Further to Alex’s post “Circumcision cuts the risk of HIV infection”

January 19, 2007 at 5:38 am (Francelle's Posts)

Hey all,

This article has been circulating here at the IOM about circumcision decreasing the risk of HIV infection in men.  It is estimated that circumcision can reduce the risks of HIV transmission by 60%.  There are lots of important concerns, including the risk of increased Hepatitis B and C infection from inexperienced practitioners and the possibility of an increase in risky behaviors of circumcised males (and a potential spike in HIV and STI rates.)  IEC campaigns and HIV counsellors should exercise caution in promoting circumcision, by qualifying that it is not 100% effective.  Countering misguided knowledge and stressing condom use alongside circumcision will be necessary.  Take a look.

Cheers,

Francelle

January 14, 2007
A Real-World AIDS Vaccine?
By TINA ROSENBERG
Last month, scientists invented the AIDS vaccine. Missed it? Perhaps that’s because you were still seeking the vaccine fantasy: the magic bullet, the impenetrable shield that finally pitches this disease into the trash bin, the shot that will end not only the AIDS epidemic but our anxiety about the AIDS epidemic as well.

The vaccine thunderbolt didn’t strike – and might never. Drearily, the real AIDS vaccine is likely to be imperfect: one more tool in our arsenal, to be used along with condoms and all our other tools. It will most likely avert millions of infections and save millions of lives. But it will not end the Age of AIDS.

The vaccine that arrived last month was not actually a vaccine. It was, instead, a confirmation of what scientists had long suspected: circumcision helps protect men from AIDS infection. For years, AIDS researchers have observed that many African tribes that circumcise boys or young men had lower AIDS rates than those that don’t, and that Africa’s Muslim nations, where circumcision is near universal, had far fewer AIDS cases than predominantly Christian ones. The first research proof came in 2005, when a study in
South Africa was stopped early in the face of evidence that the men who had been randomly assigned to be circumcised were getting 60 percent fewer H.I.V. infections than the men assigned to the control group. Last month, ethics boards halted two similar studies, in Uganda and
Kenya, when they found similar results. In both, the circumcised men caught the AIDS virus half as often as the uncircumcised control group.

Circumcision would be given more weight if the world recognized that it is, in fact, the real-world equivalent of an AIDS vaccine. In some ways, it is closer to the fantasy than a real vaccine might be. Vaccine research began in the early 1980s but with little financing or urgency and went nowhere. In 1996, the effort was revived with the creation of the International AIDS Vaccine Initiative, and financing has soared in the last five years. But a vaccine has proved elusive. Most vaccines work by mimicking infection, which stimulates the body to make antibodies that kill the disease. But H.I.V. infection generally does not produce those kinds of antibodies. H.I.V. also mutates constantly and comes in many different varieties, factors that further complicate the search for a vaccine.

Many vaccines provide nearly 100 percent protection – after my daughters finish their two doses of the measles, mumps and rubella vaccine, for example, they won’t have to think about those diseases again. But that’s not on the horizon for AIDS. “Fifty to 60 percent efficacy is what people would feel really good about,” says Frances Priddy, the director of efficacy trials with the AIDS vaccine initiative. The best candidates in the vaccine pipeline right now – which won’t be ready until 2013 at the earliest – wouldn’t keep you from getting H.I.V. They instead would seek to change your body’s response to the virus so that if you did get infected, the disease would progress more slowly – or not at all – and you would be less infectious to others.

An efficacy rate of 50 to 60 percent is actually a lot better than it sounds, because of herd immunity. We get AIDS from one another. Every time a person is rendered less infectious, the chance of an uninfected person catching H.I.V. from each sexual contact drops, and in a virtuous circle, the whole community becomes progressively safer. A vaccine of 50 to 60 percent efficacy might come close to wiping out the epidemic in places with low AIDS rates. In high-prevalence areas, it could reduce the epidemic and save millions of lives.

