Cutting AIDS Deaths

Although Ron Gray and Maria Wawer were happy to show that circumcision helps prevent the spread of HIV in Africa, the finding has created at least one problem: how to meet the demand from men who want the surgery.

"We're doing it as fast as we can, given our facilities. We're training people from all around Uganda, and providing services as rapidly as possible," says Gray, MBBS, MSc, the William G. Robertson Jr. Professor in Population and Family Planning.

Gray and his wife and colleague Wawer, MD, MHSc, both professors of Population, Family and Reproductive Health, have been collaborating for years with Ugandan colleagues in a series of studies of HIV transmission in the rural Rakai district.

Last spring they published a paper in The Lancet that showed that circumcising adult men more than halved their risk of acquiring HIV. Researchers in Kenya and South Africa reported similar findings.

Now so many men want to be circumcised that Rakai's surgeons can't keep up, despite the availability of three surgical theaters capable of circumcising 1,700 men a year. In fact, they are talking to the U.S. Army for tips on how they might set up MASH-style mobile circumcision centers.

"We hear anecdotally, from hospitals all over Uganda, that people are lining up for the procedure. The problem is that the quality of surgery they're getting may not be all that great," Gray says.

If the men get circumcisions from unqualified practitioners, they might suffer complications such as infection. That's why Gray and his colleagues are looking at ways to scale up the medical infrastructure to provide the procedure.

"This is completely unique in public health. We've never used surgery to prevent an infectious disease. The learning curve is steep," he says.

The February 2007 Lancet article reported the results of a trial which included 4,996 men. Half were circumcised immediately, while the other half had circumcision delayed, and the HIV infection rates were compared. Results were so good for the circumcised men that the trials were stopped early—HIV incidence was .66 per 100 person-years in the circumcised group, vs. 1.33 in the non-circumcised group. "The protection appears to be lifelong," Gray says. "As we follow the men in these studies, we find that the longer the time from surgery, the more pronounced the protection is. In those men who completed the second year of follow-up, the reduction in incidence was 67 percent," he says, versus the initial reduction of 55 percent. Continuing studies have shown more good news. (See above.)

On the negative side, male circumcision does not directly protect the female partner of an HIV-positive man. In fact, her risk increases if they have sex before the man's surgical wound has fully healed.

Despite that risk, Gray is in favor of circumcising HIV-positive men. First, the men benefit directly from the procedure, since studies show that they suffer less genital ulceration than uncircumcised men. Ultimately, though, refusing to circumcise HIV-positive men might put women at risk in other ways.

If circumcision becomes a marker of HIV-negative status, HIV-positive men might seek the surgery from unsafe sources, which would put them and their partners at risk. Initially, HIV-uninfected, circumcised men might even negotiate unsafe sex, using their circumcision as a guarantee of safety, but could then acquire HIV and pass it on to their partners. The WHO has recommended that HIV-positive men be offered circumcision, if they request it and do not have contra-indications for the procedure.

Gray thinks that the case for circumcision in Africa—where HIV is spread primarily through heterosexual contact—is clear. It provides lifetime protection to the men who get it, which is also indirectly protective to the women they have sex with.

"In my view, this is as close to a slam dunk as you can get," he says.