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Nature 447, 1040-1041 (28 June 2007) | doi:10.1038/4471040a; Published online 27 June 2007

Circumcision for HIV needs follow-up

Declan Butler & Lucy Odling-Smee

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Worries about behaviour change require further research.

The French National AIDS Council (CNS), an independent government advisory body on AIDS issues, last week urged prudence in implementing male-circumcision programmes to reduce the spread of HIV. It cautioned that over-zealous roll out could lead to a false sense of security and exacerbate the problem.

In March, the World Health Organization (WHO) endorsed the promotion of male circumcision as a tool for HIV prevention, alongside condoms and antiretroviral drugs. The move was based on a WHO expert consultation, which concluded that the evidence for the intervention's efficacy was "compelling". Recent criticism of this view has been received with anger (see 'Cutting criticism').

The strongest evidence comes from three recent studies. In 2005, a study1 of 3,300 heterosexual men living in and around Orange Farm, South Africa, by France's National AIDS Research Agency, showed that circumcising men reduced the risk of infection by 60%. Similar levels of protection were found in 2007 by American-funded studies in Kisumu2, Kenya, and Rakai3, Uganda.

Taken together with results from observational studies, this is "as convincing evidence as one ever gets in public health," says Helen Weiss, a statistical epidemiologist at the London School of Hygiene & Tropical Medicine.

Circumcision for HIV needs follow-up

M. SAFODIEN/AFP/GETTY

Circumcision reduces the spread of HIV, but needs to be combined with public education.

But questions remain about the intervention's applicability as a preventative tool on a large scale, says Willy Rozenbaum of the Pierre and Marie Curie University in Paris, who led the CNS study. Rozenbaum questions the speed with which the WHO has acted, and thinks the organization's endorsement — although detailing the caveats — has been misunderstood in some quarters as saying circumcision is a "miracle solution".

Rozenbaum notes that the effect of circumcision on HIV prevalence in a population will depend on a host of social and cultural factors. There is a real risk, he says, that after circumcision men may have a false sense of security and increase their number of partners, or dispense with condoms. The report also points out that circumcision leaves men more vulnerable to infection if they don't refrain from having sex until the wounds have fully healed and that women may find it more difficult to insist on condom use with circumcised men.

The impact of circumcision on HIV prevalence will depend on a host of social and cultural factors.

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Given these concerns, the CNS calls for implementation schemes to be accompanied by public education as well as research that considers the behavioural and cultural factors that affect HIV transmission. Such research is already under way at various sites. At Orange Farm, a 5-year follow-up study of 30,000 people will look at how the implementation of a real circumcision campaign affects risk behaviours, and overall HIV prevalence in the population.

Tim Farley, an official in the WHO's HIV prevention team in Geneva, says he "absolutely agrees" with the CNS view, and the need for such research. "These are concerns that need to be studied, but they are not a reason to stop," he says. "We must move ahead in the knowledge that there could be riskier behaviour."

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References

  1. Auvert, B. et al. PLoS Med. 2, e298 (2005). | Article | PubMed |
  2. Bailey, R. C. et al. Lancet 369, 643–656 (2007).
  3. Gray, R. H. et al. Lancet 369, 657–666 (2007).
  4. Talbott, J. R. PLoS One 2, e543 (2007).
  5. Vandepitte, J. et al. Sex. Transm. Infect. 82 (Suppl. 3), iii18–iii25 (2006).

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