Male circumcision and its links to HIV prevention

Male circumcision and its links to HIV prevention

IntroductionDuring the past 3rd SA AIDS Conference held in Durban in June 2007, the occurrence and viability as well as advantages of male circumcision for HIV prevention were hotly debated. This opened up, once again, the whole issue of male circumcision, especially in sub-Saharan Africa.What is male circumcision? Male circumcision refers to the removal of the foreskin of the male penis. It is normally done shortly after birth, during childhood or even adulthood. It is estimated that 30% of the world’s male population is circumcised. This accounts for approximately 670 million males.Historical background of male circumcisionMale circumcision is a very old practice, traditionally undertaken as a mark of cultural identity or because of religious importance.A few examples of male circumcision as a religious practice⁴:

• The earliest records of male circumcision were found on wall paintings in Egyptian temples dating back to 2300 BC;

• In the Jewish religion, male infants are circumcised on their 8th day of life. This tradition is almost universally practised among the Jewish people;

• Islam, the largest religious group in the world, practices male circumcision too. Although there is no clearly prescribed day for this ritual, the prophet Mohammed, recommended it to be carried out at an early age; and

• Christians, on the other hand, are not bound by this tradition at all. It is therefore seldom found amongst male Christians.

Male circumcision is also culturally motivated:

• In many cultures male circumcision is closely associated with the rite-of-passage to manhood. These cultures include aboriginal Australians, the Aztecs and Mayans, certain inhabitants of the Philippines and Eastern Indonesia and several of the Pacific Islands, such as Fiji and the Polynesian islands; and

• In South Africa the Xhosas view the foreskin as the feminine element of the penis, the removal of which, amongst other things, makes a man of the child.

Amongst certain ethnic groups of Bendel State in southern Nigeria, 43% of the men were motivated to be circumcised purely to maintain tradition.How can male circumcision prevent HIV-infection? Are there any biological risks involved? According to a report, “the foreskin’s inner mucosal surface is more susceptible to HIV because it has more immune cells that are vulnerable to HIV infection. The presence of the foreskin acts as a physical barrier, trapping HIV next to the surface of the penis for longer periods. In this moist environment, the HI-virus can survive longer”. After circumcision the penile shaft becomes less susceptible to viral infection.There are definite risks involved in the surgical procedure of circumcision. The following complications have been reported:

• Serious infection;

• Severe loss of blood;

• Mutilation;

• Penile amputation; and

• Possible death in extreme cases.

The above mentioned serious complications are due to:

• Poor training of the staff who performed the procedure;

• A lack of appropriate surgical equipment; and

• A lack of patient follow-up.

What has led to the current debate on male circumcision? The current debate was instigated by mainly three observational studies that have been done in Sub-Saharan Africa⁹. These three studies were conducted to determine the influence of circumcised men (as opposed to uncircumcised men) on HIV-infection. The findings of the three studies were as follows:

Observational study	Researchers & Date	Main result of the study
South Africa (Orange Farm): Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial.	Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Date: November 2005. The trail lasted for 2 years.	The results of the Orange Farm trial suggested that the risk of HIV infection was reduced by 60% in circumcised men.
Uganda: Trial of Male Circumcision: HIV, STD and Behavioural Effects in Men, Women and the Community.	Serwadda D, Wawer M, Gray R. Date: 2006	Adult male circumcision reduced the risk of acquiring HIV-infection by 48 percent.
Kenya: Trial of Male Circumcision to Reduce HIV Incidence.	Bailey R, Moses S, Maclean I, Parker C, Ndinya-Achola JO, Agot K, Krieger J. Date: 2006	Adult male circumcision reduced the risk of acquiring HIV-infection by 53 percent.

What are the consequences of these results? Brian Williams et al, designed a simulation model, based on the abovementioned trials, to predict the impact of male circumcision on the relative prevalence of HIV in men and women. They concluded, “Assuming that full coverage of male circumcision is achieved over the next ten years, male circumcision could avert 2 million new HIV-infections and 0.3 million deaths. In the 10 years after that, it could avert a further 3.7 million new infections and 2.7 million deaths”.

One must remember that male circumcision is only partially effective in HIV-positive female transmission to HIV-negative circumcised males.