In contrast to a vaccine, circumcision’s origins are about as far from the laboratory as you can get; carvings depicting circumcisions have been found in ancient Egyptian temples. But the effects may be very similar to those of a vaccine. So far, we have proof only that circumcision protects the circumcised men. But there are strong indications that it also protects their sexual partners. A trial in
Uganda is now testing whether H.I.V.-positive men are less likely to infect their wives if they are circumcised than if they are not.
Together, circumcision and an imperfect vaccine might be enough to stop AIDS. But they will need help from behavior change, microbicides, fighting malaria, treating genital herpes and other interventions we don’t even know about yet. That is unsatisfying. The danger does exist that circumcised men will feel invulnerable and throw sexual caution to the winds, a risk that would also exist with an imperfect vaccine. But so far, there is not much evidence of a problem. In the Uganda and
Kenya studies, the sexual behavior of the circumcised men was no more risky than that of the others. In the
South Africa study, circumcised men did report 25 percent more sexual activity. But the circumcised group as a whole still had 60 percent fewer infections. Certainly one reason that risky behavior did not jump is that the men got counseling as part of the clinical trials. Counseling goes naturally with circumcision; counseling would be harder to include in a vaccine campaign, since one of a vaccine’s great advantages is that it can be given assembly-line-style in seconds.

Circumcision is a surgical procedure, however, and in the hands of traditional ritual circumcisers, it has a high rate of infection and mishap. The solution is to train these circumcisers and give them decent tools, and at the same time encourage men to come to clinics. Since men in studies say that cost is the biggest reason they are not circumcised, the operation must be free. Countries will also have to equip these clinics and train counselors and medical circumcisers, who don’t have to be doctors.

Research on an AIDS vaccine is more crucial than ever. But we must not let our hope for a thunderbolt prevent us from racing ahead with circumcision now. For the biggest difference between circumcision and a vaccine is this: only one of them exists.

Tina Rosenberg, a former editorial writer for The Times, is now a contributing writer for the magazine.
Copyright 2007  The New York Times Company 

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9 Comments

  1. John Rowland said,

    I am a male uncircumcised with normal loose soft foreskin . Mom taught me in the tub bath time how to clean it in less then thirty seconds . I do not fuss with men nor extra women so why should I get my foreskin circcumcised .

  2. monicaey said,

    John, that’s a little too much information but I think you raise some very interesting points. I don’t think anyone is telling you to get circumcised, since a push for universal circumcision is an unlikely outcome of these study findings. This “real-world” vaccine is likely of more relevance in areas with a high prevalence and incidence of HIV infection (many sub-Saharan African countries, for example).

    But I think one thing to remember as we embrace the potential of this measure to eradicate HIV/AIDS is that male circumcision can be intrusive to an individual’s sexual and/or cultural identity. If such an intervention is to be implemented on a global scale, I think that there are some important ethical implications to consider.

    So I think John has a good point. How do you promote circumcision to people and familes who don’t perceive themselves to be at risk?

    Take good care everyone,
    Monica

  3. msoule said,

    Thanks for commenting, John. I appreciate your openness and think your question is an important one.
    I think that your behavior pattern is really the best cure for HIV. As long as your sexual practices are not putting you at risk (and promiscuity has proven to be a great risk factor, hence the intense focus of the current White House on abstinence as HIV prevention) and you are not using IV drugs and sharing equipment with other users, you are doing the most you can to prevent HIV. If you are educated about what constitutes safe sexual practices (condom use, being aware of your partner’s health history as far as circumcision is concerned, etc) and are following these practices, there is probably little need for you to pursue circumcision. However, I am not a doctor and you should speak with your doctor if you have concerns about this.
    The article does point towards the need for men with multiple partners to be circumsized. And I chose the word “need” carefully. Because we do Need ways to prevent the spread of this horrible disease and circumcision seems like it holds a lot of promise as far as that’s concerned. This information ought to be widely read and spread. So John, do spread the word if you are so inclined.

  4. Ron Low said,

    Don’t call Rosenberg’s opinion piece an article.

    In the world of facts, cut men are missing a valuable part of their anatomy (with loss of over half of their sensual nerve endings), and that they no longer have the natural frictionless rolling/gliding mode of interaction with their partners. In fact their partners are more likely to suffer lesions which would make them vulnerable to infection.

    No medical association in the world recommends routine infant circumcision. Most roundly condemn it, like the RACP (Australia/New Zealand) which today says: “After extensive review of the literature the RACP reaffirms that THERE IS NO MEDICAL INDICATION FOR ROUTINE NEONATAL CIRCUMCISION.” (emphasis theirs)

    450,000 American men who were circumcsied at birth have died of AIDS. HIV is even more rare in non-cutting Japan than it is in 95%-cut Israel. Several African nations have higher AIDS rates among the circumcsied than among the intact.

