Cutting both ways

Thursday, 28 August 2008 15:36

Health Minister Manto Tshabalala-Msimang once again caused a stir in March this year while addressing traditional healers in Polokwane as part of a series of national meetings. Her view that male circumcision should remain a cultural practice and not be seen as a preventative measure against HIV/Aids, was met with both negative and positive responses. She felt that the World Health Organization’s (WHO) view of male circumcision preventing HIV infection should be interrogated, as it was “incorrect and misleading”, yet she admitted to not knowing much about initiation and circumcision. The Department of Health would discuss the matter with traditional leaders to “inform and enlighten all concerned” and that there was no immediate plan to introduce male circumcision on a national scale in South Africa. The minister said she would not be “pushed around” and would need time to discuss a common South Africa approach to the matter. In a statement by the department, it was said that the minister had informed the traditional leaders and healers that cultural practices should not be used for “purposes other than those for which they were meant for at the beginning”. She also urged role-players not to send confusing messages that would encourage men to have themselves circumcised in the hopes of eliminating the risk of HIV infection. As controversial as Minister Tshabala-Msimang can be on occasion, there are many who agree with her that heterosexual male circumcision alone is not a guarantee to reducing the risk of HIV infection. However, her argument that the WHO’s view on the matter is incorrect and that it needs to be examined further is somewhat skewed. The overwhelming majority who do feel that male circumcision is the ‘snip to save many’, are being convinced by the compelling results of studies already conducted over the past few years – and these activists, physicians and government organisations are demanding the mass rollout of male circumcision particularly in areas of high HIV prevalence. To cut... Two of the first studies, done in Kenya and Uganda in 2006, showed a more than 50% reduction in HIV infection in circumcised men. A similar study conducted earlier in Orange Farm in South Africa found that male circumcision led to a 60% reduction in new HIV infections. According to Dr Tinyiko Khosa, director of the Zuzimpilo Medical Centre in Johannesburg, these results were the most important news in the HIV world since 1996 when the powerful effect of antiretrovirals was first reported. These three randomised controlled trials were stopped before full completion, as the protective effect of male circumcision was so evident, leaving little statistical doubt of its efficacy. It was thought to be unethical to continue withholding the procedure from the uncircumcised men in the trial. It was following these trials that the WHO and the United Nations Programme on HIV/Aids (UNAIDS) endorsed male circumcision as a means of HIV prevention and which should be considered part of a comprehensive HIV prevention package. “Its efficacy has been proven beyond reasonable doubt”, it read in their joint statement at the time. The WHO predicted that male circumcision could prevent nearly 6 million new HIV infections – potentially saving almost 3 million lives in sub-Saharan Africa over the next 20 years. Male circumcision is the excision of the foreskin from the penis. The thin inner surface of the foreskin contains Langerhans cells, which have HIV receptors, and it is pulled back down the shaft of the penis during heterosexual intercourse. An intact foreskin increases the risk of ulcerative sexually transmitted infections due to its exposure to vaginal secretions, which in turn could increase the risk of HIV infection. And as the outer foreskin is thick, it acts as a barrier, trapping the virus in the area underneath, which is warm and moist, allowing the virus to survive longer. In 2006 the results of a 20-year simulation of trends in a Soweto adult HIV-prevalence study was released at the 16th International Aids Conference in Canada. The results found that approximately 53 000 new HIV infections could be averted if more men were circumcised. The study was presented by a PHD candidate at the Yale School of Medicine, Kyeen Mesesan, who investigated amongst others the impact of an expanded adult male circumcision programme on a developing country over a period of 20 years. According to the results, the effect of male circumcision on infection rates would be “great” in an area such as Soweto, with an HIV prevalence rate of 12% among men and 20% in women. Also in 2006, the Southern African Development Community (SADC) made its voice heard about male circumcision and its role in partially preventing the spread of HIV particularly in southern Africa, the region worst affected by the Aids pandemic. Zambian surgeon and university lecturer Kasonde Bowa told health officials and experts from the SADC countries that “the evidence is substantially overwhelming [that] male circumcision reduces the transmission of HIV.” In the following year, at the 2007 International Aids Society Conference on HIV and Pathogenesis Treatment and Prevention, male circumcision was likened to a vaccine. According to Robert Bailey, Professor of Epidemiology at the University of Illinois, it was not a perfect vaccine, but an effective one – “about 60% effective in preventing new HIV infections in adult heterosexual men.” He revealed at the conference that there was already evidence available in 2000 and 2001 that showed an uncircumcised man was more at risk of contracting HIV. “Only a handful of scientists, and no policy makers, were persuaded that circumcision should be considered as a new HIV prevention strategy. Randomised