Wednesday, February 6, 2008

Now we know: Circumcision saves lives

Now we know: Circumcision saves lives

Larry Krotz, National Post
Published: Tuesday, February 05, 2008

We can all be rightly proud as Canadians that Canadian scientists, a Canadian university, and, yes, that entity in perpetual short supply, Canadian research dollars, played a substantial role in what has been designated by TIME magazine as one of the biggest medical breakthroughs in 2007. Number two on their recently published top-10 list is the discovery that circumcised men are "at least 51% less likely than uncircumcised men to acquire HIV during sex with women."

In Africa, where the clinical trials that reached this conclusion were carried out, this is very big news indeed because heterosexual sex is the main form of transmission of the deadly virus. Due to tribal customs, many African men remain uncircumcised. If they can get access to circumcision surgery, it is likely to have a dramatic effect on HIV rates.

In the late 1980's, Dr. Stephen Moses of the University of Manitoba, already involved in AIDS research in east Africa, had a hunch there might be a correlation between male circumcision and HIV infection rates. He and another Manitoban, Dr. Francis Plummer, had seen how a variety of sexually transmitted diseases created portals for HIV entry and how circumcised men had fewer STDs. But it took until 2002 for Moses to muster the right partners, the ideal study group, and enough interest from funders to support a properly controlled clinical trial.

With Dr. Bob Bailey of the University of Illinois in Chicago and a local partnership with the University of Nairobi, they opened a clinic in the west Kenya town of Kisumu in order to test the hypothesis. The Canadian Institutes of Health Research (CIHR) paid to build the clinic and, with the U.S. National Institutes of Health (NIH), promised support for five years while the scientists set out to find 2,800 young men from the Luo tribe who might volunteer to be research subjects.

Theirs was one of three such studies. Another by French scientists had been set up in Orange Province, South Africa, and a third took place in Uganda. Early on, Moses and Bailey told me how the work of all three was perceived as long-shot, peripheral research while the major efforts in the AIDS war were going into the search for a vaccine and new antiretrovirals.

The researchers experienced their share of difficulties, most of them having to do with the tricky business of carrying out complicated scientific research in a distant corner of Africa.

They had to overcome local prejudices against circumcision and labour hard simply to keep track of their 2,800 research subjects for two years. Their clinic staff were continually dealing with small crises of behaviour -- one young man had sex two times within eight days of his surgery, something he had been adamantly counselled against, while another rode his bicycle home after the surgery, which did him no good.

The early numbers were so good that some argued it was potentially unethical to require control groups to remain uncircumcised even for the duration of the studies. In 2005, the South African study was halted. Eighteen months later, in December 2006, and a year shy of completion, the Kenyan and Ugandan projects were also halted. The scientific method had been trumped by ethics.

As it was, the Manitobans and the University of Illinois already had proved their point by publishing their findings in the prestigious scientific journal Lancet. Instantaneously, Moses and Bailey moved from the fringes of the formerly sceptical AIDS-research world to the very centre. Bill Clinton singled out circumcision in his speech to the World AIDS conference, Bill Gates turned on the money tap, and finally came anointment by TIME magazine. Henceforth, circumcision as a preventative strategy will be a player along with vaccine research, condom use and antiretrovirals. "In areas where HIV-1 prevalence constitute a generalized population epidemic," stated an editorial in the Lancet, "male circumcision could have a dramatic life-saving effect."

CIHR, the government of Canada's health-research funding agency, is properly claiming bragging rights -- achieved at a bargain-level investment of $2.7 million. This is but a taste of the sort of success we could achieve with a greater commitment: Though it spends more than twice as much as it did in 1999, CIHR's current budget of $700-million is still outstripped 40 times over by the equivalent U.S. body, the National Institutes of Health, which has a budget of US$28-billion.

Dr. Moses and Dr. Plummer have done Canada proud, and are showing how much good we can do when we set our minds -- and money -- to the task.