[e-med] Le rôle de la circoncision dans la réduction du risque VIH s'affirme

["ReMeD" <c.bruneton@remed.org>]

[Nous avons déjà eu à débattre de ce sujet sur e-med, mais le sujet revient en force... comment garantir que la circoncision se fasse dans les meilleures conditions d'hygiène et prévenir la transmission de maladies ? CB]

Afrique: Le rôle de la circoncision dans la réduction du risque VIH
s'affirme
http://fr.allafrica.com/stories/200612140843.html
UN Integrated Regional Information Networks
14 Décembre 2006
Publié sur le web le 14 Décembre 2006
Johannesbourg

Des essais visant à établir une relation entre la circoncision masculine et
le risque d'infection au VIH ont été prématurément interrompus, les
résultats obtenus prouvant d'ores et déjà que les hommes circoncis avaient
moins de risques de contracter le virus que les autres.

L'Institut national des allergies et maladies infectieuses (NIAID), qui fait
partie de l'Institut national (américain) de la santé (NIH), a annoncé
l'arrêt prématuré de deux essais cliniques évaluant l'impact de la
circoncision masculine sur le risque de transmission du VIH après qu'un
examen intermédiaire des données a révélé que la circoncision effectuée chez
l'homme adulte diminuait fortement les risques de contamination par le VIH,
par voie sexuelle.

Les résultats de l'étude, qui devait durer jusqu'à mi-2007, menée à Kisumu,
une ville située dans l'ouest du Kenya, sur quelque 3 000 hommes
séronégatifs, montrent que le risque de contracter le virus est réduit de 53
pour cent chez les hommes circoncis.

Selon les conclusions d'une autre enquête conduite dans le district de
Rakai, au centre de l'Ouganda, à laquelle ont participé près de 5 000 hommes
séronégatifs, ce risque est également réduit de 48 pour cent chez les hommes
circoncis.

«Ces résultats sont d'un grand intérêt pour les politiques de santé publique
et ceux qui mettent en place des programmes généraux de prévention contre le
sida», a déclaré le docteur Elias Zerhouni, directeur du NIH.

La circoncision masculine, «effectuée en toute sécurité dans un
environnement médical, vient compléter un ensemble de mesures de prévention
du VIH et pourrait réduire le poids du VIH/SIDA, notamment dans les pays
d'Afrique sub-saharienne, où d'après les estimations de l'Onusida de 2005,
2,8 millions de nouvelles contaminations ont lieu chaque année», a-t-il
poursuivi.

Les conclusions de cette nouvelle étude viennent confirmer les résultats
d'essais cliniques menés l'année dernière par une équipe de scientifiques
français et sud-africains, selon lesquels la circoncision réduirait les
risques de transmission du VIH/SIDA de 60 pour cent.

Les écarts entre les hommes circoncis et les hommes non-circoncis étaient
tellement évidents que les essais cliniques ont été arrêtés prématurément -
ne pas pouvoir offrir la possibilité aux hommes non-circoncis du groupe
témoin de se faire opérer allant à l'encontre de l'éthique médicale.

Plus de 30 études menées à travers le monde ont indiqué que la circoncision
permettait de réduire les risques pour les hommes d'être infectés par le
VIH, mais l'essai clinique effectué en Afrique du Sud a été la première
étude clinique aléatoire à définir l'étendue de la protection assurée par la
circoncision.
Plusieurs pays africains ont déjà pris des initiatives en se fondant sur les
résultats de l'étude menée en Afrique du Sud et souhaitent intégrer la
circoncision masculine dans leurs stratégies nationales de prévention de
l'épidémie.

La Zambie et le Swaziland ont tous deux lancé des programmes nationaux de
circoncision masculine, au moment où la Communauté de développement de
l'Afrique australe (SADC) présente, dans un nouveau rapport, la circoncision
comme «une intervention chirurgicale unique qui réduit pour toujours les
risques biologiques.»

D'autres pays, comme l'Afrique du Sud, ont attendu la publication des
résultats des études conduites au Kenya et en Ouganda avant de lancer une
action.
Le NIAID a rappelé que la circoncision à elle seule ne permettait pas de
protéger les hommes d'une contamination au VIH lors d'un rapport sexuel et a
souligné que «la circoncision faisait partie d'une stratégie de prévention
plus large, qui inclut la fidélité et l'utilisation systématique du
préservatif lors des relations sexuelles.»

