HIV: trial shows male circumcision cuts risk

Published in The Hindu on August 25, 2005

One more trial has shown a positive correlation between circumcision and reduced risk of HIV infection. A trial involving more than 3,000 heterosexual male volunteers in South Africa has shown that the incidence of HIV infection in circumcised volunteers was three times lower compared with uncircumcised men.

Pronounced difference

The differences in infection rate were so pronounced — 18 in the case of circumcised compared with 51 in the case of those who were not circumcised — that officials recommended discontinuing the trial and offering circumcision to all volunteers who were not circumcised. The officials involved in the study have, however, sounded a word of caution by saying that “the risk of HIV infection is no doubt higher in `real life’ than observed in the trial.”

Though similar positive correlations have come out in various other trials and observational studies, this is by far one of the trials that has minimised the possibility of bias in the study. It was a randomised, controlled study.

Despite the huge difference in protection offered by circumcision as brought out by this study, Denis Broun, UNAIDS Country Coordinator in Delhi, highlighted the need for caution. “Even if male circumcision is confirmed to be an effective way of reducing the risk of HIV infection, this will not mean that men will be protected from HIV during sexual intercourse through circumcision alone,” he noted.

Women not protected

“It is important to keep in mind that male circumcision does not provide sexual partners protection from HIV. Therefore, even if proved to be effective to reduce the risk of transmission, male circumcision interventions will only be part of a larger prevention strategy.”

Sub-Saharan Africa that has recorded a high prevalence of HIV has a unique feature — the infection rates show huge regional variations. According to a report published in the Lancet last year, this variation could be attributed to the differing circumcision practices.

“There could be several factors related to lower incidence of HIV in many African and East Asian countries where male circumcision is routinely practiced,” stressed Mr. Broun. “Male circumcision may only be one of the factors. The relationship between male circumcision and HIV protection has not been established conclusively, as it is difficult to discount for other cultural and behavioural factors.”

“Although the trial in South Africa shows promising results, it is important to remember that these are only preliminary findings. More research is needed to confirm that these results have general applicability,” Mr. Broun highlighted.

The National AIDS Research Institute (NARI) based in Pune found circumcision in males offering protection against HIV infection. Dr. S.M. Mehendale, Deputy Director of the institute had emphasised that the study had clearly demonstrated that biological rather than behavioural characteristics played a role in providing the necessary protection (The Hindu, December 2, 2004).

The results from two trials currently underway in Uganda and Kenya will go a long way in confirming the prophylactic effect of circumcision. But even when proved unequivocally, it is imperative not to rely on circumcision alone to help prevent men from contracting HIV infection. It can, at most, be one more tool in the fight against the spread of HIV infection.

Condoms a better choice

Condoms will still be ranked as the most efficacious way to prevent HIV infection compared with circumcision, as the latter offers protection only to men.

A bigger issue is the impunity with which some circumcised men may indulge in unsafe sexual practices in case circumcision is found to really offer some degree of protection. Ironically, it may be one more way the dice gets loaded against women.

Finally, the question of safety needs to be addressed. Circumcision, like any other surgical intervention, is not a completely risk-free procedure. And should the Government promote circumcision if it is proved to be effective?

“The question of how ethical it is to promote a surgical procedure to reduce, but not remove, the risk of HIV transmission will require a lot of debate, should the preventive role of male circumcision be established against HIV. This debate will certainly take place in India,” noted Mr. Broun.