icon-    folder.gif   Conference Reports for NATAP  
  15th CROI
Conference on Retroviruses and Opportunistic Infections Boston, MA
Feb 3-6, 2008
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Male Circumcision Challenges in African Study
  Male Circumcision No Aid to Women in Study
NY Times
Published: February 4, 2008
BOSTON - A number of studies showing that circumcision among men reduces their risk of infection from the AIDS virus has raised the hope that the procedure would also benefit their female sexual partners.
But the expectations were challenged Sunday by a new study showing that male circumcision conferred no indirect benefit to the female partners and, indeed, increased the risk if the couples resumed sex before the circumcision wound was fully healed, usually in about a month.
The study did confirm the benefit of male circumcision in lowering the incidence of herpes and other genital ulcers among men.
Findings of the study, which was conducted in an area of high incidence of H.I.V., the AIDS virus, were reported at the 15th Conference on Retroviruses and Opportunistic Infections. Although the findings did not reach statistical significance, they still underscore the need for more effective education among men who undergo circumcision and their female partners, the authors of the study said.
The study - conducted by the same team of researchers from Johns Hopkins and Uganda who had shown circumcision's benefits among men in earlier studies - is believed to be the first clinical trial to provide scientific data on the effects on women of circumcision in their male partners.
For many years, epidemiologists observed that the incidence of AIDS was higher in areas of Africa where men were not circumcised and lower in areas where men were circumcised. But many scientists were skeptical that circumcision played a role in acquiring H.I.V. Then in recent years, three scientifically controlled studies in Kenya, South Africa and Uganda convinced the skeptics by showing that male circumcision could reduce the risk of H.I.V. infection by 50 percent to 60 percent.
Although circumcision is no cure-all, the World Health Organization endorsed the procedure last year, increasing demand for it among men in many areas of Africa. When trained workers performed the procedure, the incidence of infection and mishap is much lower than when traditional ritual circumcisers perform it.
Male circumcision took on new importance because of the failure of scientists to develop a vaccine to prevent AIDS. The success rates of male circumcision were high enough for many AIDS experts to call the procedure a virtual "vaccine."
Some AIDS experts also said there were strong indications that male circumcision of infected men also protects their sexual partners.
"Some infected men inevitably will seek circumcision because it leaves a physical mark" that would remove the stigma of being infected, Dr. Maria Wawer of Johns Hopkins, a co-author of the study, said at a news conference.
Also, if fewer men became infected because they got circumcised, that could provide a benefit to their sexual partners, said another author, Dr. David Serwadda of Makerere University in Kampala.
In the study reported here, all the men and women agreed in writing to participate after they were informed about other ways to prevent H.I.V. infection, wound care and abstention from sex after the surgical circumcision. The men were offered free condoms and the couples were counseled and tested for H.I.V. There were 1,015 H.I.V.-infected men who agreed to having circumcision immediately or waiting two years for purposes of a scientific control group. The timing was chosen at random, researchers said.
The 770 married men were asked to invite their spouses to participate in the study, and 566 did. Among the women, 245, or 43 percent, were not H.I.V. infected. The analysis focused on the 161 couples who enrolled at the same time and in which the men were infected but their spouses were not.
There were 93 couples in the group where the man had an immediate circumcision and 68 in the control group where the man delayed having the procedure for two years. In both groups, the incidence of infection was highest in the first six-month follow-up period, 27.3 in the immediate group and 17.8 in the delayed one.
The incidence declined for the rest of the study period, 5.7 in the immediate group compared with 4.1 in the delayed group.
The higher incidence was found among the couples who resumed sexual intercourse more than five days earlier than a trained health professional certified the circumcision wound had healed fully compared with the couples who resumed intercourse within five days of certified circumcision wound healing.
Dr. Wawer said in an interview that because the numbers in the study were small and the results not statistically significant, additional studies were needed to determine more precisely potential benefits among men and women as well as ways to reduce potential risks associated with early resumption of sex.
Rates of condom use, vaginosis (a bacterial vaginal infection), vaginal discharge, painful urination and infection of the genital-urinary tract were about the same among women in each group.

Surprising research results at AIDS conference
Sabin Russell, SF Chronicle Medical Writer
Monday, February 4, 2008
(02-04) 04:00 PST Boston --
Researchers at a major scientific conference here warned Sunday that adult male circumcision, which may dramatically reduce the risk of HIV transmission in Africa, could raise the risk for women there whose male partners seek the procedure after they are already infected.
Studies to be presented this week at the 15th annual Conference on Retroviruses and Opportunistic Infections - considered the premier scientific meeting on AIDS each year - are examining in depth new strategies that rely on medical interventions such as the use of drugs or surgical removal of the foreskin to improve the odds against infection.
Three landmark studies in 2005 and 2006 showed that adult men who are circumcised reduce their risk of HIV infection by up to 60 percent, and the World Health Organization last year added the procedure to its list of recommended AIDS prevention measures.
John Mellors, chief of infectious diseases at the University of Pittsburgh, called those circumcision results the "most important finding in HIV prevention in a decade."
The research raised hopes that circumcision might convey some protection to female partners of HIV-infected men, because circumcised men have fewer genital and urinary tract infections, and it was assumed that the women might have fewer vaginal infections as well. Scientists also theorized that an infected man's foreskin might be an effective transmitter of the virus - so lack of a foreskin and fewer genital infections might cut the HIV risk.
New studies by scientists from Johns Hopkins University and Makerere University in Kampala, Uganda, have shown, however, that when men who were already HIV-positive were circumcised, it may have raised the risk of infection to their female partners.
The researchers provided circumcisions to one group of HIV-positive men, and set up for comparison purposes a second group of HIV-positive men who were not circumcised. Couples were counseled to use condoms. Then the researchers tracked and compared the health of couples in both groups.
Unexpectedly, the study found similar rates of vaginal infections among women, whether or not their partners were circumcised, and a slightly increased risk for HIV if their infected partners were circumcised. The HIV risk could have been purely the result of chance, but researchers were alarmed that instead of clearly reducing the danger, it showed a trend toward increasing it.
Dr. Maria Wawer, the Johns Hopkins scientist who led the project, said the disappointing findings were all too familiar in HIV research. "We all want to find the next step in understanding this incredibly clever virus," she said. "No matter where we hit it, it seems to pop up in another direction."
The study found a plausible reason why the women whose HIV-positive partners were circumcised had a higher risk for HIV: The infections were clustered among couples who began sexual activity before the 30 day post-circumcision healing period was completed.
Without complete healing, HIV could pass in blood from the surgical wounds.
The news was not entirely bleak, however. A separate study conducted at Rakai, Uganda, did show some health benefits for women whose male partners were circumcised while HIV-negative. These women had a 25 percent lower rate of infection with genital herpes; a 50 percent reduction in trichomoniasis - a common sexually transmitted disease caused by a parasite - and a 20 percent reduction in bacterial vaginosis.
These kinds of infections tend to increase the risk of HIV infection in women, but this study was not designed to find out whether that indeed had happened.
Despite the disappointment that male circumcision seemed to offer no protection to female partners of HIV-infected men, Wawer stressed that the procedure will probably still benefit women because if fewer men are infected, they are less likely to pass that infection on to their partners. "We are sure there will be a population benefit," she said.