Men speak out on circumcision

Men speak out on circumcision
Beatrice Tonhodzayi
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For two weeks running we have been touching on the hot subject of adult male circumcision and how it has been found to be effective at cutting in half chances of a man getting infected with HIV during heterosexual sex.

The responses from readers have been wide and ranging but the most encouraging thing has been the fact that men, for so long viewed as a species, which does not want to open up, which is stubborn and hesitant to accept other view points- have really opened up on this subject- showing a willingness to open up to new ideas, especially if they may change life for the better.

Opening up about HIV and AIDS issues has helped us in the long run. It has led to more and more people realizing the need to get tested and know their status. Some of those that test positive are living positively and in some cases are now on treatment while those that test negative are trying to maintain their HIV negative status (I hope so.)

That is the reason I have decided to dedicate this piece to giving voices to our men out there, so they speak out on what they think and feel about male circumcision, something that very few men this side of the globe consider as important.

Now that low levels of male circumcision are being linked to our highly alarming HIV statistics in Southern Africa- let us see what our men have to say.

Some, as I expected wanted to know whether “my man” is circumcised or not and suggested that I get him circumcised before I advocate that they do the same. Other circumcised men said it was naughty to suggest that uncircumcised men performed better than them as this would lead to their partners leaving them to search for uncircumcised men.

People, people we miss the point. The point is informing each other of what latest findings say, and how we can use these findings to help ourselves. It is not about me encouraging men to go and get circumcised so they don’t get HIV at all for that is not so. It is about getting information to them so they can make informed decisions should they wish to.

It is not true that once a man gets circumcised, he will never get HIV, NO WAY. If a man goes around like a bird that lands everywhere, he is bound to land in murky waters at some point so be warned. Circumcision is just like a condom, which helps reduce the risk of transmission but is not a guarantee against HIV infection so before men just go for circumcision en masse thinking it is a license for irresponsibility- they should know why they are going for it.

One of our readers Fani wrote: “I have followed your articles about male circumcision and agree with men who are circumcised that, it is indeed a smart thing to do. Apart from reducing HIV infection and other niggling infections as indicated by research, my observation is that it gives a man complete control over his sexuality and gives endurance which translate to multiple orgasms for the female partner.

Ngoni had this to say” People should just turn to God and read the Bible I have recently been born again and been reading the Bible, and read recently this Chapter - Genesis 17:9-14 which says: “Then God said to Abraham, "As for you, you must keep my covenant, you and your descendants after you for the generations to come. This is my covenant with you and your descendants after you, the covenant you are to keep: Every male among you shall be circumcised.

You are to undergo circumcision, and it will be the sign of the covenant between you and me. For the generations to come every male among you who is eight days old must be circumcised, including those born in your household or bought with money from a foreigner - those who are not your offspring. Whether born in your household or bought with money, they must be circumcised. My covenant in your flesh is to be an everlasting covenant. Any uncircumcised male, who has not been circumcised in the flesh, will be cut off from his people; he has broken my covenant," he said.

A reader who preferred anonymity writing from South Africa had this to say: “I personally think it is a good thing to be circumcised and it should be done when children are still young, they will be grateful. My family is from Dembaremba in Honde Valley and from the great grandfathers to my generation we were all circumcised during the first five weeks of birth. I went to a boarding school, Marlborough High School and there, almost, everyone was inspired by my circumcision.

I am really happy that my parents thought of doing this and am grateful to them for such a blessing. By the way, in case other dudes are worried, SA chicks, especially Xhosas and Cape Coloreds like circumcised dudes, he said. Another reader writing from South Africa had this to say: “I am 33 years old male and went voluntarily through the procedure at the Avenues some seven years ago when I was 26 years.

The talk was already there amongst Canadian scientists that circumcision in males could reduce the transmission rate of HIV. So being the visionary that I was, I contacted Dr Raju at Baines and I got circumcised. I found it to be very hygienic. The foreskin is cauldron of bacteria because it is moist. So I can guarantee you that an uncircumcised penis is very difficult to keep clean. Women too are exposed to lots of yeast infections due to the bacteria kept in the folds of the foreskin.

I have not noticed any adverse difference in my enjoyment of sex since circumcision. One thing for sure is that my drawers don’t smell and they are clean. I have a four -ear old son and I am definitely going to have him go through the procedure. Keep the good work.’

