• Can Male Circumcision Stem The AIDS Epidemic In Africa?


    Scientific American – November 29, 2011

    For the Xhosa in South Africa, a boy’s coming of age is often marked by an elaborate and lengthy set of rituals. One of the ordeals is circumcision, which is traditionally performed by a healer and occasionally leads to an ineffective cut, infection or even death. The young men who emerge from the ceremony healthy, however, achieve not only new social status but are also much less likely to become infected with HIV.

    Adult male circumcision, in which the foreskin of the penis is surgically removed, has emerged as one of the more powerful reducers of infection risk. Some studies are finding that it decreases the odds that a heterosexual man will contract HIV by 57 percent or more. With HIV vaccine research still limping along, condoms being underused and the large-scale vaginal gel trial Vaginal and Oral Interventions to Control the Epidemic (VOICE) just called off early last week after disappointing results, the operation has been gaining ground.

    For the past three years 13 countries in southern and eastern Africa at the heart of the HIV/AIDS epidemic have been on a mission to circumcise 80 percent of their men by 2015 in an effort to cut in half the rate of sexual transmission of the disease from 2011 levels. And a new series of nine papers, published online Tuesday in PLoS Medicine, assesses whether the ambitious goals could work—and whether they are worth it.

    The analyses “give a pretty optimistic assessment,” says Atheendar Venkataramani, a resident physician and researcher at Massachusetts General Hospital, who was not involved in the new papers. But from his own research in the field, he says, he is inclined to share the optimism.
    Cutting costs

    Because HIV and AIDS are still incurable, infection means a lifetime of antiretroviral therapy. So with more people getting infected every day, the cost of treatment for the ever growing global HIV population is increasing. A surgical procedure, such as a circumcision, is not cheap either, but when compared with indefinite treatment, the one-time cut is poised to be a cost saver.

    The estimated price tag for all of the 13 countries (Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe) to reach the 80 percent male circumcision rate by 2015 would be somewhere on the order of $1.5 billion, the authors of one of the papers suggest. To keep that saturation constant for another 10 years would cost a further $500 million. These 20.3 million circumcisions, however, could prevent some 3.4 million new HIV infections in both men and women, according to the new findings. From 2016 to 2025, after accounting for the initial expenditures, the programs would save some $16.5 billion.

    Previous research had concluded that male circumcision programs would be cost-effective, but this is some of the first large-scale work to incorporate information specific to country—and in some cases, region—to assess costs and savings. The recent data can go straight to the countries’ respective ministers of health and, perhaps even more important, to the countries’ ministers of finance, points out Emmanuel Njeuhmeli of the U.S. Agency for International Development, who is a co-author of several of the papers. “Understanding the science is not enough—they need to have the resources,” he says of the countries’ health ministries. And that can be a lot to ask of a sub-Saharan African country such as Lesotho, which has a GDP of $2.1 billion and where much of the population lacks even basic medical care.

    “It’s not a difficult procedure to do well,” Venkataramani says. “Once someone is trained, you can knock out hundreds of procedures a day.” But finding medical personnel to train can be a challenge. “If you have limited health care, are you going to be drawing from the labor pool?” he asks. “And will that divert them from doing other things,” such as giving vaccinations to children or helping to deliver babies?

    New Demand

    The term for the procedure, voluntary male medical circumcision, might sound almost outlandish. Yet in the past few years some public-awareness campaigns have been so effective in educating men about the benefits of circumcision (which also extend to decreased risk of other sexually transmitted infections) that “creating the right balance of demand and service” has become the new challenge, says Caroline Ryan, director of technical leadership at the Office of the U.S. Global AIDS Coordinator.

    For groups in which male circumcision is an integral part of the culture, the move to a more medicalized procedure can be dicey. “If you bring in something that gets at the core of people’s beliefs, and it’s perceived as being disrespectful, that might be your last chance to reach that population,” Venkataramani says. He also found that males who had incomplete or delayed circumcisions were more likely to contract HIV than those who had early, medical procedures. “You can’t count on the traditional circumcision on being the protective circumcision,” he says.

    Some groups and villages have adopted a medicalized approach, however. In Zimbabwe, for example, village boys would not always return from their rite of passage after a traditional circumcision went awry. Thus, some village chiefs have encouraged the use of medical circumcision, by having doctors and nurses attending at the ceremonial camps, by allowing boys to make a trip to a clinic or by training traditional healers in how to perform a safer operation.

    “There has been a change in social norms, where the community has completely embraced medical male circumcision,” Njeuhmeli says of some of these villages. Many local women also support the move. “You can see a mother so happy that the boys, all of them, will come back,” alive and well.

