Women, don't count on male circumcision to protect against HIV

Obviously, men shouldn't bank on circumcision to keep them safe either. But the results of a study released this week are especially disappointing for researchers who'd hoped it might reduce HIV transmission to women, thus helping fight AIDS in Africa. 

The premise was promising. Earlier research had indeed suggested that male circumcision might reduce the risk of transmission to the female partners of HIV-positive men.

That seems not to be the case.

The new study, of 922 Ugandan men with the virus, found that the female partners of circumcised participants were no less likely to contract the disease than the female partners of uncircumcised participants.

The removal of the penile foreskin does seem to protect men against HIV transmission from female partners. Just not women at risk from men.
 
Here's a summary of the study, published today in the Lancet.

Its interpretation is very straightforward: "Circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months; longer-term effects could not be assessed. Condom use after male circumcision is essential for HIV prevention."

The report notes, "The trial was stopped early because of futility."

Here's a more readable story on the findings, courtesy of Reuters news agency.

And here's a fact sheet from the Centers for Disease Control and Prevention on male circumcision and HIV transmission. Of special note are the biological reasons that circumcision has been such a focus of concern:

Compared with the dry external skin surface, the inner mucosa of the foreskin has less keratinization (deposition of fibrous protein), a higher density of target cells for HIV infection (Langerhans cells), and is more susceptible to HIV infection than other penile tissue in laboratory studies. The foreskin may also have greater susceptibility to traumatic epithelial disruptions (tears) during intercourse, providing a portal of entry for pathogens, including HIV. In addition, the microenvironment in the preputial sac between the unretracted foreskin and the glans penis may be conducive to viral survival. Finally, the higher rates of sexually transmitted genital ulcerative disease, such as syphilis, observed in uncircumcised men may also increase susceptibility to HIV infection.

-- Tami Dennis

Photo: Use them -- if you can get them. Credit: Bryan Chan / Los Angeles Times

HIV is evolving at warp speed around the globe

HIV, the virus that causes AIDS, is one of the fastest evolving entities known. That's why no one has yet been able to come up with a vaccine: The virus mutates so rapidly that what works today in one person may not work tomorrow or in others.

A study published today in the journal Nature confirms that dizzying pace of evolution on a global scale.

"It's very clear there's a battle going on between humans and this virus, and the virus is evolving to become unrecognized by the immune system," said Dr. Bruce Walker, director of the Ragon Institute at Massachusetts General Hospital in Boston and one of the researchers. "It does make clear what a huge challenge making a vaccine is."

HIV evolves to escape the immune system, much in the same way that bacteria mutate under pressure by antibiotics, Walker said. Researchers looked at HIV genetic sequences in the United Kingdom, South Africa, Botswana, Australia, Canada and Japan to see how they evolved in response to a key set of molecules in the human immune system called human leukocyte antigens. These key molecules direct the immune system to recognize and kill HIV and other infectious diseases.

Genes encoding human leukocyte antigens vary among humans, and even small differences can dramatically affect a person's response to HIV infection. For example, an adult infected with HIV will survive on average about 10 years without anti-HIV drugs before developing AIDS. But some people will progress to AIDS within a year, and others can survive without treatment for 20 years.

The study published online today found mutations occurred not just in individuals but on a population level. That is, if a particular genetic immune sequence was common in a population, the HIV mutation that evolved to escape it became the most common strain of HIV even in those without that particular human leukocyte antigen gene.

"What this study does is give an explanation for why there are different HIV strains in different parts of the world," Walker said. "The genetic makeup of people in different regions is influencing the virus in specific ways."

This would appear to be bad news for the director of the newly opened Ragon Institute, which was founded to develop vaccines for HIV and other infectious diseases.

But Walker saw the results as hopeful. Mutations often come at a cost to the virus, he said. They can actually make the virus less fit -- that is, less able to replicate as quickly or do as much damage. His challenge is to find what kind of pressure results in this kind of mutation.

In addition to the Ragon Institute, the study involved researchers from Oxford University in England, Kumamoto University in Japan and the Royal Perth Hospital and Murdoch University in Australia, who analyzed the genetic sequences of HIV and human leukocyte antigen genes in 2,800 people.

-- Mary Engel

Photo credit: Ricardo DeAratanha / Los Angeles Times

Today is World AIDS Day

Today is the 20th anniversary of the first World AIDS Day back in 1988. Worldwide, around 33 million people are infected with the virus -- an earlier estimate of 40 million was downgraded by the United Nations in its most recent report, due to revised sampling methods.

There were 2.7 million new infections in 2007 (the stats on which the report is based), and 2 million died of the virus. More than 1 million people are infected with HIV in the United States.

Around the Web:

Read the UNAIDS 2008 report on the global AIDS epidemic here. (The reports are published every two years.)

