Circumcision doesn’t reduce HIV spread’
Posted by FLAVIA LANYERO
on Tuesday, March 6 2012 at 00:00
Contrary to recent popular claims that male circumcision reduces HIV/Aids transmission by 60 per cent, a group of researchers has disputed the findings, saying the action will only increase the spread of HIV/Aids and can only reduce its transmission by 1.3 per cent at most.
Researchers Gregory Boyle and George Hill in a study published by Australia’s Thomson Reuters, base their argument on a recent male-to-female transmission of HIV study in Uganda, which showed that more women contracted the virus after unprotected intercourse to infected circumcised male partners.
They concluded that male circumcision is associated with a 61-per-cent increase in HIV transmission. “Across all the three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18 per cent) became HIV-positive while among the 5,497 controls, 137 (2.49 per cent) became HIV-positive,” Boyle and Hill said.
“So the absolute decrease in HIV infection was only 1.31 per cent, which is not significant. Examination of epidemiological data shows that male circumcision does not provide protection against HIV transmission in several sub-Saharan African countries, including Cameroon, Ghana, Lesotho, Malawi, Rwanda and Tanzania, all of which have higher prevalence of HIV infection among circumcised men,” they concluded.
Uganda rolled out medical male circumcision drive two years ago after the World Health Organisation-UNAIDS in 2007 recommended male circumcision as an HIV preventive measure based on randomised clinical trials in female-to-male sexual transmission in South Africa, Kenya and Uganda, which suggested that circumcision could reduce infection by up to 60 per cent.
Thousands of men have undergone the surgical pinch in Uganda. However, President Museveni in July last year castigated the call for male circumcision as a measure to curtail HIV/Aids, saying it was “diversionary” and called for abstienence.
The Permanent Secretary in the Ministry of Health, Dr Asuman Lukwago, yesterday, said he was not aware of the new findings but said should it be proved otherwise, the country will drop the method for other viable ones.
“We do not strongly condone it and neither do we dispute it. We work in a world of information and evidence and when it is proven otherwise we shall be alerted and we change our policies just like we did for malaria medicine,” he said.
Circumcision and HIV: are we being fed on half-truths?
Posted by Agnes K. Namaganda
on Thursday, March 22 2012 at 00:00
You have probably heard an advert calling upon men to get circumcised - “Circumcision reduces the risk of contracting HIV/Aids,” word goes. However, is this really true? Sylvia, a 27-year-old feels ripe for marriage, but there is a problem. She hasn’t found that man who fits the bill. The men in her age group are just starting out with their careers and with a little money and freedom from the clutches of their parents, they think more in terms of having fun-nights out and parties- till their 30s when they have made strides in their careers and have the money to run a family. All they want is a girlfriend. No babies. No commitment.
On the contrary, quite the go-getter, Sylvia is already at managerial level in a multi-billion company. So the ‘boys’ in her age-bracket are somewhat intimidated and find her too mature because by the end of this year, she will have finished her first three rental apartments with a plan to immediately start on others thereafter.
That is how older married men-10 years and more-have managed to find a soft spot in Sylvia’s life.
“When you have a financial problem, they can easily bail you out with that kind of money because most of them are building as well and properly understand the challenges,” she says.
However, it is the men she is having affairs with that quickly give her this kind of financial help without expecting anything in return. The catch with committed men however, is that they are more reluctant than your ordinary bachelor, to want anything to do with condoms.
“It is alarming the reasons they give,” she says, reeling off some of them. “Some say they itch, some that it breaks the fun because he has to take time off to wear it, some say it burns them, and others that they don’t enjoy it as much. I literally have to fight with them into putting one on but it’s tough,” Sylvia, who says her friends have had similar encounters, explains.
Stories like Sylvia’s may explain the 2009 findings that indicated an increase in the HIV infection rate among married and cohabiting couples to over six per cent in comparison to individuals who were not in a union at 1.6 per cent. In fact, it was found that 65 per cent of all new infections in Uganda occur in married people amongst whom only three to four per cent, regularly tested for HIV.
