DR M. Bateganya
12 November 2007
opinion
I write to share my opinion with others following an article that quoted President Museveni's speech to the youth. I write to add my voice on the issue of "the role of male circumcision in Uganda's fight against HIV."
Male circumcision is a promising addition to Uganda's HIV preventive strategies and once implemented it has potential to reduce HIV infection among circumcised males. Uganda and the rest of the world are fortunate to have an additional intervention that will support the fight against the epidemic. However wide-scale implementation is premature in Uganda.
First, although several research studies that compared circumcised and uncircumcised males in several African countries including one from Rakai district in Uganda showed that circumcised males were less likely to acquire HIV than their uncircumcised counterparts, there is a big difference between what can be achieved in a study setting and the results of a public health intervention. Conditions in a clinical trial are carefully controlled and results may not really be as glowing as those from a study situation where both the study staff and participants are well motivated.
For example while side effects from surgery were minor under study conditions, they may be enormous under field conditions given the current challenges faced by Uganda's hospital surgery departments such as few and less motivated personnel, lack of proper equipment, shortage and frequent stock out of drugs and consumables.
Secondly, there may be behaviour disinhibition where people who are circumcised may incorrectly assume they are not at risk of HIV infection. Such an incorrect conclusion may lead individuals who are HIV-negative at the time of circumcision to maintain or increase their current level of HIV-risk behaviour putting themselves and their sexual partners at risk.
Similarly, HIV positive individuals may seek surgery and incorrectly think they will not transmit HIV. Hospitals implementing circumcision may not have the capacity to screen all their clients for HIV before offering circumcision, thus circumcised males may create another risk category in HIV prevention.
Male circumcision may also take away resources and attention from other prevention methods that have effectively reduced the HIV prevalence in Uganda, namely abstinence, faithfulness and condom use. In fact, those prevention efforts have already earned Uganda the coveted position as an international success story in reducing the number of people being infected with HIV (though this assertion is still being questioned and is an open debate; what worked in Uganda?).
The cost for each circumcision in the Rakai study was over $60. This is a cost ten or more times the annual budget for health for an individual. Is it worth diverting the prevention budget away from methods that seem to work for a fraction of the cost to try something that has only been tested in a study setting? I don't think so.
Dr Moses Bateganya is based at University of Washington, Seattle
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