Monday, 25 May 2009

Circumcision and HIV/AIDS

An article in the Independent on May 19 2009 reports that:

'Three landmark randomised controlled trials conducted in South Africa, Kenya and Uganda between 2005 and 2007 demonstrated that adult male circumcision reduced the risk of contracting HIV by 50 to 60 per cent'.

 It opens with the assertion that:

'New evidence suggests removal of the foreskin can protect not just against HIV, but other diseases that kill millions. Now some doctors are reconsidering their views on an ancient and controversial procedure'.

 What exactly are (or should be) doctors considering? Is circumcision the best option worldwide for HIV/AIDS prevention and why is it being promoted above condom use? Currently, around 30 per cent of males worldwide are circumcised, but this is done mostly for religious and cultural reasons rather than medical ones.

 I discussed this with Dr. Antony Lempert of the Secular Medical Forum who pointed out that interpretation of this latest research has to be tempered by the fact that the Cochrane collaboration who reported on these trials stated that the risk of bias is very high.

 Moreover, the mechanism by which circumcision may work is not even known yet. The New England Journal of Medicine (NEMJ) report, from which the Independent article is drawn, reports: ‘How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa’.

Even if the research can be shown to be good and that circumcision does reduce the transmission of HIV/AIDS, it still only brings the risk down to around 50:50 and it does not tackle the whole problem of sexually transmitted infections (STIs). According to the article, there is some emerging evidence that circumcision also reduces infection with Human Papilloma Virus (HPV) by 35% and Herpes Simplex (HSV) by 25% but again, these are not persuasive percentages when compared with condom use.

In fact, it may worsen the problem as men who have been circumcised see the operation as a licence to ride bareback, thus spreading other STIs and, of course, causing unwanted pregnancies. In fact, they may ask what is the point of being circumcised if you still have to wear a condom. Many men are not keen to use condoms as they reduce sensitivity so it is hard to see why they would opt for an operation that reduces it permanently.

 Although HIV/AIDS is the most serious of STIs, chlamidia and gonorrhoea are not without long-term risks if undiagnosed or untreated, which could be the case in remote, rural or some highly religious communities in the developing world (the jury is still out on the effectiveness of circumcision against syphilis).

 Who will benefit even from the 50:50? The NEMJ report also says: ‘Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women.’

 In addition, the new research looks only at adult men having sex with women, not at the long-term effect on boys or men having sex with men.

In fact, the Independent article quotes Professor Terence Stephenson (President of the Royal College of Paediatrics and Child Health), who says that there is ‘no evidence that circumcision is protective in men who have sex with men’.

The risks of adult circumcision are small but not negligible, especially if they are not carried out in sterile circumstances. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction. (NEMJ).

So adult male circumcision doesn’t appear to protect women or men having sex with men. With such scanty evidence in favour, who is promoting adult male circumcision, particularly in Africa?

One of the largest bodies is PEPFAR, the US President's Emergency Plan for AIDS Relief who are ‘working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs’ in Africa and other countries (including Haiti and Vietnam). 

Who are these partners? They include the Catholic Relief Services, Family Health International and the Elisabeth Glaser Paediatric AIDS Foundation. The PEPFAR website lists them and their areas of concern. For many of them, ‘Abstinence and Be Faithful’ are on that list. Taking a random sample of countries, in Rwanda 11 out of the 23 partners promote abstinence and in South Africa, 28 out of 93 partners – for a few of them,  this is their only agenda.

Given the Catholic Church’s opposition to condoms to the point of lying about their effectiveness, and that of many American Evangelical organisations, could it be possible that circumcision is being promoted over condom use for less-than scientific reasons? Abstinence has been shown to be an ineffective programme in the US and under the Bush regime, many lies were spread about condom use, so are they promoting circumcision rather than condoms? Pro-abstinence campaigners, especially religious ones, are often anti-condom.

In America, circumcision has been declining in some states but the overall prevalence is still 65% (compared with 16% in the UK). As Dr Lempert points out:  ‘the majority of the American male population has been circumcised whilst they have a rather high rate of HIV infection’.

There is also the issue of consent. Adult men may be able to weigh the facts and make their own decision, but boys and new borns cannot.

To go back to the Independent article, it implies that all parents should seriously weigh up circumcising their male children. But the issue is far more complex than is being presented. There is undeniably resistance to condom use in many cultures for a variety of reasons that need to be overcome and logistical questions of distribution, but the promotion of both circumcision and condom use is tainted with many unknowns and mixed motives; should anyone – doctors, funding bodies, sexually active men or parents - be contemplating or recommending an irreversible surgical procedure just yet?







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