Doreen Nawa
29 June 2008
PREVENTION measures in the fight against HIV/AIDS are repeatedly being criticised for having a limited impact on the predominantly heterosexual disease found in Africa.
As opposed to propagating the campaigns on condom use, HIV testing and treatment of sexually transmitted infections (STIs), most researchers have in the recent past been citing male circumcision as offering higher chances of protection, especially in cases of unprotected sex.
Although male circumcision and reduction of multiple sexual partnerships are currently getting less attention and resources, researchers say they are two interventions that could have a greater impact on minimising the further spread of the HIV.
Scientists say circumcision reduces men's chances of contracting HIV by up to 60 per cent, which is regarded as a major breakthrough in the fight against AIDS. Now, the question is how to put that fact to work to combat AIDS across Africa.
The findings were first announced in December 2006, when initial results from two major trials in Kenya and Uganda - showed promising links between male circumcision and HIV transmission. However, those trials were deemed so definitive that the tests were halted early.
For instance in Zambia, HIV prevalence rate is lower in North-Western Province were male circumcision is being practiced than in other provinces countrywide.
Society for Family Health (SFH) executive director, Harrison Richard says the way the disease was evolving in Zambia was worrying.
Speaking at a Press briefing recently, Mr Richard said WHO recommendations should be taken seriously if Zambia was to experience a remarkable drop in the HIV prevalence rate.
He said major public health initiatives like male circumcision should not be ignored if Zambia was to make a difference in HIV prevention.
SFH medical expert, Dr Manasseh Phiri said North-Western Province in Zambia has the lowest HIV prevalence rate of about 6.5 per cent and the rate has been attributed to circumcision which is practiced in that area.
Dr Phiri said there was strong evidence from time immemorial from African countries in the north where circumcision is practiced that their HIV prevalence rates were lower than in other countries where circumcision was not practiced.
In response to the urgent need to reduce the number of new HIV infections globally, World Health Organisation (WHO) and the United Nations AIDS secretariat convened an international expert consultation in March last year to determine whether male circumcision should be recommended for the prevention of HIV infection.
The UN agencies emphasise that male circumcision does not provide complete protection against HIV infection.
It should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counseling.
WHO director of the AIDS department, Dr Kevin de Cock said, "This is an extraordinary development. Circumcision is the most potent intervention in HIV prevention that has been described."
"The recommendations represent a significant step forward in HIV prevention. However, it will be a number of years before we can expect to see an impact on the epidemic from such investment," said Dr de Cock.
Dr de Cock said countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men.
He says scaling up male circumcision in such countries will result in immediate benefit to individuals.
Circumcision has long been suspected of reducing men's susceptibility to HIV infection because the cells in the foreskin of the penis are especially vulnerable to the virus.
There is now strong evidence from three randomised controlled trials undertaken in Kisumu, Kenya; Rakai District, Uganda (funded by the US National Institutes of Health); and Orange Farm, South Africa (funded by the French National Agency for Research on AIDS) that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60 per cent.
This evidence supports the findings of numerous observational studies that have also suggested that the geographical correlation long described between lower HIV prevalence and high rates of male circumcision in some countries in Africa, and more recently elsewhere, is, at least in part, a causal association.
A modeling study done last year projected that in the next decade, male circumcision could prevent 2 million AIDS infections and 300,000 deaths. Last year, 2.8 million people in sub-Saharan Africa became infected with HIV, and 2.1 million people died.
Experts say the breakthrough is a significant one on par with the identification of the virus and the use of life saving combination drug therapy.
The two US studies confirm similar results from an earlier trial in South Africa. Given the recent failure of a microbicide trial in Africa and India, and the ongoing difficulties in developing an AIDS vaccine, the potential of circumcision as a new weapon against HIV has become even more significant.
But they caution solid evidence is not justification for mass circumcisions.
African health systems are already overburdened. Circumcision requires much more planning than, for example, an immunisation campaign.
Male circumcision should always be considered as part of a comprehensive HIV prevention package, which includes the provision of HIV testing and counselling services, treatment for sexually transmitted infections, the promotion of safer sex practices and the provision of male and female condoms and promotion of their correct and consistent use.
Counselling of men and their sexual partners is necessary to prevent them from developing a false sense of security and engaging in high-risk behaviours that could undermine the partial protection provided by male circumcision.
Furthermore, male circumcision service provision was seen as a major opportunity to address the frequently neglected sexual health needs of men.
Associate director, Department of Policy, Evidence and Partnerships at UNAIDS, Catherine Hankins says, "being able to recommend an additional HIV prevention method is a significant step towards getting ahead of this epidemic."
However, Dr Hankins says it must be clear that male circumcision does not provide complete protection against HIV.
She says men and women who consider male circumcision as an HIV preventive method must continue to use other forms of protection such as male and female condoms, delaying sexual debut and reducing the number of sexual partners.
"It is a tricky one, but it is something we're going to have to move on," said Dr Hankins, a scientific adviser at UNAIDS.
"Male circumcision is such a sensitive religious and cultural issue that we need to be careful," she says.
Several African countries have already met with UN agencies to explore new strategies for increasing circumcision services.
