Circumcision Hailed As Way To Curb Aids
Bryan Appleyard, Writing in the March 26
2000 Sunday Times
The respectable London paper, "Sunday Times", recently published an article headed "Circumcision hailed as way to curb Aids", which reported research by Roger Short, professor of obstetrics at Melbourne University and his co-author, Dr Robert Szabo. in essence it argued that circumcision could help to halt the global Aids epidemic.
Short is reported as conceding that "The whole of my life's prejudice has been anti-circumcision," but he is now convinced that a high level of receptors - sites to which invading organisms attach themselves - on the inside of the foreskin make it responsible for transmission of the HIV/AIDS virus. Short does not advocate adult circumcision but suggests that future generations could be saved if mass [infant] circumcision began now. Short and Szabo believe that about 80% of male HIV infections in the world happen through the foreskin.
This is a very important finding, with major implications for public health and government health budgets, which have spent huge sums on AIDS research, without achieving either a vaccine or a cure. Treatments evolved are so expensive as to be largely useless to the great majority of Africans, almost all of whom live in countries with precarious economies.
The Uganda study to which the article refers, "showed that among a large group of ... couples where one was infected and one not - no circumcised males became infected over 30 months, even though their wives were HIV-positive". Short rightly describes these results as "staggeringly significant".
Many people will hope very much the Short/Szabo findings are right. But the existence of biases for or against circumcision also points to the great importance of taking into account cultural factors, if circumcision is to be advocated successfully. In Europe, centuries of antagonism (now fortunately waning) between Greeks and Turks has left a legacy of cultural revulsion for circumcision among Greeks, running counter to the actively promoted religious and cultural norm in favour of circumcision among the Turks.
For a similar reason the Uganda data need to be treated with some caution, since traditionally very few Ugandan peoples practiced circumcision as a puberty rite, whereas in neighbouring Kenya, most tribes circumcise, with a notable exception of the Luo, who live near the Uganda border on the shores of Lake Victoria Nyanza. Moreover, while in Europe, the North America, Australia etc boys are usually circumcised in infancy, in much of the Muslim world circumcision is customarily done at various ages up to about 12, while in central and southern Africa, boys are customarily circumcised at the onset of puberty.
This raises some important questions. How thoroughly was the circumcised status of the participants in the study determined? Are different circumcision techniques more or less effective in conferring protection from HIV infection? For example, the simplest ãpull and cutä operation leaves behind much of the inner foreskin, but its permanent exposure induces significant changes, from mucosa to epithelium. Does this conversion process reduce the high level of infection receptors? A more elaborate surgical technique, such as is/was practiced by traditional circumcisors of the Nandi tribe (who inhabit an area of Kenya north of the Luo and not far from the Uganda border) involved a second stage of surgery which carefully trimmed away every vestige of inner foreskin.
I suggest that it would be wise, as an important next stage in the Short/Szabo research on this theme, to include attention to these variables. Histological changes to foreskin post-circumcision could be analyzed in vitro, using tissue gathered from the adult circumcision revisions performed by some plastic surgery clinics. Field studies of the foreskin/circumcision status of HIV/AIDS patients will have to rely on careful observation and data gathering by medical or nursing personnel, and should include a question about the age at which the patient was circumcised and an observation of the amount of inner foreskin remaining between corona glandis and circumcision scar. Such data-gathering will gain considerable momentum from the publication of the Short/Szabo research hypothesis, with the prospect it holds of a significant check to the spread of HIV.
Thomas M.
The findings by the Australian researchers is surely interesting, as the flurry of comments in response have attested; regrettably, I did not see a copy of the article as it appeared in the "Times." If anyone has the complete article, I'm sure we'd all appreciate his (re)posting it. Lazy, I don't want to take time to fight for a copy at the public library: the medical lib. doesn't subscribe.
The mechanisms mediating attachment of HIV to certain blood and lymphoid cells and its eventual incorporation into their genome is presently the focus of a lot of investigational research. Significant new findings are reported almost daily in one or the another of the major journals or at symposia. I sure as hell don't claim to be abreast of all the current thinking, though immunology interests me greatly.
A "Reuters Health for the Professional" report was recently posted through Medscape that described possibly related research findings reported in the 3 March issue of Cell. Both the "Times" report and that in the referenced Cell paper seem to rely exclusively on in vitro findings:
Mar 03 (Reuters Health) - A newly identified dendritic cell (DC) binding protein (DC-SIGN) that facilitates HIV-1 entry into target T cells is described in the March 3rd issue of Cell. "HIV-1 utilizes a novel receptor strategy that has not been previously described in other viral systems," a multicenter Dutch and US team reports.
"DC localized in the skin and mucosal tissues such as the rectum, uterus, and cervix have been proposed to play a role in initial HIV-1 infection," they write. These cells are also known to "sequester HIV-1 and efficiently transmit the virus to CD4+ T cells." The investigators have now uncovered a new step in this process. [...] In vitro studies were conducted in Dr. Littman's laboratory by the Dutch investigators. "We have demonstrated that DC that express both DC-SIGN and CD4 preferentially use DC-SIGN to capture HIV-1 via its high affinity for HIV-1 gp120," they write in the journal. In addition to efficiently recruiting HIV-1, DC-SIGN "also facilitates HIV-1 infection of CD4+ T cells by novel in trans mechanism." This "specific interaction" is "independent from binding of virus to CD4 and CCR5."
In other words, "after HIV has been ferried by dendritic cells to the lymph nodes, the bound virus particle is presented to the chemokine-receptor complex on T-cells, greatly enhancing the entry of viral particles into these cells," according to a New York University Medical Center press release. [...]
I should imagine that the human foreskin, as well as other parts of the penis, may well be found to be provided with such dendritic cells, or with ones similar. But even if it is ultimately found that they indeed facilitate transfer of the viral particle to lymphocytes to cause human infection, consider that they abound in other structures as well, "...skin and mucosal tissues such as the rectum, uterus, and cervix..."
Check
The American Cancer Society has a web page with estimated cancer statistics for current and past years. Penile cancer only occurs in UNcircumcsied men. While the numbers are not high, do you want to be one of them? Why risk it.... enjoy all the benefits circumcision has to offer.
http://www.cancer.org/docroot/stt/stt_0.asp
