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Africa: Time for a Male Circumcision-Driven HIV Policy in Africa?

Categories: Sub-Saharan Africa, Kenya, Madagascar, Malawi, South Africa, Uganda, Citizen Media, Education, Health

After overcoming much skepticism, the idea that male circumcision is an effective measure in reducing HIV transmission [1] is now globally accepted by the health professionals community and the general public. In fact, the World Health Organization is now advocating circumsision programme [2] as part of the HIV prevention package in areas greatly affected by the virus.

However, the jury is still out on how the measure will be adopted by the target populations given their cultural specificity. Experts and bloggers weigh in on the practicality and the effectiveness of a male circumcision-driven public health policy.

A proven approach 

Even though the approach has been suggested for a decade, the validation that medical male circumcision substantially reduces the risk of contracting HIV is fairly recent. Three randomized clinical trials were conducted in Kenya, Uganda and South Africa. In 2007, The WHO and the UNAIDS provided the following comment on the results of the study [3]:

 There is now strong evidence from three randomized controlled trials undertaken (..) that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. 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.

Some newly developed technological devices may even facilitate the deployment of this policy. Donald G McNeil Jr of The New York Times recently reported that [4]:

a bloodless circumcision device for adults, will be tested in at least nine African countries in the next year [..] a two-nurse team slides a grooved ring inside the foreskin and guides a rubber band to compress the foreskin in the groove. After a week, the dead foreskin falls off like the stump of a baby’s umbilical cord

Still, not all the scientific community is convinced that this policy is the right direction to take in the fight against HIV. For instance many argue that such a policy would be offset by increased HIV risk behaviour, such as reduced condom use or increased numbers of sex partners. In a journal article, Kalichman et al. write [5]:

Circumcision likely reduces the risk of acquiring a non-HIV STI and may be partially responsible for the decreased HIV risk observed in circumcision RCTs [1]. Nevertheless, the failure of models to account for increased STI risk due to risk compensation likely inflates estimates of averted HIV infections. Estimates of HIV risks resulting from increased exposure to STIs that coincide with reductions in condom use have been included in previous models of the cost-effectiveness of HIV prevention interventions [11] and should be included in MC models.

Cultural challenges 

Despite those recommendations, the approach still encounters many challenges to getting implemented in many countries. Ugandan global health graduate Edgar Asiimwe shares his findings regarding the willingness of young men to undergo safe male circumcision [6] in Uganda, in this video uploaded to YouTube by user DukeGlobalHealth [7] on 10 July, 2012. In the video, Asiimwe explains that the Ugandan government still favors prevention programs based on abstinence which makes implementing medical circumcision difficult to implement:

In South Africa, traditional circumcision is still carried out, however, the circumcision often only partially removes the foreskin from the penis. Maughan-Brown et al. explain the results of their study [8] in Cape Town:

Partially circumcised men had a 7% point greater risk of being HIV positive than fully circumcised men (P < 0.05) and equal risk compared with uncircumcised men. Most (91%) men were circumcised between the ages of 17 and 22 years (mean 19.2 years), and HIV risk increased with age of circumcision (P < 0.10).

Efforts should be made to encourage earlier circumcisions and to work with traditional surgeons to reduce the number of partial circumcisions.

In some of areas of Madagascar, circumcision is also a tradition. The traditional method of circumcision may carry some health concerns and differs vastly from medical circumcision. Arinaina explains [9] [fr]:

 La circoncision se fait au crépuscule d’où le feu et les bougies. Tous les hommes, le grand-père, le papa, les oncles sont là pour préparer tout ce qui est nécessaire au rituel et assister l’enfant en le tenant bien fort. Un dernier homme est aussi présent; le guérisseur traditionnel ou le « rain-jaza » qui va couper avec sa lame le prépuce. [..]  la circoncision à Madagascar, c’est surtout pour que le garçon devienne un «vrai homme».

Circumcision is carried out at dawn hence the need for candles and fire. All the family men, the grandfather, the father, the uncles are present to prepare all that is necessary for the ritual and help hold the child still. Another man is also present, the traditional healer who will cut off the child's foreskin.
Painting of a circumcision in Madagascar by Arianiana (used with permission) [9]

Painting of a circumcision in Madagascar by Arianiana (used with permission)

HIV prevalence is relatively low in Madagascar compared to the other southern African states and it is possible that the cultural acceptance of circumcision plays a part in keeping HIV at low levels. This was not the case early on in Kenya though. June Odoyo, a member of the Nyanza Province Male Circumcision Task Force,  explains [10]:

Despite initial resistance from cultural leaders in the region, male circumcision has been widely accepted in Nyanza, with more than 110,000 men undergoing the procedure since 2008 [..] Rural areas experience high cases of cultural resistance to the programme, while the acceptability in urban areas is comparatively high.

Increase in demand for circumcision may have been sparked by young men's desire to have unprotected sex. A study in Malawi explains that dislike for condoms was a factor in undergoing circumcision. For instance, Peter states [11]:

so I see that most of my friends have a tendency of having sex with different kinds of women, so I do
take part in explaining to them to say; I think maybe the best thing is maybe if you can consider
this circumcision. Maybe you can be half way protected. Because there are other people who
don't like to use condoms but they want to have sex with a woman plain [no condom on].

While health policy advocates always emphasize that circumcision is by no means meant to replace the use of condoms, one has to wonder how many men would forego the use of condoms because they have undergone circumcision.

More convincing needed?

Beside the issue of potential reduction in condom use, other doubts were raised by bloggers regarding the inclusion of male circumcision in HIV prevention policy. Jason Bosch, a South African scientist in Cape Town, argues [12]:

If you tell someone it will reduce their risk then they’re more likely to take the risk. After my post I heard from a colleague of mine who has read the paper that at least one of the trials was flawed because those undergoing circumcision where educated on safe sex practices while the others were not.

James Sweet, a blogger from the United States that has lived in Ethiopia, adds [13]:

Given the sociopolitical pressures to justify circumcision, I suspect this data might be exaggerated, but there does seem to be something to it. This, of course, is weighed against the direct risk of complications from the procedure, which are rare but not unheard of.