Armed with this information, the scientists whose role is to see an end to the scourge commendably started looking for solutions to address this problem as thus, rolling out a number of being faithful campaigns including the famous ‘get off the sexual network’ campaign.
Eventually, new research findings came out, showing there is a 50-60 per cent chance of an HIV-negative circumcised man not contracting the disease from an infected female partner. These findings could have been truly godsend, an avenue for reducing on the infection rate especially among the promiscuous men who are reluctant to wear condoms for one reason or another. But there are sections of people, including scientists, raising dust on the findings.
May be, it is the way this campaign is being done that could somewhat be distorting the message. First, stakeholders in the fight against HIV/Aids have been at a loss for some time now. With ARVs, there aren’t as many people dying due to HIV/Aids, a different scenario from the mid-90s when everyone knew someone who had died in a dreadful way due to the disease as thus imparting the fear.
With victims living longer now, the initial terror with which HIV/Aids was regarded, is gone - it is no longer considered a serious threat by the public inspite of the intense awareness campaigns. The rates of new infections instead of going down have actually gone up from 6.4 per cent to 6.7 per cent in the last one year, according to a preliminary Aids Indicator Survey 2011. This means the ABC (Abstain, Be faithful or Condom use) strategy is not as effective as it was in the 90s. And that is why the circumcision findings were probably timely as a way of scaling down the HIV infection rate.
However, one would be excused to think that a cure for the disease has been found given the long queues at the health facilities that are offering free circumcision services. The campaign has been somewhat successful but at what cost.
First, it is not fair on both sexes. For the women, it seems to suggest that they should not worry about their partners straying as long as they are circumcised.
“Just look at those posters with a woman’s saying, “I am proud, I have a circumcised husband because we have less chances of getting HIV.” Isn’t that totally absurd? Isn’t it like saying we can disregard corruption just because it has been done to a smaller degree? No woman would be proud of a promiscuous albeit circumcised husband,” an angry Engineer Geraldine Mwesigye says.
Faith Namulindwa, a social worker, also thinks the campaign is to an inadvertently introducing the idea of promiscuity injecting the idea that men can avoid HIV to a certain extent if they are circumcised; that circumcision is a permanent condom of sorts? Because half a chance at infection is so much indeed if someone’s life is at stake. Isn’t also like taking it for granted that men do not have the ability to stay faithful? Isn’t this an insult to the faithful men out there?
Phillip Ssesazi, a businessman dealing in online forex trading however disagrees with the suggestion that this campaign will only increase promiscuity. Infact, he thinks the campaign is serving the intended purpose of promoting safety, even if it is 50 per cent. “To an African man, having one or two other women he can go to, on that ‘rainy’ day is not being promiscuous. It is only when we are sleeping with five or 10 women that we start to feel a little uneasy, but two three, is normal,” he argues. Ssesazi does not think the men going for circumcision are itching to go on rampage since they now have a permanent condom of sorts. “Men have been straying even while uncircumcised without using condoms or even going for an HIV test with these partners. But now that this option is here, they are thinking, well, just in case she has HIV, I have a chance of staying safe.”
The Public Relations Officer of the Aids Information Centre, Marion Natukunda explains that the circumcision campaign is not being used as that one silver bullet that can pull down the infection rates. “Since no single intervention is 100 per cent effective thus providing total protection, circumcision is part of a comprehensive HIV prevention package in our programme. We are not saying that circumcise and be safe, but that you should use a condom when necessary as well staying faithful.” Dr Vincent Kawooya of Makerere University, School of Public Health, who has participated in developing communication strategies and policy as regards circumcision disputes the notion that men will go on rampage as circumcision offers them some form of permanent protection against contracting the disease. He explains; “We are just adding circumcision to the existing strategies of combatting HIV. It is not a stand-alone strategy and the message has been very clear that it is not 100 per cent safe. Take an example of the malaria medication Coartem, it is a combo of two or three drugs that together, effectively fight the parasite.”
