Two medical studies released today confirm that widespread circumcision of adult men is a powerful weapon against HIV infections in sub-Saharan Africa, a finding that appears destined to reshape AIDS prevention strategies.
The US Global AIDS coordinator, Dr. Mark Dybul, indicated in a statement that the Bush administration, which has committed $15 billion to treating and preventing AIDS in the developing world, will now consider supporting circumcision as a prevention tool.
In the two studies, researchers in Kenya and Uganda enrolled thousands of uncircumcised men to determine if the procedure could reduce HIV transmission among heterosexuals, with some men having their foreskin removed and others remaining intact. Preliminary results so overwhelmingly favored circumcision that US health authorities overseeing the project said they were ethically obligated to stop the trials and offer circumcision to all the men.
The trial in Kenya, involving nearly 2,800 participants, found that the circumcised men were 53 percent less likely to contract HIV. The Ugandan study, with nearly 5,000 men, showed a 48 percent reduction.
The research results emerge a year after a South African study reached a similar conclusion. Africa shoulders 63 percent of the global burden of HIV, with 25 million adults and children infected with the virus that causes AIDS.
Global health authorities, long wary of the social and cultural implications of recommending routine circumcision, moved closer than ever today to embracing the procedure as an important method for reducing infections.
"It does have the potential to prevent many tens of thousands, many hundreds of thousands, maybe millions of infections over coming years," said Dr. Kevin DeCock, chief of the AIDS branch at the World Health Organization. "But this is not just like taking a pill. It's more difficult than that in the reality of African health systems, and this also has huge cultural implications." DeCock said he expects health ministers from Africa to meet with global health officials early next year to translate the findings into policy. Already, other authorities said, extensive consultations have unfolded with health agencies in five African nations -- Kenya, Lesotho, Swaziland, Tanzania, and Zambia -- about the possibility of introducing circumcision programs.
And a Ugandan researcher involved in the circumcision study, Dr. David Serwadda, predicted there would be "very strong demand" for the procedure in his country.
"The government will really have to come up with some plan on how to be able to scale up this very safely," said Serwadda, of Makerere University.
Dr. Anthony S. Fauci, director of the US National Institute of Allergy and Infectious Diseases, said the federal government's global AIDS office was already reviewing the study results and considering how circumcision could be incorporated into US-sponsored prevention campaigns in Africa.
HIV research specialists not involved with the studies said any decision to broadly recommend male circumcision in Africa must be accompanied by expanded training for physicians in how to safely perform the procedure, which costs from $25 to $500. They also reiterated the need for education campaigns stressing that other prevention approaches cannot be abandoned.
"This does not mean throwing out your condoms, this does not mean increasing your number of sex partners, and this also does not mean going to the local healer to have a ritual circumcision performed," said Rowena Johnston, vice president of research at amfAR, a leading AIDS research organization. "Adult circumcision is a serious surgery, and it has to be done under serious circumstances." Ronald Goldman, a Boston psychologist who opposes circumcision, decried the research, saying it failed to take into account any psychological damage from the surgery.
For more than a decade, African physicians had observed that circumcised men seemed less susceptible to HIV. There are biological explanations for that: The skin of the penis of circumcised men is thicker and less prone to penetration by HIV. Conversely, cells in the foreskin of uncircumcised men are especially welcoming to the virus.
Researchers involved in the Kenyan and Ugandan studies said there were few complications reported, with none resulting in permanent injuries.
They said the rate of complications was comparable to what is found among infant males in the United States, where about 70 percent of adult men are circumcised.
They also found no evidence that men in the study who underwent circumcision were more likely to adopt risky sexual practices, such as having unprotected sex or increasing the number of sexual partners.
Researchers said it was too soon to know whether the findings in Africa are relevant elsewhere, in part because while the African epidemic is linked primarily to heterosexual intercourse, it is fueled by different behaviors elsewhere.
Stephen Smith can be reached at firstname.lastname@example.org.