"Many observers of the AIDS pandemic are puzzled by glaring discrepancies in the levels of HIV prevalence between different countries and regions, despite the presence of what appear to be similar risk factors," says Robert C. Bailey, PhD, MPH, professor in the Epidemiology and Biostatistics Division at the UIC School of Public Health. "Outside the U.S. and Canada, male circumcision is restricted primarily to particular cultural and religious groups. Because circumcision is often imbedded in a complex web of deeply held cultural values and religious beliefs, it is not surprising that health professionals have been reluctant to adopt it as another HIV prevention measure."

Bailey explains that the epidemiological and biological evidence linking lack of male circumcision with HIV infection is compelling. HIV rates among those who are not circumcised are two to eight times higher than in those groups who do practice circumcision. It is a major reason for regional discrepancies in HIV infection rates. And it has been the source of Bailey’s calling to research, identify, and implement the integration of circumcision capabilities into existing reproductive health services in developing countries.

His work has included outreach efforts in sub-Saharan Africa, where 70 percent of all new HIV infections and 80 percent of all AIDS deaths occur, in an area that is home to only 10 percent of the world’s population.

"The rates are as high as 35 percent for women, who test positive for HIV during prenatal visits. In the U.S., that rate is less than 0.5 percent," says Bailey. "Unlike the situation in the U.S. and Europe, the AIDS epidemic in Africa is occurring almost purely among heterosexuals. Conditions of poverty and limited work opportunities have conspired to cause social disruption there, through work environments, such as mining sites and truck stops, where the commercial sex trade thrives among men drawn far from home and family."

Initially, Bailey and African collaborators conducted dozens of focus groups in Uganda and Kenya, compiling data on awareness and attitudes within ethnic or tribal groups that traditionally don’t practice male circumcision. He noted that while there is widespread knowledge about male hygiene and HIV, there is resistance to circumcision.

"People expressed fear of being different from their male relatives and friends," he says. "Not being circumcised is an element of ethnic identity. People felt that if they were circumcised, they might be discriminated against by their fellow tribesmen."

In his subsequent survey of health professionals, Bailey found that practitioners in these regions were not talking to their patients about circumcision. There had been little effort to take the practice from the realm of religion and ethnicity into disease prevention and hygiene. However, the participants in the original, lay focus groups had expressed an eagerness to learn more about male circumcision in the context of health and disease prevention. They had seen their loved ones dying around them and were caring for children who were orphaned due to AIDS. In their search for solutions, the intervention pathway became clearly defined.

In response to an invitation from the Nyanza Provincial Medical Office, Bailey has been working in western Kenya to set up reproductive health services and health education programs that integrate messages about penile hygiene and disease prevention. A prior survey conducted in that province found that 60 percent of uncircumcised men would opt for the procedure. However, such services were not available within the existing health care system. Working with Kenyan collaborators, Bailey initiated a trial intervention, which included physician training in the practice of male circumcision, along with efforts to ensure that medical facilities were adequately equipped.

"Many men and boys in our province have become circumcised privately and are happy," says Nyanza Provincial Medical Officer Dr. Richard Muga. "Now, finally, we are able to offer the service in our public health facilities by trained professionals and under safe, antiseptic conditions."

With only 25 percent of men worldwide having been circumcised, Bailey asserts that millions of lives could be saved by recognizing the practice as a formidable weapon against AIDS. "In many areas of the world, where most men are not circumcised and HIV is primarily transmitted heterosexually, over half of HIV infections are attributable to lack of male circumcision," he says. "We should never stop reinforcing our efforts to promote condom use and other proven HIV prevention measures, but it is possible that more heterosexual HIV infections are prevented by male circumcision than all the world’s condom promotion programs combined."

He explains that it is time to provide communities with accurate, balanced information, so that individuals may make informed choices; to provide training and resources necessary to offer safe, minimally painful, voluntary male circumcisions; and to begin investigating the feasibility of acceptable interventions in communities where HIV prevalence is high and male circumcision has traditionally not been practiced.

He quotes the leader of a South African traditional healers’ organization: "When tradition and the health of our people are in conflict, it is tradition we must sacrifice."

Contributed by Marian Lawler