He further explains that those getting circumcised under this campaign undergo counselling both before and after to clearly understand that circumcision alone will not protect them. It is important to note therefore that circumcision alone without behaviour change will not stop the new HIV infection rate.
The debate: others say circumcision only makes the HIV/aids fight absurd
Delilah Tamble says:
The Rakai District study showed no difference in the chances of catching HIV with an intact (non-circumcised) or mutilated penis. This study was closed half way through because too many women were catching HIV. The Head Researcher, Dr Maria Wawer said of the study’s results that “circumcision of HIV-infected men did not reduce HIV transmission to female partners”. The BBC News reported this in 2009, but it failed to get a mention in Uganda’s media.
The South African study also found no definite link between Male Genital Mutilation (MGM) and a lowered risk of HIV infection, likewise intact men did not have an increased risk of HIV, nor did their partners. In their research conclusion they warned against using MGM as a HIV prevention tactic, saying that the risks and life-long negative effects of MGM were not worth the possible, and as yet unproven, protection.
The Garenne study of 2006 was the only study which found any HIV decrease amongst mutilated men, which was in Kenya and Uganda, which is where Jerry Lanier was getting his 50 per cent – 60 per cent. In other words there was about a half/half chance of HIV, which in real terms makes no difference to an individual’s risk. Mr. Lanier also failed to mention that the same Garenne study found absolutely no difference in HIV rates amongst intact and mutilated men in Burkina Faso, Cote d’Ivoire, Ethiopia, Ghana, Niger, Rwanda, Tanzania and Zimbabwe, whilst Cameroon, Lesotho and Malawi had a much higher rate of HIV, as much as a 22.8 per cent increase of HIV amongst mutilated men than intact men. If you are a fan of statistics like Mr. Lanier appears to be this would actually mean that the chances of HIV increase when mutilated, even though by a slight amount; it certainly can not be used to draw the conclusion that mass MGM in Africa could ever hope to decrease HIV.
Not mentioned are two other studies which both found that penis mutilation does not lessen the chances of catching HIV, or any other STI. The studies were done by the US Navy in 2004, and Australia in 2011. According to the Kenya Aids Indicator Survey (Kais) released September 2009, the North Eastern and Coast provinces, where 97 per cent of males were circumcised, registered an increase in HIV prevalence, whilst Nyanza Province, where about 60 per cent of men are intact had the lowest HIV rate in the country. In 1999, Robert Van Howe, MD, subjected the data from 35 articles on HIV/Circumcision to rigorous statistical analysis. Van Howe found that, based on the combined data, “a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis…based on the studies published in the scientific literature, it is incorrect to assert that circumcision prevents HIV infection.”
Male circumcision for HIV prevention: What does the scientific evidence say?
By Joseph KB Matovu, Rhoda K. Wanyenze & David Serwadda
Posted Thursday, April 12 2012 at 00:00
Medics from Makerere University School of Public Health answer in detail the recent concerns over the male circumcision drive aimed at reducing the spread of HIV/Aids
Of recent, the media has published a number of articles related to male circumcision, including two articles in the Daily Monitor. The first article entitled ‘Circumcision does not reduce HIV spread’ (Daily Monitor, March 6, 2012) was written by Flavia Lanyero. Flavia’s article is based on a paper published by Gregory J Boyle and George Hill in the Journal of Law and Medicine in 2011. This paper is one among many articles authored by self-proclaimed anti-circumcision crusaders. Indeed, George describes himself as the Vice President for Bioethics and Medical Science under a programme known as ‘Doctors Opposing Circumcision’ based in Seattle, Washington, D.C. As B.J. Morris and his colleagues have concluded, these anti-male circumcision crusaders “misrepresent good scientific studies, selectively cite references, some containing fallacious information; and draw erroneous conclusions” in order to reframe the male circumcision debate in their favor. The second article entitled, “Circumcision and HIV: are we being fed on half-truths?” (Daily Monitor, March 22, 2012) was written by Agnes Namaganda. Agnes questions the truth in the statement, “male circumcision reduces the risk of contracting HIV”, and presents contrasting views about male circumcision without necessarily helping the reader to reach a definite conclusion about the effect of male circumcision in HIV prevention. While she did not explicitly state which side of the debate she falls, we believe that the taste of her article hinged more on the side of those who are opposed to male circumcision, considering the nature of evidence cited. In writing this article, we intended to not only respond to these issues but also provide a more elaborate view of male circumcision and its role in HIV prevention based on scientific evidence at hand.
