Why Circumcision is a Biomedical Imperative for the 21(st) Century

This important position paper provides the evidence that now overwhelmingly favors male circumcision in prevention of a wide array of diseases, many of which are fatal. These include HIV/AIDS, various cancers, physical problems, infections and sexual problems. The benefits exceed risks by over 100 to 1. Female sexual partners have even more to gain from having an circumcised male partner.

Sydney, New South Wales (PRWEB) October 24, 2007 -- In the November issue of the highly-ranked journal BioEssays Brian Morris, a Professor in the School of Medical Sciences and Bosch Institute at The University of Sydney, Australia presents a powerful position statement with ramifications for all in society.

He claims that circumcision of males represents a surgical "vaccine" against a wide variety of infections, adverse medical conditions and potentially fatal diseases over the lifetime of males, and also protects their sexual partners. He makes clear that in experienced hands, this common, inexpensive procedure is very safe, can be pain-free and can be performed at any age.

The benefits vastly outweigh risks. The enormous public health benefits include protection from urinary tract infections, sexually transmitted HIV, HPV, syphilis and chancroid, penile and prostate cancer, phimosis, thrush, and inflammatory dermatoses. His calculations reveal that 1 in 3 uncircumcised males will, as a result of not being circumcised, suffer a medical condition over their lifetime that will require medical attention, and many will die from some of these.

Since most complications during circumcision are on average seen in only 1 in 500, and these are easily and immediately treated, the benefits outweigh the risks by over 100 to 1. In women circumcision of the male partner provides substantial (over 5-fold) protection from cervical cancer and chlamydia. The latter can result in pelvic inflammatory disease, infertility and ectopic pregnancy, Circumcision has socio-sexual benefits and reduces sexual problems with age. It has no adverse effect on penile sensitivity, function, or sensation during sexual arousal.

He describes the evidence that reveals why most women prefer the circumcised penis for appearance, hygiene and sex. Given the convincing epidemiological evidence and biological support, he advocates routine circumcision and says that it should be highly recommended by all health professionals.

BioEssays 29:1147-1158, 2007. (c) 2007 Wiley Periodicals, Inc.

Brian J. Morris, PhD DSc FAHA
Professor of Molecular Medical Sciences

http://www.prweb.com/releases/2007/10/prweb563432.htm

The kindest cut of all helps Swazi men fight off AIDS

Oct 22, 2007 04:30 AM
Craig Timberg
Washington Post

MBABANE, Swaziland–The young men in a cramped waiting room in Swaziland's capital twitched with nerves. Feet tapped. Fingers drummed. The occasional brave joke was delivered with a smirk.

Beyond a wooden door a few metres away, two Israeli doctors donned blue hospital scrubs adorned with faded Hebrew script. Stepping into a modest room where only a dangling sheet separated the operating tables, they prepared to perform the world's oldest surgery for free.

So began Day 10 of an uncommon experiment in international assistance. Teams of Israeli surgeons have begun circumcising Swazi men, using an ancient ritual to curb the modern malady of AIDS.

Studies have shown circumcised men are at least 60 per cent less likely to contract HIV. Less clear is how meagre public health systems already overwhelmed by AIDS cases can offer the procedure widely enough to slow the epidemic.

"For us, the major constraint is surgeons, doctors," said Dudu Simelane, executive director of the Family Life Association of Swaziland, a nongovernmental group hosting the Israelis.

Medical experts in Swaziland, with fewer than 100 doctors and the world's highest rate of HIV infection, say that for five years they would like to offer the procedure to all 200,000 of this tiny southern nation's sexually active men, at a rate of roughly 200 a day – 20 times faster than the current pace in this country of 1.1 million.

No country has tried anything like it – save Israel, whose doctors circumcised 80,000 men after the 1989 fall of the Berlin Wall brought a flood of new immigrants, mostly adults who grew up in Soviet Bloc states that banned Jewish rituals.