    Nevertheless, as one of the papers on research led by Zebedee Mwandi of the U.S. Centers for Disease Control and Prevention Global AIDS Program Kenya shows, so far only Kenya is in good shape to meet the 80 percent goal, with more than two thirds of its men already circumcised—which is more than twice the global average.
    Risky prevention

    Not everyone in the AIDS-prevention field is convinced that this approach will be as effective as promised. As the old economic logic goes, once people think they are protected against something, they will be more likely to take on more risks. So a circumcised man might be more inclined to have unprotected sex or sleep with more partners. As yet, however, research has yet to bear this out.

    “It’s also a very good way to get access to men,” Ryan says of the increasingly common procedure. Women spend much more time in the health care systems in many of these countries because they often seek care during pregnancy. But with adult and adolescent males coming in for circumcision, doctors and nurses have the opportunity to give them information about condoms and other ways to reduce their risk of HIV, as well as to identify men who already have the retrovirus and get them started on treatment earlier in their illness.

    With circumcision being an imperfect protector, why not put the money toward a more sure thing, such as condoms? Despite years of campaigns and distribution, neither male nor female condoms have become as widely used as previously hoped. As Ryan points out, many other groups are supporting condom programs, so she and others working with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) are looking for approaches that are not covered by other programs.

    Unlike a condom, the operation is a one-time intervention, Ryan notes. And “now we have some very good data, so we can have an extremely strong impact.” With fewer infected men, fewer women will also be at risk for HIV infection. But, as she points out, the impact is also proportional to the breadth and speed of the scale-up. If fewer men are circumcised or if the target year is met years later, the epidemic will continue spreading all that much more quickly. This momentum is also the reason for targeting sexually active men and adolescents rather than infants. Although protecting the next generation is a long-term goal, to curb the epidemic as quickly as possible—and lessen the likelihood that children born today will face as high a risk of contracting the illness when they are grown—the analyses suggest putting money toward the older boys and men.

    “It doesn’t obviate our need to think about other policies,” Venkataramani says. But “from a harm-reduction standpoint,” he notes, “it’s as good as we’ve got right now.”

