New York Times- July 11, 2000
By LAWRENCE K. ALTMAN
DURBAN, South Africa, July 10 –
Scientists meeting here debated today what to do about a puzzling but potentially important finding about AIDS: that circumcised men are much less likely to become infected than uncircumcised men.
The finding was first made in Africa more than a decade ago and has been noted in more than 40 studies since then. Now many scientists, some of whom are in Durban taking part in the 13th international conference on AIDS, have come to suspect that circumcision is an important factor in the vast differences among African countries in rates of infection from H.I.V., the virus that causes AIDS.
In many countries in southern Africa the rates of H.I.V. infection among adults exceed 20 percent, while among central and west African countries the rates are lower, some below 3 percent.
No one believes that circumcision, which has been widely and traditionally practiced in Africa, could be the sole explanation of
such differences. Differing rates could be caused by other cultural or religious practices, or by differences in hygiene or other factors.
Yet compelling evidence from epidemiologic studies has led scientists to debate whether to promote large-scale circumcision programs as a means to help stop the AIDS epidemic.
While discussion at the session devoted to circumcision was largely academic, one participant, Dr. Daniel T. Halperin, an anhropologist at the University of California at San Francisco, addressed the reality.
"Let's not fool ourselves into thinking that we experts will decide whether men will get circumcised," Dr. Halperin said. "It is happening right now" as a small number of clinics have sprung up in Africa to offer circumcision to adult men, he said.
In studying the Luo people in Kenya, who do not practice circumcision, Dr. Robert C. Bailey of the University of Illinois at Chicago said he had found that most Luo men and women voiced the opinion that sex would be more pleasurable if the man was circumcised and that most men would prefer to be circumcised.
Dr. Bailey and other experts expressed concern about the safety of the procedure in Africa, because many of those performing it lack medical expertise and do not secure informed consent. Hygiene is a problem, and only one of eight clinics surveyed had all of the instruments needed to perform a circumcision safely, Dr. Bailey said.
Ann Buve of the Institute of Tropical Medicine in Antwerp, Belgium, studied two African cities with high H.I.V. rates and two with low rates. In Yaoundé, Cameroon, and Cotonou, Benin, where the prevalence of H.I.V. among sexually active men was 3.8 and 4.4 percent, respectively, 99 percent of the men were circumcised. The practice was less common in Kisumu, Kenya, and Ndola, Zambia, where infection rates were 26.8 percent and 25.9 percent.
Dr. Ronald Gray of the Johns Hopkins University School of Public Health expressed reservations about recommending circumcision, based on his team's studies in Rakai, Uganda. A rigorous type of study, known as a randomized controlled trial, is needed to scientifically determine the degree of protection from circumcising males at birth and as adults, Dr. Gray and others said.
Such trials could determine whether religious, cultural, behavorial and hygienic factors account for an important part of the protection that seems to be related to circumcision. But the impact of rigorous trials on the epidemic could be limited, because answers might not come until 15 to 20 years after they are started.
Researchers must decide between scientific rigor and immediate need, said Dr. Roy M. Anderson of Oxford University at a separate session about the general problem of conducting research in the face of the AIDS pandemic.
"Rigor should be adopted in some instances, particularly where controversy exists about cost-effectiveness," he said. "But common sense argues that rough and ready observational studies should be used in high-incidence regions with limited resources."
In providing a possible biological explanation, a paper in a recent issue of the British Medical Journal said the inner surface of the foreskin contains so-called Langerhans cells that have an area on their surface that allows the entry of H.I.V.
And in a new report, the Population Council in New York City urged more research to determine the cost-effectiveness of male circumcision.
In the United States, 40,000 people become infected with H.I.V. each year. Although officials of the Centers for Disease Control and Prevention consider that number unacceptably high, they gave a more encouraging view of the H.I.V. epidemic in the United States, saying American teenagers were heeding warnings about the virus. Surveys found that in 1999, 50 percent of teenagers reported having had sex at least once, compared with 54 percent in 1991. And 58 percent of teenagers said they used a condom the last time they had sex, up from 46 percent.
H.I.V. infections among American women fell by 9 percent from 1994 to 1998. But the number of women 21 to 25 years old had more than doubled in that period, suggesting that the downward trend among women overall may be masking increases in incidence among young women, said Dr. Rob Janssen of the C.D.C.