Scientists warn the foreskin has cells very receptive to AIDS but removing it lets the penis head grow thicker and more resistant to sexual infections. The World Health Organization says making circumcision widely available, inexpensive and safe could prevent 5.7 million HIV infections in the next 20 years.

The men awaiting circumcision said they wanted the easier hygiene and HIV protection it offers.

http://www.thestar.com/News/article/269060

Israeli Doctors Providing Male Circumcision in Swaziland

Global Challenges

Israeli Doctors Providing Male Circumcision in Swaziland in Effort To Prevent Spread of HIV

Oct 22, 2007

Teams of Israeli surgeons have begun providing male circumcision in Swaziland in an effort to prevent the spread of HIV, the Washington Post reports. Health officials in Swaziland, which has fewer than 100 doctors and the world's highest HIV prevalence, say that over the next five years, they hope to offer the procedure to 200,000 sexually active men at a rate of roughly 200 daily -- 20 times faster than the current pace. According to the Post, six Israeli doctors are scheduled to work for two weeks in Swaziland this year under a program organized by the Jerusalem AIDS Project and underwritten by the U.S.-based Jewish organization Hadassah and other donors.

The Israeli doctors primarily are expected to train Swazi doctors on how to perform circumcision among adult men. However, many Swazi doctors already know how to perform the surgery. According to some Swazi doctors, what they primarily need from the Israeli doctors are "extra hands to help get enough done to impact the epidemic," the Post reports. The demand for circumcision -- especially surgeries that are no cost or subsidized -- appears to "far outstrip supply in Swaziland," according to the Post. The health system "routinely runs low" on basic medical supplies -- such as sutures, gloves, dressings and surgical tools -- the Post reports. In addition, there is a "major constraint" on surgeons and doctors, Dudu Simelane -- executive director of the Family Life Association of Swaziland, a nongovernmental group hosting the Israeli doctors -- said.

Some Swazi surgeons have shown that they can each perform 10 circumcision procedures -- which take about 25 minutes -- daily during the country's occasional series of "Circumcision Saturday" events, the Post reports. According to medical experts, it would take four doctors at each of five separate facilities to perform 1,000 circumcisions weekly if Swazi doctors can maintain that speed every weekday (Timberg, Washington Post, 10/21).

http://allafrica.com/stories/200710221484.html 

Male Circumcision Findings in African Countries Substantiate New AIDS Prevention Tool

By Howard Lesser
Washington, DC
08 October 2007

Doctors in Rwanda are encouraged by test results in three African countries that show a high correlation between male heterosexual circumcision and a reduction in the transmission rate of HIV/AIDS. Consequently, Rwanda’s health ministry says it will promote circumcision through a nationwide education campaign that will reinforce other methods of aids prevention, such as condom use and abstinence. Initially targeting the army, police and students of higher education, the project will receive financial assistance from US President George W. Bush’s Emergency Plan for AIDS Relief, known as PEPFAR. Carolyn Williams, PhD, is Chief of the AIDS Division Epidemiology Branch at the US National Institutes of Health’s Allergies and Infectious Diseases Institute (NIAID). She explains how the beneficial findings were discovered.

“There were three trials of male circumcision. One was in South Africa, funded by the French, and then two were done by the National Institutes of Health (NIH). Those studies ended in December, and then once the WHO (World Health Organization) had taken some time to look at the results of our trials, then they suggested that male circumcision could be an effective part of a prevention package. So now countries are now beginning to decide how they want to integrate circumcision into their prevention programs,” said Williams.

Circumcision trials monitored various groups of African men in three countries with histories of high AIDS infection rates, South Africa, Kenya, and Uganda. One group had the surgery right away, and the other groups in each country waited, in many cases, almost two years before undergoing the procedure. Williams says the results of all three tests, in a French health ministry (INSERM) study in Johannesburg, South Africa, and in American NIH trials in rural Kisumu, Kenya and in Rakai, Uganda, drew nearly identical numbers.

