The AIDS Epidemic – Africa First, Now It’s Asia’s Turn 08/11/04

There are now about 40 million people in the world infected with HIV, the cause of AIDS. The great majority of the current cases are in sub-Saharan Africa where there have been over 20 millions deaths since the start of the AIDS epidemic in the mid 1980’s. The epidemic continues unabated with about 5 million new cases and 3 million deaths annually. Since 1988 it has been known that the penile foreskin is a risk factor in the acquisition of HIV infection. The foreskin acts as a magnet to HIV through special target cells which trap the virus. Over 30 separate research studies have shown that uncircumcised men are between 2 and 7 times more likely to become HIV-positive after sexual exposure than are circumcised men. The World Health Organization (WHO) found that in those African countries where most males are uncircumcised (Zimbabwe, Botswana, Namibia, Zambia) 19-26% of the population was HIV-positive, while in countries where circumcision is widely performed (Cameron, Nigeria, Liberia, Sierra Leone) only 3-5% of the population was HIV-positive. In certain African communities adult circumcision is now being performed with the cooperation of the local men who have seen the protective effect of removal of the foreskin. Had widespread newborn circumcision been instituted 15-20 years ago, when the relationship between the foreskin and HIV infection was first shown, there would be a much smaller at-risk sexually active male population today. It has been estimated that if all African males were circumcised there would have been 8-10 million fewer HIV –positive people.

Although the HIV prevalence rate in Asia is 5 times less than in Africa it has been increasing rapidly in the past few years, particularly in India. It is estimated that there are currently 5 million HIV-positive Indians. As in Africa, the protective effect of circumcision is obvious in India, where Muslims are circumcised and Hindus are not. In Pune, India, 2300 men were seen in clinics for sexually transmitted diseases (STDs) from 1993-2000. All were initially HIV-negative and were followed to see how many became HIV-positive over the 7 year period as related to their circumcision status. Uncircumcised men were found to be 7 times more likely to acquire HIV infection than were those who were circumcised. It was concluded that the foreskin is an important risk factor in the transmission of HIV, mirroring the African data.

Since the start of the AIDS epidemic about 2 decades ago repeated attempts to develop an effective vaccine have failed, and the use of anti-viral drugs has been stymied by costs and the rise of drug resistance. As the AIDS epidemic spreads in India and other Asian countries, circumcision should be considered as one preventive intervention along with the use of condoms and other weapons to fight this devastating lethal disease.