Others like Simba wanted to know where to go to get it done. “Which doctors would you suggest I go see and can I know if I will heal quickly for I do not want to go for two months of pain without any activity?”
Micheal Krafft, A Kenyan who has been circumcised for years however had this warning: “I think we all realize that the problems are enormous and will take more people understanding and learning about HIV in schools and in clinics for it to start subsiding. I would not want anyone to think that getting circumcised is as good as using protection. It is a little similar to people thinking that if they are riding in a jeep or landrover that they will be safe in a car crash...the key is to drive safely and not get in a car crash.”

So so true and as a parting shot- I could not have summed it up better myself.

Circumcised or uncircumcised however- be responsible and protect yourself. And do not shut your mind to circumcision men- it is worth thinking seriously about.

Till next time, get me on beatrice@safaids.org.zw

Men should seriously consider circumcision

It is not unheard of. Some men have actually done it and haven’t been maimed for life. On the contrary, some of them called in to tell me that they are circumcised and have not had any far-reaching problems as a result.

For those of you who had fears about your performance after the procedure, it might cheer you a bit to know that five brothers called to tell me that they were circumcised.

And the glory of it — they are all HIV negative.

Now, before you get excited and pin their HIV negative status on circumcision, we cannot be sure whether they are HIV negative because they were circumcised or they have just been lucky.

While two swore that they were faithful to their wives and have been faithful for the past five years, the other three say they have been naughty from time to time and indulged in unprotected sex not because "vaitemba circumcision" but because they just had to have it unprotected.

When they tested negative, however, they vowed to never be careless again.We are still on the subject of adult male circumcision as something that is increasingly becoming effective at cutting in half men’s risk of getting HIV through heterosexual intercourse.

My question last week was if that is the case, should men in this country and region, the epicentre of the pandemic, not start considering it in earnest?Male circumcision is the surgical removal of some or all the foreskin from the male reproductive organ. This removal reduces the ability of HIV to penetrate the skin of the male reproductive organ.

Men with a foreskin are more prone to sexually transmitted infections and several studies now suggest that female partners of circumcised men have a lower risk of cancer of the cervix and re-infections with yeast infections.It is against this background that my piece last week was calling out to men to consider circumcision along with other known and proven prevention methods like the condom.

My thrust was "is it not time to be open-minded and try anything, anything at all that may assist us to get the greatest treatment of all time — PREVENTION.And have you given a thought to the hygiene aspect of circumcision?I observed something --- the foreskin at times makes it difficult to really clean oneself up. How many little boys have you seen hopping from one foot to the other saying "my wee itches?"I have a three-year-old son and he used to complain about this problem and I would worry.

The granny then suggested that I bath him myself at least three times a week and really ensure that he got cleaned under the foreskin. He has not complained since and I trained my helper at home to clean him thoroughly as well.Now with a circumcised little boy (had the good fortune of seeing a niece’s son who was born in the United States) it’s very easy to clean him for everything is out in the open.

Nothing is hidden and as such, he stays dry, unlike the warm moist conditions under the foreskin where bacteria can find a really good home. In addition on the underside of the foreskin are located many immunological cells which are prime targets of HIV. In fact, among some of the responses from readers were some from women who echoed my sentiments that the foreskin hid a lot of things, even sores.

"A man without a foreskin is one without surprises. While his performance is definitely surpassed by one with a foreskin there are many bonuses, chief being that everything is there for the eye to see. There are very few surprises and there is no place for bacteria or gems to hide.

"We keep on getting re-infected with yeast infections and other transmissible infections because they find a warm spot to hide under the foreskin," the very vocal 35-year-old Lissa who is based in London said.

Matthius, who e-mailed me all the way from Australia, said a doctor in Marondera had circumcised him in 2002 after suffering from some problems that made him suffer excruciating pain during sexual encounters. This would result in bruising, which made him very vulnerable to infections.

"I got circumcised and would just like to urge my brothers back home and elsewhere in the region that if circumcision can cut the risk of catching HIV even by two percent, it is worth it. "We are really in a tight fix and should consider anything that might help people," he said.Others, of course, wanted to know whether we have in this country, medical practitioners able to perform the procedure.

