Circumcision as a Weapon Against HIV

Concern is growing among health care professionals over the increasing trend against male circumcision, a practice that they say could avert more than 20 percent of new HIV infections by 2020, saving an estimated US$16.6 billion in future medical costs.

On May 7, 2012, a regional court in the western city of Cologne in Germany found that the circumcision of under-age boys for religious reasons was an unlawful act that caused bodily harm. Although the decision has no binding force on other courts, the decision has sparked uncertainty not only among health professionals but in Jewish and Muslim communities because male circumcision is a widely accepted religious rite.

Although the World Health Organization has estimated that some 665 million males aged 15 and older are circumcised, 70 percent of them Muslim, the numbers have been declining in many first-world states including the United States, Canada, the United Kingdom, New Zealand and Australia, although voluntary medical circumcision has been rising in South Africa, the epicenter of the HIV problem.

The practice of circumcision is undeniably painful since it involves moving the flap on skin on the head of the penis, perhaps the most sensitive part of the mail body. Arguments against the practice have been growing since the 1970s because of a belief that it causes psychological trauma that could affect the child later in life, and that the flap of skin is an important conductor of pleasure for uncircumcised men.

The Bill and Melinda Gates Foundation is supporting the wider use of circumcision its propagation and the World Health Organization is being urged to do the same, with critics arguing that any such campaign carries with it the real danger that societies in Africa, where the AIDS prevention efforts are mostly focused, will result in the large scale circumcising of infants who have no choice in the matter.

It should be noted that female circumcision has nothing to do with health. It is nothing more than the practice of female genital mutilation and is a gross insult to womanhood. It stems from male fears of women’s sexuality and usually involves cutting out the clitoris, which is enormously painful though milder versions which only involve trimming the labia may have no more effect on ability to be aroused than the male counterpart.

More than 40 observational studies among heterosexual men, however, show that circumcised men have about a 60 percent reduced risk of HIV compared to uncircumcised men. Three randomized controlled trials were conducted in Sub-Saharan Africa that showed circumcised men were at 60 percent less risk of HIV than uncircumcised men.

Thus the health benefits appear undeniable. “All these three trials were stopped by independent Data Safety Monitoring Boards as the effect was so strong and it was thought unethical to not offer circumcision to men in the control arm," had said Dr Helen Weiss, Reader in Epidemiology and International Health, The London School of Hygiene and Tropical Medicine (LSHTM) in an exclusive interview to Citizen News Service (CNS) at AIDS Vaccine 2011.

There are biological mechanisms by which the foreskin increases the risk of HIV, according to research studies, which found that the foreskin is rich in HIV target cells that are particularly attracted to HIV, which is why uncircumcised men are at higher risk.

Partly protective, not completely

In Southern Africa which has the highest prevalence of HIV and quite low rates of circumcision, circumcision is being provided medically and voluntarily and being scaled up. More than half a million men have been circumcised for HIV prevention in Southern and Eastern Africa. There is no evidence of serious adverse events and no evidence that men changed their sexual behavior following circumcision. Earlier there was a concern that men might increase their risky behaviour if they think they are completely protected. It has become important to get the message across that circumcision is partially protective, not completely.

Voluntary medical male circumcision is indirectly beneficial for women, said health writer Cindra Feuer. ”If we lower the HIV rate in a community then women also benefit from VMMC indirectly” she said, pointing out, however, that male Circumcision directly protects transmission from female to male partner but it doesn’t protect against HIV transmission from male to female partner.

Medical male circumcision has also been found to reduce the transmission risk of human papilloma virus (HPV) and Herpes. “If a man is circumcised he is less likely to transmit HPV and herpes to the woman. HPV causes penile cancer in men and cervical cancer in women. Also herpes and HPV can facilitate HIV infection so it is a great benefit to reduce the risk of HIV, HPV and herpes by circumcision,” Feuer said.

After medical circumcision, men should abstain from sex for six weeks. It is very important for both women and men to know this fact. If men who undergo voluntary circumcision don’t abstain from sex for six weeks, then the risk of transmitting HIV is high.

Another fact to educate men and women is about partial efficacy: 60 percent. Cindra Feuer cautions: “Voluntary circumcision is not a silver bullet – one should not increase one’s risk if the partner is circumcised. Comparatively, infant circumcision is easier because there are fewer nerve endings, lesser risk of infection,” and the caution of abstaining from sex for six weeks is irrelevant for infants.

Scaling up Increases HIV testing

One of the aspects of circumcision is that it gives medical professionals have a strategy for young heterosexual men that seem to be very acceptable in many settings. Before men are offered circumcision they are asked to get tested for HIV – and a knock-on effect that it is also increasing the number of young men coming forward for HIV counseling and testing services. It is thus a great opportunity to bring men into sexual and reproductive health clinics, Feuer said.

The WHO and UNAIDS played a key role in providing guidelines about how circumcision should be scaled up, providing tools and guidelines which address key issues, holding meetings for people from different countries to get together and share experiences and learning, and also providing a model for liaison with communities and other stakeholders, including the ministries of health and impressing upon them the need of strong leadership and political buy-in.

In many parts of Africa, male circumcision is done culturally regardless of religion. In West Africa, almost all men are circumcised in infancy, however in Eastern and Sub Saharan Africa circumcision is less common and is being scaled up.

Circumcision and HIV prevention among MSM

Whether male circumcision will prevent HIV transmission among men who have sex with men depends on sexual practices. Circumcision will not protect a man who is a exclusively or predominantly a receptive partner, however if a man predominantly practices insertive anal intercourse there is evidence that circumcision reduces his risk of acquiring HIV as well.

There are not enough trained healthcare providers to roll out voluntary male medical circumcision and in many countries the political will to scale up is also lacking. Kenya has done well but other African countries need to scale up to meet the 2015 targets. It is being recommended by the WHO in 13 African countries (US added a 14th country - Ethiopia) as an approach for HIV prevention – because substantial HIV is spread heterosexually in Africa.

The practice has already been included as part of the standards of care package for those participating in some vaccine studies in South Africa.

(With additional reporting by Bobby Ramakant of Citizens News Service. Email: bobby@citizen-news.org, website: www.citizen-news.org)