Circumcision is backed for Africa

WASHINGTON -- The World Health Organization and UNAIDS yesterday recommended that African males living in the heart of the AIDS pandemic protect themselves against HIV by undergoing circumcision -- medical advice that could lead to surgical procedures on tens of millions, from infants to elders.

The health officials said that male circumcision is the most potent scientifically proven protection in years against the AIDS epidemic; one study predicts that circumcision could avert up to 2 million infections over the next decade.

"This is an exciting development, but this is partial protection for men," Catherine Hankins , UNAIDS's chief scientific adviser, told reporters. "It's not to be scoffed at. We haven't had news like this in a long time."

The WHO and UNAIDS aimed the recommendations at men in countries with high rates of HIV prevalence spread heterosexually, mainly in southern Africa and parts of eastern Africa.

Health officials said it was unclear whether circumcision would carry the same protective benefits for men who have sex with men -- a primary driver of the AIDS epidemic in the United States. No scientific studies have addressed that issue.

An estimated 77 percent of US males are circumcised, and the Centers for Disease Control and Prevention is planning to convene a meeting of specialists soon on the matter to determine its next step.

Hankins said that even in countries like the United States, health officials could recommend circumcision for men who face specific risks, such as a relationship with an HIV-positive woman.

But in Africa, the area of greatest need, for all the great potential of circumcision, governments are not likely nor able to provide circumcisions on a large scale, according to health advisers in Africa, Europe, and the United States.

"The truth is there hasn't been a great deal of preparation" even though the first evidence of circumcision's protective values emerged more than 18 months ago, said David Alnwick , UNICEF's Nairobi-based senior HIV/AIDS adviser for eastern and southern Africa. Since then, just six sub-Saharan African nations have convened public meetings to discuss ways of expanding the services.

Experts say the reasons are varied: for already overburdened health systems, the prospect of circumcising so many boys and men is daunting; most developing countries in Africa have a dire shortage of health workers; and governments either don't have enough money to pay for it or choose not to spend more on public health, creating a dependency on rich countries for donations.

And although an estimated 62 percent of African males are circumcised, there are still tough cultural barriers against the practice. Circumcision is common among Muslims and some nations that had been European colonies, but many tribes and other groups have no history of it.

Some countries also have resisted planning to make circumcision a public health policy until they received WHO's advice. Many want to know if the US government, the World Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria can help pay for it.

WHO and UNAIDS officials yesterday stressed that countries should offer circumcision in a package of services that includes HIV testing and counseling, promoting proper use of condoms, and counseling men on ways of reducing the risk of contracting HIV.

Circumcised men can still become infected, although their risk is lower than those who have not had the procedure, according to randomized trials involving several thousand men conducted over the last several years in South Africa, Uganda, and Kenya.

The wait-and-see approach taken by many African countries has frustrated several public health specialists.

"I'm hearing on a weekly basis where people in some ministries of health are saying, 'Wow, this data is interesting,' and they are sending their own sons to get circumcised, or their spouses, or themselves," said Daniel Halperin , a senior research scientist at Harvard's School of Public Health, who for years has prodded health agencies about circumcision as a way to slow the spread of HIV.

"The elites are rushing out already to be circumcised," he said, "but what is it going to take to put pressure on these people to make it available fo r the poor guys?"

Dr. David Serwadda , director of the Institute of Public Health at Makerere University in Uganda, one of the leaders of the Uganda circumcision trial, said that "my worry is as people would like to have this service," people who aren't qualified to perform it will rush forward to meet the demand.

A Uganda study found that 35 percent of all circumcisions performed by such people, including traditional healers, resulted in post surgical complications such as infections; in comparison, just 1.7 percent of circumcisions performed in the controlled Uganda trial had complications.

But Dr. Michel Kazatchkine , who will become executive director of the Global Fund next month and who oversaw the South African circumcision study, cautioned that all new public health interventions take time to catch on.

"We're 20 years into AIDS and we still have communities, constitutuencies, and countries that are reluctant to make condoms freely available," he said in an interview. "People will find the 150 reasons not to go into [circumcisions] just as they opposed use of condoms."

Male circumcision removes part or all of the foreskin of the penis. If an intact foreskin tears during unprotected sex, it can provide an entry point for HIV, a virus that leads to AIDS. Under the foreskin are Langerhans cells, which are more vulnerable to HIV infection.

In June 2005, when it became clear that the South Africa trial would show the protective value of circumcision, UNAIDS and WHO convened a meeting of medical leaders in Johannesburg to discuss ways of moving ahead. In the next year, they held several other meetings; the Bill & Melinda Gates Foundation donated $1 million.

Hankins said that six countries -- Lesotho, Swaziland, Zambia, Tanzania, Kenya, and Malawi -- held public meetings to discuss expanding circumcision services.

She said the most important immediate step now is to send out the proper messages on circumcision.

She said possible examples are "I'm circumcised, but I'm faithful," or "I'm circumcised and I use condoms."

John Donnelly can be reached at donnelly@globe.com