Programs in eastern and southern Africa changing people’s views on the procedure

By Nathan Seppa

Web edition: July 25, 2012
Print edition: August 25, 2012; Vol.182 #4 (p. 11)

WASHINGTON — An increase in male circumcision in a South African community coincides with lower overall HIV rates among adult men in that population, a new study finds. Meanwhile, a report from Kenya bolsters earlier findings that young men who get circumcised are less than half as likely as their uncircumcised peers to acquire HIV.

The two reports were presented July 24 at the 19th International AIDS Conference.

Researchers in Orange Farm, South Africa, devised a community-wide program in 2008 that provided free circumcision for men, plus condoms and counseling. Within three years, the adult male circumcision rate jumped from 17 percent to 54 percent, said Bertran Auvert, a physician at the University of Versailles in France who works on the project.

Surveys of several thousand men in Orange Farm in 2008 and 2011 found that the prevalence of HIV dropped from 15.4 to 12.3 percent during that time. Auvert calculated that there were 1,040 HIV infections avoided.

The decrease in HIV prevalence, he said, should lead to a decrease in HIV rates for the men’s female partners. “It’s the beginning of the story, so we’ll need some time,” he said.

An earlier trial in Orange Farm was among the first to show that male circumcision can reduce HIV infection risk. Now, a new analysis of data from a similar trial in Kisumu, Kenya, suggests the protection is long-lasting. Epidemiologist Robert Bailey of the University of Illinois at Chicago reported that 66 months after circumcision, men who underwent the operation were still less than half as likely to become infected with HIV as men who didn’t undergo it.

“After five and half years of follow-up, the fact that these results are consistent over time suggests the protective effect is sustained,” Bailey said.

But the apparent protection provided by circumcision is partial, not total. The foreskin around the penis of an uncircumcised man provides a warm, moist environment that can harbor a virus — and from which it can invade the body or subsequently be spread to a sex partner. Removing the foreskin by circumcision leaves toughened skin that’s less susceptible to viral infiltration and transmission, Bailey and others have theorized.

Researchers had noticed a link between circumcision and reduced HIV risk when maps of Africa showed higher HIV rates in regions, notably eastern and southern Africa, where male circumcision wasn’t performed as a traditional practice (SN: 1/3/09, p. 14). Before the first circumcision trials in Africa were started about a decade ago and results from those tests were made public, many people in Africa “thought that circumcision equated to becoming a Muslim,” said Samson Kironde, a physician in Jinja, Uganda, at JSI Research & Training Institute and USAID. The community-wide effect seen at Orange Farm “is significant,” he says, “and that’s the aim.”

Kironde says that by some estimates, circumcising 80 percent of men in a community “would allow you to reach a critical mass of people” that would have a potent community-wide effect.

Now there are hints that male circumcision is gaining steam in these regions as a lifestyle choice.

A survey of 101 Kenyan women whose male partners had been circumcised found that all the women were satisfied with the choice and that 91 percent reported enjoying sex more since the operation. Timothy Adipo of Nyanza Reproductive Health Society in Kisumu, however, reported that one-third of the women also said condom use was less necessary since circumcision. “They perceived themselves at lower risk,” Adipo said. “Our educational message needs prioritizing now.”