SYDNEY

Six years, over US$20 million, and probably one million new preventable infections; that's how much it took for AIDS researchers to be convinced that male circumcision should be considered as a prevention strategy.

Delegates attending the fourth International AIDS Society Conference on HIV Pathogenesis and Treatment this week, in Sydney, heard on Tuesday that studies showing the reduced risk of HIV infection were available as far back as 2001.

But it took three randomised, controlled trials in South Africa, Kenya and Uganda before the international health community could be persuaded to act on the evidence, said Prof Robert Bailey, principal investigator of the male circumcision trials in Kenya.

"I'm not sure what could have been done differently, but it does raise the question of whether we have raised the bar too high for converting evidence into action in the face of a crippling pandemic. Perhaps for the next intervention, the threshold of proof will not be quite so high and we can start acting sooner," he said.

Dr Thomas Coates, associate director of the AIDS Institute at the University of California, Los Angeles, is also puzzled by the lack of enthusiasm for male circumcision in the scientific AIDS community - particularly among social scientists, such as Prof Peter Aggleton, a researcher at the University of London, who has warned that introducing the procedure as a prevention strategy could create "new physical and social differences, around which division can solidify".

Coates accused social scientists of creating these divisions themselves. "If social scientists want to be taken seriously, they have to stop listing problems and start coming up with solutions," he commented.

"In terms of science ... this is as good as it gets ... this [evidence] is a scientist's dream. The next logical step is to go into the field and implement. Certainly, given the evidence, there's no reason to hesitate."

How to move from evidence to practice, and at what speed, is another matter. Models suggest that the faster male circumcision is scaled up, the more infections can be prevented, with each averted infection costing governments less.

Bailey noted that the cost-effectiveness of male circumcision, even at the most conservative estimates, compared "favourably" with other prevention services such as school-based prevention campaigns and treating sexually transmitted infections.

Although circumcision was another male-controlled prevention method, women could not afford to be ignored in plans to roll out this programme, Bailey warned.

"As sex partners, as sisters and mothers, women are going to be instrumental in assuring broad and rapid uptake of circumcision in these communities," he said.

Many questions still need to be researched. Bailey told IRIN/PlusNews that the protective effect regarding women, and men who have sex with men, remained unclear, and trials to look into these issues were only in the early stages.

While acknowledging the challenges, a frustrated and impatient Bailey called for male circumcision services to be made available "as soon as possible" in regions with high HIV prevalence rates.

"One cannot help but contemplate that if it were a drug or a compound or a shot with a fancy label, international agencies and donors would have been fighting to be the first to make it available many months, even years, ago," he said.

"But no one stands to profit from male circumcision - no one, that is, but the 4,000 men in Africa who will be newly infected tomorrow, their partners and their children. Haven't we delayed long enough?"