Des acteurs de la lutte contre le sida ont à plusieurs reprises tiré la
sonnette d'alarme et souligné la nécessité d'éviter la confusion entre
«réduction» du risque d'infection au VIH et «élimination» de ce risque -ce
que ne permet en aucun cas la circoncision seule.

*******************************
----- Message d'origine ----- 
De : "Leela McCullough" <leela@healthnet.org>
À : <afro-nets@healthnet.org>; <procaare@healthnet.org>
Envoyé : jeudi 14 décembre 2006 18:27
Objet : [afro-nets] Male circumcision Halves HIV Risk
Male circumcision Halves HIV Risk
---------------------------------

Copied as fair use.

(Male) Circumcision Halves H.I.V. Risk, U.S. Agency Finds

By
<http://topics.nytimes.com/top/reference/timestopics/people/m/donald_g_jr_mcneil/index.html?inline=nyt-per>DONALD
G. McNEIL Jr.
Published: New York Times, December 14, 2006

Circumcision appears to reduce a mans risk of contracting
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/aids/index.html?inline=nyt-classifier>AIDS
from heterosexual sex by half, United States government health officials
said yesterday, and the directors of the two largest funds for fighting the
disease said they would consider paying for circumcisions in high-risk
countries.
<http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm>Q&A About the
NIAID-Sponsored Adult Male Circumcision Trials in Kenya and Uganda (National
Institute of Allergy and Infectious Diseases)

The announcement was made by officials of the
<http://topics.nytimes.com/top/reference/timestopics/organizations/n/national_institutes_of_health/index.html?inline=nyt-org>National
Institutes of Health as they halted two clinical trials, in
<http://topics.nytimes.com/top/news/international/countriesandterritories/kenya/index.html?inline=nyt-geo>Kenya
and
<http://topics.nytimes.com/top/news/international/countriesandterritories/uganda/index.html?inline=nyt-geo>Uganda,
on the ground that not offering circumcision to all the men taking part
would be unethical. The success of the trials confirmed a study done last
year in South Africa.

AIDS experts immediately hailed the finding. This is very exciting news,
said Daniel Halperin, an H.I.V. specialist at the
<http://topics.nytimes.com/top/reference/timestopics/organizations/h/harvard_university/index.html?inline=nyt-org>Harvard
Center for Population and Development, who has argued that circumcision
slows the spread of AIDS in the parts of Africa where it is common.

In an interview from Zimbabwe, he added, I have no doubt that as word of
this gets around, millions of African men will want to get circumcised, and
that will save many lives.

Uncircumcised men are thought to be more susceptible because the underside
of the foreskin is rich in Langerhans cells, sentinel cells of the immune
system, which attach easily to the human immunodeficiency virus, which
causes AIDS. The foreskin also often suffers small tears during intercourse.

But experts also cautioned that circumcision is no cure-all. It only lessens
the chances that a man will catch the virus; it is expensive compared to
condoms, abstinence or other methods; and the surgery has serious risks if
performed by folk healers using dirty blades, as often happens in rural
Africa.

Circumcision is not a magic bullet, but a potentially important
intervention, said Dr. Kevin M. De Cock, director of HIV/AIDS for the
<http://topics.nytimes.com/top/reference/timestopics/organizations/w/world_health_organization/index.html?inline=nyt-org>World
Health Organization.

Sex education messages for young men need to make it clear that this does
not mean that you have an absolute protection, said Dr. Anthony S. Fauci, an
AIDS researcher and director of the National Institute of Allergy and
Infectious Diseases.

Circumcision should be used with other prevention methods, he said, and it
does nothing to prevent spread by anal sex or drug injection, ways in which
the virus commonly spreads in the United States.

The two trials, conducted by researchers from universities in Illinois,
Maryland, Canada, Uganda and Kenya, involved nearly 3,000 heterosexual men
in Kisumu, Kenya, and nearly 5,000 in Rakai, Uganda. None were infected with
H.I.V. They were divided into circumcised and uncircumcised groups, given
safe sex advice (although many presumably did not take it), and retested
regularly.