I asked around and would just like people to know that there are so many medical practitioners who are qualified to conduct the procedure.

If you need to get it done, have your general practitioner refer you to someone.I was expecting some of the doctors to write in and let the world know the medical aspect of the procedure but our good doctors did not do so. We still would welcome their input though so that we can supply our readers with the correct information.While I have opened my mind to male circumcision and am even considering taking my son in for the procedure (for hygienic purposes though I worry about his reaction when he is older, maybe he would want to make the decision, himself)!

I would like adult males who decide to have it done to know that circumcision is not a licence for irresponsible sexual behaviour. A circumcised man still has to behave very responsibly or else they will still risk getting infected with HIV. And be advised: circumcision also works best with other already proven methods of preventing HIV infection so if it is condoms — they still need to be correctly and consistently used.

If it’s being faithful to one uninfected partner — remain faithful.

Till next time, let’s keep talking about it for in talking about Aids we will demystify it and help each other with answers and information.

Get me as always on beatrice@safaids.org.zw

Perspective: Male circumcision may halve risk of infection

Beatrice Tonhodzayi
18 January 2006
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It’s not just myth or a piece of fiction. There is growing evidence that it is indeed true.

Circumcising adult men may indeed cut in half their risk of getting HIV through heterosexual intercourse.

Several cross-sectional, prospective and population level studies have actually identified lack of male circumcision as a risk factor for HIV infection. The first major clinical trial of 3 000 men in South Africa found in 2005 that circumcision cut the HIV risk by 60 percent.

I don’t know about you but to me that sounds like something worth sitting up and taking notice of.

At a time when prevention is one of the best methods we have of fighting the spread of HIV head on- should we not start looking at male circumcision as one of the ways in which together with the use of condoms, abstaining and being faithful to one uninfected partner- we can reduce some new infections.

I know this is a sore issue with most men this side of the globe, most of who view circumcision as “the last thing” they would ever agree to. They see it as taking away their manhood and as a life-altering experience.

I write this today not because I want to advocate that all men in Zimbabwe and the Southern African region should get circumcised and that way avoid getting infected with HIV. NO way, this remains an individual decision that one reaches after a lot of soul searching, after weighing the pros and cons of such action but my duty is to let you know some of these things so you can be informed and that way-make informed choices.

First of all there is need to know what male circumcision is- male circumcision is the surgical removal of some or the entire foreskin from the male reproductive organ. There are several biological explanations as to why this operation may reduce the risk of HIV infection. Removal of the foreskin reduces the ability of HIV to penetrate the skin of the male reproductive organ. The underside of the foreskin is home to many special immunological cells that are prime targets of HIV.

Men with a foreskin are more prone to have sexually transmitted infections, which can enhance HIV transmission.

While circumcision is common in the United States where it takes place at birth and Moslem countries as well as parts of North Africa and others, where HIV rates are quite low (its difficult to tell whether this is due to circumcision or other factors- though it would be worthwhile to look into it), -here in Sub Saharan Africa where Southern Africa falls- which is home to more than half of the world’ 40 million HIV infected people -it remains rare.

There are some ethnic groups, cultures that practice it but again- they are very few.

Which is why people on this side of the continent need to start thinking of circumcision in earnest-provided of course, they think, like our partners like the UN, which has lately been calling on people not to rule out circumcision when looking at methods of prevention. The UN has been saying together with other preventive methods-circumcision could be an effective tool.

I asked three male colleagues recently if they would consider circumcision and the answer from all quarters was a big fat NO, NEVER.

In fact one of them said I was crazy to suggest such a thing and should first of all get my husband to do it before I went and told other people to do it. Which brings me to the point I made earlier- it’s a sore issue and understandably sore.

The males I spoke to expressed some fears about the safety of undergoing circumcision and I decided to do some checking and found that the most common complications arising after circumcision are minor bleeding and local infection- which is normal after surgery. I delivered my son through Caesarean section and these were the same complications I was advised to expect. Luckily I never had them.

In fact in the recently completed South African study of adult circumcision by general medical practitioners in their surgical offices, the overall complication rate was 3,8 percent. The most commonly reported complications were pain, followed by swelling or hematoma, bleeding and problems with appearance. There was 0,3 percent damage to the male organs, 0,2 percent infection and the only delayed wound healing was a minimal 0,1 percent.

