Circumcision

Circumcision as a weapon in the war on AIDS - The Financial Times - London, 3 Sept., 2004

Evidence is growing that removal of the foreskin protects heterosexual men from HIV but promoting this remains controversial, says Geoff Dyer.

It can be claimed that circumcision is the most commonly performed surgical operation in the world. It is also the most controversial.

Wall paintings date the practice back to 2400 BC in Egypt. It was abhorred by the ancient Greeks but became an important ritual for Jews and Muslims. Since the late 19th century, it has also been common in the US: today, 60 per cent of male babies in the US are circumcised.

Over the years, many claims have been made about the medical benefits of circumcision. But there is one theory that is still gathering ground. A growing number of scientists believe that circumcision provides some protection for heterosexual men from Aids.

The latest evidence has come from a recently published study about a clinic in India where uncircumcised men were nearly eight times more likely to be infected by HIV than those who were circumcised.

"In India, there are around 800m Hindus who are generally not circumcised, and 150m Muslims who are," says Richard Feachem, head of the Global Fund to Fight Aids, Tuberculosis and Malaria. "India is the great laboratory for the question of whether circumcision can protect men from AIDS."

The link between circumcision and freedom from AIDS has been suggested for some time. In the late 1980s, anthropologist Priscilla Reining drew a map of the incidence of AIDS in different African cities. When another map of male circumcision patterns was placed over it, there appeared to be a strong correlation.

While infection rates are low in west and central Africa where there are large Muslim areas, they are extremely high in southern Africa where circumcision is much rarer. The high rate of circumcision in the Philippines has also been presented as one reason for the low incidence of AIDS in the country.

Interest in the hypothesis boomed in 1999 with the publication of research into couples in the Rakai district of southern Uganda. For couples with an uncircumcised husband and an HIV-positive wife, 30 per cent of the men were infected after 30 months. Yet among the circumcised men whose wives had the virus, none was infected.

Proponents of circumcision believe that they know how it protects against HIV. One route the virus takes to enter the body, they believe, is through a type of white blood cell in the immune system that is susceptible to HIV. The inner surface of the foreskin has a heavy concentration of these so-called Langerhans cells.

The circumcision theory is far from settled, however, and the debate has been fierce - especially in the US where circumcision is hugely controversial and where both sides have powerful lobbies.

Critics have noted that the studies into circumcision ignored sexual behaviour and culture. It has been suggested, for example, that a more conservative attitude to sex among Muslims, who usually account for most of the circumcised groups in the studies, might explain the lower rate of infection.

A review last year by the Cochrane Collaboration, a non-profit group that conducts rigorous assessments of healthcare issues, poured cold water on the circumcision idea. Of the 34 studies it examined, none met the standards of a fully random clinical trial that took into account religious or behavioural factors.

There was a strong association, the authors said. But they concluded: "We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men."

The research did not look at the intensity of the virus in the blood of patients being studied - the so-called "viral load" - which is widely considered to be a big determinant in someone's ability to infect another person.

Moreover, the studies ignored many potentially important factors such as the "dry sex" that is common in parts of Africa, where women are urged by their partners to apply herbs and salts to their vaginas to make them drier and tighter. The abrasions and lacerations that this causes could facilitate the transmission of HIV in both men and women, they suggested.

Some of these questions appear to have been addressed, however, by the recent study from India, which observed males attending a sexually- transmitted disease clinic in Pune. Published in The Lancet, the research was led by scientists from America's Johns Hopkins University.

The circumcised group were mostly Muslims and the uncircumcised largely Hindu, but both groups reported visiting the same prostitutes at the same brothels. Moreover, while the HIV infection rate differed sharply between the circumcised and uncircumcised groups, the incidence of other sexually-transmitted diseases was similar. Both factors indicate there was little difference in the sexual behaviour between the two groups, regardless of religion.

"The difficult thing has always been to disentangle circumcision from the customs of religions that practise it," says Roger Short, a professor at the University of Melbourne in Australia, and a supporter of the circumcision hypothesis. "This study shows that it is much more than a religious quirk."

Although decisive proof on the circumcision theory should come with three random trials currently under way in Africa, the India study has provided powerful ammunition.

Yet if India is a good laboratory for the thesis that circumcision curtails AIDS, it also demonstrates the limits of the procedure as a public health strategy.

Circumcision is intimately linked to religious identity in India. During race riots, mobs have been known to strip men to discover their religion. Health officials say that any attempt to push circumcision on uneducated Hindu men would set off a wave of conspiracy theories.

"Given all the sensitivities and religious sentiments, it would be practically impossible in India as a public health policy," says Ashok Alexander, who runs Avahan, the Bill & Melinda Gates Foundation's project in India.

Such stigma is not universal. Researchers from Harvard University in the US found considerable willingness among people in Botswana to have circumcision reintroduced for babies.

But even where circumcision will not offend cultural sensibilities, the prospect of promoting mass circumcision campaigns in places with only modest medical facilities has worried many health officials. The older a man is, the more traumatic the experience of circumcision and the greater the potential health risks and side-effects. Yet to make an immediate impact on Aids infections, it would make sense to circumcise adolescents and young adults.

If the theory is proven, advocates of circumcision will still face many tough questions about how it would be implemented as a public policy in the developing world.

Lemon Juice Kills HIV in a Test Tube

The great new hope in AIDS prevention is a group of products known as microbicides - vaginal gels and creams that women can apply before sex to block potential infections. As many women lack the power to force their partners to use condoms, microbicides could be a valuable tool. Researchers are currently testing a number of products.

But could there be microbicides for men? Roger Short, a professor at the University of Melbourne and one of the supporters of the theory that circumcision can provide protection against AIDS, believes that nature has provided an answer - lemon juice. He says that lemon juice killed HIV in a test tube. By wiping the penis with a solution containing lemon juice after sex, he argues, men could potentially prevent many infections.

Finding backing for such an experiment has not been easy, however. The AIDS epidemic has produced hundreds of claims about "natural" cures, most of which have proved to be little more than quackery. Such scepticism has so far hampered the lemon-juice theory.