OP-ED: Circumcision can curb HIV rates

Date: Saturday, January 10, 2009
Source: Weekend Australian (Australia)
Author: ALEX WODAK

Should Australia increase infant male circumcision now to control future HIV? The question is controversial, but the case for doing so is getting stronger.

The number of new HIV diagnoses in Australia increased each year from 718 in 1999, reaching 1051 new cases in 2006-07. As in all previous years since the HIV/AIDS epidemic was first recognised in the early 1980s, sex between males still accounts for the largest proportion of new cases. But the proportion of these cases has been slowly dropping in Australia and has now reached 64 per cent.

In contrast, sex between men and women, the second most numerous category since the 1980s, has been slowly increasing and reached 21 per cent in 2003-07. In most other developed countries, the proportion of new HIV cases attributed to sex between men and women has been growing steadily.

Reducing the spread of HIV among non-drug-using men and women around the world has been particularly difficult. Few have changed their sexual behaviour (including using condoms when having sex with casual partners). Compelling evidence now shows that male circumcision, surgical removal of the foreskin of the penis, can substantially reduce heterosexual HIV spread. However, the rate of infant male circumcision in Australia may be as low as 20 per cent. Australia should start trying to increase the rate of infant male circumcision to reduce heterosexual HIV spread in future decades.

Soon after the HIV/AIDS epidemic was first recognised, researchers noted that HIV was much more prevalent in African countries where male circumcision was uncommon (such as Zambia, Zimbabwe, Botswana and Swaziland), and much less prevalent in countries where male circumcision was common (such as Madagascar, Senegal and Guinea). The same pattern was noted in Asia.

Combining the results of 38 studies (mostly from Africa), circumcised men are less than half as likely to contract HIV as uncircumcised men. Three trials carried out recently in South Africa, Kenya and Uganda collectively enrolled over 11,000 men who wanted to be circumcised. These men were randomised to remain uncircumcised for the duration of the study or were circumcised by doctors specially trained for the study. All three studies were terminated early because such a large protective effect of circumcision was found that it was considered unethical to continue.

These findings have been strengthened by the identification of several plausible biological mechanisms for greater HIV spread among uncircumcised males. Circumcision removes Langerhans cells (which are specific targets for HIV) from the underside of the penis, promotes hardening of the skin of the penis, promotes more rapid drying of the penis after intercourse and reduces the likelihood of some sexually transmitted infections (which increase the likelihood of HIV being transmitted).

Male circumcision has many other benefits apart from reducing HIV. These benefits may include reducing some sexually transmitted infections (including syphilis, herpes simplex type 2 and chlamydia), urinary tract infections, penile cancer, prostate cancer and cervical cancer in female partners.

No serious complications were reported in any of the 5000 circumcised men in the three African studies. Complications were reported in only 0.2 per cent in major studies of infant male circumcision in developed countries.

How relevant are findings from developing countries with poorly controlled and predominantly heterosexual HIV epidemics to Australia, where HIV is relatively well controlled and dominated by spread of HIV among men who have sex with other men?

A recent Australian study of over 1400 men who have sex with men found that about one-third exclusively practised insertive anal sex. In this sub-group, the chance of becoming HIV-positive was about 85 per cent less among circumcised men.

We should be cautious before recommending that gay men in Australia should be circumcised on the basis of only one study. There are always possible risks, and a particular concern here would be ``risk compensation'' -- that is, gay circumcised men feeling safer and thus abandoning condoms and other hard-won safer sex strategies. More research will be needed before circumcision can be recommended to adult gay men.
The situation with infant male circumcision is quite different. We have sufficient information now on both HIV and general grounds to amply justify revising the information provided to young parents about infant male circumcision. Much of the information provided to parents today is quite biased. Young parents should be able to easily obtain objective information about the advantages and disadvantages of infant male circumcision. State and territory departments of health should remove the current substantial obstacles to infant male circumcision in our public hospitals.

The Commonwealth Department of Health should revise the relevant Medicare items to reduce the current powerful financial disincentives to infant male circumcision.

We should aim to raise the rates of infant male circumcision to the levels which existed decades ago (while respecting the right of parents who do not wish to circumcise their infant sons). Fortunately, the technology of infant male circumcision has improved considerably in recent decades. Acting now will only reduce HIV infections in decades to come. But our community should strongly endorse the objective of maintaining a low prevalence of HIV among Australians into the future.

Dr Alex Wodak is director of the Alcohol
and Drug Service at St Vincent's
Hospital, Sydney