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September 2000, Vol. 6, No. 3 HIV Prevention A growing body of research shows that uncircumcised men in certain parts of Africa are twice as likely as circumcised men to be HIV infected. This finding suggests that male circumcision may offer a measure of protection against HIV infection, and public health experts have begun to debate the possibility of encouraging male circumcision as an anti-HIV intervention. To explore this issue, the Population Council’s Horizons Project organized a two-day meeting of scientists from around the world. The participants identified several cultural, medical, and ethical issues that should be explored before the procedure is recommended as an intervention. The Horizons Project is a five-year global program devoted to HIV-related operations research and implemented by the Council, along with the International Center for Research on Women, the Program for Appropriate Technology in Health, the International HIV/AIDS Alliance, the University of Alabama at Birmingham, and Tulane University. Many unknowns Van Dam and his colleague Marie-Christine Anastasi collaborated on a publication summarizing a number of knowledge gaps and research recommendations discussed at the meeting. The publication can be downloaded from the Council’s Web site by following this hyperlink. There has been little research, as well, into the feasibility and acceptability of male circumcision as a public health intervention. For example, most circumcisions in Africa today are performed by traditional practitioners, who may not operate under sterile conditions. Some methods of circumcision may place boys and men at risk for infection, sepsis, hemorrhage, partial penile amputation, or even death. Certain practices, such as using the same knife for each man during a circumcision ceremony, may increase the risk of transmitting HIV through blood-to-blood contamination. The cost-effectiveness of such an intervention in developing countries also cannot be overlooked. “We must always strategically prioritize to achieve maximum health benefits for the limited resources available for HIV prevention… we should not rush to put these meager resources into an unproven strategy like male circumcision just because it’s new,” explains conference participant Francis Ndowa of the World Health Organization. Furthermore, not enough is known about the relationship between age at circumcision and risk of HIV infection. While it is likely that circumcision offers a similar level of protection to HIV-negative men regardless of the age at which it is performed, older men may be more likely to be infected with HIV than are younger men. Circumcision may be most protective against HIV acquisition when it is done before or soon after the onset of sexual activity. Finally, while male circumcision may benefit men, questions remain as to whether the practice would make women more or less vulnerable to HIV infection. For instance, a reduction in HIV infection in men will over time reduce the exposure of women to sexually transmitted HIV infection. If men believe they are protected from HIV infection by circumcision, however, women’s efforts to negotiate condom use may suffer. Van Dam and Anastasi report that men have referred to circumcision as the “invisible condom.” These questions and others will not be answered without further research. Participants at the conference suggested several necessary avenues of investigation that public health scientists should explore before recommending circumcision as a blanket intervention to combat HIV infection. “We need to move interventions from the domain of myth, culture, and religion to the science of public health,” notes meeting participant Robert Bailey of the University of Illinois at Chicago. Researchers should examine the transmissibility of HIV infection to women by circumcised and uncircumcised men; analyze the role of possible confounding factors, such as religion; conduct randomized controlled trials of a male circumcision intervention to examine its efficacy in preventing HIV infection; conduct descriptive studies of attitudes and beliefs regarding male circumcision as an acceptable HIV intervention in currently non-circumcising populations; test mechanisms for implementing voluntary, safe, and effective male circumcision interventions; and develop and field test a rapid-assessment tool to evaluate the feasibility and cost of introducing male circumcision. Source | |||||||||||||||||||||||||||||||||||||||||||||||
