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Circumcision, Fidelity More Effective HIV Prevention Methods Than Condoms, Abstinence, Researchers Say

Promoting male circumcision and fidelity to one partner seems to be more effective at curbing the spread of HIV than promoting abstinence and condom use, USAID researcher and technical adviser Daniel Halperin said last week, the Chicago Tribune reports. As Halperin and other researchers analyze 20 years of studies on HIV/AIDS throughout Africa, they have tried to "put aside intuitions, emotions, ideologies and look at the evidence in as coldhearted a way as we can," Halperin said. During a speech at a meeting of the Southern African HIV Clinicians Society in Johannesburg, South Africa, Halperin said he and his colleagues discovered that regular sex partners rarely use condoms, and abstinence merely delays HIV infection among young people by one or two years.

For example, condom use in Ghana and Senegal seems to have helped in the reduction of the spread of the HIV, which in those countries is particularly prevalent among commercial sex workers and their partners. However, condom use in South Africa and Botswana has had little effect in reducing those countries' HIV epidemics -- which have reached the general population -- because regular sex partners rarely use condoms consistently. In comparison, faithfulness to one partner has worked at reducing HIV prevalence in Uganda and Kenya, according to Halperin. Because a person is more likely to transmit HIV during the first three weeks of contracting the virus, an HIV-positive person who has just one partner during that time is likely to pass the disease to that one person. But if an HIV-positive person in the highly infectious stage has many sexual partners at a time, "the virus spreads like wildfire" as those people in turn have sex with other people, Halperin said. In addition, circumcision has been shown to reduce male-to-female HIV transmission by 60% to 75% (Goering, Chicago Tribune, 4/23).

A study published in the November 2005 issue of PLoS Medicine of men living in South Africa finds that male circumcision might reduce the risk of men contracting HIV through sexual intercourse with women by about 60%. Male circumcision might also reduce the risk of HIV transmission from HIV-positive men to their female partners, according to a study of couples in Rakai, Uganda (Kaiser Daily HIV/AIDS Report, 2/9).

Poverty Reduction, Status Awareness
In addition, poverty does not appear necessarily to make a person more susceptible to HIV. "[C]ontrary to popular wisdom, as income levels go up in both men and women, we see higher rates of HIV," Halperin said, adding that people who make more money tend to have more sexual partners. Other HIV prevention methods such as encouraging people to know their status and treating secondary sexually transmitted infections also have not proven effective, Halperin said (Chicago Tribune, 4/23).

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Circumcision and HIV Transmission: The Cutting Edge
Thomas C Quinn
NIAID, NIH and Johns Hopkins Med Inst, Baltimore, MD, US

Background:  From population-based studies and couple studies, the probability of HIV transmission and acquisition has been associated with the blood and genital viral load, male circumcision, sexually transmitted diseases, stage of disease, genetic haplotype, viral subtype, and levels of mucosal immune response. This presentation will review the relationship between male circumcision and HIV transmission and discuss policy implications in promoting circumcision as a prevention modality.

Methods:  This plenary will synthesize information from published and unpublished epidemiologic studies, clinical trials, and mathematical models.

Results:  A systematic meta-analysis of 38 studies, mostly in Africa, found that circumcised men appear to have a 50% or more reduction in HIV infection than did uncircumcised men. A sub-analysis of 16 of these studies found a 70% reduction in HIV infection among higher-risk men. Mapping of the HIV epidemic has demonstrated a strong correlation between regions with higher rates of HIV infection and those with lower circumcision rates. A 2-year cohort study of male partners of HIV-positive women in Rakai, Uganda, found that 40 of 137 uncircumcised men became infected compared with 0 of 50 circumcised men over 2.1 years (p = 0.0004).

Biological explanations include greater ability of the internal foreskin to absorb HIV more efficiently due to the greater presence of Langerhans and other HIV target cells and its greater susceptibility to tears, abrasions, and consequently infection by sexually transmitted diseases and HIV. One randomized controlled trial in South Africa demonstrated that circumcision afforded a 61% (95%CI 34 to 77%) reduction in HIV incidence even after controlling for behavioral factors; and 2 similar trials in Uganda and Kenya are in progress.

Conclusions:  These epidemiologic, biological, and clinical trial results provide strong evidence that male circumcision significantly lowers the risk of HIV acquisition. Mathematical models of implementing male circumcision in countries with high incident rates suggest marked reductions in HIV incidence in men with subsequent decreased transmission rates to women.

Policy implications of recommending male circumcision to populations in high-risk countries need to take into consideration cultural norms, religious traditions, national and local laws.

Circumcision may represent one important biological intervention to decreasing the acquisition of HIV, but will need to be carefully integrated into other HIV prevention and sexually transmitted disease control programs prevent subsequent behavioral disinhibition among circumcised men.

See also:

Could circumcision control HIV/AIDS in Africa?
The truth about condoms
US Aids campaign too moralistic
Pope's critics come out of the closet
Children's sexual activity in South Africa
Iran's spiritual leader attacks moral decay
Christian right