The following op ed on circumcision was posted on a Key Correspondent digital forum. It is followed by another more sanguine opinion piece on this issue in the hands of men. What do you think?
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A Cutting Edge Issue: Adult Male Circumcision
Health and Development Networks Key Correspondent
I remember well the fuss about circumcision at the International AIDS Conference in Toronto last summer. It was easy to forget that worldwide coverage of prevention tools was dismally low. The only prevention technologies that we now have are few - male condoms, female condoms, clean injecting equipment, and nevirapine. The buzz machine led by the minders of Bill Gates decided that the Toronto conference was to be the conference of new prevention technologies. The hallways and sessions were full of people talking about microbicides and cervical caps technologies which "do not yet exist" in any usable form.
One HIV prevention method that was being touted in Toronto as a new prevention technology was adult male circumcision. Why circumcision is called a new technology I don't know. It has been performed on both infant boys and adult men for thousands of years. And the first studies to demonstrate that circumcision protects men against acquiring HIV were publicized almost twenty years ago. The inside of an uncircumcised man's foreskin is thin and easily scratched, has cells that HIV loves to attach to, and conceals ulcers caused by herpes and syphilis. As Cate Hankins of UNAIDS noted at a press conference: HIV will look for any open door. And she was not referring to the Gates.
Trials are difficult to perform. It is not a 100% effective method so ethical concerns arise. Who will pay for the care of men infected during the studies? A trial in South Africa has shown promise that adult male circumcision may protect uninfected men from becoming infected. Two large trials in Kenya and Uganda have just confirmed this. They showed a positive effect so it is time to Keep the Promise and start circumcising men.
But wait a minute! What are the issues here?
A circumcised penis emitting HIV-laden semen does not protect women from infection. An even more interesting Gates-funded study is presently being carried out in Africa. Does circumcising men living with HIV prevent infection of their female partners? Watch for results over a year from now. What if circumcising men increases women's risk?
No one doubts that circumcising large numbers of adult men will be a major undertaking. If circumcision is not performed correctly it will increase the risk of infection. Should nondoctors and traditional practitioners be trained to perform it? A major surgical system infrastructure needs to be developed. Who will fund this and how long will it take? And no one has any idea on how to market the new service or what the uptake will be. Can you imagine the social marketing slogan: In the hands of men: get cut today.
In India, Muslims practice circumcision and Hindus do not and the two groups do not always get along. How can circumcision best be promoted in the noncircumcising Hindu community? In China, circumcision is exceedingly uncommon. What is needed to circumcise a quarter billion men?
Risk compensation is also a danger. Some men may throw away their condoms to depend on this less-than-100% method. And some women may get a false sense of security when having sex with a circumcised man. What can we do about this?
As a KC, you know your community well. What do "you" think are the issues surrounding adult male circumcision as HIV prevention for men (and women) in your community? What questions do you think need to be answered? Please write a few of them down and share them on the KC Forum. We can all learn something from the introduction of the first new HIV prevention technology since the female condom.
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Male circumcision: Communicating the message of HIV prevention
Author: John Howson, MSc. | Senior Technical Advisor | Health Communication Partnership/International HIV/AIDS Alliance
jhowson@jhuccp.org
On December 13, the National Institute for Allergy and Infectious Diseases (NIAID) announced that they had halted two randomized controlled clinical trials of adult male circumcision in Kenya and Uganda because the interim data revealed that medically performed male circumcision significantly reduces a man's risk of acquiring HIV.(1) The protective effect of male circumcision was found to be 53% in the Kenya study and 48% in Rakai. The results of these two trials confirm the results of an earlier male circumcision trial in Orange Farm and the surrounding area, Gauteng, South Africa, that found a protective effect of male circumcision of 60%.(2) All participants in the control arms of these studies will now be offered the intervention.
These studies conclusively confirm suggestions from observational studies that male circumcision provides a protective effect against infection with HIV-1 in heterosexual populations in high prevalence countries. These observational studies suggest that male circumcision could limit the size of the epidemic significantly in countries with high prevalence of HIV(3) and thereby massively reduce the morbidity and mortality associated with HIV.
The World Health Organization and UNAIDS have already announced they will convene a consultation to examine the results of these trials to date and their implications for countries, particularly those in sub-Saharan Africa and elsewhere with high HIV prevalence and low levels of male circumcision,(4) as well as provide technical guidance and rapid assessment toolkits to countries thinking about instituting male circumcision programs.(5)
The challenges these findings present for health communication are considerable. Translating these complex findings into information that can inform individuals and families is not straightforward. Although these trials only address adult male circumcision, many parents in high-prevalence countries may choose to circumcise their sons as infants when the risk of complications is less. Like vaccination programs, the impact of male circumcision will be felt most at a population level if the majority voluntarily chooses to be part of the intervention. The protective effect for the individual will be limited if risk of exposure is not reduced through consistent condom use or partner reduction. We already know from anecdotal evidence that the mistaken belief that male circumcision is 100% protective can lead to behavioral disinhibition and increased HIV risk taking. This could negate the protective effect of male circumcision.(6)
In many communities, circumcision, or the lack of it, is related to rites of passage and religious and tribal identity. How this new knowledge is communicated will need great sensitivity and understanding of local meaning given to male circumcision, particularly in communities where there is continued suspicion about both the origins of the virus and the measures proposed to prevent it. Given that, we should not underestimate the ability of communities to assess and interpret information to their own circumstances. Despite concern that adult male circumcision would be unacceptable, in a number of countries in southern Africa, we are already seeing men voluntarily seeking the procedure.