And that is that!

Against the fact that researchers enrolled 2 784 HIV negative men in Kisumu, Kenya and 4 996 HIV negative men in Rakai, Uganda into the studies. Some were circumcised, others were just monitored. Over two years, 22 of the circumcised Kenyans became infected with HIV compared with 47 uncircumcised men, a 53 percent reduction. In Uganda 22 circumcised men became infected versus 43 of the uncircumcised, a 48 percent reduction.

Besides showing that circumcision can be effective at cutting down one’s chances of getting infected with HIV- this also shows that circumcision is not a magic bullet. Ii does not follow that once one is circumcised they can go around like a bird- which is free to sleep land or even leave its dropping anywhere, even on your arm or car window.

Circumcised or uncircumcised – men still have to be responsible. It’s just like a condom, which helps to reduce the risk of transmission but is not a guarantee that one is safe. For circumcision to be really effective-one still has to be faithful to one uninfected partner or use it with other known preventive measures like the condom.

The real issue for most men around the issue of circumcision has been found to be concern about their sexual prowess after circumcision and here it would be interesting if some circumcised males out there would write in and share with us their experiences. Women with circumcised partners- we would also love to hear from you.

From what I came across on the Internet- some women complained that circumcised men did not have as much staying power as their uncircumcised counterparts. Circumcised men, on the other hand said their sexual lives were much better and it was easier for them to practice higher standards of hygiene

Given it that way- what do you think?

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Beatrice Tonhodzayi
SAfAIDS
Email: beatrice@safaids.org.zw

Male Circumcision Should Never Pre-Empt Other HIV Prevention Measures, UN Warns

(UN News Service (New York)

December 14, 2006

United Nations health agencies have given a guarded welcome to United States trials in Africa showing that male circumcision halves the risk of HIV infection in men in heterosexual relations, warning that it should never pre-empt other preventive measures such as the use of condoms.

Proper guidelines "will be necessary to prevent people from developing a false sense of security and, as a result, engaging in high-risk behaviours which could negate the protective effect of male circumcision," they said in a joint statement.

They plan to quickly draw up guidelines after examining the implications, particularly in sub-Saharan Africa and elsewhere with high HIV prevalence and low male circumcision levels, taking into account cultural and human rights aspects and the need to ensure that circumcisions are performed safely by well-trained practitioners in sanitary settings.

"Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection," they said. "Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners.

"Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counselling," they added.

The statement was issued by the UN World Health Organization (WHO), UN Population Fund (UNFPA), UN Children's Fund (UNICEF), the Joint UN Programme on HIV/AIDS (UNAIDS) and World Bank.

Noting that the trials' results will likely heighten interest in male circumcision from governments, non-governmental institutions and the general public, the agencies said they would define specific policy recommendations for promoting male circumcision after a detailed review of the findings.

The recommendations will take into account cultural and human rights considerations; the risk of complications from the procedure performed in various settings; the potential to undermine existing protective behaviours and strategies; and the fact that the ideal and well-resourced conditions of a randomized trial are often not replicated in other settings.

To support countries or institutions that decide to scale up male circumcision, the agencies are developing technical guidelines on ethical, rights-based, clinical and programmatic approaches.

They are also drawing up 'rapid assessment toolkits' for determining circumcision prevalence and acceptability; identifying key providers; estimating costs; and monitoring numbers of circumcisions performed, their safety, and their potential impact on sexual behaviour.

Questions and Answers: NIAID-Sponsored Adult Male Circumcision Trials in Kenya and Uganda

1. Who funded and who conducted the two adult male circumcision trials in Africa?

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), supported two clinical trials, one in Rakai, Uganda, and the other in Kisumu, Kenya, designed to determine whether adult male circumcision is safe and can prevent men from acquiring HIV infection in geographic areas where heterosexual transmission of the virus is most common.

The Ugandan study, led by Drs. Ronald Gray and Maria Wawer of Johns Hopkins Bloomberg School of Public Health and Drs. David Serwadda and Nelson Sewankambo of Makerere University in Kampala, Uganda, enrolled 4,996 men since the trial began in August 2003.

