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Dr. Wayne Cottrell investigates reports of circumcision providing protection against HIV...
QUESTION:
Dear Freedomhealth: There are reports of
circumcision being a protection against HIV.
Is this true? What are your views?
ANSWER:
There have been several reports in the media over the past few years that male circumcision might confer some protection against acquiring HIV. Despite all the efforts put into trying to prevent HIV infection, there is a steady rise in new infections every year. This has made it vitally important to look at all possible measures that could help reduce the spread of HIV, particularly in Africa, which has ten percent of the world’s population but two thirds of the worlds HIV positive population.
In many African tribes men are routinely circumcised as teenagers as part of the culture. Observational studies that date back to the 1980’s point to a higher rate of infection in the uncircumcised groups. The question was whether this was in fact due to the circumcision, or some other difference in behaviour that had some protective effect.
Auvert et al, (2005) performed a randomised controlled trial in South Africa, which showed that male circumcision provided protection of about 61%, which the researchers claimed would be equivalent to a vaccine of high efficacy.
A further two studies, one in Kenya and one in Uganda, were both halted after interim results showed a similar level of protection, at which point the participants in the studies who had not been circumcised were offered circumcision. Both studies concluded that circumcision reduces the risk of acquiring HIV infection for young males in Africa, with no apparent increase in behavioural disinhibition. Furthermore when the data of these two studies were analysed together with the data from the previous South African study, it became apparent that the overall reduction in HIV incidence in circumcised men may be as high as 65%. It is also important to note that the studies seemed to disprove fears that people who believed they were protected would adopt more risky sexual practices.
Although there seems to be good evidence that this procedure might benefit heterosexual males in this population, the question arises as to whether circumcision would provide the same level of protection in gay men, or men who have sex with men (MSM).
Unfortunately the jury is still out on this one. So far there has only been one small study done in Sydney, Australia, which concluded that in their study group, there was no significant difference between circumcised and uncircumcised males when it came to rate of HIV infection. However, it stated as a possible reason that most cases of HIV infection in Australia occurs after receptive unprotected anal intercourse, (UPAI).
Why circumcision seems to reduce the risk of infection in African heterosexual males isn’t known as yet. Some think the main reason is that the foreskin increases the surface area of mucous membrane, the area most vulnerable to infection with HIV. A definite association has also been shown between penile wetness and acquiring HIV infection, with a significantly higher rate of infection in men with more penile wetness. Finally, it has also been shown that the foreskin contains superficial Langerhans cells, a type of immune cell, that has HIV-1 receptors. My feeling is that it is probably a combination of these factors.
It seems that although there is clear evidence of a reduced rate of female to male HIV infection in heterosexual circumcised males in Africa, more studies will be needed before we can tell if this is the case in gay men or MSM. Whatever the outcome, being circumcised should not be regarded as an alternative to practicing safer sex, and anyone considering circumcision for whatever reason should discuss it with their doctor so that they are aware of the risks associated with such a procedure. +
