14 Mar 2007: ISS Today: `The Battle of the Foreskin,` Male Circumcision as an HIV Transmission Preventative Strategy and its Implications for the Arme

14 March 2007: “The Battle of the Foreskin,” Male Circumcision as an HIV Transmission Preventative Strategy and its Implications for the Armed Forces?

 

Does male circumcision (MC) work as a method to prevent the transmission of the HIV virus? If it does, is there sufficient evidence to suggest that MC would be particularly effective in Sub-Saharan Africa and, more specifically, in Southern Africa? Furthermore, if both these assumptions are accurate, what is the implication of MC to male dominated sectors such as the armed forces?

 

These are key questions that have emerged as the world tries to find a cure for HIV/AIDS and consider options that respond to the dynamics of the epicentre of the pandemic where prevalence rates range between 5 to 20% according to the 2006 UNAIDS Report, in zones lacking resources and adequate infrastructure to combat the effects of HIV/AIDS. There is also a further interesting interpretation of the prevalence data when analysed according to geographic regions on the African continent. Available evidence suggests an existing association with MC that has never been fully explained. For instance, there are inherent low rates of HIV prevalence rates averaging between 3 to 5% in West and North Africa, regions dominated by MC informed by cultural, traditional and faith-based practices. In comparison, prevalence rates of over 20% are common in Christian dominated Southern Africa, a region that has certain large groupings of uncircumcised males. Given these prevalence rates and regional disparities, and viewed against the background of Southern Africa being the highest affected region in the world, the assumption around the claims being made for MC, even without scientific underpinnings, have become elevated to a status of best-practice.

 

In so far as the global opinion has coalesced under UNAIDS and other leading international organisations such as the World Bank and the World Health Organisation (WHO), the evidence is regarded as compelling and it is a violation of legal and human rights for states not to make MC readily available. According to Mark Stirling, Director of the UNAIDS Regional Support Team for Eastern & Southern Africa based in Johannesburg, in his presentation to the Centre of the Study of AIDS, University of Pretoria seminar on MC held on 15 February this year, the evidence available from the three investigations reveals the following:

 

RCT Results, December 2006

 

 

The above scientific research findings provide a mean 54% reduction in the transmission of the HIV virus following MC and this now constitutes a compelling reason for implementation on a wider scale. Indeed, the Kisumu and Rakai investigations were considered so spectacular that further research was abandoned to take the process without delay into the next phase of implementation. In the lead, the consortium of WHO and UNAIDS has embarked upon preparing communities and states to consider ‘rolling out’ MC as a preventative measure, with the financial support from the Bill and Melinda Gates Foundation and the French Agence nationale de la  recherche sur le SIDA (ANRS).

 

It is important to acknowledge that the current initiative has a historical precedent. By 2001, simply taking into account ‘current research’, more than 40 studies had been completed that had failed to establish the link between MC and the reduction of HIV transmission in heterosexual relationships. According to Yvette Collymore, this group, led by Robert Bailey, Professor of Epidemiology at the University of Illinois in Chicago then agreed to move their non-conclusive research to the Luo community in Kenya, where they joined the United States National Institute of Health and Canada’s Institute of Health Research. Here, among the Luo, Bailey’s team began asserting that the research had shown a more positive link.

 

It was against this background of ‘new findings’ that two camps have emerged, arguing for and against MC.

 

Renewed efforts to implement the ‘highly positive results’ have been translated into the UN Male Circumcision Work Plan focussing on three aspects:

1. Assemble briefing packs for policy makers and other practitioners
2. Develop modelling and impact of MC taking into account the different options under different post-circumcision sexual risk and behavioural scenarios
3. Estimate the resources required for implementing MC at a greatly  improved level

 

This would then lead into programming and technical implementation guidelines along:

1. Acceptance assessment of MC running parallel to socio-cultural determination of existing inhibitions or otherwise
2. Clinical/surgical procedures to ensure safety & reduce complications incidence
3. Consider human rights, ethical and legal implications, including counselling, consent and availability
4. MC service management tools, including supervision and standard setting, certification, accreditation, monitoring and evaluation tools [being developed by the WHO] 

 

Just as the medical scientific community readied themselves for swift implementation, social scientists have emerged rubbishing the whole notion of MC as a viable HIV prevention strategy. In their view, the “Developed North”, where the US is actually passing legislation through Congress effectively banning female and male genital mutilations, including MC, is peddling this line. For this group then, the MC debate is steeped in power politics and even racism, if one takes the whole current focus on MC and Sub-Saharan/Southern Africa, and is not necessarily applicable throughout the world.

 

A colleague, Professor Peter Aggleton from the Thomas Coram Research Unit of the Institute of Education of the University of London who made a presentation at the CSA Seminar at the University of Pretoria in February this year points out that, focussing on MC as offering some sort of panacea is old news, going back to the pre-Christian era and Abraham of the Semitic tradition, a community that had also grappled with the challenge. During this period and to date, the “Battle of the Knife” is linked with curing a range of maladies including insanity, paralysis, bed-wetting, impotence, tuberculosis, prostate cancer, syphilis, cervical cancer in female partners and penile cancer -- all without sufficient scientific or empirical evidence.

 

Furthermore, Robert van Howe of the Department of Paediatrics, Marshfield Clinic, Wisconsin, USA, has warned that the risks involved from circumcision far outweigh any benefits that have so far been touted and, more significantly, according to him, “to portray MC as an alternative to condoms is dangerous”. On the latter issue, he has noted that in the current debate there appears to be an impression created that this does work in contexts where condoms are not used. Finally, among the more local African sceptics President Yoweri Museveni is prominent. It was in his country, Uganda, that the latest scientific examinations were conducted. In his view, noted while addressing a large gathering barely weeks after the spectacular medical science results had been released, he dismissed the research conclusions, arguing that his countrymen and women should rely upon abstinence, the correct use of condoms or being faithful to their partners as the most effective way to combat the transmission of HIV. The same sceptics also argue for those wishing to consider the MC option to think carefully, as the procedure is irreversible.

 

From the above it is clear, that advocating MC is not only controversial but also heavily contested.

 

Finally, to the question whether or not MC as a strategy is effective, the answer is of interest to the armed forces in Africa? Not only is this the largest sector dominated by males but, given the difficulty faced in maintaining their primary role of national security amidst the 20% prevalence rates, any factor that addresses the combating of the spread of HIV has to be given serious consideration.

 

In an effort to contribute as civil society to policy formulation around MC as a preventative strategy to the spread of HIV and its implications for the Armed Forces in Africa, and recognising the paucity of resources and capacity, the MilAIDS Project at the Institute for Security Studies is putting together a two-day conference on the subject, from 10-11 May, to provide an informed platform for the defence and security community to make a decision either FOR, AGAINST or MAINTAINING THE STATUS QUO.

 

In order to reach core policy decision makers in the uniformed services, the project has secured the participation of at least three Surgeons General, also known as Directors of Medical Corps (DMS) and academics drawn from the medical and social sciences, as well as NGO practitioners already engaged with HIV/AIDS issues and the militaries, cultural and traditional actors ALL prepared to offer different perspectives on the issue.

 

Consequently, a conference titled: “The Battle of the Foreskin: MC as a Strategy to Prevent HIV transmission and its Implications for the Armed Forces,” is scheduled in Pretoria with the single object of developing a broad civil society perspective on MC on behalf of policy-makers and practitioners in the armed forces as to the best way forwards on this issue.

 

Dr Martin Rupiya, MilAIDS Project Manager, ISS Tshwane (Pretoria)