By now the obvious benefits of male circumcision should be clear: it can indeed lessen the transmission of HIV. There are, as always, some conditions. Dr Catherine Hankins, chief scientific adviser to UNAIDS, gives valuable insight into possible problem areas with regard to male circumcision¹³.

• Since adult circumcision has a higher risk of adverse effect, one must propagate infant male circumcision;

• This procedure should always be undertaken by trained health workers in safe, adequately equipped facilities,  under sanitary conditions and further enhanced by appropriate pre and post-surgical counselling and follow-up;

• Cultural, religious and traditional values will always play a part and one will have to take these into account;

• male circumcision for adults should be done with consent; otherwise it becomes a violation of that person’s human rights. In the case of a child, the parents or legal guardian should give consent; and

• male circumcision has shortcomings:

• It applies only to female-to-male transmission;

• It is not 100% safe and should be treated as an additional preventative measure; and

• Other known methods, such as abstinence, limitation to one sexual partner and the use of condoms, are still to be advocated.

The way forward

• male circumcision should be part of a comprehensive HIV-prevention approach: This will include the following:

• The provision of HIV testing and counselling services;

• Treatment for sexually transmitted diseases;

• The promotion of safer sex practices; and

• Provision of male and female condoms and promotion of their correct and consistent use.

• Need for quality and safe services: The procedure must be performed under fully hygienic conditions by adequately trained and well equipped practitioners with appropriate post-operative follow-up.

• Maximizing public health benefit: An immediate up-scaling of male circumcision services and the promotion thereof is needed. Age groups with a high risk of acquiring HIV should be targeted, whilst male circumcision for younger men (even infants) should also be promoted.

• More research needed: There are some additional areas where more research is urgently needed in order to develop male circumcision programmes:

• The impact of male circumcision on sexual transmission from HIV-infected men to women;

• The impact of male circumcision on the health of women for reasons other than HIV transmission;

• The risks and benefits of male circumcision for HIV-positive men;

• The protective benefit of male circumcision in the case of partners engaging in homosexual or heterosexual anal intercourse; and

• Research into the resources needed for, and most effective ways to expand quality male circumcision services.

ConclusionIt is heart warming to know that there is some substantial evidence of other forms of HIV prevention, albeit only female to male transmission. With the high prevalence rate, especially in South Africa, it would be important for the South African government to take some decisive steps in promoting and initiating male circumcision on a much wider scale in order to support other HIV-prevention efforts.Sources

1. SOUTH AFRICA: New prevention strategies – from research to reality. http://www.plusnews.org/Report.aspx?ReportID=72582 Viewed on 13 June 2007

1. Questions and Answers: NIAID-sponsored Adult male Circumcision Trails in Kenya and Uganda. http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm Viewed on 13 June 2007

1. Male Circumcision: context, criteria and culture (Part 1) 26 February 2007 http://www.unaids.org/en/MediaCentre/PressMaterials/FeatureStory/20070226_MC_ptl.asp Viewed on 13 June 2007

1. Ibid.

1. Ibid.

1. Ibid

1. Questions and Answers: NIAID-sponsored Adult male Circumcision Trails in Kenya and Uganda. http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm Viewed on 13 June 2007

1. Ibid

1. WHO/UNAIDS Technical Consultation. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. 28 March 2007 http://www.WHO.org Viewed on 13 June 2007

1. Sharif, R.; Shari, L.; Thomas, J. Male Circumcision and HIV/AIDS: Opportunities and Challenges. AIDS Policy Development Centre ,UCLA Program in Global Health, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles p. 14-16

1. Williams, G.B.; Lloyd-Smith, J.O.; Gouws, E.; Hankins, C.; Getz, W.M.; et al. (2006) The Potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS Med. 3(7): e262. DOl: 10.1371/journal.pmed.0030262 www.plosmedicine.org Viewed on 13 June 2007

1. Ibid, page 1

1. Moving forwards: UN policy and action on male circumcision (Part 3). http://www.unaids.org/en/MidiaCentre/PressMaterials?FeatureStory/20070302_MC_Pt3.asp

1. WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention  http://www.who.int/mediacentre/news/releases/2007/pr10/en/index.html  Viewed o 13 June 2007

SOURCE:http://www.mrc.ac.za/public/facts19.htm