To snip or not to snip….that is the circumcision question

28th February, 2010

The arena of HIV and AIDS and male circumcision (MC) is swarming with political, cultural, medical and religious motives but I would like to take a step back and put across to you, simply, what the science says. I have a strong opinion on the matter of MC but I will try my best to give you an unbiased, unflinching review of the science. Male circumcision is the removal of some or all of the foreskin from the penis. According to the WHO, three out of every ten men in the world are circumcised, and close to 70% of those circumcised are Muslim.  In Malawi, 21% of males are circumcised. Without delving in too much detail, there are global controversial debates on circumcision – one camp argues that it affects penile function, sexual pleasure, and is against human rights while the other suggests that it has health benefits and causes no complication if performed by an experienced physician. However, my interest and yours in reading this article – is the fact that it has been shown consistently and significantly (and by significantly I mean by 60%!) that  male circumcision reduces the risk of HIV transmission during penile-vaginal sex (to be clear, it reduces transmission from women to men) but…as there is always a but… the cautionary note is that it only provides MINIMAL protection and by no means can and will NOT replace other prevention methods.

Several studies have been conducted to investigate the relationship between circumcision and HIV infection but three particular studies in Uganda, South Africa and Kenya led the WHO/UNAIDS  in 2007 to recommend male circumcision as an HIV prevention tool.  The trials in these three countries were stopped early because it was found that those in the circumcised group had a lower rate of HIV infection  than the uncircumcised group. The results showed that MC reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively. To date however, there is insufficient evidence to show protection of male to female transmission and men who engage in anal sex with a female partner.

As most men, about 70%,have acquired HIV through vaginal intercourse it is important to understand the biological factors that are involved in reducing HIV transmission in circumcised men.  Studies are still ongoing but it is generally recognised that the inside of the foreskin is rich in cells that are susceptible to HIV infection – this is important because the inside of the foreskin is pulled back during sexual intercourse and the whole inner surface of the foreskin is exposed to vaginal secretions, providing a large area where HIV transmission could take place. It also believed that the skin, frenulum,  that connects the foreskin to the penis is susceptible to trauma during intercourse. The frenulum is also the common place where  lesions from sexually transmitted infections (STIs) occur and since people who have STIs like syphilis or gonorrhoea are two to five times more likely to become infected with HIV, MC may be even more protective.

So in light of these glaring findings what is Malawi doing?  I was able to find a recent UNAIDS report (December 2009) that gave country updates on scaling up of MC in Southern Africa –the report basically shows that Malawi has done nothing on this issue besides forming a committee. No focal person has been indentified, no communication strategy developed with a note that more lobbying and advocacy is needed – need I remind you that it has been two years since the WHO recommendation on MC. Apparently government is confounded by the results of a survey that found high prevalence of HIV in areas such as Balaka where MC is practiced. One study  that may clarify this anomaly is being done by the College of Medicine, University of Malawi. The study’s main purpose is to investigate discordant couples (when one partner is HIV infected and the other is not) but will also look at “the effect of male circumcision in different geographic settings and by ARV treatment strategies”. We eagerly await the results when the study is completed in 2011!

Meanwhile other countries like Swaziland  have embraced the WHO recommendation to the point that the Swazi Ministry of Health and Human Services opened a facility in October 2009 committed to making Swaziland the first country in the world where 80 percent of males in the age group most vulnerable to HIV infection (15 to 29 years) would be circumcised by 2014. The procedure at Litsemba Letfu (SiSwati for Our Hope) Male Clinic is free. Before the procedure men are counselled on the risks and benefits of MC and invited to test for HIV. Men are also invited to bring their partners so that they can understand the procedure. Counsellors emphasise that MC only reduces a man’s chances of contracting HIV by about 60 percent and should be combined with other prevention strategies.

A USAID report is advocating for MC in Malawi, the report describes that  if MC was scaled up to 80% of the male adult population by 2015 in Malawi, 265,000 deaths would be prevented between 2009 and 2025 and that MC can save by the year 2025, $1.2 billion. Another study looked at acceptability of MC and found that acceptance of MC would vary by region with acceptability lowest in the North where little is known of this practice but many parents and young men across the country would use the services if it were safe, affordable and confidential. So really what are we waiting for?

This article was first published in the The Nation, Malawi – column on Lifting the Lid on HIV and AIDS, Feb 27th 2010

3 thoughts on “To snip or not to snip….that is the circumcision question

  1. In Malawi, according to the National Health and Demographic Surveys, 13.2% of circumcised men have HIV, while only 9.5% of non-circumcised men. In Swaziland, the figures are 21.8% and 19.5% . Shouldn’t these figures at least be convincingly explained before mounting mass circumcision campaigns? Malawi is right to hesitate.

    You say the three trials “showed that MC reduced vaginal-to-penile transmission of HIV by 60%, 53%, and 51%, respectively.” Relative risk reductions (like those percentages) look impressive, but the facts are that they circumcised 2,474, 1,546 and 1,391 men (respectively) and left similar numbers intact, and after less than two years, 20, 22 and 22 circumcised men had HIV, compared to 45, 47 and 45 of the intact men. The whole claim that “millions could be protected” rests on 25, 25 and 23 circumcised men who didn’t get HIV, who otherwise might have. Meanwhile, 100, 87 and 140 circumcised men dropped out of the studies, their HIV status unknown.

    Randomisation of subjects between the experimental and control groups was the only control for number of partners, HIV status of those partners, number of acts of intercourse, exposure to non-heterosexual or non-sexual transmission, and it was assumed without evidence that circumcision, painful and memorable as it is, had no effect on any of those factors.

    You say, “To date however, there is insufficient evidence to show protection of male to female transmission.” That’s putting it mildly: a study in Uganda was cut short after 18% of the women with circumcised partners contracted HIV, compared to only 12% of the women in the non-circumcised control group – but before it could reach statistical significance. Women are already at more risk of transmission from men, so if circumcision does actually increase the risk to them, that could easily undo any reduction in the rate of transmission to men.

  2. interesting and informative, thanks muza. we will start offering male (adult) circumcision at our hospital mid march and i’m curious to see the uptake.

    i was taught that one of the main reasons MC does not prevent HIV is because it requires a 6 week abstinence period after the op, which many men do not comply with, causing re-opening of the wound with obvious repercussions. i think this was demonstrated in mangochi. did you come across any mention of this in your review?

    • In Swaziland they counsel men on this and also encourage them to bring their partners so that they understand abt the 6 wk abstinence period but what man will abstain for 6wks….?@£!

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