Circumcision may cut AIDS risk

Researchers have routinely dismissed the idea that the procedure can stem the spread of HIV. That may be about to change.

By Sabin Russell

Jun 30, 2000 | Young Nelson Mandela sat in a row of 27 teenage boys, anxiously awaiting the arrival of the ingcibi, who was about to change them from boys to men. The old man soon knelt before the future president of South Africa, pulled the 16-year-old's foreskin forward, and brought down the ceremonial blade in a single, swift motion.

"I looked down and saw a perfect cut, clean and round, like a ring," Mandela wrote in his remarkable autobiography, "Long Walk to Freedom." "I count my years as a man from the date of my circumcision."

At the dawn of the 21st century, circumcision may confer more than manhood to a new generation of African boys. It could help to determine whether or not they, their future wives and girlfriends, or their children will die of AIDS.

As the latest United Nations report laid out in stark detail this week, the epidemic is now threatening an entire generation of Africans. In nations where the adult infection rate exceeds 15 percent, UNAIDS projects that one-third of today's 15-year-olds will eventually die of AIDS. In South Africa, where HIV infection rates jumped to 20 percent from 12 percent two years ago, half the 15-year-olds are similarly doomed. And in neighboring Botswana, where 36 percent of adults are infected, only one in three 15-year-olds can expect to be spared.

For more than a decade, AIDS researchers studying the catastrophic spread of HIV throughout Africa have been amassing a body of evidence suggesting that the epidemic is not consuming populations at a uniform rate, but seems cruelly selective in the people and places it does the most harm. In 1988, American anthropologist Priscilla Reining drew up a map of the African cities enduring the highest HIV infection rates and superimposed upon it a map of those places where the predominant cultural practices were to circumcise or not to circumcise. The correlation was striking: HIV was spreading fastest in places where male circumcision was not routinely performed. Despite this, in the decade since the correlation's discovery, the issue has been routinely ignored, ducked and dismissed.

"It's fascinating that the one intervention that is simple, apparently effective, cheap and lifelong is the one most violently opposed by men in this field," said Brian Williams, a South African AIDS researcher who is studying the disease in the mining communities west of Johannesburg. Even members of his own government health department do not take the issue seriously, he said. "There is a strange reluctance even to discuss it."

There will be no way to avoid the topic, however, at the 13th International AIDS Conference to be held in South Africa next month. Armed with years of epidemiological data, researchers are determined to bring the debate out of the shadows. No one expects the developing world to embark on a sudden, mass circumcision program, but supporters are hopeful for an open and frank debate. With hope for a vaccine a distant dream and the cost of medications out of reach, circumcision could be a low-cost, one-time intervention that could slow the spread of this global plague.

"The more you look at AIDS, the more you can see that the circumcision hypothesis has a lot of explanatory power," said Edward Green, an anthropological consultant with the U.S. Agency for International Development. "Look at Nigeria, a country with a high level of sexually transmitted disease, but a low rate of HIV [4 percent]. In Nigeria, they circumcise."

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