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Zambia: Circumcision Cardinal Tool in Aids Fight

Doreen Nawa

29 June 2008

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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.

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