The Kenyan trial, also known as the UNIM trial (Universities of Nairobi, Illinois and Manitoba trial), opened in February 2002, in a collaborative effort between U.S., Canadian and Kenyan researchers. Drs. Robert Bailey, University of Illinois, Chicago, Stephen Moses, University of Manitoba, Jeckoniah Ndinya-Achola, University of Nairobi, and Kwango Agot, UNIM, are funded by NIAID and the Canadian Institute of Health Research. This trial enrolled 2,784 men.

2. What is a Data and Safety Monitoring Board, and how does it monitor this study?

A Data and Safety Monitoring Board (DSMB) is an independent committee composed of clinical research experts, statisticians, ethicists and community representatives. The DSMB reviews data while a clinical trial is in progress to ensure the safety of participants. The DSMB may recommend that a trial, or part of a trial, be stopped if there are safety concerns or if the trial objectives have either been achieved or are unlikely to be achieved. During the trial, the DSMB looks at analyses that are not available to the investigators or to anyone else.

3. What were the results of the most recent DSMB review of the two circumcision trials?

The NIAID adult male circumcision trials have been under the review of the NIAID Prevention DSMB. On December 12, 2006, the NIAID DSMB reviewed an interim data analysis of the trials and determined the following:

Adult male circumcision performed by trained medical personnel and with appropriate post-surgical follow-up to ensure management of any infections or other problems with wound healing was shown to be safe.
Among men in these trials, adult male circumcision reduced the risk of acquiring HIV infection by 48 percent in the Ugandan study and by 53 percent in the Kenyan study.
Given these results, both trials will offer men in the control group circumcision. In order to understand the long term impact of adult male circumcision, the studies will continue to measure HIV infection rates and to study the risk-taking behavior and attitudes of participants.

4. What is adult male circumcision and how was it performed in these studies?

Adult male circumcision is a surgical procedure to remove the foreskin (prepuce) of the male penis. The NIAID-supported trials tested whether there is a decreased risk of HIV infection among men who were circumcised, in which their foreskin has been nearly or completely removed, compared with men who were not circumcised. Both studies performed the circumcision in a surgical room with local anesthesia.

The circumcision procedure used in the Kenyan trial was the foreskin clamp method. The Kenyan trial procedure took about 25 minutes and used stitches to control bleeding and improve wound closure. The circumcision procedure used in the Ugandan trial is known as the sleeve method and takes about 30 minutes. The Ugandan trial used cauterization of the blood vessels to control bleeding and stitches to close the wound. Both methods are commonly used throughout the world.

5. How were the studies designed?

Both trials recruited healthy, HIV-negative uncircumcised men who planned to remain near the study site for the duration of the trial. The trial in Uganda recruited men between 15 and 49 years old; the trial in Kenya recruited men between 18 and 24 years old.

After an initial HIV screening and a medical exam, eligible men were randomly assigned either to receive circumcision immediately or to wait two years before circumcision. All participants were closely followed for two years to collect information about their health, sexual activity, and theirs and their partners’ attitudes about circumcision; to counsel participants in HIV prevention and safe sex practices; and to check the HIV status of the volunteer. Participants in the Kenyan study were scheduled for six visits over the two-year follow-up, compared with four visits for the Ugandan trial participants. In addition to the study visits, men enrolled in the Kenyan trial were encouraged to receive all of their outpatient health care at the study clinics, which enabled researchers to collect information on the safety of the procedure and the number of other sexually transmitted diseases the men had during follow-up.

6. What were the primary objectives of the adult male circumcision trials?

The primary objectives of these studies were to determine whether adult male circumcision 1) can be administered safely, and 2) reduce the risk of acquiring HIV infection through heterosexual contact.

7. Why were these studies done?

Previously published studies on male circumcision found a protective effect against HIV acquisition ranging from 40 to 88 percent. However, since male circumcision is closely tied to culture, it was not possible to rule out other cultural factors as the reason for the lower HIV rates in circumcised men. Scientists concluded that there was insufficient evidence from these observational studies to support adult male circumcision as a means of reducing HIV acquisition in men, and therefore, called for randomized controlled trials of adult male circumcision.

