Monday, December 18, 2006

It's the end of the foreskin as we know it

Another C -- circumcision -- looks set to be added to the “Abstain, Be Faithful and Condomise” HIV prevention campaigns after conclusive evidence emerged this week that removing a man’s foreskin can halve his chances of catching HIV.

Two clinical trials, in Uganda and Kenya, have confirmed previous South African research into the protective power of circumcision.

The news has been hailed as one of the most significant breakthroughs in the fight against HIV for years, with the potential to prevent millions of new infections.

Circumcision as a prevention measure is not a part of the South African government’s draft strategic plan on HIV/Aids, although Aids experts expect this now to change rapidly.

The way is open for governments and funders to roll out mass circumcision campaigns and several of the biggest donor organisations are said to be looking at providing funding.

No African country has yet adopted mass circumcision as a policy, although several countries have been discussing the measure. And some, such as Kenya, have created task teams to tackle implementation.

Swaziland has “circumcision Sundays” to encourage men to undergo the operation.

The Kenyan and Ugandan clinical trials were terminated early, after preliminary research found that circumcision was so safe and effective that it would be unethical not to offer the operation to the uncircumcised control group.

In 2005 a similar trial in South Africa’s Orange Farm was also halted on ethical grounds after it found at least a two-thirds reduction in new HIV infections among circumcised men. Research into whether circumcision also protects female sexual partners from HIV infection is ongoing, although there is indirect evidence suggesting it will.

Male circumcision as a public health measure has been controversial, with some arguing that it is mutilation. There is also concern that circumcised men may practise riskier sex out of over-confidence, and that circumcision may be culturally inappropriate.

However, studies in Africa indicate most men would have the operation as protection against HIV, even if circumcision is not part of their culture.

Anthony Fauci, the director of the National Institute of Allergic and Infectious Diseases, which oversaw the latest research, said there did not seem to be a significant rise in risky sex among circumcised men, although this would continue to be monitored. As circumcision confers only partial protection, men and their partners are still urged to practise safer sex, especially condom usage.

“This data is going to put some people on the spot,” said Harvard researcher Daniel Halperin, who has advocated expanding circumcision for several years. “The response of the international agencies and donors will be crucial. Many people were basically putting aside the Orange Farm data and saying lets see what Uganda and Kenya show. It’s now shown to be at least 50% to 60% effective. Considering how many people are dying from this disease, that is a rather powerful result. Circumcision services need to be made available, safe and affordable.

“The ideal scenario now would be an increase in male circumcision and a decrease in concurrent sexual partners, probably the two strongest things impacting on the spread of HIV, along with consistent condom use.”

In the Kenyan trial, involving 2 784 men, circumcision reduces participants’ risk of catching HIV by 53%. In the Ugandan research there was 48% reduction among the 4 996 participants.

The protective effect is the result of the removal of the mucosal inner lining of the foreskin, which is far more vulnerable to HIV infection than vaginal mucus membranes. An uncircumcised penis also provides a comfortable environment for other sexually transmitted diseases, in turn providing a portal into the body for HIV.

The challenge will now be to be to spread the news among men and their partners, and to implement safe mass circumcision campaigns. One danger is that men may use unregulated and risky circumcision providers, such as “initiation” schools.

In South Africa, the most common method is to use forceps and scissors to slice off the unwanted piece of skin. The wound is cauterised and stitched with dissolvable thread, and healing takes, at most, six weeks.

The procedure is often carried out under local anaesthetic injected into the base of the penis.

But there is growing research into other techniques, including “bloodless” procedures where the foreskin is held tightly in a clamp for several days until the blood-starved skin dies and drops off. Involuntary erections can, however, interfere with the procedure, while the different kinds of clamp need to be sized to fit each individual man.

Other options being examined are surgical glue rather than stitching, because it is fast and potentially less vulnerable to infection. However, the highly adhesive glue could lead to serious -- and potentially permanent -- problems if applied accidentally to the wrong areas.

Circumcision: A History of the World's Most Controversial Surgery