The trials were stopped this week by the N.I.H. Data Safety and Monitoring
Board after data showed that the Kenyan men had a 53 percent reduction in
new H.I.V. infection. Twenty-two of the 1,393 circumcised men in that study
caught the disease, compared with 47 of the 1,391 uncircumcised men.

In Uganda, the reduction was 48 percent.

Those results echo the finding of a trial completed last year in Orange
Farm, a township in South Africa, financed by the French government, which
demonstrated a reduction of 60 percent among circumcised men.

The two largest agencies dedicated to fighting AIDS said they would now be
willing to pay for circumcisions, which they have not before because there
was too little evidence that it worked.

Dr. Richard G. A. Feachem, executive director of the Global Fund to Fight
AIDS, Tuberculosis and Malaria, which has almost $5 billion in pledges, said
in a television interview that if a country submitted plans to conduct
sterile circumcisions, I think its very likely that our technical panel
would approve it.

Dr. Mark Dybul, executive director of President Bushs $15 billion Emergency
Plan for AIDS Relief, said in a statement that his agency will support
implementation of safe medical male circumcision for H.I.V./AIDS prevention
if world health agencies recommend it.

He also warned that it was only one new weapon in the fight, adding,
Prevention efforts must reinforce the A.B.C. approach abstain, be faithful,
and correct and consistent use of condoms.

Researchers have long noted that parts of Africa where circumcision is
common particularly the Muslim countries of West Africa have much lower AIDS
rates, while those in southern Africa, where circumcision is rare, have the
highest.

But drawing conclusions was always confounded by other regional factors,
like strict Shariah law in some Muslim areas, rape and genocide in East
Africa, polygamy, rites that require widows to have sex with a relative,
patronage of prostitutes by miners, and mens insistence on dangerous dry sex
with the womans vaginal walls robbed of secretions with desiccating herbs.

Outside Muslim regions, circumcision is spotty. In South Africa, for
example, the Xhosa people circumcise teenage boys, while Zulus do not. AIDS
is common in both tribes.

<http://topics.nytimes.com/top/reference/timestopics/people/m/nelson_mandela/index.html?inline=nyt-per>Nelson
Mandelas autobiography, Long Walk to Freedom, contains an unnerving but
hilarious account of his own Xhosa circumcision, by spear blade, as a
teenager. Although he was supposed to shout, I am a man! he grimaced in
pain, he wrote.

But not all initiation ceremonies are laughing matters. Every year, some
South African teenagers die from infections, and the use of one blade on
many young men may help spread AIDS.

In recent years, as word has spread that circumcision might be protective,
many southern African men have sought it out. A Zambian hospital offered $3
circumcisions last year, and Swaziland trained 60 doctors to do them for $40
after waiting lists at its national hospital grew.

Private practitioners also do it, Dr. Halperin said. In some places, its
$20; in others, much more. Lots of the wealthy elite have already done it.
It prevents
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/venerealdiseases/index.html?inline=nyt-classifier>S.T.D.s,
its seen as cleaner, sex is better, women like it. I predict that a lot of
men who cant afford private clinics will start clamoring for it. (S.T.D.s
are sexually transmitted diseases.)

Male circumcision also benefits women. For example, a study of the medical
records of 300 Ugandan couples last year estimated that circumcised men
infected with H.I.V. were about 30 percent less likely to transmit it to
their female partners.

Earlier studies on Western men have shown that circumcision significantly
reduces the rate at which men infect women with the virus that causes
cervical
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/cancer/index.html?inline=nyt-classifier>cancer.
A study published in 2002 in The
<http://topics.nytimes.com/top/reference/timestopics/organizations/n/new_england_journal_of_medicine/index.html?inline=nyt-org>New
England Journal of Medicine found that uncircumcised men were about three
times as likely as circumcised ones with a similar number of sexual partners
to carry the
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/humanpapillomavirushpv/index.html?inline=nyt-classifier>human
papillomavirus.

The suspected mechanism was the same cells on the inside of the foreskin
were also more susceptible to that virus, which is not closely related to
H.I.V.

--
Leela McCullough, Ed.D.
Director of Information Services
AED-SATELLIFE Center for Health Information and Technology
30 California Street, Watertown, MA 02472, USA
Tel: +1-617-926-9400    Fax: +1-617-926-1212
Web: http://www.healthnet.org
Email: mailto:lmccullough@aed.org