Till date more than 30 cross-sectional studies have found the prevalence of HIV to be significantly higher in uncircumcised men than in those who are circumcised and 14 prospective studies all show a protective effect, ranging from 48% to 88%. Current conclusion is primarily drawn from results of three major randomized control studies involving nearly 10000 adult males performed in South Africa, Uganda and Kenya by different researchers.
Pathophysiology and possible mechanism of HIV prevention by circumcision:
- The protective effect of circumcision against HIV infection is thought to derive in part from postsurgical development of a barrier layer of keratinised squamous epithelial cells that limit viral entry to underlying HIV target cells (Langerhans’ cells, CD4+ T cells and macrophages). Without circumcision, inner mucosal surface of the human foreskin, when exposed upon erection, has nine times higher density of HIV target cells (and even more when person has recent history of sexually transmittable disease) than does cervical tissue and thereby increasing chance of acquring infection from vaginal cavity.
- Other less satisfactory mechanisms among uncircumcised males include poor hygiene, greater incidence of ulcerative sexually transmitted infections and susceptibility of the foreskin to abrasions.
All three trials are stopped early may overestimate efficacy when compared with subsequent studies, and therefore demanding long-term post-circumcision trial surveillance is essential to determine the overall effectiveness of circumcision in populations with varying HIV prevalence.
When? Whether neonate circumcision would be effective strategy or not will at least take a generation to show any benefit if present and on the other side, performing adult male circumcision has its own challenges. i.e.: Complexity and safety of procedure, readiness for voluntary circumcision considering religious and cultural practices, public awareness and expenses related to current heath care system, especially in resource poor set-up.
At present, it is not sure whether or not male circumcision has any benefit in HIV prevention in female partners. Logically by creating herd of circumcised males, females risk of getting infection can be minimized.
Efficacy of circumcision in areas where male-to-male HIV transmission is greater than heterosexual transfer; importantly greater risk to recipient of anal intercourse.
Rising debate of male circumcision is mutilation, or whether it is justified for health, religious, and cultural reasons.
Upcoming global strategies:
The best way in halting HIV juggernaut is a multi-modality approach involving more than one existing preventive methods in co-operation with public, government and social agencies to create awareness and self-implication of central theme: Safe Sexual Practice
| Courtesy and Ref.: |
| Lancet 24 Feb 2007 | Volume 369 Number: 9562 |
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