    Circumcision does not prevent AIDS. Correct condom use is far more effective. Unfortunately, a cut man’s reduced sensitivity makes him less likely to use a condom, and these misleading pseudo-scientific reports make it harder for his partner to convince him he needs to use one. Instead of promoting a dangerous and mutilating procedure which will not protect men or their partners, we should be disussing correct condom use.

  5. msoule said,

    Ron-
    Thanks for your post. I agree with you on condom use. To me, it is certainly the most proven method of harm reduction. If anything, we need a long discussion about condom use and how organizations are promoting it in different cultures.
    Like you, I am leery of any article that claims anything like a cure to AIDS as well and so I am glad of the skeptic’s lens you brought to the discussion.
    However, you and Rosenberg cite percentages and studies to back up your positions. You refer to this report’s numbers as pseudo-science. Where are they coming from? I ask not as a challenge but because I do not know. Where are your numbers coming from and what is the cultural relevance of them? For instance, are Israelis less likely to use condoms than Japanese? Could this be the real reason for a higher Israeli infection rate? And the piece does not say that circumcision is a panacea; those 450,000 American men were obviously not saved by being circumsized, but nobody’s saying they would have been.
    And as someone who seems like he would know (because one best knows one’s opponents), what exactly are the pro-circumcizers arguing that the procedure does to make the recipients safer?

  6. David Wilton said,

    The Mishra study backs up Ron’s statistics. Find an abstract here:

    http://www.iasociety.org/abstract/show.asp?abstract_id=2197431

    Another study by Stallings drew the same conclusion about female circumcision. The abstract is here:

    http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138

    Another study determined access to clean water would provide about same claimed benefits as circumcision. And clean water of course has many more uses than mere post-coital cleanliness. Find a synopsis here:

    http://www.nam.co.uk/en/news/C0915E30-5F1D-4779-A307-A9C5A73DFC9B.asp

    I don’t think overcoming cultural resistance to circumcision will be nearly as easy as inculcating a positive attitude towards using condoms – provided the resources are there to do so. It’ll be a distraction for a few years until the next break through comes along such as HAART was in 1996.

  7. David Wilton said,

    Oh, and about the alleged mechanism for the protective effect from circumcision. The authors of the studies so far have said they don’t know why circumcision may provide a lower infection rate. However, they have wildly speculated about all kinds of possible reasons, including in a simplified paraphrase: there’s less penis there and thus less chance for infection. Less penis is a reference to surface area and mucosal tissue. But they have no scientific evidence that this is in fact correct.

  8. Alexandra Coria said,

    I’m not sure where you all are getting your information, but Tina Rosenberg’s piece is based on two DSMB-monitored, tightly controlled, NIH-funded scientific studies that confirmed another very credible study and has been accepted as trustworthy and reliable by the scientific community. No, it’s not as effective to circumcise as to use condoms, and no, it’s not a panacea. Yes, this behavior change will need to be carefully monitored and culturally sensitive. But the studies were good, and will hold up under all scrutiny. All other things being equal, circumcision cuts risk for AIDS in men. That’s all. In fact, circumcision was SO effective that the study was stopped after the first data were analyzed because it was deemed categorically unethical to not offer circumcision to the control population.

    The studies cited above are observational in nature, and thus subject to a wide variety forces, from political to historical to economic to behavioral, that can be controlled for much better in an experimental study. The reason that this study was done in the first place was that there was a need to examine this phenomenon in as much of a vaccuum as possible, because of the debate around it. These data are now out of date.

    In response to Ron’s comment about circumcision actually exposing women to HIV, there are currently studies ongoing to examine the effects of circumcision on a man’s female partners. There is not yet ANY scientific evidence of whether circumcision in men puts women more or less at risk for HIV.

  9. David said,

    And update over a year later. Turns out women are more at risk from circumcised men and gay men receive no benefit whatsoever from circumcision viz HIV. We also know that disinhibition is vastly more problematic than we thought it would be, reports out of Swaziland indicate.

    Alexandra, perhaps if circumcision in “vacuum” was the real world reality, your points would carry your argument. But that is rather ridiculous. Circumcision is more biomedical trickery foisted on a continent whose solution to the HIV/AIDS problem continues to elude.

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