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Wednesday, December 13, 2006 12:00 AM

Male circumcision cuts HIV transmission

Should adult men in areas rife with unprotected sex and AIDS be encouraged to go under the knife?

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  • Wednesday, December 13, 2006 07:15 PM

    Poo on science

    Some of these letters sound like creationist arguments, "I just don't buy it, even though I haven't bothered to learn the last thing about it." Dude, use the internet. PubMed, WHO, UNAIDS, NIH, something.

    One suspected biological mechanism for why circumcision reduces HIV transmission is that the foreskin has a high count of CD4 cells, the white blood cells that HIV latches onto and uses to replicate itself. That's the major idea in play right now. It's been observed for a while that HIV transmission rates were lower in places that had higher rates of circumcison, but people thought there were other factors related to both that might explain the relationship. That's why they did these randomized trials, to isolate that it was, in fact, the circumcision.

    The ethics of doing it on babies are certainly worth discussing -- the main problem with waiting is that it's a bit more complicated to do in adults because there are more blood vessels in the adult foreskin. There's also another question about when "adulthood" begins for deciding: Just before people start having sex? Or when we commonly think people can make their own decisions?

    The behavioral issues are also worth discussing. We all balance the risks we're willing to take, and so it's challenging to get across the message that circumcision still means condom use and other protective behavior (abstinence, fewer sex partners). But it's giant drop in transmission akin to what researchers expect to see from a good vaccine (the nature of HIV makes a super effective vaccine pretty unlikely). It can't be ignored.

    And it hasn't been ignored. Since the first trial ended, there has been rising demand for male circumcision (http://www.who.int/bulletin/volumes/84/7/news10706/en/), and that demand will only increase. Encouragement is hardly necessary. What is necessary is ensuring that males have access to safe, sterile, hygenic surgeries that they want.

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