    Researcher Charged In Major HIV Vaccine Fraud Case
    June 25, 2014 – Responding to a major case of research misconduct, federal prosecutors have taken the rare step of filing charges against a scientist after he admitted falsifying data that led to millions in grants and hopes of a breakthrough in AIDS vaccine research.
    Lower Risk Of Prostate Cancer Seen In Circumcised Blacks: Study
    June 6, 2014 – A new study on prostate cancer suggests that circumcision might have a preventive effect in black men and men who undergo the procedure later in life.
    New Mobile HIV Testing Vans Directed Towards Black Gay And Bisexual Men
    An eye-catching new mobile health screening van launched on February 28 is carrying out its mission of encouraging black gay and bisexual men throughout the city to get tested for HIV.
    Experts Say HIV Prevention Drug Shows Big Promise During Testing
    Exciting research suggests that a shot every one to three months may someday give an alternative to the daily pills that some people take now to cut their risk of getting HIV.
    Major Grant Awarded To Black Gay HIV Study
    The University of Pittsburgh Graduate School of Public Health announced this week that it was awarded a $3.2 million grant to study the reasons why black gay men are disproportionately affected by HIV and AIDS, Pittsburgh City Paper reports.
    Only 1 in 3 HIV-Infected Black Americans Gets Effective Treatment: Study
    Even though drugs that can keep HIV at bay are available, only about one in three black Americans with the AIDS-causing virus have their infection under control, U.S. health officials said Thursday.
    President Obama Pledges $100 Million To Find HIV/AIDS Cure
    President Barack Obama announced a new initiative at the National Institutes of Health in pursuit of a cure for HIV, saying his administration is redirecting $100 million into the project to find a new generation of therapies.
    Vaccine Cures HIV-Like Virus In Monkeys, Potential Human Trials In The Works
    Researchers have achieved a potential major breakthrough in the treatment of HIV after successfully curing monkeys of the equivalent of the virus.
    5 Common Causes Of Impotence
    If there’s one condition that men hope to never get, it’s erectile dysfunction. A man’s ability to get and sustain an erection is often equated with virility and masculinity. The inability to do so can greatly affect men’s self-esteem. To help avoid preventable causes of impotence, it’s important to understand what may cause the condition.
    HIV And AIDS Among African American Youth
    African American youth continue to be one of the groups most severely affected by HIV infection in the United States. In fact, black youth represent half of all new HIV infections among young people aged 13 to 29.
    Doctors Cure An HIV-Positive Baby: What It Means For The Fight Against AIDS
    Worldwide, about 1,000 babies are born with HIV each day. There’s new reason to be hopeful about their future. On Sunday night, medical researchers reported that a girl born HIV-positive has been “functionally cured.
    Rate Of New HIV Infections Drops For First Time Among Black Women: CDC Says
    For the first time, the rate of new HIV infections among black American women declined between 2008 and 2010, according to a report released Wednesday by the U.S. Centers for Disease Control and Prevention.
    New Guidelines Push For Most In U.S. To Get At Least 1 HIV Test
    HIV testing could become as common as cholesterol check-ups. New screening guidelines proposed by an independent panel insist Americans ages 15 to 64 should get an HIV test at least once—not just people considered at high risk for the virus.
    Faces Of HIV: Four Powerful Stories Of Hope And Strength
    Through insightful interviews, captivating portraits and poignant journal writing, the Faces of HIV project examines the effects of stigmas, the personal relationships and care issues associated with being HIV positive.
    Growing Proof That HIV & Aids Can Be Cured
    Aids researchers believe the time may have come to think the unthinkable: a growing body of expert opinion believes a cure for HIV infection is no longer a scientific impossibility but a realistic goal that scientists could reach in the very near future.
    Mysterious Disease Leaves Patients With AIDS-like Symptoms, But Not HIV
    Researchers have identified a mysterious new disease that has left scores of people in Asia and some in the United States with AIDS-like symptoms even though they are not infected with HIV.
    Heterosexuals Should Receive HIV Prevention Pill Too, Health Officials Say
    Doctors should consider giving an AIDS prevention pill to women and heterosexual men who are at high risk for getting the virus, U.S. health officials said Thursday.
    New Data Strengthens View Of HIV Threat For Gay Black Men
    A study of black gay and bisexual men in six U.S. cities found HIV infection rates that were 50 percent higher than among their white counterparts, and rates were even higher for men under the age of 30 in the same community, researchers said….
    NAACP Develops HIV Manual For Black Churches
    Houston pastor Timothy W. Sloan has felt for years that he needed to talk about HIV and AIDS with his congregation. But he worried the 3,000 mostly African-American parishioners at St. Luke Missionary Baptist Church in Humble, Texas, could be offended and leave the church or curtail their giving.
    National Black HIV/AIDS Awareness Day
    February 7 marks the 12th annual National Black HIV/AIDS Awareness Day (NBHAAD), a national community mobilization initiative to boost HIV awareness and advance HIV prevention, testing, and treatment among blacks in the United States.
    Vaccine Could Reduce HIV To Minor Infection
    HIV could be reduced to a “minor chronic infection” akin to herpes, scientists developing a new vaccine have claimed. Spanish researchers found that 22 of 24 healthy people (92 per cent) developed an immune response to HIV after being given their MVA-B vaccine.
    Annual HIV Infections In U.S. Relatively Stable, Alarming Increase Among Young, Black Gay And Bisexual Men
    ”More than 30 years into the HIV epidemic, about 50,000 people in this country still become infected each year. Not only do men who have sex with men continue to account for most new infections, young gay and bisexual men are the only group in which infections are increasing, and this increase is particularly concerning among young African American MSM….
    FDA Approves New HIV Treatment
    The U.S. Food and Drug Administration today approved Edurant (rilpivirine) in combination with other antiretroviral drugs for the treatment of HIV-1 infection in adults who have never taken HIV therapy…..
    Black Couples Benefit From Program To Curb Spread of HIV
    A couple-focused program cut risky sexual behaviors among black American couples in which one partner has HIV and the other is HIV-free, researchers report.
    Black And Hispanic Infants Much More Likely to Have HIV
    Rates of HIV infection in infants are significantly higher among blacks and Hispanics than whites, and preventive measures are needed to reduce the disparity, a new government report says.
    Burden Of HIV Highest For Blacks, CDC Reports
    Although blacks make up only 13.6 percent of the U.S. population, they account for 50.3 percent of all diagnosed cases of HIV, federal health officials reported Thursday.
    Black Americans And HIV/AIDS
    Black Americans have been disproportionately affected by HIV/AIDS since the epidemic’s beginning, and that disparity has deepened over time. Blacks account for more new HIV infections, AIDS diagnoses, people estimated to be living with HIV disease, and HIV-related deaths than any other racial/ethnic group in the U.S.
    US Helps To Fight HIV/AIDS In Africa
    Two new agreements will further the Obama administration’s fight against HIV/AIDs in Africa. U.S. State Department officials have recently signed Partnership Frameworks with the governments of South Africa and Botswana under the U.S. President’s Emergency Plan for AIDS Relief or PEPFAR. These five-year joint strategic plans aim to promote a sustainable approach to combating HIV/AIDS in the partner countries through service delivery, policy reform and coordinated financial commitments.
    African Americans And Sexually Transmitted Diseases (CDC)
    Sexually transmitted diseases (STDs) pose a serious and widespread health threat in the United States. Though most STDs can be easily diagnosed and treated, many have no noticeable symptoms, and infected individuals may not seek testing or treatment. As a result, many infections go undetected. Without treatment, individuals with STDs are at risk of serious health problems, such as infertility.
    Higher HIV Risk In Black Gay Men Is Linked To Partner Choice
    Young black men who have sex with men get infected with HIV nearly five times more often than MSM from other races, even though they don’t have more unprotected sex. The discrepancy has long mystified public health experts, but a new study by investigators at Johns Hopkins and elsewhere now offers a possible explanation for it.