Evidence from over 35 studies is increasingly showing that male circumcision provides significant protection against heterosexual HIV infection and that circumcised males are two to eight times less likely to become infected by women with the virus.

Male circumcision is now being considered as a potential intervention in the prevention of sexually transmitted HIV infection, even though this procedure may have profound cultural implications and carries the risk of complications, a factor that could be addressed.

Earlier this year, the Horizons Project convened a meeting of international researchers in Washington DC to explore the programmatic and research implications of the association between male circumcision and HIV prevention.

Horizons is a five-year (1997-2002) global research project designed to identify and test potential strategies to improve HIV/AIDS prevention, care and support programmes and service delivery.

The researchers at the meeting agreed that there were some unknowns. These related to the mechanisms and the role of the foreskin in the acquisition of HIV infection by men and the expected effect of male circumcision on HIV infection in different populations.

They said little was known about the impact and cost-effectiveness of male circumcision among high risk versus lower risk sero-negative men, while according to some researchers questions remain about the relationship between the age of the person circumcised and risk of HIV infection.

One of the most important concerns, also expressed in South Africa, was that there is also the potential danger that if the idea is popularised that a circumcised man is less likely to become infected with HIV, this could lead to increased risk taking by such men.

But as one South African epidemiologist said: “Most South African men are not using condoms anyway, at least if they are circumcised you decrease the risk.”

Professor Daniel Halperin, based at the University of California, San Francisco and one of the leading researchers on the subject, pointed out that HIV rates in South Africa were high in provinces such as KwaZulu-Natal, North West and Gauteng. These are provinces where the Zulus, Swazis and Tswana, usually non-circumcising ethnic groups, primarily live.

He said one might have guessed, say10 years ago, that the Eastern Cape should have a worse epidemic than KZN as “there is much multiple partnerning, sex work, poverty, high STD rates”.

Yet the epidemic has hit much earlier and much harder in Kwazulu-Natal than the Eastern Cape. Halperin claims that lack of male circumcision could be at least part of the reason for this difference.

There is also increasing evidence of a possible link between lack of male circumcision and dry sex practices, which seem to be much more common among Zulus than Xhosas.

However, Halperin pointed out that HIV rates are now starting to climb in the traditionally circumcising areas such as the Eastern Cape.

Halperin said this could be due to a number of factors, including:

“Also, culturally there may be practices of ‘€˜celebrating’€™ one’s newly established manhood by seeking out lots of women to have sex with.”

Halperin said there was no doubt that a substantial number of men might be getting infected before they got circumcised.

He said most Xhosa men interviewed initially stated that you had to do the circumcision in the mountains or at the circumcision school to be a real man.

“However, when I asked them about going to the school for all the cultural teachings, then at the moment of actual cutting having it done at a nearby clinic, or a doctor or trained nurse coming in to do it, most of them said that would be acceptable or preferable for them or for their boys.”

Halperin found that most men interviewed in Soweto, including those from circumcision practicing ethnic groups, had not been circumcised.

“But they either want to do it or, once appraised of some of the health benefits, many would seriously consider it.”

A study conducted in Kigali, Rwanda, of 837 married men who volunteered for HIV testing showed that uncircumcised men had a statistically significantly higher prevalence of HIV than circumcised men.

This was despite the fact that they had a relatively low-risk profile; that is, they reported fewer lifetime sexual partners and prostitute contacts than circumcised men, were more likely to live in rural areas with lower HIV prevalence rates, and were less likely to report a history of sexually transmitted disease.

Halperin and US researcher Robert Bailey concluded in a paper published in The Lancet that there was now compelling epidemiological evidence from over 35 studies which showed that male circumcision provided significant protection against HIV infection.

Halperin also said there was widespread, though still anecdotal, evidence that circumcised men found is physically easier to use condoms.

Celicia Ferenata, deputy-director of the AIDS Directorate in the national health department said they were watching the ongoing research in other African countries.

“We have discussed whether we should be doing some research here, but don’€™t think it is viable at this stage. The environment is not really conducive to do this type of research where you are dealing with issues such as cultural norms,” Ferenata said.

She said the department would continue to monitor the ongoing research in other African countries, but the department was worried that people may intrepret the promotion of male circumcision as implying that it was okay not to wear a condom if you are circumcised. — Health-e News Service.