Cutting Progress?

By Alix Morris, contributing writer

In December 2006, the US National Institutes of Health halted two clinical trials in Kenya and Uganda after study results indicated that male circumcision cut a man’s risk of contracting HIV by more than half (see VAX December 2006 Global News). These studies confirmed results from a previous randomized, controlled trial of adult male circumcision conducted in South Africa. Soon after, the World Health Organization (WHO) issued guidelines urging countries to consider adding male circumcision to their existing HIV/AIDS prevention strategies (see VAX April 2007Global News). Last year, the US-based news magazine Time ranked circumcision as the number one medical breakthrough of 2007 because of its potential to slow the spread of HIV. But to date, only a handful of health ministries in sub-Saharan Africa, the region most severely affected by HIV/AIDS, have started developing national policies on circumcision, and even fewer have established actual programs. This has spurred some public health officials to question the delay.

In an editorial published in the January issue of the journal Future HIV Therapy, Daniel Halperin, senior research scientist at Harvard University, and colleagues emphasized the benefits of male circumcision and called upon countries, international leaders, and donor agencies to introduce safe circumcision practices. Halperin says that in response to the WHO guidelines, approximately nine African governments conducted consultations with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the WHO. I think in every case, after doing the consultation, they decided that they wanted to have a circumcision program or circumcision policy,he says. But so far few policies have been enacted. A lot of these countries are on their way, but only Kenya and Rwanda have actual policies as far as I know.

This month Rwanda launched a voluntary national circumcision campaign aimed at reducing the risk of HIV transmission. The campaign prioritizes circumcision for male soldiers, policemen, and students. In September of 2007, Kenya’s Ministry of Health published its national policy on male circumcision. The Kenyan policy stipulates that safe, voluntary male circumcision should be promoted in conjunction with other HIV prevention strategies, and delineates the roles of the Ministry of Health, the National AIDS Control Council, and other partner organizations in coordinating these programs. But there is no indication when circumcision programs will be implemented.

Providing circumcision services in areas with high HIV prevalence could have a considerable effect on reducing the number of new infections. Surgically removing the foreskin eliminates a site with a high concentration of cells that are targets for HIV (see Primer, this issue). Computer modeling studies conducted by the WHO and other health agencies to determine the impact circumcision could have on the course of the HIV epidemic suggest that if all males in sub-Saharan Africa were circumcised, two million HIV infections could be averted over the next 10 years. Using this same model, an additional 3.7 million new infections could be prevented over the following 10 years.

Evidence for the potential impact of circumcision programs can already be seen on the population level, says Halperin. It’s not just about modeling. We can actually see the real-world impact. For example, in Cameroon, a country where male circumcision is common practice, the adult HIV prevalence rate is only 5%, whereas in Botswana and Swaziland, countries where the majority of men are uncircumcised, adult HIV prevalence rates are up to five times higher.

If more males were circumcised there would also be a herd immunity effect although only men directly benefit from the procedure, reducing the level of HIV in the population would also result in fewer new infections among women.

Many challenges have contributed to delays in introducing male circumcision programs, including cultural hurdles, a shortage of trained professionals, and financial constraints. While the US President’s Emergency Plan for AIDS Relief (PEPFAR) has agreed to fund circumcision programs, the governments and health ministries need to specifically request this support. Once they ask for it, it’s like anything else, it takes a while for the money to come down, says Halperin. It’s going to vary in different places but I’m sure there will be a lag before things really get going.