Africa and Aboriginal Tuesdays: Make Circumcision Compulsory For Men by Freddie Ssengooba

Recently New Vision carried an article about Ugandan men who had joined, as subjects, the research on the impact of circumcision in prevention of HIV/AIDS. The question is, could circumcision be the answer to HIV?

Despite decades of intensified campaigns for abstinence, faithfulness to sexual partners and condom-use to prevent HIV infection, over100,000 new HIV infections still occur every year in Uganda and nearly five million new infections worldwide. The search for solutions to eliminate new infection has now turned to the centuries-old custom - male circumcision. Globally, over 70 published studies have been done since 1980s to evaluate the effect of male circumcision (MC) on HIV infection. Two weeks ago, the Minister of Health, Dr Stephen Malinga, launched the HIV/AIDS Sero-Behavioural Survey (HSBS) report authored by his ministry (MoH). The report observed that circumcised Ugandan males aged 15-59 years had a 32% less HIV infection rate compared to the uncircumcised. At face value, 35,000 new infections could be prevented if all Ugandans in the age group 15-50 age group were circumcised, according to this report.

Should male circumcision become mandatory as a strategy to reduce new HIV infection? At what age should it be done? Can the health system handle this additional demand? These are major policy question for Uganda and other countries in the region.

Siegfried and colleagues in a study in The Lancet journal in 2005 said that after reviewing nearly 70 globally available studies of MC, they found a protective effect of MC ranging from 20-80 percent.

Studies done in Rakai District by Ron Gray and Makerere University researchers observed a 40 percent protective effect of MC among Rakai men. The Ron Gray team also observed dramatic results among HIV discordant couples over a period of two and a half years. Zero (0%) new infections were recorded among circumcised men married to HIV positive women, whereas 40 new infections (29%) were observed among similarly exposed uncircumcised men.

The biggest shortcoming of these studies was that the influence of other factors linked to MC could not be subtracted to give conclusive estimate of the magnitude of the benefit of MC in HIV infection. For example, not drinking alcohol may be the reason for less HIV infection among Muslims and not because they are circumcised.

Other factors that may hide behind MC and yet influencing HIV infection include cultural differences, sexual and genital hygiene practices.

The first study to provide conclusive evidence and a refined estimate was published by Bertran Auvert and his group in PloS Medicine Journal last November.

Bertran demonstrated that MC provided a 60 percent protection from acquiring HIV among adult males aged 18-24 years. In addition, this study demonstrated that this benefit could be achieved within two years of circumcision among adult men. In his conclusion, Bertran notes that MC is as effective as the HIV vaccines currently being tested. By the end of this year the Rakai Research Program will provide results from a similar study among Rakai men.

Given the South African results, Uganda can reduce the 100,000 new infections every year by 60 percent via MC. Although logistically expensive, the benefits go beyond HIV. Other benefits include reduced STDs, cancers of the penis and improved general hygiene. Indeed MC would be the most efficient way to spend the Global Fund money.

MC as a protection against HIV should be put in context. For example, some sexual practices are too vigorous and leads to traumatic bruises to the thin membrane in uncircumcised penis. These bruised areas provide ready entry points for the HIV virus.

Toughening (keratinization) of the skin after circumcision reduces the vulnerability of the penis to infection and bruises. It also allows for quick drying-up of the penis after penetrative sex thus killing infective agents. Removing the foreskin reduces the surface area and target cells used as the entry point by the HIV virus.

Over 75% of the male population in Uganda is uncircumcised. Will they accept to be 'cut' ? Acceptance is obviously easy in research. For example, participants in the South African study were given free surgery plus $50 as compensation for a week out of work. The surgery was done by surgeons in first-class theatres and with highly trained and motivated clinical staff - situations that do not pertain in the general health system.

It would be important for MoH to start on the policy of male circumcision and plan for public information campaign, operational logistics and surgical skills training. We need to persuade our leaders at all levels to lead by example in MC campaign. And newborn-boys should not be leaving hospitals and health centres with their foreskin.

Freddie Ssengooba is a medical doctor and a lecturer at Makerere Institute of Public Health. He can be reached via email at sengooba@iph.ac.ug. This article appears in The New Vision.

Freddie Ssengooba

Tuesday, July 25, 2006