ViewpointMale circumcision and HIV infection: 10 years and counting
Section snippets
Epidemiological findings
In their study of the risk factors for HIV infection among 422 men who visited commercial sex workers in Nairobi, Kenya, Cameron and colleagues found that men who were not circumcised had a 8·2-fold increased risk of seroconversion, compared with circumcised men.1 Subsequently, six more prospective studies from four countries investigated the relative risk of heterosexual HIV-1 infection in uncircumcised men. Four studies reported significant relative risks that ranged from 2·3 to 4·5 after
Biological mechanisms
For over a decade researchers have suggested that the foreskin provides a vulnerable portal of entry to HIV and other pathogens.6 The highly vascularised prepuce has been discovered to contain a higher density of Langerhans cells—primary target cells for sexual transmission of HIV—than cervical, vaginal, or rectal mucosa.7 Other scientists and clinicians have noted that the foreskin is more susceptible to traumatic epithelial disruptions during intercourse, which allows additional vulnerability
Public-health response
In the face of such compelling evidence, we would expect the international health community to at least consider some form of action. However, the association between lack of male circumcision and HIV transmission has met with fierce resistance,12 cautious scepticism,13 or, more typically, utter silence, which is evidenced by a dearth of public-health information on the issue. For example, the Johns Hopkins Media/Materials Clearinghouse has been unable to identify among its comprehensive
Response on the ground
In east and southern Africa, increasing numbers of people are becoming aware of the differences in prevalence of AIDS and STDs between circumcised and uncircumcised men, and they are taking action. Male circumcision is increasingly recommended by traditional healers.14 Private clinics that specialise in male circumcision, many of which are run by people with minimum or no medical training, are sprouting up in Tanzania, western Kenya, Rwanda, and Uganda,2, 9 and many advertise their services as
Time for action
By avoiding this issue althogether, medical professionals and public-health authorities may inadvertently be harming the very individuals whom they are trying to help. As increasing numbers of men and boys turn to circumcision as perceived protection from AIDS, many will be exposed to harm by untrained practitioners who use unsafe methods. Yet, contrary to some popular misconceptions, safe and inexpensive male circumcision is routinely performed in developing countries in clinical settings. The
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