Israeli experts advise circumcision in Third World

Research shows six in 10 circumcised men are immune to HIV infection, but only about a fifth of men around the world are circumcised.

By JUDY SIEGEL-ITZKOVICH
africa 88 (photo credit: )
africa 88
(photo credit: )
Israeli experts are urging a visiting World Health Organization (WHO) team to promote circumcisions of both adults and of newborns in the Third World to help reduce HIV transmission. Current research shows that six in 10 circumcised men are immune to HIV infection, but only about a fifth of men around the world have been circumcised for religious, medical or cultural reasons. Dr. Tim Farley of the WHO's department of reproductive health and research and WHO consultant and University of Edinburg expert Dr. Timothy Hargreaves viewed the ritual circumcision Monday at Jerusalem's Misgav Ladach surgical clinic of a 21-year-old Jewish immigrant from Russia who had not undergone a brit mila as a baby. After the 20-minute procedure, carried out under local anesthesia by an Orthodox surgeon who also immigrated from the former Soviet Union, the former soldier got up and walked out to go home. Dr. Inon Schenker, director of the Jerusalem AIDS Project (JAIP) and a senior HIV/AIDS prevention specialist, told The Jerusalem Post that over the years, 20,000 Israeli males - immigrants from Eastern Europe and Ethiopia and converts - have undergone ritual circumcisions as non-infant children, teenagers and adults. Schenker, a collaborator with the WHO on male circumcision and HIV research, said the JAIP has been collecting data on circumcision for years. The WHO officials said they were most interested in adult male circumcision rather than on infants, as it would take 15 to 20 years for babies in sub-Saharan Africa, where AIDS is endemic, to become sexually active. However, the two dozen Israeli experts who met the WHO officials urged that infant boys be circumcised in large numbers because the operation involves a very low rate of complications if performed in sanitary environments; anesthesia is not necessary; a trained non-medical practitioner can learn to do it quickly and safely; and early contact between the infant's family and family health services can promote health promotion and disease prevention. In Israel, there are a few hundred ritual circumcisers (mohalim) who circumcise Jewish infants, plus about 30 urologists and surgeons - all religiously observant - who operate on older boys and men (in clinics and hospitals). Schenker said Muslim boys were circumcised from infancy through the age of 13 by traditional Muslim circumcisers, male nurses and a handful of physicians. These ceremonies are usually performed at home or in a medical setting, but rarely in event halls or hotels. Farley and Hargreaves were given an English-language WHO manual on circumcision to help protect against HIV/AIDS that was reviewed and improved on by Israeli experts. Schenker said, however, that "as a public health person, I am very worried from the message to Israeli teenage boys and men who may think that since they're circumcised, they can go from bed to bed and will be immune to HIV infection. This is not true, as four in 10 will still get infected." Regarding the lack of a foreskin as an "invisible condom" could, he said, offer the same sense of false security that comes from sunscreen that can help protect against skin cancer but not completely prevent it; people who use sunscreen may stay out in the sun longer as a result. Schenker said Muslim countries, which also observe 100% circumcision rates, would also be at risk if men thought circumcision protected them completely from AIDS. "We at JAIP have much experience in developing communication and education strategy for prevention of infection and can be a model for others," he said. Farley, who is a New Zealand citizen but works in Geneva, told the Post he had been in contact with Schenker for years on the subject, especially after a major study at Orange Farm, South Africa, last year showed circumcision offered men significant protection against HIV infection. This study showed that male circumcision provides a degree of protection against acquiring HIV infection equivalent to what any highly effective vaccine would have achieved. Circumcision can be dangerous if carried out in unhygienic environments and by an inexperienced practitioner, so the WHO is interested in improving the skills of circumcisers and the sanitary conditions of clinics. In addition, men must be warned that during the monthlong healing period after the operation, they are at an even higher risk of HIV infection and must be told to avoid sex. It is not known whether the current studies in Kenya and Uganda due to be completed in 2007 will confirm the results of the South African study, but there are signs that more men in Botswana, Lesotho, Swaziland and other African countries already want cheap and safe circumcisions. A clinical trial being carried out in Uganda and due to be completed by the end of 2007 is looking into whether women get significant protection when having sex with circumcised men. So far the protective effect for women is not regarded as significantly as it is for males. Homosexual partners are apparently not protected even partially by circumcision. "What we learned in Israel," said Farley, "will be useful to inform other countries interested in expanding male circumcision of babies and adults. The WHO doesn't have funds to subsidize this, but it can encourage countries to improve and expand circumcision services. We are especially interested in clinic-based circumcision in sub-Saharan Africa." There are several biological explanations of why circumcision reduces the risk of infection. Removal of the foreskin minimizes the ability of the AIDS virus to penetrate the skin of the penis. In addition, Langerhans cells and other special immunological bodies are located on the underside of the foreskin, and these are targeted by the virus. It may also be that tiny lacerations in the inner surface of the foreskin during sex may allow easier entry for HIV.