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On December 13, the
National Institute of Allergy and Infectious
Diseases (NIAID) announced the latest
scientific evidence demonstrating that medically performed circumcision
significantly reduces a man’s risk of acquiring HIV through heterosexual
intercourse. NIAID stopped two clinical trials in Kisuma, Kenya, and
Rakai, Uganda,
after an interim review of data from the
trials showed that circumcised men were half as likely to acquire HIV
relative to uncircumcised men.
Ronald Gray,
MBBS, MSc, the William G. Robertson Professor of Reproductive
Epidemiology at the Bloomberg School of Public Health, led the
investigative team responsible for the Uganda trial. The trial involved
4,996 HIV-negative heterosexual men who were randomly selected to be
circumcised by trained medical professionals or were assigned to a
control group and were not circumcised.
Tim Parsons, director of Public
Affairs, spoke with Gray about the trial and its findings.
Tim Parsons: The Uganda and
Kenya trials and an earlier South African study have all shown that
circumcision provides men partial protection against HIV. What is the
significance of this finding and what does it mean for HIV prevention?
Ronald Gray:
Since the development of antiretroviral drugs in the mid-90s, this is
the first major breakthrough supported by unassailable evidence for a
preventive measure. If we can implement programs to provide circumcision
in those countries where it is an uncommon practice and where most HIV
transmission is heterosexual, we believe we could have a fairly major
impact on the epidemic. Statistical models suggest we could abort this
epidemic over the next 10 to 20 years. That would be by both adult
circumcision in the short term and neonatal circumcision in the long
term.
It is very encouraging and hopeful
news, at least in some parts of the world, that we will be able to
abate, if not ultimately end, this epidemic. On the other hand, we are
very concerned that people could become complacent and increase their
risk behaviors, which we know could negate any benefits from the
surgery.
TP: Are you afraid men will
think they are impervious to HIV if they are circumcised?
RG:
We have a mantra: Protection is partial. Secondly, we only know the
duration of this benefit for two years. We have to do more studies to
see if the protection lasts a lifetime. People still have to practice
safe sex either by abstaining or being faithful to a partner and using
condoms.
TP: Does male circumcision
confer any protection for women from HIV?
RG:
We currently have an ongoing trial to answer that question. It won’t be
finished until 2008. The results will be of paramount importance. If
there is a benefit in both sexes, this intervention could have a much
bigger impact.
TP: Will we see male
circumcision become policy?
RG:
The World Health Organization (WHO), other health agencies and
foundations are trying to meet in January to review all of the evidence
and come up with policy. There will be policy guidelines that come out
of the WHO, but the ultimate decision will be up to each country. We’re
hoping that a policy can be agreed upon internationally. We’ve already
heard that a number of major funding sources like PEPFAR (President’s
Emergency Plan for AIDS Relief) are looking at investing in scaled-up
circumcision programs.
We have to focus on adult
circumcision now in order to get short term reductions in HIV. The
ultimate goal would be to provide neonatal circumcision.
TP: Now that the trial has
stopped early, what do you plan to do in Uganda?
RG:
In Uganda, for the immediate future, we plan to offer our facilities to
the ministry of health and to NGOs as a training center. We’ve had more
experience with adult male circumcision than anyone else in the country.
We are going to train personnel as quickly as possible to perform this
surgery. How this will be implemented is still under discussion. Doctors
could be trained to provide the surgery in Uganda’s medical centers
where they have basic surgical facilities. In more rural areas, we could
train teams who would go out and set up surgery theaters to perform this
procedure safely.
What we are all trying to avoid is
having poorly-trained or untrained general practitioners doing this
surgery, because we know it is very unsafe in those hands. Another
important issue we are stressing is the need for proper follow-up care.
You have to see these patients after surgery to avoid serious
complications.
TP: Why was the trial stopped
early?
RG:
The trial was stopped early because at an interim analysis, the
independent Data Safety Monitoring Board determined that there was a
significantly reduced risk of HIV in the circumcised men. If you are
seeing benefits from an intervention, you are ethically obliged to
provide that intervention to the control group. Once you’ve reached the
point where, in a statistical sense, where you are as certain as
possible, you need to stop. However, trials that are stopped prematurely
tend to show bigger effects than subsequent studies, so we need to
continue surveillance in these men to determine whether benefits are
sustained, and whether there may be increases in risk behaviors because
men or their partners think they are protected by circumcision.
TP: Will your findings have
any implications on the prevention of HIV in United States?
RG:
The United States already has a high proportion of circumcised men—about
60 percent. There are no trials in the U.S., but a number of
observational studies suggest that circumcised men are at lower risk for
HIV even if they are having homosexual relationships, but the body of
evidence in the U.S. is much smaller than it is for Africa. It will be
up to groups like the Centers for Disease Control and Prevention to
determine if these African studies have any application in the U.S.
Public Affairs media contacts for the Johns Hopkins Bloomberg School of
Public Health: Tim Parsons or Kenna Lowe at 410-955-6878 or
paffairs@jhsph.edu.
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