Swaziland, for instance, recently experimented with a series of "circumcision Saturdays," where existing health care facilities, normally closed on weekends, were opened by local doctors to circumcise approximately 40 men a day on certain Saturdays.
Providing circumcisions across Africa would not be the first time surgical procedures have been adopted by public health campaigns.
"Cataract surgeries have been carried out extremely efficiently to prevent blindness worldwide," said Dr Richard Hayes, an AIDS expert at the London School of Hygiene and Tropical Medicine. In some places, the cataract surgeries are performed by trained paramedics.
In recent years, the fight against the AIDS has focused on the provision of life saving drugs. The circumcision data gives prevention, rather than treatment, renewed emphasis.
"Treating people with antiretroviral is completely unsustainable unless we can turn off the tap of infection," said Dr Hayes.
While circumcision may offer new hope, it is not a cure for the disease.
"This is an additional tool, and it must not replace other interventions," said de Cock, who added that there would be no push for universal circumcision. "There is no one size fits all solution for AIDS epidemic."
Together with the United Nations AIDS agency, WHO is convening a meeting in Switzerland in early March to evaluate the circumcision data, and to decide on the next steps in slowing the AIDS.
In the Kenyan study, 1,391 circumcised men were compared to 1,393 who were not. And in Uganda, 2,474 circumcised men were compared to 2,522 men who were not.
After tracking the men for two years, scientists found that circumcised men were 51 to 60 per cent less likely to contract HIV than their uncircumcised counterparts.
Since the studies were stopped, all the men have been offered the opportunity to be circumcised.
And all the men were warned not to lapse into sexually risky behavior, such as abandoning condom use.
Scientists theorise that women would benefit indirectly from lower HIV prevalence in men and a study is currently ongoing in Uganda to determine this.
In areas where HIV is spread primarily through heterosexual sex, such as sub-Saharan Africa, male circumcision could theoretically slash the infection rate in half.
It is unknown whether circumcision would be equally effective in concentrated AIDS epidemics, as in Asia and eastern Europe, where AIDS primarily strikes gay men and drug users.
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If you look at all the scientific papers and news releases supporting the claims that circumcision prevents HIV, that circumcision will save millions of lives, that circumcised men will not stop using condoms, that circumcision does not impair sexuality, and that circumcision is "acceptable" to parents, and so on - you will find the same few names again and again: Daniel T Halperin, Robert Bailey, Malcolm Potts, Helen Weiss, Bertran Auvert, Frank Klausner, Stephen Moses, Roger Short, Xavier Castellsagué, Stefan Bailis. Are they more interested in preventing AIDS or promoting circumcision?
Daniel T Halperin has been at the forefront of promoting circumcision for over a decade. He is on record as thinking his descent from a ritual circumcisor means “maybe in some small way I’m ‘destined’ to help pass along [circumcision] to people in [other] parts of the world … .” ('The Case for Circumcision' by Gordy Slack, East Bay Express Online, May 19-24, 2000) Whatever else that it, it’s not science.
The flaws in the research are many: * Not double-blinded * Not placebo-controlled * Significant drop-out rate - 5 times as many as were infected. * Non-sexual transmission ignored * Non-identical treatment of controls and experimental group * One of the three trials used a method that removed significantly less tissue than the others, yet the "protection" was the same.
And “60% reduction” sounds impressive, but what it means is that they circumcised a total of 5,400 men and found that after less than two years, 64 (1.2%) had HIV, compared to 137 (2.5%) in similar-sized groups left intact - 39 circumcisions for each HIV infection deferred (not prevented). How does the cost of that compare to education or condoms?
In several African countries, the HIV rate is higher among circumcised men than non-circumcised, according to the National Demographic and Health Surveys. Something very funny is going on.
I appeal to scientists who get involved in AIDS prevention, to conduct further research on the relationship between HIV and ultraviolet radiation. I am quite sure the HIV occurs due to ultraviolet radiation and its interaction with the local radiation / local nuclid radioactive. The HIV strains are determined by the local nuclid radioactive. On its connection with the free sex behavior, the free sex doer make themselves the absorber of radiation. I am quite sure if the effects of radiation are terminated, the HIV will automatically " die " by itself. For AIDS treatment, first I suggest AIDS patient must be treated in FRR ( Free Radiation treatment Room ). Sincere yours, Gatot Soedarto.
This is total nonsense. Circumcision is being heavily promoted by members of minority religious groups that practice this mutilating ritual.
Circumcision didn't prevent the spread of HIV in the United States, where 80% of men were victims of male genital mutilation at the height of the epidemic, while in civilized countries that didn't subject men to this practice, rates were much lower; if anything, it would appear that circumcision INCREASES the spread of HIV.
The statistics in Africa don't take into account that the circumcised Africans lead totally different lifestyles, and have different attitudes towards sexual morality. The statistics are badly flawed, and are being deliberately used to foster this practice.
And rates of HIV infection would also be higher in Africa, where the disease supposedly began.
HIV is caused by a virus, not by a foreskin.
It didn't work in the USA, why would it work in Africa?
These men will think that they're immune to HIV, and also the women, and the rate of infection is going to go up, not down.