8. What other trials have been conducted?

The first randomized controlled trial of adult male circumcision was funded by the French government’s research agency, Agence Nationale de Recherches sur la SIDA (ANRS). The trial, ANRS-1265, was conducted in South Africa to test the effect of adult male circumcision on HIV acquisition. Led by Dr. Bertran Auvert, the investigators found a 60 percent reduction in HIV acquisition for the men enrolled in the circumcised arm of the trial. (Auvert B, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Epub 2005 Oct 25.) There were a total of 69 HIV infections among participants: 20 were among the 1,546 circumcised men and 49 among the 1,582 uncircumcised men.

Despite these results, there was still debate among clinicians, policy makers and the international community over whether these results could be generalized to different populations. These NIAID-sponsored trials provide additional scientific evidence for the role of adult male circumcision in HIV prevention.

9. How could male circumcision prevent HIV infection?

There are several proposed mechanisms for how male circumcision might reduce a man’s risk of HIV infection. The foreskin’s inner mucosal surface is more susceptible to HIV because it has more immune cells vulnerable to HIV infection than the external surface. Furthermore, the foreskin acts as a physical barrier, trapping HIV next to the mucosal surface of the penis for a longer period of time. In this moist environment, the virus can also survive longer, potentially increasing the risk of infection. Small tears in the foreskin as a result of intercourse could also promote entry of the virus. After circumcision the penile shaft and glans develops more epithelial keratinization, a process which makes the penis less susceptible to viral invasion.

10. What are possible negative biological and behavioral complications associated with adult male circumcision?

Male circumcision is a surgical procedure with recognized risks. There have been multiple reports of serious complications and adverse events following improperly performed male circumcision, including serious infection, severe loss of blood, mutilation, penile amputation and death. These serious complications are due to poor training of those performing circumcision, lack of appropriate surgical equipment, and lack of patient follow-up.

Furthermore, the procedure requires some time for healing, and during that time there is a break in the epithelial (skin) surface of the penis. This incision site may be a portal for HIV entry and until fully healed, it may increase the risk of HIV infection. For this reason, men in the trials were cautioned to not resume sexual activity until the incision was fully healed and checked by the physician.

As with most prevention strategies, adult male circumcision is not completely effective at preventing HIV transmission. Millions of circumcised men have become infected with HIV through heterosexual exposure to the virus. Men who receive adult male circumcision may perceive that they are at decreased risk for transmission and, therefore, may not maintain other risk reduction strategies. Modest increases in the number of sexual partners could negate the protective effect and increase the rate of HIV transmission in a community. Adult male circumcision will be most effective when integrated into a comprehensive prevention strategy which includes the ABCs (Abstinence, Be Faithful, and Condoms) of HIV prevention.

11. How common is male circumcision in Africa?

Studies have shown that overall, 62 percent of adult males in Africa are circumcised. However, there are significant differences in these rates by region and tribal groups. In particular, male circumcision is strongly tied to religious beliefs. In Southern Africa, where the HIV epidemic is the most severe, rates of male circumcision are less than 20 percent.


12. How acceptable is adult male circumcision in Africa?

Surveys conducted in Africa in both men and women have found that adult male circumcision is acceptable (50 to 86 percent), provided that the procedure is safe, affordable and has minimal side effects or pain. Among the reasons cited include better hygiene, lower sexually transmitted disease rates, more modern/urban appearance, peer pressure and perceived attractiveness to women. However, because of varying religious and cultural norms, not all groups or communities practice adult male circumcision.

13. How might these new findings affect future HIV prevention strategies?

These results indicate that HIV transmission to men could be lowered, though not eradicated, by increased rates of male circumcision.

Adult male circumcision is only one component of a comprehensive prevention strategy. As a partially effective procedure, it can be an important component of a comprehensive prevention strategy that also stresses the ABCs: abstinence and delay of sexual debut, overall partner reduction and reduction in number of concurrent partners and correct and consistent use of condoms.
These studies looked only at risk of heterosexual HIV transmission from females to males. The risks associated with other modes of transmission, such as male-to-male and male-to-female sexual transmission, are not addressed, and risks associated with needle sharing are not affected.

14. How will these findings influence other prevention trials already under way?

Other trials and research are under way to evaluate methods and strategies (e.g., microbicides, pre-exposure prophylaxis, vaccines and behavioral interventions) for HIV prevention. These studies are being conducted in a variety of different populations and settings.

