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Male circumcision called a “surgical vaccine”

Over time, male circumcision would probably protect more African women, albeit indirectly, than nearly any other achievable strategy for preventing human immunodeficiency virus (HIV) transmission, write Malcolm Potts of the School of Public Health, University of California at Berkeley, et al. (Science, 2008;320(May 9):749-750).

In nine southern African countries, more than 12% of adults are said to be infected with HIV, and infection has spread outside of the accepted high-risk groups, creating a generalized, heterosexual epidemic. This has frequently been attributed to poverty, illiteracy, limited health services, war, and gender inequity.

HIV has, however, remained concentrated in high-risk groups in countries where male circumcision is common and multiple sexual partnerships, especially concurrent ones, are unusual. For example, Niger, a Muslim country where male circumcision is universal and sexual behavior relatively constrained, HIV prevalence is 0.7%, although it is the lowest ranking country on the Human Development Index.

Botswana, the second wealthiest country in sub-Saharan Africa, has an HIV rate of 25%. It has high levels of multiple concurrent sexual partnerships and lacks circumcision.

UNAIDS has spent nearly $1 billion on condom promotion, probably contributing to a decline in some generalized epidemics, but “there is no evidence of a primary role.” Potts et al. write: “[C]onsistent condom use has not reached a sufficiently high level, even after many years of widespread and often aggressive promotion, to produce a measurable slowing of new infections.”

More than 45 studies have shown that male circumcision significantly reduces risk of heterosexual transmission. All three randomized controlled trials in Africa had to be stopped early for ethical reasons because of initial findings of at least a 60% reduction in HIV risk.

Modeling suggests that male circumcision could avert up to 5.7 million new HIV infections and 3 million deaths over the next 20 years in sub-Saharan Africa. Studies suggest that up to 80% of men in high-prevalence countries would accept the procedure if it were safe and inexpensive.

Educational efforts to reduce promiscuity have also proved effective. In Swaziland, the number of people reporting two or more partners in the preceding month was halved after a 2006 campaign focusing on the dangers of having a “secret lover.” HIV prevalence has declined significantly in Uganda and Kenya after similar campaigns.

At present less than 1% of requested funding is for this “surgical vaccine,” while large donor investments are made in interventions for which evidence of impact is weak.

An article in the Aug 6, 2008, issue of JAMA assesses risk factors for recent HIV conversion in Uganda. The adjusted odds ratio for being uncircumcised was 2.5 (P < .02), which was comparable to that for having more than two sex partners in the last year (2.9). For married men, the adjusted odds ratio for being uncircumcised was higher than for not using a condom with extramarital partners (4.1 compared to 3.2) (JAMA 2008;300:540-549).

Infant circumcision in the U.S. is a topic sparking tremendous interest on the www.SueEasy.com website, as pointed out by Medical Justice, Inc. One complainant said he would claim damages of $10 million.

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