Re: The dilemma of circumcision for Hindus

[Guest guest]

Dear FORUM,

Re: The dilemma of circumcision for Hindus. Absolutely... The dilemma will be

profound in the minds of all the parents to think abt this eventuality as the

guiding prinicple for circumcising their newly born sons and i amnot even

talking abt the religious dilemma which to me is irrelevent if it ever was!.

For me it is yet another case of transplanting the ethos and findings of foreign

study into indian shores with out looking in to the social implications of it.

I still believe that the authors of such reports would not be wanting the public

health officials in the developing world to lap it up with giving a thought into

the practical difficulties.

Dr Sreejit E M

67,Pearson road

Ipswich,IP3 8 NL

UK

Ph:+44-1473-437837

mob:+44-7722015047

e-mail: <emsree@...>

[Guest guest]

Dear FORUM,

Re: /message/7051

I think Dr. Gupta raised some very important issues that ought to be considered

before launching a mass circumcision campaign anywhere.

In a recently published article, my colleagues and I reported that circumcised

male and female virgins and adolescents in Kenya, Lesotho, and Tanzania are

_more_ likely to be infected with HIV than their uncircumcised counterparts.

There are widespread observations of unhygienic circumcision practices in

sub-Saharan Africa, and the available evidence suggests that HIV transmission

may occur through circumcision-related blood exposures. Clinical settings there

are also plagued by poor infection control, so medical circumcision may not be

any guarantee for hygienic care. This article is available on request from

http://www.interscientific.net/AOE2007.html.

We found, as have many others, that circumcised adults (both men and women) were

less likely to be HIV infected than uncircumcised adults. This difference in

the direction of the relationship (circumcised more likely to be infected among

adolescents, circumcised less likely to be infected among adults) may be due to

circumcision-related HIV mortality (that is, most persons infected during

circumcision in adolescence dying before reaching middle to late adulthood).

The circumcision trials that you mentioned consistently demonstrated substantial

reductions in genital symptoms following circumcision.

As a result, circumcised men may also be less likely to seek treatment for

genital symptoms and consequently receive fewer blood exposures to HIV from

unhygienic care (such as with unsterilized, reused syringes).

The three trials demonstrated that circumcision in presumably sterile conditions

decreased the rate at which men acquired HIV. However, the mechanism of this

effect is unclear. The trial investigators have argued that the effect is due

to physiology. The most frequently cited physiologic mechanism is the

elimination of foreskin with its dense population of Langerhans cells. These

cells have been thought to be especially vulnerable to HIV infection, but

research published two weeks ago showed that these cells actually produce a

protein that strongly _protects against_ HIV infection (see

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed & cmd=Retrieve & dopt=Abstra\

ctPlus & list_uids=17334373 & query_hl=2 & itool=pubmed_docsum). Altogether, the

findings I've mentioned here call into question the physiologic basis of the

effect observed in the trial. It remains for further research to identify the

mechanism, but some other possibilities might be reduced exposure to

unhygienic formal or informal medical care (as a result of reduced genital

symptoms) and changes in sexual repertoire after circumcision (perhaps shifting

from anal sex to vaginal sex; types of sex apparently not measured in the

trials).

The uncertainties about circumcision also highlight the broader issue of

nonsexual transmission of HIV. You have nicely outlined several aspects of such

transmission on one of your web pages

(http://t8web.lanl.gov/people/rajan/AIDS-india/MYWORK/blood.6.00.html).

Mariette Correa and Gisselquist, contributors to this list, have also

published a number of informative articles and reports on this dimension of the

epidemic in India (see, for example,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed & cmd=Retrieve & dopt=Abstra\

ctPlus & list_uids=17062177 & query_hl=4 & itool=pubmed_docsum).

Devon Brewer

e-mail: interscientific@...

www.interscientific.net