Adult male circumcision is not without risk of serious complications, is painful, and requires a person to avoid sex for about 6 weeks post-operatively to allow for healing. If the newly circumcised man has sex during this time, serious complications can occur and his risk of HIV infection could increase. These trial results are based on the procedure being carried out in sterile clinical environments by trained medical personnel. Although in sub-Saharan Africa male circumcision is often performed on an outpatient basis under anesthetic
, many men continue to be circumcised by traditional and religious practitioners.(7) The potential role of religious and traditional practitioners in male circumcision intervention programs needs careful consideration, and I hope the WHO and UNAIDS consider this in their reflections.
What we need now are interventions that pilot a comprehensive male circumcision intervention package with excellent pre- and post-operative care, and where male circumcision is offered within a strategic communication framework that includes community sensitization, effective interpersonal communication of the risks and benefits, and prevention education to counteract the potential for behavioral disinhibition. Given other health benefits associated with male circumcision -- hygiene, reduced incidence of some STIs, particularly HPV infection and its impact on cervical cancer -- male circumcision could be set within a broader men's sexual health program. Operations research would help influence future models of intervention.
Although the results of these trials offer some hope for reduction of HIV burden in some of the most affected countries, male circumcision is not a panacea. What part it will play in a comprehensive HIV prevention response is yet to be known and continued work to find effective female-controlled HIV prevention methods must remain a global priority.
In the history of the epidemic, the results of these trials are as important as the results of the Pediatric AIDS Clinical Trials Group study (PACTG 076)(8) that showed a two-thirds reduction of perinatal transmission through a complex regimen of zidovudine for mother and infant. It took more than six years before we had resource-appropriate interventions that were available in developing country settings and, sadly, most women still do not have access to comprehensive perinatal HIV prevention services. Perhaps the global community will not wait so long before discerning the difficult task of how to translate these findings into appropriate, safe, and contextually relevant programs.
Additional Reading:
Q&A: NIAID-Sponsored Adult Male Circumcision Trials in Kenya and Uganda (http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm)
Newsweek: Circumcision and AIDS: What findings mean (http://www.msnbc.msn.com/id/16227308/site/newsweek/)
Reuters AlertNet: UN urges circumcision in AIDS-hit southern Africa (http://www.alertnet.org/thenews/newsdesk/DEL81446.htm)
Notes:
(1) National Institute of Allergy and Infectious Diseases (NIAID). Adult male circumcision significantly reduces risk of acquiring HIV: Trials in Kenya and Uganda stopped early. Dec. 13, 2006. (http://www.nih.gov/news/pr/dec2006/niaid-13.htm)
(2) Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R., Puren, A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine. 2(11): e298. 2005. (http://dx.doi.org/10.1371/journal.pmed.0020298)
(3) Weiss, H.A., Quigley, M.A., Hayes, R.J. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS. 14(15): 2361-70.
(4) Alcorn, K. Two circumcision studies halted after circumcised men's HIV risk halved. Aidsmap. (London, UK), Dec. 13, 2006. (http://www.aidsmap.com/en/news/376EF102-A6E5-408F-A671-789D7B325CCD.asp)
(5) World Health Organization (WHO), United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF), World Bank, and UNAIDS. Statement on Kenyan and Ugandan trial findings regarding male circumcision and HIV. Dec. 13, 2006. (http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html)
(6) Gray R.H., Li, X., Kigozi, G., Serwadda, D., Nalugoda, F., Watya, S., Reynolds, S.J., Wawer M. The impact of male circumcision on HIV incidence, and cost-per infection prevented: A stochastic simulation model from Rakai, Uganda. 2006. (Forthcoming)
(7) Halperin, D.T. and Bailey, R.C. Male circumcision and HIV infection: 10 years and counting. The Lancet 354(9192): 1813-1815. Nov. 20, 1999. (http://dx.doi.org/10.1016/S0140-6736(99)03421-2)
(8) Connor E.M., Sperling R.S., Gelber R., Kiselev P., Scott G., O'Sullivan M.J., VanDyke, R., Bey, M., Shearer, W., Jacobson, R.L., Jimenez, E., O'Neill, E., Bazin, B., Delfraissy, J.F., Culnane, M., Coombs, R., Elkins, M., Moye, J., Stratton, P., Balsley, J. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. New England Journal of Medicine 331(18): 1173-1180. Nov. 3, 1994. (http://content.nejm.org/cgi/content/abstract/331/18/1173)
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