“The trial results in Kenya showed a 53 percent reduction in the risk of getting HIV, and Uganda showed a 48 percent reduction. And then, that was the same as the 50 percent reduction that was seen in the trial in South Africa. And so that raised a lot of interest in the role that circumcision might play as a prevention tool,” she noted.

Although evidence has been available for a long time suggesting that male circumcision has helped prevent the transmission of venereal diseases and other infections, epidemiologist Carolyn Williams notes that this is the first time that a surgical procedure has won approval as a deterrent to contracting HIV/AIDS.

“It’s been studied for some time that there is an association between lower rates of HIV infection in communities where there is more circumcision. But it’s a surgical procedure, very closely tied to cultural reasons why people do and don’t circumcise, and it’s the first time that we’ve ever suggested a surgical procedure to prevent an infectious disease. So while male circumcision can be performed safely, and it’s not a very difficult surgical procedure, it is a surgery, and there are risks associated with it,” she said.

One of the hallmarks of Rwanda’s promotion of heterosexual male circumcision will focus on a nationwide education campaign, which will receive financial assistance from the Bush Administration’s PEPFAR (President’s Emergency Plan for AIDS Relief) initiative. Carolyn Williams explains that since the World Health Organization has endorsed male circumcision as an HIV preventive measure, the PEPFAR initiative will be supporting countries that want to make male circumcision part of their prevention program.

“Starting in 2007, countries can apply for funding to include male circumcision services. And now, the National Institutes of Health is working with the World Health Organization, and they are helping to guide ministries of health if they develop the programs that would be necessary to actually offer male circumcision around the world,” she noted.

http://voanews.com/english/Africa/2007-10-08-voa4.cfm

Cutting Out HIV Risk through Circumcision - Is it an Option?

By Stephen J. Fallon, Ph.D.

Putting a condom on reduces your risk of catching HIV and some sexually transmitted diseases. Taking something off reduces risks, too. The something that comes off is foreskin.

No, this isn’t a plot synopsis for Nip and Tuck. Circumcising adult men reduces their susceptibility to HIV infection by a large enough margin that New York City’s Department of Health is considering promoting, and possibly even paying for the procedure. The United Nations has even developed a kit to teach doctors in developing nations how to perform a circumcision safely on adults.

Our skin is supposed to serve as our immune system’s first line of defense, a barrier that blocks most pathogens from getting inside of us. The foreskin is rich in Langherans cells, which are designed to help trigger a fuller antibody response before any topical infection can fester. Yet HIV thwarts this front line defense by riding in through the Langherans cells, and invading the main machinery of the immune system.

Lab experiments long ago suggested that foreskin seems to have a tendency to “soak up” HIV, and some other STDs. “Uncut” guys have lots of Langerhans cells in their foreskin. Circumcised guys only have some inside the urethra.

In February, the last of three real world studies confirmed exactly how much risk uncut men face when having unprotected sex. The study in Lancet randomly assigned 2,474 out of nearly 5,000 men to receive an adult circumcision. Checking back two years later, researchers found that men who had been circumcised had 55 to 60 percent lower HIV infection rates. The first study had put the risk reduction at 48 percent.

So should gay men in New York or any other city consider the sort of outpatient surgery that makes even butch men weak in the knees? Would circumcision help protect them from HIV and STDs? Let’s look at how circumcision might or might not help for gay men.

Tops are not invulnerable: Lots of gay men already believe that they can’t catch HIV as long as they only top. Studies do show that penetrating partners (“tops”) generally face much lower risks than penetrated partners (“bottoms”). The urethra presents a smaller “port of entry” for HIV than does the rectum.

Now here’s the catch: other factors can pretty much erase the relative safety of being on top. If the guy on bottom has an STD, or if the top has one, or if the bottom was very recently HIV infected, each of these influences will increase the risks for the top three times to twelve times higher, to nearly the same average risk level the bottom faces in unprotected sex. Even circumcision can’t protect tops from all of those risk amplifiers.

It’s not just about STDs: Since STDs amplify the ability to catch or transmit HIV, one old study famously suggested that it was genital ulcers, not foreskin, that caused higher HIV rates in some men. Take away the genital ulcer variable, the authors said, and circumcised guys are actually more prone to HIV.

