Aids and Circumcision in the United States and Africa

 Skrevet av Henry Midgley - Publisert 24.07.2007 kl. 04:32

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Circumcision might help him avoid Aids- but would it
help reduce Aids in the United States as well
Aids kills and at the moment it is killing predominately in sub Saharan Africa where millions of people are infected and dying of the disease, but it also kills in the West and in other parts of the world- notably in Russia and the Indian subcontinent. Whilst it may not as some feared in the 1980s eliminate vast swathes of the population, and whilst some notably the journalist Andrew Sullivan for example are able to live with the HIV virus, HIV still represents one of the most dangerous and most daunting of the challenges to human health and to the welfare of millions that the planet sees at the moment.

Studies of how to treat aids though have to take into account the fact that the virus that causes Aids- HIV is prevalent in many different places in the world- in the prosperous West and the poor South, in the emerging world and the old communist world. Everywhere where humans seem to be the HIV virus and its consequence- Aids- seems to have followed. Most of us would agree that the ways that societies cope with Aids are governed by the set up of those societies- where you have only hundreds of doctors you have a very different situation from where you have millions, the impact of an internet public health campaign in the United States would have very different results from a similar campaign on the internet directed at Liberians. What possibly isn't so obvious is that not merely extra-medical strategies but even medical strategies to take on the virus become more or less appropriate depending on where you are in the world.

The Battle against Aids is being fought on various different level. The HIV virus is transmitted as most know through sexual intercourse- whether homosexual or heterosexual. Efforts therefore have been made on two levels to help people prevent transmission. The first and most obvious way is to persuade people to abstain from sex and to have fewer sexual partners who they know better- in many ways it is conventionally remarked upon the sexual revolution in the 1960s began with the pill and ended with the discovery that sex was not free of its own dangers. The second method and much more commonly used is that of putting a barrier between the two bodies interacting in sex- a condom normally- which prevents the exchange of semen, blood or vaginal fluid and thus reduces the risk of Aids. Obviously these methods do help reduce the risk of transmission- but scientists have also looked to other ways to continue that reduction.

So far so clear. Yet it seems there is another strategy- that is at the moment being exported widely to Africa and that some think that we should apply in the West. One of the leading ways to reduce Aids, studies across Africa in South Africa, Uganda and Kenya have found is to encourage male circumcision. The male foreskin is targetted by the HIV virus- and presents several chemical features which make it a hospitable host for the virus. A paper published in the American Journal of Pathology in 2002 drew specialists' attention to the fact that the foreskin of the penis contains many cells that HIV targets and that other tissues- the specialists evaluated the outer side of the foreskin and cervical skin from a woman do not contain these particular cells. The biological findings therefore seem to bear out the findings of the studies on the ground- one way to reduce the risk of HIV spreading through a population is to circumsise that population.

However questions have been asked about whether that would be a wise idea- and a recent paper at the Public Library of Science's medical journal questions whether it would indeed be such a wise idea- because Africa and America don't share the same culture as regards sex. Ultimately the sexual spread of HIV in Africa as the article notes is mostly vaginal penetration- ie sex between a man and a woman. The sexual spread of HIV in the United States has tended not to be- its mostly at present spread by sex between a man and another man- which given the anatomical realities has to be anal sex.

And it seems that in anal sex the evidence is not as conclusive that lacking a foreskin protects you. The writers hypothesise that in the US most infection is through the rectal canal into which the penis is inserted- furthermore there may be chemical differences between vaginal fluid and rectal secretions, how much of the virus they contain and hence how effective removing some of the targets for the virus to attack is. Studies are inconclusive- in the States they have suggested reduced levels of HIV in active homosexual circumsised men compared to their non-circumsised brethren, in Australia studies have shown no impact whatsoever of circumsision- and the authors rightly therefore call for more research.

Its also less clear that circumcision would make a huge difference in the States where a large number of boys are already circumsised and where there may be increased political difficulties from adult circumsision. The authors conclude that circumsision may have doubtful effects on the white population in the States for these reasons- though within minority populations where the practise is more prevalent circumsision may help reduce the infection rate of HIV. They also call for more research particularly on anal sex and whether the same conclusions about the influence of circumsision upon Aids transmission through vaginal sex can be drawn for Aids transmission through anal sex.

A strategy therefore that might reduce dramatically the HIV and hence aids rates in African countries might not have the same effect in the United States because of cultural and historical factors that have nothing to do with the disease. Adult Circumsision will be a less effective way of stopping the virus spreading in a society with more circumsised people already and possibly it might be less effective in stopping the virus spreading through homosexual sex. What we are seeing here is a consequence of culture, even in work done on reducing the chemical exposure of the penis to a virus, the culture of a country is key to deciding what is the appropriate policy response.

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