How the male circumcision debate begun
Male circumcision has been practiced for generations. It is one of the oldest surgical procedures known to mankind. Over time, the scientific community observed that the risk of acquiring sexually transmitted infections (STIs), including HIV, was lower in men who were circumcised than in those who were not. While nobody could clearly explain the science behind these observations, there was a general perception that male circumcision could be the reason for the observed differences.
However, since there was evidence of high HIV prevalence in some circumcising communities, it was not possible to come to a conclusion about the protective effect of male circumcision, before subjecting it to rigorous scientific scrutiny. Whereas proponents argue for increased scale-up of male circumcision programs, opponents have initiated campaigns to discredit male circumcision. But what does science tell us about male circumcision?
Some studies indicated lower HIV prevalence in circumcised men vis-à-vis uncircumcised men, but these studies had methodical challenges. For example, in many parts of Africa where circumcision was shown to be associated with low HIV prevalence in men, these areas also happened to have a high number of Muslim men. It was, therefore, not clear whether it was circumcision per se that was protective or whether it was because of other attributes already known to be associated with Muslim men (e.g. Muslim men do not drink alcohol) that reduced their risk for HIV infection. On the other hand, there are studies that have shown that circumcised men have high HIV prevalence, which, on close examination, found that most of these men were circumcised as result of having STIs. All these observations made it difficult to conclude whether male circumcision per se reduced chances of acquiring HIV among adult men.
To respond to this question, scientists designed further research studies known as randomized clinical trials. These types of studies are taken as the “gold standard” of research evidence. In these studies men who were not circumcised and who were free from HIV infection were divided into two groups with one group circumcised immediately while the other group was asked to wait for some time to receive circumcision and thus acted as the comparison group. Scientists followed both groups for a defined period of time, and tested them for HIV at regular intervals. They also provided free counseling services to all men as well as free condoms to those who were interested in using them. These trials, conducted in three countries (South Africa, Kenya and Uganda) between 2000 and 2006, involving a total of 5,411 men in the circumcised arm and 5,497 in the comparison group indicated that circumcised men were less likely to acquire HIV than those who were not circumcised. The level of protection of male circumcision from the risk of HIV infection ranged between 50 per cent to 60 per cent across the three countries. These findings, from studies conducted in different countries and communities, were so convincing that in 2007 the World Health Organisation (WHO) together with the Joint UN Programme on HIV/AIDS (Unaids) recommended male circumcision as part of a comprehensive HIV prevention strategy (alongside condom use, being faithful to one’s HIV-free sexual partner, treatment of sexually transmitted infections, among others) in ‘countries with heterosexual epidemics, high HIV and low male circumcision prevalence’, such as those found in sub-Saharan Africa.
It is important to note that the WHO guidelines refer to ‘medical’ or ‘safe’ male circumcision as opposed to the culturally performed circumcision which may be associated with other risks such as serial use of unsterilized instruments that could potentially transmit HIV. This and other cultural practices around circumcision may partly explain the high HIV prevalence among communities that perform circumcision for cultural reasons, as has been cited in some communities in Botswana and elsewhere.
Recent evidence on the impact of male circumcision at the community level
Studies done after the end of the clinical trials in Kenya and Uganda have found that male circumcision’s protective effect against HIV is sustained and may even become stronger over time. The risk of HIV infection among circumcised men was reduced by 67 per cent after 4.5 years in Kenya and by 73 per cent after 4.8 years in Uganda.
Equally exciting are recent results confirming that this level of protection can be achieved outside the relatively controlled setting of a clinical trial.
