(October 2001) Scientific evidence points to an association between male circumcision and a reduced risk of HIV infection, and efforts are being mounted to provide definitive evidence of the link. The international community, however, is yet to be persuaded that the routine circumcision of men and boys should be among AIDS prevention strategies.

The initial hypothesis that male circumcision offers some protection against HIV came nearly a decade and a half ago — in the early stages of the AIDS epidemic — and scientists have since produced an array of studies and literature on the issue. With no AIDS vaccine in sight, the pressure to expand the range of virus prevention measures is building.

Several studies have drawn a correlation between high rates of HIV in some areas of sub-Saharan Africa and the tendency in those areas not to practice male circumcision (the partial or full removal of the foreskin or prepuce of the penis). The studies note, for instance, that in many of the predominately non-circumcising eastern and southern African countries, HIV infection rates among adults are extremely high. In some parts of southern Africa, the rates exceed 20 percent, with a high in Botswana of 36 percent. Yet in some West African countries where male circumcision is widespread, HIV infection rates among adults are less than 3 percent.

“There are now 40 studies that have shown that men who are not circumcised are at anywhere from a 1.8 to an 8.2-fold increased risk for HIV infection,” said Robert Bailey, professor of epidemiology and anthropology at the University of Illinois at Chicago. Still, Bailey noted, the studies to date have been mainly “observational,” not controlled experiments.

Bailey and his colleagues are preparing to take the research a step further with a rigorous study involving the Luo of western Kenya, one of a few ethnic groups in that country who do not routinely practice circumcision. The randomized controlled trial, to begin in January 2002 with funding from the U.S. National Institutes of Health and the Canadian Institutes of Health Research, should help to advance the international debate on whether male circumcision should be among measures to reduce sexually transmitted HIV.

Meanwhile, other researchers have publicly expressed their skepticism. “Based on the studies published in the scientific literature, it is incorrect to assert that circumcision prevents HIV infection,” according to an article in the International Journal of STD & AIDS. Robert Van Howe of the Department of Pediatrics at Marshfield Clinic in Wisconsin wrote: “Even if studies showing circumcision to be beneficial are accurate, the risk from circumcision outweighs any small benefit it may have. To depend on circumcision to protect against HIV infection in lieu of condoms, which have been shown to be efficacious, is dangerous.”

Although the correlation appears straightforward in Africa, the focus of most of the studies to date, it is not so in more developed countries. The Joint United Nations Programme on HIV/AIDS (UNAIDS) points out that HIV infection rates among gay men do not vary greatly across more developed countries that have varying rates of circumcision. The examples include Japan, where few men are circumcised, and the United States, where four-fifths of men have undergone the practice. But this may be because circumcision is more apt to be effective in preventing transmission of the virus through heterosexual intercourse than through homosexual sex.

Both sides point out that circumcision itself is fraught with risks. A botched procedure can lead to anything from infection and excessive bleeding to dismemberment, and the use of unsanitary tools could actually contribute to the spread of HIV. Of even greater concern, however, is the possibility that male circumcision could encourage risky behavior if it were viewed as a protection against HIV and other sexually transmitted infections (STIs).

Bailey said that an assessment of the risks is an important part of the upcoming trial in Kenya. And Bailey noted that the research is designed to address the concerns raised by Van Howe. Young men from the city of Kisumu in western Kenya, ages 18 to 24, will be recruited for the trial over a two-year period, tested for HIV, and counseled in prevention strategies. Those who do not have HIV will be invited to participate as subjects. Half will be assigned to a circumcision group, and the others will remain uncircumcised. Researchers will follow both groups for two years, providing counseling, condoms, and tests and treatment for STIs including HIV. Bailey and his team have found that more than 70 percent of young men around Kisumu would prefer to be circumcised; at the end of two years of follow-up, subjects from both groups will be offered voluntary circumcision.

At a meeting organized by the Population Council’s Horizons Project last year, an international group of researchers suggested that randomized controlled trials like the one Bailey and his colleagues are about to embark on could answer many additional important questions:

  • What is the foreskin’s biological role in male infection with HIV and other STIs?
  • Are there differences in transmission of HIV to women by circumcised and uncircumcised men?
  • Is circumcision’s apparent protective effect due to culturally or religiously dictated behaviors, such as limiting the number of sexual partners and practicing postcoital washing?

Yvette Collymore is senior editor at PRB.


References

Bob Huff, “Male Circumcision: Cutting the Risk?” (American Foundation for AIDS Research, August 2000), accessed online at www.qpmpa.com/html/male_circumcision.html, on July 31, 2001.

N. O’Farrell and M. Egger, “Circumcision in Men and the Prevention of HIV Infection: A ‘Meta-Analysis’ Revisited,” International Journal of STD & AIDS 11, no. 3 (March 2000): 137-142.

Report on the Global HIV/AIDS Epidemic (Geneva: Joint United Nations Programme on HIV/AIDS, June 2000).

Robert Szabo and Roger V. Short, “How Does Male Circumcision Protect Against HIV Infection?” British Medical Journal 320 (June 10, 2000): 1592-1594.

Johannes van Dam and Marie-Christine Anastasi, Male Circumcision and HIV Prevention: Directions for Future Research (Washington, DC: Population Council, 2000).

Robert S. Van Howe, “Circumcision and HIV Infection: Review of the Literature and Meta-Analysis,” International Journal of STD & AIDS 10, no. 1 (January 1999): 8-16.

Robert S. Van Howe et al., “Some Science Would Not Have Gone Amiss,” Letter to the Editor: Male Circumcision and HIV Prevention, British Medical Journal 321 (Dec. 9, 2000): 1467.