Here, at cnn.com, are remarks by Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Fauci notes that on the first World Aids Day in 1988, there was only one drug for treating those infected with the virus -- AZT -- and HIV fast became resistant to it. Now, Fauci notes, there are two dozen drugs that are taken in various combinations (reducing the chances that HIV will develop resistance.) Fauci notes that this makes it possible for people to live normal lives for at least a decade and maybe even live normal lifespans.

But Fauci notes that the drugs must be made available to far more people throughout the world -- less than one-third of people infected with the virus "in low- and middle-income countries" are getting these drugs, he notes.

Another barrier to routine AIDS testing falls

Another obstacle to routine screening for HIV is about to fall, this time for the Department of Veterans Affairs, the nation's largest provider of HIV care. You may recall that in 2006, the Centers for Disease Control and Prevention issued revised recommendations for testing adults, adolescents and pregnant women for the virus that causes AIDS.

The new recommendations, while acknowledging that 38% to 44% of adults in the U.S. have been tested for HIV, are aimed at the approximately 25% of HIV-positive Americans who are unaware that they harbor the virus. So -- in bureaucratic lingo -- the CDC switched to an opt-out, rather than an opt-in, recommendation. What that means to people who go to hospitals, emergency rooms, clinics and other healthcare settings is that AIDS was to be treated like any other disease when it came to testing.

AIDS testing was to become more like Pap test screening for cervical cancer, or blood pressure readings to check out the heart. Patients have the right to say "no" to such screenings in a medical setting, but if they don't object -- or opt out -- a simple explanation from the physician acknowledged by the patient is enough to grant permission. The CDC said in 2006 that it was time to treat AIDS the same way. Specific signed consent for AIDS screening should no longer be required.

Since the early days of the AIDS epidemic in the 1980s, the disease had different rules from those of most others. Because of the stigma and potential for discrimination associated with the disease, along with the fact that until 1996, there was very little in the way of treatment to slow down the progression from HIV to AIDS to death, federal recommendations were that patients could not be subjected to testing for the disease unless they expressly asked to be tested -- or opted in.

But a CDC report found that of all HIV infections reported in 2004, 40% progressed from HIV-positive to AIDS within a year of diagnosis. That means they've been HIV-positive for a long time. Since the average time from infection with the virus to onset of the disease is about seven to nine years, a lot of infected people are out there, possibly spreading the disease without even knowing it. And the average survival rate is about 11 years longer when people with AIDS are diagnosed early.

The CDC wanted more people to know their HIV status, but that has meant that 20 states had to re-write their laws, eliminating a need for separate written consent for HIV testing. So far, 11 of the states with restrictive HIV-testing laws, including California, have passed new laws removing those barriers.

Now Congress has passed a law removing the barrier to opt-out testing from the VA, according to a news release from OraSure, maker of a rapid results HIV test. It's expected to be signed into law soon, meaning more veterans will be routinely screened.

It's been two years since the CDC recommended that adults 13 to 64 get routinely screened for HIV, according to an article in the Aug. 27 Journal of the American Medical Assn., and there are still problems. AIDS discrimination is still real, some insurers won't cover HIV-screening and many hospital emergency rooms simply don't have the time, personnel and resources to do routine screening on everyone who comes in the door.

But now there's one less barrier to identifying the 250,000 to 312,000 Americans who are HIV-positive and don't know it.

-- Susan Brink

-- Photo Illustration: Getty Images

AIDS in Africa. Exhibit offers a child's-eye view.*

Step out of your comfortable life and experience the devastation of AIDS in some of the hardest-hit areas in sub-Saharan Africa, from the point of view of a child.

That's the purpose  of a traveling exhibit featuring a 2,340-square-foot replica of an African village. Tour the village while listening on headsets to a personal audio track telling the true stories of four children -- Kombo, Babirye, Emmanuel and Mathabo -- whose lives have been affected by AIDS.

The exhibit was inspired by the U.S. Holocaust Memorial Museum In Washington, D.C. There, visitors can see the displays while reading the personal story of an individual Holocaust victim.

The AIDS exhibit, sponsored by World Vision, makes a stop in Los Angeles from now until Aug. 26 at two locations.  Until Aug. 18, you can "Step Into Africa" at the Holman United Methodist Church, 3320 W. Adams Blvd. in Los Angeles. And Aug. 22-26 you can experience it at Calvary Community Church, 5495 Via Rocas, Westlake Village.

The exhibit will travel to 80 cities, and some 200,000 people are expected to see it.

Be prepared to spend some time. As the voice says through the headset: "The pace is relaxed. Much like life in Africa."

And while the exhibit is moving, it is not hopeless. As you can see and hear, there is music, joy and hope in the people of Africa, where 25 million people are infected with the AIDS virus.

Short of getting on an airplane to see the continent for yourself, the exhibit gives you a sense of what it is like to be in a village "alive with activity, but people say it has the smell of death," as the gentle African voice will tell you.

-- Susan Brink

Photos: Robert Coronado, World Vision. Top: Faces of those affected by HIV and AIDS in a church in Babirye's village. *Earlier version said the scene was at the exhibit. Below: Bed in a one-room hut.