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Last year, a community-based study indicated that providing male circumcision in a South African township reduced the rate of new HIV infections among circumcised men by 76 per cent in three years. In a recent paper entitled Population-level impact of male circumcision on HIV incidence: Rakai, Uganda, Ronald H. Gray and colleagues found that the number of new HIV infections among non-Muslim men decreased with greater uptake of male circumcision. Dr. Gray and his colleagues conducted an observational study among 14,000 individuals in 50 communities in Rakai District between 2000 and 2009.
Male circumcision among non-Muslim men in Rakai increased from 5.6 per cent in 2000 to 25.3 per cent in 2009. The number of new HIV infections decreased by 37 per cent during the same period among non-Muslim men. No effect on new HIV infections was seen among females in this study. This study focused on non-Muslim men because it is the practice in the Muslim community to circumcise young boys.
There are concerns expressed that male circumcision will lead to an increase in risky sexual behaviors, such as less frequent use of condoms or increased numbers of sexual partners. However, recent evidence suggests that male circumcision does not lead to increased risky behaviors.
For instance, a study done among 2,500 circumcised men who were followed up for up to five years in Rakai did not find increased risk behaviour among these men compared to uncircumcised men with respect to number of sexual partners or condom use. Other studies in Kenya and South Africa have found out that male circumcision does not result in increased risky sexual behaviors such as having sex with multiple sexual partners or abandonment of condom use.
On the contrary, circumcised men report increased safer sexual practices following risk-reduction counselling, suggesting that male circumcision programmes should incorporate risk-reduction messages into the promotional campaigns. It is interesting to note that such concerns were also voiced with the introduction of antiretroviral drugs (ARVs), but this did not stop rolling out ARVs.
Does male circumcision protect uninfected women against acquiring HIV?
Although male circumcision reduces the risk of HIV acquisition in HIV-negative men, evidence of protection for HIV-negative female partners of HIV-positive men is not conclusive. Studies carried out earlier in Uganda, particularly among HIV discordant couples (with one partner HIV-negative and the other positive), had indicated that if the HIV positive partner was circumcised, there was a reduced risk of transmission of HIV to the HIV-negative women; these studies were conducted among men who were circumcised at birth.
However, no studies had demonstrated whether the same protective effect could be seen among men circumcised as adults. A randomised clinical trial by Maria J. Wawer and her colleagues shows that female partners of HIV-positive men, circumcised as adults, may be at an increased risk of acquiring HIV if the couple resumes sex before the wound of the HIV-positive partner has healed.
It is important to note that the trend towards increased risk was seen only among women in couples who resumed sex too soon after circumcision, i.e. before proper wound healing. Gregory and George’s article, and indeed other articles from anti-male circumcision crusaders don’t mention this fact. It is crucial for couples to follow the recommendation to abstain from sex for six weeks post-circumcision (after wound heals). One can argue that logically, when fewer men are infected, transmission to women at population level would also reduce over time. Indeed, there are several studies that indicate some protective effect for women, but until such evidence is available consistently across different studies, male circumcision will continue to me promoted as a strategy for the prevention of ‘heterosexually acquired HIV infection in men’, as per the WHO recommendations. Other benefits of male circumcision beyond HIV prevention
There is overwhelming evidence to prove that male circumcision provides other benefits beyond HIV prevention. Male circumcision improves male hygiene, reduces risk of genital ulcer disease and cancer of the penis, and lowers the risk of cervical cancer among women with circumcised male partners by reducing the prevalence of the virus that is associated with this cancer (Human Papilloma Virus).
The role of male circumcision in relation to other HIV prevention approaches
We should point out that a circumcised man can still acquire or transmit HIV (if HIV-positive), except that male circumcision reduces the risk of HIV infection among initially HIV-negative, circumcised men. We should also point out that the risk of acquiring as well as transmitting HIV among circumcised men increases when sexual intercourse is resumed too early (before complete healing) or when circumcised men increase their risky behaviors due to the belief that they are protected.