This was a misleading study. The researchers did not personally examine any men, but instead counted numbers of past HIV infections in certain countries. The U.S. has higher HIV infection rates than, say, Israel or Mexico, where there are large numbers of uncircumcised men. So the authors concluded that circumcision made guys more vulnerable to HIV. Actually different risk trends in these countries explain the results.

A newer, more rational study in the journal Emerging Themes in Epidemiology proves that circumcision directly reduces HIV risk. While circumcised men also benefit from lower STD rates, the impact of this overlapping factor was much smaller than the direct protection against HIV that removing the foreskin offered.

Benefits for bottoms: Even though circumcision does not directly protect bottoms, to the extent that it might lower overall rates of HIV among tops, it could mean lower odds that a bottom would have an HIV infected top as his partner. A recent U.N. report notes this community protecting potential. Condoms are still a must if bottoming for a non-monogamous or untested partner. But if a condom breaks or is forgotten in the heat of the moment one night, your HIV risk might be lower if your top is circumcised.

Circumcision doesn’t protect against denial: The three major circumcision studies discussed here only looked at heterosexual males. Gay men would get the same 48 to 60 percent protection from HIV that circumcision offers, but only when they top. Now here’s the bad news: HIV doesn’t care if you’re “mostly top,” or built like a top (whatever that means), or were exclusively the top in your last relationship. Only your next unprotected sex matters.

Everyone knows versatile guys who claim to be total tops. Or, frankly, total bottoms who claim to be tops. Even if you do get circumcised to reduce your risks, any time you bottom without insisting on condoms, you’ll still be at the highest risk of getting infected.

http://www.sfbaytimes.com/index.php?sec=article&article_id=6308

Rwanda Endorses Male Circumcision to Help Stem HIV/AIDS Infection

By Noel King
Kigali
02 October 2007

Rwanda's Ministry of Health has announced plans to endorse male circumcision as a measure to help stem the spread of HIV/AIDS in the country, a health official said on Tuesday. Noel King has more in this report from Kigali.

Rwanda announced plans to urge male circumcision after seeing encouraging results in medical studies conducted in South Africa and Uganda. The studies suggest a direct link between circumcision and lower rates of transmission of the disease.

Some 190,000 people in Rwanda , or about 3 percent of the population, are infected with HIV/AIDS.

Fewer than twenty percent of Rwandan men are currently circumcised.

Dr. Anita Asiimwe, managing director of the Center for the Treatment and Research of AIDS at Rwanda 's Ministry of Health, tells VOA that circumcision will be promoted via a nationwide education campaign.

"We have decided to take up male circumcision as another measure to use in HIV prevention," she said. "It's not that male circumcision is going to take over. Rather it is coming in to compliment what we have been enforcing."

Asiimwe says that the push for male circumcision is intended to bolster, not replace, other measures, including campaigns aimed at urging abstinence and condom use.

The United Nations World Health Organization says studies conducted in South Africa , Uganda and Kenya indicate male circumcision can slash rates of transmission of HIV/AIDS by up to 60 percent.

Rwanda is known for its aggressive approach to combating the disease.

In July, Rwanda became the first country in the world to take advantage of a World Health Organization waiver, which allows poor nations to bypass patent laws and import generic HIV/AIDS medications or manufacture the medicines domestically.

Officials in Rwanda say they intend to import generic anti-retroviral drugs made by Toronto-based drug-maker Atopex Inc. Health officials are currently conducting studies on the suitability of the drugs for public use.

Rwanda's three percent infection rate is relatively low when compared to neighboring nations. But health officials say more challenges lie ahead.

Formerly displaced Rwandans who have recently returned from neighboring Tanzania have brought high rates of the disease.

The impact on Rwanda of refugees fleeing violence in neighboring Democratic Republic of Congo is still unclear.

http://www.voanews.com/english/2007-10-02-voa34.cfm