These result indicate that adult male circumcision may play an important role in the prevention of heterosexual HIV transmission to males in some areas of the world. In areas where international and country-specific HIV prevention recommendations are adapted to include male circumcision, research trials will need to determine how to ensure that education about, and access, to safe male circumcision is incorporated into comprehensice trial prevention services.

15. Will these results have an effect on policy in Africa and other regions?

United Nations agencies, including the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO), are multinational organizations that guide health ministries and aid organizations in determining how research findings should be applied to recommendations for and provision of health services in different parts of the world. These agencies will review the data from these studies and develop appropriate policy guidelines. In preparation for the possibility of these findings, WHO and UNAIDS are working with key stakeholders in several countries to host country consultations and conduct needs assessments to help prepare for any change in policy that may result from the findings of these studies. To learn more about the international response to the study findings, visit the WHO website at www.who.int/hiv and the UNAIDS website at www.unaids.org.

16. How will these results affect the U.S. epidemic?

These NIH studies have focused on populations in Africa, where the infection rate is high and where heterosexual sex is the predominant mode of HIV transmission. In the United States, the majority of adult men are already circumcised. According to the U.S. Centers for Disease Control and Prevention (CDC), in a 1992 survey, 77 percent of men in the United States reported being circumcised. In addition, there is a lower prevalence of HIV in this country, and the men at greatest risk have been those who have sex with other men. The degree of protection that circumcision may afford for men who have sex with men is unknown. For all of these reasons, the study findings will likely have less of an impact in the United States. Information about circumcision is available from the CDC at http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm.

17. Are other studies of male circumcision being conducted?

In addition to the NIAID trials in Uganda and Kenya, a randomized trial led by researchers at Johns Hopkins University is studying whether male circumcision reduces male-to-female HIV transmission. (In contrast, the NIAID trials studied whether male circumcision reduces female-to-male transmission.) The Johns Hopkins-led trial, which is supported by a grant from the Bill & Melinda Gates Foundation, is scheduled for completion in 2007.

Adult Male Circumcision Significantly Reduces Risk of Acquiring HIV: Trials Kenya and Uganda Stopped Early

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), announced an early end to two clinical trials of adult male circumcision because an interim review of trial data revealed that medically performed circumcision significantly reduces a man’s risk of acquiring HIV through heterosexual intercourse. The trial in Kisumu, Kenya, of 2,784 HIV-negative men showed a 53 percent reduction of HIV acquisition in circumcised men relative to uncircumcised men, while a trial of 4,996 HIV-negative men in Rakai, Uganda, showed that HIV acquisition was reduced by 48 percent in circumcised men.

“These findings are of great interest to public health policy makers who are developing and implementing comprehensive HIV prevention programs,” says NIH Director Elias A. Zerhouni, M.D. “Male circumcision performed safely in a medical environment complements other HIV prevention strategies and could lessen the burden of HIV/AIDS, especially in countries in sub-Saharan Africa where, according to the 2006 estimates from UNAIDS, 2.8 million new infections occurred in a single year.”

“Many studies have suggested that male circumcision plays a role in protecting against HIV acquisition,” notes NIAID Director Anthony S. Fauci, M.D. “We now have confirmation—from large, carefully controlled, randomized clinical trials—showing definitively that medically performed circumcision can significantly lower the risk of adult males contracting HIV through heterosexual intercourse. While the initial benefit will be fewer HIV infections in men, ultimately adult male circumcision could lead to fewer infections in women in those areas of the world where HIV is spread primarily through heterosexual intercourse.”

The findings from the African studies may have less impact on the epidemic in the United States for several reasons. In the United States, most men have been circumcised. Also, there is a lower prevalence of HIV. Moreover, most infections among men in the United States are in men who have sex with men, for whom the amount of benefit provided by circumcision is unknown. Nonetheless, the overall findings of the African studies are likely to be broadly relevant regardless of geographic location: a man at sexual risk who is uncircumcised is more likely than a man who is circumcised to become infected with HIV. Still, circumcision is only part of a broader HIV prevention strategy that includes limiting the number of sexual partners and using condoms during intercourse.