control trials had to be done before the international health community could be persuaded to move.” And that was “six years, 23 million dollars and probably a million new preventable infections” too late. Prof. Bailey added that there was nothing else like this in the field of HIV prevention and that “all the highest HIV prevalence countries are those where circumcision is little practised. No country with nearly universal circumcision coverage has ever had an adult HIV prevalence higher than 8%.” According to a new policy analysis led by researchers this year at the Harvard School of Public Health (HSPH) and the University of California in Berkeley (which appeared in the 9 May 2008 issue of the journal Science), providing male circumcision services should be part of the fight against HIV/Aids, together with reducing multiple sexual partners. The researchers found that the more common HIV prevention strategies – including condom promotion and abstinence – are having a limited impact on the predominantly heterosexual epidemics in Africa, and that giving more attention and resources to male circumcision would have a greater impact on the Aids pandemic. The authors also noted that only 1% of the total prevention funding requested by UNAIDS was earmarked for male circumcision – a situation they feel needs to change. From the above, it is not surprising that so many people are touting male circumcision as a simple defence mechanism against HIV infection and ultimately a means of curbing the now-rampant Aids pandemic. Many African countries have begun to embrace this newly-found “vaccine” in the hopes of reducing the numbers of new infections. Already in 2007 Malawi conducted a two-day national debate on whether to adopt male circumcision. According to official figures, of the 12 million population 14% is infected with HIV and annually there are 78 000 Aids-related deaths and 100 000 new infections in the country. This dire state of affairs has cut life expectancy to 36 years. The circumcision fever hit Swaziland last year, after the findings of the Ugandan and Kenyan trials were released. Nurses brought in their sons and husbands to undergo the procedure and the Swaziland Ministry of Health had been eager to roll out a mass programme. A similar situation arose in Kenya, with requests for circumcision having tripled in the western Nyanza Province where this practice is not traditionally done. Then in April this year, the Kenyan government embarked on a national programme to fast-track the rollout of circumcision for males of all ages in a culturally sensitive manner and in a clinically safe environment. The rollout was preceded by social mobilisation exercises to train and educate Kenyans on the benefits of circumcision and to limit resistance to the procedure. Traditional circumcisers would also be persuaded to participate in the re-education of their communities. ... or not to cut So why are some parties against male circumcision even in the light of evidence that supports it? Many believe that a mass rollout of circumcision would be fraught with challenges, particularly in the sub-Saharan countries and similarly so in South Africa. Since an increasing number of South Africans are relying on the state to look after their medical needs, the country’s public health system has taken on strain. This, together with the dwindling numbers of health workers, will result in male circumcision taking a lower priority. Even if men were to be referred to district hospitals and local clinics, the shortage of staff in these institutions would send them back to square one. In the traditional circumcision context, traditional leaders and circumcisers would have to be included in any plans the government may implement – as was being done in Kenya – to educate their communities and ensure that the procedures are carried out in a safe environment. University of Cape Town researchers Alex Myers and Jonny Myers wrote in a paper that appeared in the May 2007 issue of the South African Medical Journal that male circumcision should not be seen as a “silver bullet” in fighting HIV infection. “The current zeal and naive enthusiasm for promoting circumcision as an Aids prevention tool show lack of regard for the limited degree of benefit likely,” they stated. Their research showed that HIV infection was three times more likely as a result of the circumcision procedure itself in Kenya, Tanzania and Lesotho. In addition, the HIV prevalence in the Eastern Cape – where most men were circumcised – was not significantly lower than in KwaZulu-Natal where most were uncircumcised. They also warned of surgical complications “and worse” from the operation (including penile amputation and even death) and increased medical costs and strain on health facilities. But perhaps the greatest concern is that newly circumcised men would believe they are “immune” to HIV infection and engage in risky sexual behaviour. Strong campaigns should be conducted to promote the use of condoms and being faithful to one partner even when circumcised. It has also been found that the procedure could put women at increased risk of infection. Preliminary results were put forward last year at a UN consultation in Switzerland on the potential impact of male circumcision on Aids in Africa. The first evidence suggested that there was a period immediately after the operation, before they have healed completely, when men may more easily transmit the virus to their female partners. Dr Kevin De Cock, director of WHO’s Aids department, sums it up well: “While male circumcision has extraordinary potential to prevent HIV infection... [it] is an additional prevention strategy rather than a replacement for anything else.” Tania Griffin

Last Updated on Wednesday, 01 October 2008 15:54