Male circumcision – HIV prevention in one simple tool?

For years researchers have observed that male circumcision dramatically reduces the risk of HIV infection. However, until now, the science behind this was a mystery. In a recent study published in mBio, researchers have stated that a change in the “quantity and diversity of bacteria” surrounding the circumcised penis explains why (Liu et al.). A genetic analysis of the microbes living around the penises of circumcised and uncircumcised men in Uganda revealed a dramatic reduction in the amount of anaerobic bacteria—those that can survive in the low oxygen conditions at the tip of the penis (Bakalar). How does this reduce HIV transmission? A higher bacterial load interferes with the ability of “specialized immune cells known as Langerhans to activate immune defenses” (Park).  Ordinarily, the function of Langerhans is to train immune cells by presenting them with pathogens. But the large amount of bacteria in the “uncircumcised penile environment” increases inflammation, causing the Langerhans to infect healthy immune cells with the virus (Park).

Does this mean that circumcision will become the next means of HIV/AIDS intervention? “We’re not trying to prove that everyone should be circumcised,” replies the senior author of the study, Lance B. Prince. “We’re trying to understand how it works and, by understanding, possibly establish alternative strategies to reduce people’s risk for HIV.” (qtd. In Bakalar). However, not everyone shares the same goal. Since 2007, health experts have known that circumcision reduces HIV transmission by at least 60%. While highly common in Western countries, the tool is used much less frequently in countries  suffering the most from AIDS. In 2011, only 13 million circumcisions had been performed in sub-Saharan Africa—far below the WHO’s target of 20 million by 2015 (Adams). Dr. Stefano Bertozzi, director of HIV for the Bill and Melinda Gates Foundation, stated in 2011 that “circumcision is “clearly the most obvious, most cost-effective intervention we could use to dramatically change the course of H.I.V. in the near future” (qtd. in Adams).  It has been calculated that financing circumcision in AIDS-burdened countries could prevent up to 2 million infections per year.

Evidently, the promotion of male circumcision is not far from becoming our primary strategy for preventing the spread of HIV in Africa. On one hand, this tool in prevention has advantages in cost and efficiency. Increasing coverage of circumcision will be tremendously cheaper than financing anti-retroviral therapy in poor African countries. Moreover, the potential of reducing transmission by 60% seems promising. But the ethical considerations also bear weight. A factor to be considered is that there are various cultural meanings associated with circumcision. In some communities, circumcision is performed for religious reasons or as a rite of passage. But in other communities, circumcision is viewed as culturally unacceptable or “forbidden” by religion (WHO 24). It may not be ethically permissible to place medical recommendations above cultural beliefs and religious practices. While circumcision is being promoted in African countries, neonatal circumcision rates have been steadily dropping in most Western countries, due to changing cultural preferences. People are beginning to see neonatal circumcision as barbarous, useless mutilation, and in the United Kingdom it has ceased to become routine procedure (WHO 12). In this context, promoting male circumcision in areas of high HIV prevalence seems to devalue the cultural and religious traditions in non-Western countries.

Also, promoting circumcision may not have as great an impact as other interventions, such as sexual health education. The danger of using this intervention in areas of high HIV prevalence is that circumcision does not provide absolute protection. The public health message that circumcision “may reduce, but does not eliminate risk of infection” and does not rule out the need for “safer sex practices” has proven difficult to communicate (WHO 28). In fact, studies in Africa have shown that male circumcision often leads to a false sense of security, causing people to engage in more unprotected sex. Randomized controlled trials do not take risk compensation into account—a real life obstacle to the effectiveness of circumcision. A statistical analysis by Gray et al. estimates that “if newly circumcised men were to increase the number of sexual partners by an average of more than 25%, this would offset any beneficial effect of circumcision, even assuming a high efficacy of 60%” (WHO 28). Clearly, male circumcision alone is not enough to stem the AIDS epidemic in Africa. Without public education on safe sex, circumcision will have limited efficacy as an intervention.

While endorsing higher circumcision rates may seem like a pain-free, low-cost solution to the problem of AIDS, the answer is not as simple. The development of HIV treatment suitable for the health infrastructure of African countries is still critical. In terms of prevention, Africa is not an exception– the most effective strategies remain HIV testing, promotion of safer sex practices such as condom use, and proper hygiene. In essence, these findings on the effect of circumcision on HIV show how imperative it is that we step in to improve Africa's picture of overall health.

http://mbio.asm.org/content/4/2/e00076-13

http://whqlibdoc.who.int/publications/2007/9789241596169_eng.pdf
http://healthland.time.com/2013/04/17/why-circumcision-lowers-risk-of-hiv/
http://well.blogs.nytimes.com/2013/04/18/how-circumcision-may-stem-h-i-v/
http://opinionator.blogs.nytimes.com/2013/03/20/in-one-simple-tool-hope-for-h-i-v-prevention/