15 Dec 2006: ISS Today: Study Says Circumcision Can Halve HIV Risk

15 December 2006: Study Says Circumcision Can Halve HIV Risk

The jury is back – male circumcision dramatically reduces the risk of HIV infection, by up to 50%, according to the World Health Organization (WHO). This finding overturns formal, anecdotal and informal attempts that sought to portray a contrary view (1). Furthermore, with this finding being announced in a situation in which the discovery of effective vaccines is still several years away, the significance of male circumcision is all the more significant.

The announcement on 13 December, based on findings from the two sites of Kisumu in Kenya with 2 784 men and Rakai in Uganda, hosting 4 996 men, was so decisive that the WHO trials, still expected to run through to 2007 were immediately abandoned by the funder, the National Institute of Allergies and Infectious Diseases (NIAid) (2). In the WHO trials, participants had been randomly selected as being either circumcised or not and, of the Kenyan 2 784 volunteers, of whom 22 were in the circumcised group while 47 were not; compared to the 4 996 Ugandans, of whom 22 were in the circumcised group while 43 were not, the study found 69 Kenyan infections and 65 Ugandan infections by the time the trial was ended. With the end of the trials, all the uncircumcised participants were offered the medical procedure whose effects now appear so beneficial.

It is illustrative to note that the Kisumu and Rakai scientific study sites had been preceded (3) by similar attempts at the Orange Farm near Johannesburg whose preliminary findings were also found to be highly positive before the study was prematurely abandoned.

The actual scientific positive finding determined that: ... the mucosal surface of the foreskin contains large numbers of a group of cells particularly susceptible to being targeted by the virus and the area under the foreskin is moist.” (4).

This part therefore lends itself as one of the most convenient and accessible areas for infection. Consequently, removing this foreskin eliminates this host area, ‘decreasing the transmissibility of HIV,’ without biologically affecting the person as well as their sexual functions. In practice, effecting male circumcision under hygienic and clinical conditions is cheap, and can be undertaken by nurses specially trained in the surgical procedure.

The implications of the finding, in the opinion of the WHO, is likely to drastically reduce the number of infected men  “…by many hundreds of thousands and maybe millions over the coming years.” (5). Meanwhile, Mitchell Warren, executive director of the Aids Vaccine Advocacy Coalition asserts that, the results are “a milestone in the history of the Aids epidemic.” (6). For Sub-Saharan Africa, a region that is host to two-thirds of the global 38.6 million people living with HIV & AIDS and lacking the resources and infrastructure to respond to the spread and effects of the dreaded virus, this development has immense significance. This is all the more so within Southern Africa, a sub-region hosting 30% of all global HIV cases, according to the most recent finding by UNAIDS. Southern Africa also reflects the correlation of high poverty levels and disease. For instance, there are extremely high HIV prevalence rates, the highest in the world, reaching some 40% in Lesotho, Swaziland and Botswana in countries that simply do not have the wherewithal to combat the spread and effects of the pandemic unless serious injections of support is received from outside.  Secondly, there is also a relationship between the recent findings and male dominated societies and institutions. Much more specifically, we have in mind the institutions of the security sector whose ranks are overwhelmingly male, resulting in most of the organisations having to address the debilitating effects of HIV & AIDS in order to maintain operational efficiency.

The next step WHO intends to take is to engage governments so that they adopt male circumcision as one of the important measures to combat the spread of HIV. However, in seeking to popularise this idea there are several challenges:

• The major challenge facing everyone is to misconstrue the male circumcision reduction in HIV infection as a panacea and ignore other  measures such as taking precautions or practising safe sex using condoms. As the leader of the WHO scientific research team, Kevin de Cock pointed out, “It is not a magic bullet.” This finding is limited to the fact that one has a 50% chance of contracting HIV following sex without protective devices if one is circumcised or the reverse – if one is not circumcised, then you are actually exposed to double the chance of getting infected. Stated differently, if this finding leads to a reduction of condom use then it would have failed.

• The second challenge is to overcome cultural, religious and other social related taboos against male circumcision. In the case of South Africa, the anecdotal norm has been to regard Xhosa males as required to be circumcised before entering manhood while, it is argued, the same is not true for the Zulu and other ethnic groups. These societal inhibitions will need extensive education and awareness campaigns to be overcome and result in male circumcision becoming commonplace amongst other measures.

• There is a fear that the news may lead to a cottage industry emerging amongst traditional groups carrying out circumcision under unhealthy and unhygienic conditions. WHO, UNAIDS and other UN agencies are already putting into place country and regional support and training for clinically based circumcision procedures capable of handling several hundreds of thousands in the new year.

• One of the most important challenges, now that the results have been received is the reaction of governments and leaders of institutions and their sensitivity to embrace aspects of combating the deleterious effects of HIV and AIDS? Our recommendation is that there be a robust response in which male circumcision awareness is raised, the concept mainstreamed within male dominated institutions, mount educational campaigns aimed at youths as well as offering incentives, if not outright legislation, for compliance, designed to encourage cadres taking up circumcision as a precautionary method.

• A further challenge is related to our ignorance on the whole question of whether or not women whose partners are circumcised are less likely to become infected? This query also provides the challenge for spouses to become involved in the decision of whether or not the male partner goes for the surgical operation? In other words, the decision is taken away from the individual and becomes a partnership concern.

The finding that male circumcision reduces the risk of HIV infection by half is groundbreaking. However, even though the two trial sites in Kenya and Uganda have been closed, the scientific group under De Cock was the first to admit, there are still areas of uncertainty that need further research. But, its important that we do not underestimate its positive potential, on condition that we properly and in timely fashion, take advantage of what is on the table at this moment and apply this to our situations in the march towards finding a permanent cure for HIV and AIDS.

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

1. For instance, see the editorial contribution by Daniel Ncayiyana, History of Circumcision in the South African Medical Journal, Vol.93, No.8, August 2003 who argued that there was no scientific evidence to link circumcision with HIV and extended his convictions to reflect sentiment in the US, UK, Canada, Australia and New Zealand.

2. Study: Circumcision can halve HIV Risk in Mail & Guardian Online, 14 December 2006

3. Study: Circumcision can halve HIV risk in Mail & Guardian Online, p. 2.

4. Ibid.

5. Study: Circumcision can halve HIV risk in Mail & Guardian Online, p. 2.