Possible explanations are that Muslim men may have fewer casual sex partners f because they are allowed multiple wives f or that religious teaching requires frequent washing, which may decrease viral transmission.


Among married couples, the benefit of circumcision seems more apparent. In the Rakai study, 50 circumcised men were married to HIV-positive women, and none acquired the virus over more than a year's observation. In couples in which the man was infected and the woman not, circumcision did not affect the woman's risk of acquiring HIV.