The co-principal investigators of the Kenyan trial are Robert Bailey, Ph.D., M.P.H., of the University of Illinois at Chicago, and Stephen Moses, M.D., M.P.H., University of Manitoba, Canada. In addition to NIAID support, the Kenyan trial was funded by the Canadian Institutes of Health Research and included Kenyan researchers Jeckoniah Ndinya-Achola, M.B.Ch.B., and Kawango Agot, Ph.D., M.P.H. The Ugandan trial is led by Ronald Gray, M.B.B.S., M.Sc., of Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. Additional collaborators in the Ugandan trial were David Serwadda, M.Med., M.Sc., M.P.H., Nelson Sewankambo, M.B.Ch.B., M.Med.M.Sc., Stephen Watya, M.B.Ch.B., M.Med., and Godfrey Kigozi, M.B.Ch.B., M.P.H.

Both trials involved adult, HIV-negative heterosexual male volunteers assigned at random to either intervention (circumcision performed by trained medical professionals in a clinic setting) or no intervention (no circumcision). All participants were extensively counseled in HIV prevention and risk reduction techniques.

Both trials reached their enrollment targets by September 2005 and were originally designed to continue follow-up until mid-2007. However, at the regularly scheduled meeting of the NIAID Data and Safety Monitoring Board (DSMB) on December 12, 2006, reviewers assessed the interim data and deemed medically performed circumcision safe and effective in reducing HIV acquisition in both trials. They therefore recommended the two studies be halted early. All men who were randomized into the non-intervention arms will now be offered circumcision.

“It is critical to emphasize that these clinical trials demonstrated that medical circumcision is safe and effective when the procedure is performed by medically trained professionals and when patients receive appropriate care during the healing period following surgery,” notes Dr. Fauci.

Researchers have noted significant variations in HIV prevalence that seemed, at least in certain African and Asian countries, to be associated with levels of male circumcision in the community. In areas where circumcision is common, HIV prevalence tends to be lower; conversely, areas of higher HIV prevalence overlapped with regions where male circumcision is not commonly practiced.

Results of the first randomized clinical trial assessing the protective value of male circumcision against HIV infection, conducted by a team of French and South African researchers in South Africa, were reported in 2005. That trial of more than 3,000 HIV-negative men showed that circumcision reduced the risk of acquiring HIV by 60 percent.

More proof that a snip in time could save men from HIV

JOHANNESBURG, 13 December (PLUSNEWS) - American research bodies have called an early halt to trials of adult male circumcision in Kenya and Uganda after results showed that men who had undergone the procedure dramatically lowered their risk of contracting the HI virus.

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), announced an early end to two clinical trials of adult male circumcision after an interim review of the data revealed that medically performed circumcision significantly reduced a man's risk of acquiring HIV from having heterosexual intercourse.

The trial involving almost 3,000 HIV-negative men in Kisumu, in the western highlands of Kenya, showed a 53 percent reduction in contracting HIV among those who were circumcised, while a trial with about 5,000 HIV-negative men in the Rakai District of central Uganda showed that HIV acquisition fell by 48 percent in circumcised men.

"These findings are of great interest to public health policy-makers who are developing and implementing comprehensive HIV prevention programmes," said NIH Director Dr Elias Zerhouni in a statement. "Male circumcision, performed safely in a medical environment, complements other HIV prevention strategies and could lessen the burden of HIV/AIDS, especially in countries in sub-Saharan Africa where, according to the 2006 estimates from UNAIDS, 2.8 million new infections occurred in a single year."

This confirmed research conducted last year by a team of French and South African scientists, who found that circumcision appeared to reduce the chances of HIV infection in such men by up to 60 percent. So dramatic was the protective effect that the South African trial was also stopped early because it was considered unethical not to offer the uncircumcised men in the control group the chance to have the operation immediately.

More than 30 studies around the world have suggested that circumcision can protect men from HIV to some degree, but the South African trial was the first randomised, controlled study to demonstrate the extent of protection.

After calls for safe male circumcision to be integrated into national HIV-prevention strategies, several African countries have acted on the results of the South African-based study: Zambia and Swaziland both launched national male circumcision programmes, while a report by the 14-member Southern African Development Community described male circumcision as "a one-off intervention conferring lifelong reduced biological risk". Other countries, including South Africa, have delayed action until the results of the study in Kenya and Uganda were available.

NIAID has warned that this does not mean circumcision alone can prevent men from becoming infected with HIV during sexual intercourse, emphasising that "circumcision is only part of a broader HIV prevention strategy that includes limiting the number of sexual partners and using condoms during intercourse".